Disruptive behavior disorder – Children are expected to behave within the socially acceptable limits, which is determined by their age, social norms, training/moral standards and parent-child relationship. Negativism i.e. opposition to parental instructions is a normal phase of development during 18- 36 months of age, leading to anger/frustration. By 4-5 years, children leam to control their behavior.
Disruptive behavior disorder denote an anti-social behavior, usually due to parent-child conflict, child’s urge for autonomy and expression of underlying angers defiance or frustration. Emotional neglect and over-disciplined child rearing are two most important determinants of early disruptive behavior, apart from biological temperament, role models and social circumstances.
Although many types of disruptive behavior disorder are seen in children, the most important ones are breath-holding spells in children <2 years, temper tantrums in 2-5 years of age and conduct disorders like stealing, lying, truancy (running away form home) etc. in older children. Some other Behavioral disorder like substance abuse, teen pregnancy etc. are major social problems in adolescents, discussed in Ch. 13.3.
Breath-holding spells is the commonest but benign manifestation of Behavioral disorder in infancy and early childhood, characterized by ‘sudden holding of breath in expiration (apnea), leading to cyanosis or pallor with/without loss of consciousness, hypotonia and seizures’. Frequency of these spells may vary from occasional attacks to> 10-15 spells a day.
Incidence: Breath-holding spells are most common between 6 months to 2 years of age, during which — 4- 5% children experience at least one of these spells. Other high-risk factors are male sex, similar family history and labile temperament.
Etiology of disruptive behavior disorder: Breath-holding spells are means of expression in a baby for internal frustration, anger and aggression.
Clinically, there are two major types of breath-holding spells – more common cyanotic spells and less common pallid spells.
Cyanotic breath-holding spells are usually provoked by anger or frustration (akin to temper tantrum in older children) with a typical sequence of events – a loud-shrill cry > forced expiration > breath-holding i.e. apnea> cyanosis & unresponsiveness. Usually, each spell does not last for more than 10-15 seconds and terminates with a deep gasp> re-breathing and > gradual disappearance of cyanosis. Baby may remain drowsy for a few minutes after the spell, before complete recovery. However, occasional attack of disruptive behavior disorder may progress to develop generalized seizures, ophisthotonus & bradycardia. Interictal EEG is normal.
Pallid breath-holding spells, are less common and differ from cyanotic spells on counts
a) usually provoked by sudden painfultimulus e.g. fall, or loud noise (startle),
b) pallor and limpness instead of cyanosis, and
c) usually abnormal interictal EEG. Pallid spells may be induced by supraorbital pressure to stimulate oculo-cardiac reflex, though such maneuvers are risky and should be avoided.
Diagnosis depends on typical sequence of events, and should be differentiated from epilepsy, anoxic spells in cyanotic heart diseases (d/d cyanotic spell) and arrhythmias e.g. long-QT syndrome (did pallid spells).
Prognosis: Except a rare prolonged spell with significant cerebral hypoxia, breath-holding spells are essentially benign and disappear after 2-3 years. However, these children tend to have higher risk of late Behavioral disorder like temper-tantrum and syncopal attacks.
Management aims towards behavioral modification of the child and for early abortion of the attack, & includes —
a) Management during the attack: These spells can be easily aborted by physical stimulation e.g. pinching, shaking, supra-orbital pressure, blowing air on face or sprinkling water on face, for which the parents must be trained.
b) Parental counseling in disruptive behavior disorder: Parents must be reassured regarding benign nature of these spells & the underlying behavioral basis. It is important to emphasize the need for certain discipline & consistency in child-care. The baby’s demand, which has provoked the spell, should not be fulfilled immediately on recovery (purposeful neglect) to ensure that s/he derives no benefit from the episode.
c) Pharmocologic therapy: Iron supplements may be effective in some cases to reduce the frequency of attacks, even in absence of significant anemia. In children with history of pallid spells, recurrence may be prevented by previous atropinization during painful procedures.
Temper tantrum is another medium of expressing internal anger and frustration in relatively older children (>18 months), characterized by ‘physical aggression like crying, howling, kicking, head banging, throwing objects etc.’ Overindulgent child-rearing in a setup of single child or working parents, is the most important contributor for temper-tantrums.
Most of these children learn to control their disorder by 5 years with gradual reduction in frequency of temper tantrums.
Management includes parental counseling regarding — a) prevention of injury during the attack, b) firm and consistent attitude towards the child but with good communication, c) purposeful neglect during attack i.e. ignoring the child’s demand till his Behavioral disorder is controlled, d) positive reinforcement i.e. praising or awarding him for periods of controlled anger.
Conduct disruptive behavior disorder, usually seen in older children or adolescents, are characterized by broad range of recurrent anti-social behaviors e.g. stealing, lying, truancy, cruelty to animals/property etc., lasting for over 6 months.
Many consider these disorders as a combination of three different syndromes of increasing severity — i) aggression, ii) intermittent anti-social behavior and iii) delinquency.
Oppositional defiance disruptive behavior disorder like temper tantrums, arguing and defiance of rules and blaming to others is a milder variant of conduct disorder, more common in early childhood.
Check out this excellent discussion on Disruptive behavior disorder –