October/ 2019

Department of Health Research

Ministry of Health and Family Welfare, Government of India

Standard Treatment Workflow (STW) for the Management of

CHILDHOOD BEHAVIORAL DISORDERS
ICD10- F90-98
OPPOSITIONAL DEFIANT DISORDER (ODD) DIAGNOSIS
• Doesn’t obey or listen, back-answers, rude behaviors
• Demanding, stubborn, throws tantrums when
demands are not met • Symptoms are present
CONDUCT DISORDER and persistent over
• Aggressive – angry, abusive, fights, hits or hurts several months
people, bullies other children, damages articles • Attempt further
• Stealing, lying, threatening or misbehaving classification into ADHD,
with people, truant (keeps away from school ODD and CD (ADHD
without parents’ knowledge), runs away from may be present with or
home, bad company, cruelty to animals without ODD and CD
CLINICAL
ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
PRESENTATION • Restless, always on the move / running, can’t sit in
CAUTION
a place,talkative
• Abrupt onset
• Can’t focus attention on a task, poor concentration,
gets easily distracted, disorganized, does not • Recent onset (few weeks
complete school work to few months)
• Too mischievous, can’t be left alone, troubles • Sudden increase in
people or damages things, or gets injured severity (consider another
• Impatient, always in a hurry, can’t wait for his turn, psychiatric disorder such
does not care for danger, acts without thinking as bipolar affective
disorder, hypomanic or
ALL 3 DISORDERS
Poor or erratic school performance and / or manic episode -> follow
complaints about behaviour from school the relevant STW)

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ASSESSMENT (History From Multiple Sources)

PARENT INTERVIEW FAMILY SITUATION SCHOOLING CHILD INTERVIEW

• Symptoms- onset, duration, • Health (including mental health) and • Attendance • Develop rapport( discuss neutral topics; avoid direct
type(ODD, Conduct, ADHD-as wellbeing of family members • Performance tackling of misbehaviors)
above) and severity • Cohesion, mutual understanding and • Learning • Observe:
• Developmental problems, harmony in the family
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problems, - Features of ADHD (restless, fidgety, easily distracted,
emotional disturbances and • Parenting and childrearing practices: • Classroom attention keeps shifting)
stress caring and disciplining, criticism, unfair behaviors - Speech and language ability, intelligence, academic
• Alcohol and substance use comparison and physical punishments, • Recent changes skills and mood
/misuse mutual blaming of parents for child’s in syllabus and/or • Enquire about any stress or difficulties child is facing at
• Impact on child and family problem school home, school, and with peers and anger control
r.o
MANAGEMENT

WORK WITH FAMILY WORK WITH THE CHILD WORK WITH THE
• PSYCHOEDUCATION
SCHOOL
- Explain the child’s behaviours are not intentional • Avoid advice
- Not child’s fault, do not blame the child • Feedback to school
• Anger management ( count
- Multifactorial causes-lack of self-regulation, and adverse environment regarding child’s
from 10 -1 backwards, move
- Can be improved with proper management condition
away from situation, deep
m

- Parents can directly contribute to the child’s improvement • Teachers to give extra
breaths, relax, self-talk to
• Help parents deal with their own worries and stress (listening, giving space to attention, help and
ventilate, validate and empathize their difficulties, reassure) cool down)
support for the child
• Recognize and manage mental health problems such as depression and alcohol • Children with ADHD:
• Extra coaching, if
problem in parents “stop-think-act” or “halt and
needed in case of
• Parent management training* proceed” technique
learning problems
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*PARENT MANAGEMENT TRAINING MEDICATION (AVOID BEFORE 5 YEARS)

