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
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.
2. Make aggression ineffective by modifying its consequences
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.

References
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.

Healthy Baby Contests - judging psychological development objectively

Psychological development is a key aspect of any ‘Healthy Baby Contest”. Pathfinder Clinic judged the psychological development of toddlers participating in one such local event. Healthy baby contests are among the most attractive activities organized by many preschools and communities. Assessment is a sensitive issue at any Healthy Baby competition. Parents of contestants are concerned regarding partiality and subjective errors. Judging a Healthy Baby Contest objectively is crucial to the credibility of the event.

Can psychological development be objectively assessed in 5 minutes?
Psychological assessment can be time consuming and difficult to operationalize. The child’s development is captured in speech, social interaction, and manipulation of every- day objects. Usually a child’s developmental milestones are judged ‘objectively’ based on the parents responses to available screening questionnaires.

We decided to get our knees dirty and go down to toddler level to get a direct assessment of where they were at. The caveat, the organisers wanted us out of the way in two hours. We judged 39 toddlers aged 2 to 4.5yr. We took three hours; less than 5 minutes per child on an average.

Method

The atmosphere around the play rooms was intense -  mainly contributed by parental anxiety. Pre-school coordinators ensured each child walked into the room with their parents. Despite some adult anxieties each family was safely seated at toddler level. Every child was greeted and asked their name. They were then asked to point to and name parts of the body and animal figures;  draw age-appropriate figures; manipulate wooden blocks or coloured beads; and catch a large ball.

Children were assessed on these categories

1. Speech and language
2. Social function
3. Fine motor function
4. Gross motor function
5. Cognitive function

The scores were entered into a proforma and results tabulated

Are healthy baby contests a waste of time?

Of course things didn’t always go smoothly, but under all the levity some serious assessment work was done. We learnt from the kids. Fans and lights are passe as objects to point out - a laptop will always bring out a prompt pointing index finger. The advantages are apparent

• With a reliable scoring system, the results are easy and quick to interpret and more acceptable.
• The results can be explained scientifically
• The protocol can serve as a guideline for educating caregivers and teachers regarding simple criteria for monitoring the child’s health status. These also serve as a checklist for their activities.
• Screening of at risk children - one child screened positive for autism (prevalence rate in the literature is 1 in 110). The parents were advised the need for follow-up.
• Data obtained is used to establish local norms for child development

Healthy Baby Contests can have a positive impact on the community when conducted scientifically. Psychological development of infants and toddlers can be effectively judged through direct observation in a short time-frame.

References

1. Bhat G, Pardeshi S, Kakrani V, Pratinidhi A. Making healthy baby contests more objective. Indian J Med Sci [serial online] 2001 [cited 2012 Mar 23];55:553-8. Available from: http://www.indianjmedsci.org/text.asp?2001/55/10/553/12035
2. M.L. Kulkarni, G.L. Mohan. Healthy Baby Contests-Beyond show, Beyond Objectivity Towards Health Education Indian Pediatrics 1999; 36:417-418 http://www.indianpediatrics.net/apr1999/apr-417-418.htm

Bipolar disorder and hypomania - irritability and depression

Chronic unstable mood with irritability and superimposed bouts of depression is a common form of bipolar II disorder or hypomania. Persons with this pattern of illness tend to have an unstable course and stormy interpersonal relationships. They also have more irritable and hostile hypomanic episodes. The classical Bipolar II disorder or hypomania of mild elevation of mood, sharpened and positive thinking, and increased energy and activity levels is less disruptive.

Persons with this irritable type of hypomania and bipolar illness have unrealistically high expectactions of those with whom they interact; whether at the workplace, at home, or other casual day-to-day interactions. When these expectations are not met they pass on their irritation and negative mood to unsuspecting others.

There is usually a grain of truth in their version of the incident, but the growing number of incidents with various people at all levels reduces their credibility. At the workplace they are frequently in search of a new job and personally they have problems sustaining meaningful relationships.

