Behavioural Disorders in Children Updated February 2017

Behaviour Problems
Identification and management for

Canadian primary care professionals
Compiled by
Peter Kondra, MSc, MD, FRCPC,

and Brenda Mills, C&Y MHC
Hamilton Family Health Team
Child & Youth Mental Health Initiative
in collaboration with
Helen Spenser MD, CCFP, FRCPC,

Children’s Hospital of Eastern Ontario, Ottawa, Ontario
and Blair Ritchie MD, FRCPC,

Alberta Health Services, University of Calgary
Disclaimer
This information is for general education only. The accuracy, completeness,
adequacy or currency of the content is not warranted or guaranteed. Users
should always seek the advice of physicians or other qualified health providers
with questions regarding a health condition. Any practice described here should
be applied by a health professional in accordance with professional standards of
care used with regard to the unique circumstances that apply in each practice
situation. The author disclaims any liability, loss, injury or damage incurred as a
consequence, directly or indirectly, of the use and application of any of the
contents of this information.
This work is “licensed” under a Creative Commons License

Attribution-NonCommercial 4.0 Canada,
https://creativecommons.org/licenses/by-nc-nd/4.0/
1
Behaviour Problems in Primary Care
Epidemiology
Oppositional Defiant Disorder (ODD)
Conduct Disorder (CD)
Identification
Treatment
2
Epidemiology
Behaviour problems include Oppositional

Defiant Disorder (ODD) and Conduct Disorder
(CD)
• 5 to 15% of children have an ODD and

approximately 4% of children develop CD
• Often occur with other mental health conditions

such as ADHD, depression, anxiety, substance
use and family problems
• Boys are more likely than girls to suffer from

behavioural disorders.
• Characterized by:
 temper tantrums that are intense and
frequent
 disobeying rules, arguing
 aggressive behaviour
 trouble empathizing or taking the other
person’s feelings into account
 harsh parenting practices
 persistent violation of the rights of others
 behaviours persist for a period of 6
months or more
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3
• It is important to differentiate between normal
developmental stages associated with
disruptive behaviour:
 Temper tantrums are common for toddlers
and preschool age children.
 All children misbehave, are defiant and act
impulsively at times.
 Children and adolescents commonly test
limits and rules.
 Risk-taking behaviours increase during
adolescence.
• It is important to differentiate between learning

difficulties and intellectual disabilities:
 Children with speech and language delays
and troubles with reading and writing act
out more often.
• It is important to rule out acute stressors that

might be disrupting the child’s behavior such
as:
 loss of a loved one
 major changes in the child’s life such as a
separation/divorce
 family violence
 being bullied
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4
Note: Behaviour disorders are more likely in
families where there are harsh parenting
practices. Children are at increased risk in
families where domestic violence, poverty, poor
parenting skills or substance abuse are a
problem.
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5
Oppositional Defiant Disorder (ODD)
• Affects approximately 5 to 15% of children

• Most often co-occurs with ADHD, depression,
anxiety
• Boys outnumber girls 2:1
• Hostile, angry, easily annoyed or irritated by
others
• Difficulty with authority figures, particularly
parents and teachers
• Frequent temper tantrums
• Refuses to obey rules
• Seems to deliberately try to annoy or
aggravate others
• Low frustration threshold
• Blames others for their behavior
• Poor peer relationships and low self-esteem
• Difficult pregnancies, premature birth and low
birth weight may contribute in some cases to
behaviour problems
• Temperamental or aggressive from an early
age
• ODD during childhood can manifest into
Conduct Disorder later in the child’s life
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6
Conduct Disorder
• 5% of children have conduct disorder

• More common in boys than girls 4:1
• 1/3 have co-morbid ADHD
• Early history of ODD
• Harming or threatening themselves, other
people or pets
• Damaging or destroying property, setting
fires
• Lying or stealing
• Initiating physical fights
• Use of weapons
• Contact with the law
• Not doing well in school, skipping school
• Early smoking, drinking or drug use
• Early sexual activity
• Frequent tantrums and arguments
• Consistent hostility towards authority figures
• Lack of empathy for others or understanding
how other people think
• A tendency to run away from home
• Suicidal tendencies
• Can evolve into antisocial personality
disorder in adult life
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Identification
• May need to evaluate intellectual disability or

learning disorders with psychological testing
• May need to evaluate physiological/genetic

issues with fasting blood sugar, thyroid
function, genetic testing
• Interview multiple informants (parents,

teachers, the child/youth, probation officers,
etc.)
• Consider using standardized screening tools

such as:
 SNAP-IV long version – ADHD, ODD,
Conduct
 Depression screen (PHQ-9 Adolescent
Depression Screen)
 Anxiety Screen (SCARED Child
Questionnaire), (SCARED Parent
Questionnaire)
 Substance Use screen (CRAFFT
Adolescent Alcohol and Substance Use
Screen)
8
Identification (continued)
• Diagnosis methods may include:

 Clinical interview with parents:
o Gather information about the
pregnancy pre- and post-natal
o Birth history
o Developmental history
o Ask questions about the family history
(medical conditions, mental health
history, relationship issues)
o Explore issues of family violence, abuse
and criminal history (emotional,
physical, sexual)
o Gather trauma history
 Clinical interview with child/youth:

o Emotional/behavioural history
o Friendships
o Strengths/interests
o Academic history
o Family relationships (siblings, parents,
extended family)
o Substance use and history
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9
Treatment
A multi-modal approach is recommended and

depends upon the severity of the issues.
1. Parental education: Teaching parents

positive parenting practices and strategies
to manage their child’s behaviour (when
possible, group treatment is effective in
helping parents support one another)
http://www.empoweringparents.com
http://www.livesinthebalance.org
2. Family counselling: To increase

communication and problem-solving skills
3. School collaboration: Meeting with

teachers and school to discuss the child or
youth’s difficulties and establishing a plan
to support the child/youth
4. Cognitive behavioural therapy (CBT):

To help the child to control their thoughts
and behavior
5. Recreational Activities: Opportunities to

develop social skills, interpersonal skills
and build self-esteem
10
6. Social skills training: Teaches positive
communication, expression of feelings, co-
operation and problem-solving skills
7. Anger management: Emotional

regulation, recognizing triggers and positive
coping skills are among a range of topics
covered
8. Relaxation techniques and stress

management skills
9. Bibliotherapy and online resources for

parents
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11

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Behaviour Problems

Identification and management for

Peter Kondra, MSc, MD, FRCPC,

Helen Spenser MD, CCFP, FRCPC,

and Blair Ritchie MD, FRCPC,

This work is “licensed” under a Creative Commons License

Oppositional Defiant Disorder (ODD)

Conduct Disorder (CD)

Behaviour problems include Oppositional

• 5 to 15% of children have an ODD and

• Often occur with other mental health conditions

• Boys are more likely than girls to suffer from

• It is important to differentiate between learning

• It is important to rule out acute stressors that

• Affects approximately 5 to 15% of children

• 5% of children have conduct disorder

• May need to evaluate intellectual disability or

• May need to evaluate physiological/genetic

• Interview multiple informants (parents,

• Consider using standardized screening tools

• Diagnosis methods may include:

 Clinical interview with child/youth:

A multi-modal approach is recommended and

1. Parental education: Teaching parents

2. Family counselling: To increase

3. School collaboration: Meeting with

4. Cognitive behavioural therapy (CBT):

5. Recreational Activities: Opportunities to

7. Anger management: Emotional

8. Relaxation techniques and stress

9. Bibliotherapy and online resources for

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