Recognising Conduct Disorder in Children
Conduct disorders are characterised by repetitive and persistent patterns of antisocial, aggressive or defiant behaviour that is more frequent and severe than other children of their age.
Main key symptoms of conduct disorder in children
The most common type of conduct disorder in children aged 10 years and under is known as Oppositional Defiant Disorder (ODD).
Children with ODD show the following signs:
- Frequent or severe temper tantrums
- Arguing with adults
- Actively defying or refusing adults’ requests or rules
- Deliberately doing things that annoy other people
- Blaming others for their own mistakes or misbehaviour
- Touchy or easily annoyed by others
- Seeming angry or resentful.
- Seeming spiteful or vindictive.
Main key symptoms in older children
When a child shows the above behaviours, as well as more extreme behaviours (including violence, use of weapons, stealing, lying, fire-setting, and cruelty to animals), it is known as Conduct Disorder (CD).
This can be separated into unsocialised conduct disorder (where the child does not have lasting peer relationships) and socialised conduct disorder (where the child does have some meaningful connections with peers).
How common are conduct disorders in children?
Conduct disorders are the most common mental and behavioural problem in children and young people. The prevalence of conduct disorders rises across childhood and is more common overall in boys.
Roughly 7% of boys and 3% of girls meet criteria for conduct disorders. In 11-16-year olds this increases to 8% of boys and 5% of girls.
Many children with conduct disorder also have at least one other mental health problem, particularly Attention Deficit Hyperactivity Disorder (ADHD).
A small number of children with conduct disorder also show a lack of guilt or remorse; lack of concern about performance; and shallow emotion expression.
A significant minority may also have an anxiety disorder or depression. These are quite different kinds of disorder and are often missed due to the focus on behaviour problems.
Does the behaviour need to occur both at home and at school?
No, some children can show behaviour difficulties in all settings, but others may only present with challenging behaviour at home (known as conduct disorder confined to the home).
It can be very difficult for parents to feel understood and especially not blamed when it is only at home or only with one parent in particular – but these are well-recognised presentations and the problem is still ‘real’.
Risk factors for developing ODD and CD
Parental factors – Children are at higher risk of developing conduct disorders when they experience a harsh and inconsistent parenting style or are exposed to parental mental health difficulties (such as depression, antisocial personality disorder and substance misuse)
Environmental factors – Experiences of poverty and being involved with child protection services (such as being looked after or being on the safeguarding register) increase a child’s risk of developing conduct disorders.
Individual factors – Children with low educational attainment and the presence of other mental health problems are more likely to meet criteria for conduct disorders.
Ethnicity factors – Conduct disorders in the UK also vary across ethnic groups; they are less common in children of south Asian family origin, and more common in children of African- Caribbean family origin – but these factors can covary with the environmental ones.
Research has shown a strong link for ‘transactional processes’ such that features in the child or parents or environment may make parenting more challenging, and this leads to less effective discipline which then promotes poorer behaviour, challenging parenting even further.
What are the long-term consequences?
In addition to resulting in stress in the family, conduct disorders can result in poor educational attainment and social isolation. It can also affect children’s socialisation and self-esteem as their peers become less likely to want to play with them. If it is not addressed, can also lead to further difficulties in adolescence, such as substance misuse and increased contact with the criminal justice system.
What caregivers can do to help
When children show a lot of challenging behaviours, it is easy to get into a cycle of paying lots of attention to the difficult behaviours, and less attention to the positive behaviours. We know that children prefer to receive any kind of attention (even yelling) than no attention at all, so try your best to notice the positive behaviours (no matter how small) and deal with the misbehaviour as quickly and calmly as you can. Ensuring that parenting is consistent across caregivers, for example within the home and into school, can also help.
What teachers can do to help
As above, ensuring that discipline is fair and consistent, and children are rewarded for positive and prosocial behaviour can help to decrease their behavioural problems.
When to refer
Many children show challenging behaviour at times, but when this becomes much more frequent and severe than other children their age, and/or it’s having a big impact on your household, or on the child’s ability to engage in education or make and keep friendships, then it can be useful to seek help.
Whom to refer to
You GP or school Special Educational Needs Coordinator (SENCO) can help by making a referral to your local child and adolescent mental health service (such as CAMHS) or another appropriate local support service.
After a child is accepted to an appropriate mental health service, they will undergo an assessment to better understand their difficulties and recommend treatment.
What treatments are available?
Group Parent/Carer Training Programmes – This recommended treatment for children aged 3-11 years provides psychoeducation about conduct disorder and supports caregivers to respond to the child’s behaviour in a way that helps to minimise misbehaviour and increase prosocial behaviours, using social learning theory principles.
1:1 Parent/Carer Training – This is recommended when a child’s behaviour is particularly extreme or complex. This also uses social learning theory principles to assist caregivers to manage misbehaviour, but can be better tailored to fit the family’s unique circumstances and can involve the use of live-coaching of parenting skills.
Group Child-Focussed Programmes – This treatment is recommended for children aged 9-14 years, to assist the child with social skills and problem-solving skills.
Although medication is not indicated for conduct disorder, pharmacological management of ADHD symptoms may assist the behaviour of children who have both Attention Deficit Hyperactivity Disorder (ADHD) and conduct disorder. This can be prescribed by a psychiatrist within a child mental health service or by your GP and should be closely monitored to ensure that it is effective and does not produce unwanted side-effects.
Dr Matt Woolgar
South London and Maudsley NHS Foundation Trust