Challenging Behaviours Workshop Professor Alasdair Vance Consultant Child and Adolescent Psychiatrist Department of Paediatrics University of Melbourne Royal Children’s Hospital Email: [email protected]
Challenging Behaviours Workshop
Professor Alasdair VanceConsultant Child and Adolescent PsychiatristDepartment of PaediatricsUniversity of MelbourneRoyal Children’s HospitalEmail: [email protected]
Definition of challenging behaviours
Outline:
1. -common paediatric behavioural problems-their detection and brief assessment
2. -diagnosis of disruptive behaviour disorders
3. -diagnosis of depressive disorders
Common paediatric behavioural problems
Key Principles:
1. Common: -5-10% prevalence in our community-anxiety symptoms/disorders and disruptive behaviour/disordersmost common; similar prevalence estimatesin other cultures-anxiety symptoms include generalised anxiety disorder, specific phobia,separation anxiety disorder, social anxiety disorder;obsessive compulsive disorder; panic disorder +/-agoraphobia rare in childhood; bed wetting after alternative other physical causes excluded; somatisation-primarily headaches, stomachaches,nausea, dizziness, limb pain/reduced movement
Common paediatric behavioural problems
Key Principles:
1. Common: -rarely conversion symptoms occur, although these symptoms are more common in [1] childhoodrather than adulthood and [2] in hospital ratherthan community settings; PTSD rare, althoughtraumatic events unfortunately common-disruptive behaviour includes Attention DeficitHyperactivity Disorder (ADHD),oppositional defiant disorder, conduct disorder-depressive disorders: dysthymic disorder, majordepressive disorder
2. Externalising and internalising symptoms are commonly linked:-disinhibition, oppositional defiant behaviour,
motor restlessness can be markers of anxiety
Common paediatric behavioural problems
Key Principles:
3. Multi-informant assessment:-parent perspective, child perspective, teacher perspective, clinician/other perspective-concordance between perspectives can be low-parental attitudes towards, understanding of a givenchild’s symptoms and behaviour are crucial to the priorities of the treatment plan at any given time
4. Family context:-family system’s flexibility and adaptiveness tochange within the life cycle
Common paediatric behavioural problems
Key Principles:
5. Developmental context:-the social and cultural forces that shapethe nature and strength of the interpersonallinks between a given child and their family members and school peer group/teachers need to be considered in the longitudinal assessment
6. Developmental context:-age, gender, IQ
Common paediatric behavioural problems
Key Principles:
7. Comorbid developmental vulnerabilities:-speech/language, fine/gross motorcoordination, specific learning difficulties
Oppositional defiant disorder
-a recurrent pattern of negativistic, defiant, and hostile behaviour
-onset usually before 7 years of age
-usually first emerges in the home setting
-always a precursor for Conduct disorder (approximately 3% ofchildren with ODD develop CD)
-prevalence (2%-16%) have been reported (Loeber et al. 2000)
-comorbid conditions: ADHD, combined type, language learning difficulties
Conduct disorder
-repetitive and persistent pattern of behaviour in whichthe basic rights of others and/or major age-appropriate normsor rules are violated, evidenced by three or more of the following criteria within the previous 12 months, with at leastone criterion present in the past 6 months:
Aggression/Cruelty towards people and/or animalsDestruction of propertyTheftSerious violations of social rules/norms
-behaviours are clinically impairing in the domains of social, academic or occupational functioning
->/= 18 years of age, criteria for antisocial personality disorder not met
ADHD
-six or more symptoms, at least six months duration, maladaptive/inconsistent with developmental level-inattention dimension and/or hyperactivity-impulsivity dimension
-evident in at least two settings-onset before seven years of age-impairment in social, academic, occupational functioning-symptoms not due to a PDD, Psychotic, Mood, or Anxiety Disorder
subtypes: combined type, inattentive type, hyperactive-impulsive type
Major depressive disorder
– one or more major depressive episode(s)characterized by the following: period of two weeks or more -depressed and/or irritable mood predominant and/or-loss of interest or pleasure-3 or 4 or more of the following; feelings of worthlessness or excessive or inappropriate guilt,>5% weight change in a given month, in/hyper somnia, psychomotoragitation/retardation, anergia (fatigue),decreased concentration or ability to think or decisiveness, recurrentthoughts of death, suicidal ideation, suicide plan or suicide attemptsymptoms cause impairment in interpersonal, social, academic,occupational functioningnot due to a substance, medical condition or bereavement
Dysthymic disorder
