BEHAVIOUR DISORDERS IN CHILDREN AND ADOLESCENTS
Acknowledgements: Most of the information included in this chapter was obtained from the Handbook
of Psychiatry, 2005, Mental Health Information Centre of SA, Department of Psychiatry, University of
Stellenbosch.
Chapter by Professor Susan Hawkridge, Dr Linda Keyter and Dr Bennie Steyn
A. THE “HYPERACTIVE” CHILD AND ATTENTION DEFICIT/HYPERACTIVITY DISORDER
Three groups of children can be distinguished according to temperamental characteristics: easy,
difficult and “slow to warm up”. “Difficult” infants’ biological functions are irregular, they react
negatively to new stimuli, they adapt with difficulty and their expressions of mood are forceful and
often negative. Some of these infants will later meet the criteria for attention deficit/ hyperactivity
disorder (AD/HD).
AD/HD occurs in 3-5% of school going children in the USA, but international studies confirm rates of
around 5% in many countries, including China and India. It occurs more often in boys than girls at a
ratio of 3-5:1. The diagnosis is most often only made when the child starts to attend school.
There is still controversy about AD/HD, particularly in the lay media. Allegations are made of overdiagnosis and over-treatment of this disorder.
Without doubt, there are areas (predominantly wealthy and urban) where the disorder is over- or
misdiagnosed. There are no overall studies of the incidence in South Africa, but it appears that our
children suffer more from under-diagnosis and -treatment, particularly in the rural areas and
underprivileged schools.
The specific causes of this syndrome remain undefined. Significant genetic factors contribute to the
condition, and there are often other family members with the same symptoms.
The diagnosis is made on the basis of history, school report and clinician observation. Excessive
crying, irritability, restlessness and irregular sleeping and eating patterns often mark the infant years
of these children. Associated symptoms during childhood are a low frustration threshold, restless
sleep and oppositional behaviour. Secondary problems may arise, especially when the child begins
to experience problems at school. Comorbid depression, oppositionality or conduct disorder, low self
esteem and poor interpersonal skills can cause the child to become unpopular, isolated and “difficult”.
A vicious circle develops in which the teacher’s interaction with the child is consistently negative – the
child then begins to find school an unpleasant experience. The same pattern develops at home, and
the parents complain that they continually have to limit, scold and punish the child.
The most important comorbid diagnoses are depression, anxiety disorders, specific learning or
developmental disorders, mild mental retardation or borderline intellectual functioning, and in older
children, oppositional defiant disorder, conduct disorder and substance abuse.
When all possible general medical and environmental causes of confirmed symptoms have been
ruled out, and the child meets the diagnostic criteria, a treatment programme must be formulated.
B. OTHER DISRUPTIVE BEHAVIOUR DISORDERS
1. Conduct Disorder
There are several factors that predispose a child to the development of conduct disorder. These
include: scholastic problems, attention deficit/hyperactivity disorder, borderline intellectual functioning,
subtle neurological abnormalities, parents who abuse alcohol or other substances or have antisocial
personality disorder, rejection by parents or child abuse, harsh and inconsistent discipline and chaotic
domestic circumstances. Children who are not raised by their own parents but either in institutions or
by foster parents, with multiple changes of caregiver, are also at greater risk of developing conduct
disorder.
As children grow up they learn, under normal circumstances, to accept the norms of the community.
They do not only do what is enjoyable for them, but learn to obey certain rules and take into account
the interests of other people. In a normal family the child is taught this with love. Social reinforcers of
good behaviour are the smile or hug of the proud parent. When the child errs, this parent can
discipline him without having to hit the child.
2. Isolated behavioural symptoms
a. Aggression
Children are often referred for aggressive behaviour. Three types of problem are encountered:
1.
The child is verbally aggressive
2.
The child hits, kicks, bites or pinches other children or adults
3.
The child has a passive-aggressive attitude towards his parents or other authority figures.
b. Stealing
Children are often referred because they have started stealing money from their mothers’ handbags.
This type of stealing, which usually occurs in younger children, is called “comfort stealing”. It is found
in children who for one or other reason (e.g., maternal illness, birth of a sibling) feel rejected by their
mothers. When the stealing has a clear cause, such as the birth of a sibling, the problem is
interpreted as the child’s attempt to get more love and attention.
When stealing occurs without a clear precipitant, there may be serious family pathology. The parents
may not supply the love, attention and empathy that children need. In some cases it is difficult to bring
about changes in the family, and referral to a social worker, a parent advice centre or even a child
psychiatry unit is preferable.
