HEALTHWATCH

Compiled and coordinated by Edward Arambewala

Conduct disorder in children

Dr. Ruwan M. Jayatunge

Children with conduct disorder repeatedly violate the personal or property rights of others and age-appropriate social standards and rules. Conduct disorder has a multifactorial etiology that includes biological, psychosocial and familial factors.

Associated features of conduct disorder include an inability to appreciate the importance of others’ welfare and little guilt or remorse about harming others.

The etiology of conduct disorder involves an interaction of genetic/constitutional, familial and social factors.

Children with Conduct Disorder often view the world as a hostile and threatening place and they have difficulty maintaining friendships.

They often have low self-esteem and low frustration tolerance. Peers and family members become negative and irritated with their misbehaviour which leads to a vicious cycle.

The literature abounds with studies indicating the comorbid relationships between Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Learning Difficulties, Mood Disorders, Depressive symptoms, Anxiety Disorders and Communication Disorders.

Conduct disorder is more common among boys than girls, with studies indicating that the rate among boys in the general population ranges from 6 per cent to 16 per cent while the rate among girls ranges from 2 per cent to 9 per cent. According to research cited in Phelps and McClintock (1994), 6 per cent of children in the United States may have conduct disorder.

The onset of conduct disorder may occur as early as age five or six but more usually occurs in late childhood or early adolescence. Studies have found that neurological abnormalities are inconsistently correlated with conduct disorder.

This disorder not only affects the individual, but also his or her family and surrounding environment. Conduct disorder appears in various forms, and combinations of factors appear to contribute to its development and maintenance.

Symptoms of conduct disorder

* Aggressive behaviour that harms or threatens other people or animals;

* Destructive behaviour that damages or destroys property;

* Vandalism

* Poor peer relationships

* Lying or theft

* Truancy or other serious violations of rules

* Early tobacco, alcohol, and substance use and abuse; and running away from home

* Precocious sexual activity

A diagnosis of conduct disorder is likely when symptoms continue for 6 months or longer. Children who exhibit these behaviours should receive a comprehensive evaluation.

Risk factors of the development of Conduct Disorder

* Early maternal rejection;

* Separation from parents, without an adequate alternative caregiver;

* Early institutionalisation;

* Family neglect;

* Abuse or violence;

* Marital conflicts and unfavourable home atmosphere;

* Parental substance abuse;

* Parental mental illness;

* Poverty.

Illustrative case 1

Master N is a 15 year old boy from a leading school punished by the sectional head for destroying school property and assaulting a prefect. Previously he was caught while smoking a cigarette in a classroom by one of the teachers. His academic skills are deteriorating and Master N got low marks for the recent term test.

According to his mother he is stubborn at home and does not listen to her. His behaviour gradually changed after his father went to Italy one and a half years ago.

He associates friends who are older to him and spends time with them. Often he refuses to go to school.

He became more isolated and hostile. On one occasion he ran away from home and stayed two nights at a friend’s place.

Illustrative case 2

Master P who is an eleven year boy has the following behavioural features.

1. He often bullies and intimidates his peers.

2. Frequently initiates physical fights and assaults school mates.

3. He was warned by the class teacher for using bad words at the classroom.

4. He is cruel to animals especially to the cat which lives in their house.

5. Whenever he finds the opportunity he steals money from the father’s wallet.

6. He refuses to go to school and sometimes keeps away from lessons.

7. He never does homework or does not show any interest in studies.

Master P has mood swings and sometimes engages in age inappropriate behaviour. Recently a parent complained that he tried to harass another body at school. When he was questioned by the teacher he simply denied the accusation.

His teacher finds that Master L is becoming intolerable at the classroom. His peers are afraid of him and they try to avoid him. At home when he gets angry he damages the house property. His father stated that a few weeks ago he dashed the TV.

Treatment for Conduct Disorder

Treatment of children with conduct disorder can be complex and challenging. Treatment can be provided in a variety of different setting depending on the severity of the behaviours. Childhood conduct disorder, left untreated, has a poorer prognosis. Therefore the treatment is essential. The research indicates that in about 40 per cent of cases, childhood-onset conduct disorder develops into adult antisocial personality disorder.

The treatment consists of medication and psychotherapy. Medications may be useful for co-morbid disorders or for controlling impulsive behaviour or irritability. Some doctors prescribe antidepressants, mood stabilisers and these medications may help specific symptoms. Also the medication may improve children’s capacity to benefit from other psychosocial interventions.

