Symposium: How to manage children and adolescents with mental health problems (2)
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1 Symposium: How to manage children and adolescents with mental health problems (2) Sue Hawkridge: Behavioural problems Bernice Castle: Struggling academically Lee Theron: Substance abuse
2 Management of behavioural problems Sue Hawkridge Principal Specialist: CAMHS Metro East Department of Psychiatry, Stellenbosch University
3 Meaning what, exactly? Infants: Excessive crying, irregular sleep patterns, fussy feeding, hard to soothe, colicky Toddlers & preschoolers: Oppositionality, tantrums, power struggles, separation issues Prepubertal: Dissatisfied, disobedient, always in conflict, unpopular, dishonest, cheeky Adolescence: Rebellious, sex & substances, neglecting school work, moody, aggressive, risk-taking behaviour BEHAVIOUR MEANS SOMETHING
4 Causes? Normal developmental stage Temperament/temperamental mismatch Reaction to external stressors General medical condition Inappropriate parenting Parental psychopathology Psychiatric disorder in the child
5 Developmental stage Infancy: Adaptation to child s routine by parent, reduction of anxiety in parent(s) Toddler: Basic job description autonomy Preschooler: Separation issues, sibling rivalry Prepubertal: Negotiating success/failure/status Adolescence: Peer group primacy, separation from parents, individuality, romantic relationships, future plans
6 Sibling rivalry Aggression towards sibling(s) Feelings of displacement Perceptions of favouritism Need of any child to feel special & best-beloved Formulation and acceptance of underlying feelings, reassurance, establishment of fair rules, alternative methods of communication
7 Temperament Biological regularity sleeping/eating/etc. Activity level Approach/withdrawal Adaptability Threshold and intensity of response Mood quality Distractibility, attention span and perseverance
8 External stressors Unmet basic needs: food, shelter, contact Under-/over-stimulated/uncontained Loss of attachment figures/parental conflict Chaotic household/inconsistent discipline Abuse (physical, sexual or emotional) Inappropriate/inadequate educational system Community instability/violence
9 General medical conditions Intrinsic to disorder/treatment/reaction Chronic hunger/illness with fatigue & irritability Anxiety-provoking illnesses: cardiac, respiratory Disfiguring conditions: fear & anger Endocrine disorders CNS disorders: e.g., delirium, seizure disorders Substance/medication-induced
10 Parental pathology Ignorance/cognitive impairment: inappropriate expectations Personality pathology: especially cluster B Substance abuse Mood disorders Anxiety disorders Psychosis
11 Psychiatric disorders in the child Reactive attachment disorder Developmental disorders: global, specific and pervasive Disruptive behaviour disorders Anxiety/mood disorders Eating disorders Psychotic disorders
12 Reactive attachment disorder Pathological care causing inability to attach Inhibited type: ignore others, failure to mix with peer group, unable to establish trusting relationships Disinhibited type: indiscriminate attachment, inappropriate degree of intimacy, clinging to adult figures Insecure attachment : ambivalent behaviour
13 Mental retardation Delayed development Passage through normal stages at later age Takes longer to learn appropriate behaviour Intense emotions may be expressed physically Self-stimulating/soothing behaviour Difficult to manage because child is larger Parents may be unable to accept diagnosis
14 Specific developmental disorders May affect child s ability to understand adults Affect child s ability to comply School system may increase stress Targeting by peers/teachers/parents Poor self esteem leading to depression/anxiety Poor verbal skills lead to acting out of distress
15 Pervasive developmental disorders Autistic disorder : unable to attach in any mutual way, resistant to change, outbursts Autistic spectrum disorders: Fluctuating, intense anxiety Aggressive outbursts Irrational, unpredictable behaviour Undiagnosed Asperger s disorder in older children: lack of social skills
16 Attention deficit / hyperactivity disorder Impaired attention and concentration Excessive motor activity level Difficulties at home and school Disciplinary conflicts Negative spiral Self esteem damage in child and parents Appropriate treatment may improve all facets
17 Oppositional defiant disorder Argumentative, resentful and unhappy Often provoke conflict Unpopular and feel unloved Disobedient on principle Frequently dysthymic/depressed Family approach usually helpful; may need individual treatment for comorbid disorders
