looking. To a degree, this kind of behavior is common, especially in children or teenagers, and isn't necessarily a sign of trouble 5.10 LEARNING ACTIVITY 1. Discuss an example of a case study of a child with attention deficit/hyperactivity disorder (ADHD)? ………………………………………………………………………………………………… ………………………………………………………………………………………………… 2. Study the incidence of attention deficit/hyperactivity disorder (ADHD) in children in India? ………………………………………………………………………………………………… …………………………………………………………………………………………………. 5.11 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What are causes of ADHD (Attention Deficit Hyperactivity Disorder)? 2. What are the symptoms of ADHD? 3. What is the difference between ADD (Attention Deficit Disorder) vs. ADHD? 4. Diagnosing ADHD 5. What are ADHD treatment options? Long Questions 1. How is behaviour therapy done in schools? 2. How does behaviour therapy for ADHD work for adults? 3. What Is CBT (Cognitive Behavioural Therapy)? 4. How Does CBT Help People with ADHD? 5. What is Disruptive Mood Dysregulation Disorder B. Multiple Choice Questions 151 1. Behavioral disorders may involve: a. Inattention b. Hyperactivity c. Criminal Activity d. All of these CU IDOL SELF LEARNING MATERIAL (SLM)
2. Children with this form of ADHD are not overly active. a. Combined Inattentive b. Hyperactivity c. Inattentive d. Impulsivity 3. Also known as behavior modification. Involves reinforcing desired behaviors through rewards and praise and decreasing problem behavior by setting limits and consequences. a. Behavioral therapy b. Cognitive Behavioral therapy c. Cognitive Therapy d. Medication Therapy 4. Is a new DSM-5 addition that is characterized by severe and recurrent temper outburst that are grossly out of proportion in intensity or duration to the situation. a. Disruptive Disorder b. Disruptive Mood Dysregulation Disorder c. Social Communication Disorder d. Child Mental Disorder 5. This refers to a diagnosed mental health person that substantially disrupts a child’s ability to function socially, academically, and emotionally. a. Caseness b. Diagnostic system c. Serious emotional disturbance d. Mental Disorder Answers 1-(d), 2-(c), 3-(a), 4-(b), 5-(c) 5.12 REFERENCES Textbook • Lamb, M. E. (Ed.). (2010). The role of the father in child development (5th ed). Hoboken, N.J.: Wiley. • Lovejoy, M. C., Weis, R., O'Hare, E., & Rubin, E. C. (1999). Development and initial validation of the Parent Behavior Inventory. Psychological Assessment. • Lundahl, B. W., Tollefson, D., Risser, H., & Lovejoy, M. C. (2007). A meta-analysis of father involvement in parent training. Research on Social Work Practice. 152 CU IDOL SELF LEARNING MATERIAL (SLM)
• Macfadyen, A., Swallow, V., Santacroce, S., & Lambert, H. (2011). Involving fathers in research. Journal for Specialists in Pediatric Nursing. References: • Parent, J., McKee, L. G., & Forehand, R. (2016). Seesaw discipline: The interactive effect of harsh and lax discipline on youth psychological adjustment. Journal of Child and Family Studies • Paolacci, G., & Chandler, J. (2014). Inside the turk understanding mechanical turk as a participant pool. Current Directions in Psychological Science. • Paolacci, G., Chandler, J., & Ipeirotis, P. G. (2010). Running experiments on amazon mechanical turk. Judgment and Decision Making. • Patterson, G. R. (1982). Coercive family process (Vol. 3). Eugene, OR: Castalia Publishing Company. 153 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT 6: BEHAVIOURAL DISORDERS PART II STRUCTURE 6.0 Learning Objectives 6.1 Introduction 6.2 Assessment with Cognitive Tests 6.3 Psychological Tests 6.4 Specific Syndrome Tests 6.5 Prognosis and Treatment 6.6 Summary 6.7 Keywords 6.8 Learning Activity 6.9 Unit End Questions 6.10 References 6.0 LEARNING OBJECTIVES After studying this unit, students will be able to: • Assess behavioural disorder using Cognitive Testing • Explain Psychological Testing and Specific Syndrome Testing • Explain prognosis and treatment of behavioral disorder 6.1 INTRODUCTION The disruptive behavior disorders are abnormal behaviours that are expressed in many different forms. Such behaviours are usually portrayed as inappropriate among most individuals in a society. They are also called Behavioral Disorders. These behaviours also violate the social norms of others and especially towards their siblings. People “break the rules” a little all the time and children also, and especially the rules that they believe are not as important. Over time, children tend to mature and outgrow these disruptive behaviours. When they do not, psychological evaluation is usually advised as this behavior can lead to other more serious disorders (antisocial personality disorder, etc. 154 CU IDOL SELF LEARNING MATERIAL (SLM)
All children and adolescents act out from time to time—having tantrums, testing boundaries, or questioning rules—especially if they’re overly distressed or tired. In fact, such behavior is an expected part of development in toddlers and young teens. But when behavioral problems disrupt a child’s family, school, and social life, it may indicate a more serious condition. Oppositional defiant disorder and conduct disorder are two types of behavioral disorders in children and teens. Other conditions may have similar symptoms or appear at the same time in a child with behavioral problems, including anxiety and other mood disorders, attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), and autism spectrum disorders. Diagnostic Evaluation To diagnose a behavioral problem in a child or adolescent, an expert trained in childhood development and behavior meets with you and your child to perform a comprehensive evaluation. The first part of the evaluation involves interviews—both individually and together with parents—to assess your child’s background, medical history, and symptoms. When a clinician conducts the diagnostic interview with a child, he or she speaks with the child and observes the child's nonverbal communication, such as facial expressions and posture. You also complete questionnaires to give the team a sense of your child’s behaviours and how they’re affecting daily life. Our clinicians also talk with your child’s teachers and caregivers. After our child and adolescent psychologists, psychiatrists, or developmental–behavioural paediatricians have gathered the information about a child’s behavior, they meet with parents and the child to discuss the diagnosis and treatment options. Our specialists aim to help you understand your child’s behavior and provide you with a treatment plan to meet your child’s—and your family’s—needs. 6.2 ASSESSMENT WITH COGNITIVE TEST Cognitive testing checks for problems with cognition. Cognition is a combination of processes in your brain that's involved in almost every aspect of your life. It includes thinking, memory, language, judgment, and the ability to learn new things. A problem with cognition is called cognitive impairment. The condition ranges from mild to severe. There are many causes of cognitive impairment. They include side effects of medicines, blood vessel disorders, depression, and dementia. Dementia is a term used for a severe loss of mental functioning. Alzheimer's disease is the most common type of dementia. 155 CU IDOL SELF LEARNING MATERIAL (SLM)
Cognitive testing can't show the specific cause of impairment. But testing can help your provider find out if you need more tests and/or take steps to address the problem. There are different types of cognitive tests. The most common tests are: • Montreal Cognitive Assessment (MoCA) • Mini-Mental State Exam (MMSE) • Mini-Cog All three tests measure mental functions through a series of questions and/or simple tasks. Other names: cognitive assessment, Montreal Cognitive Assessment, MoCA test, Mini- Mental State Exam (MMSE), and Mini-Cog Cognitive testing is often used to screen for mild cognitive impairment (MCI). People with MCI may notice changes in their memory and other mental functions. The changes aren't severe enough to have a major effect on your daily life or usual activities. But MCI can be a risk factor for more serious impairment. If you have MCI, your provider may give you several tests over time to check for a decline in mental function. You may need cognitive testing if you show signs of cognitive impairment. These include: • Forgetting appointments and important events • Losing things often • Having trouble coming up with words that you usually know • Losing your train of thought in conversations, movies, or books • Increased irritability and/or anxiety Your family or friends may suggest testing if they notice any of these symptoms. What happens during a cognitive test? There are different types of cognitive tests. Each involves answering a series of questions and/or performing simple tasks. They are designed to help measure mental functions, such as memory, language, and the ability to recognize objects. The most common types of tests are: • Montreal Cognitive Assessment (MoCA) test. A 10–15-minute test that includes memorizing a short list of words, identifying a picture of an animal, and copying a drawing of a shape or object. • Mini-Mental State Exam (MMSE). A 7-10 minute test that includes naming the current date, counting backward, and identifying everyday objects like a pencil or watch. 156 CU IDOL SELF LEARNING MATERIAL (SLM)
• Mini-Cog. A 3-5 minute test that includes recalling a three-word list of objects and drawing a clock. Will I need to do anything to prepare for cognitive testing? You don't need any special preparations for a cognitive test. Are there any risks to testing? There is no risk to having cognitive testing. What do the results mean? If your test results were not normal, it means you have some problem with memory or other mental function. But it won't diagnose the cause. Your health care provider may need to do more tests to find out the reason. Some types of cognitive impairment are caused by treatable medical conditions. These include: • Thyroid disease • Side effects of medicines • Vitamin deficiencies In these cases, cognition problems may improve or even clear up entirely after treatment. Other types of cognitive impairment are not curable. But medicines and healthy lifestyle changes may help slow mental decline in some cases. A diagnosis of dementia may also help patients and their families prepare for future health needs. If you have questions or are concerned about your results, talk to your health care provider. Is there anything else I need to know about cognitive testing? The MoCA test is usually better at finding mild cognitive impairment. The MMSE is better at finding more serious cognitive problems. The Mini-Cog is often used because it is quick, easy-to-use, and widely available. Your health care provider may do one or more of these tests, depending on your condition. 6.3 PSYCHOLOGICAL TEST Psychological tests are written, visual, or verbal evaluations administered to assess the cognitive and emotional functioning of children and adults. Purpose 157 CU IDOL SELF LEARNING MATERIAL (SLM)
Psychological tests are used to assess a variety of mental abilities and attributes, including achievement and ability, personality, and neurological functioning. For children, academic achievement, ability, and intelligence tests may be used as tools in school placement, in determining the presence of a learning disability or a developmental delay, in identifying giftedness, or in tracking intellectual development. Intelligence testing may also be used with teens and young adults to determine vocational ability (e.g., in career counselling). Personality tests are administered for a wide variety of reasons, from diagnosing psychopathology (e.g., personality disorder, depressive disorder) to screening job candidates. They may be used in an educational setting to determine personality strengths and weaknesses. Description Psychological tests are formalized measures of mental functioning. Most are objective and quantifiable; however, certain projective tests may involve some level of subjective interpretation. Also known as inventories, measurements, questionnaires, and scales, psychological tests are administered in a variety of settings, including preschools, primary and secondary schools, colleges and universities, hospitals, outpatient healthcare settings, and social agencies. They come in a variety of formats, including written, verbal, and computer administered. Achievement and ability tests Achievement and ability tests are designed to measure the level of a child's intellectual functioning and cognitive ability. Most achievement and ability tests are standardized, meaning that norms were established during the design phase of the test by administering the test to a large representative sample of the test population. Achievement and ability tests follow a uniform testing protocol, or procedure (i.e., test instructions, test conditions, and scoring procedures) and their scores can be interpreted in relation to established norms. Common achievement and ability tests include the Wechsler intelligence scale for children (WISC-III) and the Stanford-Binet intelligence scales. Personality tests Personality tests and inventories evaluate the thoughts, emotions, attitudes, and behavioral traits that comprise personality. The results of these tests can help determine a child's personality strengths and weaknesses, and may identify certain disturbances in personality, or psychopathology. Tests such as the Minnesota Multiphasic Personality Inventory for Adolescents (MMPI-A) and the Million Pre-Adolescent Clinical Inventory III (M-PACI), are used to screen children for specific psychopathologies or emotional problems. 158 CU IDOL SELF LEARNING MATERIAL (SLM)
