Disruptive Behaviors in Children with Down SyndromeThe term disruptive behavior refers to an observable pattern of behaviors that disrupt interpersonal or group activities. It is important to distinguish active children with “mental-age" appropriate behavior from those with a mental-age discrepant behavior and a persistent pattern of behavioral problems associated with poor social and/or academic achievement. The psychiatric literature recognizes several different conditions which describes many, but not all, types of disruptive behavior seen in childhood. Not every child with misbehavior has a “disruptive behavior disorder.” The severity, intensity and pattern of negativistic, oppositional, disruptive, destructive or aggressive behavior distinguish these related conditions from one another. Together, they are aligned along a continuum of severity of conduct disturbance.
Common disruptive behavior disorders
- Attention Deficit Hyperactivity Disorder (ADHD)
- Oppositional Defiant Disorder (ODD)
- Disruptive Behavior Disorder - not otherwise specified (DBD-NOS)
Sometimes a different label may be used to describe a child with disruptive behavior, such as
- Unspecified disturbance of conduct
- Impulse control disorder
- Adjustment reaction with disturbance of conduct or emotion
When are disruptive behaviors typically noticed?
Typically, disruptive behaviors are diagnosed in the elementary school years when a child is between four to seven years old. However, some young children with DS may display oppositional behavior, high motor activity and distractibility prior to age three. Temperamentally predisposed toddlers may develop oppositional behavior without obvious hyperactivity or attention problems. It is common to observe some degree of stubbornness or refusal in preschoolers with DS that can be managed successfully using a firm, consistent discipline style.
Do disruptive behaviors occur more often in children with DS?
The prevalence of disruptive behavior in persons with Down syndrome is difficult to know. The pattern or tendency for disruptiveness changes across time and circumstance for any individual; but certain children appear to be predisposed and will exhibit disruptive behavior as their personal calling-card.
What underlying factors may predispose some children with Down syndrome to exhibit a persistent pattern of disruptive behavior?
Consider:
- Too frequent or too many “performance demands” based on the child’s capacity for speech-language, problem-solving and self-help. Especially if the child becomes anxious or easily frustrated
- Attempting a sudden transitioning from a preferred activity to a non-preferred activity
- A learned pattern of behavior intended to gain social attention or to escape-avoid task demands
- Some environmental triggers (a loud fire-alarm or siren, yelling or crying)
Also consider:
- Temperament mismatch between child-therapist, child-teacher or child-parent
- A rigid or inflexible cognitive style
- Problems with anxiety, hyperactivity, or impulse control
- Certain medical conditions resulting in discomfort or pain
Children with Intellectual disability are quite capable of using disruptive behavior to manipulate their caretakers and establish a pattern of learned, undesirable behavior that is difficult to change. Certain medical conditions, such as unrecognized pain, constipation, hyperthyroidism, sleep disturbance, visual or hearing impairment, or medication side effects, also can predispose some individuals to become disruptive.
How are disruptive behavior disorders confirmed?
- Observing them at home or school
- Surveying the child’s environment to search for specific triggers and reinforcer of the displayed behavior
- Having a behavior specialist conduct a functional behavior analysis
- Having parents, teachers or therapists complete behavior checklists or rating scales
- Having a medical evaluation to search for physiologic factors which suggest an underlying medical or psychiatric component
- Having a developmental-behavioral assessment to determine a child’s current level of speech-language, problem-solving and self-help skills.
How are specific types of disruptive behavior categorized?
In preschool children, some degree of stubborness, or negative-resistance is expected and does not indicate a “disorder” per se. Some children develop behaviors to avoid or resist academic instruction or a task demand that is perceived as “not fun” or too difficult. Such children may appear unfocused, distracted, restless and uncooperative with requests particularly during classroom instruction or more typically homework. The various disruptive behavior disorders have their own thresholds and criteria which must be met in order to warrant the label. These behaviors are not just occasional. They are part of a sustained pattern and lead to a disturbance in social, family and/or academic function during the past six-month period.
ADHD criteria need to be considered in terms of developmental age, and include: a short attention span, distractibility, poor impulse control, motor hyperactivity, fidgeting, easy frustration, disorganization, failure to complete tasks when able, moodiness, frequently interrupts and displays a poor sense of danger. Some symptoms appear before seven years of age.
ODD criteria need to be considered in terms of developmental age, and include: periodic or situational opposition, defiance and non-compliance with requests, frequently argumentative and/or frequent tantrums.
DBD-NOS criteria include periodic or situational aggressiveness toward others, physical disruption or property destruction in certain settings. In many younger children, "aggression" is often impulsive or attention seeking rather than malicious.
