The difficult child

Sue Hawkridge: Behavioural problemsBernice Castle: Struggling academicallyLee Theron: Substance abuseSymposium: How to manage children and adolescents with mental health problems (2)

Sue HawkridgePrincipal Specialist: CAMHS Metro EastDepartment of Psychiatry, Stellenbosch UniversityE-mail: smh@sun.ac.za Management of behavioural problemsMeaning what, exactly?Infants: Excessive crying, irregular sleep patterns, fussy feeding, hard to soothe, colickyToddlers & preschoolers: Oppositionality, tantrums, power struggles, separation issuesPrepubertal: Dissatisfied, disobedient, always in conflict, unpopular, dishonest, cheekyAdolescence: Rebellious, sex & substances, neglecting school work, moody, aggressive, risk-taking behaviour

BEHAVIOUR MEANS SOMETHINGCauses?Normal developmental stageTemperament/temperamental mismatchReaction to external stressorsGeneral medical conditionInappropriate parentingParental psychopathology Psychiatric disorder in the childDevelopmental stageInfancy: Adaptation to childs routine by parent, reduction of anxiety in parent(s)Toddler: Basic job description autonomyPreschooler: Separation issues, sibling rivalryPrepubertal: Negotiating success/failure/statusAdolescence: Peer group primacy, separation from parents, individuality, romantic relationships, future plansSibling rivalryAggression towards sibling(s)Feelings of displacementPerceptions of favouritismNeed of any child to feel special & best-belovedFormulation and acceptance of underlying feelings, reassurance, establishment of fair rules, alternative methods of communicationTemperamentBiological regularity sleeping/eating/etc.Activity levelApproach/withdrawalAdaptabilityThreshold and intensity of responseMood qualityDistractibility, attention span and perseveranceExternal stressorsUnmet basic needs: food, shelter, contactUnder-/over-stimulated/uncontainedLoss of attachment figures/parental conflictChaotic household/inconsistent disciplineAbuse (physical, sexual or emotional)Inappropriate/inadequate educational systemCommunity instability/violenceGeneral medical conditionsIntrinsic to disorder/treatment/reactionChronic hunger/illness with fatigue & irritabilityAnxiety-provoking illnesses: cardiac, respiratoryDisfiguring conditions: fear & anger Endocrine disordersCNS disorders: e.g., delirium, seizure disorders Substance/medication-inducedParental pathologyIgnorance/cognitive impairment: inappropriate expectationsPersonality pathology: especially cluster BSubstance abuseMood disordersAnxiety disordersPsychosisSome parents aren't quite up to it!

Psychiatric disorders in the childReactive attachment disorderDevelopmental disorders: global, specific and pervasiveDisruptive behavioural disordersAnxiety disorders, especially PTSDMood disordersEating disordersPsychotic disordersAttention deficit / hyperactivity disorderImpaired attention and concentrationExcessive motor activity levelImpulsivityDifficulties at home and schoolDisciplinary conflictsNegative spiralSelf esteem damage in child and parentsAppropriate treatment may improve all facetsDefinitely not my dog...

Oppositional defiant disorderArgumentative, resentful and unhappyOften provoke conflictUnpopular and feel unlovedDisobedient on principleFrequently dysthymic/depressedFamily approach usually helpful; may need individual treatment for comorbid disordersCreative oppositionality?

Isolated antisocial symptomsStealing: comfort stealing, buying friends, feelings of deprivationTruanting: learning disorders, anxiety disorders, school-related stressors, etc.Arson: curiosity, mental retardation, conduct disorderVandalism: peer group pressure, anger, envyConduct disorderViolation of major societal normsVulnerable to depressive disorders and substance abuseOften comorbid learning disordersUsually severe family pathology presentEarly psychosocial intervention is crucial Management of comorbidityPaediatric Bipolar disorderVery difficult diagnosis to make in prepubertal childrenUse of second generation antipsychotics and mood stabilisers widespread in USA for children with severely disruptive behaviour limited efficacy and significant adverse effectsDanger of overlooking other pathology or family issuesBipolar disorder does occur in a small number of children and a larger number of adolescents, and requires psychiatric assessment and management

General principlesThorough medical and developmental historyAscertain onset, extent and course of symptomsIdentify medical and/or psychiatric conditions and manage/refer appropriatelyIdentify parental psychopathology and manage/refer appropriatelyIdentify family process problems and refer20The hazards of a non-holistic approach

Medication in behavioural disordersNot as first line treatment except for methylphenidate in children with clear AD/HDSpecialists may use antipsychotic medications and/or mood stabilisers as a last resort in behavioural disordersPrescription of an antipsychotic medication as a first line treatment for a disruptive child is not good practiceSignificant adverse effects require strong clinical grounds for use, an acceptable evidence base in that specific disorder in that specific age group, and a favourable risk:benefit ratioAfter accurate assessment and diagnosis, first line of treatment is referral to good parenting skills resource unless medication is strongly indicatedStimulant treatment of AD/HDMethylphenidate regarded as a first line treatment (MTA study) but...MUST be part of multimodal management if at all possibleAssistance of clinical psychologist, education professionals, occupational therapist, parenting skills counsellors, other mental health professionals for parents if neededCardiovascular concerns: increased risk of sudden death in younger patients as well as olderSubstance abuse: risk mediated by conduct disorderGrowth retardation: remains a concern monitoringLong acting formulations usually preferredNon-stimulant treatment of AD/HDAtomoxetineOther adrenergic agonists: clonidine etcEfficacy in AD/HD symptom reduction, longer onset time, also has cardiovascular side effectsAlternative/natural medications evidence base is still scantyUse of antipsychotic medications in behavioural disordersNot the first line treatment in any accepted protocolMost evidence is in children with developmental disordersSome evidence for reduction of impulsive aggression, not premeditated aggressive behaviourSerious concerns around rapid-onset metabolic side effects: lipograms, glucose metabolism, weight increaseHyperprolactinaemia/neuroleptic malignant syndromeCognitive effectsIf regarded as necessary, should be used in consultation with child psychiatrist if possibleMood stabilisers in behavioural disordersOnly with adequate evidence of a mood disorder (bipolar disorder, severe depression) or impulsive aggression associated with PTSDSide effect profiles cause for concern:Valproate hepatic dysfunction, ?polycystic ovary syndromeLamotrigine dermatologicalLithium renal and thyroid

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