Title: Behaviour Disorders and Behaviour Management
1Behaviour Disorders and Behaviour Management
- Paul Wilkinson
- Clinical Lecturer
2Aims
- Describe psychiatrically-defined behaviour
disorders - Discuss management of behaviour disorders
- Discuss behavioural management of the normal
child
3Behaviour Disorders
4- Childrens behaviour is on a continuum
- At one end, we say there is a behaviour
disorder - disruptive behaviour disorder
- Oppositional defiant disorder (ODD)
- Conduct disorder (CD)
- Juvenile delinquency (JD)
- DSM-IV definitions
5Oppositional Defiant DisorderGeneral
disobedienceAt least six months of at least 4 of
often
- Losing temper
- Arguing with adults
- Defying adult requests/rules
- Deliberately annoying others
- Shifting blame to others
- Touchy or easily annoyed
- Angry and resentful
- Spiteful or vindictive
6Conduct DisorderMore deviant behavioursAt least
6 months of at least 3 of
- Bullying, threatening, intimidating
- Starting fights
- Using serious weapons in fights
- Physically cruel to people
- Physically cruel to animals
- Stealing with force
- Forced sexual acts
- Destroyed others property
- Broken into car or house
- Cons others
- Stealing without force
- Often out at night without permission
- Ran way overnight twice
- Truancy, before age 13
- Fire-setting to cause damage
7Truancy
- Deliberately missing school to do something more
fun - Often without parental permission
- Often a group activity
- Linked with conduct disorder
- And predictors of conduct disorder
- School refusal missing school because too
anxious to go - There is sometimes overlap
82 Types in ICD-10
- Socialised
- Normal peer relationships
- Cause trouble with their mates
- Unsocialised
- Abnormal peer relationships
- Cause trouble on their own
- Quite a miserable bunch
9Juvenile Delinquency
- Legal definition - law-breaking
- 10-17 years old
- Being found guilty of an offence which would be
criminal in an adult - 90 is against property
10Problems with Diagnoses
- A lot of overlap
- CD trumps ODD
- Not helpful to mention ODD if CD diagnosis
- Simple symptom counts
- Must also meet criterion of clinically-significan
t impairment - Takes no account of relative importance of
different symptoms - Arbitrary cut-off does define research population
11Epidemiology
12Conduct Disorder
- 3-5 in developed world
- Malefemale 41
- Older studies (UK) urban rural
- Newer studies (N America) urban rural
13Oppositional Defiant Disorder
- Prevalence 2.7 (N. Carolina)
- Male female 1.5 1
- Reduction in milder oppositional behaviour with
age - Increase in more antisocial behaviour with age
14Juvenile Delinquency
- Peak in law-breaking in late teens
- Theft and property offences peak in late teens
- Violence peaks in early 20s
- 50-75 will not be convicted again
- Male female 3 -10 1
- Number of boys who are convicted at some point in
adolescence - ??? - 20 !!!!
15Age of Criminal Responsibility
- Age at which young person responsible for their
criminal acts - Currently 10 years old in UK
- Below that, parents responsible
- Action is normally by social services
- Higher in many other countries
16Aetiology of CD
17Social Risk Factors
- Family dysfunction
- Parental mental illness
- Low income
- ? Only for under 12 year olds
- Criminality in father
- Overcrowding
- Institutional care
- Abuse
- Deviant peer group
18Psychological Risk Factors
- Hyperactivity
- Poor school achievement / low IQ
- Specific reading disorder
- Cognitive attributions
- Perceive others acts as hostile
19Biological Risk Factors
- In utero nicotine, (alcohol, cocaine)
- CD clusters in families
- Shared environment probably main reason
- Probably some genetic effect
- Heritability is 0.4
- Heritability is greater for early-onset and
persistent conduct disorder - Strong genetic influence for ADHD/conduct
disorder symptoms rather than pure conduct
disorder symptoms
20Biological Correlates
- Especially in early-onset
- Low heart rate
- Low heart rate variability
- Low cortisol and high testosterone
- Deficient 5-HT activity
- Impaired executive function
- Eg impaired planning, response inhibition
- Even in absence of ADHD
21Psychiatric Co-morbidity
- ADHD increases risk for CD
- Autistic spectrum disorder increases risk for
behaviour problems, but may not have high enough
IQ/opportunities to carry out delinquent acts - Depression and CD overlap
- Behaviour problems ? told off lots/peer rejection
? low self-esteem ? depression - Depression ? irritability ? Behaviour problems
and social isolation
22Outcome of CD
23- 40 of children/adolescents with CD become
delinquent young adults - Ongoing behaviour problems
- Disrupted relationships
- 90 of delinquent young adults had CD as
children/adolescents
24Risk of Poor Outcome Worse if
- Early onset
- Wider range of symptoms
- More severe symptoms
- Pervasiveness in different environments
- Hyperactivity
- Parental psychiatric disorder
- Parental criminality
- High family hostility
25Management of Behaviour Disorders
26Who Does It?
- Health visitors
- Education
- Social services
- Mental health services
- To varying degrees
27Why Do It?
- Government see it as an important issue
- CD leads to crime
- Probably cost-effective to society to treat it
28Why CAMHS?
- Someone has to
- Some overlap with clear psychiatric diagnoses
- ADHD
- Depression
- Psychosis
- Were used to dealing with complicated family
relationships
29When to Do It?
- As young as possible
- Much harder to change ingrained behaviour
- Secondary problems worsen with time
- Deviant peer group
- Low self-esteem
- Educational problems
- Sense of alienation from society
30Psychological
- Main line of treatment
- Teach parents how to manage their children
- Just with one set of parents or as a group
- A lot of evidence for Webster-Stratton child
behaviour management courses - A group of parents
- Videos and discussions
- Same principles as managing normal kids
- Ill cover this later
31- Less evidence for psychological treatment of
child - Anger management
- Social skills training
- Identify and address cognitive biases
- Broad CBT approach
- If child unhappy/depressed/anxious, treat that
32Social
- Address problematic social environment
- Family
- Address family difficulties
- If necessary, remove child
- School
- Address (specific) learning difficulties
- Address problems like bullying
33Physical
- Treat ADHD with medication
- Some evidence for antipsychotics (esp.
risperidone) in reducing CD symptoms - Significant side-effects
- Compliance problem
- Must also use psychological/social management
34Child Behaviour Management
35- All children sometimes behave how their parents
dont want them to - Why do parents try to control their children?
36Main Principles
- The attention principle
- Children like attention
- Children will act in a way that they have learned
gets them attention - Consistency
- Between caregivers
- Within one caregiver
37The Attention Principle - Example
- A mother is at home with her two children
- She has to make dinner, and leaves the kids in
the lounge, playing - Big brother hits little sister, who cries
- Mum comes in, sister says, He hit me
- After a big discussion and lots of lying, brother
eventually owns up
38Response
- Mum tells her son to go to the naughty step
- He says, No, why should I?
- She asks him again, he keeps saying NO
- Eventually, she carries him to the bottom step
- He runs back to lounge
- She carries him back and sits next to him,
telling him how disappointed she is with his
behaviour
39- What will happen when mum goes back to finish
making dinner? - He has learnt that mum gives him lots of
attention for hitting his sister
40Other Responses?
- Change balance of benefits
- Consider difficult situation in advance
- Do kids really have to be in lounge?
- Could give them an activity in kitchen that
allows mum to still cook - If you two play really nicely while mummy makes
dinner, Ill give you both.. - Give attention to the child who was hit and
ignore the hitter - possibly by sending to room
41Avoid Arguments
- Argument lots of attention
- Stop it!
- Do what mummy says or go to your room
- Im going to count to three and I want you to
sit quietly on the bottom step before I get to
three.
42Focus on Positives
- Keep on praising kids good behaviour
- Be specific in praise
- Daddy really likes it when you come to dinner
when he calls - Ignore mild bad behaviour
- Give loads of attention to the children behaving
well - Even the naughtiest child will have moments of
good behaviour that theyll love being praised for
43Rewards
- Give rewards for desired behaviour
- Can use a sticker chart, leading to a rewards
- Keep talking about the sticker chart, the reward
and the good behaviour
44Timing
- Make consequences (positive or negative) as close
to the incident as possible, to increase the
chance the link is made and remembered - Not Wait until your father gets home
45Attention Principle - Summary
- Give the child plenty of incentives for being
good - Praise
- Time together
- Material
- Make it more fun to be good than bad
- Make consequences of bad behaviour boring
46Consistency
- To use attention principle, child must learn the
consequences of good and undesired behaviour - These consequences must be consistent!
- The child must know what to expect
- Both parents should have same set of rules
- Children might get confused
- Theyll play parents off against each other!
47Other CBM Tips 1. Commands
- Child must be able to understand command
- Simple, clear sentences
- Speak slowly and calmly
- Especially if lots of emotions about
48Commands, example
- 4 year old, who is angry, is told
- For the millionth time, dont take the chocolate
cakes out of the fking cupboard. Dont even
think of doing it again, if you do, I swear Ill
give you what for, you naughty little monkey - He hears
- Take four million chocolate cakes. Think of
doing it again, Ill give you four little
monkeys. - Mummy, what does fking mean?
49Commands, alternative
- Use positive commands
- Makes them think of positive stuff
- If they dont hear one word, theyll still get
the message - Please walk down the stairs instead of
- Dont slide down the stairs
50Commands
- Dont ask them if they want to comply
- Would you like to tidy your room?