Another type of personality test is the projective personality assessment. A projective test asks a child to interpret some ambiguous stimuli, such as a series of inkblots. The child's responses provide insight into his or her thought processes and personality traits. For example, the Holtzman Ink blot Test (HIT) uses a series of inkblots that the test subject is asked to identify. Another projective assessment, the Thematic Apperception Test (TAT), asks the child to tell a story about a series of pictures. Some consider projective tests to be less reliable than objective personality tests. If the examiner is not well-trained in psychometric evaluation, subjective interpretations may affect the evaluation of these tests. Neuropsychological tests Children and adolescents who have experienced a traumatic brain injury, brain damage, or other organic neurological problems, are administered neuropsychological tests to assess their level of functioning and identify areas of mental impairment. Neuropsychological tests may also be used to evaluate the progress of a patient who has undergone treatment or rehabilitation for a neurological injury or illness. In addition, certain neuropsychological measures may be used to screen children for developmental delays and/or learning disabilities. Precautions Psychological testing requires a clinically trained examiner. All psychological tests should be administered, scored, and interpreted by a trained professional, preferably a psychologist or psychiatrist with expertise in the appropriate area. Psychological tests are only one element of a psychological assessment. They should never be used as the sole basis for a diagnosis. A detailed clinical and personal history of the child and a review of psychological, medical, educational, or other relevant records are required to lay the groundwork for interpreting the results of any psychological measurement. Cultural and language differences among children may affect test performance and may result in inaccurate test results. The test administrator should be informed before psychological testing begins if the test taker is not fluent in English and/or belongs to a minority culture. In addition, the child's level of motivation may also affect test results. Preparation Prior to the administration of any psychological test, the administrator should provide the child and the child's parent with information on the nature of the test and its intended use, complete standardized instructions for taking the test (including any time limits and penalties for incorrect responses), and information on the confidentiality of the results. After these disclosures are made, informed consent should be obtained from the child (as appropriate) and the child's parent before testing begins. 159 CU IDOL SELF LEARNING MATERIAL (SLM)
Normal results All psychological and neuropsychological assessments should be administered, scored, and interpreted by a trained professional. When interpreting test results, the test administrator will review with parents what the test evaluates, its precision in evaluation, any margins of error involved in scoring, and what the individual scores mean in the context of overall test norms and the specific background of the individual child. Risks There are no significant risks involved in psychological testing. Parental concerns Test anxiety can have an impact on a child's performance, so parents should not place undue emphasis on the importance of any psychological testing. They should speak with their child before any scheduled tests and reassure them that their best effort is all that is required. Parents can also ensure that their children are well-rested on the testing day and have a nutritious meal beforehand. 6.4 SPECIFIC SYNDROME TEST The American College of Obstetricians and Gynaecologists recommends offering the option of screening tests and diagnostic tests for Down syndrome to all pregnant women, regardless of age. • Screening tests can indicate the likelihood or chances that a mother is carrying a baby with Down syndrome. But these tests can't tell for sure or diagnose whether the baby has Down syndrome. • Diagnostic tests can identify or diagnose whether your baby has Down syndrome. Your health care provider can discuss the types of tests, advantages and disadvantages, benefits and risks, and the meaning of your results. If appropriate, your provider may recommend that you talk to a genetics counsellor. Screening tests during pregnancy Screening for Down syndrome is offered as a routine part of prenatal care. Although screening tests can only identify your risk of carrying a baby with Down syndrome, they can help you make decisions about more-specific diagnostic tests. Screening tests include the first trimester combined test and the integrated screening test. The first trimester combined test 160 CU IDOL SELF LEARNING MATERIAL (SLM)
The first trimester combined test, which is done in two steps, includes: • Blood test. This blood test measures the levels of pregnancy-associated plasma protein-A (PAPP-A) and the pregnancy hormone known as human chorionic gonadotropin (HCG). Abnormal levels of PAPP-A and HCG may indicate a problem with the baby. • Nuchal translucency test. During this test, an ultrasound is used to measure a specific area on the back of your baby's neck. This is known as a nuchal translucency screening test. When abnormalities are present, more fluid than usual tends to collect in this neck tissue. Using your age and the results of the blood test and the ultrasound, your doctor or genetic counsellor can estimate your risk of having a baby with Down syndrome. Integrated screening test The integrated screening test is done in two parts during the first and second trimesters of pregnancy. The results are combined to estimate the risk that your baby has Down syndrome. • First trimester. Part one includes a blood test to measure PAPP-A and an ultrasound to measure nuchal translucency. • Second trimester. The quad screen measures your blood level of four pregnancy- associated substances: alpha fetoprotein, estriol, HCG and inhibin A. Diagnostic tests during pregnancy If your screening test results are positive or worrisome, or you're at high risk of having a baby with Down syndrome, you might consider more testing to confirm the diagnosis. Your health care provider can help you weigh the pros and cons of these tests. Diagnostic tests that can identify Down syndrome include: • Chorionic villus sampling (CVS). In CVS, cells are taken from the placenta and used to analyse the fetal chromosomes. This test is typically performed in the first trimester, between 10 and 13 weeks of pregnancy. The risk of pregnancy loss (miscarriage) from a CVS is very low. • Amniocentesis. A sample of the amniotic fluid surrounding the foetus is withdrawn through a needle inserted into the mother's uterus. This sample is then used to analyse the chromosomes of the foetus. Doctors usually perform this test in the second trimester, after 15 weeks of pregnancy. This test also carries a very low risk of miscarriage. Preimplantation genetic diagnosis is an option for couples undergoing in vitro fertilization who are at increased risk of passing along certain genetic conditions. The embryo is tested for genetic abnormalities before it's implanted in the womb. 161 CU IDOL SELF LEARNING MATERIAL (SLM)
Diagnostic tests for new-borns After birth, the initial diagnosis of Down syndrome is often based on the baby's appearance. But the features associated with Down syndrome can be found in babies without Down syndrome, so your health care provider will likely order a test called a chromosomal karyotype to confirm diagnosis. Using a sample of blood, this test analyses your child's chromosomes. If there's an extra chromosome 21 in all or some cells, the diagnosis is Down syndrome. Down syndrome Down syndrome is a genetic disorder caused when abnormal cell division results in an extra full or partial copy of chromosome 21. This extra genetic material causes the developmental changes and physical features of Down syndrome. Down syndrome varies in severity among individuals, causing lifelong intellectual disability and developmental delays. It's the most common genetic chromosomal disorder and cause of learning disabilities in children. It also commonly causes other medical abnormalities, including heart and gastrointestinal disorders. Better understanding of Down syndrome and early interventions can greatly increase the quality of life for children and adults with this disorder and help them live fulfilling lives. Symptoms Each person with Down syndrome is an individual — intellectual and developmental problems may be mild, moderate or severe. Some people are healthy while others have significant health problems such as serious heart defects. Children and adults with Down syndrome have distinct facial features. Though not all people with Down syndrome have the same features, some of the more common features include: • Flattened face • Small head • Short neck • Protruding tongue • Upward slanting eye lids (palpebral fissures) • Unusually shaped or small ears • Poor muscle tone • Broad, short hands with a single crease in the palm 162 CU IDOL SELF LEARNING MATERIAL (SLM)
• Relatively short fingers and small hands and feet • Excessive flexibility • Tiny white spots on the coloured part (iris) of the eye called Bushfield’s spots • Short height Infants with Down syndrome may be average size, but typically they grow slowly and remain shorter than other children the same age. Intellectual disabilities Most children with Down syndrome have mild to moderate cognitive impairment. Language is delayed, and both short and long-term memory is affected. Causes Human cells normally contain 23 pairs of chromosomes. One chromosome in each pair comes from your father, the other from your mother. Down syndrome results when abnormal cell division involving chromosome 21 occurs. These cell division abnormalities result in an extra partial or full chromosome 21. This extra genetic material is responsible for the characteristic features and developmental problems of Down syndrome. Any one of three genetic variations can cause Down syndrome: • Trisomy 21. About 95 percent of the time, Down syndrome is caused by trisomy 21 — the person has three copies of chromosome 21, instead of the usual two copies, in all cells. This is caused by abnormal cell division during the development of the sperm cell or the egg cell. • Mosaic Down syndrome. In this rare form of Down syndrome, a person has only some cells with an extra copy of chromosome 21. This mosaic of normal and abnormal cells is caused by abnormal cell division after fertilization. • Translocation Down syndrome. Down syndrome can also occur when a portion of chromosome 21 becomes attached (translocated) onto another chromosome, before or at conception. These children have the usual two copies of chromosome 21, but they also have additional genetic material from chromosome 21 attached to another chromosome. There are no known behavioral or environmental factors that cause Down syndrome. Is it inherited? Most of the time, Down syndrome isn't inherited. It's caused by a mistake in cell division during early development of the foetus. 163 CU IDOL SELF LEARNING MATERIAL (SLM)
