Diagrama de proceso laminado

When reviewing the literature on aggression in CYP, one can observe the

existence of two contexts: an educational context (EC) and a health context (HC). Within the EC (school and educational research), aggressive behaviour is a common problem in CYP identified by educational services as having BED

Direct/overt, other- directed aggression

Non-physical

Non-verbal Verbal

(e.g. verbally threatening to hurt another individual)

Symbolic

(e.g. making threatening gestures at someone else)

Object

(e.g. destroying someone else’s property)

Physical

CHAPTER 1: INTRODUCTION

12

(Teachernet, 2006; Bennathan, 2004; Department for Education and Skills (DfES), 2001; Gadow and Sprafkin, 1993).

Within the HC (health care and health research), types of aggression (e.g. direct or overt aggression) are generally regarded as one of the diagnostic criteria of some psychiatric diagnoses such as conduct disorder (CD) and oppositional defiant disorder (ODD) (Diagnostic and Statistical Manual-IV (American

Psychiatric Association (APA), 2000); International Classification of Diseases-10 (World Health Organisation (WHO), 1992)). Aggression is a common sign seen in the presentation of a wide variety of psychiatric disorders including attention deficit hyperactivity disorder (ADHD), mood disorders (MD), pervasive developmental disorders (PDD), mental retardation, specific developmental

delays, some personality disorders, and substance- and alcohol-related disorders. The majority of these psychiatric diagnoses are syndromes, aggression being one of the problems contributing to such syndromes. CYP with some psychiatric disorders such as depression and anxiety may show aggressive behaviour

(Connor and McLaughlin, 2006; Knox et al., 2000) even if this is not a criterion for the diagnosis they are given. Although commonly associated, aggression is not equivalent to, and not specific for a diagnosis of conduct disorder or oppositional defiant disorder (Connor and McLaughlin, 2006).

Aggression is, however, a specific behaviour that can be objectively measured, both overall and in its subtypes, and targeted for intervention, regardless of any associated diagnoses (Connor and McLaughlin, 2006; Collett et al., 2003).

CHAPTER 1: INTRODUCTION

for the referral of CYP to mental health services (Barnes et al., 2004; Rice et al., 2002; O’Donnell, 1985 cited in Knox et al., 2000; Steiner, 1997). Aggression is more frequent in psychiatrically referred compared to non-referred 9- to 16-year- olds (Connor and McLaughlin, 2006). Aggressive behaviours are also common among CYP who are using mental health inpatient services and pose serious therapeutic and management problems (Recklitis and Noam, 2004; Knox et al., 2000; Vivona et al., 1995; Grosz et al., 1994; Davis, 1991). In such health settings, aggressive behaviour is often referred to as challenging behaviour.

1.4.2.1 BEHAVIOURAL AND EMOTIONAL DIFFICULTIES/ DISTURBANCES/ DISORDERS

The two major classification systems of psychiatric disorders currently used within health settings (clinical and research), the International Classification of Diseases of the WHO and the Diagnostic and Statistical Manual of the APA, employ the terms behavioural and emotional disorders and disruptive behaviour disorders, respectively, to describe presentations that include aggression. There are similarities and differences between the two classification systems. The ICD-10 (WHO, 1992) group of ‘behavioural and emotional disorders with onset usually occurring in childhood and adolescence’ comprise a number of diagnoses, each having specific diagnostic criteria (hyperkinetic disorders, conduct disorders, mixed disorders of conduct and emotions, emotional disorders with onset specific to childhood, disorders of social functioning with onset specific to childhood and adolescence, tic disorders and other behavioural and emotional disorders with onset usually occurring in childhood and adolescence). The DSM-IV-R (APA,

CHAPTER 1: INTRODUCTION

14

diagnostic categories (attention deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder and disruptive behaviour disorder not otherwise specified). Aggression is one of the diagnostic criteria for conduct and

oppositional disorders, mixed disorders of conduct and emotions and hyperkinetic conduct disorder. It is also a commonly associated sign but not a diagnostic criterion for other behavioural and emotional disorders (Connor and McLaughlin, 2006; Knox et al., 2000). Research also indicates that aggression is a significant problem in residential care institutions for CYP with behavioural and emotional disorders (Vander Laenen, 2009; D’Oosterlinck et al., 2006).

Within educational settings (school and research) the terms emotional and

behavioural difficulties/disturbances/disorders are frequently used to describe the presentation of children who have special educational needs because of

behaviours and emotions that include aggression (DfES, 2001). There is no absolute definition of emotional and behavioural difficulties and levels of associated aggression may fall across a wide spectrum (Teachernet, 2006; Bennathan, 2004). Pupils with such difficulties may be aggressive, disruptive, self-injurious, hyperactive, withdrawn or depressed (Teachernet, 2006; DfES, 2001; Cole et al., 1998; Sprafkin and Gadow, 1987).

1.4.3 CAMHS

CAMHS is a term used in National Health Service (NHS) documentation (NHS Health Advisory Service, 1995) and in most publications on mental health

services for CYP in the UK. Specialist outpatient (Tier 2 and 3) CAMHS form part of the 4-Tier, multi-agency provision for CYP with mental health problems (see

CHAPTER 1: INTRODUCTION

Table 1.2). Most CAMHS see CYP (usually aged up to and including 17 years of age), who have behavioural or emotional problems. Referral is through

professionals such as general practitioners and educational psychologists. Generally, CAMHS are multidisciplinary but the staffing, location and services offered vary from one service to another (Barnes et al., 2004). Child

psychologists, child psychiatrists, nurses, social workers, primary mental health workers, a range of child psychotherapists (e.g. psychodynamic and family psychotherapists) and experiential therapists (e.g. art therapists) can work in such services.

As mentioned above, CYP are often referred to CAMHS because of their

aggressive behaviour but assessment of CYP referred for other reasons indicates that many of them also exhibit aggressive behaviour. CYP assessed at CAMHS often have co-morbid behavioural and emotional disorders (Barnes et al., 2004).

CYP who exhibit aggressive behaviour cause great concern to many services such as social services (in relation to care and control issues), juvenile justice services (in terms of delinquency), education services ( for the management of aggressive behaviour and helping CYP with special educational needs) as well as health services (for the diagnosis and treatment of specific disorders). CYP with aggressive behaviour tend to be referred to different services depending on age: children under 5 years of age tend to be sent to child health (e.g. paediatric) services; primary school-aged CYP tend to be sent to specialist education

CHAPTER 1: INTRODUCTION

16

CYP presenting to CAMHS are therefore more likely to be in the primary school age category (Barnes et al, 2004; NHS Health Advisory Service, 1995).

Table 1.2 Multi-agency provision for CYP with mental health problems

TIER 1 General practitioners, health visitors, residential social workers, school nurses, teachers, juvenile justice workers

TIER 2 CAMHS professionals, educational psychologists, community paediatricians

TIER 3 Multidisciplinary CAMHS team TIER 4

Tertiary services such as day units, highly specialised outpatient teams and inpatient units for severely mentally ill children and young people or those at very high risk of suicide

Source: NHS Health Advisory Service (1995)