BEHAVIORAL DISORDERS & LEARNING DISABILITIES.pptx

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1. BEHAVIORAL DISORDERS & LEARNING DISABILITIES PRESENTER: Dr. Halima Simin MODERATOR: Dr. Naveen Kumar

2. BEHAVIORAL DISORDERS Behavioral problems include disorders that represent significant deviation from normal behavior . It is necessary to differentiate between mischevious children and actual child behavior problems.

3. COMMON BEHAVIORAL PROBLEMS Habit problems Problems of eating Sleep disorders Speech disorders Personality disorders Antisocial disorders

4. Based on agegroup 1. INFANTS AND TODDLERS Repetitive behavior Breath holding spells Thumb sucking Nail biting Stranger anxiety Evening colic Temper tantrums

5. PRESCHOOL AGE Lack of clarity of speech Stuttering Tic disorders Encopresis Sleep disturbances SCHOOL AGE Stuttering Sleep problems Eneuresis Encopresis School phobias Maladjustment Conduct disorders

6. ADOLOSCENT AGEGROUP Juvenile delinquency Eating disorders Conduct disorder Oppositional defiant disorder

7. FACTORS ASSOCIATED WITH BEHAVIORAL PROBLEMS CHILD: Health Development Coping mechanisms PARENTS: Misinterpreted behavior Mismatched expectations Parenting styles Coping mechanisms

8. Thumb sucking It’s a sensory solace to infants and toddlers to cope with stressful situations Mostly given up by age of 2 years, however if it persists beyond 4 years it leads to sequalae such as Malocclusion Misalignment of teeth Difficulty in mastication and swallowing May cause deformity of thumb and speech difficulties Lisps Management : Parents should be counselled regarding the self limiting nature Positive feedback is helpful when the child is not doing the act Use of bitter agents or typing a cloth to the thumb is not the first line approach

9. Repititive behavoiur Benign and self-limiting Begin between 6-10years Eg : Head-banging, body rocking Head-banging is seen I 5-20% of children during infancy and toddlers years Can result in abrasions, callus formation Management : Reassure the parents teach parents to ignore it

10. Temper Tantrums Seen in children between 18months to 3 years due to development of autonomy Child displays defiance/ negativisms Gets reinforced when parents responds to it with punitive anger. Management: Parents are advised to pay attention to the child, have open communication, have consistency in behaviour During the temper tantrum: parents are to ignore the child and when the child is calm, explain that such behavior is not acceptable Verbal reprimand should not be abusive Never beat or threaten the child Impose time out

11. Breath holding spells It is a behavioral problem in infants and toddlers Child cries and then holds breath until limp Cyanosis may occur; sometimes loss of consciousness or even convulsions It is a child’s attempt to control the environment It is a benign condition and not associated with epilepsy in any manner Types: 1. Cyanotic 2. Pallid 3. Mixed

12. Cyanotic spells are the dominant type Iron deficiency, with or without symptoms, may be present and some children with breath holding spells respond to iron therapy Medical conditions to rule out include seizures, dysautonomia, cardiac arrhythmias and CNS lesions Management: Help parents intervene before the child is highly distressed Parents can be instructed to calmly remind child of the expected behaviour and the consequences If child doesn’t comply, should be placed in time out Time out can be effectively used in children upto age 10 years Reinforce positive behaviour

13. Eneuresis Enuresis is defined as normal nearly complete evacuation of the bladder at wrong place and time at least twice a month after the 5 th year of life. Primary : bed wetting in children who have never been dry for extended periods (3 times more common in boys) Secondary : the onset of wetting after a period of established urinary continence Causes of bed wetting: Neurological-developmental: delayed development other neurological developmental issues these can range from mild to severe. Infection: less than 5% is caused by infections like UTI usually associated with secondary nocturnal eneuresis and daytime wetting Physical abnormalities: Smaller than normal bladder Stress Psychological Improper toilet training

14. Investigations : Full medical history Time/duration/total incidents Genital and neurological examination Rule out diabetes chronic renal failure Examination of urine for albumin sugar microscopy If the child has evidence of UTI he should be further evaluated with ultrasound voiding cystourethrogram and urodynamics studies