Anger management alone is usually not effective. It needs to be combined with specific treatment for the bipolar illness. At the clinic couples and individuals come in for anger and interpersonal issues that are not resolved with counselling.

"I never realised how much my moods controlled my actions"

Treatment for bipolar disorder including hypomania hinges on medication and psychotherapy. Treatment requires patience by all parties in the therapy. Relapses are frequent when medication is stopped.

"I can see the difference when he stops his medication;

help me get him back, doctor"

It takes time for the affected person to accept he or she has hypomania or bipolar illness. The degree of realisation fluctuates during the course of therapy. Regular psychiatric review is essential to prevent relapse in bipolar illness and hypomania

Mental health checklists and screening tests for rampaging bus drivers

Checklists and psychological screening questionnaires for mental illness are effective, easy to use and widely available. Pune was shocked into considering the need for mental health screening of its bus drivers after one of them wilfully killed eight people and injured 32 others. He hijacked a bus at the depot and mowed down victims in broad daylight. Amidst the protests, and outrage the Pune administration has decided that all its bus driver undergo psychological testing.

We have already looked at screening of police personnel for mental health problems, and also screening of teenagers for alcohol and drug abuse. Here we specifically examine the feasibility of regularly screening the 8600 PMPL staff and Pune bus drivers for mental health problems.

Mental illness in bus drivers

• Mental health problems are higher for bus drivers who suffer from back pain, are dissatisfied with their jobs or undertake long-distance driving. This is more so for employees who have worked for >10 years. (Issever et al 2002)
• Aggressive bus drivers have more anxiety, hostility, and anger. They display competitiveness when driving aggressively, and display anger at slow drivers and traffic obstructions (Galovski 2002). Aggressive drivers with Intermittent Explosive Disorder (IED) endorse more assaultiveness and resentment. They display more impatience, hostility and have an angry temperament.
• Bus drivers have higher hospital admissions with diagnoses of mood reactions, paranoia and non-specific psychoses. (Ugesker 1989)

Ideal mental health screen

Easy to administer

it is to be conducted regularly without consuming excessive time

Culturally acceptable

anything stigmatising will be shunned

Sensitive

picks up potentially vulnerable persons

Specific

excludes those who do not have mental health problems

Easy to interpret

results should be available immediately

The aim of mental health screening is to identify individuals who require a more detailed examination. One counsellor will never be able to carry out any evaluation of 8600 staff.

Mental health checklists and screening instruments

There are already valid (test identifies persons mental illness) and reliable (results remain the same when administered by different testers and on re-testing) checklists for mental health screening. Two mental health screening instruments that satisfy many of the ideal criteria are the COOP/WONCA charts and the WHO-5 questionnaire. Both have high diagnostic accuracy for mental disorders. Specificity, sensitivity and positive predictive values range from 0.85 to 0.87 (Anything more than 0.7 is good).

COOP/WONCA

The COOP/WONCA measures six core aspects of functional status: physical fitness, feelings, daily activities, social activities, change in health and overall health through six charts. The charts have been successfully used in illiterate populations, and have guidelines for translation where required. The average time for completion is less than five minutes. One-time assessment with the COOP/WONCA Charts is a valid and feasible option for screening for mental disorders at the primary care level.

WHO-5

The WHO-Five Well-being Index (WHO-5) is a set of 5 questions that can be used when six charts are too much.

A mental health check is most acceptable as part of the regular or annual ‘health check’. Those who score above the cut-off are taken up for detailed assessment by a psychiatrist or other mental health professional. No additional man-power is required. The process will not cost in crores. Our roads will be safer.

We need to use available checklists and screening tests for early detection of mental illness in Pune’s bus drivers.

