Children who meet criteria for a behavioural disorder such as conduct disorder or oppositional defiant disorder have a pattern of behaviours characterised as aggressive or antisocial.
Most children misbehave, or are aggressive, defiant or have tantrums from time to time. That’s perfectly normal. To reach a diagnosis of conduct disorder or oppositional defiant disorder, the behaviours have to be more frequent and/or more severe than their same aged peers. But it is important to remember that many children who meet diagnosis of a conduct disorder or oppositional defiant disorder are not necessarily doing different kinds of things compared to their same aged peers, it is just that they stand out for how much or how intensely they do them.
Conduct Disorder or Oppositional Defiant Disorder?
There has been a tendency to distinguish between conduct disorder as a more severe presentation than oppositional defiant disorder. Conduct disorder tends to be found in older children and the types of behaviours that characterise conduct disorder are more likely to imply that someone is a victim (fighting with someone; stealing from them, hurting or victimising them) or reflect significant deviations from age-related social norms (for example persistent truancy from school or stating ???out at night against parental wishes; both beginning before the age of 13.)
In contrast, oppositional defiant disorder tends to be found in younger children and consists of less severe behaviours such as a persistent pattern of defiance to adult requests; severe temper tantrums; being unusually angry or very touchy etc.
There is a debate in the scientific literature as to whether oppositional defiant disorder is really just an earlier and less severe form of conduct disorder, or whether it is a different but related problem. Probably, research is now pointing towards the latter, but whatever else, the two types of disorder have a lot in common and children who present with these difficulties in the classroom are likely to pose significant challenges for teachers. From here on, both conduct disorder and oppositional defiant disorder will be jointly referred to as conduct problems.
How common are they?
Conduct problems are the most common mental health disorder and found in approximately 5 to 6% of the normal population of children in primary and secondary school. It is about twice as common in boys than girls. Why that might be is not entirely clear. Some people have suggested it is to do with gender socialisation practices; some suggested it is more to do with male biology; others have suggested that perhaps girls have similar rates of antisocial behaviour, but more as relational aggression (e.g., within friendships and harming others’ social status) than as overt physical aggression (e.g., fighting and arguing) and so gets noticed less. Probably it is a complicated mix of all those reasons and some others. However, it may be interesting to note that the peak of aggressive behaviour in human development is reliably between 18 and 36 months (“the terrible twos”) and that boys and girls reach similar peak levels, although girls’ socialisation, away from the aggressive peak, appears to be quicker than boys; perhaps because of their more rapid language development.
Different types – which settings?
It is also important to realise that for some children their conduct disorder is found across settings, for example at home and at school; whereas for other children it can be found only in one place but not the other. Some children only pose significant behavioural challenges at home, others only at school; so it is very important to get the parents’ perspective on how the child presents at home and see if some learning and collaboration can be established.
Different types – overt or covert?
Even where problems are present in school, children with conduct problems can look very different to each other. There will be some children whose expression of problems is overt, and you can easily see, for example, aggressive, fighting, bullying and arguing behaviours. Other children’s behaviours can be expressed more covertly, and might include lying, stealing, or victimising peers in subtle ways that don’t easily get noticed.
There is sometimes a distinction drawn between those children whose aggressive antisocial behaviours are impulsive or “reactive” to perceived threats (and these are often not ‘real’ threats at all, but arise from a bias towards a hostile understanding of social situations) versus those whose behaviour seems to have a calmer, more “instrumental” feel, in which aggression might be used as a means to achieving an end. In fact, the vast majority of children with conduct problems show both types of behaviour, at different times.
Furthermore, some children will restrict their behaviours to their peers, whereas others may confront the authority of adults such as teachers as well. A child who shouts at or threatens a teacher impulsively, without thinking about the consequences may be considered quite different to one who more calmly challenges the teacher, without any apparent sense of concern about consequences.
Different types – socialised?
Some children with conduct problems are able to maintain relatively good social relationships with other children, whereas others may get excluded from their peer group, typically because of a history of hurting or harming their peers. These children with less socialised conduct problems are at particular risk of failing to get opportunities to develop more prosocial behaviours, which could address some of their problems, or at least mitigate them.
The course of development
A diagnosis of either oppositional defiant disorder or conduct disorder is not fixed for life – it is certainly not the case that most children with these problems will go on to live seriously antisocial adult lives. The typical course of a child with conduct problems is, over time, to become less antisocial by the time of adulthood. However, research shows that those children who do “recover” from conduct problems by adulthood, remain at risk of living less prosocial and well-functioning adult lives; as if the opportunities they have missed out upon growing up – in education and in the community – have left a legacy on their social development. Therefore, it is extremely important to help these children recover as soon as possible and thereby promote as much opportunity to develop helpful, caring and considerate social relationships with others; as well as to reach their academic potential through education.
While most children do recover over time, there is a small group of children – especially those who started with problems in the early years and whose problems persisted into secondary school – who are more likely to have persistent antisocial behaviour into their adult lives (the so-called “early starter, life course persistent” cohort). These children often have other, frequently neurodevelopmental components to their presentation which seem to make their difficulties more entrenched. However, although intervening with these children may be harder, it is still possible and can be very effective
Children and young people with conduct problems frequently stand out because of aggressive and antisocial behaviours, but a significant number of these children also have other problems that may get “masked” by their overtly negative behaviour.
