Behavioral Problems in Children

At the age of 2-3 years old the child, willing to explore the world, begins to develop the sense of identity and independence. This is the age often referred to as the ‘terrible twos’ where the toddler is often noncompliant and oppositional to adults’ instructions. 

This normal developmental stage is the one edge of the continuum which potentially expands with age and severity to oppositional defiant disorder (ODD), conduct disorder (CD) and delinquency and at the very end antisocial personality disorder (Wierson & Forehand, 1994). Aggression and oppositionality can be normal and useful. Persistence and impairment of disruptive behaviour are the indicators of deviance from the normal range. In order for a CD diagnosis to be made child’s behaviour has to be extreme and persistent (Goodman & Scott, 2005). Pervasiveness of the condition is related to severity and worse outcome. Conduct problems cover a wide range of behaviours including amplified aggression, noncompliance with authority and negative affect (Webster- Stratton & Hammond, 1997). Impulsivity, risky behaviour, destructivity and oppositionality can cause a great deal of distress and impairment to the child and the family. Antisocial behaviour against other people’s rights or property along with callous unemotional traits can be extremely challenging not only for parents and teachers but also for mental health professionals.

An early study examining the developmental course of disruptive behaviour concluded that different behaviours are associated with different ages (Achenbach & Edelbrock, 1981). Specifically, arguments and stubbornness appear around year 4, oppositional behaviour develops at the age of 8, fire setting and stealing emerge around year 12 and finally truancy, vandalism and substance misuse come forward at the age of 16. The majority of epidemiological studies have indicated that conduct disorders are the commonest psychiatric problems in children. The prevalence is higher for non clinical cases who suffer from behavioural difficulties. According to Audit Commission, around 40% of the child mental health services referrals are regarding clinical antisocial behaviour (Clinical Audit, 1999). The prevalence of male: female ratio varies between 2:1 to 4:1 (Richardson & Joughin, 2002).

The early onset conduct problems are usually accompanied by emotional disturbances, attentional and scholastic difficulties. These need to be thoroughly assessed and included in the treatment plan. Comorbidity rates of conduct disorder reach 50- 65% for ADHD but are high enough for mood disorders (35%) and developmental delays (Richardson & Joughin, 2002). Specific learning disorder is present at 1/3 of children with CD and educational failure follows (Goodman & Scott, 2005). Another important common associated feature is poor social skills and lack of stable peer relationships (Goodman & Scott, 2005)Behavioural or conduct problems are often referred to as externalizing problems or disruptive behaviour.

Prognosis

The long term prognosis of behavioural difficulties is rather poor, especially if left untreated. Conduct difficulties in childhood tend to persist during adolescence and even adulthood, many times resulting to a psychiatric diagnosis. Several cohort studies have revealed that more than half cases of moderate to severe behavioural difficulties in preschool age persist during school years, with at least 67% clinically diagnosed, with one or more of ADHD, ODD, CD (Webster- Stratton & Hammond, 1998). Comorbity is associated with poorer prognosis. Life course persistence of conduct problems has been observed to have early onset which is in turn linked to neurodevelopmental aetiology (Caspi & Moffit, 1995)According to NSO 2001, conduct problems often obstruct school achievement and social functioning, while constitute an important family and societal burden. Several other problems in adulthood are related with early onset disruptive behaviour, including financial difficulties, employment, homelessness, substance dependence,  drug-related and violent crime, poor physical (i.e. injuries, STIs, dental problems) and mental health (Moffitt et al, 2002). Challenging behaviour developed in childhood is often associated with delinquency and violent acts, criminality and substance misuse later in life (Patterson et al, 2000). While social exclusion is also linked with conduct problems which subsequently lead to several unwanted consequences such as emotional difficulties (Scott, 2005). The coexistence of emotional symptoms with childhood conduct problems enhances the risk for depressive disorder and deliberate self harm in later years (Goodman & Scott, 2005). As a result of all the above, the interrelated cost and the impact on the individual, the family, as well as on the society are significantly raised. The cost can be translated both in financial terms and at the same time in psychological ones. Specifically, it is calculated that the cost of each child with untreated conduct disorder is £15,270 per year in UK (Richardson & Joughin, 2002). All these negative implications associated with behavioural problems constitute prevention, early intervention and treatment of conduct problems extremely important and necessary.

Risk Factors

The factors increasing the risk of conduct difficulties can be detected in child’s characteristics and the environment s/he grows up. The different pathways of interactions between genes and environment offer three alternative mechanisms through which conduct problems can be developed. In one perspective, parents provide both the genetic endowment and the environment (passive). Sometimes though, child’s challenging behaviour elicits harsh parenting (evocative). Finally, the case can be that the sensation- seeking temperament of the child leads him/her to high risk environments and situations (active) (Rutter, 1997). Identifying the mechanisms through which behavioural problems emerge is extremely crucial as they can act as guidelines of treatment plan and intervention implementation. Further research is required in order to evaluate the degree of the impact of neurodevelopmental factors to the development of behavioural difficulties. As it is already mentioned, hyperactivity is highly interrelated with conduct disturbances. In parallel, IQ, executive functioning and difficult temperament are believed to play a crucial role, although still not clear.

Other child attributes that tend to accompany conduct problems are physical illness, cognitive deficits (such as delays in language development) and poor social skills (Richardson & Joughin, 2002).  In addition, deficits in social- cognition and the way environmental cues are encoded believed to direct behaviour. So, if a child perceives a neutral stimulus as threatening it is more likely that s/he would act in a disruptive manner. The role of constitutional mechanisms, such as neurotransmitter and metabolic disturbances and hormonal imbalance, in the development of conduct problems is still under examination (Goodman & Scott, 2005). Abnormal arousal patterns and difficulty to return to normal levels after frustration have been also observed in children with disruptive behaviour along with lower heart rates (Goodman & Scott, 2005).

