term paper on emotional and behavioral disorders

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• World J Clin Pediatr
• v.7(1); 2018 Feb 8

Behavioural and emotional disorders in childhood: A brief overview for paediatricians

Michael o ogundele.

Department of Community Paediatrics, NHS Fife, Glenwood Health Centre, Glenrothes KY6 1HK, United Kingdom

Correspondence to: Dr. Michael O Ogundele, MBBS, MRCP, MSc, Consultant Paediatrician, Department of Community Paediatrics, NHS Fife, Glenwood Health Centre, Napier Road, Glenrothes KY6 1HK, United Kingdom. [email protected]

Telephone: +44-1592-765096 Fax: +44-1592-765096

Mental health problems in children and adolescents include several types of emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive developmental (autism) disorders, characterized as either internalizing or externalizing problems. Disruptive behavioural problems such as temper tantrums, attention deficit hyperactivity disorder, oppositional, defiant or conduct disorders are the commonest behavioural problems in preschool and school age children. The routine Paediatric clinic or Family Medicine/General Practitioner surgery presents with several desirable characteristics that make them ideal for providing effective mental health services to children and adolescents. DSM-5 and ICD-10 are the universally accepted standard criteria for the classification of mental and behaviour disorders in childhood and adults. The age and gender prevalence estimation of various childhood behavioural disorders are variable and difficult to compare worldwide. A review of relevant published literature was conducted, including published meta-analyses and national guidelines. We searched for articles indexed by Ovid, PubMed, PubMed Medical Central, CINAHL, EMBASE, Database of Abstracts and Reviews, and the Cochrane Database of Systematic reviews and other online sources. The searches were conducted using a combination of search expressions including “childhood”, “behaviour”, “disorders” or “problems”. Childhood behaviour and emotional problems with their related disorders have significant negative impacts on the individual, the family and the society. They are commonly associated with poor academic, occupational, and psychosocial functioning. It is important for all healthcare professionals, especially the Paediatricians to be aware of the range of presentation, prevention and management of the common mental health problems in children and adolescents.

Core tip: Mental health problems in children and young people (CYP) include several types of emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive developmental (autism) disorders, characterized as either “internalizing” or “externalizing”. The routine Paediatric or General Practitioner clinic present with several desirable characteristics that make them ideal for providing effective mental health services to CYP. Childhood mental health disorders have significant negative impacts on the individual, the family and the society. It is particularly important for all Paediatricians to be aware of the range of presentation, prevention and management of the common mental health problems in CYP.

INTRODUCTION

Mental health disorders (MHD) are very common in childhood and they include emotional - obsessive-compulsive disorder (OCD), anxiety, depression, disruptive (oppositional defiance disorder (ODD), conduct disorder (CD), attention deficit hyperactive disorder (ADHD) or developmental (speech/language delay, intellectual disability) disorders or pervasive (autistic spectrum) disorders[ 1 ]. Emotional and behavioural problems (EBP) or disorders (EBD) can also be classified as either “internalizing” (emotional disorders such as depression and anxiety) or “externalizing” (disruptive behaviours such as ADHD and CD). The terminologies of “problems” and “disorders” are interchangeably used throughout this article.

While low-intensity naughty, defiant and impulsive behaviour from time to time, losing one’s temper, destruction of property, and deceitfulness/stealing in the preschool children are regarded as normal, extremely difficult and challenging behaviours outside the norm for the age and level of development, such as unpredictable, prolonged, and/or destructive tantrums and severe outbursts of temper loss are recognized as behaviour disorders. Community studies have identified that more than 80% of pre-schoolers have mild tantrums sometimes but a smaller proportion, less than 10% will have daily tantrums, regarded as normative misbehaviours at this age[ 2 , 3 ]. Challenging behaviours and emotional difficulties are more likely to be recognized as “problems” rather than “disorders” during the first 2 years of life[ 4 ].

Emotional problems, such as anxiety, depression and post-traumatic stress disorder (PTSD) tend to occur in later childhood. They are often difficult to be recognised early by the parents or other carers as many children have not developed appropriate vocabulary and comprehension to express their emotions intelligibly[ 5 ]. Many clinicians and carers also find it difficult to distinguish between developmentally normal emotions ( e.g ., fears, crying) from the severe and prolonged emotional distresses that should be regarded as disorders[ 6 ]. Emotional problems including disordered eating behaviour and low self-image are often associated with chronic medical disorders such as atopic dermatitis, obesity, diabetes and asthma, which lead to poor quality of life[ 7 - 9 ].

Identification and management of mental health problems in primary care settings such as routine Paediatric clinic or Family Medicine/General Practitioner surgery are cost-effective because of their several desirable characteristics that make it acceptable to children and young people (CYP) ( e.g ., no stigma, in local setting, and familiar providers). Several models to improve the delivery of mental health services in the Paediatric/Primary care settings have been recommended and evaluated recently, including coordination with external specialists, joint consultations, improved Mental Health training and more integrated on-site intervention with specialist collaboration[ 10 , 11 ].

A review of relevant published literature was conducted, including published meta-analyses and national guidelines. We searched for articles indexed by Ovid, PubMed, PubMed Medical Central, CINAHL, the Cochrane Database of Systematic reviews and other online sources. The searches were conducted using a combination of search expressions including “childhood”, “behaviour”, “disorders” or “problems”.

CLINICAL PRESENTATIONS OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Various definitions for a wide range of childhood behavioural disorders are being used. The DSM-5[ 12 ] offers the commonest universally accepted standard criteria for the classification of mental and behaviour disorders. The ICD-10 is the alternative classification standard[ 13 ].

Challenging behaviours

Any abnormal pattern of behaviour which is above the expected norm for age and level of development can be described as “challenging behaviour”. It has been defined as: “Culturally abnormal behaviour (s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy or behaviour which is likely to seriously limit or deny access to and use of ordinary community facilities”[ 14 ]. They can include self-injury, physical or verbal aggression, non-compliance, disruption of the environment, inappropriate vocalizations, and various stereotypies. These behaviours can impede learning, restrict access to normal activities and social opportunities, and require a considerable amount of both manpower and financial resources to manage effectively.

Many instances of challenging behaviour can be interpreted as ineffective coping strategies for a young person, with or without learning disability (LD) or impaired social and communication skills, trying to control what is going on around them. Young people with various disabilities, including LD, Autism, and other acquired neuro-behavioural disorders such as brain damage and post-infectious phenomena, may also use challenging behaviour for specific purposes, for example, for sensory stimulation, gaining attention of carers, avoiding demands or to express their limited communication skills[ 15 ]. People who have a diverse range of neurodevelopmental disorders are more likely to develop challenging behaviours[ 16 ].

Some environmental factors have been identified which are likely to increase the risk of challenging behaviour, including places offering limited opportunities for making choices, social interaction or meaningful occupation. Other adverse environments are characterized by limited sensory input or excessive noise, unresponsive or unpredictable carers, predisposition to neglect and abuse, and where physical health needs and pain are not promptly identified. For example, the rates of challenging behaviour in teenagers and people in their early 20s is 30%-40% in hospital settings, compared to 5% to 15% among children attending schools for those with severe LD[ 15 ].

Aggression is a common, yet complex, challenging behaviour, and a frequent indication for referral to child and adolescent Psychiatrists. It commonly begins in childhood, with more than 58% of preschool children demonstrating some aggressive behaviour[ 17 ]. Aggression has been linked to several risk factors, including individual temperaments; the effects of disturbed family dynamics; poor parenting practices; exposure to violence and the influence of attachment disorders. No single factor is sufficient to explain the development of aggressive behaviour[ 18 ]. Aggression is commonly diagnosed in association with other mental health problems including ADHD, CD, ODD, depression, head injury, mental retardation, autism, bipolar disorder, PTSD, or dyslexia[ 19 ].

Disruptive behaviour problems

Disruptive behaviour problems (DBP) include attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD). They constitute the commonest EBPs among CYP. Recent evidence suggests that DBPs should be regarded as a multidimensional phenotype rather than comprising distinct subgroups[ 20 ].

