Behavioural problems in children and school refusal

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					Behavioural problems in

      G Mustafa.
                        Case 1
   Richard 12 yr old boy found to be missing school

   You have done the physical examination and ruled
    out any organic cause for his symptoms – none found.
   It this a case of school refusal or truancy?
   Can u identify factors contributing to his behavioural
   How would you go about managing this case?.
Factors contributing to Richard’s
                                 Anxiety disorder
                                    in mother

 Weak marital                                                        Maternal over
  relationship                                                        protection
 of his parents.                                                   and over concern.
                               SEPERATION ANXIETY
                              leading to school refusal.

             Over closeness
                                                       Inadequate support
                                                            to mother
            over dependence
                                                         from his father.
               on mother
          School Non-attendance.
   10% absent from school at any one time.
   Children do not attend school for a variety of reasons
    not all related to mental health issues.
   Physical illness – commonest cause
   Parental withholding
   Truanting – staying away from school without the
    school or parents know anything about it.
   School refusal - difficulty attending school due to
    emotional stress.
   Wilful or deliberate non-attendance
   Children can be off because of a variety of above.
    2 Big groups of non-attenders
SCHOOL REFUSAL.                      TRUANCY
 Severe emotional ,may include       Lack of anxiety or fear
  anxiety , somatic symptoms or
  temper tantrums.                     about attending school.
 Child remains symptoms free         Child conceals absence from
  during weekends and holidays.        school
 Parents aware child’s absence       Frequently shows disruptive
 No significant anti-social           problems such as stealing,
  behaviour like fighting and
                                       fighting, lying) often in
                                       company of antisocial peers.
 Child feels safe at home and
  might be happy to do school work    Lacks interest in school
  at home.                             work and doesn’t stay at
         Interesting observations.
   Berg et al. (1993)– 80 children aged 13-15 who did
    not attend school for at least 40% of school term.
    Outcome: half the sample had no significant
    psychiatric problems, 1/3rd had disruptive behaviour
    disorder, 1/5th had severe anxiety or depressive
   Bools et al (1990)- 100 school refusal cases, = half
    met criteria for psychiatric problems
   boys = girls
   Any age but peaks at school entry age then at transfer
    to secondary school and in adolescence .
        Causes of school refusal.
Separation anxiety :
- Most common cause
-   Common in younger age
-   Can have somatic symptoms
Social phobia:
  – Common in older children
  - Have more severe school refusal.
Other disorders:
-   GAD or depression – seen mostly in adolescents
-   Specific phobias e.g.. Public transport.
-   Oppositional defiant behaviour. (ODD)
      Causes for separation anxiety in school
                   refusal cases.
Negative re-enforcement
                                                             Positive re-enforcement

                 Avoidance of negative
                        emotions.               Obtaining attention
                   ( stress, anxiety,         from significant others
                      depression)                    (parents)

                  Escape from evasive
                     social situations          Seeking tangible
                        ( bullying)              re-enforcement
                 or evaluative situations           or rewards
                ( interaction with others /   (watching TV, sleeping)
    Management of school refusal.
  CBT session for child and family, followed by gradual return
   to school
 Education and support treatment - parents

 Three pronged approach in most cases :

 1- Liaison with school to implement gradual re introduction.
 2- Individual interventions. i.e CBT
 3- Family work to address specific family issues and assist
   family to cope with developmental challenges.
 Home tutoring as a last resort . Think about pupil referral units
   and ultimate re-integration into school.
                         Management (cont.)
 Referral to paediatrician
 Referral to CAMHS

 Referral to EWO (Educational Welfare Officer, also called
  educational social worker)
 Some areas have local tutorial units ( pupil referral units)

 Usefull sites for parents / carers :

Reference : WHO guide to mental and neurological health in primary care
            Case studies in child and adolescent mental health – MS Thambirajah
            oxford specialist handbook – child and adolescent psychiatry.
                    CASE 2
   Dylan, 8yr old, suspended from school for
    abusive and aggressive behaviour
   What condition would his behaviour fit into?
   What risk factors can you identify for his
    behavioural problem?
   What advice and management can you think
                CASE 2 cont.
Risk factors for Dylan's behaviour:
 Poor or non existent family network or support.

 Inadequate supervision at home

 Exposure to media violence due to lack of

 Lack of consistency in parenting styles due frequent

  changes in care givers – mum ,dad, carers
 Family h/o of ASB and substance abuse.
               CASE 2 (cont.)
Management plan :
 Parental Education – very important.

 Reduction of risk factors which have been identified.

 Consistent management of Dylan's violent and
  aggressive behaviour across school and home.
 Regular meetings with mother and his school.

