DISRUPTIVE BEHAVIOURS

IN
CHILDREN
 Autism Spectrum
Disorders or Pervasive
Developmental Disorder
 Types of PDD (ICD-10)
• Childhood autism
autistic ds, infantile autism, infantile psychoses,
Kanner’s syndrome
• Atypical autism
• Rett’s syndrome
• Childhood disintegrative ds
• Overactive ds associated with MR
• Asperger’s syndrome
• PDD- not otherwise specified
Diagnosis: 3 main areas of impairment in
PDD or ASD

Delay and abnormal quality in:

• reciprocal social interaction
• language and communication
• imaginative thinking - restricted,
repetitive activities and
interests
&
• early onset: before age 3
 Social impairment

• Qualitative impairment in reciprocal social

relationships
• non-verbal cues: poor eye contact, facial
expressions, body postures, gestures
• failure to develop peer relationship
• fail to share enjoyment or seek comfort
when hurt (lack of pointing, requesting)
• difficulties with understanding social cues
• lack of social empathy (difficulty to
recognise others’ emotions)
 Language & communication
• Delay in receptive and expressive
language
• stereotyped or repetitive use of language
• idiosyncratic use of words
• unable to initiate or sustain a
conversation (those with speech)
• echolalia, pronoun reversal, invented
• reduced gestures or poorly co-ordinated
(abnormal pointing)
• lack of social imitative or pretend play
Repetitive stereotyped activities and
interests
• Rigid and inflexible thought processes
• resistance to change, insist on same
routines, ritualistic behaviours
(lengthy mealtime ritual)
• repetitive activities and interests
(complex or simple)- hand flapping,
twirling objects, fascinated with
unusual parts of objects, same
segment TV show)
• persistent preoccupation with parts of
objects
 Other features: not required for
diagnosis

• Unusual responses to sensory stimuli eg

certain sounds, fascination by certain
visual stimuli, dislike gentle touch, but
enjoys firm pressure
• poor motor co-ordination
• over or underactivity
• food fads
• erratic sleeping patterns
• abnormalities of mood- excitement/
misery
 Age of Onset

• Delay or abnormal functioning in at

least one area must be before age 3
years
 Prevalence
• Childhood autism:
• 3-4 per 10,000 population
• 20 per 10,000 (broader definition)

• Asperger Syndrome
• 36 per 10,000

• Male preponderance
 Differential diagnoses of childhood autism

• Deafness
• Developmental language disorder
• Mental retardation with autistic features
• Mental retardation without autistic
features
• Intense early deprivation
• Pervasive developmental disorders:
Asperger Syndrome, Rett’s syndrome,
Degenerative disorder, atypical
autism, PDD-not otherwise specified
 Treatment plan
 Establish goals for educational
purposes
 Establish target symptoms for
intervention
 Co-morbid conditions
 Monitoring
 Multiple domains of functioning
 Medication
 The little “ Rascals ”

@
Attention Deficit Hyperactive Disorder
(ADHD)
Hyperkinetic children
“Hyperactive”
– parents
 all manner of behaviours
 e.g. frequent night awakenings, talking loudly, naughtiness,
exuberance
 depends on attitudes and tolerance of parents
 MUST always pay attention to the stage of
development
 when deciding normality and abnormality
 Hyperactive Children

“Hyperactive”
– psychiatrists
 more restrictive definition
 restlessness
 inattentiveness
 impulsiveness
 Hyperactive Children

Overactive :
 increase in amount and tempo of purposeful activity
 increase in number of purposeless minor movements
irrelevant to tasks
 e.g. wriggle and squirm in seat
fidget with objects
restless
 unable to suppress activity when stillness is required
 e.g. in classroom or at meal table
 Little “ Rascals ”
Core symptoms
• Hyperactivity
– More active than children their age
• Inattentive
– Short attention span
• Impulsive
– Poor impulse control
• Pervasive
– Symptoms occur across all situations
 Little “ Rascals ”
Hyperactivity

• Fidgets with hands or feet

• Squirms in seat
• Runs about or climbs excessively
• Difficulty playing or engaging in leisure activities
quietly
• Talks excessively
• Always “ on the go ”
• Described as if “ driven by a motor ”
 Little “ Rascals ”
Inattentiveness
• Fails to give attention to details
• Makes careless mistake
• Do not follow through instructions
• Fails to complete schoolwork, chores or duties
• Reluctance to engage in tasks requiring sustain
mental efforts
• Difficulty organizing tasks & activities
• Easily distracted
• Often forgetful for their age
 Little “ Rascals ”
Impulsive
• Blurts out answers before question
completed
• Difficulty awaiting their turn
• Interrupts or intrudes on others
• Makes poor judgement
• Accident prone
 Little “ Rascals ”

Do you fit these criteria…

 Little “ Rascals ”
Epidemiology
• Prevalent in 1-3% of children
• Male : Female
– 3:1
• Hyperactivity dates back to pre-school years
• Referral delayed until primary school
– Present with inattentiveness, learning difficulties
& disruptiveness
 Little “ Rascals ”
Etiology