ADHD is the commonest neuro-behavioural disorder in children and adolescents, with prevalence ranging between 5% and 12% in the developed countries[ 21 ]. ADHD is characterized by levels of hyperactivity, impulsivity and inattention that are disproportionately excessive for the child’s age and development[ 12 ]. The ICD-10[ 13 ] does not use the term “ADHD” but “hyperkinetic disorder”, which is equivalent to severe ADHD. DSM-5 distinguishes between three subtypes of the disorder: predominantly hyperactive/impulsive, predominantly inattentive and combined types (Table ​ (Table1 1 ).

Subtypes of attention deficit hyperactivity disorder (based on DSM-5)

ADHD: Attention deficit hyperactivity disorder.

CD refers to severe behaviour problems (Table ​ (Table2), 2 ), characterized by repetitive and persistent manifestations of serious aggressive or non-aggressive behaviours against people, animals or property such as being defiant, belligerent, destructive, threatening, physically cruel, deceitful, disobedient or dishonest, excessive fighting or bullying, fire-setting, stealing, repeated lying, intentional injury, forced sexual activity and frequent school truancy[ 13 , 22 ]. Children with CD often have trouble understanding how other people think, sometimes described as being callous-unemotional. They may falsely misinterpret the intentions of other people as being mean. They may have immature language skills, lack the appropriate social skills to establish and maintain friendships, which aggravates their feelings of sadness, frustration and anger[ 12 ].

DSM-5 definition of conduct disorder and oppositional defiant disorder

CD is the commonest reason for CYP referral for psychological and psychiatric treatment. Roughly 50% of all CYP with a MHD have a CD[ 23 ]. About 30%-75% of children with CD also have ADHD and 50% of them will also meet criteria for at least one other disorder including Mood, Anxiety, PTSD, Substance abuse, ADHD, learning problems, or thought disorders[ 24 , 25 ]. Majority of boys have an onset of CD before the age of 10 years, while girls tend to present mainly between 14 and 16 years of age[ 26 ]. Most CYP with CD grow out of this disorder, but a minority become more dissocial or aggressive and develop antisocial personality disorder as adults.

ODD is considered to be the mildest and commonest of the DBPs, with prevalence estimates of 6%-9% for pre-schoolers and boys outnumbering girls by at least two to one[ 27 ]. CYP with ODD are typically openly hostile, negativistic, defiant, uncooperative, and irritable. They lose their tempers easily and are mean and spiteful towards others (Table ​ (Table2). 2 ). They are mostly defiant towards authority figures, but they may also be hostile to their siblings or peers. This pattern of adversarial behaviour significantly negatively impact on their lives at home, school, and wider society, and seriously impairs all their relationships[ 28 ].

Emotional problems

Emotional problems in later childhood include panic disorder, generalized anxiety disorder (GAD), separation anxiety, social phobia, specific phobias, OCD and depression. Mild to moderate anxiety is a normal emotional response to many stressful life situations. Anxiety is regarded as a disorder when it is disproportionately excessive in severity in comparison to the gravity of the triggering circumstances, leading to abnormal disruption of daily routines. Panic disorder is characterized by panic attacks untriggered by external stimuli. GAD is characterized by generalized worry across multiple life domains. Separation anxiety disorder is characterized by fear related to actual or anticipated separation from a caregiver. Social anxiety disorder (also called social phobia), is characterized by fear of social situations where peers may negatively evaluate the person[ 12 ].

Common manifestations of Anxiety disorders include physical symptoms such as increased heart rate, shortness of breath, sweating, trembling, shaking, chest pain, abdominal discomfort and nausea[ 29 ]. Other symptoms include worries about things before they happen, constant concerns about family, school, friends, or activities, repetitive, unwanted thoughts (obsessions) or actions (compulsions), fears of embarrassment or making mistakes, low self-esteem and lack of self-confidence[ 30 ].

Depression often occurs in children under stress, experiencing loss, or having attentional, learning, conduct or anxiety disorders and other chronic physical ailments. It also tends to run in families[ 7 - 9 , 31 ]. Symptoms of depression are diverse and protean, often mimicking other physical and neurodevelopmental problems, including low mood, frequent sadness, tearfulness, crying, decreased interest or pleasure in almost all activities; or inability to enjoy previously favourite activities, hopelessness, persistent boredom; low energy, social isolation, poor communication, low self-esteem and guilt, feelings of worthlessness, extreme sensitivity to rejection or failure, increased irritability, agitation, anger, or hostility, difficulty with relationships, frequent complaints of physical illnesses such as headaches and stomach aches, frequent absences from school or poor performance in school, poor concentration, a major change in eating and/or sleeping patterns, weight loss or gain when not dieting, talk of or efforts to run away from home, thoughts or expressions of suicide or self-destructive behaviour[ 31 ].

Disruptive mood dysregulation disorder (DMDD) is a childhood disorder characterized by a pervasively irritable or angry mood recently added to DSM-5. The symptoms include frequent episodes of severe temper tantrums or aggression (more than three episodes a week) in combination with persistently negative mood between episodes, lasting for more than 12 mo in multiple settings, beginning after 6 years of age but before the child is 10 years old[ 32 ].

Autistic spectrum and pervasive development disorder

The definition of Autism has evolved over the years and has been broadened over time. DSM-IV-TR[ 33 ] and the ICD-10[ 13 ] defined the diagnostic category of pervasive developmental disorders (PDD) as the umbrella terminology used for a group of five disorders characterized by pervasive “qualitative abnormalities in reciprocal social interactions and in patterns of communication, and by a restricted, stereotyped, repetitive repertoire of interests and activities” affecting “the individual’s functioning in all situations”. These included autism, asperger syndrome, childhood disintegrative disorder (CDD), pervasive developmental disorder not otherwise specified (PDD-NOS) and Rett syndrome.

Autism and Asperger Syndrome are the most widely recognised and clinically diagnosed among this group of disorders. CDD is a term used to describe children who have had a period of normal development for the first 2-3 years before a relatively acute onset of regression and emergence of autistic symptoms. PDD-NOS was used, particularly in the United States, to describe individuals who have autistic symptoms, but do not meet the full criteria for Autism or Asperger’s Syndrome, denote a milder version of Autism, or to describe atypical autism symptoms emerging after 30 mo of age, and autistic individuals with other co-morbid disorders[ 34 ].

The category of PDD has been removed from DSM-5[ 12 ] and replaced with Autism Spectrum disorders (ASD). ASD (Table ​ (Table3) 3 ) is diagnosed primarily from clinical judgment usually by a multidisciplinary team, with minimal support from diagnostic instruments. Most individuals who received diagnosis based on the DSM-IV should still maintain their diagnosis under DSM-5, with some studies confirming that 91% to 100% of children with PDD diagnoses from the DSM-IV retained their diagnosis under the ASD category using the new DSM-5[ 35 , 36 ], while a systematic review has found a slight decrease in the rate of ASD with DSM-5[ 37 ].

DSM-5 criteria for autism spectrum disorders

There are many intervention approaches and strategies, used alone or in combination, for supporting individuals with ASD. These interventions need to individualized and be closely tailored to the level of social and linguistic abilities, cultural background, family resources, learning style and degree of communication skills[ 38 ].

Various communication enhancement strategies have been designed to manage ASD[ 39 ], including augmentative and alternative communication (AAC), Facilitated Communication, computer-based instruction and video-based instruction (Table ​ (Table4). 4 ). Several behavioural and psychological interventions (Table ​ (Table5) 5 ) have also been used successfully in managing ASD children, including applied behaviour analysis (ABA) and functional communication training (FCT)[ 40 ].

Summary of common social communication enhancement strategies

Summary of common behavioural modification strategies for management of childhood emotional and behavioural disorder

ABA: Applied behaviour analysis; ADHD: Attention deficit hyperactivity disorder; ASD: Autistic spectrum disorder.

Social (pragmatic) communication disorder

Social (pragmatic) communication disorder (SCD) is a new diagnosis included under Communication Disorders in the Neurodevelopmental Disorders section of the DSM-5[ 12 ]. It is characterized by persistent difficulties with using verbal and nonverbal communication for social purposes, which can interfere with interpersonal relationships, academic achievement and occupational performance, in the absence of restricted and repetitive interests and behaviours (Table ​ (Table6). 6 ). Some authors consider that CYP with SCD present with similar but less severe restricted and repetitive interests and behaviours (RRIBs) characteristic of children on the autistic spectrum[ 41 ]. SCD is thought to occur more frequently in family members of individuals with autism[ 42 ].