Translocation Down syndrome can be passed from parent to child. However, only about 3 to 4 percent of children with Down syndrome have translocation and only some of them inherited it from one of their parents. When balanced translocations are inherited, the mother or father has some rearranged genetic material from chromosome 21 on another chromosome, but no extra genetic material. This means he or she has no signs or symptoms of Down syndrome, but can pass an unbalanced translocation on to children, causing Down syndrome in the children. Risk factors Some parents have a greater risk of having a baby with Down syndrome. Risk factors include: • Advancing maternal age. A woman's chances of giving birth to a child with Down syndrome increase with age because older eggs have a greater risk of improper chromosome division. A woman's risk of conceiving a child with Down syndrome increases after 35 years of age. However, most children with Down syndrome are born to women under age 35 because younger women have far more babies. • Being carriers of the genetic translocation for Down syndrome. Both men and women can pass the genetic translocation for Down syndrome on to their children. • Having had one child with Down syndrome. Parents who have one child with Down syndrome and parents who have a translocation themselves are at an increased risk of having another child with Down syndrome. A genetic counsellor can help parents assess the risk of having a second child with Down syndrome. Complications People with Down syndrome can have a variety of complications, some of which become more prominent as they get older. These complications can include: • Heart defects. About half the children with Down syndrome are born with some type of congenital heart defect. These heart problems can be life-threatening and may require surgery in early infancy. • Gastrointestinal (GI) defects. GI abnormalities occur in some children with Down syndrome and may include abnormalities of the intestines, oesophagus, trachea, and anus. The risk of developing digestive problems, such as GI blockage, heartburn (gastroesophageal reflux) or celiac disease, may be increased. • Immune disorders. Because of abnormalities in their immune systems, people with Down syndrome are at increased risk of developing autoimmune disorders, some forms of cancer, and infectious diseases, such as pneumonia. 164 CU IDOL SELF LEARNING MATERIAL (SLM)
• Sleep apnea. Because of soft tissue and skeletal changes that lead to the obstruction of their airways, children and adults with Down syndrome are at greater risk of obstructive sleep apnea. • Obesity. People with Down syndrome have a greater tendency to be obese compared with the general population. • Spinal problems. Some people with Down syndrome may have a misalignment of the top two vertebrae in the neck (atlantoaxial instability). This condition puts them at risk of serious injury to the spinal cord from overextension of the neck. • Leukaemia. Young children with Down syndrome have an increased risk of leukaemia. • Dementia. People with Down syndrome have a greatly increased risk of dementia — signs and symptoms may begin around age 50. Having Down syndrome also increases the risk of developing Alzheimer's disease. • Other problems. Down syndrome may also be associated with other health conditions, including endocrine problems, dental problems, seizures, ear infections, and hearing and vision problems. For people with Down syndrome, getting routine medical care and treating issues when needed can help with maintaining a healthy lifestyle. Life expectancy Life spans have increased dramatically for people with Down syndrome. Today, someone with Down syndrome can expect to live more than 60 years, depending on the severity of health problems. Prevention There's no way to prevent Down syndrome. If you're at high risk of having a child with Down syndrome or you already have one child with Down syndrome, you may want to consult a genetic counsellor before becoming pregnant. A genetic counsellor can help you understand your chances of having a child with Down syndrome. He or she can also explain the prenatal tests that are available and help explain the pros and cons of testing. Treatment Early intervention for infants and children with Down syndrome can make a major difference in improving their quality of life. Because each child with Down syndrome is unique, 165 CU IDOL SELF LEARNING MATERIAL (SLM)
treatment will depend on individual needs. Also, different stages of life may require different services. Team care If your child has Down syndrome, you'll likely rely on a team of specialists that can provide medical care and help him or her develop skills as fully as possible. Depending on your child's particular needs, your team may include some of these experts: • Primary care paediatrician to coordinate and provide routine childhood care • Paediatric cardiologist • Paediatric gastroenterologist • Paediatric endocrinologist • Developmental paediatrician • Paediatric neurologist • Paediatric ear, nose, and throat (ENT) specialist • Paediatric eye doctor (ophthalmologist) • Audiologist • Speech pathologist • Physical therapist • Occupational therapist You'll need to make important decisions about your child's treatment and education. Build a team of health care providers, teachers and therapists you trust. These professionals can help evaluate the resources in your area and explain state and federal programs for children and adults with disabilities. Coping and support When you learn your child has Down syndrome, you may experience a range of emotions, including anger, fear, worry and sorrow. You may not know what to expect, and you may worry about your ability to care for a child with a disability. The best antidote for fear and worry is information and support. Consider these steps to prepare yourself and to care for your child: 166 CU IDOL SELF LEARNING MATERIAL (SLM)
• Ask your health care provider about early intervention programs in your area. Available in most states, these special programs offer infants and young children with Down syndrome stimulation at an early age (typically until age 3) to help develop motor, language, social and self-help skills. • Learn about educational options for school. Depending on your child's needs, that may mean attending regular classes (mainstreaming), special education classes or both. With your health care team's recommendations, work with the school to understand and choose appropriate options. • Seek out other families who are dealing with the same issues. Most communities have support groups for parents of children with Down syndrome. You can also find internet support groups. Family and friends can also be a source of understanding and support. • Participate in social and leisure activities. Take time for family outings and look in your community for social activities such as park district programs, sports teams or ballet classes. Although some adaptations may be required, children and adults with Down syndrome can enjoy social and leisure activities. • Encourage independence. Your child's abilities may be different from other children's abilities, but with your support and some practice your child may be able to perform tasks such as packing lunch, managing hygiene and dressing, and doing light cooking and laundry. • Prepare for the transition to adulthood. Opportunities for living, working, and social and leisure activities can be explored before your child leaves school. Community living or group homes, and community employment, day programs or workshops after high school require some advance planning. Ask about opportunities and support in your area. Expect a bright future. Most people with Down syndrome live with their families or independently, go to mainstream schools, read and write, participate in the community, and have jobs. People with Down syndrome can live fulfilling lives. 6.5 PROGNOSIS AND TREATMENT Behavioral Disorder Treatment Program Options Behavioral disorders are common in today’s society and include a spectrum of disorders, such as obsessive-compulsive disorder, attention deficit hyperactivity disorder and addiction conditions. While many behavioral disorders cannot be cured, proper treatment can ensure these conditions are effectively managed, allowing those who suffer from them to live balanced, productive lives. Is there a Cure for Behavioral Disorders? 167 CU IDOL SELF LEARNING MATERIAL (SLM)
Despite intensive research over the past several decades, the cause of these disorders remains difficult to pin down. Without any one particular smoking gun of a cause, efforts to uncover anything in the way of a permanent cure are all but guaranteed to be disappointing. Unfortunately, none of these disorders can be cured quickly and easily; however, they can be effectively managed. Therapies for Behavioral Disorders In the absence of a sure-fire cure for these complex issues, treatment will be confined to management of the more disruptive symptoms they manifest. Fortunately, there now exist many therapies for behavioral disorders that seem to be delivering results researchers and mental health practitioners could only have dreamed of just 30 or 40 years ago. When you or another person who is close to you shows signs of a serious behavioral disturbance, it can be tempting to overlook the problems caused by the disorder. Some people will resist admitting that there is a problem long past the point at which it has begun to seriously affect their quality of life. Delaying or denying the need for treatment is almost always a mistake and can make the underlying disorder more difficult to address if and when treatment finally is sought out. For guidance in seeking treatment, or just to talk to somebody who knows what you’re going through, please don’t hesitate to call today. The line is always open, so you can call anytime. Cognitive Behavioral Therapy Treatment Formerly known as talk therapy, cognitive behavioral therapy treatment (CBT) is by far the most commonly used mechanism for managing the symptoms of behavioral disorders. CBT is usually administered in hour-long sessions by a single therapist who will engage the patient on a deep level. The therapy places its focus on helping the patient to overcome the effects of negative thoughts and feelings through a heightened awareness of internal states and a more thorough understanding of the relevant issues. Patients are taught strategies for learning how to cope with destructive impulses and actions, as well as mechanisms for coping with the social and emotional baggage that comes with being so afflicted. The sessions are generally limited in scope and duration, as they are intended to be a short-term intervention that’s included in a larger spectrum of other treatments. Other Therapeutic Methods Other therapeutic methods will typically be incorporated into a comprehensive plan for treatment of behavior issues. In addition to CBT, traditional psychotherapy may be attempted. Also popular for the treatment of behavioral disorders, especially addiction, is one or another variant of group therapy, in which two or more patients interact with one or more therapists and each other. One of the benefits of this approach is that it reduces the feeling – 168 CU IDOL SELF LEARNING MATERIAL (SLM)