For example, approximately ¼ of children with conduct disorder will also have ADHD; the two things occur so commonly, that they have their own specific psychiatric disorder called “hyperkinetic conduct disorder”. Note that ADHD does not make children naughty, but in some children it can contribute, or at least cooccur, with behaviour problems. Remember that treating ADHD effectively is very important, but it may or may not have an impact on a child’s challenging behaviours. They are different things
A further significant proportion of children with conduct problems (probably around 20%) also present with problems to do with anxiety and/or low mood. These are problems that can very easily be masked by challenging behaviours. It may be helpful to remember, as a rule of thumb, that “bad” children can also be “sad” children.
There are also other neurodevelopmental problems that can often cooccur and complicate presentation of conduct problems, including low IQ (“intellectual disability”) and autism spectrum disorders.
From an educational viewpoint, conduct problems are also associated with poor academic performance and especially literacy. In the research, again, there has been some debate as to whether conduct problems drive down educational attainment in literacy because children do not engage in school, or whether struggling to read and engage in school triggers increases in behaviour problems, perhaps as a way of avoiding or managing these difficulties in class.
Probably, it is a mixture of both these processes, to a greater or lesser extent and differs for different children. However, there is clear evidence that the co-occurrence of behaviour problems, plus ADHD plus impaired literacy has especially poor outcomes for the life chances of children and these children would benefit from being identified and fast tracked for appropriate interventions across education and CAMHS working together.
What to do – Overview
From the perspective of a teacher, or indeed a parent, whether or not a child quite meets criteria for a diagnosis of a conduct problem may be less important than the experience of persistent antisocial or aggressive behaviour. Luckily, the types of interventions that work for children who present with diagnostic levels of behaviour problems, also work for the children who are just below threshold or at risk of developing them. The same kind of things tend to work.
It is also true that the same kinds of approaches tend to work for older children as for younger children. However, interventions tend to be more effective for younger children because older children have more influences beyond the immediate classroom setting that could be feeding into and maintaining the pattern of behaviours. In general, the earlier in a child’s life an intervention is started, the greater the improvement is likely to be.
What to do – Observe and define
Because there are so many ways for a child to have conduct problems, one of the first steps to help you in the classroom would be to be clear what behaviours you want to address. And then to be clear which behaviours are most important and which can wait.
One of the best ways to do this is to make use of an ABC chart (Antecedent, Behaviour, Consequences), in which as soon as possible after a target behaviour has occurred, you make a note of the things that preceded it (antecedent) and then what happened afterwards (consequences), including not just what you as the teacher did, but also what others, such as classmates, were doing.
ABC charts are incredibly helpful for understanding sequences of behaviours and indeed for also being clear about what the behaviour is, but they are also time-consuming. It is unrealistic to expect busy teachers to fill multiple ABC charts in during the day, so “less is more” and quality over quantity; just identify one or two behaviours in the day, and make a note as soon as you possibly can after the behaviours occurred so the elements are fresh in your mind.
What to do – Balancing Opportunities & Limits
Intervention will seek to balance a) the opportunity for positive, prosocial behaviours (which are noticed and praised) alongside b) consistent boundaries and limits. Generally, approaches that only prioritise one of these components tend to be much less effective.
What to do – Opportunities
Because many children with conduct problems have failed to learn how to be prosocial – and in very young children they perhaps haven’t yet made a move away from peak aggression in toddlerhood – an approach that promotes positive socialisation is extremely important.
Children who are antisocial need reasons to try out and develop more prosocial patterns of behaviour, to see the benefits of those behaviours and to keep doing them.
Seek out as many opportunities as possible to “catch the child being good” and that doesn’t have to mean actively prosocial like helping or sharing, but also just getting on with things quietly or doing a range of normal behaviours that are incompatible with antisocial ones. It is easy to forget to notice a child being “not bad”, such as quietly reading, but as these are the behaviours we want to see more of, they are extremely important to notice if we want to see more of them.
What to do – Limits
A challenge for any adult attempting to set effective limits for a child with conduct problems is to make them consistent and relevant to the behaviours being addressed. This is why careful observation is incredibly important. Of course, for a teacher, setting limits for one or two disruptive children in a class, has to be balanced with the behaviour management approaches taken for the whole class.
While some children can have effective limit setting working for them as part of a broader whole class approach, there will be others who need something more specific and tailored to their needs. Often this will require an additional pair of hands to make it effective (perhaps, for example, as identified in an EHCP).
What to do – Maintaining gains
Whatever else, while behaviour management techniques that enable the whole class to continue working and which limit the impact of a child with conduct problems are extremely important, they must always be paired alongside opportunities for positive and prosocial interactions if you want any gains in positive behaviour to be maintained.
But this can be extremely hard for any of us to manage – so do get support from your peers and other professionals (see below).
Getting help – getting the information
Unfortunately, there has been an increasing tendency for children with conduct problems not to be formally diagnosed in CAMHS services, and therefore they have become less likely to receive appropriate and effective treatment. Hence, schools will often be the first time the possibility of conduct problems is raised about the child. If you are concerned that a child in your class may have conduct problems, then it is worth keeping track of the kinds of behaviours that are concerning you, as well as how frequent and/or severe they are, compared to his or her same aged peers, so you can use this information when you seek out help.
Getting help – which services
There are a number of services that can help with children with conduct problems in schools. In some areas CAMHS services may be able to help; as may social care. Educational psychologists may be able to assess and advise individual children and consider their management in a whole classroom context. There are also an increasing number of education mental health practitioners who are trained in a range of evidence-based approaches, including parenting interventions for conduct problems.
It could also be helpful to review the MindEd resources.
Dr Matt Woolgar, Consultant Clinical Psychologist
Conduct Problems Clinic and Adoption and Fostering Team
South London & Maudsley NHS Foundation Trust