Monday, April 30, 2012

Aggression in children - need for parental intervention

Aggression is uncommon in school children and should be addressed

A Pune teenager was kidnapped and murdered by his school friends a few weeks ago. The victim was deliberately selected and his parents were manipulated for a ransom. Violence, theft and destructiveness are end stage behaviours of conduct problems in children and adolescents.

Trajectories of aggression in children

The commonest path of violence in children is 'adolescence-limited'. The antisocial behaviours usually occur when the adolescents are 'hanging out' in a group.  This type of aggression reflects an anti-authoritarianism. Anti-authoritarianism results from frustration over being denied the benefits of full adult independence despite reaching physical maturity. Adolescent limited aggression is less violent, relies on peer encouragement, and generally diminishes by adulthood  These adolescents are usually able to integrate into society as young adults.

A less common path of violence is 'life-course-persistent'. In this group of antisocial children, problem behaviors unfold in a sequence at home and school
  1. Early noncompliance - with excessive arguing and disobedience
  2. Poor rule adherence - staying out late, playing in prohibited locations
  3. Low frustration tolerance - temper tantrums, abusiveness, aggression
Aggression is common among preschoolers. The prevalence rate of aggression in children reduces dramatically once they enter school. Children whose fighting does not  reduce in the early school years are at high risk for persistent violent behavior. This important subgroup of proactively aggressive youth is profoundly indifferent to the consequences that their misbehavior has upon others. They rarely display genuine remorse. Their personality of 'callous-unemotional traits' is characterised by a lack of empathy, self-centeredness, and shallowness. As youths they are responsible for a large number of violent offenses. Their aggressive behavior is often persistent as features of psychopathic or sociopathic personality.

Parenting can prevent violence

  1. Make aggression irrelevant by modifying the setting
  2. Aggression is significantly affected by the parent-child relationship. Children with conduct problems tend to have acrimonious and negative interactions with their parents. The parent is perceived as just an agent of coercion. It is important to change this environment. Positive interactions between the parent and child serves to reinforce the perception of the parent as a source of positive attention, affection, support and encouragement. This makes the child responsive to parents' authority and to the rewards and punsihment that  the parent dispenses.
  3. Make aggression ineffective by modifying its consequences
  4. The reactions of others to the aggressive behavior sustains and reinforces it. They may give in to what the child wants, give up trying to get compliance, or even bar the child from school -  which may be exactly what the child wants. To render the aggression ineffective parents/ teachers have to respond by ignoring milder misbehaviour and handing out consequences. These include time outs, loss of privileges (TV, cell phone, Facebook) that the child will want to avoid, and limit setting (curfew times, restricting location).
    Parents need to establish  their authority and implement some of these measures in aggressive children. This teaches children that aggression is an ineffective means of fulfilling a particular wish. These lessons are better learned early under caring parents rather than later in a centre for juvenile delinquents.
Brennan LM. Toddler-age externalizing behaviors and school-age academic achievement: independent associations and the impact of parental involvement University of Pittsburgh. Thesis presented 27-Aug-2010.

Tuesday, July 26, 2011

Discrimination of psychiatrically ill persons by hospitals

Healthcare discrimination of mentally ill persons
Discrimination of mentally ill persons by hospitals
A young woman with psychiatric illness was refused admission at a leading tertiary care hospital in Pune. The reason - “mentally unstable patients are known to cause harm not only to themselves but to others as well. The hospital lacks facilities and infrastructure for catering to psychiatric patients.” A similar unwritten policy of denying inpatient care on grounds of psychiatric illness exists in at least one other large corporate hospital in Pune.

We have already stressed the importance of access to healthcare for persons with mental illness. We will now further explore the stereotype of harm in mental illness. The stigma associated with this stereotype has an adverse impact on timely delivery of healthcare to persons with psychiatric illness.

Are mentally ill persons likely to harm other hospital inpatients?

Hospital and healthcare settings have the highest levels workplace related violence across all industry sectors (CDC 2002).  The place where patient perpetrated violence is most likely to occur is the Emergency or Casualty department not the wards (Farooq 2009). Patients of all categories mostly attack staff or junior doctors - the ones they are in regular and direct contact with. In most cases violence is perpetrated by arrogant patient attendants not the patients themselves, whatever their diagnosis. For the rest violence is a result of unacceptable staff behaviour, and dissatisfied patients or attendants. It is rare for patients of any diagnosis to physically attack and harm each other in a hospital. Even in acute inpatient psychiatry units violence towards other patients or staff is less than 3% of total incidents of violence (Biancosino 2009). So much for psychiatric illness being “known to cause harm”.