very common among addicts and people suffering from depression – that they are completely alone in the world. Another benefit is to encourage patients to come out of their shells and begin to form relationships with other patients with whom they can usually empathize. This will be seen as an especially desirable outcome for the treatment of autistic spectrum disorder. Residential Inpatient Behaviour Disorder Treatment Centres Sifting through the residential inpatient behaviour disorder treatment centres in your area can be a difficult and time-consuming business. In any reasonably populous area, you can expect to find a plethora of residential care centres offering services to people with behavior issues. Many of these are able to offer the kind of care that individuals with behavior issues need to manage, if not partially recover from, the effects that the disorder has had on their lives. Calling will put you in touch with a trained professional who understands what it’s like to deal with the impact a behavioral disturbance can have and who has the information you need to make a choice between centres. The typical residential care facility will take in a patient who has been referred by a physician or therapist for some set period of time such as 30, 60 or 90 days and begin an intensive regimen of inpatient care in the safe, controlled environment of the centre. The Benefits of Residential Behavioral Treatment Among the benefits of residential behavioral treatment in an inpatient facility or other clinical setting is the ability to manage serious disturbances in peace, without extraneous influences and under almost totally controlled conditions. The individuals who seek treatment in a residential care program may be assured that while they are at the most vulnerable stage of their recovery, they will be fully taken care of by a staff of dedicated professionals. Meals, medications and therapy sessions, as well as any unrelated medical issues, will be wholly looked after in such a place, minimizing the risk that a serious behavior problem will lead to harm for the patient or those around them. Luxury Behavioral Disorder Facilities For patients who would benefit from getting away from a largely sterile clinical treatment environment, an entire class of treatment centres exists to render care in a setting that seems closer to that of a spa or resort than a medical centre. These luxury behavioral disorder facilities are generally privately owned and operated, though they will typically hold some form of accreditation and submit to state inspections. For many patients, they present a viable alternative to the sometimes-upsetting environment of a more traditional facility, while at the same time maintaining a constant level of care to rival other modes of inpatient care. Outpatient Behavioral Rehab and Treatment Programs 169 CU IDOL SELF LEARNING MATERIAL (SLM)
For those who cannot or do not wish to reside even temporarily at an inpatient treatment centre, outpatient behavioural rehab and treatment programs present a viable hands-off approach to care. Such facilities come in a wide variety of configurations and might be as simple as a neighbourhood clinic that will dispense medication and assist the patient in taking it to a full-scale adult day-care centre that differs from inpatient care only in sleeping arrangements. According to a study that was published in 2011 by the peer-reviewed journal Clinical Practice & Epidemiology in Mental Health, such brief strategic therapy (BST) compares well to the gold standard of CBT over time, at least in the treatment of eating disorders, which is where the paper’s research was focused. It certainly is too early to generalize about this kind of treatment approach, but the results so far have been promising. Executive Behavioral Disorder Programs Executive behavioral disorder programs are of a different kind. These programs are intended to efficiently treat those patients who are likely to suffer more from a protracted stay in an inpatient clinic than they would from a short stay, followed by a rapid return to their home, job and family. Outpatient Behavioural Rehab and Treatment Programs For those who cannot or do not wish to reside even temporarily at an inpatient treatment centre, outpatient behavioural rehab and treatment programs present a viable hands-off approach to care. Such facilities come in a wide variety of configurations and might be as simple as a neighbourhood clinic that will dispense medication and assist the patient in taking it to a full-scale adult day-care centre that differs from inpatient care only in sleeping arrangements. According to a study that was published in 2011 by the peer-reviewed journal Clinical Practice & Epidemiology in Mental Health, such brief strategic therapy (BST) compares well to the gold standard of CBT over time, at least in the treatment of eating disorders, which is where the paper’s research was focused. It certainly is too early to generalize about this kind of treatment approach, but the results so far have been promising. Prescription and Over-the-Counter Medications Managing a behavioral disorder with prescription and over-the-counter medications is a very popular way of dealing both with the central issues of a behavior problem and with the secondary issues that will inevitably arise for someone living with the disorder. Over-the- counter medications are the ones most laypeople will be familiar with. These include such widely available agents as Benadryl, which is a non-prescription antihistamine that has found new life as an agent for both night-time sedation and the reduction of intermittent anxiety, according to a helpful chart compiled by the Diagnostic Centre Southern California. Other 170 CU IDOL SELF LEARNING MATERIAL (SLM)
OTC medications shown to be effective include vitamin B6 with magnesium, which helps to manage the behavior of children with ASD, as does folic acid. Prescription medications for behavioral disorders pack serious power and must only be taken on the advice and under the supervision of an attending physician. Some of these include lithium carbonate, for the control of mania in bipolar individuals, naltrexone, which has been shown to restrict self-injury among ASD patients, and major tranquilizers such as haloperidol, pimozide, risperidone, olanzapine, quetiapine and others, which are used to stabilize the mood and restrict explosive outbursts among people with bipolar disorder, ASD and Tourette’s syndrome. Each of these medications, as well as many more, has its own laundry list of side effects and interaction warnings. Only a trained medical professional can be expected to craft a treatment plan that safely incorporates these powerful agents. 6.6 SUMMARY • Challenging behavior becomes a concern when it is frequent and unexpected and leads to trouble at home, at school and with peers. • Behavioral disorders generally fall into two categories: oppositional defiant disorder and conduct disorder. • Behavioral disorders can be associated with a family history of challenging behavior, family stresses and a poor ability to manage emotions and activity levels. • See your child’s doctor if your child’s behavior changes suddenly or if their behavior is more challenging than expected for their developmental stage. 6.7 KEYWORDS • Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. Cognitive impairment ranges from mild to severe. • Depression: A group of conditions associated with the elevation or lowering of a person's mood, such as depression or bipolar disorder • Dementia is a collective term used to describe various symptoms of cognitive decline, such as forgetfulness. It is a symptom of several underlying diseases and brain disorders • Alzheimer's disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks • Mini-Cog is a 3-minute instrument that can increase detection of cognitive impairment in older adults. 171 CU IDOL SELF LEARNING MATERIAL (SLM)
6.8 LEARNING ACTIVITY 1. Discuss Cognitive ability tests, such as the Wonderlic test, Revelian tests and Predictive Index tests ………………………………………………………………………………………………...... ………………………………………………………………………………………………….. 2. Study prevalence of dementia in India is reported to be 2.7%. As the age increase, prevalence of dementia increases. For example, nearly 20% of people above 80 suffer from dementia. Mean age of presentation is relatively younger at 66.3 years in India, about 10 years lesser than in the developed countries ………………………………………………………………………………………………….. ……………………………………………………………………………………………….. 6.9 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What is cognitive testing? 2. What is cognitive testing used for? 3. Why do I need cognitive testing? 4. What are diagnostic tests during pregnancy 5. What are diagnostic tests for new-borns Long Questions 1. Write a note on : Personality tests 2. Write a note on : Neuropsychological tests 3. Write a note on : Down syndrome 4. What are the steps to prepare yourself and to care for your child in down syndrome? 5. What is Behavioral Disorder Treatment Program Options B. Multiple Choice Questions 172 1. ____________ often used to screen for mild cognitive impairment. a. Cognitive Testing b. Psychological Testing CU IDOL SELF LEARNING MATERIAL (SLM)
c. Personality Test d. Psychomotor Testing 2. A 10–15-minute test that includes memorizing a short list of words, identifying a picture of animal, and copying a drawing of a shape of object. a. Mini-mental State Exam b. Montreal Cognitive Assessment c. Mini-Cognitive d. None of these 3. ___________ are written visual or verbal evaluations administered to assess the cognitive and emotion functioning of children and adult. a. Personality Testing b. Cognitive Testing c. Psychological Testing d. Ability Testing 4. Down Syndrome is a genetic disorder caused when abnormal cell division results in an extra full or partial copy of chromosomes ______. a. 23 b. 24 c. 28 d. 21 5. Today, someone with Down syndrome can expect to live more than ________ years. a. 60 b. 58 c. 15 173 CU IDOL SELF LEARNING MATERIAL (SLM)
d. None of these Answers 1-(b), 2-(b), 3-(c), 4-(d), 5-(a) 6.10 REFERENCES Textbook • Armstrong TD, Costello EJ (2002), Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. J Consult Clin Psychol. · • Banaschewski T, Brandeis D, Heinrich H, Albrecht B, Brunner E, Rothenberger A (2003), Association of ADHD and conduct disorder - brain electrical evidence for the existence of a distinct subtype. J Child Psychol Psychiatry • Banerjee T (1997), Psychiatric morbidity among rural primary school children in West Bengal Indian J Psychiat • Barkley RA(1987). Defiant children: a clinician’s manual for parent training. New York: Guilford. References: • Campbell SB (2002), Behavior Problems in Preschool Children: Clinical and Developmental Issues. New York: Guilford. • Campbell SB, Shaw DS, Gillion M (2000), Early externalizing behavior problems: toddlers and pre-schoolers at risk for later maladjustment. Dev Psychopathy. • Cantwell DP, Swanson J, Connor DF (1997), Case study: adverse response to clonidine. J Am Acad Child Adolesc Psychiatry • Carey G, DiLalla D (1994), Personality and psychopathology: genetic perspectives. J Abnormal Psychol. 174 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT 7: DISRUPTIVE BEHAVIOUR DISORDERS PART I STRUCTURE 7.0 Learning Objectives 7.1 Introduction 7.2 Oppositional Defiant Disorder 7.3 DSM Criteria 7.4 ICD-10 7.5 Incidence 7.6 Prevalence 7.7 Co-Morbidity 7.8 Summary 7.9 Keywords 7.10 Learning Activity 7.11 Unit End Questions 7.12 References 7.0 LEARNING OBJECTIVES After studying this unit, students will be able to: • Identify the different disruptive behavior. • Explain the cause, symptoms and treatment of a certain disruptive behavior. • Familiarized the criteria for: DSM 5 Criteria and ICD codes for Disruptive Behavior • Explain coexisting or comorbid conditions 7.1 INTRODUCTION Disruptive behavior disorders are among the easiest to identify of all coexisting conditions because they involve behaviours that are readily seen such as temper tantrums, physical aggression such as attacking other children, excessive argumentativeness, stealing, and other forms of defiance or resistance to authority. These disorders, which include ODD and CD, 175 CU IDOL SELF LEARNING MATERIAL (SLM)
often first attract notice when they interfere with school performance or family and peer relationships, and frequently intensify over time. Behaviours typical of disruptive behavior disorders can closely resemble ADHD— particularly where impulsivity and hyperactivity are involved—but ADHD, ODD, and CD are considered separate conditions that can occur independently. About one third of all children with ADHD have coexisting ODD, and up to one quarter have coexisting CD. Children with both conditions tend to have more difficult lives than those with ADHD alone because their defiant behavior leads to so many conflicts with adults and others with whom they interact. Early identification and treatment may, however, increase the chances that your child can learn to control these behaviours. Oppositional Defiant Disorder Many children with ADHD display oppositional behaviours at times. Oppositional defiant disorder is defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) as including persistent symptoms of “negativistic, defiant, disobedient, and hostile behaviours toward authority figures.” A child with ODD may argue frequently with adults; lose his temper easily; refuse to follow rules; blame others for his own mistakes; deliberately annoy others; and otherwise behave in angry, resentful, and vindictive ways. He is likely to encounter frequent social conflicts and disciplinary situations at school. In many cases, particularly without early diagnosis and treatment, these symptoms worsen over time—sometimes becoming severe enough to eventually lead to a diagnosis of conduct disorder. Conduct Disorder Conduct disorder is a more extreme condition than ODD. Defined in the DSM-IV as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate social rules are violated,” CD may involve serious aggression toward people or the hurting of animals, deliberate destruction of property (vandalism), stealing, running away from home, skipping school, or otherwise trying to break some of the major rules of society without getting caught. Many children with CD were or could have been diagnosed with ODD at an earlier age—particularly those who were physically aggressive when they were younger. As the CD symptoms become evident, these children usually retain their ODD symptoms (argumentativeness, resistance, etc) as well. This cluster of behaviours, combined with the impulsiveness and hyperactivity of ADHD, sometimes causes these children to be viewed as delinquents, and they are likely to be suspended from school and have more police contact than children with ADHD alone or ADHD with ODD. Children with ADHD whose CD symptoms started at an early age also tend to fare more poorly in adulthood than those with ADHD alone or ADHD with ODD—particularly in the areas of delinquency, illegal behavior, and substance abuse. 176 CU IDOL SELF LEARNING MATERIAL (SLM)
