Evaluating child with disruptive behaviour

1. Evaluating child with disruptive behaviour
BY DR WASIM
UNDER GUIDANCE OF
DR GUNJAN SOLANKI

2. What is disruptive behaviour?
 Disruptive behaviour in children refers to behaviours that occur
when a child has difficulty controlling their actions.
 This is often in social settings, and can happen for many different
reasons.
 Examples of disruptive behaviours include temper tantrums,
interrupting others, impulsiveness with little regard for safety or
consequences, aggressiveness, or other socially inappropriate acts.
 In younger children, some disruptive behaviours are considered
developmentally normal if they occur some of the time.
 For instance, temper tantrums, seen as periods of intense emotional
expression such as anger or sadness, along with crying or screaming,
would be considered normal in toddlers. As the child develops and
learns to understand their emotions and behaviour, their ability to
control behaviour improves.

3. When does it become a problem?
 Whether a particular behaviour can be considered abnormal depends
on whether that behaviour is to be expected for each child’s
developmental stage.
 For instance, it would be unusual for a developmentally normal 10
year old child to have regular tantrums.
 Likewise, impulsiveness, often seen as distractibility or apparently
thoughtless behaviour without regard for safety or consequences, is
developmentally normal for a 2 year old, but highly unusual for a 12
year old.
 A disruptive behaviour disorder may be present when the disruption
caused by a child’s difficulties with emotional and behaviour control,
is more than what would be considered typical for a child of their age
and developmental level.

4. What Causes Disruptive Behaviour?
Disruptive behaviour can have a number of different causes. These
causes may have biological, psychological, or social factors that help
explain the behaviour.
 Examples of Biological factors include:
1. Difficulties with hearing: leaving a child unable to understand what is
said to them or asked of them;
2. Illness or injury that causes pain: meaning that their usual ability to
control their own emotions and behaviour is affected;
3. Learning impairment or delays in cognitive development: meaning
that a child is less able to understand their world compared to other
children;
4. Difficulties with concentration or attention:, meaning a child is unable
to focus and sustain attention that is out of keeping with normal
concentration for the child’s age;

5.  Examples of Psychological factors include:
1. Being more prone to worry: resulting in the child behaving in a way
that helps them to avoid doing something that is frightening or
anxiety provoking;
2. Children who have experienced significant trauma: avoiding or
hiding from things that bring up their memories of their traumatic
experiences;
3. Children who are prone to worry, arising from traumatic
experiences: always being on the lookout for danger, and possibly
reacting to defend themselves in situations they believe are causing
them threat.
 Examples of Social factors include:
1. Children who have had little opportunity to learn about social rules
being placed in new environments and being expected to follow
rules they do not know;
2. Stress affecting other family members being felt by the children,
who are aware of feelings of tension in the family, but are unable to
put words to it.

6. When do parents need to seek professional help?
 Some disruptive behaviour will disappear without any intervention,
and will not require any change to your parenting style.
 Help should be sought, however, if disruptive behaviours stay for
more than a few weeks, or if the behaviours are causing harm to the
child, or others around the child.
 Harm refers to not just physical injury, but psychological harm, or
harm arising from missing usual activities such as school or other
extracurricular activities.

7. What disorders or illnesses can result in disruptive behaviour?
 Disruptive behaviour can feature in a variety of childhood mental and
behavioural disorders.
 Examples include
 Attention deficit hyperactivity disorder
 Disruptive behaviour disorder
 Post-traumatic stress disorder
 Intellectual disability
 Anxiety & Depression
 Psychosis, Organic brain syndrome…
A comprehensive assessment by a specialist or a child health service will consider all of
the possible contributing factors, and make an appropriate diagnosis to assist with
devising a treatment plan.

8.  Well-replicated findings for disruptive behavior problems.
1) Disruptive behavior problems commonly start before age 2 years
and may persist over many years.
2) In adult life they are associated with criminality; with the
behavioral and social difficulties identified as DSM Antisocial
Personality Disorder; and with psychiatric disorders such as
substance misuse and depression.
3) Rates of antisocial and delinquent behaviors increase markedly
during adolescence and fall in adult life.
4) Between 50% and 70% of children with disruptive behavior
problems show improvement during childhood, but some
continue to have adjustment problems.
5) Disruptive behavior problems are more common in boys than in
girls.

9.  Numerous risk factors are associated with childhood disruptive
behavior.
 parental criminality and psychiatric disorders
 prenatal anxiety
 smoking in pregnancy
 Single parent status, marital discord, partner violence, poor parental
supervision, harsh parenting, child physical abuse.
 social deprivation
 neighbourhood violence
 low IQ, language delay, low school achievement,
 large family size, low family income, antisocial peers
 high delinquency-rate schools, and high crime neighbourhoods.
(Murray & Farrington, 2010).

