Child Psychology: Behavioural Management of problem behaviours in Children

The following is the out line of modules used to manage manage Problem behaviors in Children. It is not an exclusive list and is intended only for education of Parents and Caregivers. These are highly effective and proven measures of intervention.
The strategies are arranged as to be least intrusive to most intrusive. Therapist should be clear and confident about specific strategies. Parental consent is a must for using these strategies.

Depending on the degree of the problem, the strategies are used at several levels.

Level I: It includes manipulation of the antecedents that trigger the problem behaviours.
Eg. If a child is engaging himself in thumb sucking behaviour whenever he is free this behaviours can be reduced by keeping him busy in some adaptive manual activities like, counting objects, finger painting etc.

Level II: Strategies of differential reinforcement, where Differential Reinforcement refers to the process in which desirable behaviours are reinforced and undesirable behaviours are not reinforced.
Types:
1. Differential reinforcement of low rate behaviors (DRL).
2. Differential reinforcement of other behaviours (DRO)
3. Differential reinforcement of incompatible behaviours (DRI)
4. Differential reinforcement of alternative behaviours (DRA)

DRL: It is used when the primary focus is to reduce the behaviour but not to eliminate the behaviour.
Eg: If child has habit of shouting we can’t expect him to totally stop talking but he will be rewarded when he speaks at normal voice.

DRO: When a target problem behaviour has not occurred/ or been postponed for a specific period of time, then the reinforcement is provided.
Eg: If a child has a habit of getting up from seat frequently, he would be reinforced when he remains in seat for a specific period of time.

DRA: Here reinforcement is provided on occurrence of alternative desirable behaviours.
Eg: In a specific interval, if the child asks permission to go out rather than running away, he will be rewarded for asking permission (i.e. alternative behaviour).

DRI: In this module, reinforcement is provided on occurrence of the behaviour that is physically incompatible to the problem behaviour.
Eg: If child has the habit of thumb sucking, he will be engaged in some manual activity so that his hand will not be free for sucking. And reinforcement is given when he engages in that particular manual activity.

Level III:
Extinction: It simply means terminating reinforcing event that maintains problem behaviour.
Eg: If a child cries only to get the attention of adults that can be safely ignored.

Extinction is mainly used for attention seeking behaviours or if, the function is clearly measurable.
It should not be used if the function of behaviour is escape or self stimulatory.

Level IV: Removal of undesirable behaviour stimuli. It includes 2 techniques:

Response cost: If a child shows a particular target behaviour he will be made to pay cost for it.
Eg: Tokens or rewards may be withdrawn when a child breaks an object. But, this technique is possible only when the child has some token/rewards and does not run out of them to pay as cost.

Time-out: It means, removal of reward from the child or the child from reinforcing situation.
Eg.: While everybody is playing, if a child is disturbing others with a toy, the toy will be taken away from him or he will be removed from the situation for a specific period of time.
In case, if time-out room is used, the child should not be secluded for more than 1 to 5 minutes. And there should not be any recreational or potentially dangerous articles in the time- out room.
This strategy should not be used with very young children, or if they have associated medical problems like seizures etc. or if the function of behaviour is “escape” or “self-stimulatory”.

Level V:  Presentation of aversive stimuli.

Unconditioned aversive stimuli: It includes the use of stimuli like water spray directly on face or mild tick or pungent odors. But this strategy is very rarely used. It is proved to be successful in managing stereotypical behaviours.

Conditioned aversive stimulus: As in conveying verbal displeasure (Like, an emphatic ‘No’)

Over-correction: It is considered to be educative. The purpose of overcorrection is to teach student to take responsibility for their problem behaviour and teach them desirable behaviors. It involves two methods.
a. Bringing the situation back to normalcy (Restitution)
b. Teaching appropriate behaviour (Positive practice)
Eg: If a child spits on the floor, he will be made to wipe the place (Restitution) and also taught where to spit, like in a wash-basin. (Positive- practice).

Sexual Disorders: Premature Ejaculation

According to the tenth revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10, WHO), sexual dysfunction refers to a person's inability to “participate in a sexual relationship as he or she would wish.” The dysfunction is expressed as a lack of desire or of pleasure or as a physiological inability to begin, maintain, or complete sexual interaction.”
They can be lifelong or acquired, generalized or situational, and due to psychological factors, physiological factors, or combined factors. They can be attributable entirely or partially to a medical condition, drug/alcohol use, or adverse effects of medication.

