Behavioural problems in
children.
G Mustafa.
Case 1

Richard 12 yr old boy found to be missing school

You have done the physical examination and ruled
out any organic cause for his symptoms – none found.
It this a case of school refusal or truancy?
Can u identify factors contributing to his behavioural
problem?
How would you go about managing this case?.



Factors contributing to Richard’s
behaviour.
Anxiety disorder
in mother
Maternal over
protection
and over concern.
Weak marital
relationship
of his parents.
SEPERATION ANXIETY
leading to school refusal.
Over closeness
and
over dependence
on mother
Inadequate support
to mother
from his father.
School Non-attendance.








10% absent from school at any one time.
Children do not attend school for a variety of reasons
not all related to mental health issues.
Physical illness – commonest cause
Parental withholding
Truanting – staying away from school without the
school or parents know anything about it.
School refusal - difficulty attending school due to
emotional stress.
Wilful or deliberate non-attendance
Children can be off because of a variety of above.
2 Big groups of non-attenders
SCHOOL REFUSAL.
 Severe emotional ,may include
anxiety , somatic symptoms or
temper tantrums.

Child remains symptoms free
during weekends and holidays.

Parents aware child’s absence

No significant anti-social
behaviour like fighting and
offending

Child feels safe at home and
might be happy to do school work
at home.
TRUANCY
 Lack of anxiety or fear
about attending school.
 Child conceals absence from
school
 Frequently shows disruptive
problems such as stealing,
fighting, lying) often in
company of antisocial peers.
 Lacks interest in school
work and doesn’t stay at
home.
Interesting observations.




Berg et al. (1993)– 80 children aged 13-15 who did
not attend school for at least 40% of school term.
Outcome: half the sample had no significant
psychiatric problems, 1/3rd had disruptive behaviour
disorder, 1/5th had severe anxiety or depressive
disorder.
Bools et al (1990)- 100 school refusal cases, = half
met criteria for psychiatric problems
boys = girls
Any age but peaks at school entry age then at transfer
to secondary school and in adolescence .
Causes of school refusal.
Separation anxiety :
- Most common cause
Common in younger age
Can have somatic symptoms
Social phobia:
– Common in older children
- Have more severe school refusal.
Other disorders:
GAD or depression – seen mostly in adolescents
Specific phobias e.g.. Public transport.
Oppositional defiant behaviour. (ODD)
Causes for separation anxiety in school
refusal cases.
Negative re-enforcement
Positive re-enforcement
Avoidance of negative
emotions.
( stress, anxiety,
depression)
Obtaining attention
from significant others
(parents)
Escape from evasive
social situations
( bullying)
or evaluative situations
( interaction with others /
teachers)
Seeking tangible
re-enforcement
or rewards
(watching TV, sleeping)
Management of school refusal.
CBT session for child and family, followed by gradual return
to school
 Education and support treatment - parents
 Three pronged approach in most cases :
1- Liaison with school to implement gradual re introduction.
2- Individual interventions. i.e CBT
3- Family work to address specific family issues and assist
family to cope with developmental challenges.
 Home tutoring as a last resort . Think about pupil referral units
and ultimate re-integration into school.

Management (cont.)
Referral to paediatrician
 Referral to CAMHS
 Referral to EWO (Educational Welfare Officer, also called
educational social worker)
 Some areas have local tutorial units ( pupil referral units)
 Usefull sites for parents / carers :
www.ace-ed.org.uk
www.youngminds.org.uk
www.schoolrefuser.org.uk

Reference : WHO guide to mental and neurological health in primary care
Case studies in child and adolescent mental health – MS Thambirajah
oxford specialist handbook – child and adolescent psychiatry.
CASE 2




Dylan, 8yr old, suspended from school for
abusive and aggressive behaviour
What condition would his behaviour fit into?
What risk factors can you identify for his
behavioural problem?
What advice and management can you think
of?
CASE 2 cont.
Risk factors for Dylan's behaviour:
 Poor or non existent family network or support.
 Inadequate supervision at home
 Exposure to media violence due to lack of
supervision
 Lack of consistency in parenting styles due frequent
changes in care givers – mum ,dad, carers
 Family h/o of ASB and substance abuse.
CASE 2 (cont.)
Management plan :
 Parental Education – very important.
 Reduction of risk factors which have been identified.
 Consistent management of Dylan's violent and
aggressive behaviour across school and home.
 Regular meetings with mother and his school.
 A formal cognitive assessment to identify gaps in
development
 Parent management training and other psychological
interventions.
Case 3
6 yr old boy with mum concerned about his
behaviour since early childhood, now school
has been complaining about his behaviour.
1- What's the diagnosis doctor!
2- Identify the risk factors?
3- How would you manage him ?
Oppositional Defiance Disorder
(ODD) & Conduct Disorder ( CD)
DSM IV
ODD