is characterized by the following: 1 year or more (most of the day, for more days than not), <2 months absence in a given year
-depressed and/or irritable mood predominant-2 or more of the following: feelings of hopelessness, low self-esteemappetite change, in/hyper somnia, anergia (fatigue), decreased concentration or decisivenessno major depressive episode evident in first year of the symptomssymptoms cause impairment in interpersonal, social, academic,occupational functioningnot due to a substance, medical condition or bereavement
Summary
-Careful and systematic assessment
-Multi-informant reports used
-Age, gender, IQ effects considered
-Comorbid conditions considered
-Longitudinal assessment performed
Medication treatment
Outline:
-key principles of medication use
-key types of medication in clinical use
Medication treatment
Key Principles:
1. Medication:-‘do no harm; least number and the lowest dosepossible’
-clear goals that include the following: 1. arousal regulation2. mood regulation3. executive functioning-planning, organising
prioritising abilities4. motor acitivity, for example, restlessness-diagnosis driven medication use is debatable-systematic clinical research is imperative
Medication treatment
Key Principles:
2. Synergism between medication and psychological interventions:-particular goals for both medication and psychological treatments that are interdependentand additive
3. Developmental Context:- the prioritisation of particular interventionsgiven a child’s developmental stage
4. Monitoring of psychological and medication interventions:
5. Coordination of other specialised treatment programmes:- speech therapy- occupational therapy- psychology/educational psychology
Medication treatment
Key Principles:
6. Referral to specialist mental health services should be considered if any of the factors below fail to be achieved:
- Engagement- Negotiate a management plan- Gain multi-informant information- Assess and monitor treatment goals- Goals of treatment not being met- Enmity between key informants prevents any of the above
A model for intervention
-assessment and treatment focuses on delineation of risk factors andresilience factors-biologically (eg, executive function deficits; good arousal regulation) psychologically (eg, externalise blame; balanced critical self-reflection) and socially (eg, hostile critical interpersonal environment; confiding, nurturing consistent interpersonal environment)
-monitoring of these risk and resilience factors and their response totreatment through developmental phases
A model for intervention-a practical approach
[A] psychological and social treatment approach implementedfor 4-6 weeks (may take 6 months of new habit formation beforesustained behavioural change)
key elements are the interpersonal and the intra-individual milieuinterpersonal: positive reinforcement, response cost, token economy, contingency planning (turn taking, active listening, active ignoring, empathy skills, etc), making and keeping friendsintra-individual: controlled breathing, muscle biofeedback,guided visual imagery
A model for intervention
- a practical approach
[B] key other vulnerabilities addressed – vision, hearing, specific verbal and/or visuospatial learning difficulties, developmental coordination difficulties, speech and language difficulties
A model for intervention
a practical approach
[C] medication use to facilitate availability of the young person to learn from the psychological and social interventions through
better executive functioningbetter mood regulationbetter arousal regulation
A model for intervention
Summary- medication can aid a child’s ability to invest ina psychosocial treatment program and learn from this program
- can take 6 months of practice before new habits are formed
- biological and psychosocial treatments maximize resilienceand minimize risk factors through shared effects on the brainand the mind
A useful clinical model for understanding these problems
Executive functioning
Response inhibition: motor and cognitionoptimise response speed and accuracy
Working memory: verbal and visuospatialoptimise span and strategy
A useful clinical model for understanding these problems
Mood dysregulation: decrease irritabilityincrease emotional salience
Arousal dysregulation: optimise physiological arousaloptimise habituation
Useful medication approaches
Response inhibition:
motor and cognition stimulant medication-linear dose response
speed and accuracy clonidine higher dose
Working memory:
span stimulant medication-inverted parabolic response
strategy stimulant medication-linear dose responseclonidine higher dose
Useful medication approaches
Mood dysregulation:
irritability stimulant medicationSSRITCAantipsychotic medication
emotional salience stimulant medicationSSRI?TCA?
Arousal regulation:
physiological arousal clonidinebenzodiazepinesTCAantipsychotic medication
habituation response clonidinebenzodiazepinesTCA?antipsychotic medication?