PREMATURE EJACULATION (PME)
From an evolutionary point of view, a rapid completion of coitus is more adaptive in situations where predators are at large, but then we have moved out of jungles a long time back.
In PME, the man repeatedly reaches orgasm and ejaculation occurs before he desires to do so...and before there is full satisfaction in the sexual act. There is no definite time frame within which to define the dysfunction. The diagnosis is made when the man regularly ejaculates before or immediately after entering the vagina or after minimal sexual stimulation. Sometimes 15 seconds taken as the upper time limit, at other times when a man could not control ejaculation long enough during intravaginal containment to satisfy his partner in at least half of their episodes of coitus).

Duration = ?

The factors that affect duration of the excitement phase, such as age, novelty of the sexual partner, and the frequency and duration of coitus should also be considered before making a diagnosis.

Difficulty in ejaculatory control is sometimes associated with anxiety regarding the sexual act. Both anxiety and ejaculation are mediated by the sympathetic nervous system. Other psychological factors that can contribute are sexual guilt, a history of parent–child conflict, interpersonal hypersensitivity, and perfectionism or unrealistic expectations about sexual performance.

Few men are more vulnerable to sympathetic stimulation, hence, they ejaculate rapidly. Others have found a shorter bulbocavernosus reflex nerve latency time in men with lifelong premature ejaculation than in men who had acquired the dysfunction.

Premature ejaculation also may result from negative conditioning. The man who has most of his early sexual contacts in situations in which discovery would be embarrassing, such as there is lack of privacy or with has had prior intercourses with prostitutes who demand that the sex act proceed quickly, become conditioned to achieving orgasm rapidly.
A stressful marriage exacerbates the disorder.

The problem is quiet common, but under reported due to obvious reasons. About that 30 percent of the male population are reported to suffer, and approximately 40 percent of men treated for sexual disorders have premature ejaculation as the chief complaint.

Sex therapy

This shoud be done under supervision of an expert only. In cases of premature ejaculation, an exercise known as the squeeze technique is used for the purpose of raising the threshold of penile excitability. In this exercise, the man or the woman stimulates the erect penis until the earliest sensations of impending orgasm and ejaculation are felt. Penile stimulation is then abruptly stopped, and the coronal ridge of the penis is squeezed for several seconds. The technique is repeated several times.

Another variation is the stop–start technique, in which stimulation is interrupted for several seconds but no squeeze is applied. The man is encouraged to focus on sensations of excitement rather than distract himself from them. This makes him more familiar with his excitement pattern and lets him feel in control rather than overwhelmed by sensations of arousal. Communication between the partners is improved because the man must let his partner know his level of sexual excitement so that she can squeeze the penis before the ejaculatory process has started. Sex therapy has been successful with some premature ejaculators; however, a subgroup of dysfunctional men may need pharmacotherapy as well.

Medications

Delayed orgasm is a peculiar side effect of Selective Serotonergic Reuptake Inhibitors type of antidepressants, and this aspect has been used to prolong the sexual response in patients with premature ejaculation. This approach is particularly useful in patients refractory to behavioral techniques or who may have physiologically determined premature ejaculation.
Dapoxetine is a new, short acting SSRI specifically developed to treat premature ejaculation.
Other on demand treatment for premature ejaculation is topical anaesthetic such as lidocaine cream or spray in mild strength, which is applied to the glans of the penis.

Again all these approaches are to be used only under medical supervision.

Drug use in Pregnancy- FDA Categories

In view of such events as the thalidomide crisis in the 1960’s when in-utero exposure lead to Phocomelia, and the teratogenic effects of diethylstilbestrol in 1979 US Food and Drug Administration developed strict guidelines regarding drug labeling, use of medications in pregnancy with safety parameters before it was marketed.
FDA classifies various drugs used in pregnancy into five categories, categories A, B, C, D and X. Category A is considered the safest while category X is absolutely contraindicated in pregnancy.

Pregnancy Category A
Adequate and well-controlled human studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).

Pregnancy Category B
Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women OR Animal studies have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester.
Pregnancy Category C
Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Pregnancy Category D
There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Pregnancy Category X
Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.
Source

Journal Impact Factor

The best evaluation system for the quality of a Journal would involve actually reading all its articles but then the amount of information available is too much, and expanding for this sort of evaluation to carry on.


Here comes the role of Journal Impact Factor.

The Impact factor was devised by Eugene Garfield, the founder of the Institute for Scientific Information, now part of Thomson, a large worldwide US-based publisher.

It is not a perfect tool but is generally considered a good technique for scientific evaluation. For those who have some experience in research publications will know that it is difficult to get an article published in the best of journals, which incidentally also have the highest impact factors.