Markedly defiant and
disobedient and provocative
behaviour.
Active defiance of adult
requests or rules.
Deliberately annoying
people.
Angry, resentful and easily
annoyed by other people
Blaming other people
Loose temper readily.
CONDUCT DISORDER






Aggression to people – bullying
threatening, intimidating,
initiating physical fights
Using weapons to cause
damage,
Deceitfulness and theft
Destruction of property,
intentional fires.
Serious rule violations – staying
out at night, running away from
home, truancy.
Forcing others into sexual
activity
Characteristics of ODD.

Control :
-
Intractable and difficult to control
Conflicts at bedtime and meal times.
Food refused and thrown around the room.
Prolong tantrums several times / day.
Conflicts around getting ready for school.
Aggression :
Verbal if they can talk,
Physical mainly aimed at parents, rarely others,
Frustration results in immediate attack. This may
result in the child being isolated and found
unacceptable.
-
-

-
-
Characteristics of ODD

Activity:
– Child restless and difficult to settle since birth,
Feeding is usually a problem,
Lack of concentration or paying attention
Anxiety -Panic reaction when mum out of site.
Breath holding attacks –(18mnth – 4 yrs) hold
breath at culmination of tantrum, response to
frustration. In minority can result to LOC and brief
convulsion adds to parental anxiety
Aetiology and risk factors.
Biological :
- Familial clustering of ODD, CD, ADHD and
substance use disorder.
- Deficient nutrition and vitamins.
- Abnormalities in prefrontal cortex.
- Physical illness affecting CNS.
- Adverse temperamental characters from birth.
Psychological factors.
- Deficient social learning and information processing.
- Reading problems.
Aetiology and risk factors.
Social factors
- Low socioeconomic status
- Peer relationship difficulties.
- Parental mental health issues.
- Parental drug abuse and criminality.
- Parental disharmony, family dysfunction.
- Erratic harsh discipline, rejection, low parental
involvement in child’s activities.
- Child maltreatment neglect and abuse.
Assessment.
Clinical interview with parents:
Description of current problem
Developmental history of child
Medical history and physical examination
Parenting behaviour
Social history
Consider ethnic and cultural issues
Interview with child or adolescent:
Child may not perceive their behaviour as a problem . Build a
working relationship with the young person.
Observe child – parent relationship
Assessment.
Collateral information:
From teachers, others in regular contact with the young person,
social worker, health visitor etc.
Psychological and neuropsychological assessments
Specific questionnaires and rating scales.
- Child behavioural check list
- Conner's parent and teacher rating scales.
- Eyberg child behaviour inventory
Differential diagnosis and presence of co-morbidities
- ADHD
Mental retardation
PTSD, adjustment disorder, anxiety disorders
Depression, psychoses
Management
Depends on severity and how disabling it is.
 Practical behavioural advice : change in parental behaviour –
reward good behaviour, ignore or succeed in not giving
attention to ‘bad’ behaviour
- Negative reinforcement trap – parental command  child
refuses to comply and protests parent may give in or give up
to stop child from protesting or complete task in a more timely
manner  child learns loud protest and defiance are effective
in overcoming undesirable parental directions.
- Positive reinforcement trap – child misbehaves  frequent ,
effective parental attention ( which otherwise would be
considered as normal and good parenting ) a powerful
reward to a difficult child.

Management

-
-
-
Parent management training :
Supported by substantial evidence.
NICE recommends group based parent training.
Focuses more on parents, addressing parental ,
family, community issues.
Daily behaviour charts and establishing points
systems.
40 – 50% parents drop out for a variety of reasons.
Also service is not widely available
Management
Other psychological interventions :
- Individual behavioural therapy, CBT.
- school based interventions, family therapy.
- No evidence to support effectiveness so far.
 Social measures – support with housing
applications.
 Not much role for medication
Reference:
Case studies and child and adolescent mental health, MS Thambirajah
Oxford specialist handbook in child and adolescent psychiatry.
Where do we fit in?






Validate parents concern.
Assess and refer for diagnosis and treatment.
Collaborate with regional CAMHS for a
consistent approach.
Monitor and support the family.
Ensure programmes are consistently conducted
by carers.
Assist with referral and coordination of other
services needed.