15. Treatment options: Waiting : almost all children will outgrow bed wetting Bed wetting alarm : which sound a loud tone when they sense moisture. This can help condition the child to wake up at the sensation of a full bladder Desmopressin : it is a synthetic replacement for ADH- 20 to 40 micrograms nasal spray for 4 weeks Tricyclic antidepressants like amitriptyline Dry bed training : consists of a strict schedule of waking the child at night attempting to condition the child into waking by himself or herself Decrease fluid intake after 5:00 PM Teach bladder stretching exercises Remind child to empty bladder second hourly

16. Encopresis Encopresis is repeated involuntary or intentional passage of feces into inappropriate places. The event must occur at least once a month for at least 3 months and the developmental age of the child must be at least 4 years. The faecal incontinence must not be due to effects of a substance like laxatives or a General Medical condition. 2 types: Primary : child has never achieved faecal continence by 4 years. it is frequently observed as a result of neglect, lack training methods, mentals abnormalities and familial causes. Secondary : more common in males than in females, It is in a child over 4 years of age after a period of established faecal continence

17. Causes : moving to new school unfamiliar toilet facility anal fissures involuntary retention because of emotional problems disturbed mother child relationship Clinical manifestations: hard pellet like stools stiff posture standing at corner red face hiding behind furniture refusing to go to school offensive odour children not liked by peer group and rejected by parents

18. Management: Thorough history Physical assessment Healthy child to sit toilet at routine intervals Diet management with high fiber Decrease milk products and dairy products Behavioral therapy Family counselling

19. EATING PROBLEMS Pica The child may develop habit of eating non edible substances. This is normal up to 2 years of age. Persistence of this habit beyond 2 years may be a manifestation of parental neglect or supervision or lack of affection Predisposing factors are : parental neglect, poor supervision, mental retardation, family disorganization, autism. Screening indicated for iron deficiency anemia worm infestation lead poisoning Family dysfunction In case of these causes, treat accordingly Pica usually limits in childhood by itself

20. Anorexia nervosa It is the most common chronic illness for teenage girls. It is a psychosomatic disorder and is characterised by self starvation stemming from an intense fear of gaining weight and distorted body image Causes Genetic neurobiological factors nutritional factors zinc deficiency causes a decrease in appetite Psychological factors social and environmental factors

21. Signs and symptoms: extreme concern with body weight and shape feeling fat despite dramatic weight gain fear of weight gain denial of hunger excessive exercise regimen loss of menstrual periods avoidance of meal times reduction of bone density resulting in osteoporosis fainting and fatigue hair loss excessive hair growth all over the body

22. Management Diet management Set a goal convince the patient and meet the goal slowly Practice good eating habits Behavioral support in the form of positive eating behaviour Clearly defined diet modification plan and follow Address thoughts, feelings and beliefs concerning food and body image Treat any physical complication and associated mental health problem

23. Bulimia nervosa It is characterised by episodes of binge eating followed by inappropriate methods of weight loss in the form of purging. Symptoms: Eating uncontrollably Purging Strict dieting Using the bathroom frequently after meals Vomiting blood Depression or mood swings Heartburn Bloating indigestion constipation Dental problems Bloodshot eyes Swollen glands in neck and face

24. Medical complications : dental cavities stomach ulcers rupture of the stomach and oesophagus electrolyte imbalance dehydration abnormal buildup of fluid in the intestines Management : treatment focuses on breaking the binge-purge cycles behavioral modification techniques individual and family counselling antidepressants may also be used in case of depression support groups

25. SPEECH PROBLEMS STUTTERING It is a defect in speech characterised by hesitation or stumbling and spasmodic repetition of some syllables with pauses. There is difficulty in pronouncing the initial consonant and it is caused by spasm of lingual and palatal muscles. Usually seen in age groups 2 to 5 years. Major cause is environmental and emotional stress Management: Reassure the parents that between the age group it is normal and they should not show undue concern and accept his/her speech without pressurrising him Older children should be referred to speech therapist.

