Behavioural problems

Most children behave in challenging ways from time to time. It’s very unlikely that your child will always behave perfectly.

In younger children, behavioural problems can look like throwing a tantrum in a supermarket or hurting a sibling. Older children might break the rules you set by staying out later than they should or acting rudely or aggressively.

Behavioural problems can come and go. For example, children sometimes ‘act out’ if something stressful is happening in their lives. At other times, it can be a way of communicating that they are frustrated, tired or anxious, or that something difficult is happening in their life.

Sometimes these behavioural problems can be tackled by parents and schools before they become serious. However, sometimes behavioural problems become a bigger issue and can cause problems for your child in one or more of these environments:

• at school
• at home
• with their friends and other family members.

If your child has been showing behavioural problems for a long time or they are severe, you might need to ask for more support.

Making the first step to get help for your child’s behavioural problems can be incredibly difficult. You might feel as though it is your fault, or as though people will blame you for your child’s behaviour. Whatever the reasons are for your child’s behavioural problems, you should congratulate yourself for asking for help and working to improve things for your child and your family.

If your child’s behavioural problems are causing challenges with their schooling or home life, it is important to ask for support. The kind of support you need will depend on how old your child is, and any other problems they might be having.

Younger children

If your child is under five, speak to your health visitor. These are trained nurses or midwives who might have visited you and your child when your child was born. They can continue to support you until your child is five years old. You can find out more about health visitors on the website of the pregnancy and baby charity Tommy’s.

Older children

If your child is having problems at school, their school should work with you to create a plan. This plan should help come up with strategies for responding to your child’s behaviour that will help them to remain in school and get the most out of their education. At the same time this plan can help to keep them and other children safe. Some schools have teachers and other support staff who can support with behavioural problems and direct you to further support if necessary.

If your child is also having behavioural problems at home, you may be able to get help and support from a local parenting support service or family support charity. Health visitors, GPs or schools may be able to tell you about local services.

Further support

If these problems are more severe and are making it difficult for them or your family to live a normal life, your child might benefit from an assessment for oppositional defiant disorder or conduct-dissocial disorder. You can find out more about these conditions below. Speak to your GP if you need more help for your child’s behavioural problems. 

Oppositional defiant disorder and conduct-dissocial disorder sit in the group of ‘disruptive behaviour and dissocial disorders’. In the past conduct-dissocial disorder was just called ‘conduct disorder’.

Your child might be diagnosed with one of these conditions if they are having persistent behavioural problems. For example, if they are consistently:

• Defiant – They refuse to do what they are asked.
• Disobedient – They do things they know they shouldn’t do.
• Provocative – They do things to intentionally annoy or upset others.

This behaviour can also include more serious issues like:

• overstepping the rights of others
• breaking rules
• and even breaking the law.

It is normal to feel alarmed by such strong words, or by your child receiving one of these diagnoses. However, these are just the names that researchers have given to groups of symptoms. These names help researchers and doctors to:

• communicate among themselves
• develop more studies to understand how to improve the care and treatment they give to children
• offer you a care pathway that is most appropriate for you and your child.

Remember, a lot of children who have behavioural problems don’t have oppositional defiant disorder or conduct-dissocial disorder, and don’t need support from CAMHS or other services. However, some children will need more support.

Oppositional defiant disorder

Children with oppositional defiant disorder will have behaviour that is very:

• defiant
• disobedient
• argumentative
• provocative
• spiteful
• irritable
• angry.

This behaviour will happen in different settings and with different people, not only with their siblings or parents.

Children with oppositional defiant disorder might:

• have conflict with authority figures like teachers and other adults
• struggle to get along with others
• have severe temper outbursts or meltdowns.

For a diagnosis of oppositional defiant disorder to be made, these behaviours need to:

• have been going on for more than six months
• be more severe than what is typical for other children your child’s age
• cause significant problems with your child’s:
  • schooling
  • friendships
  • family life
  • any other environments.

Conduct-dissocial disorder

Children with conduct-dissocial disorder will have more serious behaviours than children with oppositional defiant disorder. These can include:

• overstepping the rights of others
• breaking rules, or even laws
• acting aggressively towards people or animals
• destruction of property
• lying, hiding things or stealing things

For a diagnosis of conduct-dissocial disorder to be made, these behaviours need to:

• have been happening for at least one year
• cause significant problems with your child’s:
  • schooling
  • friendships
  • family life
  • any other environments.

Temperamental traits

Children who are born with traits like irritability or limited prosocial emotions are more likely to have behavioural problems than children who do not have these traits. We explain more about irritability and limited prosocial emotions below.

What is irritability?