DSM-5 criteria for social (pragmatic) communication disorder

The term “pragmatic” has been used previously to describe the communication skills that are needed in normal social intercourse and the rules that govern routine interpersonal interactions, including ability to pay at least some attention to the other person in a conversation, take turns, not interrupting the other speaker unless there is a very good reason, match language and volume to the situation and the listener, etc [ 43 ]. Social and pragmatic deficit are known to also occur in diverse clinical populations, including ADHD, William’s syndrome, CD, closed head injury and spina bifida/hydrocephalus[ 44 ].

Treatment modalities that have been used for supporting children with SCD are similar to those that have been used for several years in children with ASD (Tables ​ (Tables4 4 and ​ and5). 5 ). The first randomized controlled trial of social communication interventions designed primarily for children with SCD was reported in 2012[ 45 ]. The Social Communication Intervention Project ( http://www.psych-sci.manchester.ac.uk/scip/ ) targets development in social understanding and interaction, verbal and non-verbal pragmatic skills and language processing among children with SCD.

Pathological demand avoidance or Newson’s syndrome

Pathological demand avoidance (PDA) or Newson’s Syndrome is increasingly being accepted as part of the autism spectrum. PDA was first used in 2003[ 46 ] for describing some CYP with autistic symptoms who showed some challenging behaviours. It is characterized by exceptional levels of demand avoidance requested by others, due to high anxiety levels when the individuals feel that they are losing control. Avoidance strategies can range from simple refusal, distraction, giving excuses, delaying, arguing, suggesting alternatives and withdrawing into fantasy, to becoming physically incapacitated (with an explanation such as “my legs don’t work”) or selectively mute in many situations. If they feel threatened to comply, they may become verbally or physically aggressive, best described as a “panic attack”, apparently intended to shock[ 46 ]. They tend to resort to “socially manipulative” behaviours. The outrageous acts and lack of concern for their behaviour appears to draw parallels with conduct problems (CP) and callous-unemotional traits (CUT), but reward-based techniques, effective with CP and CUT, seem not to work in people with PDA[ 47 ]. PDA is currently neither part of the DSM-5[ 12 ] nor the ICD-10[ 13 ].

Though demand avoidance is a common characteristic of CYP with ASD, it becomes pathological when the levels are disproportionately excessive, and normal daily activities and relationships are negatively impaired. Unlike typically autistic children, people with PDA tend to have much better social communication and interaction skills, and are consequently able to use these abilities to their advantage. They often have highly developed social mimicry and role play, sometimes becoming different characters or personas. The people with PDA appear to retain a keen awareness of how to “push people’s buttons”, suggesting a level of social insight when compared to CYP with Autism. On the other hand, children with PDA exhibit higher levels of emotional symptoms compared to those with ASD or CD. They also often experience excessive mood swings and impulsivity. While the prevalence of ASD in boys is more than four times higher compared to that of girls, the risk of developing PDA appears to be the same for both boys and girls[ 47 ].

O’Nions et al[ 48 ] have recently reported on the development and preliminary validation of the “Extreme Demand Avoidance Questionnaire” (EDA-Q), designed to quantify PDA traits based on parent-reported information, with good sensitivity (0.80) and specificity (0.85). EDA-Q is available online (https:// www.pdasociety.org.uk/resources/extreme-demand-avoidance-questionnaire ).

PREVALENCE OF BEHAVIOURAL AND EMOTIONAL DISORDERS IN CHILDHOOD

Accurate estimation of various childhood EBPs is difficult due to the problems of research methodologies relying on subjective assessments and varying definitions used. According to most studies, between 10% and 20% of CYP are affected annually by MHDs, and the rates are very similar across different racial and ethnic groups after controlling for income, resident status, education, and neighbourhood support. However, poverty and low socioeconomic status are risk factors that appear to increase the rate of MHDs across populations[ 49 ]. A 2001 WHO report [ 50 ] indicated the 6-mo prevalence rate for any MHD in CYP, up to age 17 years, to be 20.9%, with disruptive behaviour disorders (DBD) at 10.3%, second only to Anxiety disorders at 13%. About 5% of CYP in the general population suffer from Depression at any given point in time, which is more prevalent among girls (54%)[ 31 , 51 ].

A previous British Child and Adolescent Mental Health (CAMH) survey carried out by the office of National Statistics (ONS) in 1999 and 2004, comprising 7977 interviews from parents, children and teachers, found the prevalence of MHD among CYP (aged 5-16 years) to be 6% for conduct problems, 4% for emotional problems (Depression or Anxiety) and 1.5% for Hyperkinetic disorders[ 51 ]. A similar survey in the United States between 2005 and 2011, the National survey of children’s health (NSCH) involving 78042 households, indicated that 4.6% of CYP aged 3-17 years had a history DBD, with prevalence twice as high among boys as among girls (6.2% vs 3.0%), Anxiety (4.7%), Depression (3.9%), and ASD (1.1%)[ 24 ]. Reported prevalence rates for DMDD range from 0.8% to 3.3% with the highest rate in preschool children[ 52 ].

AETIOLOGY AND RISK FACTORS FOR CHILDREN’S BEHAVIOURAL AND EMOTIONAL DISORDERS

The exact causes of various childhood EBPs are unknown. Several studies have identified various combinations of genetic predisposition and adverse environmental factors that increase the risk of developing any of these disorders. These include perinatal, maternal, family, parenting, socio-economic and personal risk factors[ 53 ]. Table ​ Table7 7 summarizes the evidence for various risk factors associated with development of childhood EBPs.

Summary of common risk factors for development of childhood emotional and behavioural disorder

ADHD: Attention deficit hyperactivity disorder; ASD: Autistic spectrum disorder; DBD: Disruptive behaviour disorder; PDA: Pathological demand avoidance.

There is ample evidence supporting the genetic inheritability of many EBDs in CYP from their parents. From a prospective study of 209 parents along with their 331 biological offsprings, moderate inheritability ( r = 0.23, P < 0.001) between parental and offspring CD was found[ 74 ]. Anxiety seems to be transmissible from mothers to their preschool children, through both genetic factors and also through behaviour modelling and an anxious style of parenting[ 6 ].

A developmental taxonomy theory has been proposed by Patterson et al[ 75 ] to help understand the mechanisms underlying early onset and course of CPs. They described the vicious cycle of non-contingent parental responses to both prosocial and antisocial child behaviour leading to the inadvertent reinforcement of child behaviour problems. Parents’ engagement in “coercive cycles” lead to children learning the functional value of their aversive behaviours ( e.g ., physical aggression) for escape and avoidance from unwanted interactions, ultimately leading to the use of heightened aversive behaviours from both the child and parents to obtain social goals. This adverse child behavioural training combined with social rejection often lead to deviant peer affiliation and delinquency in adolescence[ 76 ].

NEUROBIOLOGY OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Conflicting findings have been reported in the brain structural variations among CYP with EBPs using magnetic resonance imaging (MRI) studies. The most consistently reported structural abnormalities associated with the DBD include reduced grey matter volume (GMV) in the amygdala, frontal cortex, temporal lobes, and the anterior insula, which is involved in part of a network related to empathic concern for others. Reduced GMV along the superior temporal sulcus has also been found, particularly in girls[ 77 ]. A decreased overall mean cortical thickness, thinning of the cingulate and prefrontal cortices; and decreased grey matter density in different brain regions have been reported[ 78 ].

Subtle neurobiological changes in different parts of the brain of CYP with EBPs have been reported from many research studies of functional scans. Peculiar brain changes have been found in the hypothalamus, inferior and superior parietal lobes, right amygdala and anterior insula[ 79 ]. Functional MRI studies have demonstrated less activation in the temporal cortex in violent adult offenders[ 80 ] and in antisocial and psychopathic individuals[ 81 ] compared to non-aggressive offenders.

