A perfect answer to behavioural disorder in children
Behavioural disorders in children as early experiences shape the architecture of the developing brain, they also lay the foundations of sound mental health. Disruptions to this developmental process can impair a child’s capacities for learning and relate to others — with lifelong implications. By improving children’s environments of relationships and experiences early in life, society can address many costly problems, including incarceration, homelessness, and the failure to complete high school.
Significant mental health problems can and do occur in young children. Children can show clear characteristics of anxiety disorders, attention-deficit/hyperactivity disorder, conduct disorder, depression, posttraumatic stress disorder, and neurodevelopmental disabilities, such as autism, at a very early age. That said, young children respond to and process emotional experiences and traumatic events in ways that are very different from adults and older children. Consequently, diagnosis in early childhood can be much more difficult than it is in adults.
The interaction of genes affects childhood mental health. Genes are not destiny. Our genes contain instructions that tell our bodies how to work, but the chemical “signature” of our environment can authorize or prevent those instructions from being carried out. The interaction between genetic predispositions and sustained, stress-inducing experiences early in life can lay an unstable foundation for mental health that endures well into the adult years.
Toxic stress can damage brain architecture and increase the likelihood that significant mental health problems will emerge either quickly or years later. Because of its enduring effects on brain development and other organ systems, toxic stress can impair school readiness, academic achievement, and both physical and mental health throughout the lifespan. Circumstances associated with family stress, such as persistent poverty, may elevate the risk of serious mental health problems. Young children who experience recurrent abuse or chronic neglect, domestic violence, or parental mental health or substance abuse problems are particularly vulnerable.
It’s never too late, but earlier is better. Some individuals demonstrate remarkable capacities to overcome the severe challenges of early, persistent maltreatment, trauma, and emotional harm, yet there are limits to the ability of young children to recover psychologically from adversity.
Even when children have been removed from traumatizing circumstances and placed in exceptionally nurturing homes, developmental improvements are often accompanied by continuing problems in self-regulation, emotional adaptability, relating to others, and self-understanding. When children overcome these burdens, they have typically been the beneficiaries of exceptional efforts on the part of supportive adults. These findings underscore the importance of prevention and timely intervention in circumstances that put young children at serious psychological risk.
It is essential to treat young children’s mental health problems within the context of their families, homes, and communities. The emotional well-being of young children is directly tied to the functioning of their caregivers and the families in which they live. When these relationships are abusive, threatening, chronically neglectful, or otherwise psychologically harmful, they are a potent risk factor for the development of early mental health problems.
Healthy development depends on the interactive influences of genes and experiences, which shape the architecture of the developing brain. The active ingredient of those experiences can be described as mutual responsiveness or the “serve and return” of young children’s interactions with adult caregivers.1 For example, when an infant babbles and an adult responds appropriately with attention, gestures, or speech, this builds and strengthens connections in the child’s brain that support the development of communication and social skills. When caregivers are sensitive and responsive to a young child’s signals, they provide an environment rich in serve and return experiences, like a good game of tennis or Ping-Pong.
However, if depression interferes with the caregiver’s ability to regularly provide such experiences, these connections in the child’s brain may not form as they should. The difference between a child who grows up in a responsive environment and one who does not can be the difference between the development of strong or weak brain architecture, which serves as a foundation for the learning, behaviour, and health that follow. Maternal depression is particularly worrisome because of its prevalence. Although it is all the same underlying disorder, mothers’ experiences of depression may differ in timing, severity, and duration.8,9 For a substantial proportion of mothers, depression comes in spells that may last just a few months; but, for others, depression is more chronic.
Some mothers may experience depression primarily during their children’s infant and toddler years; others endure depression that is prolonged or recurs over many years of a child’s life. Chronic depression can manifest itself in two types of problematic parenting patterns that disrupt the “serve and return” interaction that is essential for healthy brain development: hostile or intrusive, and disengaged or withdrawn.19 When parents are hostile and/or intrusive, it is as if the parent is “serving” the ball in ways that make it difficult for the child to “return.”
Children sometimes argue, are aggressive, or act angry or defiant around adults. A behaviour disorder may be diagnosed when these disruptive behaviours are uncommon for the child’s age at the time, persist over time, or are severe. Because disruptive behaviour disorders involve acting out and showing unwanted behaviour towards others they are often called externalizing disorders.
Oppositional Defiant Disorder(ODD)
When children act out persistently so that it causes serious problems at home, in school, or with peers, they may be diagnosed with Oppositional Defiant Disorder (ODD). ODD usually starts before 8 years of age, but no later than by about 12 years of age. Children with ODD are more likely to act oppositional or defiant around people they know well, such as family members, a regular care provider, or a teacher. Children with ODD show these behaviours more often than other children their age.
Examples of ODD behaviours include
• Often being angry or losing one’s temper
• Often arguing with adults or refusing to comply with adults’ rules or requests
• Often resentful or spiteful
• Deliberately annoying others or becoming annoyed with others
• Often blaming other people for one’s own mistakes or misbehaviour
Conduct Disorder (CD) is diagnosed when children show an ongoing pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These rule violations may involve breaking the law and result in arrest. Children with CD are more likely to get injured and may have difficulties getting along with peers.