18 Isolated antisocial symptoms Stealing: comfort stealing, buying friends, feelings of deprivation Truanting: learning disorders, anxiety disorders, schoolrelated stressors, etc. Arson: curiosity, mental retardation, conduct disorder Vandalism: peer group pressure, anger, envy
19 Conduct disorder Violation of major societal norms Vulnerable to depressive disorders and substance abuse Often comorbid learning disorders Usually severe family pathology present Early psychosocial intervention is crucial Management of comorbidity
20 Personality pathology Not diagnosed as disorder under 18 years or in presence of major psychiatric illness Borderline traits: recurrent self-destructive behaviour, promiscuity, substance abuse, mood swings Antisocial personality traits: 1/3 of children with conduct disorder
21 Anxiety disorders Separation anxiety disorder, OCD, panic disorder, GAD, PTSD, social or specific phobia Symptoms may cause family conflict Younger children may express anxiety through disruptive behaviour/tantrums/clinging Vulnerable to later substance abuse Effective treatment & psychoeducation
22 Depressive disorders Irritable mood; oppositional, self destructive and clinging behaviour Poor performance at school Social isolation In adolescents may resemble conduct disorder or borderline personality pathology Effective treatment, including family intervention
23 Paediatric Bipolar disorder Very difficult diagnosis to make in prepubertal children Use of second generation antipsychotics and mood stabilisers widespread in USA limited efficacy and significant adverse effect profiles Danger of overlooking other pathology or family issues Bipolar disorder does occur in a small number of children and a larger number of adolescents and requires psychiatric assessment and management
24 Eating disorders Major battle ground in the toddler wars Recurrence in pre-puberty/adolescence Anorexia nervosa/bulimia May be related to drive for autonomy Peer group and cultural influence need for acceptance Usually require specialist intervention
25 Psychotic disorders Symptoms usually of recent onset Aberrant behaviour causes family friction Unexplained poor academic performance Social withdrawal in schizophrenia Manic episodes may embarrass family or cause legal complications Effective treatment and family psychoeducation
26 General principles Thorough medical and developmental history Ascertain onset, extent and course of symptoms Identify medical or psychiatric conditions and manage/refer appropriately Identify parental psychopathology and manage/refer appropriately Identify family process problems and refer
27 Medication in behavioural disorders Not as first line treatment except for methylphenidate in children with clear AD/HD Specialists may use antipsychotic medications and/or mood stabilisers as a last resort in behavioural disorders Prescription of an antipsychotic medication as a first line treatment for a disruptive child is not good practice Significant 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 ratio After accurate assessment and diagnosis, first line of treatment is referral to good parenting skills resource unless medication is strongly indicated
28 Stimulant treatment of AD/HD Methylphenidate regarded as a first line treatment (MTA study) but... MUST be part of multimodal management if at all possible Assistance of clinical psychologist, education professionals, occupational therapist, parenting skills counsellors, other mental health professionals for parents if needed Cardiovascular concerns: increased risk of sudden death in younger patients as well as older Substance abuse: risk mediated by conduct disorder Growth retardation: remains a concern monitoring Long acting formulations usually preferred
29 Non-stimulant treatment of AD/HD Atomoxetine Other adrenergic agonists: clonidine etc Efficacy in AD/HD symptom reduction, longer onset time, also has cardiovascular side effects Alternative/ natural medications evidence base is still scanty
30 Use of antipsychotic medications in behavioural disorders Not the first line treatment in any accepted protocol Most evidence is in children with developmental disorders Some evidence for reduction of impulsive aggression, not premeditated aggressive behaviour Serious concerns around rapid-onset metabolic side effects: lipograms, glucose metabolism, weight increase Hyperprolactinaemia/neuroleptic malignant syndrome Cognitive effects If regarded as necessary, should be used in consultation with child psychiatrist if possible
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