Reduced basal Hypothalamic-Pituitary-Adrenal (HPA) axis activity has been reported in relation to childhood DBDs and exposure to abuse and neglect[ 82 ]. It has been hypothesized that high levels of prenatal testosterone exposure appears to be part of the complex aetiology of EBDs, providing possible explanation for the higher prevalence in males for DBDs, by increasing susceptibility to toxic perinatal environments such as exposure to maternal nicotine and alcohol in pregnancy[ 83 ].

COMPLICATIONS OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

EBDs in childhood, if left untreated, may have negative short-term and long-term effects on an individual’s personal, educational, family and later professional life. CD has been linked to failure to complete schooling, attaining poor school achievement, poor interpersonal relationships, particularly family breakup and divorce, and experience of long-term unemployment. DBPs in parents have been linked to the abuse of their offspring, thereby increasing their risk of developing CD[ 84 , 85 ]. Children presenting with hyperactivity-inattention behaviours are more likely to have a more favourable educational outcome compared with those with aggression or oppositional behaviours[ 86 , 87 ].

A high prevalence of sleep disturbances is associated with various childhood EBPs. Sleep problems in early childhood is associated with increased prevalence of later Anxiety disorders and ODD[ 88 , 89 ].

Several studies have confirmed a strong relationship between early childhood EBPs and poor future long-term physical and mental health outcomes. Chronic irritability in preschool children, CD and ODD in older children each may be predictive of any current and lifetime Anxiety, Depression and DBDs in later childhood, Mania, Schizophrenia, OCD, major depressive disorder and panic disorder[ 84 , 90 - 92 ]. Individuals on the adolescent-onset CP path often consume more tobacco and illegal drugs and engage more often in risky sexual behaviour, self-harm, and have increased risk of PTSD, than individuals without childhood conduct problems. They also frequently experience parenting difficulties, including over-reactivity, lax and inconsistent discipline, child physical punishment and lower levels of parental warmth and sensitivity[ 74 , 84 , 93 , 94 ]. Approximately 40%-50% of CYP with CD are at the risk of developing antisocial personality disorder in adulthood[ 84 ]. Other potential complications include adverse mental and physical health outcomes, social justice system involvement including incarceration, substance use and abuse, alcoholism, homelessness, poverty and domestic abuse[ 95 , 96 ].

An analysis of several Scandinavian studies up to the 1980s has shown higher rates of violent death, estimated to be almost five times higher than expected among young people with previous MHD, with common associated predictive factors including behavioural problems, school problems, and co-morbid alcohol or drug abuse and criminality[ 97 ].

ASSESSMENT AND DIAGNOSIS OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Assessment through detailed history taking as well as observation of a child’s behaviour are indispensable sources of information required for clinical diagnosis of EBPs[ 1 ]. This should include general medical, developmental, family, social, educational and emotional history. Physical and neurological examination should include assessment of vision, hearing, dysmorphic features, neuro-cutaneous stigmata, motor skills and cognitive assessment. Condition-specific and generic observer feedback on screening rating scales and questionnaires can be used to complement direct clinical observations.

There is no single gold-standard diagnostic tool available for the diagnosis of EBDs, which largely depends on the clinical skills of an integrated collaboration of multi-professional experts. Diagnosis relies on interpretation of subjective multi-source feedback from parents or carers, teachers, peers, professional or other observers provided through a number of psychometric questionnaires or screening tools[ 98 ]. Significant discrepancies between various respondents are quite common and clinical diagnosis cannot rely on the psychometric tools alone. There is evidence from the literature suggesting that parents have a tendency to over-report symptoms of ODD and CD in children compared to the teachers[ 99 ].

There are several screening tools that are used for assessing the risk of MHD among CYP. The tools help to identify which individuals would require more in-depth clinical interventions[ 100 ]. Supplement material shows a list of common Mental Health screening and assessment tools, summarizing their psychometric testing properties, cultural considerations and costs. The commonest behaviour screening tools include the Behavioral and Emotional Screening System (BESS; ages 3-18 years), the Behavior Assessment System for Children-2 nd edition, Pediatric Symptom Checklist (PSC), the Ages and Stages Questionnaire-Social Emotional (ASQ-SE, Ages 0 to 5 years) and the Achenbach System of Empirically Based Assessment (ASEBA), for children aged 1.5 years through adulthood.

MANAGEMENT OF BEHAVIOURAL AND EMOTIONAL DISORDERS IN CHILDREN

Identification of appropriate treatment strategies depend on careful assessment of the prevailing symptoms, the family and caregiver’s influences, wider socio-economic environment, the child’s developmental level and physical health. It requires multi-level and multi-disciplinarian approaches that include professionals such as Psychologists, Psychiatrists, Behavioural Analysts, Nurses, Social care staff, Speech and language Therapists, Educational staff, Occupational Therapists, Physiotherapists, Paediatricians and Pharmacists. Use of pharmacotherapy is usually considered only in combination with psychological and other environmental interventions[ 15 ].

Holistic management strategies will include various combinations of several interventions such as child- and family-focused psychological strategies including Cognitive Behavioural Therapy (CBT), behavioural modification and social communication enhancement techniques, parenting skills training and psychopharmacology. These strategies can play significant roles in the management of children with a wide range of emotional, behavioural and social communication disorders. Effective alternative educational procedures also need to be implemented for the school age children and adolescents.

In early childhood, similar parenting strategies have been found useful to manage several apparently dissimilar EBPs ( e.g ., infant feeding or sleeping problems, preschool tantrums, disruptive and various emotional problems). This may suggest there is a common maintaining mechanism, which is probably related to poor self-regulation skills, involving the ability to control impulses and expressions of emotion[ 101 ].

Several studies have confirmed the effectiveness of various psychological and pharmacologic therapies in the management of childhood EBDs. A meta-analysis of thirty-six controlled trials, involving 3042 children (mean sample age, 4.7 years), evaluating the effect of psychosocial treatments including parenting programmes on early DBPs, demonstrated large and sustained effects (Hedges’g = 0.82), with the largest effects for general externalizing symptoms and problems of oppositionality and non-compliance, and were weakest, relatively speaking, for problems of impulsivity and hyperactivity[ 102 ].

The treatment of CD among CYP with callous-unemotional traits is still at early stages of research. The mainstay of management for CDs includes individual behavioural or cognitive therapy, psychotherapy, family therapy and medications[ 103 ].

Parental skills training

Any challenging behaviour from CYP is likely to elicit persistent negative reactions from many parents, using ineffective controlling strategies and a decrease in positive responses[ 104 ]. There is evidence from published research that social-learning and behaviourally based parent training is capable of producing lasting improvement in children with callous-unemotional traits or CD, reducing externalizing problems for children with DBDs, leading to significant parent satisfaction, particularly when delivered early in childhood[ 84 , 105 - 107 ]. These interventions are typically delivered in a group format, one 2-h session per week for 4-18 wk, by trained leaders, with the focus on improving parenting skills to manage child behaviour, where parents typically learn to identify, define and observe problem behaviours in new ways, as well as learn strategies to prevent and respond to oppositional behaviour[ 108 , 109 ].

Pooled estimates from a review of 37 randomised controlled studies identified a statistically significant improvement on several rating scales among children with CD up to the age of 18 years[ 23 ]. A previous meta-analysis of 24 studies confirmed that Parent-Child Interaction Therapy (PCIT) demonstrated significantly larger effect sizes for reducing negative parent behaviours, negative child behaviours, and caregiver reports of child behaviour problems than did most or all forms of Positive Parenting Programme (Triple P)[ 110 ]. A recent Cochrane review of 13 studies confirmed the efficacy and cost-effectiveness of group-based parenting interventions for alleviating child conduct problems, enhancing parental mental health and parenting skills, at least in the short term[ 111 ].

Differentiated educational strategies

Research has focused on identifying alternative educational strategies that can be used to improve learning opportunities for children presenting with challenging behaviours from various causes. Supportive school strategies for children with EBDs have traditionally focused on classroom management, social skills and anger management, but many researchers have more recently argued that academically-focused interventions may be most effective[ 112 ]. Traditional school policies of suspending or expelling children with EBD can be harmful to them. Researchers have developed “step-by-step” guidelines for teachers to guide them in the selection and implementation of evidence-based strategies that have been identified as effective in increasing levels of engagement and achievement by children with EBD, including peer-assisted learning procedures, class-wide peer tutoring, self-management interventions and tiered intervention systems - most notably Response to Intervention (RtI) and Positive Behavioural Interventions and Supports (PBIS)[ 113 , 114 ].