Examples of CD behaviours include
• Breaking serious rules, such as running away, staying out at night when told not to, or skipping school
• Being aggressive in a way that causes harm, such as bullying, fighting, or being cruel to animals
• Lying, stealing, or damaging other people’s property on purpose
These may manifest as a disturbance in:
• Emotions – eg, anxiety or depression.
• Behaviour – eg, aggression.
• Physical function – eg, psychogenic disorders.
• Mental performance – eg, problems at school.
This range of disorders may be caused by several factors such as parenting style which is inconsistent or contradictory, family or marital problems, child abuse or neglect, overindulgence, injury or chronic illness, separation or bereavement.[1, 2]
The child’s problems are often multi-factorial and how they are expressed may be influenced by a range of factors including developmental stage, temperament, coping and adaptive abilities of family and the nature and duration of stress. In general, chronic stressors are more difficult to deal with than isolated stressful events.
Children do not always display their reactions to events immediately, although they may emerge later. Anticipatory guidance can be helpful to parents and children in that parents can attempt to prepare children in advance of any potentially traumatic events – eg, elective surgery or separation. Children should be allowed to express their true fears and anxieties about impending events.
All children will at some developmental stage display repetitive behaviours but whether they may be considered as disorders depends on their frequency and persistence and the effect they have on physical, emotional and social functioning. These habit behaviours may arise originally from intentional movements which become repeated and then incorporated into the child’s customary behaviour. Some habits arise in imitation of adult behaviour. Other habits such as hair pulling or head-banging develop as a means of providing a form of sensory input and comfort when the child is alone.
• Thumb sucking – this is quite normal in early infancy. If it continues, it may interfere with the alignment of developing teeth. It is a comfort behaviour and parents should try to ignore it while providing encouragement and reassurance about other aspects of the child’s activities.
• Tics – these are repetitive movements of muscle groups that reduce tension arising from physical and emotional states, involving the head, the neck and hands most frequently. It is difficult for the child with a tic to inhibit it for more than a short period. Parental pressure may exacerbate it while ignoring the tic can reduce it. Tics can be differentiated from dystonias and dyskinetic movements by their absence during sleep.
• Stuttering – this is not a tension-reducing habit. It arises in 5% of children as they learn to speak. About 20% of these retain the stuttering into adulthood. It is more prevalent in boys than in girls. Initially, it is better to ignore the problem since most cases will resolve spontaneously. If the dysfluent speech persists and is causing concern to refers to a speech therapist.
Many behaviours, which are probably undesirable but a normal occurrence at an early stage of development, can be considered pathological when they present at a later age. In the young child, many behaviours such as breath-holding or temper tantrums are probably the result of anger and frustration at their inability to control their environment. For some of these situations, it is wise for parents to avoid a punitive response and, if possible, to remove themselves from the room. It is quite likely that the child will be frightened by the intensity of their behaviour and will need comfort and reassurance. While some isolated incidents of stealing or lying are normal occurrences of early development, they may warrant intervention if they persist. Truancy, arson, antisocial behaviour and aggression should not be considered as normal developmental features.
Attention deficit hyperactivity disorder is characterised by poor ability to attend to tasks (eg, makes careless mistakes, avoids sustained mental effort), motor overactivity (eg, fidgets, has difficulty playing quietly) and impulsiveness (eg, blurts out answers, interrupts others). For the diagnosis to be made, the condition must be evident before the age of 7, present for >6 months, seen both at home and school and impeding the child’s functioning. The condition is diagnosed in 3-7% of children of school age. Methylphenidate (initiated by specialists only) is a stimulant medication that provides reduction of symptoms, at least in the short term Behavioural modification and neuro-feedback are the non-pharmacological treatments with the largest evidence base. Various dietary interventions have been mooted, of which the addition of essential fatty acids has the widest support.
Sleep disorders can be defined as more or less sleep than is appropriate for the age of the child. By the age of 1-3 months, the longest daily sleep should be between midnight and morning. Sleeping through the night is a developmental milestone but, at the age of 1 year, 30% of children may still be waking in the night. Stable sleep patterns may not be present until the age of 5 but parental or environmental factors can encourage the development of circadian rhythm.
Treatment for behaviour disorders
Starting treatment early is important. Treatment is most effective if it fits the needs of the specific child and family. The first step to treatment is to talk with a healthcare provider. A comprehensive evaluation by a mental health professional may be needed to get the right diagnosis. Some of the signs of behaviour problems, such as not following rules in school, could be related to learning problems which may need additional intervention. For younger children, the treatment with the strongest evidence is behaviour therapy training for parents, where a therapist helps the parent learn effective ways to strengthen the parent-child relationship and respond to the child’s behaviour. For school-age children and teens, an often-used effective treatment is a combination of training and therapy that includes the child, the family, and the school.