ODD and CD: What to Look For A child with ADHD and a coexisting disruptive behavior disorder is likely to be similar to children with ADHD alone in terms of intelligence, medical history, and neurological development. He is probably no more impulsive than children with ADHD alone, although if he has conduct disorder, his teachers or other adults may misinterpret his aggressive behavior as ADHD-type impulsiveness. (Attention-deficit/hyperactivity disorder behavior without CD, however, does not typically involve this level of aggression.) A child with ADHD and CD does have a greater chance of experiencing learning disabilities such as reading disorders and verbal impairment. But what distinguishes children with ODD and CD most from children with ADHD alone is their defiant, resistant, even (in the case of CD) aggressive, cruel, or delinquent, behavior. Other indicators to look for include • Relatives with ADHD/ODD, ADHD/CD, depressive disorder or anxiety disorder. A child with family members with ADHD/ODD or ADHD/CD should be watched for ADHD/CD as well. Chances of developing CD are also greater if family members have experienced depressive, anxiety, or learning disorders. • Stress or conflict in the family. Divorce, separation, substance abuse, parental criminal activity, or serious conflicts within the family are quite common among children with ADHD and coexisting ODD or CD. • Poor or no positive response to the behavior therapy techniques at home and at school. If your child defies your instructions, violates time-out procedures, and otherwise refuses to cooperate with your use of appropriate behavior therapy techniques, and his aggressive behavior continues unabated, he should be evaluated for coexisting ODD or CD. 7.2 OPPOSITIONAL DEFIANT DISORDER Even the best-behaved children can be difficult and challenging at times. But if your child or teenager has a frequent and persistent pattern of anger, irritability, arguing, defiance or vindictiveness toward you and other authority figures, he or she may have oppositional defiant disorder (ODD). As a parent, you don't have to go it alone in trying to manage a child with ODD. Doctors, mental health professionals and child development experts can help. Behavioral treatment of ODD involves learning skills to help build positive family interactions and to manage problematic behaviours. Additional therapy, and possibly medications, may be needed to treat related mental health disorders. Symptoms 177 CU IDOL SELF LEARNING MATERIAL (SLM)
Sometimes it's difficult to recognize the difference between a strong-willed or emotional child and one with oppositional defiant disorder. It's normal to exhibit oppositional behavior at certain stages of a child's development. Signs of ODD generally begin during preschool years. Sometimes ODD may develop later, but almost always before the early teen years. These behaviours cause significant impairment with family, social activities, school, and work. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, lists criteria for diagnosing ODD. The DSM-5 criteria include emotional and behavioral symptoms that last at least six months. Angry and irritable mood: • Often and easily loses temper • Is frequently touchy and easily annoyed by others • Is often angry and resentful Argumentative and defiant behavior: • Often argues with adults or people in authority • Often actively defies or refuses to comply with adults' requests or rules • Often deliberately annoys or upsets people • Often blames others for his or her mistakes or misbehaviour Vindictiveness: • Is often spiteful or vindictive • Has shown spiteful or vindictive behavior at least twice in the past six months ODD can vary in severity: • Mild. Symptoms occur only in one setting, such as only at home, school, work or with peers. • Moderate. Some symptoms occur in at least two settings. • Severe. Some symptoms occur in three or more settings. For some children, symptoms may first be seen only at home, but with time extend to other settings, such as school and with friends. Causes There's no known clear cause of oppositional defiant disorder. Contributing causes may be a combination of inherited and environmental factors, including: • Genetics — a child's natural disposition or temperament and possibly neurobiological differences in the way nerves and the brain function 178 CU IDOL SELF LEARNING MATERIAL (SLM)
• Environment — problems with parenting that may involve a lack of supervision, inconsistent or harsh discipline, or abuse or neglect Risk factors Oppositional defiant disorder is a complex problem. Possible risk factors for ODD include: • Temperament — a child who has a temperament that includes difficulty regulating emotions, such as being highly emotionally reactive to situations or having trouble tolerating frustration • Parenting issues — a child who experiences abuse or neglect, harsh or inconsistent discipline, or a lack of parental supervision • Other family issues — a child who lives with parent or family discord or has a parent with a mental health or substance use disorder • Environment — oppositional and defiant behaviours can be strengthened and reinforced through attention from peers and inconsistent discipline from other authority figures, such as teachers Complications Children and teenagers with oppositional defiant disorder may have trouble at home with parents and siblings, in school with teachers, and at work with supervisors and other authority figures. Children with ODD may struggle to make and keep friends and relationships. ODD may lead to problems such as: • Poor school and work performance • Antisocial behavior • Impulse control problems • Substance use disorder • Suicide Many children and teens with ODD also have other mental health disorders, such as: • Attention-deficit/hyperactivity disorder (ADHD) • Conduct disorder • Depression • Anxiety • Learning and communication disorders 179 CU IDOL SELF LEARNING MATERIAL (SLM)
Treating these other mental health disorders may help improve ODD symptoms. And it may be difficult to treat ODD if these other disorders are not evaluated and treated appropriately. Prevention There's no guaranteed way to prevent oppositional defiant disorder. However, positive parenting and early treatment can help improve behavior and prevent the situation from getting worse. The earlier that ODD can be managed, the better. Treatment can help restore your child's self-esteem and rebuild a positive relationship between you and your child. Your child's relationships with other important adults in his or her life — such as teachers and care providers — also will benefit from early treatment. Best practices for managing disruptive behavior Effective prevention Establishing norms helps prevent disruptive behavior and allows you to react effectively in the moment. In addition to using your syllabus to set academic expectations, you can also utilize it to create classroom behavioral expectations. The factors that constitute appropriate and inappropriate behavior are often dependent on the nature of class and faculty comfort level, and can vary widely from lectures to labs and across content areas. Faculty have found it helpful to: • Outline both productive and disruptive types of behavior. • Outline the process by which disruptive behavior will be addressed. • Outline consequences for ongoing disruptive behavior. • Verbally address classroom expectations regarding behavior on the first day of class. It is especially effective to talk about behavior you want to see, as well as the type that’s disruptive. • Model the type of behavior you expect from your class. How to respond to a disruption, in the moment Your direct intervention will work for a majority of situations; however, some students and situations are ongoing and will require additional consultation and follow up. The departments and campus partners within Student Life are available to work with you on handling disruptive situations. It is important to remember that if the disruption causes immediate concern for personal safety, do not hesitate to call UWPD. What to do Stay calm and listen to student concerns – identifying the catalyst for disruption can help you address the situation in the moment or in a later meeting. 180 CU IDOL SELF LEARNING MATERIAL (SLM)
• Be steady, consistent and firm. • Acknowledge the feelings of the individual. • Remember that disruptive behavior is often caused by stress or frustration. • Address the disruption individually, directly and immediately. • Be specific about the behavior that is disruptive and set limits. • Remove the student from that class session if the student does not comply with your actions. If the student does not leave after being asked to do so, you can call UWPD for backup. • Ask the student to see you after class to address the disruption, explore the causes of the incident and discuss appropriate behavior. • Pay attention to warning signs that the situation is nearing escalation toward violence. • Be aware of your own limitations – operate within your own scope of comfort: o Faculty can contact UWPD and have the student removed from class. o Faculty can bring class to an end for the day. o Faculty can seek out additional resources and coaching to handle the disruptive student. What to avoid • Do not allow the behavior to continue. • Avoid making it a class issue – address only the student who is causing the disruption. • Avoid an argument or shouting match. • Do not blame or ridicule the student, or use sarcasm. • Do not touch the students Suggestions for intervening in a disruption • Keep your focus on the student. Rather than say, “Class, we all know that talking during lecture is disruptive,” say, “Jane, you’re talking during class is disrupting the lecture and I need to ask you to stop.” • Be clear about the behavior. If the student is talking out of turn, tell them. Rather than ask, “Do you have a question?” say, “Jane, now is not the time for discussion. There will be an opportunity for questions and debate at the end of the lecture.” • Nip the situation in the bud, referring to the syllabus regarding expectation and behavior. “Jane, you will note that in the syllabus, talking during lecture is considered disruptive behavior. If I need to ask you to stop talking again, I will need to ask you to leave.” • Distress is often the cause of a disruption. It is important to recognize the stress while still addressing the behavior. Rather than say, “John, you are clearly emotional right now and you need to stop arguing,” say, “John, I can see that this topic has you upset; however, we need to bring this debate to a close.” • If you need to ask the student to leave, do so clearly and directly. Rather than say, “Get out! Go! Get out of here!” say, “John, your behavior has exceeded what is acceptable for 181 CU IDOL SELF LEARNING MATERIAL (SLM)
