Childhood Behavioural Problems
Associate Director for Children and Young People
Centre for Mental Health
All children misbehave from time to time, but for a small minority behavioural problems become persistent and severe. Good quality parenting programmes can make a real difference but most children and families at risk do not get the help they need.
GPs are commonly approached by parents worried about their children's behaviour and are ideally placed to offer help before problems become entrenched.
The Centre for Mental Health has produced a briefing, endorsed by the Royal College of General Practitioners, to help GPs offer help to families. Click here to read the briefing.
Why is behaviour so important to health?
About 5% of children aged 5-10 have problems sufficiently severe to justify a clinical diagnosis of conduct disorder. A further 10-15% have sub-threshold problems which nevertheless imply increased risk of poor long-termsoutcomes. Prevalence is twice as high among boys as girls and is higher among children from disadvantaged backgrounds.
Children can develop behavioural problems at any age and most will grow out of them. However, severe problems which develop before the age of 10 predict a range of particularly distressing, damaging and costly outcomes both in children and later life.
These children are more likely to:
- have co-occurring physical, mental health and developmental problems
- suffer from accidental injuries
- become teenage parents
- have sexual health problems
- experience every type of adult mental illness
- be smokers (twice as likely)
- become dependent on drugs (four times as likely)
- have serious adult physical health problems
- die earlier
- commit suicide
In one study, 75% of children with severe behavioural problems had been taken to the GP during the previous twelve months, 50% has also been admitted to hospital, and 25% attended A&E before being referred to mental health services.
What can be done?
For most children with or at risk of behavioural problems, simple low-cost parenting programmes such as Triple P and Incredible Years result in a range of improvements. However, a small number of children with more complex needs may require more specialised support.
- NICE guidance on conduct disorder. There is no medication recommended for conduct disorder in the NICE guidance but most parents whose children are experiencing moderate to severe behavioural problems can be referred to NICE-recommended parenting programmes.
- Parenting support programmes: Parenting support programmes are usually delivered in groups and run for between 8 and 20 sessions. Groups are led by trained facilitators and are highly interactive, collaborative and non-judgemental. They improve children's behaviour by helping parents pick up practical techniques such as positive parenting by improving their relationship with their child. They also help to reduce family stress, improve parent's' mental health and strengthen child development.
What can GPs do?
GPs can identify children with serious behavioural problems by looking out for a range of concerns during consultations with parents. During initial consultations, GPs can pick up parents' concerns and assess the severity, persistence and impact of behavioural problems. The particular parenting programmes referred to in this article work best when targeted towards children with the greatest need. The Strengths and Difficulties Questionnaire (SDQ) can help GPs and parents to establish whether a child's behaviour falls outside healthy developmental norms. It is not a diagnostic tool but an easy-to-use screen reliable for children between the ages of 4 and 16 years.
The Centre for Mental Health has produced a video which explains the 'feel' and the benefits of these programmes. This video was made by parents for parents and can be found here.
The parents of children with behavioural problems often feel confused, embarrassed or defensive. The use of appropriate language is therefore crucial in promoting engagement with support programmes. Key messages which improve parents' engagement include promoting the many benefits of early intervention for children rather than focusing on any problematic behaviour and emphasising the practical and supportive feel of parenting groups. It is also worth highlighting that these programmes are known to reduce family stress and help parents' wellbeing. Parents value not being judged and being given common sense practical tips and strategies. They want a better understanding of their child's behaviour and how to manage it.
Families with additional needs
If speech and language difficulties or other co-existing neurodevelopmental problems are evident or suspected, GPs can refer directly to speech and language services or to school nurses to help access special education needs provision in schools.
A small minority of children (around 1%) have very extreme behavioural problems, including unpredictable childhood violence, possibly placing siblings and other at risk. If the SDQ highlights these problems, parents may need to be referred to CAMHS and possibly social services (if other children are at risk) for fuller multi-agency assessment.
The children of first-time teenage mothers are a high-risk group for poorer health and social outcomes. Many areas now provide Family Nurse Partnerships (FNPs). These involve intensive home visiting from nurses before the birth of a child and for up to two years after. Long term studies have shown that this intervention reduced a range of poor outcomes for these children, including conduct problems. Referrals are made via community midwives when pregnancy is confirmed.
Problems which surface during teenage years
Some children with behavioural problems get missed early on; whilst some children develop problematic behaviour for the first time during teenage years. A number of interventions, such as Multi-Systemic Therapy and Functional Family Therapy have a good record of turning around behavioural problems at this later stage. These therapies are delivered by highly trained therapists. They tend to be more resource intensive, working for up to six months with families, often focusing on other key systems impacting on these children's lives e.g. school, peers.
Summary: gaps in provision
It is, of course, vital that evidence-based parenting programmes are available locally and delivered faithfully by practitioners with adequate training and supervision. Where this is not the case, it represents a major commissioning gap. As members of clinical commissioning groups, GPs may be able to work alongside local authority partners to make the case for investment in parenting programmes and to improve access locally ensuring that patients do not miss out on the vital help and support they can provide.
Find out what the Royal College of General Practitioners are doing with regards to mental health as a Clinical Priority here.