We all feel irritable from time to time. If you are feeling irritable, it can feel like you are more likely to ‘snap’ at someone. Or you might feel like you are full of negative feelings about what is going on around you. Feelings of irritability can happen occasionally in every child.

Irritable children will get angry quicker and more often than other children their age. You might think of irritability as ‘anger’. You might also hear medical professionals calling it ‘dysregulation’. Irritable children can also have exaggerated responses to being told they can’t do something or being asked to do something they don’t want to do.

If your child is very irritable this can understandably be extremely frustrating for you as a parent. It might lead you to become frustrated and angry yourself, which can escalate your child’s anger. Or you might end up giving in and letting your child have what they want. This can cause your child to learn that angry behaviour can help them to get what they want. It can feel impossible to know what the ‘right thing’ is to do.

This is where parenting interventions can be helpful, as you will be supported to find ways to approach challenging behaviour that are helpful for you and your child. We look at parenting interventions in the support section in this resource.

What are prosocial emotions?

Usually children feel a certain amount of guilt at having done something wrong, or for getting in trouble with an authority figure. They will be able to tell you that they feel sorry for what they have done, and apologise.

However, there are a small number of children that do not feel this way. We say that these children have ‘limited prosocial emotions’.

Children with limited prosocial emotions will:

• lack or have less remorse or guilt
• lack or have less empathy for others
• not seem to care if they don’t do well at school or in other activities
• show fewer emotions, or show emotions that seem superficial (fake or ‘put on’).

Research suggests that genetic and environmental risk factors contribute to the development of these traits. However, there is still a lot we don’t understand about these traits.

Children with limited prosocial emotions are a much smaller group of children with oppositional defiant disorder or conduct-dissocial disorder. However, their conduct problems can be more severe and persistent.

The person working with your child should find out if your child has limited prosocial emotions. This is because this will inform the kind of parenting interventions you are offered. For example, if your child has limited prosocial emotions, they will respond better to rewards than punishment. So you might learn skills around giving rewards to encourage good behaviour.

Unfortunately, there is rarely a simple explanation for a child’s behaviour. The causes tend to be complex and related to multiple areas. There are lots of factors that can make children more likely to develop one of these conditions. These factors can be biological, environmental, or a combination of the two.

Biological factors

Sometimes these disorders run in families. This has been shown in studies with adopted children whose biological parents had behavioural problems. In these studies, some of these children had more behavioural problems than their peers.

As discussed in the previous section, some children have a more irritable temperament than others. These children are more likely to have behavioural problems than children who do not have these traits.

Environmental factors

Environmental factors are related to the environments your child spends time in. Environmental factors that might lead to someone developing one of these conditions include things like:

• being bullied
• experiencing neglect or abuse currently or in the past
• spending time with other children with behavioural problems.

Just because a child has one or more of these factors does not mean that they will definitely develop one of these conditions.

These conditions are quite common. In 2017 it was reported that just under 1 in 20 young people aged 5 to 19 in England had a behavioural or conduct-dissocial disorder.

Oppositional defiant disorder and conduct-dissocial disorder can often happen alongside other mental health or neurodevelopmental conditions. These other conditions can sometimes be incorrectly confused with behavioural disorders.

It can be difficult to work out if this other condition is:

• causing your child’s behavioural problems
• or happening alongside your child’s behavioural problems.

It is important that healthcare professionals work to understand how everything is connected because it can help to ensure that your child receives the right treatment and support.

For example, if your child has started showing behavioural problems after they have experienced a traumatic event, it is important for doctors to establish if these behaviours are caused by post-traumatic stress disorder (PTSD). If they are, treating and supporting your child’s PTSD should resolve the behavioural problems.  

Some of the conditions that can cause or happen alongside behavioural problems include:

Attention deficit hyperactivity disorder (ADHD)

Children with ADHD can have problems with:

• following instructions
• remaining seated
• staying on-task.

Your child might have behavioural problems that are related to their ADHD. If so, they should not be diagnosed with oppositional defiant disorder or conduct-dissocial disorder.  

If your child is getting in trouble at school for interrupting in class and has ADHD, this will be a symptom related to impulsivity, which is a symptom of ADHD. Behavioural problems will be things like lying, hitting or stealing.

Mood disorders

If your child is refusing to do something because they:

• lack the energy
• don’t enjoy anything anymore
• or are hopeless about the future

they might have a condition like depression. If this is the case, they won’t be refusing to do something because they are being oppositional.