this class and it is time for you to leave. I will be in contact with you via email to discuss future class sessions.” At this point, it is a good idea to pause class until the student exits the room. What to do following a disruption While many disruptions are minor and can be managed in the moment, it can be beneficial both to document the incident and follow up with the student. Documenting what you experienced and the steps you took will be helpful if you need to pursue a violation of the student conduct code. Clear communication with the student helps to set expectations and prevent further disruption. The following are suggestions to consider following an incident: • Document the details about the incident, including the time/date/location, the behavior of the student, the actions you took and how the situation was resolved in the moment. • For minor disruptions, an email can serve as both a tool to remedy behavior and to document the incident. In the email, you should include the observed behavior, your expectations for class and how they differ from the observed behavior, and the consequences of continued disruption. • If the disruption is more egregious or a behavior is ongoing, you should contact your departmental leadership for appropriate next steps. Keeping them in the loop regarding behavior of concern is always recommended. • In some cases, a meeting with the student is required to discuss the behavior in more depth, explore appropriate solutions and set clear guidelines and consequences. Often, you can find support for these meetings within your department or with Community Standards and Student Conduct. • If additional support is necessary, please contact Community Standards and Student 7.3 DSM CRITERIA Highlights and Changes from DSM-IV TR to DSM 5 The chapter on disruptive, impulse- control, and conduct disorders is new to DSM-5. It brings together disorders that were previously included in the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” (i.e., oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified, now categorized as other specified and unspecified disruptive, impulse-control, and conduct disorders) and the chapter “Impulse-Control Disorders Not Otherwise Specified” (i.e., intermittent explosive disorder, pyromania, and kleptomania). These disorders are all characterized by problems in emotional and behavioral self-control. Of note, ADHD is frequently comorbid with the disorders in this chapter but is now listed in DSM 5 with the neurodevelopmental disorders. It had previously (DSM-IV TR) been considered within the DBDs. It will not be addressed as a primary diagnosis in this guideline because it is covered separately and may be accessed at http://psychiatry.uams.edu/PsychTLC). Four refinements have been made to the criteria for 182 CU IDOL SELF LEARNING MATERIAL (SLM)
oppositional defiant disorder. First, symptoms are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. This change highlights that the disorder reflects both emotional and behavioral symptomatology. Second, the exclusion criterion for conduct disorder has been removed. Third, given that many behaviours associated with symptoms of oppositional defiant disorder occur commonly in normally developing children and adolescents, a note has been added to the criteria to provide guidance on the frequency typically needed for a behavior to be considered symptomatic of the disorder. Fourth, a severity rating has been added to the criteria to reflect research showing that the degree of pervasiveness of symptoms across settings is an important indicator of severity. Figure 7.1 Symptoms & Clinical Features of Disruptive Behaviour Disorders 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 183 CU IDOL SELF LEARNING MATERIAL (SLM)
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 behaviours observed in CD (Dulcan & Loeber, 1995) Conduct Disorder Exhibits a pattern of behavior that violates the rights of others or disregards age-specific social norms • Deliberately break rules • Aggressive toward people or animals • Destructive of property • Lying and theft Violation of rules For example skipping school and substance use As noted in the following diagram, the possibility of progression is present in Disruptive Behavior Disorders. However, there are also protective factors that can mitigate the escalation. Protective factors would include • Late onset 184 • Early assessment • Effective treatment • The absence of co-occurring disorders • Negative family history for DBD CU IDOL SELF LEARNING MATERIAL (SLM)
Table 7.1 Differential Diagnosis Figure 7.2 Comorbid Conditions for Disruptive Behaviour Disorders 185 CU IDOL SELF LEARNING MATERIAL (SLM)
7.4 ICD-10 ICD-10-CM Codes - Mental, Behavioral and Neurodevelopmental disorders F01-F99 Mental, Behavioral and Neurodevelopmental disorders F01-F99 Type 2 Excludes • symptoms, signs, and abnormal clinical laboratory findings, not elsewhere classified (R00-R99 ) Includes • disorders of psychological development • Behavioral and emotional disorders with onset usually occurring in childhood and adolescence Note: • Codes within categories F90-F98 may be used regardless of the age of a patient. These disorders generally have onset within the childhood or adolescent years, but may continue throughout life or not be diagnosed until adulthood • F90 Attention-deficit hyperactivity disorder... • F91.0 Conduct disorder confined to family context • F91.1 Conduct disorder, childhood-onset type • F91.2 Conduct disorder, adolescent-onset type • F91.3 Oppositional defiant disorder • F91.8 Other conduct disorders • F91.9 Conduct disorder, unspecified • F93 Emotional disorders with onset specific to childhood • F93.0 Separation anxiety disorder of childhood • F93.8 Other childhood emotional disorders • F93.9 Childhood emotional disorder, unspecified • F94 Disorders of social functioning with onset specific to childhood and adolescence • F94.0 Selective mutism • F94.1 Reactive attachment disorder of childhood • F94.2 Disinhibited attachment disorder of childhood • F94.8 Other childhood disorders of social functioning • F94.9 Childhood disorder of social functioning, unspecified • F95 Tic disorder • F95.0 Transient tic disorder • F95.1 Chronic motor or vocal tic disorder 186 CU IDOL SELF LEARNING MATERIAL (SLM)
• F95.2 Tourette's disorder • F95.8 Other tic disorders • F95.9 Tic disorder, unspecified • F98 Other behavioural and emotional disorders with onset usually occurring in childhood and adolescence • F98.0 Enuresis not due to a substance or known physiological condition • F98.1 Encopresis not due to a substance or known physiological condition • F98.2 Other feeding disorders of infancy and childhood • F98.21 Rumination disorder of infancy • F98.29 Other feeding disorders of infancy and early childhood • F98.3 Pica of infancy and childhood • F98.4 Stereotyped movement disorders • F98.5 Adult onset fluency disorder • F98.8 Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence • F98.9 Unspecified behavioral and emotional disorders with onset usually occurring in childhood and adolescence 7.5 INCIDENCE Incidence and comorbidities of disruptive behavior disorders diagnosed in Finnish specialist psychiatric services Purpose Disruptive behavior disorders (DBD), including oppositional defiant disorder (ODD) and conduct disorder (CD), are some of the most common psychiatric conditions in childhood. Despite this, there has been limited research on DBDs. We examined the incidence, comorbidity and gender differences of DBDs diagnosed by specialist services. Method This was a nationwide register study of 570,815 children and adolescents born in 1996–2005. The 7050 individuals diagnosed with DBD by specialist healthcare services were matched to 26,804 controls. Results By the age of 15, the cumulative incidence of diagnosed DBDs was 3.5% for boys and 1.4% for girls. The yearly incidence rate increased for girls after 13 years of age, while the incidence for boys was relatively stable between 8 and 15 years of age. When we compared subjects born between 1996–1998 and 1999–2001, we found that by the age of 12, the 187 CU IDOL SELF LEARNING MATERIAL (SLM)
cumulative incidence per 100 people had increased from 0.56 to 0.68 among girls and from 2.3 to 2.6 among boys. This indicated a minor increase in treated incidence. The parents of children diagnosed with DBDs had lower educational levels than the parents of controls. Children with DBD were also more likely to have been diagnosed with other psychiatric disorders. Conclusion Although DBDs were 3.5 times more common among boys during the whole follow-up period, the yearly incidence during adolescence was fairly similar between boys and girls. DBD existed alongside various psychiatric disorders at a relatively young age and only a minor increase in treated incidence was found during childhood. 7.6 PREVALENCE Prevalence Rate of Disruptive Behavior Disorders In some cases, one aspect of child psychopathology may be demonstrative of climax of specific trajectory in comparing to normal range of that aspect in a normal child (Sartorius et al., 2008). There is fine Border between normal and abnormal, which has not been precisely defined. Although, sometimes cutting point may be exact and demonstrative. Major classifications of children psychiatric disorders are: Developmental disorders, Emotional problems, or internalization, Disruptive behavior disorders or Externalization (Sartorius et al., 2008).The 1964 UK Isle of Wight epidemiological survey showed that approximately 7% of children suffer from at least one type of psychiatric disorders in mid- childhood (Oseberg, 1998). This number proved to be lower than actual number and the actual prevalence is two times bigger than aforementioned number (Crank, Greenburg, 1997). Disruptive behavior disorders are prevalent and disabling disorders, which cause problems for teachers, parents and even children themselves. These disorders are accompanied by so many complications such as social problems; most of the times they are diagnosed in early period of primary school. Furthermore, these disorders affect the child’s educational process and they will elevate the risk of mental problems in adulthood in these children (Najafi et al., 2009). Conduct Disorder (CD), Oppositional Defiant Disorder (ODD) and Attention Deficit Hyperactivity Disorder (ADHD) can mentioned as disruptive behavior disorders or externalization (Sartorius et al., 2008).Adverse consequences of these disorders are not limited to period of childhood and they also may endanger the future life of these children and their families Conduct Disorder (CD) is characterized by a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, 188 CU IDOL SELF LEARNING MATERIAL (SLM)
as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months (Sadock et al., 2006): Aggression to people and animals: (1) often bullies, threatens, or intimidates others (2) often initiates physical fights (3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun) (4) has been physically cruel to people (5) has been physically cruel to animals (6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery) (7) has forced someone into sexual activity. Destruction of property: (1) has deliberately engaged in fire setting with the intention of causing serious damage (2) has deliberately destroyed others’ property (other than by fire setting). Deceitfulness or theft: (1) Has broken into someone else’s house, building, or car(2) Often lies to obtain goods or favours or to avoid obligations (i.e., “cons” others)(3)Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery) Serious violations of rules: (1) often stays out at night despite parental prohibitions, beginning before age 13 years (2) has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period) (3) is often truant from school, beginning before age 13 years. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning (Halgin, Whitborne, 2002). Prevalence Rate of Disruptive Behavior Disorders among the Preschool Children According to DSM-1V, existence of three out five behaviours is essential for diagnosis: 1. Aggression and bullying 2.Threatening 3) Intimidating others 4) Staying out at night despite parental prohibitions 5) Onset before 13 (APA, 2008). Prevalence of this disorder in general population has been estimated between 1-10% and it is 4-12 times more prevalent among boys (Sadock et al., 2006). These children maintain higher tendency toward Alcohol dependency and antisocial personality disorder in their adulthood (APA, 2008). Oppositional Defiant Disorder (ODD) is one of the most common reasons of children’s reference to mental health centres. A lot of children, who demonstrate negative/defiant behavior, tend to find different ways in order to express themselves in their adulthood (Sadock et al., 2006). In ODD burst of anger in child, constant disobey from authority figure are beyond expectation in comparing to normal children. ODD can be identified as, persistent pattern of anger, irritability, arguing, defiance or vindictiveness toward you and other authority figures without violating any serious social norms (Halgin, Whitborne, 2002). Epidemiological studies of non-clinical samples showed that these behaviours could be 189 CU IDOL SELF LEARNING MATERIAL (SLM)