References

1. Galovski T, Blanchard EB. Psychological characteristics of aggressive drivers with and without intermittent explosive disorder. Behav Res Ther. 2002 Oct;40(10):1157-68. 
2. Issever H, Onen L, Sabuncu HH, Altunkaynak O. Personality characteristics, psychological symptoms and anxiety levels of drivers in charge of urban transportation in Istanbul. Occup Med (Lond). 2002 Sep;52(6):297-303. 
3. Joao Mazzoncini de Azevedo-Marques, MD, PhD1 and Antonio Waldo Zuardi, MD, PhD. COOP/WONCA Charts as a Screen for Mental Disorders in Primary Care.  Annals of Family Medicine 9:359-365 (2011) doi: 10.1370/afm.1267
4. C. van Weel, C. König - Zahn, F.W.M.M. Touw - Otten, N.P. Van Duijn, B. Meyboom - de Jong. Measuring functional status with the COOP/WONCA charts: a manual. Northern Centre of Health Care Research 1990. ISBN 90 72156 33 1 
5. WHO. WHO-Five Well-being Index (WHO-5) Accessed 17-Feb-2011 
6. Ugeskr Laeger. Psychiatric admissions among city bus drivers. A prospective study. Ugeskr Laeger. 1989 Jan 30;151(5):302-5. 

Dyslexia - Difficulty with Reading, Maths & Spelling

Difficulty with reading, spelling and maths is rampant among Indian students. Two recent reports have highlighted this academic underachievement. The academic infrastructure is definitely a major contributor. However, unrecognised dyslexia or other learning disability also needs to be considered by every concerned parent and enlightened teacher. We have already discussed the management of dyslexia. Here we underline the urgent need for action.

India ranked 72nd of 73 countries in a comparative international survey (PISA) of 15-year-old students. All students were assessed on the same test for knowledge and skills in reading, mathematical and scientific literacy. A sample of more than 5000 students from 200 Indian schools were assessed in this program. In none of these categories did more than 17% of Indian students scored above baseline levels as compared to 81% of students from OECD countries (US, UK, Australia etc).

15-year-olds scoring above baseline 

Test	India	China	OECD avg
Reading	11-17 %	95.3%	81%
Mathematics	12-15%	94.5%	75%
Science	11-16%	96.3%	82%

The Annual Status of Education Report (2010) paints an equally dismal picture.
Reading ability

• Only half the students in Class 5 can read the Class 2 text

Maths

• Only a third of Class 1 children can recognise numbers 1-9
• Only a third of Class 3 students can do subtraction in two digits
• Only a third of Class 5 students can do simple division
• A third of Class 8 students could not use a calender

This may be a scathing indictment of our education system, but it also reflects the presence of unrecognised Learning Disorder in our students. Learning Disorder affects 5-10% of students worldwide. Learning Disorder manifests in varying combinations and severity of difficulty with reading, spelling and arithmetic.

If your child has difficulty reading, spelling or in mathematics

• Have them assessed for dyslexia or other learning disability
• The earlier remedial teaching is instituted the more likely the child is to benefit
• Identification of dyslexia or learning disability entitles your child to waivers at the 10th and 12th board exams.

The Right of Children to Free and Compulsory Education Act (RTE) of 2009 lays down the duties of government, local authorities and parents; the responsibilities of schools and teachers; and the norms for schools. These norms include the number of teachers, buildings, minimum teaching hours, teaching aids, library, and recreational equipment. However, the teaching to be done is not mentioned and nor is it monitored. Rote learning is emphasised. Students fail to acquire basic reading, writing and calculation skills that are required to continue learning as adults.

Don't just wait for the government 

Act NOW to secure your child's place in a global future

References:

1. ASER 2010 - Rural. Annual Status of Education Report (Rural)Date of publication: January 14, 2011
2. Maurice Walker. PISA 2009 Plus Results: Performance of 15-year-olds in reading, mathematics and science for 10 additional participants. ACER Press. Victoria. 2011.  ISBN: 978-1-74286-067-1
3. The Right of Children to Free and Compulsory Education Act (RTE).