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Behaviour Disorders and Behaviour Management

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Title: Behaviour Disorders and Behaviour Management


1
Behaviour Disorders and Behaviour Management
  • Paul Wilkinson
  • Clinical Lecturer

2
Aims
  • Describe psychiatrically-defined behaviour
    disorders
  • Discuss management of behaviour disorders
  • Discuss behavioural management of the normal
    child

3
Behaviour Disorders
  • What are they?

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

5
Oppositional 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

6
Conduct 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

7
Truancy
  • 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

8
2 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

9
Juvenile 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

10
Problems 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

11
Epidemiology
12
Conduct Disorder
  • 3-5 in developed world
  • Malefemale 41
  • Older studies (UK) urban rural
  • Newer studies (N America) urban rural

13
Oppositional 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

14
Juvenile 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 !!!!

15
Age 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

16
Aetiology of CD
17
Social 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

18
Psychological Risk Factors
  • Hyperactivity
  • Poor school achievement / low IQ
  • Specific reading disorder
  • Cognitive attributions
  • Perceive others acts as hostile

19
Biological 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

20
Biological 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

21
Psychiatric 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

22
Outcome 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

24
Risk 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

25
Management of Behaviour Disorders
26
Who Does It?
  • Health visitors
  • Education
  • Social services
  • Mental health services
  • To varying degrees

27
Why Do It?
  • Government see it as an important issue
  • CD leads to crime
  • Probably cost-effective to society to treat it

28
Why CAMHS?
  • Someone has to
  • Some overlap with clear psychiatric diagnoses
  • ADHD
  • Depression
  • Psychosis
  • Were used to dealing with complicated family
    relationships

29
When 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

30
Psychological
  • 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

32
Social
  • Address problematic social environment
  • Family
  • Address family difficulties
  • If necessary, remove child
  • School
  • Address (specific) learning difficulties
  • Address problems like bullying

33
Physical
  • 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

34
Child Behaviour Management
35
  • All children sometimes behave how their parents
    dont want them to
  • Why do parents try to control their children?

36
Main 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

37
The 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

38
Response
  • 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

40
Other 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

41
Avoid 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.

42
Focus 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

43
Rewards
  • 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

44
Timing
  • 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

45
Attention 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

46
Consistency
  • 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!

47
Other CBM Tips 1. Commands
  • Child must be able to understand command
  • Simple, clear sentences
  • Speak slowly and calmly
  • Especially if lots of emotions about

48
Commands, 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?

49
Commands, 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

50
Commands
  • 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

51
2. 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

52
3. 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

53
Why 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

54
Summary 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

55
Giving 11 Advice to Parents
  • Parent will come in complaining of childs
    behaviour
  • Take a history
  • Empathise
  • How do parents manage behaviour?
  • Good and bad

56
Simple 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

57
Exams
58
Essay
  • 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

59
PMPs
  • 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

60
ISQs
  • 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.

68
Aims
  • Describe psychiatrically-defined behaviour
    disorders
  • Discuss management of behaviour disorders
  • Discuss behavioural management of the normal
    child
  • Look at possible exam questions

69
Questions
  • Summary to Follow

70
Summary
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

72
THE END
73
Reference
  • 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!
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