ODD criteria need to be considered in terms of developmental age, and include: periodic or situational opposition, defiance and non-compliance with requests, frequently argumentative and/or frequent tantrums.
DBD-NOS criteria include periodic or situational aggressiveness toward others, physical disruption or property destruction in certain settings. In many younger children, "aggression" is often impulsive or attention seeking rather than malicious.
These conditions are not always easily separate from one another. Children with DS+ADHD may at times be oppositional, disruptive or mildly aggressive; some children with DS+DBD may have poor impulse control with remarkably good attention.
Are disruptive behaviors a spectrum disorder?
Taken together, ADHD-ODD-DBD in children with Down syndrome do appear to align along a continuum of severity. However, even within a specific diagnostic category (e.g. ODD), there are individual differences.
Taken together, ADHD-ODD-DBD in children with Down syndrome do appear to align along a continuum of severity. However, even within a specific diagnostic category (e.g. ODD), there are individual differences.
Disruptive behaviors are often considered a developmental diagnosis, with varied expression and manifestations depending on a child’s age, maturity and physiologic makeup. Environments and social situations differ for each child. Thus “disruptiveness” may only declare itself under very specific or uncommon settings. There is also variation in the degree or severity of impairment among the behavioral features mentioned above., resulting in a highly individualized profile of symptoms. The presence of underlying physiologic symptoms varies considerably among individuals, and influences how we conceptualize and give meaning to the behavior.
Can disruptive behaviors be confused with other conditions?
Yes, diagnostic confusion or uncertainty is quite common. Rarely are two people likely to interpret the same observation (behavior) or circumstances (setting events) with complete agreement. All people especially those with professional training are somewhat biased to interpret what they see based on their previous training or experiences. It is therefore common to be given different interpretations for the same set of observations according to the person who’s opinion is being expressed. This happens quite frequently with the provision of medical services, and even more often in the delivery of behavior and mental health care because of the variety of practitioners and their varied training backgrounds.
Some common examples
- In cases involving preschoolers, parents may be told that disruptive behavior simply represents a normal stage of toddler development or a normal attribute of children with DS. Medical factors are often overlooked. For instance, if a child has a high degree of hyperactivity and impulsivity, only a diagnosis of ADHD may be given. Hyperthyroidism, sleep disturbance or medication side effects need to be considered, too.
- Many times, only certain aspects of the behavioral symptom-complex may be recognized. Thus, while aggressive or disruptive behaviors are easily identified, one might overlook other physiologic symptoms such as sensory aversion, anxiety, cognitive rigidity, irritability or fluctuating mood.
- In addition to disruptiveness, some parents may see features of autistic-like behavior (e.g. repetitiveness, sensory aversions, poor social-play skills or developmental regression) leading them to conclude that Autism-spectrum disorder is the primary diagnosis. This may or may not be so. Even if ASD is not the primary diagnosis, autistic-like features do complicate the diagnosis and management of children with disruptive behavior.
There are psychiatric symptoms that can co-occur with disruptive behavior. While disruptive behavior itself is of great concern and is easily recognized, additional physiologic features may be overlooked. These features can provide important clues regarding a medical or psychiatric component which may be contributing to complex cases.
A rigid, inflexible cognitive-behavioral style, and “need-for-sameness” or routines may become evident during childhood and could be a behavioral “marker” of obsessive-compulsive disorder (OCD), which has yet-to-reveal itself. Irritability, rapid mood fluctuation, and decreased need for sleep in school-age children could be a behavioral marker of a cyclic-mood disorder, such as bipolar disorder.
What are the long-term concerns with disruptive behavior disorders?
For the Child
- May experience academic failure, or social rejection by peers
- Placement in a more restrictive classroom setting
- Risk of repeated physical injury to self or others
- Difficulty with medical and dental procedures
- Chronic, learned patterns of behavior may develop
- Failure to respond to treatments despite good faith attempts at behavioral, functional communication and medical interventions.
- A more complex psychiatric disorder, such as anxiety, OCD or mood-disorder, may yet appear
- With maturation impulsivity and hyperactivity may lessen, and many disruptive youngsters grow up to become remarkable adults
For the Caretaker
- May become frustrated, anxious, easily upset and sleep-deprived
- Difficulty with community and vacation travel or special events
- Increased out-of-pocket financial costs for care, supervision and therapies
- Isolation from other families and friends
- Marital and family stress may result
- You will develop an appreciation for the complexities of human behavior and our general inability to alter it
- You will learn to speak and think of your child as the person they are and not just a problem
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