There is increasing evidence to confirm that school-based interventions to address emerging DBPs produce significant reductions in both parent-, self- and teacher-reported internalizing and externalizing symptoms[ 114 , 115 ].

Treatment and Education of Autistic and Related Communication Handicapped Children (TEACCH) is an educational system designed for the management of children with Autism and related communication disorders[ 116 , 117 ]. There is some evidence that TEACCH programmes also lead to some improvements in motor skills and cognitive measures[ 117 ].

Best practice management strategies for children with PDA are known to differ from those with Autism. Specific guidelines for children with PDA[ 118 ] have been published by the British institute for Learning Disabilities. Educational support for CYP with PDA relies on highly individualized strategies that allows them to feel in control. They would respond much better to more indirect and negotiative approaches. For example, “I wonder how we might…” is likely to be more effective than “Now let’s get on with your work”[ 118 ].

Child-focused psychological interventions

Cognitive behavioural therapy (CBT) is one of the most widely used non-pharmacologic treatments for individuals with emotional disorders, especially depression, and with individuals with behavioural problems including ASD[ 119 ]. CBT integrates a combination of both cognitive and behavioural learning principles to encourage desirable behaviour patterns. Research evidence from several trials[ 120 ] provide strong support for the effectiveness of cognitive–behavioural interventions among CYP with Anxiety and Depression. A recent study of child-focused CBT programme introduced at schools has shown that it produces significant improvement in disruptive behaviours among children[ 121 ].

Self-esteem building strategies can help many children with EBDs, who often experience repeated failures at school and in their interactions with others. These children could be encouraged to identify and excel in their particular talents (such as sports) to help build their self-esteem.

Behavioural modification and social communication enhancement strategies

Behavioural interventions and techniques are designed to reduce problem behaviours and teach functional alternative strategies using the basic principles of behaviour change. Most interventions are based on the principles of Applied Behaviour Analysis (ABA) which is grounded on behavioural learning theory. Table ​ Table5 5 summarizes the common behavioural modification strategies for management of childhood EBDs.

Several strategies have been designed to help children acquire important social skills, such as how to have a conversation or play cooperatively with others, using social group settings and other platforms to teach peer interaction skills and promote socially appropriate behaviours and communication. There is ongoing research in the development of social communication treatment approaches[ 45 ]. Table ​ Table4 4 summarizes common social communication enhancement strategies.

PSYCHOPHARMACOLOGY OF CHILDHOOD BEHAVIOURAL AND EMOTIONAL DISORDERS

Medications are often prescribed as part of a comprehensive plan for the management of childhood EBDs that includes other therapies. The greatest level of evidence for pharmacotherapy of childhood EBDs is available for their use in the management of childhood and adolescent ADHD. There is less evidence of any efficacy for medications in the management of other DBPs including ODD and CD. Table ​ Table8 8 lists the common classes of medications used in the management of childhood EBD.

Major classes of medications used in management of childhood emotional and behavioural disorders

Modified from “Medications used for behavioral and emotional disorders. A guide for parents, foster parents, families, youth, caregivers, guardians, and social workers.” May 2010. Available Online: URL: http://www.ct.gov/dcf/lib/dcf/ccmu/pdf/cmcu_-_educational_booklet_5-7-2010.pdf . ADHD: Attention deficit hyperactivity disorder; ASD: Autistic spectrum disorder; PTSD: Post traumatic stress disorder; OCD: Obsessive-compulsive disorder.

Psychostimulants (including different formulations of Methylphenidate and Dexamphetamines) remain the primary medication of choice for management of ADHD in CYP for more than 60 years. About 75% to 80% of children with ADHD will benefit from the use of psychostimulants. Non-stimulant therapy with Atomoxetine or alpha 2-adrenergic agonists (Clonidine and Guanfacine) are also effective second-line alternative options[ 133 ]. A recent analysis of 16 randomized trials and one meta-analysis, involving 2668 participants with ADHD, showed that both stimulant and non-stimulant medications led to clinically significant reductions in core symptoms with consistently high effect sizes. The psychosocial treatments alone combining behavioural, cognitive behavioural and skills training techniques demonstrated small- to medium-sized improvements for parent-rated ADHD symptoms, co-occurring emotional or behavioural symptoms and interpersonal functioning[ 134 ].

The use of pharmacological treatments for symptoms of ASD is common but challenging, as there are no medications that directly treat the social and language impairments present in individuals with ASD. The medications used most frequently include antipsychotics ( e.g ., Risperidone) and Selective Serotonin Reuptake Inhibitors (SSRI) to treat mood and repetitive behaviour problems, and stimulants and other medications used to treat ADHD-related symptoms. The evidence base is good for using atypical antipsychotics to treat challenging and repetitive behaviours, but they also have significant side effects[ 119 , 135 ]. Naltrexone is an opioid antagonist that has been shown from a systematic review (involving 155 children from 10 studies) to significantly improve symptoms of self-injury, irritability, restlessness and hyperactivity in autistic children, with minimal side effects and generally good tolerance, although long-term data are lacking[ 136 ].

Medication use in preschool children for control of ASD and ADHD symptoms is still largely controversial. Stimulant medications for treatment of ADHD are not uniformly licensed for pre-schoolers as there is limited available research evidence to confirm efficacy and safety. Moreover, the effectiveness of parenting interventions in this age group are comparable to the effects of using stimulant drugs among the older CYP[ 137 , 138 ].

Research evidence from two systematic reviews and 20 randomized controlled trials has recently documented the efficacy of psychopharmacology in the management of childhood DBP. Psychostimulants have have been shown to have a moderate-to-large effect on oppositional behaviour, conduct problems, and aggression in youths with ADHD, with and without ODD or CD, while Atomoxetine has only a small effect. There is very-low-quality evidence that Clonidine and Guanfacine have a small-to-moderate effect on oppositional behaviour and conduct problems in youths with ADHD[ 139 ].

Other behavioural disorders in children could also be successfully treated by medications. Traditional and the newer atypical antipsychotics can be used for OCD, Depression, aggression and mood instability[ 140 ].

The commonest antidepressants in used in children are the SSRI and Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) medications as they work well and usually have fewer side effects compared to the older Tricyclic Antidepressants. Antidepressants can be used in the management of Major Depression, Anxiety, Seasonal Affective Disorder (SAD), OCD, PTSD and Social Anxiety. They may also be used to treat enuresis and pre-menstrual syndrome[ 141 ].

Childhood EBDs have significant negative impacts on the society, in the form of direct behavioural consequences and costs, and on the individual, in the form of poor academic, occupational and psychosocial functioning and on the family. The costs to society include the trauma, disruption and psychological problems caused to the victims of crime or aggression in homes, schools and communities, together with the financial costs of services to treat the affected individuals, including youth justice services, courts, prison services, social services, foster homes, psychiatric services, accident and emergency services, alcohol and drug misuse services, in addition to unemployment and other required state benefits[ 23 ].

Prevention and management of EBD is not easy and it requires an integrated multidisciplinary effort by healthcare providers at different levels to be involved in the assessment, prevention and management of affected individuals, and also to provide social, economic and psycho-emotional support to the affected families.

There is increasing evidence base for several psychosocial interventions but less so for pharmacological treatment apart from the use of stimulants for ADHD. Preventive measures that have been researched for controlling the risk of childhood emotional and behaviour problems include breastfeeding[ 142 ], avoiding second-hand smoke exposure in non-smoker youths [ 143 ] and intensive parenting interventions.

Conflict-of-interest statement: The author declares no conflict of interest for this article.

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First decision: November 20, 2017

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In This Article Expand or collapse the "in this article" section Emotional and Behavioral Disorders

Introduction, general overviews.

