Overview of Behavioral Problems in Child and Adolescent

1. Arifah Nur Istiqomah Departemen/SMF Ilmu Kedokteran Jiwa FK Unpad/RSHS Overview of Behavioral Problems in Child and Adolescent

2. Behavioural Problems Behavioural disorder Normal behaviour Behavioural symptoms

3. Normal Behaviour Emile Durkham (Rules of Sociological Method ) • Child and adolescent behaviour considered as normal as far as behavior does not lead to unrest in society, occurs within certain limits and unintentional

4. Behavioral Disorder • Behavioural symptoms of varying levels of severity are very common in the population. • Onlychildren and adolescents with a moderateto severe degree of psychological, social, educational or occupational impairment in multiple settingsshould be diagnosed as having behavioural disorders WHO Mgap, 2010

5. Behavioral Disorder Behavioural disorders is an umbrella term that includes more specificdisorders: • Attentiondeficit hyperactivitydisorder* • Disruptive behavioral disorder: • Conduct Disorder • Oppositional Behavioral Problems WHO Mgap, 2010

6. Attention Deficit HyperactivityDisorder

7. Attention Deficit HyperactivityDisorder Impaired attention • Breakingoff from tasks and leaving activities unfinished; shiftsfrequently from one activity to another • Diagnosedas a disorder only ifthey are excessive for the child or adolescent’s age and intelligence, and affect their normal functioning and learning WHO mhGAP, 2010

8. Attention Deficit HyperactivityDisorder Overactivity • Excessive restlessness, especially in situations requiring relative calm • Running, jumping around • Gettingup from a seatwhen he or she was supposed to remain seated • Excessivetalkativeness andnoisiness • Fidgetingand wriggling WHO mhGAP, 2010

9. DisruptiveBehavioral Disorders

10. Disruptive Behavioral Disorders These disorders are compelling to understand and treat because: • Common in community • High rates of morbidity • High rates of associated psychiatric illness and psychopathology • Very costly for society Connor MD, 2009

11. Oppositional Deviant Disorder • A recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures • Clearlymore frequent, more intense, and more persistent across the child's development than is typically observed in individuals of similar age and developmental level. • The symptoms cause impairment in the child's social, academic, or occupational functioning Connor MD, 2009

12. Conduct Disorder • Repetitiveand persistent pattern of dissocial, aggressive or defiantconduct • Such behaviour, when at its most extreme for the individual,should be much more severe than ordinary childish mischief or adolescent rebelliousness Connor MD, 2009

13. Interactional Developmental Model Corwin M, 2005

14. Course of Ilness

15. Course of Illness • Symptoms of ADHD persist into adolescence or adult life in approximately 50% of cases. • In the remaining 50 %, they may remit at puberty, or in early adulthood. • In some cases, the hyperactivity may disappear, but the decreased attention span and impulse-control problems persist Connor MD, 2009

16. Course of Ilness • Many youth who exhibit negativistic or oppositional behaviors will find other forms of expression as they mature and will no longer demonstrate these behaviors in adulthood Connor MD, 2009

17. Course of Ilness • Children who develop enduring patterns of aggressive behaviors that begin in early childhood and violate the basic rights of peers and family members, may be destined to an entrenched pattern of conduct disordered behaviors over time Sadock & Sadock, 2007

18. Intervention for Behavioral Problems

19. Intervention • Biological intervention: psychopharmacology • Psychosocial intervention

20. Psychopharmacology Do not use medication in primary care for behavioral problems without consulting a specialist WHO mhGAP, 2010

21. Psychopharmacology ADHD • Stimulant medication Methylphenidate • Non stimulant medication Atomoxetine HCL, venlavaxine, clonidine Sadock & Sadock, 2007

22. Psychopharmacology Disruptive Behavioral Problems: • Focus on impulsivity, affective lability, negative emotions (fear,irritability), explosive aggression • Psychopharmacological interventions are generally palliative and not curative: typical and atypical antipsychotics, mood stabilizers for explosive agression Connor MD, 2009

23. Family Psychoeducation • Consistent about what the child is allowed and not allowed to do • Praise or reward the child after observe good behaviourand respond only to most important problem behaviours; • Avoid severe confrontations or foreseeable difficult situations. • Give clear, simple and short commands that Emphasize whatthe child should do rather than not do. WHO mhGAP, 2010

24. Family Psychoeducation • Never physically or emotionally abuse the child. Makepunishment mild and infrequent compared to praise. • As a replacement for punishment, use short and clear-cut“time out” after the child shows problem behaviour. (temporary separation from a rewarding environment,as part of a planned and recorded programme to modifybehaviour). • Put off discussions with the child until parent become calm. WHO mhGAP, 2010

25. Teacher’s Role • Make a plan on how to address the child’s special educational needs WHO mhGAP, 2010

26. Support for carers • Identify psychosocial impact on carers. • Assess the carer’s needs and promote necessary support andresources for their family life, employment, social activities andhealth arrange for respite care, which means a break now andthen when other trustable caregivers take over temporarily. WHO mhGAP, 2010