26. DISRUPTIVE, IMPULSE CONTROL AND CONDUCT DISORDERS Oppositional defiant disorder is a pattern lasting for at least 6 months of angry, irritable mood, defiant behaviour or vindictiveness during interaction with at least one individual who is not a sibling. The severity of the disorder is considered mild if symptoms are confined to one setting, moderate if at least 2 settings and severe it more than 4 settings Intermittent explosive disorder: recurrent verbal or physical aggression that is grossly disproportionate to the provocation. The outburst typically last less than 30 minutes and frequently in response to a minor provocation by close intimate Conduct disorder: repetitive and persistent pattern for at least 12 months of serious rule violating behaviour there is aggression to people and animals destruction of property deceitfulness and serious rule violation.

27. The prevalence of ODD is approximately 3% and in pre-adolescence It is more common in males than females 1.4:1 Some of the earliest manifestations are stubbornness, defiance and temper tantrums It often precedes the development of conduct disorder but also increases the risk for development of depressive and anxiety disorder Rates of ODD are much higher in children with ADHD which suggest shared temperamental risk factors. Risk factors: biological risk factors like perinatal or postnatal insult cognitive and linguistic impairment poor frustration tolerance and impulsivity ineffective parenting family genetic liability

28. Management Early intervention and diagnosis becomes key to preventing major sequalae as these children are at higher risk of developing anxiety and depression. Cognitive Behavioral therapy Parent training 2 classes of medication- stimulants and atypical antipsychotics(like risperidone)have strong evidence for the management of impulse and aggressive behaviour.

29. ATTENTION-DEFICIT /HYPERACTIVITY DISORDER ADHD is the most common neurobehavioural disorder of childhood. Characterised by inattention; poor impulse control; motor overactivity and restlessness. Etiology : No single factor has been identified Mothers of children with ADHD are more likely to have birth complications Maternal drug abuse Maternal smoking, alcohol usage and pre/postnatal exposure to lead are usually linked with ADHD Genetic component: DAT1 (Dopamine transporter gene) and DRD4 ( Dopamine 4 receptor gene) are implicated. Structural and functional abnormalities have been identified in brain of children with ADHD Brain injury increases rsisk Psychosocial family stressors

30. Prevalence: 5-10% of school-age children are affected In adoloscents , prevalence is 2-6% Pathogenesis: Children with ADHD have 5-10% reduction in volume of brain structures, especially prefrontal cortex and basal ganglia. Functional MRI shows deficits in dispersed functional network for selective and sustained attention in ADHD that include striatum, prefrontal region, parietal and temporal lobes. Dopamine hypothesis : Disturbances in dopamine system maybe related to onset of ADHD.

31. Types: 1 . Inattentive: More common in females and higher rates of anxiety and low mood 2. Hyperactive- impulsive 3. Mixed Clinical Criteria: According to DSM-5: Children between 5-12years with Behaviour that is developmentally inappropriate for age Must begin before 12years Present for atleast 6months Present on 2 or more occasions Reported by independent observers Must not be secondary to another disorder

32. Diagnosis: 1 . Clinical interview and History 2. Behavior rating scales ( Vanderbeit ADHD diagnostic rating scale. Conner rating scale, ADHD rating scale 5) 3. Physical examination and Lab findings: No lab tests are available to identify ADHD in children. In the presence of hypertension, ataxia or symptoms of sleep or thyroid disorder- should prompt further neurological or endocrine diagnostic evaluation. Identify any possible vision or hearing problems. Consider testing for elevated lead levels.