• For Teachers and Other Professionals
• Identification and Prevalence
• Types or Facets
• School and Post School Outcomes
• Disproportionality
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• Positive Behavior Supports
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Emotional and Behavioral Disorders by Sarup R. Mathur , Katie Sprouls , Rebecca I. Hartzell LAST REVIEWED: 11 January 2018 LAST MODIFIED: 11 January 2018 DOI: 10.1093/obo/9780199756810-0072

The term emotional and behavioral disorders (EBD) encompasses a wide variety of behaviors and characteristics. Students with EBD often exhibit behaviors that interfere with academic success in schools. Like other students with disabilities, they also experience difficulties learning in various content areas, such as reading and math. Many of these students have difficulty maintaining appropriate social relationships with peers and adults. Some of these students exhibit noncompliant behavior, aggression, and disrespect toward authority figures. Due to these challenging behaviors, they experience unfortunate predicaments, such as misidentification, marginalization from access to education, and exclusion from general education environments. Since the 1980s, the federal government in the United States has become a major player in the movement to provide services for students with EBD. Although the implementation of the laws has not always produced consistent and positive outcomes, they have increased an international concern with the issue of education and treatment of students with EBD. It has become apparent that we need to elevate our expectations for positive outcomes for students with EBD around the world.

Schools are the largest providers of emotional, behavioral, and educational supports for children and adolescents in the United States ( Hoagwood and Johnson 2003 ). More students in the school-aged population exhibit emotional, behavioral, and mental health issues necessitating supports and interventions than those who actually receive it. Reviews of research suggest that students with EBD need early interventions and ongoing supports for positive outcomes in their lives ( Bradley, et al. 2004 ; Landrum, et al. 2003 ). EBD coexists with multiple identifiable conditions (e.g., depression, anxiety, attention deficit hyperactivity disorder, and obsessive-compulsive disorder) that require comprehensive care, which is not consistently available to many of these students. Studies have examined the importance of early intervention programs for children with EBD and have found that these programs benefit children with EBD ( Egger and Angold 2006 ; Kauffman, et al. 2007 ; Marsh, et al. 2017 ; Wagner, et al. 2005 ).

Bradley, R., K. Henderson, and D. A. Monfore. 2004. A national perspective on children with emotional disorders. Behavioral Disorders 29.3: 211–223.

Highlights that one-third (31 percent) of all children with EBD are served in more restrictive settings. When compared to students from other disability categories, that percentage is significantly higher than the average.

Egger, H. L., and A. Angold. 2006. Common emotional and behavioral disorders in preschool children: Presentation, nosology, and epidemiology. Journal of Child Psychology and Psychiatry 47.3–4: 313−337.

DOI: 10.1111/j.1469-7610.2006.01618.x

Reviewed research on behavioral and emotional psychiatric disorders in preschool children (children ages two through five years old), and focused on the five most common groups of childhood psychiatric disorders: attention deficit hyperactivity disorders, oppositional defiant and conduct disorders, anxiety disorders, and depressive disorders.

Hoagwood, K., and J. Johnson. 2003. School psychology: A public health framework; From evidence-based practices to evidence-based policies. Journal of School Psychology 41:3–21.

DOI: 10.1016/S0022-4405(02)00141-3

Highlights that school psychologists can play a central role in bridging the gap between research and practice, through the use of evidenced-based practices (EBP) in schools for students with disabilities, including those with EBD.

Kauffman, J. M., D. R. Mock, and R. L. Simpson. 2007. Problems related to underservice of students with emotional or behavioral disorders. Behavioral Disorders 33.1: 43–57.

Students with EBD are dramatically underidentified and underserved. Only a relatively small percentage of students with EBD receive special education or any other kind of treatment; and the negative consequences of nontreatment and treatment delay are serious.

Landrum, T. J., M. Tankersley, and J. M. Kauffman. 2003. What is special about special education for students with emotional or behavioral disorders? Journal of Special Education 37.3: 148–156.

DOI: 10.1177/00224669030370030401

Identifies three broad intervention areas of inappropriate behavior, academic learning problems, and interpersonal relationships. Provides a brief overview of a number of empirically validated practices. The authors argue for specialized interventions for students with EBD because of their unique needs.

Marsh, R. J., J. J. Morgan, K. Higgins, A. Lark, and J. T. Watts. 2017. Provision of mental health services to students with emotional and behavioral disorders. Journal of Disability Policy Studies 28.2: 90–98.

DOI: 10.1177/1044207317710698

An analysis of the provision of mental health and how services are delivered in the educational environment for students with emotional and behavioral disorders.

Wagner, M., K. Kutash, A. J. Duchnowski, M. H. Epstein, and W. C. Sumi. 2005. The children and youth we serve: A national picture of the characteristics of students with emotional disturbances receiving special education. Journal of Emotional and Behavioral Disorders 13.2: 79–96.

DOI: 10.1177/10634266050130020201

Presents longitudinal trends of characteristics for students with EBD served in special education using data from the Special Education Elementary Longitudinal Study and the National Longitudinal Transition Study. The findings indicate programming that addresses both the academic and the behavioral needs of these children and youth.

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Overview of Emotional and Behavioral Disorders

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91 References

Issues in the identification and placement of behaviorally disordered students, psychopathology and education of the brain-injured child, autistic disturbances of affective contact., emotional and behavioral disorders: a 25-year-focus., abnormal psychology and modern life, the fort bragg managed care experiment: short term impact on psychopathology, drug abuse prevention among minority adolescents: posttest and one-year follow-up of a school-based preventive intervention, diagnostic, taxonomic, and assessment issues, students with emotional and behavioral disorders: an australian perspective.

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The Transition of Youth with Disabilities to Adult Life: A Position Statement of the Division on Career Development and Transition, The Council for Exceptional Children

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Comprehensive Overview of Emotional and Behavioral Disorders

• Emotional and Behavioral Disorders

Mental Health Is Important

Mental health is how people think, feel, and act as they face life's situations. It affects how people handle stress, relate to one another, and make decisions. Mental health influences the ways individuals look at themselves, their lives, and others in their lives. Like physical health, mental health is important at every stage of life.

 All aspects of our lives are affected by our mental health. Caring for and protecting our children is an obligation and is critical to their daily lives and their independence.

 Children and Adolescents Can Have Serious Mental Health Problems

Like adults, children and adolescents can have mental health disorders that interfere with the way they think, feel, and act. When untreated, mental health disorders can lead to school failure, family conflicts, drug abuse, violence, and even suicide. Untreated mental health disorders can be very costly to families, communities, and the health care system.

In this fact sheet, "Mental Health Problems" for children and adolescents refers to the range of all diagnosable emotional, behavioral, and mental disorders. They include depression, attention- deficit/hyperactivity disorder, and anxiety, conduct, and eating disorders. Mental health problems affect one in every five young people at any given time.

"Serious Emotional Disturbances" for children and adolescents refers to the above disorders when they severely disrupt daily functioning in home, school, or community. Serious emotional disturbances affect 1 in every 10 young people at any given time.1

Mental Health Disorders Are More Common in Young People than Many Realize

Studies show that at least one in five children and adolescents have a mental health disorder. At least one in 10, or about 6 million people, have a serious emotional disturbance.¹

The Causes Are Complicated

Mental health disorders in children and adolescents are caused mostly by biology and environment. Examples of biological causes are genetics, chemical imbalances in the body, or damage to the central nervous system, such as a head injury. Many environmental factors also put young people at risk for developing mental health disorders. Examples include:

Exposure to environmental toxins, such as high levels of lead; Exposure to violence, such as witnessing or being the victim of physical or sexual abuse, drive-by shootings, muggings, or other disasters; Stress related to chronic poverty, discrimination, or other serious hardships; and The loss of important people through death, divorce, or broken relationships.

Signs of Mental Health Disorders Can Signal a Need for Help

Children and adolescents with mental health issues need to get help as soon as possible. A variety of signs may point to mental health disorders or serious emotional disturbances in children or adolescents. Pay attention if a child or adolescent you know has any of these warning signs:

A child or adolescent is troubled by feeling:

Sad and hopeless for no reason, and these feelings do not go away. Very angry most of the time and crying a lot or overreacting to things. Worthless or guilty often. Anxious or worried often. Unable to get over a loss or death of someone important. Extremely fearful or having unexplained fears. Constantly concerned about physical problems or physical appearance. Frightened that his or her mind either is controlled or is out of control.