10. How do we approach the these child
Councilor
pediatrician
teacher
parents
Paramedical
staff
Child and adolescent psychiatrist
Referrals

11. Disruptive
Disorders
Affective
Disorders
Psychosis
PTSD
Neurological/
Medical
Child and adolescent psychiatrist:
D.D. and Comorbidity

12. Evaluation of the child
History of child
Classification Criteria
Psychiatric status
Possible Diagnosis according
to probabilities
Specific Rating Scales
Cognitive tests
Continuous
Performance Tests
Specialized tests:
MRI, CT..
Diagnosis and Comorbidity

13. Algorithm for Disruptive behaviour problems

14. Disruptive Behaviour in ADHD
 The first symptoms include:
1. Unregulated sleep and appetite
2. Early motor development
3. Tendency to inattention, a need of parents’ attention and holding
 The most prominent feature: the hyperactivity – impulsivity
 Attention is sometimes very difficult to measure.
 Young children with ADHD exhibit more problem behavior and are
less socially skilled than normal counterparts.

15. Differential Diagnosis
 Difficult temperament
 Children who have been given no clear limits.
 Behavioral disorder or ODD
 Deviations in IQ (talented / retarded).
 Spasms of Petit Mal type.
 Chronic inflammation of the middle ear, antihistaminic
medications.
 Undiagnosed sight and hearing problems.
 Other physical and/or chronic conditions, such as impaired
sight, impaired hearing, hyperthyroid, hypothyroid and
severe anemia.

16. ADHD: Comorbidity
 Preschool children with ADHD are likely to exhibit ODD, anxiety, or
mood disorders.
 Many children with ADHD also show developmental disorders such
as: fine motor skills disorder, language disorder, etc.
Childhood ADHD
 The time factor begins to be critical (before adolescence)
 There is high frequency of comorbidity, which increases with age.

17. Disruptive Behavior Disorders
 The term “disruptive behavior disorders” refers to a broad set of
aggressive, disruptive, oppositional, and anger-related behaviors.
 A core paradox about childhood disruptive behavior problems is that
while they are widely viewed as having social origins, reflecting
parental and societal failures, and so readily amenable to social,
educational, economic or political solutions, they are also among the
most intransigent and harmful of known mental health disorders.
 A review of conceptual issues has to embrace both sides of this
paradox.
 On the one hand many of these problems represent a failure of
socialization in childhood and then in adult life, so that sufferers find
themselves in disadvantageous situations, such as social isolation and
school exclusion in childhood, youth offender institutions in
adolescence and prison in adult life. This socialization process might
be altered by changes in social, educational, or economic conditions.

18.  On the other hand, children with behavioral problems differ from
other children in multiple ways, genetic, temperamental,
physiological and social cognitive, and even early in childhood many
do not gain from improvements in environmental conditions.
 Children who display a broad range of behaviors that bring them into
conflict with their environment.
Age-inappropriate actions and attitudes that violate family
expectations, societal norms, and personal property rights of
others.
 Heterogeneous Behaviors fall along a continuous dimension of
externalizing behavior, which includes a pattern of….
Impulsivity
Over-activity
Defiance
Aggressiveness
Delinquency (*legal term)

19. Prevalence:
General Disruptive Behavior
 50% of preschoolers display disobedience.
 26% of preschoolers destroy property.
 60% of teenagers engage in more than one type of
delinquent behavior.
 Referrals for males outnumber females anywhere from 4:1
to 6:1

20. Prevalence:
Diagnosable Behavior Problems
One of the most common referrals (1/3-2/3 of all
child referrals)
8-12% of children meet specific DSM criteria for
diagnosis of ODD and/or CD

21.  The Disruptive Behavior Disorders might best be described along a
continuum as the emergence of ODD may be a precursor to CD. It is
estimated that ADHD is a co-occurring condition in approximately half
of all children with ODD or CD.
 Although ODD is more common among boys prior to puberty, the
trend does not persists after puberty. The ratio of CD is greater in
males than females. The manifestation of CD is also different
between males and females.
 CD onset in girls is generally prior to adolescence (Keenan, 2010).
 As the following diagram depicts, the possibility of progression exists
with a Disruptive Behavior Disorder. Steiner and Remsing (2007)
indicate that approximately two-thirds of children diagnosed with
ODD will no longer meet diagnostic criteria after three years.
However, earlier onset is three times more likely to progress to CD.
They also report that forty percent of those diagnosed with CD
eventually meet the criteria for Antisocial Personality Disorder .

23.  Etiology
There are a number of factors associated with the cause of Disruptive
Behavior Disorders.
 Biological
 Parent with a diagnosis of:
Alcohol Dependence
Antisocial Personality Disorder
Attention Deficit/Hyperactivity Disorder
Conduct Disorder
Schizophrenia
 Sibling with a Disruptive Behavior Disorder
 ODD: Familial Pattern ODD is more common in families in which at
least one parent has a history of Mood Disorder, ODD, CD, ADHD,
ASPD, or a Substance Related Disorder. ODD is more common in the
families where there is serious marital discord.