Are patients with psychiatric illnesses the only ones that harm other patients? At the height of the swine-flu scare in 2009 no patient suspected of having the disease was denied treatment or admission. Yet swine-fly is known to be highly contagious and lethal. Special protocols and facilities were drawn up and earmarked overnight. So the potential for harm is not the overriding factor in denial of treatment.

Patients with psychiatric illness require minimal investigation, and respond rapidly to cheap and effective medication. Return on investment may be what it is all about. Psychiatrically ill pateintsdo not make much money for a hospital. It is more lucrative to provide skewed facilities for a liver transplant that would require weeks of ICU care, extensive investigation and invasive procedures. It would also make news for all the right reasons.

Mental illness accounts for 80-90% of completed suicides. Serious suicide attempts by poisoning or jumping result in emergency hospital admissions. Treatments would entail stay in the Intensive Care Unit, utilisation of the Operation Theatre, mechanical ventilation, and extensive monitoring and investigations. All this translates into large cash transactions over a short period of time. No hospital administrator would deny admission to these critically ill patients - ethical considerations, policy and stigma not withstanding.

Is it really possible to exclude patients with psychiatric illness from the hospital healthcare system?

The dichotomy between soma and psyche, physical and mental is artificial. This was formally enunciated in Para 1 of the WHOs Alma-Ata declaration (1978) and is the accepted definition of health for medical students since decades. Psychiatric and somatic illnesses coexist with and impact eachother. Ignoring this interaction is adversely affecting the outcomes of chronic illnesses like diabetes, heart disease, cancer and respiratory disease. The World Mental Health Day 2010 document specifically evaluates the evidence and stresses the urgent need to integrate mental heatlhcare for these chronic illnesses which account for 60% of the worlds deaths.

Walk into any hospital ICU and you will see at least one delirious patient strapped to the bed with physical restraints. Psychological aspects of critical illness are given the short shrift only because the mindset is one of discrimination and disrespect for the individual. Psychiatric and physical health problems do not exist in isolation. Their physical basis and vice versa cannot be excluded by artificial dichotomies.

Is it desirable to treat persons with mental illness in a general hospital setting?

Integration of mental healthcare delivery with existing facilities is a major thrust of the WHO (2008). Hospitals need to provide an accessible and acceptable location for treatment of acute exacerbations of mental health disorders in the same way that they currently do for physical health disorders. This would also enable access to services for physical health problems that arise during the inpatient stays of persons with mental health problems.

Deinstitutionalisation of psychiatric and mental health care has been stressed as a human right since the mid 20th century. A step in this direction for Pune's hospitals would be to draw up and implement guidelines to prevent and manage hospital violence. These guidelines already exist (CDC 2002, OSHA 2004).

  1. Biancosino B, Delmonte S, Grassi L, Santone G, Preti A, Miglio R, de Girolamo G; PROGRES-Acute Group. Violent behavior in acute psychiatric inpatient facilities: a national survey in Italy. J Nerv Ment Dis. 2009 Oct;197(10):772-82.
  2. CDC. Violence - occupational hazards in hospitals.  DHHS (NIOSH) Publication No. 2002–101. April 2002
  3. J Farooq, A Mustafa, D Singh, GH Yattoo, A Tabish, GJ Qadiri. Violence in hospitals. Journal of the Academy of Hospital Administration, Volume 21, No. 1 & 2 Jan-June & July-December 2009; 16-20
  4. Occupational and Safety Health Administration. Guidelines for preventing workplace violence for health care and social service workers. 2004. Publication no. OSHA 3148-01R
  5. Soliman AE, Reza H. Risk factors and correlates of violence among acutely ill adult psychiatric inpatients. Psychiatr Serv. 2001 Jan;52(1):75-80.
  6. World Federation for Mental Health (WFMH). Mental health and chronic physical illness - the need for continued and integrated care. World mental health day. 10 October 2010.
  7. World Health Organisation (WHO) Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978
  8. WHO/Wonca.  Integrating mental health into primary care: a global perspective. World Health Organisation and World Organization of Family Doctors (Wonca). 2008.

