Mental health articles

Behavioural disorders are probably most likely to come to the attention of adults because the symptoms are easily observable and have a direct impact on others. Oppositional defiant and conduct disorders refer to a constellation of symptoms in which children display angry, destructive, aggressive and antisocial behaviour. The distinction between the two relates to the spectrum of symptoms with conduct disorder having more severe aggressive and antisocial behaviour and generally occurring in older children and adolescents.

The importance of early identification of these two disorders is that appropriate treatment during primary school years has been demonstrated consistently to reduce the disorder. Oppositional defi ant and conduct disorders account for roughly half of all referrals to Child and Adolescent Mental Health Services (CAMHS). The treatment shown to be effective is a specifi c form of ‘parent training’ in which parents are taught the principles of contingent behavioural reinforcement (both positive and negative), and given support through therapy in modelling and carrying out these behavioural responses. The fact that parent training is the most effective treatment does not necessarily imply that faulty parenting is the underlying cause of the problem. Although this may be true in a proportion of cases, other child-based and environmentbased factors may contribute to the development of oppositional behaviour, which is best treated by appropriate boundaries and contingent behavioural response from parents.

There is less systematic research on treatment during adolescence but what is available suggests that parent-based intervention alone may be ineffective (presumably in large part because the social networks of adolescents are so much wider), and multisystems therapy (MST), a more comprehensive and more expensive treatment, is the only intervention shown to lead to signifi cant improvement. Attention defi cit hyperactivity disorder (ADHD) comprises a cluster of symptoms including overactivity, inattention and impulsivity, and affects some 3–5% of the population. In the UK, many practitioners continue to make reference to the more severe form of the disorder, as defi ned by the International Classifi cation of Diseases, termed ‘hyperkinetic disorder’. The latter requires all three symptom areas to be present, and for symptoms to be pervasive across domains of functioning, i.e. home, school and leisure activities. This more severe disorder is present in 1–3% of school-aged children. Although milder cases of ADHD may show a good response to behavioural intervention, more severe ADHD and hyperkinetic disorder are unlikely to show a good response to behavioural treatment alone, while medication will substantially improve symptoms in up to 90% of children. NICE guidance indicates that the diagnosis and initial treatment of ADHD should be conducted by a child specialist, either a child psychiatrist or community paediatrician with expertise in behavioural disorders.

Once a satisfactory medication regimen has been implemented, routine prescribing can be maintained by GPs, with back-up and regular reviews from a child specialist. Many children with ADHD also show elements of aggressive and antisocial behaviour and the possibility of ADHD should always be considered in such a presentation, because of the role of a specifi c treatment approach.

Tags: Behavioral, behavioral disorders, children, disorders