noticed in 16% to 2% of school kids and it’s more prevalent between boys in comparing to girls (Sadock, Sadock, 2005). Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neurodevelopment disorders among children that may persist even till adulthood and it can disturb individual’s social life, educational process and it may cause a lot of family disturbances (Barkley, 2010).ADHD, similar to hyperkinetic disorder in the ICD-10 is a developmental DSM neuropsychiatric in which there are significant problems with executive functions (e.g., attentional control and inhibitory control) that cause attention deficits, hyperactivity, or impulsiveness which is not appropriate for a person's age (Sadock, Sadock, 2007). In past it was assumed that hyperactivity is main disabling symptoms of this disorder; nowadays scientists believe that hyperactivity is secondary symptom of impulse control deficit (APA, 2008). Today in diagnosis criteria of ADHD, hyperactivity and impulsivity share common aspect(Barkley, 1997).In the United States, thiscriteriais defined by the American Psychiatric Association in the Based on the DSM criteria, there are three sub-types of ADHD: 1. ADHD mainly inattentive type presents with symptoms including being easily distracted, forgetful, daydreaming, disorganization, poor concentration, and difficulty completing tasks. 2. ADHD, predominantly hyperactive-impulsive type presents with excessive fidgetiness and restlessness, hyperactivity, difficulty waiting and remaining seated, immature behavior; destructive behaviours may also be present. 3. ADHD, combined type is a combination of the first two subtypes. Regarding diagnosis, onset of some of the symptoms should be before 7 years old, however in most cases diagnosis is being made after 7 years old, when this disorder has disrupted the individual’s life already (Closson, 2010).In early 1900, this disorder was defined as impulsive children who suffered from neurocognitive damages as encephalitis and it was categorized under Hyperactivity syndrome (Conners, 1970).In 1960, heterogeneous group of children afflicted by Akathisia, learning disability and emotional instability without any neurological problems and with minimum brain damage were discussed, after that various hypotheses were discussed regarding this disorder (Sadock, Sadock, 2007). Epidemiological studies in United States showed that 2% to 20% of primary school children are under diagnosis of this disorder (Tamm et al., 2005) and approximately 3% to 7% of this number is diagnosed before puberty. Furthermore, prevalence rate is higher as 1/2 in boys and 1/9 in girls (Bussing et al., 2010). Since behavioral problems influence all personal/social aspects of afflicted individuals; hence, assessing and identifying various aspects of this disorder in children in order to implement proper prevention/intervention procedure seems to be vital. According to various 190 CU IDOL SELF LEARNING MATERIAL (SLM)
studies, behavioral problems may persist and even worsen as the child ages. Thus, precise and impeccable intervention plays a substantial role in dealing with these problems. Main goal of this study was to assess the behavioral problems of preschool children in Hamedan City. Hopefully the results may help the clinicians to intervene and implement suitable therapeutic approach in a process of dealing with these disabling disorders. Materials and Methods Current study is cross-sectional research. Statistical society of this study included all preschool children of Hamedan city during 2013-2014. Current sample included 602 individuals (301 boys, 301 girls), who were chosen via cluster sampling method. Regarding analysing data, descriptive statistics methods (percentage, frequency) and for comparing gender’s proportions (Z test) were used. Data of this cross-sectional research have been collected through complied questionnaire based on the DSM-5 Disruptive Behavior Disorder symptoms and CSI-4 (Parent Checklist) test. The Child Symptom Inventory-4 (CSI-4) is a behavior rating scale that screens for DSM-V emotional and behavioral disorders in children between 5 and 12 years old. Parent Checklist contains 112 questions and 41 of it are about A, B, C groups which assess ADHD, CD and ODD. Details of group are as explained below: Group A: ADHD; Attention deficiency sub-type (9 questions), Impulsivity sub-type (9 questions), combined sub-type (18 questions) Group B: ODD (8 questions) Group C: CD (15 questions) (MohamadEsmail, 2001). Child Symptoms Inventory has been assessed in different studies and its validity, reliability and accuracy have been studied. In a study conducted by Grayson and Carlson (Grayson, Carlson, 1991), accuracy of CSI-3R with respect to ODD, CD and ADHD were reported as 93%, 93% and 77% respectively. Other studies reported correlation of CSI-3R between ODD, CD and ADHD as 66%, 58% and 72% respectively (Gadow, Sprafkin, 1994). In Kalantari and Colleagues study (Neshatoost et al., 2008), validity of this inventory via Bi- Section algorithm was assessed and the result for Parent Checklist and Teacher Checklist estimated to be 91% and 85% respectively. In Mohammad Esmail’s study (2001), 9 psychiatrists confirmed content related validity of CSI-4. Based on Tavakoli and Colleagues ‘study (Tavakoli et al., 2005), reliability of Parent Checklist via retest reliability was 90%. In Najafi and Colleagues’ study, reliability of this checklist was via Cronbach’s Alpha was estimated as 90%. According to Table No2, regarding Attention Deficit Z was 5/98; it means that Attention Deficit is more prevalent among boys. With respect to Hyperactivity-Impulsivity Z estimated as 5/85. It again means that Hyperactivity-Impulsivity is more prevalent among boys. As same as Attention Deficit and Hyperactivity Impulsivity types, regarding Combined type 191 CU IDOL SELF LEARNING MATERIAL (SLM)
(Z=4/84) boys have higher tendency in comparing to girls. Viewing ODD (Z=5/86), meaningful difference is noticed between prevalence of this disorder with respect to gender. It means that boys are more prone to ODD. Considering CD Z (4/68), meaningful difference is noticed between proportions of this disorder with respect to gender. It means that boys maintain higher prevalence rate toward CD in comparing to girls. Discussion and Conclusion Current study was conducted in order to assess prevalence of disruptive behavior disorder (CD, ODD and ADHD) among preschool children. General prevalence of behavioral disorders estimated as 42/01 in a range of mild to severe. Based on Carr’s (Carr, 1999) researches, higher percentages of these disorders are noticed in urban societies rather than rural and western cultures rather than eastern. Based on recent findings, most prevalent behavioral disorders were: Hyperactivity-Impulsivity (13/78), Attention Deficiency (11/79), Combined type (9/63), ODD (5/31) and CD (4.48). General prevalence of ADHD in current study via CSI-4 estimated as 5/95 in boys and 4/41 in girls. Analysis of data showed that there is significant difference between boys and girls regarding Attention deficit disorder and it was more prevalent among boys and this result is consistent with the results of the studies conducted by Bussing and Colleagues (Bussing et al., 2010),Sadock and Sadock(2007), Halgin and Whitborne(2002) and American Psychiatric Association(2000). For diagnosis, onset of some of the symptoms should be before 7 years old and sometimes parents can’t spot this disorder till primary school (Sadock, Sadock, 2005) and teachers notice this disorder by noticing problematic learning function of the child. These children may have lower score in educational progress tests in comparing to normal children. In parents of these children, rate of hyperkinesia, antisocial behavior, alcohol dependency and substance abuse is higher comparing to parents of normal children (Sadock, Sadock, 2007). In current study, ODD was more prevalent among boys and this result is consistent with the results of the studies conducted by Cohen and Colleagues (1993), Sadock and Sadock(2007), Halgin and Whitborne(2002) and American Psychiatric Association(2000). General prevalence ofCD is in a range of 2-10% and it may differ based on different methods of collecting data. Proportion between male and female may differ as 1-3 or 1-5 based on age of individuals. Result of current study is consistent with the results of the study conducted by Sadock and Sadock(2007), Halgin and Whitborne(2002). American Psychiatric Association (2000), Anderson and Colleagues (1987), Fombonee(1994) and Carr(1999). General findings of this study about higher prevalence of these disorders in boys in comparing to girls are consistent with the results of the studies conducted by McGoey and Colleagues (2002), Whitmore and Colleagues (1997) and McDermott (1996). In their studies they discussed role of educational level of family in mental disorders. Higher prevalence of 192 CU IDOL SELF LEARNING MATERIAL (SLM)
behavioral disorders in boys may be due to higher biological vulnerability of boys in comparing to girls. Since prenatal period, boys are much more prone to prenatal death and it seems that serious diseases, inappropriate diet and nutrition harm boys more than girls. Because of small sample size of current study, generalization of the results to other cities or nations with different ethological/cultural/educational backgrounds is inappropriate and generalization should be followed precisely. The prevalence of behavioral disorders among preschool/school children should be studied more and clinicians, teachers and parents should elevate their awareness regarding this spectrum of disorders in order to be able to facilitate impeccable interventional procedures. 7.7 CO-MORBIDITY “Comorbidity refers to the occurrence of more than one disorder at the same time. It may refer to co-occurring mental disorders or co-occurring mental disorders and physical conditions.” (Australian Department of Health.) This simply means that someone has more than one condition or illness at the same time. Other terms used, but meaning the same thing, include dual diagnosis and co-occurring disorders. “Coexisting” is the preferred term in a recovery approach. “Comorbid” or “comorbidity” is more likely to be used as a medical or clinical term. Co-existing conditions used to be called ‘dual diagnosis or ‘co-morbidity’. However, the preferred language now is ‘co-existing disability or impairment’. There is information about having a mental illness and: • An intellectual disability • An acquired brain injury • Epilepsy • Dementia • Personality disorder • Other disability Intellectual disability It’s not always easy to identify mental illness or a mental health condition in a person with intellectual disability. There are a number of reasons for this. People with intellectual disability: • can’t always describe their symptoms to a doctor or psychiatrist 193 CU IDOL SELF LEARNING MATERIAL (SLM)
• may not be able to communicate very well or at all verbally • may have symptoms that are different from those described in the diagnostic guidelines for mental illnesses • may be wrongly assumed to have behavioural problems because of their intellectual disability rather than a mental illness • may have physical conditions that produce symptoms similar to mental illness • may experience side effects from medication that confuse people who come in contact with them in the community or as health professionals Acquired brain injury The Brain Injury Association of NSW defines an acquired brain injury as: “… damage to the brain that occurs after birth but is not due to an inherited disorder or degenerative disease. Damage may be caused either by a traumatic or non-traumatic injury to the head.” The NSW Brain Injury Association distinguishes between a ‘traumatic brain injury ‘and ‘non-traumatic brain injury’. Traumatic Brain Injury is damage to the brain caused by an external physical force to the head. This can happen as a result of a motor vehicle accident, assault or a fall. Non-traumatic acquired brain injury can result from tumour, brain infection, aneurysm or anoxia, drug and/or alcohol abuse, stroke, or disease such as Huntington’s disease. People with mental health conditions may also have an acquired brain injury and this can affect access to services and treatment. Acquired brain injury and mental health conditions There are various ways acquired brain injury can be linked to mental illness: • Some mental illness may be either based on or associated with a physical condition or biological process. • Some people with an acquired brain injury have psychological problems that may be made worse by their injury. • Mental illness can develop as a direct result of the brain injury because of damage of specific areas of the brain. • A person with an acquired brain injury can develop mental illness in reaction to the traumatic stress associated with the accident that caused their injury or ongoing negative experiences in life linked to the injury. 194 CU IDOL SELF LEARNING MATERIAL (SLM)
