Behavioural Problems

1. In all patients, when working up a behavioural problem,

   • Ensure a thorough assessment of medical and mental health conditions (e.g., schizophrenia in adolescents and young adults) and psychosocial factors before offering a diagnosis or definitive advice (i.e., do not dismiss the problem as being “a phase,” or “hormones,” or “just adolescence”)

   • Use a validated assessment tool if available

   • Use multiple sources of information (e.g., workplace, family, school) with consent

   • Explore the patient’s own perspective, not just that of the caregiver

2. In assessing behavioural problems in adolescents specifically look for substance use, peer issues, abuse, and other stressors.

3. While assessing behavioural problems in a patient,

   • Evaluate the impact of the behaviour

   • Explore any underlying emotional distress with the patient

   • Destigmatize embarrassing behaviours

4. When making a diagnosis of a behavioural problem in a patient,

   • Avoid premature labelling of a behaviour as a disorder

   • Follow up with support and regular visits until the situation is clearer and any therapeutic requirements are more evident

5. When managing behavioural problems:

   • Assess and address immediate risk for the patient and others

   • Do not limit treatment to medication; address other dimensions (e.g., do not just use amphetamines to treat ADHD, but add social skills teaching, time management, etc.) and match to available community resources

6. When there is a challenging relationship with a patient with behavioural problems maintain a continuous, therapeutic, and non-judgmental relationship with the patient and family.

General Overview

DDx: Behavioral issues often multifactorial

• • Medical

    • Hearing/vision impairment

    • CNS (head trauma, seizures)

    • Metabolic (thyroid)

    • Toxin (lead)

    • Anemia

    • Perinatal/Genetic

  • Psychosocial

    • Child abuse/neglect

    • Housing/food

    • Substance use

    • Life Stressors (eg. family/peer issues)

    • Parental expectations/parenting style

  • Psych

    • Mood disorder (eg. bipolar)

    • Psychotic disorder

    • ADHD

    • Learning disorders

    • Autism Spectrum Disorder

      • M-CHAT screening

        • If you point at something across the room, does your child look at it? (FOR EXAMPLE, if you point at a toy or an animal, does your child look at the toy or animal?)

        • Have you ever wondered if your child might be deaf?

        • Does your child play pretend or make-believe? (FOR EXAMPLE, pretend to drink from an empty cup, pretend to talk on a phone, or pretend to feed a doll or stuffed animal?)

        • Does your child like climbing on things? (FOR EXAMPLE, furniture, playground equipment, or stairs)

    • Oppositional Defiant Disorder

    • Conduct Disorder

History

• • Ask child about his/her perception

  • Get collateral history

Physical Exam

• • Head circumference (micro/macrocephaly, increase/decreased growth velocity)

  • Weight and height (growth)

  • Dysmorphic features (hypertelorism, micrognathia)

  • Eyes (visual acuity, strabismus, cataracts)

  • Ears (hearing acuity, effusion)

  • Abdomen (organomegaly)

  • Skin (Cafe-au-lait spots for neurofibromatosis)

  • Neuro

    • Tone, strength, deep tendon reflexes, primitive reflexes

    • Midline defects, spina bifida

Use multidisciplinary approach

• • Parent management therapy (encourage parents to be more positive and less harsh)

    • Peer support groups for family (Autism Society)

  • Behavioral interventions (positive reinforcement, charts, checklists, reachable goals, set limits and clear consequences for misbehaviour)

  • Time management (schedules)

  • School-based interventions (accomodations)

  • Social skills / psychotherapy

    • Psychometric testing

DSM-V Definitions

Autism Spectrum Disorder

• Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history

  1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

  2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

  3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

• Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history

  1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases).

  2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns or verbal nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat food every day).

  3. Highly restricted, fixated interests that are abnormal in intensity or focus (e.g, strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interest).

  4. Hyper- or hyporeactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

• Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life)

• Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

• Severity

• • Level 1 "Requiring support"

  • Level 2 "Requiring substantial support"

  • Level 3 "Requiring very substantial support"

Oppositional Defiant Disorder

1. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with at least one individual who is not a sibling.

   • Angry/Irritable Mood

     • Often loses temper.

     • Is often touchy or easily annoyed.

     • Is often angry and resentful.

   • Argumentative/Defiant Behavior

     • Often argues with authority figures or, for children and adolescents, with adults.

     • Often actively defies or refuses to comply with requests from authority figures or with rules.

     • Often deliberately annoys others.

     • Often blames others for his or her mistakes or misbehavior.

   • Vindictiveness

     • Has been spiteful or vindictive at least twice within the past 6 months.

2. Impacts negatively on social, educational, occupational, or other important areas of functioning.

Conduct Disorder

1. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:

   • 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 favors 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 the parental or parental surrogate home, or once without returning for a lengthy period.

     3. Is often truant from school, beginning before age 13 years.

2. Clinically significant impairment in social, academic, or occupational functioning.

3. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Antisocial Disorder

• A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:

  1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.

  2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.

  3. Impulsivity or failure to plan ahead.

  4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.

  5. Reckless disregard for safety of self or others.

  6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.

  7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

• The individual is at least age 18 years.

• There is evidence of conduct disorder with onset before age 15 years.

• The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.