New guidelines on child antisocial behaviour

New guidelines on child antisocial behaviour: 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.

What is meant by conduct disorders?

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:

• aggression towards people or animals
• destruction of property
• persistent lying and theft
• serious violation of rules

Children with conduct disorders often have other mental health problems, particularly attention deficit hyperactivity disorder (ADHD).

How common are conduct disorders?

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.

What causes conduct disorders?

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:

• a “harsh” parenting style
• parental mental health problems such as depression and substance misuse
• parental history, such as the breakup of a marriage
• poverty
• individual factors, such as low achievement
• the presence of other mental health problems

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.

What happens to children with 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.

How can conduct disorder be treated?

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.

What are the warning signs and symptoms I should look out for in my children?

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:

• being highly aggressive towards people and animals
• stealing or damaging property
• lying
• fighting
• violating rules

If you are concerned about your child’s behaviour, seek advice from your GP as soon as possible.

What recommendations have NICE made about diagnosing conduct disorders?

NICE has made a number of recommendations about the diagnosis and treatment of conduct disorders. Its key recommendations are outlined below.

Selective prevention

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:

• they are growing up in a poor household
• they are underachieving at school
• there is a history of child abuse or parental conflict
• their parents are separated or divorced
• one or both of the parents has a history of mental health problems and /or substance abuse problems
• one or both parents have come into contact with the criminal justice system 

Assessment

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:

• a coexisting mental health problem (for example, depression or post-traumatic stress disorder)
• a neurodevelopmental condition (in particular ADHD and autism)
• a learning disability or difficulty
• substance misuse (in older children)

The initial assessment should then be followed by a more comprehensive assessment. This should include asking about and assessing the following:

• core conduct disorder symptoms in younger children (aged under 11) – particularly symptoms associated with oppositional defiant disorder, defined by NICE as “patterns of negativistic, hostile, or defiant behaviour”
• core conduct disorder symptoms in older children (aged over 11) such as aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules” in children aged over 11 years
• current functioning at home, school or college, and with peers
• parenting quality
• history of any past or current mental or physical health problems 

What recommendations have NICE made about treating conduct disorders?

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.

Parent/foster parent/guardian training programmes

NICE recommend that this treatment should be offered to children who:

• have been identified as being at high risk of developing oppositional defiant disorder or conduct disorder
• have oppositional defiant disorder or conduct disorder
• are in contact with the criminal justice system because of antisocial behaviour

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.

Child-focused programmes

NICE recommend that this treatment should be offered to children who have been identified as:

• being at high risk of developing oppositional defiant disorder or conduct disorder
• have oppositional defiant disorder or conduct disorder
• are in contact with the criminal justice system because of antisocial behaviour

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

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.

Medication

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:

• Parkinson’s like symptoms such as muscle jerks and problems with body movements
• headaches
• insomnia 

Research recommendations

NICE have also made a number of research recommendations in order to improve patient care in the future. These include:

• research into what the effectiveness of parent training programmes for older children
• research into how to get children to become more engaged with psychological treatments
• research into the best way to prevent relapses in people who have responded well to treatment
• research into whether classroom based interventions can be effective in treating conduct disorders

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter.

Links To The Headlines

Guide to help parents to spot 'problem behaviour'. BBC News, March 27 2013
Learn to play with your child the NHS way. The Daily Telegraph, March 27 2013
Expert: Treating conduct disorders could save money. ITV News, March 27 2013