33. Treatment: Psychosocial treatment : Behaviorally oriented treatment geared towards behaviour management occurs in 8 to 12 sessions. the goal is to identify targeted behaviours that cause impairment in a child’s life. the clinician should guide the parents and teachers in setting appropriate expectations consistently implementing rewards to encourage desired behaviour. Medications: psychostimulant medications like methylphenidate, amphetamine and dextroamphetamine. longer acting once daily forms of these are available over the first 4 weeks position should increase the medication dose as tolerated No response: use a second class of stimulant No response: Atomexetine - (noradrenergic reuptake inhibitor)0.3 milligram/kg/day titrated over one to 3 weeks Guenfacine and Clonidine

34. Impacts of ADHD

35. AUTISM SPECTRUM DISORDER It is a neuro biologic disorder with onset in early childhood impairment in social communication and social interaction accompanied by restricted and repetitive behaviour is seen Diagnostic criteria according to DSM 5 there is focus on symptoms in 2 primary domains Epidemiology: prevalence is one in 59 persons as per CDC 4:1 male predominance Prevalence is increased in siblings particularly in identical twins

36. Etiology : Thought to result from disrupted neural connectivity and it’s primarily impacted by genetic variations affecting early brain development Functional studies show abnormalities of processing information numerous genes involved in brain development and synaptic functions have been associated Heterozygous mutations in genes search as present in deletion or duplication of 15Q11.2 or 16P11.2 may have variable expression within a family Environmental contributions : older maternal or paternal age Maternal obesity/ overweight Premature birth certain prenatal infections like rubella and cytomegalovirus individuals with genetic vulnerability may be more sensitive to these environmental factors Previously some vaccines were implicated however no evidence was found to support this claim

37. Differential diagnosis language disorder global developmental delay hearing loss children with ADHD social anxiety obsessive compulsive disorder Landau kleffner syndrome

38. Comorbid conditions: 50% of individuals with ASD have intellectual disability associated language impairments gastrointestinal problems such as Constipation, esophagitis and gastroesophageal reflux disease are reported in up to 70% of children epilepsy occurs in up to 35% higher risk of disorders of attention, anxiety and mood disorders sleep problems including delayed sleep onset and frequent right waking restrictive feeding patterns and food selectivity

39. Screening: Modified checklist for autism revised follow up interview(MCHAT-R/FU): a 20 item parent report measure used from age 16 to 30 months Assessment: Direct observation of the child to evaluate social skills and behaviour. Tools such as autism diagnostic observation schedule second edition (ADOS-2) and autism diagnostic observation schedule toddler module (ADOS-T) Medical evaluation includes detailed history and physical examination measurement of head circumference evaluate for dysmorphic features and screening for tuberous sclerosis Audiological test to rule out hearing loss Genetic testing : Chromosomal microarray and Karyotyping Fragile X DNA test in males MeCP2 sequencing in females

40. Treatment and management: Educational: Intensive behavioral therapies are done Educational approaches such as the treatment and education of autistic and communication handicapped children (TEACHH) Augmentative communication approaches using photographs or pictures icons can improve comprehension and ability to communicate Social skills program that include training peer mentors Occupational and physical therapy training in life skills and vocational skills 2. Co-occurring conditions Seizures should be managed with appropriate medications GI problems to be managed Promote sleep hygiene Nutrition counselling and behavioural based feeding therapy treating any Co occurring attention and mood disorders

41. 3. Pharmacology There are no medications to treat the core symptoms of ASD Intranasal therapy with neuropeptide oxytocin may improve social functioning Stimulant medications may be used for ADHD in ASD SSRI for anxiety and OCD Clonidine may be used for sleep onset Risperidone and aripiprazole reduce irritability, aggression and self injury

42. LEARNING DISABILITY Learning disability has been defined as a neurodevelopmental disorder of biological origin manifesting in learning difficulties and problems in acquiring academic skills, which are markedly below age level. LD manifests during early school years and it is not attributed to intellectual disabilities, or neurological or motor disorders. The difficulties should last for at least six months, to warrant a diagnosis. The reported prevalence in India ranges from 1.6%-15%, varying based on age-range, survey method, tool used, and region of the country.

43. Types of Learning Disabilities 1. Dyslexia: Dyslexia or reading disability is a specific type of reading disorder caused by deficits in phonologic processing. Dyslexia presents initially with problems in letter-sound relationships (i.e., decoding words and reading fluently in kindergarten or grade one). Problems in reading comprehension usually present in the latter part of the primary school years, when the focus is on reading to learn rather than learning to read - these can be identified by low overall reading achievement, or by low reading ability, relative to overall intelligence.