Evidence suggests that the most common risk factors for conduct difficulties and antisocial behaviour can be detected in family environment. Low socioeconomic status (SES), high rates of life stress, isolation, poor neighborhoods and large family size are very often associated with conduct problems. Moreover, parental characteristics such as criminality, psychopathology and substance misuse are linked with child’s poor outcome. Interestingly, all these factors and especially SES have been found to mediate by parenting skills and marital discord (Farrington, 1992). It appears that parents with the above characteristics are usually unable to provide their children with a safe and consistent environment that can nourish them and build up their emotional and behavioural well being. On the contrary, neglect of child’s need and abuse are often present.

Applying social learning theory on parenting strategies can contribute to the understanding of the mechanism through which child rearing practices can lead to and maintain disruptive behaviour. This can be achieved by ignoring child’s positive behaviour and provide attention to undesirable behaviour (Patterson, 1982, cited in Scott 2005).The risk of developing behavioural and emotional problems elevates with insecure attachment, lack of supervision and inadequate involvement. Harsh and inconsistent parenting (Farrington, 1995), as well as domestic violence function as major stepping stones for disruptive behaviour and criminality in later years (Richardson & Joughin, 2002). Juvenile delinquency is also linked with increased criticism deriving from parents, lack of warmth, involvement and encouragement. An important protective factor is considered to be supervision during adolescence (Farrington et al, 1998). The identification of all these risk factors has encouraged the establishment of modification of child’s environment and parenting practices as the cardinal feature of effective interventions.

Parental Competencies

The role of parenting is crucial both in terms of predisposing and maintaining behavioural problems in children and adolescents. It appears to be the single most influential factor for child’s behaviour, social skills and emotion regulation. It is able to even buffer the strong effect of low SES and adverse life events (Webster- Stratton & Hammond, 1997). Functional parenting competencies act as a protective factor of conduct difficulties and are associated with less problematic children’s behaviours (Webster- Stratton & Hammond, 1997). Research on good parenting suggested that this involve sensitively respond to child’s needs, encourage desirable behaviour and child’s strengths and set consistent limits calmly (Dodge et al, 2003).  The role of a parent also includes transmission of values, sub- cultures and selection of environments (Dodge et al, 2003). All these aspects of parental role are integrated in the planning of treatment and the way this is delivered. 

Child’s well being, in terms of physical, psychological and educational condition is determined in a great extent from child- rearing practices. Therefore, upgrading parental competencies and strategies can contribute to the improvement of child’s emotional and behavioural repertoire. The majority of interventions use parenting as a tool and a medium to reach and shape children’s behaviour.

Parent Training

Before the 1960’s child therapy approaches were applied in order to tackle behavioural problems. Since then the relationship between disruptive behaviour and parenting practices had become salient. The precipitating and perpetuating effect of parenting on child’s behavioural problems had led to the development of Parent Training Programs (PTP). This is considered to be the most effective intervention for treating behavioural difficulties including ODD and CD (Brestan et al, 1998). The objective of such interventions is to eliminate family risk factors by enhancing parental understanding, communication and competencies. The aim is to promote positive child behaviour and eliminate undesirable one. The emphasis is placed on the quality of parentchild relation which is known to have a long-term positive impact on child’s life and family’s functioning. A new term sometimes used instead of PTP is Parent–Child Relationship Improvement Programmes. A variety of PTP was created integrating different components, using several techniques and settings, focusing on particular content and targeting different populations. Successful treatment is extremely important because it prevents the emergence of associated difficulties, found later on the developmental pathway (Zonnevylle- Bender et al, 2007; cited in Matthys et al, 2010).

Parent training has been used for a big range of child difficulties such as hyperactivity, anxiety, enuresis, sleep disturbances, feeding, developmental disabilities and child neglect and abuse. Nevertheless, research has focused on the parent training interventions for persistent behavioural problems of preadolescents (including temper tantrums, aggressive and non compliant behaviour) which are very widely used.  This is mainly because of the significance of the family environment on the development and maintenance of conduct problems. Parents exhibit a great deal of control on child’s environment, holding ethical and legal responsibility for child’s care. Additionally, children usually spend most of their time within their families under the ‘presence’ their parents (McMahon & Forehand, 2003).

Thorough assessment of the child and the family including recognizing difficulties, strengths and appropriate intervention for comorbit conditions and stressors is absolutely vital for the effective treatment of conduct problems. In some cases risk assessment and corresponding planning is crucial. It is important to keep in mind that conduct problems have a multi-factorial etiology and usually a complex presentation and as such, they require intervention in different levels.

The National Institute of Clinical Excellence (NICE, 2006) guideline based on a number of Randomized Control Trials (RCT) recommends parenting training as the first line treatment for disruptive disorders (CD, ODD, ADHD) for children before the age of twelve. Accordingly, the parenting training should fulfill the following preconditions. It should by based on social learning principles and adhere to evidence based manuals. The emphasis should be on improving family’s relationships and encourage parents identifying their own treatment objectives. A sufficient number of sessions is considered 8- 12 facilitated by trained and supervised therapists and involving role play and homework assignment.

The majority of evidence suggests that PTP have managed to improve child- parent interaction, conduct problems and interrupt the pathway leading towards antisocial and delinquent behaviour. Improvement in parent’s attitude and skills as well as in children’s social, scholastic, attentional and emotional difficulties have been reported (Barlow et al, 2000; cited in Nowak, 2008). A growing body of research suggests that PTP also contribute to the quality of family dynamics, siblings behavior and to the improvement of parental anxiety and depressive disorder (Long et al, 2001). 


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