Anxiety

If your child is anxious, for example has a specific phobia, they might act in problematic ways when they are faced with the thing they are scared of or anxious about. This will be because they are trying to avoid it. For example, if they are afraid of the dark, they may have difficult behaviours around bedtime. If your child is only experiencing a phobia, these behaviours will go away if the phobia is tackled.

However, if they have behavioural problems that do not improve when the phobia is treated, this might be better explained by oppositional defiant disorder or conduct-dissocial disorder.

Autism

Autism is a neurodevelopmental condition. It affects how people communicate and interact with others.

Autistic children are more likely to experience irritability than other children. They might also have tantrums or meltdowns if:

• they are unable to explain how they are feeling or what they need
• their routine is changed
• they are overwhelmed by sensory inputs around them, such as noises or lights.

If these meltdowns are only due to challenges related to these core traits of autism, they will not be diagnosed with oppositional defiant disorder or conduct disorder. The aim of any treatment and support will be to make it easier for them to cope with the situations that make life difficult for them.

Getting information from different people

When your child is being assessed for oppositional defiant disorder or conduct-dissocial disorder, the person assessing them should collect information from:

• your child
• you and any other parents or carers
• their teachers
• any other professionals who know them. For example, youth workers.

This information should come from multiple settings including:

• home
• school
• clubs. For example, youth clubs or after school clubs.

Understanding the problem

Doctors call this ‘formulating’ the problem. This can help to understand:

• the vulnerability factors for your child. For example, if they:
  • have always been irritable
  • have another condition. For example, neurodevelopmental, mental health, or physical problems such as head injuries or seizures.
  • have a learning difficulty
  • have been bullied or are currently being bullied at school.
• what might have triggered the behaviours. For example, experiencing a traumatic event, or hanging out with problematic friends who also have behavioural problems.
• what is keeping the behaviours going. For example, not treating a condition they may have, or inconsistent and low-involvement parenting.

Risk assessments and safety plans

The person assessing your child should also consider making a risk assessment if your child’s behaviours are putting them or others at risk. The assessment will help to establish a clear safety plan. It should be drawn up with anyone else who is involved in your child’s care, such as their school.

Once healthcare professionals have understood the areas mentioned above, they will be able to work with you to create a plan. This plan is called a management plan. It will cover the different kinds of treatment and support you and your child need.

The treatment and support you are offered should be personalised to you. It should be focused on the specific areas that you, your child and your family are having problems with.

There is very good research in this area of child and adolescent psychiatry. The support offered to you should always be based on high-quality research.

The interventions will aim to support your child, you and any other parents, and how you interact with each other. Examples include:

1. Support for your child

Psychoeducation

Psychoeducation involves explaining to the child or young person, in words that they can understand:

• what doctors have understood in their assessment of them
• and what they can do to help.

It may include drawings and pictures, depending on how old your child is.

Treating other conditions

As we have already said, children who have other conditions should receive treatment and support for these. Children should not be denied help for other mental health or neurodevelopmental conditions because they also have behavioural problems.

Sometimes treating other conditions will be enough to improve behavioural problems. For example, a child with PTSD who has meltdowns when they experience a flashback might stop having meltdowns once their PTSD is treated. However, sometimes children will need more help.

Your child might be offered medication to address these other conditions. You and your child should be provided with information on the benefits and side-effects of any medication.

Treatment of other traits

Even if your child doesn’t receive a diagnosis of oppositional defiant disorder or conduct-dissocial disorder, they might still have some traits like those listed below. These might also benefit from support:

Poor social skills
Social skills work can help your child to:

• increase their interactions with others
• enter group settings
• start conversations
• share with others
• ask questions politely
• listen and negotiate.

Poor problem-solving skills
Problem-solving therapy is a brief intervention. It involves identifying problems your child is having and teaching them how to solve them appropriately.

Poor control of negative mood
Emotional regulation work can help your child to:

• manage their self-control
• reduce large mood swings and explosiveness
• consider how best to respond in provoking situations.

Cognitive distortions and inaccurate self-evaluation
Cognitive-behavioural therapy (CBT) can help your child to understand themselves and others better.

CBT typically involves three stages:

1. A therapist will work with your child to help them understand more about their own thoughts, behaviour and mood, and the links between these things.
2. The therapist will work with your child to identify areas that they want to improve
3. The therapist will support your child to learn and practice new patterns of thoughts and behaviours, and to see what effect these have.

Encouraging strengths

It is very important to encourage your child’s strengths and abilities. You can also empower them to take part in hobbies and activities where they can use these strengths. For example, joining a sports team, or a drawing class, depending on what things they enjoy. This can increase your child’s sense of achievement, self-esteem and hope for the future.