• Analyse the problem behaviors and understand patterns : time of occurance, triggers, • Severe and persistant aggression:
duration and consequencies - T. Risperidone under close supervision (starting
• Engage with child in mutually enjoyable, pleasurable activities (playing games, dose-0.25 mg, single daily morning dose after
discussing interesting things or doing activities together) breakfast. Based on response, increase by 0.25 mg
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• Set clear do’s and don’ts and explain to child in clear, simple, short instructions the weekly up to 1 mg single daily dose).
consequencies (like withholding privileges following misbehavior; use star-charting Not to exceed 1 mg/day
(contingency management) and rewards based on number of stars earned - Response + : continue 3 months f/b slow taper
• In children with ADHD, develop clear daily routines, supervise activities and appreciate - Response - : 4 weeks trial, then refer
on completion of taks - Monitor adverse effects: weight gain,
st

• Limit screen time/ monitor use of electronic devices extra-pyramidal symptoms (EPS)
[if EPS : add I mg Trihexyphenidyl OD morning]
• Dos • Don’ts • Severe hyperactivity and impulsivety:
– Consistency in enforcing rules – Bribe - T. Clonidine (starting dose-25 μg single daily
– Catch the child being good and praise – False promises and threats
dose before sleep, increase by 25 μg weekly up
– Ignore negative behaviours – Harsh punishments
to100 μg per day in 2-3 divided doses
– Child can be put in a boring place till he/ – Excessive criticism and blaming
she becomes quiet for a few minutes especially in front of others - Monitor BP and drowsiness
(time-out) – Unfair comparison - Advise against sudden discontinuation
– Encourage age appropriate responsibilities – Yielding to unreasonable demands

REASONS FOR REFERRAL

Severe, complicated presentation Lack of response to treatment Severe aggression Highly dysfunctional family Alcohol and substance abuse

SECONDARY CARE (DISTRICT HOSPITAL) TERTIARY CARE (MEDICAL COLLEGE / REGIONAL REFERRAL CENTRE)
• Review and reassess diagnosis (clinical evaluation • Evaluate and manage severe behavior disorders – severe ADHD, ODD, and CD, if necessary on
using Rutter’s multi-axial system) and all the short-term inpatient basis
pointers given above • Multi-modal management with clear individualized plan
• If failed trial of Clonidine/ Moderate ADHD: • Trial of Methylphenidate in moderate / severe ADHD under expert supervision
T. Atomoxetine (starting dose-10 mg single daily • Recognize and treat comorbid disorders such as bipolar disorder, substance use disorder, and
morning dose after breakfast. Increase up to internalizing disorders and manage
1mg/ kg/day under close supervision). • Pharmacological management of older children / adolescents with severe aggression /
Monitor adverse effects and response impulsivity with Risperidone and/or Lithium
• Systematic parent management training / • Family therapy for dysfunctional / discordant families, contributing to child’s condition
behavioral management and individual therapy • Management of children in difficult circumstances with mental health issues (children in need
(as given above) of care and protection; children in conflict with law)

REFERENCES
• World Health Organization. mhGAP intervention Guide–Version 2.0 for mental, neurological and substance user disorders in non-specialized health settings. Geneva: WHO. 2016.
• Pliszka S, AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American
Academy of Child & Adolescent Psychiatry. 2007 Jul 1;46(7):894-921.
• Steiner H, Remsing L. Practice parameter for the assessment and treatment of children and adolescents with oppositional defiant disorder. Journal of the American Academy of Child & Adolescent
Psychiatry. 2007 Jan 1;46(1):126-41.

KEEP A HIGH THRESHOLD FOR INVASIVE PROCEDURES

This STW has been prepared by national experts of India with feasibility considerations for various levels of healthcare system in the country. These broad guidelines are advisory, and
are based on expert opinions and available scientific evidence. There may be variations in the management of an individual patient based on his/her specific condition, as decided by
the treating physician. There will be no indemnity for direct or indirect consequences. Kindly visit our web portal (stw.icmr.org.in) for more information.
© Indian Council of Medical Research and Department of Health Research, Ministry of Health & Family Welfare, Government of India.