A child or adolescent experiences big changes, such as:

Showing declining performance in school. Losing interest in things once enjoyed. Experiencing unexplained changes in sleeping or eating patterns. Avoiding friends or family and wanting to be alone all the time. Daydreaming too much and not completing tasks. Feeling life is too hard to handle. Hearing voices that cannot be explained. Experiencing suicidal thoughts.

A child or adolescent experiences:

Poor concentration and is unable to think straight or make up his or her mind. An inability to sit still or focus attention. Worry about being harmed, hurting others, or doing something "bad". A need to wash, clean things, or perform certain routines hundreds of times a day, in order to avoid an unsubstantiated danger. Racing thoughts that are almost too fast to follow. Persistent nightmares.

A child or adolescent behaves in ways that cause problems, such as:

Using alcohol or other drugs. Eating large amounts of food and then purging, or abusing laxatives, to avoid weight gain. Dieting and/or exercising obsessively. Violating the rights of others or constantly breaking the law without regard for other people. Setting fires. Doing things that can be life threatening. Killing animals.

Comprehensive Services through Systems of Care Can Help

Some children diagnosed with severe mental health disorders may be eligible for comprehensive and community-based services through systems of care. Systems of care help children with serious emotional disturbances and their families cope with the challenges of difficult mental, emotional, or behavioral problems. To learn more about systems of care, call the National Mental Health Information Center at 1-800-789-2647, and request fact sheets on systems of care and serious emotional disturbances, or visit the Center's web site at http://www.mentalhealth.samhsa.gov

Finding the Right Services Is Critical

To find the right services for their children, families can do the following:

Get accurate information from hotlines, libraries, or other sources. Seek referrals from professionals. Ask questions about treatments and services. Talk to other families in their communities. Find family network organizations.

It is critical that people who are not satisfied with the mental health care they receive discuss their concerns with providers, ask for information, and seek help from other sources.

Important Messages About Child and Adolescent Mental Health:

Every child's mental health is important. Many children have mental health problems. These problems are real, painful, and can be severe. Mental health problems can be recognized and treated. Caring families and communities working together can help. Information is available; call 1-800-789-2647.

Below are descriptions of particular mental, emotional, and behavioral disorders that may occur during childhood and adolescence. All can have a serious impact on a child's overall health. Some disorders are more common than others, and conditions range from mild to severe. Often, a child has more than one disorder (U.S. Department of Health and Human Services, 1999).

Anxiety Disorders

Young people who experience excessive fear, worry, or uneasiness may have an anxiety disorder. Anxiety disorders are among the most common of childhood disorders. According to one study of 9- to 17-year-olds, as many as 13 of every 100 young people have an anxiety disorder (U.S. Department of Health and Human Services, 1999). Anxiety disorders include:

• Phobias, which are unrealistic and overwhelming fears of objects or situations.
• Generalized anxiety disorder, which causes children to demonstrate a pattern of excessive, unrealistic worry that cannot be attributed to any recent experience.
• Panic disorder, which causes terrifying "panic attacks" that include physical symptoms, such as a rapid heartbeat and dizziness.
• Obsessive-compulsive disorder, which causes children to become "trapped" in a pattern of repeated thoughts and behaviors, such as counting or hand washing.
• Post-traumatic stress disorder, which causes a pattern of flashbacks and other symptoms and occurs in children who have experienced a psychologically distressing event, such as abuse, being a victim or witness of violence, or exposure to other types of trauma such as wars or natural disasters.

Severe Depression

Many people once believed that severe depression did not occur in childhood. Today, experts agree that severe depression can occur at any age. Studies show that two of every 100 children may have major depression, and as many as eight of every 100 adolescents may be affected (National Institutes of Health, 1999). The disorder is marked by changes in:

• Emotions—Children often feel sad, cry, or feel worthless.
• Motivation—Children lose interest in play activities, or schoolwork declines.
• Physical well-being—Children may experience changes in appetite or sleeping patterns and may have vague physical complaints.
• Thoughts—Children believe they are ugly, unable to do anything right, or that the world or life is hopeless.
• It also is important for parents and caregivers to be aware that some children and adolescents with depression may not value their lives, which can put them at risk for suicide.

Bipolar Disorder

Children and adolescents who demonstrate exaggerated mood swings that range from extreme highs (excitedness or manic phases) to extreme lows (depression) may have bipolar disorder (sometimes called manic depression). Periods of moderate mood occur in between the extreme highs and lows. During manic phases, children or adolescents may talk nonstop, need very little sleep, and show unusually poor judgment. At the low end of the mood swing, children experience severe depression. Bipolar mood swings can recur throughout life. Adults with bipolar disorder (about one in 100) often experienced their first symptoms during their teenage years (National Institutes of Health, 2001).

Attention-deficit/Hyperactivity Disorder

Young people with attention-deficit/hyperactivity disorder are unable to focus their attention and are often impulsive and easily distracted. Attention-deficit/hyperactivity disorder occurs in up to five of every 100 children (U.S. Department of Health and Human Services, 1999). Most children with this disorder have great difficulty remaining still, taking turns, and keeping quiet. Symptoms must be evident in at least two settings, such as home and school, in order for attention-deficit/hyperactivity disorder to be diagnosed.

Learning Disorders

Difficulties that make it harder for children and adolescents to receive or express information could be a sign of learning disorders. Learning disorders can show up as problems with spoken and written language, coordination, attention, or self-control.

Conduct Disorder

Young people with conduct disorder usually have little concern for others and repeatedly violate the basic rights of others and the rules of society. Conduct disorder causes children and adolescents to act out their feelings or impulses in destructive ways. The offenses these children and adolescents commit often grow more serious over time. Such offenses may include lying, theft, aggression, truancy, the setting of fires, and vandalism. Current research has yielded varying estimates of the number of young people with this disorder, ranging from one to four of every 100 children 9 to 17 years of age (U.S. Department of Health and Human Services, 1999).

Eating Disorders

Children or adolescents who are intensely afraid of gaining weight and do not believe that they are underweight may have eating disorders. Eating disorders can be life threatening. Young people with anorexia nervosa, for example, have difficulty maintaining a minimum healthy body weight. Anorexia affects one in every 100 to 200 adolescent girls and a much smaller number of boys (National Institutes of Health, 1999).

Youngsters with bulimia nervosa feel compelled to binge (eat huge amounts of food in one sitting). After a binge, in order to prevent weight gain, they rid their bodies of the food by vomiting, abusing laxatives, taking enemas, or exercising obsessively. Reported rates of bulimia vary from one to three of every 100 young people (National Institutes of Health, 1999).

Children with autism, also called autistic disorder, have problems interacting and communicating with others. Autism appears before the third birthday, causing children to act inappropriately, often repeating behaviors over long periods of time. For example, some children bang their heads, rock, or spin objects. Symptoms of autism range from mild to severe. Children with autism may have a very limited awareness of others and are at increased risk for other mental disorders. Studies suggest that autism affects 10 to 12 of every 10,000 children (U.S. Department of Health and Human Services, 1999).

Schizophrenia

Young people with schizophrenia have psychotic periods that may involve hallucinations, withdrawal from others, and loss of contact with reality. Other symptoms include delusional or disordered thoughts and an inability to experience pleasure. Schizophrenia occurs in about five of every 1,000 children (National Institutes of Health, 1997).

Treatment, Support Services, and Research: Sources of Hope

Now, more than ever before, there is hope for young people with mental, emotional, and behavioral disorders. Most of the symptoms and distress associated with childhood and adolescent mental, emotional, and behavioral disorders can be alleviated with timely and appropriate treatment and supports.

In addition, researchers are working to gain new scientific insights that will lead to better treatments and cures for mental, emotional, and behavioral disorders. Innovative studies also are exploring new ways of delivering services to prevent and treat these disorders. Research efforts are expected to lead to more effective use of existing treatments, so children and their families can live happier, healthier, and more fulfilling lives.