CALCULATION

The impact factor for a journal is calculated based on a three-year period. It can be viewed as an approximation of the average number of citations in a year, given to those papers in a journal that were published during the two preceding years. For example, the 2003 impact factor for a journal would be calculated as follows:

A = the number of times articles published in 2001-2 were cited in indexed journals during 2003

B = the number of "citable items" (usually articles, reviews, proceedings or notes; not editorials and letters-to-the-Editor) published in 2001-2

2003 impact factor = A/B

(note that the 2003 impact factor was actually published in 2004, because it could not be calculated until all of the 2003 publications had been received.)

A convenient way of thinking about it is that if a journal is cited once for each article published it will have an Impact Factor(IF) of ‘1’ in the expression above.

In the field of psychiatry... Archives of General Psychiatry is the Highest rated in terms of IF. The impact factor of Indian Journal of Psychiatry cannot be calculated as of now as it has been indexed for less than an year.

Sci-Bytes provides ranking and impact factor for selective journals. The list is located here:

http://www.sciencegateway.org/rank/index.html

COGNITIVE BEHAVIOURAL THERAPY

 


Even if you take a pill for every ill, medications can't do everything.

 So the next step is COGNITIVE BEHAVIOURAL THERAPY. Few facts below.

IS IT USEFUL?
CBT is one of the established methods of treatment of mental health problems.
It is one of the most effective treatments for conditions where anxiety or depression is the main problem
It is the most effective psychological treatment for moderate and severe depression
It is as effective as antidepressants for many types of depression


WHERE DOES IT HELP?
It can help people suffering from Anxiety, depression, panic, phobias (including agoraphobia and social phobia), poor stress coping, eating disorders, obsessive compulsive disorder, post-traumatic stress disorder.
Those with anger outbursts, or with a low opinion of self or chronic physical health problems, like pain or fatigue, can also benefit a lot.

HOW DOES IT WORK?

It is a way of talking about:
      How you think about yourself, the world and other people?
      How what you do affects your thoughts and feelings?
CBT can help you to change how you think ("Cognitive") and what you do ("Behaviour)".
These changes can help you to feel better.
There is focus on the "here and now" problems and difficulties instead of focussing on the causes of distress in the past.

Problems can be overwhelming... but by breaking them down into smaller parts... makes it easier to see how they are connected and how they affect you.

In a test situation (e.g.a problem, event or difficult situation), there can follow: Thoughts + Emotions + Physical feelings + Action.

Each of these areas can affect the others.

The key point is How you think about a problem... it can affect how you feel physically and emotionally. It can also alter what you do about it.

AN EXAMPLE
Situation: After a bad day in office, feeling tired, you drag yourself for shopping and while coming back, your neighbour walks by you, apparently, ignores you.
REACTION 1: Unhelpful

• Thoughts: He/she ignored me – it means they don't like me  
• Emotional Feelings: Low, sad and rejected
• Physical: Stomach cramps, low energy, feel sick  
• Action: $##@*@#$, Go home and avoid them

REACTION 2: Helpful

• Thoughts He/she looks a bit wrapped up in themselves - I wonder if there's something wrong?
• Emotional Feelings: Concerned for the other person
• Physical: None - feel comfortable
• Action: Get in touch to make sure they're OK

There are helpful and unhelpful ways of reacting to most situations, depending on how you think about them.
When we are distressed, we are more likely to jump to conclusions and to interpret things in extreme and unhelpful ways.
CBT can help you to break this vicious circle of altered thinking, feelings and behaviour.

When you see the parts of the sequence clearly, you can change them - and so change the way you feel.

CBT aims to get you to a point where you can "do it yourself", and work out your own ways of tackling these problems.

DIFFICULTIES WITH CBT
CBT is not a quick fix. It takes time and effort both from the patient and the therapist.
The therapist advises and encourages - but cannot 'do' it for the patient. If someone is feeling low, it can be difficult to concentrate and get motivated.
To overcome anxiety, it has to be confronted. This may lead you to feel more anxious for a short time.


Smile, it's free therapy

  

Anxiety: Normal to Disorder

What is anxiety? 

• It’s a vague unpleasant emotion that is experienced in anticipation of some future misfortune
• A state of apprehension, uncertainty or fear, resulting from the anticipation of a realistic or imaginary threatening event or situation
• May have emotional, behavioural, cognitive and physical components

Anxiety is commonly experienced by virtually all living beings including humans. It is an alerting signal and warns of threat, both internal and external, and is the first line of defense.
When the body prepares to deal with a threat: blood pressure and heart rate are increased, sweating is increased, blood flow to the muscles is increased, and other functions are inhibited (the fight or flight response) causing what we call the manifestations of anxiety.
It prepares us for the situations, and its consequences. It is beneficial to an individual and is NORMAL.