- Give them a warning that youll want them to do
something if theyre busy playing - In one more minute, Id like you to wash your
hands for dinner
512. Model Desired Behaviour
- Dont fking swear!
- Kids arent born with 20 year old brains and so
dont understand complex reasoning for behaviour - Kids think their parents are great
- Of course, they will copy them
- Do what you want them to do
523. Choose Your Battles
- It is easy to give lots and lots of commands to
your kids. - You cannot enforce them all
- Kids learn.
- It doesnt matter if I dont follow commands
- Solution think what commands really matter
- And enforce them absolutely
53Why no Hitting?
- 1. Kids copy their parents
- 2. It often happens when parents are really at
the end of their tether - They have less control
- More likely to be excessive
- 3. Parents cant know how much force to use to
get the right amount of pain - Kids can be traumatised
- 4. Focus is on the negative behaviour
- Used instead of more positive techniques
54Summary The Happy Child
- Gets praised lots
- Knows exactly what their parents expect them to
do - Consistent experience
- Clear instructions
- Copies parents
- Isnt nagged all the time
- Have freedom within clear boundaries
- Doesnt live in fear of physical violence
55Giving 11 Advice to Parents
- Parent will come in complaining of childs
behaviour - Take a history
- Empathise
- How do parents manage behaviour?
- Good and bad
56Simple Advice
- Try one change at a time
- Something may jump out from the history
- A good place to start.
- Encourage them to catch more of the good
behaviour and reward it
57Exams
58Essay
- Should people with behaviour problems be seen by
mental health teams? - Refers to paediatric CD as well as adults DSPD
- Overlap with psychiatric illnesses (esp ADHD)
- Expertise on behavioural strategies
- Adolescents/adults make choices to be bad,
dont act like it due to an illness they dont
want
59PMPs
- May be asked to say whether a child with
behavioural problems has ADHD or pure behaviour
disorder - How to manage pure behaviour disorder
- Came up 2 y ago
60ISQs
- Maternal smoking in pregnancy is associated with
conduct disorders - True This association is stronger for males,
stronger for persistent conduct disorders and
stronger for violent than non-violent
criminality.
61- Being the first child in the family increases the
risk of violence - False There is no evidence of this. However,
behavioural problems are associated with large
family size.
62- Conduct disorder is associated with mood
disorders in adulthood. - True Conduct disorder is associated with
increased antisocial personality traits,
substance abuse, anxiety, depression, somatic
complaints, self harm, suicide and time spent in
psychiatric hospitals
63- Children with unsocialised conduct disorder have
low self esteem - True Unsocialised conduct disorder is conduct
disorder with pervasively abnormal peer
relationships. There is isolation, unpopularity
and peer rejection, and relationships with adults
are often marked by discord and hostility. This
all increases the risk for low self-esteem.
64- About 10 of British urban teenagers are
delinquent. - False Juvenile delinquency is a legal term. It
refers to an act committed by a young person, for
which they are convicted, and which would have
been regarded as criminal if they were adults.
3-6 of males are persistent young offenders,
while 20 of boys are convicted at some point in
adolescence. 10 is therefore likely to be wrong
(OTP4-836).
65- Juvenile delinquency is more likely to be
associated with future mental health problems in
girls than in boys - True Juvenile delinquency is more common in boys
than girls. Juvenile delinquency is more likely
to be part of a group activity, without
underlying mental illness, in boys. In girls, a
higher proportion of delinquency is associated
with mental illness, in particular substance
misuse and developing personality disorder.
66- More than 50 of children with conduct disorder
have EEG abnormalities - False There is no evidence of EEG
abnormalities. Consistent biological findings
include lower levels of electrodermal
conductivity, lower mean resting heart rate,
lower heart rate reactivity and variability and
reduced serotonergic activity.
67- Irrespective of the child's aggression, peer
rejection on its own increases later antisocial
behavior. - False Several studies have shown peer rejection
to be predictive for later antisocial behavior.
However, Dodge et al (2003) also measured
aggression at baseline and showed that peer
rejection increases the risk for later antisocial
development only in children initially disposed
towards aggression.
68Aims
- Describe psychiatrically-defined behaviour
disorders - Discuss management of behaviour disorders
- Discuss behavioural management of the normal
child - Look at possible exam questions
69Questions
70Summary
71- Behaviour disorders are fairly common
- Undesired behaviour happens in most kids
- Parents need to manage their kids from an early
age - If they cant, services need to help them
- By advising parents
- Parents need to make desired behaviours more
rewarding than undesired behaviours - Parents need to make it clear what behaviour is
desired
72THE END
73Reference
- Webster-Stratton, C. (1992) The incredible years
A trouble-shooting guide for parents of chidren
aged 3-8. Umbrella Press, Toronto. - Every child mental health professional should
read this book - Every parent of 1-12 year olds should own this
book!