• Unknown
• Unlikely to be a single etiological factor
• Most likely an interplay
– psychosocial & biological factors
 Little “ Rascals ”
Management

• Requires a multi-disciplinary approach

– Pharmacological treatment
– Psychological intervention
– Educational support
 Little “ Rascals ”
Prognosis
• Hyperactivity wanes in adolescence
• 30% have residual symptoms in adulthood
– Restless & inattentive
• 30% have no symptoms with good functioning
– Choose job which allow freedom of movement
• 30% continuous display of symptom
– Develop other psychopathologies
• E.g. substance abuse & anti-social personality
CONDUCT DISORDER
 Conduct Disorder
• Core symptoms characterised by
- persistent failure to control behaviour
appropriately within socially defined rules

- aggression & violation of the rights of

others
 Conduct Disorder
• 3 domains :
* defiance – of someone in authority
* aggressive – when relating to others
* antisocial behaviour
- violates other people’s rights ,
property or person
 Conduct Disorder

• None of these 3 is in itself

- abnormal or pathological
• Disobedience & disruptive behaviour
- is part of normal behaviour
- usually diminish with maturity
• Dx should only be made when
- behaviours are both extreme & persistent
 Conduct Disorder
• Epidemiology
- evolves over time
- often persistent
- boys more than girls
- 6% to 16% boys
- 2% to 9% girls
- onset : before 10 y.o or during
adolescence
 Conduct Disorder

• Etiology
* no single factor
* contributing bio-psycho-social
factors
 Conduct Disorder

• Biological factors
- proposed neurotransmitter imbalance
- excessive testosterone
- abnormal arousal with failure to calm
down after frustration
 Conduct Disorder
• Social factors
- Family
* chaotic home
* verbal aggression
* severe punishment
* marital discord
* child abuse
* parental psychopathology
 Conduct Disorder
• Social factors
- Community
* economically deprived
* high criminality
* unsupportive social network
 Conduct Disorder

• Psychological factors
- anger
- frustration
- hatred
- dissatisfaction
 Conduct Disorder

• Diagnostic Criteria ( DSM – IV )

- disturbance for 12 months
- involving at least 3 of the following
:
 Diagnostic Criteria
• Often bullies , threatens or
intimidates • Has destroyed other’s property
• Often starts fights • Has broken into a car or
• Has used serious weapons in house
fights • Cons others
• Physically cruel to people • Often out at night without
• Physically cruel to animal permission
• Stealing • Ran away from home
• Has forced someone into overnight twice
• Often truants , beginning under
sexual acts
13 y.o
• Fire-setting to cause damage
 Management
• Proved difficult to treat
• Clinicians may feel overwhelmed
& ineffective
• Multi focus
- child focused
- family focused
- community focused
 Factors predicting outcome
• In the child
- poor outcome
* early onset
* many symptoms
* greater severity
* a/w hyperactivity
 Factors predicting outcome
• In the family
- poor outcome
* parental psychiatric d/o
* parental criminality
* high hostility
* high discord
Oppositional Defiant Disorder
Characterised by an enduring pattern
of behaviours :

• negativistic
• hostile
• defiant

* in the absence of serious violation of

- social norms or rights of others
 Caution :
• Opposing others is crucial to normal
development
• Relates to establishing
- autonomy
- forming identity
- setting inner standards & control
 Caution :
• Children may have strong temperamental
predisposition
- strong will
- strong preferences
- great assertiveness
Child’s temper outbursts , active
refusal to comply with rules &
annoying behaviours . . .

• exceed expectations compared to

others of the same age
= ODD
 Pathology
• If power & control are issues for parents
• Or if parents exercise authority for their own
needs
- the ensuing struggle can set stage for
development of d/o
 Pathology

• What begins for a child as an effort to

establish self-determination
- is transformed into a defense
 Diagnostic Criteria – DSM IV

• Disturbance for 6 months

• Involving at least 4 of the following
symptoms :
 Diagnostic Criteria – DSM IV

• Often loses temper • Often shifts blame to

• Often argues with others
• Often touchy or easily
adults
annoyed
• Often defies adult
• Often angry & resentful
requests & rules
• Often deliberately • Often spiteful or
annoys others vindictive
 Oppositional Defiant Disorder
• Epidemiology
- prevalence in general population
* about 1.5 %
- male : female ratio
* 2 : 1 to 3 : 1
- peak age of onset
* early childhood
- onset after age 10 years
* unusual
 Oppositional Defiant Disorder
• Course
* symptoms persist to adulthood
- in up to 14 %
* association with CD
- is strong
* 56 % shows improvement
- with psychotherapy
 Management
• Individual Psychotherapy
- to restore self-esteem
• Behaviour modification
- reinforce & praise appropriate behaviours
• Counsel parents
• Parenting skills
• Social skills training
- learn new strategies to develop sense
of success in social situations