24.  CD: Familial Pattern Twin and adoption studies show genetic and
environmental factors.
 Maternal smoking during pregnancy
 Environmental Risk Factors
 Parental rejection/neglect
 Harsh discipline
 Inconsistent parenting/multiple caregivers
 Lack of Supervision
 Large family size
 Single parent status
 Marital discord
 Abuse – emotional, physical or sexual
 Poverty
 Parental criminality & psychopathology
 Drug and alcohol use by parents/caregivers

26.  Early Warning Signs
 Irritable temperament
 Inattentiveness
 Impulsivity
 Defiance of adults
 Poor social skills
 Lack of school readiness
 Coercive interactive style
 Aggression toward peers
 Lack of problem-solving skills

27. Diagnostic Criteria
 Oppositional Defiant Disorder
 Loses temper
 Angry
 Arguing with adults
 Disobedience
 Easily annoyed
 Spiteful
 Blames others for mistakes
 Deliberately annoys others
 The principal subdivision to be made in ODD is between the variety
that appears to progress to CD and the variety that does not.
 Greater severity and early onset of oppositional behavior, frequent
physical fighting, parental substance abuse and low socio-economic
status appear to increase the risk of progression to more severe
antisocial behaviors observed in CD (Dulcan & Loeber, 1995)

28.  Conduct Disorder
Exhibits a pattern of behavior that violates the rights of others
or disregards age-specific social norms
o Deliberately break rules
o Aggressive toward people or animals
o Destructive of property
o Lying and theft
o Violation of rules
Protective factors would include
o Late onset
o Early assessment
o Effective treatment
o The absence of co-occurring disorders
o Negative family history for DBD

29. Angry, argues, easily
annoyed, disobedient,
spiteful, loses temper,
blames others
Violates others’ rights,
physical harm, property
damage, deceitful,
serious violations of
rules
Prognosis Guarded with onset
before age 10 or if more
serious symptoms are
present
Guarded
Risk Factors As an infant was fussy,
reactive or excessive
motor activity
Male, parental
rejection, harsh
parenting, peer
rejection, trauma
Family History
Protective
Factors
Early identification ,
Effective treatment,
Absence of ADHD,
No family history of
DBD
Mild symptoms,
Early Assessment and
Effective, Timely
Treatment,
No co-occurring
Substance Use,
No family history

31.  Differential Diagnosis for Disruptive Behavior Disorders
• In many children, increased negativity and hostility may occur in the
context of a mood or psychotic disorder, and the diagnosis of ODD is
not allowed when the symptoms occur exclusively during the course
of one of these.
• Many children and adolescents who meet the criteria for a diagnosis
of CD or ODD have coexisting psychiatric disorders that may have led
to their disruptive behavior and will influence their responsiveness to
treatment and their long term.

32. Disruptive behaviour in Child with PTSD
SIX GROUP OF SYMPTOMS
1. A communicative style of avoidance: difficulties in forming ties with
people
2. Depressive symptoms
3. A high degree of anxiety (stress syndrome).
4. A high degree of aggressiveness
5. Suicidal tendencies.
6. A more widespread use of primitive defense mechanisms: denial,
projection, interviction (identification with the attacker), regression
and also repression.
The fourth characteristic is the chief one which includes these children
in the category of “difficult children”.

33. Salmon & Bryant (2002): 3 groups of symptoms
PTSD children exhibit 3 groups of symptoms
1. A recurrent experience of the trauma
2. Avoidance characteristics
3. Arousal symptoms such as insomnia, irritability, lack of
concentration and heightened startle response
This third group is what makes the child “difficult”.

34. Disruptive behaviour in ID
 The diagnosis of an intellectual disability (ID) relates to a
heterogeneous group of individuals, approximately 3% of the
population, whose intelligence quotient is <70.
 Behaviour disorders are frequent in children with an ID, can create
problems in everyday life.
 The four most common of behavioural problems: sleep disturbances,
agitation (as it relates to attention-deficit hyperactivity disorder
[ADHD]), aggression and self-injury in ID.
 The prevalence rate of ADHD in the general population is 5%, and
between 9% to 16% in the paediatric population with an ID. The long-
term impact of ADHD is significant in children with an ID, and can
result in anxiety, aggression and social ostracism problems, especially
in adolescents.
 Children with an ID manifest aggressive behaviour more often than
children with average intelligence. In this population, planned
aggressive behaviours are quite rare.

35. References:
 Rutter’s child and adolescent psychiatry 6th edition.
 Disruptive Behaviors in Children and Adolescents (Molly M. Gathright, M.D.Assistant Professor, Laura H. Tyler, PhD, LPC Assistant Professor
Updated 3-31-2014.)
 Ageranioti-Bélanger S, Brunet S, D’Anjou G, Tellier G, Boivin J, Gauthier M. Behaviour disorders in children with an intellectual disability.
Paediatrics & Child Health. 2012;17(2):84-88.

36. THANK YOU