 A formal cognitive assessment to identify gaps in
 Parent management training and other psychological
                   Case 3
6 yr old boy with mum concerned about his
  behaviour since early childhood, now school
  has been complaining about his behaviour.
1- What's the diagnosis doctor!
2- Identify the risk factors?
3- How would you manage him ?
     Oppositional Defiance Disorder
    (ODD) & Conduct Disorder ( CD)
                              DSM IV
                                  CONDUCT DISORDER
                                      Aggression to people – bullying
   Markedly defiant and               threatening, intimidating,
    disobedient and provocative        initiating physical fights
                                      Using weapons to cause
   Active defiance of adult           damage,
    requests or rules.
                                      Deceitfulness and theft
   Deliberately annoying
                                      Destruction of property,
                                       intentional fires.
   Angry, resentful and easily
                                      Serious rule violations – staying
    annoyed by other people
                                       out at night, running away from
   Blaming other people               home, truancy.
   Loose temper readily.             Forcing others into sexual
         Characteristics of ODD.
   Control :
-   Intractable and difficult to control
-   Conflicts at bedtime and meal times.
-   Food refused and thrown around the room.
-   Prolong tantrums several times / day.
-   Conflicts around getting ready for school.
   Aggression :
-   Verbal if they can talk,
-    Physical mainly aimed at parents, rarely others,
-   Frustration results in immediate attack. This may
    result in the child being isolated and found
        Characteristics of ODD
   Activity:
– Child restless and difficult to settle since birth,
-  Feeding is usually a problem,
-  Lack of concentration or paying attention
-  Anxiety -Panic reaction when mum out of site.
-  Breath holding attacks –(18mnth – 4 yrs) hold
   breath at culmination of tantrum, response to
   frustration. In minority can result to LOC and brief
   convulsion adds to parental anxiety
      Aetiology and risk factors.
Biological :
- Familial clustering of ODD, CD, ADHD and
  substance use disorder.
- Deficient nutrition and vitamins.
- Abnormalities in prefrontal cortex.

- Physical illness affecting CNS.

- Adverse temperamental characters from birth.
Psychological factors.
- Deficient social learning and information processing.

- Reading problems.
      Aetiology and risk factors.
Social factors
- Low socioeconomic status

- Peer relationship difficulties.

- Parental mental health issues.

- Parental drug abuse and criminality.

- Parental disharmony, family dysfunction.

- Erratic harsh discipline, rejection, low parental
  involvement in child’s activities.
- Child maltreatment neglect and abuse.
Clinical interview with parents:
-  Description of current problem
-  Developmental history of child
-  Medical history and physical examination
-  Parenting behaviour
-  Social history
-  Consider ethnic and cultural issues
Interview with child or adolescent:
-  Child may not perceive their behaviour as a problem . Build a
   working relationship with the young person.
-  Observe child – parent relationship
Collateral information:
From teachers, others in regular contact with the young person,
  social worker, health visitor etc.
Psychological and neuropsychological assessments
Specific questionnaires and rating scales.
- Child behavioural check list
- Conner's parent and teacher rating scales.
- Eyberg child behaviour inventory
Differential diagnosis and presence of co-morbidities
- Mental retardation
- PTSD, adjustment disorder, anxiety disorders
- Depression, psychoses
  Depends on severity and how disabling it is.
 Practical behavioural advice : change in parental behaviour –
   reward good behaviour, ignore or succeed in not giving
   attention to ‘bad’ behaviour
 - Negative reinforcement trap – parental command  child
   refuses to comply and protests parent may give in or give up
   to stop child from protesting or complete task in a more timely
   manner  child learns loud protest and defiance are effective
   in overcoming undesirable parental directions.
 - Positive reinforcement trap – child misbehaves  frequent ,
   effective parental attention ( which otherwise would be
   considered as normal and good parenting ) a powerful
   reward to a difficult child.
   Parent management training :
-   Supported by substantial evidence.
-   NICE recommends group based parent training.
-   Focuses more on parents, addressing parental ,
    family, community issues.
-    Daily behaviour charts and establishing points
-    40 – 50% parents drop out for a variety of reasons.
-   Also service is not widely available
Other psychological interventions :
- Individual behavioural therapy, CBT.

- school based interventions, family therapy.
- No evidence to support effectiveness so far.

 Social measures – support with housing
 Not much role for medication

Case studies and child and adolescent mental health, MS Thambirajah
Oxford specialist handbook in child and adolescent psychiatry.
            Where do we fit in?
   Validate parents concern.
   Assess and refer for diagnosis and treatment.
   Collaborate with regional CAMHS for a
    consistent approach.
   Monitor and support the family.
   Ensure programmes are consistently conducted
    by carers.
   Assist with referral and coordination of other
    services needed.