Behavioural disorders in children

All young children can be naughty, defiant and impulsive from time to time, which is perfectly normal. However, some children have extremely difficult and challenging behaviours that are outside the norm for their age.

The most common disruptive behaviour disorders include oppositional defiant disorder (ODD), conduct disorder (CD) and attention deficit hyperactivity disorder (ADHD). These three behavioural disorders share some common symptoms, so diagnosis can be difficult and time consuming. A child or adolescent may have two disorders at the same time. Other exacerbating factors can include emotional problems, mood disorders, family difficulties and substance abuse.

Oppositional defiant disorder

Around one in ten children under the age of 12 years are thought to have oppositional defiant disorder (ODD), with boys outnumbering girls by two to one. Some of the typical behaviours of a child with ODD include:

• Easily angered, annoyed or irritated
• Frequent temper tantrums
• Argues frequently with adults, particularly the most familiar adults in their lives, such as parents
• Refuses to obey rules
• Seems to deliberately try to annoy or aggravate others
• Low self-esteem
• Low frustration threshold
• Seeks to blame others for any misfortunes or misdeeds.

Conduct disorder

Children with conduct disorder (CD) are often judged as ‘bad kids’ because of their delinquent behaviour and refusal to accept rules. Around five per cent of 10 year olds are thought to have CD, with boys outnumbering girls by four to one. Around one-third of children with CD also have attention deficit hyperactivity disorder (ADHD).

Some of the typical behaviours of a child with CD may include:

• Frequent refusal to obey parents or other authority figures
• Repeated truancy
• Tendency to use drugs, including cigarettes and alcohol, at a very early age
• Lack of empathy for others
• Being aggressive to animals and other people or showing sadistic behaviours including bullying and physical or sexual abuse
• Keenness to start physical fights
• Using weapons in physical fights
• Frequent lying
• Criminal behaviour such as stealing, deliberately lighting fires, breaking into houses and vandalism
• A tendency to run away from home
• Suicidal tendencies – although these are more rare.

Attention deficit hyperactivity disorder

Around two to five per cent of children are thought to have attention deficit hyperactivity disorder (ADHD), with boys outnumbering girls by three to one. The characteristics of ADHD can include:

• Inattention – difficulty concentrating, forgetting instructions, moving from one task to another without completing anything.
• Impulsivity – talking over the top of others, having a ‘short fuse’, being accident-prone.
• Overactivity – constant restlessness and fidgeting.

Risk factors in children’s behavioural disorders

The causes of ODD, CD and ADHD are unknown but some of the risk factors include:

• Gender – boys are much more likely than girls to suffer from behavioural disorders. It is unclear if the cause is genetic or linked to socialisation experiences.
• Gestation and birth – difficult pregnancies, premature birth and low birth weight may contribute in some cases to the child’s problem behaviour later in life.
• Temperament – children who are difficult to manage, temperamental or aggressive from an early age are more likely to develop behavioural disorders later in life.
• Family life – behavioural disorders are more likely in dysfunctional families. For example, a child is at increased risk in families where domestic violence, poverty, poor parenting skills or substance abuse are a problem.
• Learning difficulties –problems with reading and writing are often associated with behaviour problems.
• Intellectual disabilities – children with intellectual disabilities are twice as likely to have behavioural disorders.
• Brain development – studies have shown that areas of the brain that control attention appear to be less active in children with ADHD.

Diagnosis of children’s behavioural disorders

Disruptive behavioural disorders are complicated and may include many different factors working in combination. For example, a child who exhibits the delinquent behaviours of CD may also have ADHD, anxiety, depression, and a difficult home life.

Diagnosis methods may include:

• Diagnosis by a specialist service, which may include a paediatrician, psychologist or child psychiatrist
• In-depth interviews with the parents, child and teachers
• Behaviour check lists or standardised questionnaires.

A diagnosis is made if the child’s behaviour meets the criteria for disruptive behaviour disorders in the Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association.

It is important to rule out acute stressors that might be disrupting the child’s behaviour. For example, a sick parent or victimising by other children might be responsible for sudden changes in a child’s typical behaviour and these factors have to be considered initially.

Treatment of behavioural disorders in children

Untreated children with behavioural disorders may grow up to be dysfunctional adults. Generally, the earlier the intervention, the better the outcome is likely to be.

A large study in the United States, conducted for the National Institute of Mental Health and the Office of School Education Programs, showed that carefully designed medication management and behavioural treatment for ADHD improved all measures of behaviour in school and at home.

Treatment is usually multifaceted and depends on the particular disorder and factors contributing to it, but may include:

• Parental education – for example, teaching parents how to communicate with and manage their children.
• Family therapy – the entire family is helped to improve communication and problem-solving skills.
• Cognitive behavioural therapy – to help the child to control their thoughts and behaviour.
• Social training – the child is taught important social skills, such as how to have a conversation or play cooperatively with others.
• Anger management – the child is taught how to recognise the signs of their growing frustration and given a range of coping skills designed to defuse their anger and aggressive behaviour. Relaxation techniques and stress management skills are also taught.
• Support for associated problems – for example, a child with a learning difficulty will benefit from professional support.
• Encouragement – many children with behavioural disorders experience repeated failures at school and in their interactions with others. Encouraging the child to excel in their particular talents (such as sport) can help to build self-esteem.
• Medication – to help control impulsive behaviours.
• Some children have extremely difficult and challenging behaviours that are outside the norm for their age.
• These problems can result from temporary stressors in the child’s life, or they might represent more enduring disorders. The most common disruptive behaviour disorders include oppositional defiant disorder (ODD), conduct disorder (CD) and attention deficit hyperactivity disorder (ADHD).
• Boys are more likely than girls to suffer from behavioural disorders.
• Treatment options include parent management training, cognitive behaviour therapy, medication and treatment for associated problems.
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