44. 2. Dysgraphia: Dysgraphia or writing disabilities are caused by a range of neurodevelopmental weaknesses, including problems with handwriting (fine motor or grapho -motor) and visual-spatial perception. Children present with difficulties in copying efficiently from the board; may show excessive grammar and punctuation errors; may produce overtly simple written text and/or produce disorganized text that is difficult to follow. In contrast, problems exclusively in spelling (also called ‘encoding’, which is the ability to use letter-sound relationships effectively) in absence of problems in written expression is more indicative of a phonologic processing deficit (i.e., dyslexia), than a dysgraphia.

45. 3. Dyscalculia: Dyscalculia or mathematical disabilities may include problems with number sense, problems retrieving math facts (arithmetic combinations or calculations), difficulty with the language of math (correctly reading and understanding numbers and symbols), word problems in math (correctly reading and understanding the text of word problems) and the visual-spatial and organizational demands of math. Students may reverse numbers or make errors while reading them aloud. These problems are usually seen in conjunction with disabilities in reading or written expression. Math functions depend upon the ability of the student to understand words associated with arithmetic operations and word problems. Dyslexia can aggravate difficulties in acquiring math skills.

46. Diagnosis The diagnosis of LD is made primarily by history. Diagnostic criteria and differential diagnoses (e.g. normal variations in academic achievement, ADHD, Intellectual disability, Learning disorders due to sensory or neurological impairments) have been provided in the DSM-5 [1]. These conditions can be differentiated by history, examination, laboratory tests (e.g. blood lead level), hearing and vision assessment, specialized screening/referral. Psychometric tests help to confirm the presence of LD and identify targets for intervention. A mandatory vision and hearing assessment should be part of the protocol. Investigations for lead toxicity may be conducted, if suspected.

47. Assessment Studies conducted in India to measure prevalence of LD have used screening questionnaires such as Specific Learning Disability-Screening Questionnaire (SLD-SQ) [8] or designed screening tools for class teachers to identify LD. The Rehabilitation Council of India (RCI) recommends informal assessment (i.e., parental interviewing after consent; gathering information from teacher/school; reviewing student’s workbooks; and interviewing the child) and formal testing (i.e., criterion and normreferenced tests). Tests for LD have two components: (a) testing for potential performance discrepancy – where a two-year discrepancy between potential and performance is an indicator of possible LD and, (b) testing of processing abilities.

48. Intervention approach A basic intervention approach should focus on: a) interpretation of evaluation reports; b) description of specific skills that may be delayed (e.g., phoneme awareness and phonics, reading comprehension, spelling instruction, number sense, and organizational skills), and c) identification of co-morbidities. Intervention Strategies: 1. Phoneme awareness-Reading : During these sessions the child with dyslexia undergoes systematic and highly structured training exercises to learn that words can be segmented into smaller units of sound (‘phoneme awareness’). During these sessions, the remedial teacher explicitly and directly teaches the following tasks: ( i ) Phoneme segmentation: e.g., what sounds do you hear in the word pot? What is the last sound in the word tap? 2. Reading-Phonics instruction : Phonics instruction begins only after phonemic awareness gets developed. The child is taught that these sounds (“phonemes”) are linked with specific letters and letter patterns (“phonics”). Spellings are taught through ‘phonics-based teaching’ using colour -coded segmentation (e.g., bot/ tle ), word formation games and sight-word identification

49. Key message The cornerstone of treatment of LD is thorough comprehensive evaluation and outcome-based, documented multidisciplinary intervention. Screening of all children at the age of 7 years for LD in the pediatric clinic will be highly beneficial (2-3 years after school exposure). No Detention Policy (NDP) leads to delayed identification of learning problems, and needs to be seriously reviewed. Concept of multiple intelligence needs to be highlighted i.e., students with LD can be poor in academic intelligence but may be better in other domains. LD lowers the scores of a student’s performance and provisions are intended to function as a corrective lens, which will deflect the distorted array of observed scores back to where they ought to be. These provisions aim to ‘level the playing field’ for these students as their academic performance would now be matching with their intellectual potential.