Cognitive-behavioural approaches especially CBT or Cognitive-Behaviour Therapy are often used. CBT is to improve problem solving skills, communication skills, impulse control, and anger management skills. Behaviour modification therapy acts positively with the conduct disorder.

Positive reinforcement for desirable behaviour will reduce reliance on punishment. The child’s disrupted behaviour can be modified and new skills can be taught. Hence the child gains an insight and gradually minimises dissocial behaviour.

Parental counselling and awareness of the illness is vital. Following parental counselling they find a way to deal with the child’s problem. Family therapy often enhances the disrupted family communication. Family therapy is often focused on making changes within the family system and improving family interactions.

As a mode of psychotherapy some therapists prefer to use cyber therapy which reduced stress factors and diminish the free floating aggression in the child. As a stress breaker music therapy has shown its efficacy in conduct disorder.

Children with conduct disorder may have academic difficulties. Therefore educational therapy is needed to improve their underlying learning difficulties. Some therapists recommend concept developmental learning aid programs and strategies to improve reading skills.

Conduct disorder has a complex nature. In this condition not only the child even the parents, siblings, peers, and teachers are affected by the child’s disturbed behaviour. It’s vital to understand that the illness is causing such disturbances and not the child himself.

Therefore compassionate approach would be needed to manage the conduct disorder.

Beware of HBV: More infectious than HIV

Dr. Viraj Peramuna, Member Medical Advisory Panel HealthWatch

Health education of the public is one of the key components of disease prevention that the doctors can undertake in building up a healthy society.

It is in fulfilling that objective in my capacity as a doctor and a member of the HealthWatch Medical Advisory panel that I am writing this article basing on a WHO study on Hepatitis B where it describes the virus (Hepatitis B) as more infectious than even the HIV/AIDS virus.

This red light warning alone is enough for the public to take all precautions to avoid falling into this disease inferno.

WHO estimates

World Health Organisation estimating the annual death rate from Hepatitis B at 2 million worldwide says “Hepatitis B is caused by the Hepatitis B virus (HBV) which is one of the most common viruses in the world, and is 100 times more infectious than HIV and much more resilient”.

Symptoms and signs of hepatitis

Hepatitis A and B share many of the same symptoms, including fever, dark-coloured urine, light coloured stools, tiredness or “flu-like” symptoms, nausea, vomiting, stomachache, diarrhoea, skin rash, loss of appetite, yellow tinged skin and eyes. They can be distinguished by blood tests.

Hepatitis B

Hepatitis B is caused by the hepatitis B virus (HBV). HBV is one of the most common viruses in the world. HBV is 100 times more infectious than HIV and much more resilient.

It is estimated that more than one third of the population of the world has at some time been infected with HBV. It is also estimated that there are about 350 million chronic carriers of the virus. 25% of these Chronic carriers will die prematurely of liver cirrhosis or liver cancer.

If you get hepatitis B you have a 5 - 10% chance of having it for life. chronic hepatitis B is the 9th leading cause of death worldwide. The World Health Organization (WHO) has estimated that hepatitis B results in 2 million deaths every year worldwide.

How does Hepatitis B Spread?

HBV is spread in a completely different way from HAV. HBV is passed from one person to another through infected blood and other body fluids. Therefore, the sources of infection are:

Person to person

* From infected mother to child before, during and after child birth.

* Exposure to infected blood or other body fluids.

- From an infected child to another through injuries (sports).

- Through sexual relationship with an infected partner.

Indirectly

* Sharing an infected person’s earrings, razor, needle or toothbrush.

* Touching surfaces that have dried hepatitis B virus on them.

* Through needles used for piercing, acupuncture or tattooing.

Unknown

* Approximately 30% of cases have no known cause.

Who is at high risk?

* Health care workers

* Patients repeatedly receiving blood products (even though all blood transfused in Sri Lanka is screened for hepatitis B, very rarely an infected case could be missed with the available test).

* Patients receiving organ transplants

* Sex workers

* Sexual contacts of infected persons

* Institutionalized persons

* IV drug users

* Travellers to areas with high endemicity.

* Household and close contacts of infected patients and carriers.

* Babies born to HBV positive mothers.

What happens when a person contracts hepatitis B

When HBV enters the liver it usually causes an acute inflammation. Many people infected with HBV have no symptoms during the acute infection. Others may suffer from influenza-like symptoms, fever, tiredness, loss of appetite, nausea, vomiting, stomach ache and jaundice.