Another type of stealing seen in young children that can also be placed in this category is the stealing
of money or small toys and articles from friends or at school. Often the child wants to use the money
to treat his friends so that they will like him more. This is usually accompanied by poor self-esteem,
and is considered to be another form of comfort stealing.
When a child begins to steal outside the family and school, or when large sums of money or clear
secondary gain are involved, and particularly when the child is older and well aware of what is right or
wrong, this is a more serious situation, and often the beginning of a severe conduct disorder.
c. Truanting
Children often stay out of school without their parents’ knowledge. These children usually come from
chaotic families with absent or uninvolved parents. It goes without saying that such children do not
find school satisfying. They are often children who perform poorly and suffer from learning problems.
They readily join gangs and often land up in court because of this. Because of their age, they are
extremely vulnerable to exploitation. Early identification of learning problems and AD/HD, as well as
appropriate referral and treatment thereof, is essential in trying to avoid such outcomes.
Truanting must always be carefully differentiated from school refusal, which happens with the
knowledge of the parent. Possible causes include separation anxiety disorder, other anxiety disorders
(e.g., post-traumatic stress disorder, obsessive-compulsive disorder, specific phobias), depressive or
psychotic conditions, problems at school (e.g., bullies, unbearable teasing, unacceptable punishment
methods, repeated academic failure or abuse), substance dependence and general medical
conditions (e.g., temporal lobe epilepsy).
d. Vandalism
Sometimes children who usually behave well will participate in damaging property as a result of peer
group pressure. The group that behaves so destructively is often (but not always) a group of
adolescents from families or environments with multiple social problems, not necessarily including
poverty.
e. Fire setting
By this we do not mean making fires as part of play or from curiosity, but the intentional setting on fire
of property. Children who do this may be mentally retarded, but they are always seriously disturbed.
Other behavioural problems are usually present. Similarly, multiple problems such as alcoholism,
child abuse and crime are often found in the family.
f. Substance abuse
Children who are bored and who grow up in abnormal circumstances or are neglected often
experiment with various drugs. This also occurs in groups of more privileged school children.
3. Oppositional defiant disorder
Opposition and defiance begin when the child realises that he is a separate individual and discovers
that his parents have control over him and can oppose his wishes and actions. Temper tantrums and
challenging behaviour occur normally in the second year, almost as part of the toddler’s “job
description”. As the child’s intellectual capacities develop, he begins to reason and understand how to
get what he wants in a less disruptive manner. After the age of three years he usually realises that life
proceeds more smoothly when he cooperates with his parents.
When parents accept and respect their child as an individual with his own opinions, ideals and needs,
oppositional behaviour should not become a major problem. Conversely, unrealistic expectations,
over-strict control, unsympathetic treatment, etcetera, by the parents will elicit a reaction from any
normal child. In such cases, the parent tries to keep control over the child by acting more harshly.
More resistance ensues and thus a vicious circle is established.
C. SUBSTANCE ABUSE IN CHILDREN AND ADOLESCENTS
In collaboration with Prof WP Pienaar
The causes of substance abuse amongst young people appear to be multifactorial. Psychological
factors are important: often even before the onset of drug abuse the child may have behaviour
problems, poor self-esteem, anxiety disorders, depression and poor self-control. Some of the children
who will later abuse substances are born with a so-called “difficult temperament”.7 Characteristic of
these children are a negative mood, intense response levels, social withdrawal and slow adaptability.
AD/HD, conduct disorder and oppositional defiant disorder are often also present.
Social factors are also important. In particular, the children of substance-abusing parents tend to
begin to use substances themselves.8 Poor parenting skills constitute an independent risk factor.
Cultural attitudes to substance abuse are an important determinant of the ease with which a young
person will begin to use a substance. Drugs are freely available, cheap and may be seen by
teenagers as “cool”. Peer group pressure can significantly influence children’s behaviour. In some of
our communities alcohol abuse amongst teenagers is common and is seen as a normal part of social
activities.9
It remains unclear whether there is continuity between adolescent and adult substance abuse or
whether the condition is usually “outgrown”.17 It is also not yet known which factors determine the
long term outcome of young substance abusers. Longstanding drug use causes the adolescent to
miss out on his normal young life and development, and to become an ill-equipped adult. Because of
the physical, social and psychological damage caused by adolescent drug use, it makes no sense to
delay treatment until the child has become an addicted adult. What is beyond doubt is the fact that
young people can suffer serious, sometimes fatal, short-term consequences of substance abuse (e.g.,
rape with HIV transmission, motor vehicle accidents, physical violence, overdose, etc.).
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