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Anna Freud National Centre for Children and Families
Conduct Disorders in Alternative Education
Brenda McHugh
TBAP Conference 2018
s
“Conduct disorders are characterised by repetitive and persistent patterns of antisocial, aggressive or defiant behaviour that amounts to significant and persistent violations of age-appropriate social expectations” NICE
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Anna Freud National Centre for Children and Families
MISSED OPPORTUNITIESCentre for Mental Health 2016
Three quarters of parents of children with a mental health problem seek help
One quarter of children get help
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Anna Freud National Centre for Children and Families
Mental Health problems seen in specialist services1. Anxious away from care givers (Separation anxiety)
11.Extremes of mood (Bipolar disorder)
21.Family relationship difficulties
2. Anxious in social situations (Social anxiety/phobia)
12. Delusional beliefs and hallucinations (Psychosis)
22. Problems in attachment to parent/carer (Attachment problems)
3. General anxiety (generalised anxiety)
13. Drug and alcohol difficulties (Substance abuse)
23. Peer relationship difficulties
4. Compelled to do or think things (OCD)
14. Difficulties sitting still or concentrating (ADHD/Hyperactivity)
24. Persistent difficulties managing relationships with others (includes emerging personality disorder)
5. Panics (Panic Disorder) 15. Behavioural difficulties (CD or ODD)
25. Does not speak (selective mutism)
6. Avoids going out (Agoraphobia) 16. Poses risk to others 26. Gender discomfort Issues (GID)
7. Avoids specific things (Specific phobia)
17.Carer management of CYP behaviour (e.g. management of child)
27. Unexplained physical symptoms
8. Repetitive problematic behaviours (Habit problems)
18. Doesn’t go to the toilet in time (Elimination problems)
28. Unexplained developmental difficulties
9. Depression/low mood (Depression) 19. Disturbed by traumatic event (PTSD)
29.Self-care issues (includes medical care management, obesity)
10.Self-harm (Self injury or self-harm)
20.Eating issues (Anorexia/Bulimia) 30. Adjustment to health issues4
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Anna Freud National Centre for Children and Families
1. Anxious away from care givers (Separation anxiety)
11.Extremes of mood (Bipolar disorder)
21.Family relationship difficulties
2. Anxious in social situations (Social anxiety/phobia)
12. Delusional beliefs and hallucinations (Psychosis)
22. Problems in attachment to parent/carer (Attachment problems)
3. General anxiety (generalised anxiety)
13. Drug and alcohol difficulties (Substance abuse)
23. Peer relationship difficulties
4. Compelled to do or think things (OCD)
14. Difficulties sitting still or concentrating (ADHD/Hyperactivity)
24. Persistent difficulties managing relationships with others (includes emerging personality disorder)
5. Panics (Panic Disorder) 15. Behavioural difficulties (CD or ODD)
25. Does not speak (selective mutism)
6. Avoids going out (Agoraphobia) 16. Poses risk to others 26. Gender discomfort Issues (GID)
7. Avoids specific things (Specific phobia)
17.Carer management of CYP behaviour (e.g. management of child)
27. Unexplained physical symptoms
8. Repetitive problematic behaviours (Habit problems)
18. Doesn’t go to the toilet in time (Elimination problems)
28. Unexplained developmental difficulties
9. Depression/low mood (Depression) 19. Disturbed by traumatic event (PTSD)
29.Self-care issues (includes medical care management, obesity)
10.Self-harm (Self injury or self-harm)
20.Eating issues (Anorexia/Bulimia) 30. Adjustment to health issues
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Conditions with recognised evidence-based treatments
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CONDUCT DISORDER WORKSHOP ANNA FREUD CENTRE 200517
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DSM- 5 15 Conduct Disorder Criteria in 4 Categories:
Aggression to people & animals Deceitfulness or theft
1. Often bullies, threatens or intimidates others 2. Often initiates physical fights 3. Has used a weapon that can cause serious physical harm to to others (e.g., a bat, brick, broken bottle, knife, gun) 4. Has been physically cruel to people 5. Has been physically cruel to animals 6. Has stolen whilst confronting a victim 7. Has forced someone into sexual activity
10. Has broken into someone else’s house, building or car 11. Often lies to obtain goods or favors or to avoid obligations (i.e. ‘cons’ others) 12. Has stolen items of non trivial value without confronting a victim
Destruction of property Serious violations of rules
8. Has deliberately engaged in fire setting with the intention of causing serious damage 9. Has deliberately destroyed others’ property (other than by fire setting)
13. Often stays out at night despite parental prohibitions, beginning before age 13 years 14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period 15. Is often truant from school, beginning before age 13 years
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Anna Freud National Centre for Children and Families 8
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Anna Freud National Centre for Children and Families
In an average class of 30 fifteen year-old pupils:
3 could have a mental disorder
10 are likely to have witnessed their parents separate
1 could have experienced the death of a parent
7 are likely to have been bullied
6 may be self-harming
Public Health England (2015)
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Summary of Conduct Disorder Pathways
Paul J. Frick, Ph.D.
Conduct Disorder
Childhood-OnsetSubtype
Primarily ImpulsiveType
Callous-UnemotionalType
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Summary of Conduct Disorder Pathways
Conduct Disorder
Primarily ImpulsiveType
Callous-Unemotional Conduct Disorder.