2. Support for parents

As a parent your main focus will probably be on getting help for your child. However, you and any other adults involved in your child’s life deserve support as well. It is important that the people working with you and your child identify areas you might need support in. These could make it easier for you to support your child with their behavioural problems.

This might mean seeking help for physical or mental health problems, or getting support if you are struggling financially or with your housing.

Are behavioural problems my fault?

The professionals working with you and your child might want to find out more about your parenting. This is not because they think that your child’s behavioural problems are caused by your parenting. They will be aware that there are many reasons for your child’s behavioural problems, and that some of these reasons might have been completely out of your control.

If you are referred for an assessment, the professionals working with you and your child will try to come up with an intervention plan. This will look at all of the different things that might be involved in your child’s behaviour, including:

• looking at some aspects of your parenting and seeing where there are things you could change
• finding out if your child has other problems affecting their behaviour. For example,  neurodevelopmental conditions (such as ADHD or autism) or problems at school.

Healthcare professionals should support you as a parent to become a ‘co-therapist’. They should do this by listening to your background and your ideas about parenting. This can be a key part of treatment.

For example, a parent who is naturally calm will respond to defiant behaviour very differently to a parent who is anxious or on-edge. Knowing this can help to improve the approach to your child’s treatment.

3. Support for the parent-child relationship

All of our relationships are two-way. Parents and children often have different personalities that interact with each other in different ways. Parenting interventions enable parents to:

• strengthen their relationship with their child
• and manage behavioural problems confidently by adapting their parenting style.

There are lots of different kinds of programmes and therapies available for behavioural problems. You should only be offered those that are evidence-based and recommended by the National Institute for Health and Care Excellence (NICE) guidelines. The kind of programme you will be offered will depend on what is available where you live.

Depending on how old your child is, you might take part in a programme on your own (with any other parents or carers involved in your child’s care). Or you might take part in a programme with your child. Older children might also take part in programmes or therapies on their own.

For younger children

If your child is aged 3 to 11, you might be offered a parent training programme. This will take place with a therapist, and might be:

• as part of a group of other parents
• one-on-one with you and any other parents or carers

There are some individual programmes where you and your child will take part in sessions together. In these, the therapist will coach you directly while you play with your child.

The aim of these training programmes is to strengthen your parenting skills. This can help to increase your child’s sociable and helpful behaviours. You will learn new skills, and be supported to strengthen skills you already have. With the therapist, you will be supported to:

• express interest, warmth and approval when your child is displaying appropriate behaviours
• safely ignoring inappropriate behaviours.

These might be things you have already tried to do on your own. A training programme can help by giving you access to the support of someone who is specially trained in behavioural problems.

Two examples of these programs are:

Personalized Individual Parents Training (PIPT)
In PIPT, both you and your child will be present in sessions. Your therapist will coach you directly as you play with your child. They will help you to strengthen the relationship with your child and learn where you can apply new techniques and ideas. You will usually be offered eight appointments, though you might be offered more depending on the needs of you and your child.

Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD)
VIPP-SD will help you to care for your child by building a strong relationship with them, and seeing the world through their eyes. You will spend time with your child, and this will be recorded. Afterwards you will watch this recording to learn more about your parenting and how your child responds to your parenting.

You will usually be offered up to seven appointments, each lasting around 90 minutes. These sessions can take place in a clinical setting (such as a therapist’s office) or can take place in your own home.

For adolescents

Older children can benefit from:

Family-focused therapy

This therapy is given to the family. Depending on the type of therapy, it focuses on one or more of the following things:

• helping the family to change any dysfunctional patterns they have
• using strategic interventions to resolve immediate issues quickly
• understanding and changing the functions of behaviours within family dynamics.

Some examples of family-focused therapy include Strategic Family Therapy (SFT) or Functional Family Therapy (FFT).

Multi-modal therapy

This involves the family and the community. One example of this is multisystemic therapy (MST).

MST offers an intensive, home-based approach that looks at different ‘systems’. These systems include:

• the family itself
• the school your child goes to
• their peers
• your wider community.

Understanding these systems can help to address severe behavioural issues in young people who have high-risk behaviours. MST takes place more regularly than usual therapy, sometimes as often as 3 or 4 times a week over 3 to 5 months.

Other

Non-violent resistance

Non-violent resistance (NVR) is designed for children with high levels of aggression. It can help to address the way in which violent behaviours are responded to at home. It concentrates on having a consistent and unified approach from all parents and carers.

This information was produced by the Royal College of Psychiatrists’ Child and Family Public Engagement Editorial Board (CAFPEB). It reflects the best available evidence at the time of writing.

Expert author: Dr Carmen Pinto

Full references for this resource are available on request.