Anxiety and Performance
An increase in the anxiety to some extent helps a person grow and improve his performance.
In very low level of anxiety, performance is very low, as the anxiety increases the performance increases. A phase comes when performance is at its peak any increase in anxiety does not increase performance. At this stage any anxiety leads to discomfort. Now the anxiety symptoms will appear and any increase will reduce the performance and may lead to deterioration.
The complete absence of anxiety is as pathological as excessive anxiety.

Anxiety Disorders
  When anxiety becomes excessive, and being detrimental rather than adaptive, then it fall's under the classification of an anxiety disorder. There are several specific forms of the disorder as per the current classificatory systems. Some of these are: Agoraphobia, Social phobias, Specific (isolated) phobias, Panic disorder, Generalized anxiety disorder, Mixed anxiety and depressive disorder, Anxiety disorder- unspecified.

Anxiety can also be a symptom of any other underlying medical condition such as mitral valve prolapse, hypoglycemia, pheochomcytoma, hyperthyroidism, hyper parathyroid, cardiac arrhythmias, seizures, chronic obstructive pulmonary disease (COPD), heart failure; or as a part of drug abuse and withdrawls.

Identify the Anxiety Symptoms
  1- Physiological

• Palpitations or thumping of heart.
• Tremors
• Tightness of chest and choking sensation
• Difficulty in breathing
• Hyperventilation
• Sweating
• Dizziness
• Tingling
• Urinary frequency
• Increased motility of GI tract
• Restlessness
• Insomnia
• Pupillary dilatation
• Light headedness

2-Psychological

• Diffuse,vague, unpleasant sense of apprehension, fearfulness,
• Nervousness, irritability
• Inability to relax,
• Poor concentration
• Inability to think clearly
• Derealisation, depersonalization
• Feeling of impending doom / disaster, the perception of danger is very real, as if he or she is about to die or pass out.

“There are more things to alarm us than to harm us, and we suffer more often in apprehension than reality.”

International Day against Drug Abuse and Illicit Trafficking (26 June, 2010)

Health is the theme of this year's world drug campaign, to be launched on International Day against Drug Abuse and Illicit Trafficking (26 June, 2010).

The United Nations Office on Drugs and Crime (UNODC) is leading the international campaign to raise awareness about the major challenge that illicit drugs represent to society as a whole, and especially to the young.

The goal of the campaign "Think health - not drugs" is to mobilize support and to inspire people to act against drug abuse. The campaign encourages young people to put their health first and not to take drugs.

Drugs have the power both to improve and to damage health, depending on the type of drugs used, the quantity consumed and the purpose for which they are taken. For example, while morphine can relieve pain, heroin can be highly addictive. Such examples illustrate the need to control drugs.

Drugs under international control include amphetamine-type stimulants, cannabis, coca/cocaine, hallucinogens, opiates and hypnotic sedatives, all of which have immediate physical effects. While some of the physical effects might sound pleasant, they do not last long. Drugs can also severely hinder psychological and emotional development, particularly in young people. In addition, some users risk addiction.

Drug use is preventable. UNODC has developed prevention activities that provide the public, particularly young people, with the information, skills and opportunities they need to make healthy choices, including the choice to avoid using harmful drugs.

The world drug campaign calls on young people, who are twice as likely as adults to take drugs, to protect their health.

Parents, teachers and other interested individuals can also join the campaign. There are a number of ways to get involved, including providing information, by spreading the word about the campaign and organizing outreach or institutional events to mark International Day against Drug Abuse and Illicit Trafficking on 26 June.

We can all play a role in promoting health in our communities.

Signs of drug use

Although there are certain emotional and physical symptoms of substance use, do not immediately assume that the person is on drugs. There could be other reasons why he or she behaves unusually.

Emotional and social signs
• Moodiness, excitement, anger, hostility, depression
• Constant lying and stealing
• Refusing to admit to the harmful effects of drugs
• Avoiding old friends or people who could confront them about behaviour changes
• Being secretive about phone calls
• Having friends they do not want you to meet or talk about
• Being evasive about their whereabouts
• Loss of motivation
• No interest in everyday life
• Playing truant from school

Physical signs
• Drowsiness
• Trembling
• Red eyes, dilated pupils
• Lack of interest in personal hygiene and appearance
• Slurred speech
• Loss of, or increase in appetite
• Uncoordinated movements
• Circles under the eyes
• Irregular sleeping habits
• Frequent colds and coughs
• Weight loss

(source: www.unodc.org)