Sunday, June 19, 2011

School bullying

School Bully

Bullying by children in schools has serious mental health effects on the victim and the bully. Up to 25% of high school students report being victimised by bullies. 13% of victims have considered suicide. In rural India 31% of middle school students report being bullied (Kshirsagar 2007). Bullying is twice more prevalent in coeducational schools than in girl schools. The prevalence of bullying increases from 13% in the 3rd grade to 46% in the 6th grade. Bullying is higher in classes with more retained students.

Bullying occurs in a variety of settings that are an extension of your child's school life. Bullying can occur face to face, by texting or on the web (cyberbullying). Bullying is not a phase of growing up, it is not a joke, and it is not a sign that boys are being boys. Bullying can cause lasting harm - to the victim, the bully and the bully-victim (children who are bullied and also bully other children).

Bullying takes many forms
  • Verbal: Name calling, teasing
  • Social : Spreading rumours, leaving people out of groups on purpose, breaking up friendships
  • Physical : Hitting, punching, shoving (5% in Indian schools)
  • Cyberbullying

When is it bullying? It’s bullying when there are three features to the interaction
  1. Imbalance of power: People who bully use their power to control or harm. The victims may have a hard time defending themselves.
  2. Intent to cause harm: The person bullying intends to harm the victim
  3. Repetition: Incidents happen to the same person over and over by the same person or group
It’s not bullying when there are
  • Mutual arguments and disagreements
  • Single episodes of social rejection or dislike
  • Single episode acts of nastiness or spite
  • Random acts of aggression or intimidation

Effects of bullying

Those who are victims are at a high risk for mental health problems
  • Higher risk of depression and anxiety with increased thoughts of suicide
  • More likely to have health complaints
  • Have decreased academic achievement
  • More likely to miss or drop out of school
  • More likely to retaliate (12/15 shooters have a history of being bullied)
Bullies are more likely to manifest behaivour problems that continue into adulthood when these behaviours manifest as criminality
  • Higher rates of alcohol/substance abuse
  • More likely to get into fights, vandalise property
  • More likely to be abusive towards partners, spouses or children later in life.
Bully-victims are the worst affected. They develop both mental health and behavioural problems

Is your child being bullied?

If your child has any of these features it is very likely they are being bullied in school
  • Comes home with torn clothing or missing belongings
  • Appears sad, moody, depressed or anxious especially on returning home from school
  • Prefers to be alone
These symptoms are also likely in victims of bullying
  • Is afraid of going to school
  • Vomiting
  • Sleep disturbances including insomnia and nightmares
These symptoms are commonest in victims
  • Frequently falling sick
  • Headaches
  • Bodyache is the next most common symptom in female victims. In male victims nightmares are the next most common.
Is your child a bully? Consider these common traits of bullies
  • Become violent with others, gets into physical or verbal fights
  • Get sent to the Principal’s office often
  • Has extra money or new belongings which cannot be explained
  • Will not accept responsibility for their actions
  • Need to win and be best at everything

Do’s and Don’ts

For parents whose children are victims of bullying (Carr-Gregg 2011)
  • Tell the your child to ignore the bullying. This allows the bullying and its impact to become more serious
  • Blame your child or assume that they have done something to provoke the bullying
  • Encourage retaliation
  • Criticise how your child dealt with the bullying
  • Contact the bully or parents of the bully
  • Communicate with your child
    1. Listen carefully. Ask who was involved and what was involved in each episode
    2. Empathise and reinforce that you are glad your child has disclosed this
    3. Ask your child what they think can be done to help
    4. Reassure your child that you will take sensible action
  • Contact the teacher and/or principal and take a cooperative approach in finding a solution
  • Discuss the matter in a face-to-face meeting. Stay calm. Take along any evidence you may have gathered. Ask three key questions
    1. How will this matter be investigated?
    2. How long will this investigation take?
    3. When will you get a follow up meeting to discuss the results?
  • Contact school authorities if bullying persists and escalate your communications up the chain of command. Here’s where your paper trail comes in useful
Every child deserves an education free of fear
  1. Carr-Gregg M, Manocha R. Bullying - effects, prevalence and strategies for detection. Aust Fam Physician. 2011 Mar;40(3):98-102.
  2. V .Y. Kshirsagar, Rajiv Agarwal and Sandeep B Bavdekar. Bullying in Schools: Prevalence and Short-term Impact. Indian Pediatrics 2007; 44:25-28