Executive functioning
- stimulant medication is the first line treatment
short-acting forms: methylphenidate, dexamphetamine long-acting forms: OROS-methylphenidate, LA-methylphenidate
clear and substantial evidence for methylphenidate efficacy up toa dose of 60mg daily for treatments periods of approximately 12 months
methylphenidate and dexamphetamine similar efficacy and adverse effects profile although individual preferences manifest
Executive functioning
- Stimulant medication benefits
decrease core symptoms of ADHDdecrease aggressionincrease quality of social interactionsincrease compliance
- Stimulant medication indications
ADHD diagnosis and psychosocial interventions insufficient
Executive functioning
- Stimulant medication adverse effects
initial insomnia,appetite suppression
nervousness, restlessness, dysphoria,easy crying, agitation, depressive symptoms, stomach acheheadache, dizziness, rash, motor tics, mannerisms
in overdose: delirium, sweating, tremor, twitching, vomiting
Executive functioning
- Stimulant medication adverse effects
growth retardation (MTA 3y f/u: 2cm /2.7kg )weight loss
epileptic seizures not adverse effects but careful psychotic episodes monitoring neededabuse potential in vulnerable patients
Executive functioning
- Atomoxetine is the second line treatment
specific potent noradrenaline re-uptake inhibitor indicated when stimulant medication ineffective,associated with significant adverse effects
common adverse effects: nausea, drowsiness, initialinsomnia, appetite suppression
Executive functioning
- Imipramine is a third line treatmenttricyclic compound similar to atomoxetine(a phenylpropanolamine derivative) but with lessspecific noradrenaline effect and significant cardiac adverse effects
- Clonidine is a third line treatmentcentral α-2 noradrenergric agonistsignificant effect; primarily hyperactivity/impulsivenesssignificant drowsiness, hypotensive and cardiac adverse effectsgradual withdrawal because of rebound hypertension and tics
Executive functioning
- Neuroleptic medication is a third line treatmentatypical neuroleptic medication: eg risperidone / aripiprazolelow doses (up to risperidone 1.5mg daily equivalent)severe aggression, affective lability, PDD, ID
typical neuroleptic medication: eg pericyazine - thioridazineequivalent (now withdrawn)
third line treatments only used with careful monitoring and involvement in a treatment-resistant unit
Executive functioningConclusion
- start low, go slow, finish slow, although ensure optimal dosesare used
- medication facilitates each child’s ability to learn in the classroom, playground and home environment: new habitscan take 6 months to evolve
- Comprehensively assess and treat with approved medicationand/or psychosocial treatments all comorbid conditions
Mood regulation
- SSRI fluoxetine first line treatment
clear and substantial efficacy in the short and longer-terms4-6 weeks for clinical effect; can be earlier
primary adverse effects: nausea, drowsiness, initial insomniairritability, increased inner tension, suicidal ideation (rare)\
monitor first 5-7 days daily, then weekly
1-2 terms (3-6 months) duration of use before trial of weaning
We need an adequate evidence base for medication treatment,psychosocial treatment and their combination….
In the context of
careful
systematic
comprehensive
training…
TRANSLATIONAL CLINICAL SCIENTISTS
From laboratory bench, social/cultural factors toclinical practice
Tools for Translation: 2008
Genes Cells Systems Individual SocialWGASSequencingTransgenicsEpigeneticsDatabases
Stem CellsTranscriptprofilesProteomicsOpticalimagingDatabases
Electrode ArraysZebrafishPETfMRIDTIDatabases
SensorsEye gazeCognitivetools
Web 2.0Knowledgemanagement
Repositories – Data Sharing - Integration
Future research directions
Outline:
-individual tests of treatment responsivenesssymptoms, cognition, neurophysiological measures
-individual pharmacogenomics
ADHD: developmental stages
Common possible developmental pathways: all associated witheducational, social, occupational under-achievement, alcohol/substance abuse/dependence disorders, altered adult personality
childhood adolescence adulthood
ADHD-CT ADHD-IA ADHD-IA
ADHD-CT Depressive d Depressive d
ADHD-CT Conduct d ASPD
r2= .52
-1-0.5
00.5
11.5
22.5
-4 -2 0 2 4 6Cognitive z-composite score
Beh
avio
ural
z-c
ompo
site
scor
e
r2 = .73
-2
0
2
4
6
-4 -2 0 2 4 6Cognitive z-composite score
Beh
avio
ural
z-c
ompo
site
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e
Composite z-scoresADHD children in thelow dose and high dose Condition (dex. 2.5mg/7.5mg) (Mollica et al.,Human Psychopharmacology 2004)
Spatial working memory task - CANTAB
0
5
10
15
20
25
30
35
40
BSE2 BSE3 BSE4 BSE6 BSE8
Level of Difficulty
Bet
wee
n Se
arch
Err
ors
(mea
n)
ADHD-CT(um)ADHD-CT(m)Controls
Total cerebral growth curves
900
1000
1100
5 7 9 11 13 15 17 19 21Age (y)
mL
NV Males
ADHD Males
NV Females
ADHD Females
Castellanos et al., JAMA 2002
Controls > ADHD
p<.003
Silk, Vance et al, B J Psych 2005 N=14, CBCL inattention subscale T score: 72.23 (10.72)
Region of activation BA C (mm) ZControl Group greater than ADHD-CT GroupParieto-Occipital
R Precuneus 19 24 -70 32 3.53R Cuneus 19 32 -90 28 2.82
Posterior ParietalR Inf. Parietal 40 36 -40 50 2.82
Frontal/SubcorticalR Caudate Nucleus, Body 18 -12 22 2.82
Vance et al, Mol Psych 2007 N=24, CBCL inattention subscale T score: 72.14 (9.43)
N=14, CBCL inattention subscale T score: 70.88 (9.75)
Cognitive deficits in ADHD are associated with thesekey candidate genes:
Healthy children:
DAT1 3’ VNTR 10-repeat alleleDAT1 intron 8 VNTR 3-repeat allele R spatial inattentionDAT1 3’ UTR VNTR 10-repeat allele (η2 = .07/.08/.08)
- this 10/3DAT1 haplotype – ADHD (OR 2.58)