• Self-medication (such as the use of non-prescription drugs or alcohol) for mental illness may cause a non-traumatic acquired brain injury. Epilepsy Epilepsy is not a mental illness, but is a common neurological condition that affects approximately 1-2% of the Australian population. Although it is more likely to be diagnosed in childhood or in later life, it can affect anyone at any stage of their lives. People with Epilepsy experience sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain which are called ‘seizures. Some seizures are severe and are easily recognized as a seizure, whilst others are subtle and may not be noticed by most people. Epilepsy is usually effectively treated with anti-convulsant medication (such as Epilim (or Sodium Valproate)). With regular medication and a sensible lifestyle most people with Epilepsy are able to live a full and active life. Dementia Dementia is a general term that is used to describe a collection of symptoms that are caused by disorders affecting the brain. Alzheimer’s disease is the most common form of dementia, accounting for around two-thirds of all cases. Dementia can happen to anybody, but the risk of developing dementia increases with age. Most people with dementia are in the older age group, but mostly older people do not get dementia. Dementia is not a normal part of ageing, it is a brain disease. Dementia affects the way people think, behave and their ability to perform everyday tasks. Dementia may be diagnosed if a person becomes impaired in two or more cognitive functions such as in memory, language skills, ability to understand information, spatial skills, judgement and attention. The primary feature of dementia is an inability to carry out everyday activities as a consequence of diminished cognitive ability. People with dementia may have difficulty solving problems and controlling their emotions. They may also experience personality changes. Dementia is usually progressive, gradually spreading throughout the brain resulting in a person’s symptoms becoming worse over time. People with dementia may also have or develop mental health conditions, including symptoms of mental illness, such as mood and perceptual disturbances which may be treated with mood stabilizing or anti-psychotic medication. Personality Disorder Personality disorder refers to an individual’s long-term pattern of thinking, behaviour and emotions that cause them distress and makes it difficult for them to function in everyday life. People with personality disorders find it hard to change their behaviour or adapt to different 195 CU IDOL SELF LEARNING MATERIAL (SLM)
situations. They may have trouble sustaining work or forming positive relationships with others. There are several different types of personality disorders. More common personality disorders include Borderline Personality Disorder, Obsessive Compulsive Personality Disorder and Narcissistic Personality Disorder each of which has distinctive features. Unfortunately these disorders have become stigmatizing diagnoses that frequently lead to people being discriminated against both in the community and in services, because of the difficulties these people tend to experience with interpersonal relationships. Depending on their specific condition, some people with a personality disorder may appear withdrawn, some distressed and emotional, and others odd or eccentric. The one thing they have in common is that their symptoms are severe enough to affect many different areas of life. People often develop early signs of developing a personality disorder in adolescence. The exact number of Australians suffering from personality disorders is not known. People with personality disorders also have high rates of coexisting mental health conditions such as depression and substance abuse. Due to the nature of these disorders, it can be difficult for people to recognize they have a problem or to seek help. Treatment is available for people with personality disorders, and psychotherapy can help them to develop insight into their condition, manage symptoms and relate more positively to others. The first step in seeking help is to visit a doctor or mental health professional and arrange a mental health assessment. Other disability People with disabilities are at greater risk of mental health problems than other members of the community. Many factors contribute to this association including the life consequences of disability, the poor health of people with mental disorders and the circular relationship that exists between disability, social exclusion and mental health problems. There is a poor understanding across service systems as to the relationship between mental health and other disability and the integration of health care delivery at all levels. Having a mental disorder has been shown to influence both the chances of illness or impairment and the chances that an illness or impairment will have a disabling effect. The physical health of people with mental disorders is notoriously poor. Mental disorders have been shown to increase the risk of disease including heart disease, diabetes, stroke, HIV/AIDS and tuberculosis and to contribute to accidental and non-accidental injuries. This is partly due to: the associations between mental disorders and lifestyle risk factors such as obesity, smoking and the negative side effects of psychiatric medications including heart disease. 196 CU IDOL SELF LEARNING MATERIAL (SLM)
For those with an existing illness or impairment, having a mental disorder as well is associated with worse outcomes (such as complications and poor functioning), than for those without a co-morbid mental disorder. Evidence shows that people with mental disorders do not receive the same level of treatment as other people. Often the physical health of people with mental disorders are accorded less priority than other patients, and people with mental health conditions may be at greater risk of non-adherence to medical and behavioural treatment programs. How can coexisting conditions complicate a person’s wellbeing? • Conditions can be harder to diagnose or can go undiagnosed. • The person may not recognize that they are experiencing more than one condition. • The person may not want to acknowledge an issue (particularly with substance use). • Treatment may be complicated, as what helps one condition may affect the other. • The combination of conditions can impact a person’s access to specialist health and support services. What are some examples of coexisting conditions for people with mental health conditions? • Alcohol and drug use • Autism spectrum disorders • Brain injury • Intellectual disability • Gambling addiction • Physical conditions • Multiple mental health conditions Mental health conditions affect everyone differently. This also applies to people with coexisting conditions. 7.8 SUMMARY While at present there remains much that is not known about the causes of comorbidity, there is increasing evidence to suggest that simple causal hypotheses may not easily explain the association. There is a broad convergence of risk factors for both problematic substance use and mental disorders; a plausible hypothesis for the comorbidity between these disorders is that substance use and mental disorders (mood disorders, anxiety disorders, personality disorders and psychotic disorders) share common risk factors and life pathways. A number of longitudinal cohort and twin studies have explicitly examined this hypothesis and have concluded that common factors explain the comorbidity between alcohol, tobacco and cannabis use; dependence on different illicit drugs; alcohol and nicotine dependence; and nicotine dependence and major depression. 197 CU IDOL SELF LEARNING MATERIAL (SLM)
7.9 KEYWORDS • Neurodevelopmental disorders are disabilities in the functioning of the brain that affect a child's behaviour, memory or ability to learn e.g. mental retardation, dyslexia, attention deficit hyperactivity disorder (ADHD), learning deficits and autism. • Conduct Disorder (CD) is characterized by callous disregard for and aggression toward others, from pushing, hitting and biting in early childhood to bullying, cruelty and violence in adolescence. • Deceitfulness: The act or practice of deceiving: cunning, deceit, deception, double- dealing, duplicity, guile, shiftiness. • Bullying the behaviour of a person who hurts or frightens someone smaller or less powerful, often forcing that person to do something they do not want to do: Bullying is a problem in many schools. • Vindictiveness is a strong desire to get back at someone. People who hold grudges and seek revenge are full of vindictiveness 7.10LEARNING ACTIVITY 1. Study Oppositional Defiant Disorder in India ………………………………………………………………………………………………...... ………………………………………………………………………………………………….. 2. Visit a nearby school and study on Oppositional Defiant Disorder ………………………………………………………………………………………………….. …………………………………………………………………………………………………. 7.11 UNIT END QUESTIONS A. Descriptive Questions 198 Short Questions 1. What is Oppositional Defiant Disorder 2. Discuss symptoms of Oppositional Defiant Disorder 3. What are Causes and Risk factors of Oppositional Defiant Disorder 4. Discuss Early Warning Signs for Oppositional Defiant Disorder 5. What is Prevalence Rate of Disruptive Behavior Disorders Long Questions 1. What are subtypes of Oppositional Defiant Disorder using DSM criteria CU IDOL SELF LEARNING MATERIAL (SLM)
2. Discuss suggestions for intervening in a disruption 3. What to do following a disruption in Oppositional Defiant Disorder 4. What does coexisting or comorbid conditions mean? 5. What is Intellectual disability B. Multiple Choice Questions 1. According to the DSM-IV in order to diagnose a person with ODD they must meet which criteria a. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. b. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder. c. Show four or more symptoms for six months. d. All of these 2. Which of the following is NOT a typically related mental health issue of ODD? a. Anxiety b. Attention-deficit/hyperactivity disorder (ADHD) c. Depression d. Mania 3. Which of the following are tools for evaluation and identification that a person may have ODD? a. Pediatric Symptom Checklist b. ANGR - Anger Navigation and Gradation Record c. SNAP-IV d. NICHQ Vanderbilt Assessment Scale 4. Symptoms of ODD include a. Frequent temper tantrums b. Often questioning rules c. Mean and hateful talking when upset d. All of these 5. Treatment of ODD may include: a. Parent Management Training to help parents and others manage the child's behavior b. Individual Psychotherapy to develop more effective anger management c. Family Psychotherapy to improve communication and mutual understanding 199 CU IDOL SELF LEARNING MATERIAL (SLM)
d. All of these Answers 1-(d), 2-(d), 3-(b), 4-(d), 5-(d) 7.12 REFERENCES Textbook • Armstrong TD, Costello EJ (2002), Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. J Consult Clin Psychol. · • Banaschewski T, Brandeis D, Heinrich H, Albrecht B, Brunner E, Rothenberger A (2003), Association of ADHD and conduct disorder - brain electrical evidence for the existence of a distinct subtype. J Child Psychol Psychiatry • Banerjee T (1997), Psychiatric morbidity among rural primary school children in West Bengal Indian J Psychiat • Barkley RA(1987). Defiant children: a clinician’s manual for parent training. New York: Guilford. References: • Campbell SB (2002), Behavior Problems in Preschool Children: Clinical and Developmental Issues. New York: Guilford. • Campbell SB, Shaw DS, Gilliom M (2000), Early externalizing behavior problems: toddlers and pre-schoolers at risk for later maladjustment. Dev Psychopathology. • Cantwell DP, Swanson J, Connor DF (1997), Case study: adverse response to clonidine. J Am Acad Child Adolesc Psychiatry • Carey G, DiLalla D (1994), Personality and psychopathology: genetic perspectives. J Abnormal Psychol. 200 CU IDOL SELF LEARNING MATERIAL (SLM)
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