These characteristics include:Lack of empathy or sensitivity to the feelings of others and a lack of concern for others’ distress;
Lack of remorse, shame or guilt over their own behavior (unless prompted by being apprehended);
Lack of concern over poor performance in school, work, or other important activities;
Limited expression of emotions, particularly positive or loving feelings toward others, or only doing so in ways that seem shallow, insincere, or instrumental;
Relative indifference to the probability of punishment;
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Strong genetic component Professor Essi Viding
• In a large (n=7374) population-based study of 7-year old twins, genetic influences on childhood-onset conduct problems were greater in those high on CU traits (81%), compared to those with normal levels (30%)
• But the environment still matters greatly including the internet. Online life for children has good & bad elements Zimbardo, 2015
CONDUCT DISORDER WORKSHOP ANNA FREUD CENTRE 200517
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Animal StudiesMichael Meaney’s animal studies
Pups experiencing High Levels Licking
Grooming
Decreased startle response
Increased open field exploration
Better adaptation to novel environments
Robust negative feedback in HPA axis
Pups experiencing Low Levels Licking
Grooming
Increased startle response
More anxious in new surroundings
Decreased HPA negative feedback
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Anna Freud National Centre for Children and Families
“Super highway to learning”
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Anna Freud National Centre for Children and Families
Key executive function skills for learning and mental wellbeing
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mentalization
mentalization is the ability to understand the mental state, of oneself or others, that
underlies overt behaviour.
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Anna Freud National Centre for Children and Families 17
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Powerful emotion
Poor mentalising
Inability to understand or even pay attention to feelings of others
Others seem incomprehensible
Frightening, undermining, frustrating, distressing or
coercive interactions
Try to control or change others or oneself
Person 1
Powerful emotion
Poor mentalising
Inability to understand or even pay attention to feelings of others
Others seem incomprehensible
Try to control or change others or oneself
Frightening, undermining, frustrating, distressing or
coercive interactions
Person 2
Vicious Cycles of Mentalizing Problems
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Anna Freud National Centre for Children and Families 19
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Anna Freud National Centre for Children and Families
Wingen et al., (2011)
Amygdala
Anteriorinsula
Children Soldiers
McCrory et al., (2011)
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Amygdala
Cerebral cortex
(reflective thinking and reasoning)
Amygdala carries out threat assessment ‘en route’
In fight/flight/appease situation, amygdala enables ultra-rapid active/reactive thinking and bodily responses
However, it also blocks route to cortex, making reflective
thinking unavailable
Some children will have an over-reactive stress system
and have real difficulties turning off their over-
sensitive alarm systems.
Perception of events is coloured by feelings of threat
and distress, leaving no opportunity to think clearly
Impact of highly-chargedevents on brain function
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Anna Freud National Centre for Children and Families
Executive skills competence and attention skills training
Social information processing- mentalization
Nurtured heart techniques
Sensory processing
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Welcome to SmartGym Attention Skills
Training
Getting Started
on your circuitFitLights
Neurotracker
Cardiowall
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Anna Freud National Centre for Children and Families 24
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Anna Freud National Centre for Children and Families
Kiss your brains
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Anna Freud National Centre for Children and Families 26
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Anna Freud National Centre for Children and Families
Stress Contagion
Staff wellbeing
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Anna Freud National Centre for Children and Families
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Anna Freud National Centre for Children and Families
Management of Stress Contagion
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Crisis support using a de-brief and re-set model using skilled senior staff or external expertise
Regular mandatory wellbeing check-in meetings for all staff using a personal or
peer support model
Staff wellbeing team established and supported to offer regular events
Staff wellbeing policy
Mental health awareness training for all staff
Staff education on Child and Family mental health
Culture of no blame and stigma for mental health needs of school community
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Anna Freud National Centre for Children and Families
Check-in and re-set post incident
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Anna Freud National Centre for Children and Families 31
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Anna Freud National Centre for Children and Families
Toolkit for Alternative Provision
New Pupil Toolkit
- measuring and monitoring
- Pupil support
- Family approach
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Anna Freud National Centre for Children and Families
Who needs help and what works?
1) Taking a snapshot of well-being across pupils
2) Identifying those who might benefit from additional support and
3) Evaluating the effectiveness of that support.
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Anna Freud National Centre for Children and Families
Elements of a whole-school approach
Figure 1: High-level domains that inform measurement of mental health and wellbeing (informed by
PHE publication: Measuring Mental Wellbeing in Children and Young People)
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Anna Freud National Centre for Children and Families
Prevention
Identification
Early and complementary support
Accessing specialist support
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Anna Freud National Centre for Children and Families
Focus on four areas
Prevention – ideally to reduce the incidence of mental
health issues longer term and promote good health and well being.
Identification – to spot emerging issues earlier and more
accurately, facilitating good early support or/and swift referral.
Early and complementary support – to help prevent
problems escalating and/or help the management of problems to reduce adverse impact on other outcomes and avoid crisis situations.
Access to specialist support – to result in swifter access to
the right specialist support and treatment when it is needed and to support engagement in education.
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Anna Freud National Centre for Children and Families
Kids want to know video
https://mindfulschools.us17.list-manage.com/track/click?u=ae4b49988af32d959531de154
Share this video with your students&id=6c9f1d4673&e=f5cec2b784
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Prevention, early intervention, identification and referral
https://www.gov.uk/government/publications/mental-health-and-behaviour-in-schools--2
https://www.gov.uk/government/publications/counselling-in-schools
https://pshe-association.org.uk/resources_search.aspx
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Anna Freud National Centre for Children and Families
Where can you find more information?
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Anna Freud National Centre for Children and Families
http://www.youtube.com/watch?v=yyaVKvuEBkk
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Anna Freud National Centre for Children and Families
Useful Tools Youth Wellbeing Directory
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