BBC News is reporting that there is a new ‘Guide to help parents to spot 'problem behaviour’’, while The Daily Telegraph claims that ‘More than one million parents could be offered state-funded lessons in how to play with their children under NHS guidelines’.
Both reports are based on new guidelines, published today by the National Institute for Health and Clinical Excellence (NICE) and the Social Care Institute for Excellence (SCIE), into a condition known as conduct disorder.
Conduct disorder is a relatively common but often overlooked mental health condition in children and young people, which causes defiant behaviour (‘I won’t do what you tell me’) and sometimes severe aggressive and /or antisocial behaviour.
The guideline says half of children with conduct disorders not only miss out on parts of their childhood but go on to develop serious mental health problems, such as antisocial personality disorders, as adults. They also have an increased risk of ending up in prison and developing a drug misuse problem.
The guidelines argue that early intervention in at-risk children is essential to break this chain.
The new guidelines highlight the key role of parents and other carers in detecting and managing conduct disorders and recommends specific training for health and social care workers to help them.
Conduct disorders are the most common type of mental and behavioural problem in children and young people. They are characterised by repeated and persistent patterns of antisocial, aggressive or defiant behaviour, much worse than would normally be expected in a child of that age. Types of behaviour include stealing, fighting, vandalism, and harming people or animals.
Younger children often have a type of conduct disorder called “oppositional defiant disorder”. In these children, the antisocial behaviour is less severe and often involves arguing (“opposing”) and disobeying (“defying”) the adults who look after them.
In teenagers with conduct disorders, the pattern of behaviour can become more extreme and include:
Children with conduct disorders often have other mental health problems, particularly attention deficit hyperactivity disorder (ADHD).
These disorders are the most common reason for children being referred to mental health services, with 5% of all children between five and 16 years old diagnosed with the condition.
The proportion of children with conduct disorders increases with age and they are more common in boys than girls. For example, 7% of boys and 3% of girls aged five to 10 years have conduct disorders; in children aged 11 to 16 years, the proportion rises to 8% of boys and 5% of girls.
It is not yet clear why conduct disorders develop. A prevailing view is that, like many mental health conditions, a combination of environmental and biological factors may be involved.
Possible environmental factors include:
In terms of biology, researchers who looked at the brain structures of teenage boys with conduct disorders have found differences in areas of the brain associated with emotions such as empathy and behaviours such as risk-taking.
There may be certain genetic variants that a child inherits that may also make them more prone to develop conduct disorders.
Children and young people diagnosed with conduct disorders often fail at school or college and become socially isolated. In adolescence, they may misuse drugs and alcohol or become involved with the criminal justice system. As adults, this group do badly in terms of education and jobs, are often involved in crime and also have high levels of mental health problems such as antisocial personality disorder.
Several approaches have been developed for children at risk of, or diagnosed with, conduct disorders. In particular, parenting programmes are run by health and social care professionals to help parents improve their children’s behaviour. Treatment for the children themselves includes psychological therapies and sometimes, medication. The treatment of children with conduct disorder can involve many different agencies including health professionals, social services, school and college.
Recognising that a child may be at risk of, or has developed conduct disorder at an early age may help prevent problems later.
Conduct disorder is different from the occasional tantrum or “naughtiness” in a child.
The behaviour of a child with conduct disorder may depend on their age. Younger children (aged under 11) may repeatedly argue with, disobey and defy those looking after them.
Older children with conduct disorder may consistently exhibit antisocial behaviour, such as:
If you are concerned about your child’s behaviour, seek advice from your GP as soon as possible.
NICE has made a number of recommendations about the diagnosis and treatment of conduct disorders. Its key recommendations are outlined below.
One of the key messages contained in the NICE guidelines is the importance and usefulness of selective prevention. Selective prevention means identifying individual children with an above average risk of developing a conduct disorder and then providing treatment to try and prevent that from occurring. The rationale being that it is usually easier to prevent a disease than to cure one.
NICE recommend that younger children aged three to seven years should be considered for selective prevention if:
NICE recommends that children or young people at risk of developing a conduct disorder or who are suspected of having a conduct disorder are assessed by qualified health or social care professionals.
Initial assessment should involve checking for the following complicating factors:
The initial assessment should then be followed by a more comprehensive assessment. This should include asking about and assessing the following:
In younger children aged between three and 11 years, a type of treatment programme known as group parent training programme is recommended.
In older children, aged from nine to 14 years, a type of treatment programme known as child-focused programmes are recommended.
Older children and younger people aged 11-17 years also benefit from what are known as multimodal interventions (involving many services).
In some cases, drug treatments may also be recommended.
NICE recommend that this treatment should be offered to children who:
Parent/foster parent/guardian training programmes are based on the premise of helping parents make the most of their parenting skills so they can help improve their child's behaviour. The programmes are run by specially trained health or social care professionals. They cover communication skills, problem-solving techniques and how to encourage positive behaviour in children.
It is best if both parents, foster carers or guardians attend the programme if this is possible and in the best interests of the child or young person.
The programmes are usually run on a group basis involving 10 to 12 parents, over the course of 10-16 meetings, with each meeting lasting around 1½ to 2 hours.
NICE recommend that this treatment should be offered to children who have been identified as:
Child-focused programmes involve group work with other children or young people of a similar age and similar issues. The therapist encourages the children to better understand their thoughts, feelings and behaviour, and the connections between them. This is designed to help the children learn how to get along better with other people.
The children usually meet with their group once a week for about 10 to 18 weeks. Each meeting should last for about two hours.
Multimodal interventions involve psychological therapies that encourage individuals to look at different aspects of their life and talk with a wider circle of people, including their family, people at their school or college and other people who are important in their life. This type of treatment should be provided by a specially trained professional called a case manager. The case manager should visit you three or four times a week for three to five months.
In cases where ADHD is thought to be a contributing factor, then medications used to treat ADHD, such as methylphenidate or atomoxetine, may be recommended.
In a minority of cases, where a child or young person is finding it especially difficult to control their anger, a medication called risperidone, which helps reduce aggressive tendencies, may be recommended.
However, this is seen as a treatment of last resort when other treatments have failed. And risperidone should only be prescribed under the supervision of a professional with experience in treating conduct disorders.
Children and young people taking risperidone should have their health carefully monitored due to the risk of side effects. The most common side effects of risperidone include:
NICE have also made a number of research recommendations in order to improve patient care in the future. These include: