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Part I
Background
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1 Conduct problems and the risk factors for poor outcomes
Introduction
Between the ages of 3 and 10 years, children’s behavioural problems are easy to identify, remain relatively stable and, if not resolved, put them at risk of later conduct problems, significant antisocial behaviour problems in adolescence and subsequent lifelong problems (Hutchings and Gardner, 2012). Conduct problems comprise the single biggest source of referral to child mental health services and are extremely costly to educational, health, social care and justice systems (Bonin, Stevens, Beecham, Byford and Parsonage, 2011; National Collaborating Centre for Mental Health (NCCMH), 2013). Young children’s conduct problems typically involve simple aggressive, disruptive and non-compliant behaviours that produce immediate consequences, whereas the replacement behaviours, cooperation, compliance and self-regulation, are complex and harder to learn (Allen and Duncan-Smith, 2009).
Early childhood behavioural difficulties, that have the potential to develop into conduct disorders, are a large and growing problem. A recent meta-analysis estimated that worldwide prevalence of disruptive behaviour disorders was 5.7 per cent (Polanczyk, Salum, Sugaya, Caye and Rohde, 2015). The 1999 and 2004 British surveys concluded that 8 per cent of boys aged 5 to 16, and 4 per cent of girls, were conduct disordered (Green, McGinnity, Meltzer, Ford and Goodman, 2005) and for children living in disadvantaged neighbourhoods the proportion is nearer to 15 per cent (Green et al., 2005; Meltzer, Gatward, Goodman and Ford, 2000).
Children are diagnosed as having a behaviour disorder when they are exhibiting severely disruptive, aggressive and/or destructive behaviour that is causing problems for their parents or carers. There are currently two major diagnostic systems. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013) uses the global term Disruptive, Impulse-Control and Conduct Disorders for children exhibiting these behaviour patterns, but this can be broken down into Oppositional Defiant Disorder (ODD) for children with symptoms of anger/irritable mood, argumentative/defiant behaviour and vindictiveness and Conduct Disorder (CD) for children who show persistent and repetitive aggression towards others, destruction of property, deceitfulness or theft, and serious violation of rules. The International Classification of Diseases, 10th Revision (ICD-10; World Health Organization, 1992) uses the term CD for children up to the age of 18 years, but includes ODD as a subtype for children under 10 years.
The problems associated with behaviour disorders are often associated with deficits in essential life and school readiness skills, since many of the problematic behaviours are very easy to learn (hitting, kicking, running away, etc.) and the replacement alternative behaviours, i.e. waiting, asking, recognising feelings and managing frustration, are much more complex skills. Without intervention, child behaviour problems, especially those that have their origins in the preschool years, are relatively stable over time (Côté, Vaillancourt, Barker, Nagin and Tremblay, 2007; Dishion and Patterson, 2006; Piquero, Carriaga, Diamond, Kazemian and Farrington, 2012). When young children with behaviour problems start school, they experience secondary effects of their behaviour that can hamper their education and development. Their lack of social skills and aggressive behaviour can make them difficult to teach (Webster-Stratton, Reid and Stoolmiller, 2008) and can lead to them being rejected by their peers (Ladd and Troop-Gordon, 2003) and more likely to associate with other antisocial children and turn to more antisocial ways of obtaining attention. Approximately half of young children diagnosed with CD go on to develop serious psychosocial problems in adulthood, including criminal convictions, drug misuse and violent behaviour (NCCMH, 2013).
There are now several longitudinal studies that indicate that, although many of those young children assessed as “antisocial” do not go on to become antisocial adults, antisocial adults have almost always been antisocial children (Farrington and Welsh, 2007). The Cambridge Study in Delinquent Development has followed the development of 411 South London males from the age of eight to 32 years (Farrington, 2000). Measures of the sample’s antisocial behaviour taken at ages 10, 18 and 32 were significantly correlated, supporting the view that antisocial behaviour is stable over time. They found that overall frequency of offending peaked at around the age of 18 and then decreased. Participants were less antisocial at 32 than at age 18, but those who were most deviant at 18 tended to be the most deviant at 32 years old. The Christchurch Health and Development Study found that children with high levels of conduct problems at ages 7 to 9 years had significantly higher rates of adverse outcomes in adulthood, including crime, substance misuse, mental health problems and sexual/partner relationships (Fergusson, Horwood and Ridder, 2005). Other longitudinal studies have found similar results (e.g. Dunedin Health and Development Study: Caspi, Moffitt, Newman and Silva, 1996; Oregon Youth Study: Patterson, Capaldi and Bank, 1991; Pittsburgh Youth Study: Loeber and Hay, 1997).
Early childhood difficulties that remain untreated can result in long-term problems that are costly to society (Sainsbury Centre for Mental Health, 2009; Welsh et al., 2008). As time passes, behaviour difficulties can become more resistant to preventive services and treatment (Allen, 2011) and incur the need for increasingly costly services. Using data from a longitudinal study of Inner London children, Scott and colleagues (2001) have demonstrated how childhood antisocial behaviour leads to quantifiable costs to society. By the time they were 27 years old, children who at age 10 had displayed no signs of antisocial behaviour were estimated to have cost the state £7,400 in relation to crime, special education, social security, health, foster/residential care and relationship breakdown. The equivalent figure for those with conduct problems at the age of 10 was £24,300, increasing to £70,000 for those with diagnosed, chronic CD. A UK study, Romeo, Knapp and Scott (2006) estimated an annual cost of £5,960 per child with conduct problems without criminal justice costs with 78 per cent of the total cost falling on families. Health, education and voluntary services accounted for 8 per cent, 1 per cent and 3 per cent of the total cost, respectively. However, early interventions to reduce problem behaviour have been shown to be cost-effective in the long-term (Bonin et al., 2011; Edwards et al., 2007; Muntz, Hutchings, Edwards, Hounsome and O’Ceilleachair, 2004; Sainsbury Centre for Mental Health, 2009).
Between 3 and 8 years, most children experience nursery and then commence compulsory school attendance. Children who start school without the necessary social and self-regulation skills needed in a school environment are likely to have negative academic and social experiences in school that contribute further to the development and/or maintenance of conduct problems (Duncan et al., 2007). Antisocial children tend to be isolated, with few friends (Gross, 2008), and are more likely to respond aggressively to benign situations. Rejection by peers can draw them towards similarly antisocial peers during later childhood years, further increasing the risk of long-term involvement in drug misuse, offending and/or mental health problems (Allen, 2011; Farrington and Welsh, 2007).
Risk and protective factors
Several environmental variables are associated with early childhood behaviour problems and it is possible to recognise factors that place young children at increased risk of developing conduct problems. There is evidence that the greater the number of associated risk factors present in the child’s living environment, the higher the risk for the child (Barker, Copeland, Maughan, Jaffee and Uher, 2012; Sabates and Dex, 2015; Trentacosta et al., 2008). Risk factors can be considered under a number of headings: family and social circumstances, individual factors, parental factors, and school and community.
Individual factors
Boys are more likely than girls to develop behaviour problems (Hutchings, Williams, Martin and Pritchard, 2011; Zahn-Waxler, Shirtcliff and Marceau, 2008) with the risk three to four times higher than for girls (Martel, 2013; Merikangas, Nakamura and Kessler, 2009). Boys are rated as having more behaviour problems by both parents and teachers (Miner and Clarke-Stewart, 2008). Differences have also been shown in the type of behaviour problems with young boys showing more physical aggression than girls (Alink et al., 2006).
A significant proportion of children with behavioural problems also show increased levels of attentional/impulsivity problems (Biederman, 2005; Hartman, Stage and Webster-Stratton, 2003; Jones, Daley, Hutchings, Bywater and Eames, 2008). Impulsivity is positively associated with externalising behaviour in three-year-olds (Karreman, de Haas, van Tuijl, van Aken and Dekovic, 2010) and higher levels of impulsivity in childhood has been linked to externalising behaviour problems in adolescence (Leve, Kim and Pears, 2005). Both attentional/impulsivity and behaviour problems are associated with language and cognitive delays (Daley, Jones and Hutchings, 2009), leading to further difficulties, including poor literacy skills (Gross, 2008).
Genetics also have a role to play in the development of childhood behaviour problems. A review by Moffitt (2005) exploring the behavioural-genetic literature found that the estimated genetic influence on behaviour problems was approximately 50 per cent, with an estimated 20 per cent of the variance due to shared environment (e.g. living in poverty) and the remaining 30 per cent due to environmental factors experienced uniquely by individuals (e.g. victims of abuse). Patterns within families have also been found, with higher rates of behaviour problems in the first-degree relatives of boys with diagnosed CD (Blazei, Iacono and Krueger, 2006). Herndon and Iacono (2005) found that children born to parents exhibiting behaviour problems were at increased risk of developing CD by adolescence.
Parental factors
Poor parenting affects every aspect of children’s development (Allen and Duncan-Smith, 2008; Belsky and de Haan, 2011). Harsh parenting, physical punishment, lax supervision and inconsistent discipline play a significant role in the development and maintenance of child behaviour problems (Hoeve et al., 2009). By contrast, positive parenting practices, including frequent joint activities, monitoring, structuring the child’s time and constructive discipline strategies, are protective (Gardner, Burton and Klimes, 2006). Interventions that develop these skills are associated with improvements in serious behaviour problems over time that are independent of other risk factors, including single and/or young parenthood, maternal depression and poverty (Gardner, Hutchings, Bywater and Whitaker, 2010; Hartman et al., 2003; Hoeve et al., 2009). These studies further demonstrate that it is parenting, rather than these disadvantaging factors per se, that both predicts behavioural problems in children (Patterson, Forgatch, Yoerger and Stoolmiller, 1998) and can be successfully supported in interventions (Hutchings et al., 2007).
Parenting behaviours
Poor parenting has been shown to be the major factor associated with early antisocial behaviour and later delinquency (Farrington and Welsh, 2007). Patterson’s detailed observation of parent–child interactions first demonstrated the way in which antisocial child behaviour patterns were reinforced by parental responses (Patterson, 1982). The evidence is now clear that many children learn and establish problem behaviours because parents lack key parenting skills, use them inconsistently (Lunkenheimer et al., 2016) and/or fail to use them at appropriate times (Hoeve et al., 2009). Studies, including longitudinal studies, have consistently identified children’s experience of harsh parenting and inconsistent discipline, with little supervision and positive parental involvement with the child, as significant factors in the development of child behaviour problems and later adult offending (Farrington and Welsh, 2007; Hoeve et al., 2009). By contrast, the use of positive parenting skills, such as frequent joint activities, monitoring, structuring the child’s time and constructive discipline strategies, appears to be protective and has been associated with improvements in child behaviour over time that are independent of other risk factors (Forgatch and DeGarmo, 2002). The identification of parenting style as a major influence on child behaviour has been borne out by the fact that many well-designed parent training programmes have led to improvements in children’s behaviour (Furlong et al., 2012).
Parents do not set out to be harsh parents. Rearing children is one of the hardest jobs and many parents are not well prepared for it. A limited experience of young children, together with other factors, described here, make parenting more challenging. Having a child with a “difficult” temperament from the start is likely to be a factor which influences how parents behave towards their child. P...