Few could even die of severe illness. In the liver, acute infection with HBV causes the body to mount an immune response to get rid of the virus. The immune system tries to clear the virus by destroying HBV infected liver cells. In some patients this immune response succeeds.

The virus, along with the infected liver cells are completely destroyed and the patient makes a complete recovery.

This happens in about 90 to 95% of the time when adults get Hepatitis B. Complete recovery may take up to six months. However, in about 5 to 10% of patients who get the disease, the immune response to the infection is insufficient to get rid of the virus for many months/years or at all.

They become chronic carriers of the virus. In about 25% of chronic carriers a slow persistent destruction of liver cells continues. This can lead to fibrosis, cirrhosis and even liver cancer, in 10 to 20 years.

HBV Carriers

People infected with HBV whose immune systems cannot get rid of the virus are referred to as chronic HBV carriers.

They can pass on the virus to others. When children under two years of age get infected the chance of clearing the virus is only about 10%. In other words about 90% become chronic carriers. This is because their immune system is immature.

Therefore, the carrier rate and risk of later liver disease is much higher when a child under two years gets infected with HBV. Because of this, in many countries immunization against Hepatitis B is now included in the routine immunization schedule of infants.

The situation in South Asia

In Sri Lanka:

* Prevalence of Hepatitis B is estimated to be less than 2 per cent of the population.

* Hepatitis B due to blood transfusion is rare because all blood is screened.

*Prevalence in blood donors is less than 1 per cent

*30-40 per cent of patients warded in hospitals for acute hepatitis are Hepatitis B antigen positive.

*2-10 per cent of chronic hepatitis is due to hepatitis B (In India Pakistan and Bangladesh this figure is over 40 per cent).

In India Hepatitis B prevalence varies from 2 to 10 per cent (means 6 per cent).

The prevalence is also high in Pakistan and Bangladesh.

In these countries blood transfusion is a well-known cause of Hepatitis B, as the rate of infection among professional blood donors is high.

(To be Continued next week)

Laughter the best medicine

Sitting in the back of a taxi, a nun notices that the cab driver is staring at her. “I don’t want to offend you” he says, “but my fantasy is to be kissed by a nun”.

“Well, all right” says the nun “But you have to be a practising Catholic and single”. The driver says he is, so the nun plants a lingering, passionate kiss on his lips. The man is momentarily ecstatic but then starts crying.

“What’s the matter” asks the nun.

“Forgive me sister, but I have sinned. I lied to you. I am married and I am Jewish”. The nun replies “Oh that’s OK. My name is Kevin and I am off to a fancy dress party.”

Sent by Asanka Gunaratne, Dehiwala

Doctors who have gone that extra mile (3)

Transforming the General Hospital, Ampara

Dr. Lankathilake Jayasinghe was appointed as MOI/C at the Rural Hospital, Wadinagala, Ampara following his internship. He began a quality improvement pilot project in that hospital and learned from its success. His staff was taught to cater to customer (patient) needs.

After following a course in Medical Administration he was appointed as acting District Medical Officer of Base Hospital, Ampara. When the hospital was upgraded to a General Hospital, he was appointed the Medical Superintendent, a post he has held for the past 8 years.

In addition, he is the acting Regional Director of Health Services for the Ampara District. He has now completed his MSc in Medical Administration. Following his appointment he initiated an “all quality and productivity improvement programme” with excellent cooperation from the staff. The management pattern was changed based on the Japanese “5S” system.

The staff, patients and visitors were given opportunities to take part in the quality improvement programme through a Kaizen suggestions program.

Toxicology Society Revived

The Toxicology Society of Sri Lanka was revived recently and the following office bearers were appointed. Professionals who wish to join the Society are requested to contact the President at 2686142 or 2694016 or email [email protected]

President - Prof. Ravindra Fernando
Vice Presidents - Dr. G.K. Manuweera, Prof. Andrew Dawson
Secretary - Mr. Rohitha Nanayakkara
Treasurer - Ms. Sandarekha Rupasinghe
Asst. Secretary - Dr. Shantha De Silva
Asst. Treasurer - Mr. Lohith Wijesooriya
Public Relation Officer - Mr. Hiran Weerasekara

Council Members

Dr. Lanka Dissanayake, Dr. Indika Gawarammanna, Dr. Ariyarani Gnanadasan, Dr. Pradeepa Jayawardana, Ms. Dammi Weerasooriya, Ms. Shanaz Packeer, Dr. M.A.J. Mendis, Mr. Zahid Mathayes, Mr. Indika Gunawardana and Mr. Justin Perera