Many of these research studies are funded by Federal agencies within the Department of Health and Human Services, including the:

• National Institutes of Health
• National Institute of Mental Health
• National Institute of Child Health and Human Development
• National Institute on Drug Abuse
• National Institute on Alcohol Abuse and Alcoholism
• Substance Abuse and Mental Health Services Administration
• Center for Mental Health Services
• Center for Substance Abuse Prevention
• Center for Substance Abuse Treatment
• Administration for Children and Families
• Health Resources and Services Administration

Related activities are taking place within the:

• Department of Education
• Department of Justice

Important Messages About Children's and Adolescents' Mental Health

• Every child's mental health is important.
• Many children have mental health problems.
• These problems are real and painful and can be severe.
• Mental health problems can be recognized and treated.
• Caring families and communities working together can help.

Mental Health Resources on the Internet

Centers for Disease Control and Prevention www.cdc.gov

ClinicalTrials.gov, National Institutes of Health http://clinicaltrials.gov/

Substance Abuse and Mental Health Services Administration http://www.mentalhealth.samhsa.gov

National Institute of Mental Health www.nimh.nih.gov

U.S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services.

National Institutes of Health. (1999). Brief Notes on the Mental Health of Children and Adolescents. Retrieved September 5, 2001, from the World Wide Web.

National Institutes of Health. (2001). Fact Sheet: Going to Extremes, Bipolar Disorder. Bethesda, MD: National Institutes of Health.

National Institutes of Health. (1997). Press Release: Progressive Brain Changes Detected in Childhood Onset Schizophrenia.

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Handbook of Research on Emotional and Behavioral Disorders

DOI link for Handbook of Research on Emotional and Behavioral Disorders

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The Handbook of Research on Emotional and Behavioral Disorders explores the factors necessary for successful implementation of interventions that foster productive relationships and ecologies to establish, reinforce, and sustain adaptive patterns of emotional and behavioral functioning across childhood and into adulthood.

Although there has been a concerted focus on developing evidence-based programs and practices to support the needs of children and youth with emotional and behavioral disorders, there has been less emphasis on the developmental, social, and environmental factors that impact the implementation and effectiveness of these approaches. Chapters from leading experts tackle this complexity by drawing on a range of disciplines and perspectives including special education; mental health services; school, clinical, and community psychology; social work; developmental psychology and psychopathology; and prevention science.

An essential resource for scholars and students interested in emotional and behavioral disorders, this volume crafts an essential framework to promote developmentally meaningful strategies for children and youth with even the most adverse experiences and intensive support needs.

TABLE OF CONTENTS

Part 1 | 80  pages, developmental processes and timing, chapter 1 | 20  pages, the development, prevention, and treatment of emotional and behavioral disorders, chapter 2 | 12  pages, the epidemiology of childhood emotional and behavioral disorders, chapter 3 | 15  pages, prevention and intervention in preschool and early elementary school years, chapter 4 | 15  pages, developmental processes and emotional and behavioral disorders during the middle and high school years, chapter 5 | 16  pages, the transition to adulthood, part 2 | 102  pages, targeting social processes and environmental ecologies, chapter 6 | 13  pages, interaction-centered model of language and behavioral development, chapter 7 | 15  pages, peer to peer support, chapter 8 | 14  pages, the family check-up, chapter 9 | 15  pages, classroom peer ecologies and cultures, and students with ebd, chapter 10 | 13  pages, implementation of violence prevention programs, chapter 11 | 14  pages, interventions for youth who experience trauma and adversity, chapter 12 | 16  pages, strengthening social processes to support youth with emotional and behavioral difficulties, part 3 | 232  pages, selected effective programs and practices, chapter 13 | 15  pages, the family check-up for elementary and middle school youth and families emotional/behavioral disorders, chapter 14 | 14  pages, multi-tiered systems of support, chapter 15 | 13  pages, best in class, chapter 16 | 18  pages, an adaptive, correlated constraints model of classroom management, chapter 17 | 16  pages, multi-tiered social-emotional learning, chapter 18 | 15  pages, checking the connections between effective interventions for students with emotional/behavioral disorders, chapter 19 | 14  pages, multisystemic therapy for high-risk youth, chapter 20 | 16  pages, treatment foster care, chapter 21 | 15  pages, residential programs, chapter 22 | 20  pages, managing and adapting practice (map), chapter 23 | 15  pages, best practices for prescribing and deprescribing psychotropic medications for children and youth, chapter 24 | 15  pages, the homework, organization, and planning skills (hops) intervention, chapter 25 | 15  pages, the daily report card intervention, chapter 26 | 14  pages, cognitive-behavioral prevention and intervention approaches to student emotional and behavioral functioning, chapter 27 | 15  pages, school-based mental health, part 4 | 64  pages, preparing and supporting the ebd workforce, chapter 28 | 16  pages, leveraging implementation science and practice to support the delivery of evidence-based practices in services for youth with emotional and behavioral disorders, chapter 29 | 16  pages, recruiting, preparing, and retaining a diverse emotional and behavioral disorders educator workforce, chapter 30 | 13  pages, leading the team for youth with emotional and behavioral disorders, chapter 31 | 17  pages, professional development to support service providers of children and adolescents with or at risk of emotional and behavioral disorders.

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What Are Emotional and Behavioral Disorders in Children?

Emotional and behavioral disorders are specific mental health disorders that cause extreme difficulties with both emotions and behaviors. They affect a child’s functioning in most or all areas of their life.  Emotional and behavioral disorders (E/BD) make it difficult for a child to regulate emotions and make appropriate behavior choices in a wide variety of situations.

An emotional and behavioral disorder negatively impacts a child’s ability to be successful in school, control feelings and actions, and generally be happy in life. These disorders affect the whole child— feelings, behaviors, social development, and cognitive functioning. Children living with an E/BD have a hard time coping with life’s numerous demands.

Emotional and Behavioral Disorders Definition

A definition of emotional and behavioral disorders in children includes these elements:

• A pattern of disruptive behaviors and emotions
• Intense and often prolonged emotions and behaviors
• Inhibited healthy functioning at home, in school, in social situations, and in other settings
• Long duration; the behaviors and emotional disturbances must last six months or longer

A word of caution is in order: Most, if not all, children exhibit strong emotions and disruptive behaviors occasionally. That’s normal and part of their developmental stages (such as tantrums in young children). Typical challenging behaviors and negative emotional reactions don’t indicate an emotional and behavioral disorder, but when they’re severe, frequent, and last beyond a certain age (such as tantrums beyond early childhood) there might be a deeper issue.

What, exactly, might that deeper issue be? Several different disorders fall under the E/BD umbrella.

Types of Emotional and Behavioral Disorders

The following disorders can occur in children over the age of five. While signs can be present before age five, a diagnosis is almost never made in very young children. Even in older children, these diagnoses are made only with extreme caution, as there is controversy around the notion of labeling children.

Children can be diagnosed with the following types of emotional and behavioral disorders:

• Anxiety disorders
• Bipolar disorder
• Psychotic disorders
• Obsessive-compulsive disorder
• Attention-deficit/hyperactivity disorder *
• Oppositional-defiant disorder
• Conduct disorder

(*note: Some mental health professionals and groups include ADHD among emotional and behavior disorders, while others do not but do list and recognize some symptoms of ADHD as part of behavioral disorders.)

Together, these disorders of behavior and emotions have distinct characteristics that set them apart from “typical” childhood misbehavior.

Characteristics of Emotional and Behavioral Disorders

Children with E/BD have distinct traits that set their emotions and behaviors apart from other, less extreme actions or feelings. These characteristics of the emotional and behavioral disorder can include:

• Impulsiveness
• Short attention span
• Aggression, such as acting out or fighting
• Defiance, refusal to follow rules
• Disrespect for authority
• Difficulty handling frustration
• Blaming others, denying responsibility for actions
• Self-injury
• Excessive fear, often in reaction to personal problems
• Immaturity (crying, tantrums, lack of coping skills inappropriate for the age)
• Behaviors that are age-inappropriate
• Learning problems , other problems at school
• Difficulty forming and keeping relationships with other children, teachers, and even family members
• Pervasive unhappy and/or angry mood

Parenting, teaching, or otherwise caring for a child with emotional and behavioral disorders is challenging and exhausting (" Parenting Is Hard! How to Conquer Burnout and Exhaustion "). Knowing that your child’s taxing behavior and general intensity isn’t personal can help you put it in perspective. Emotional and behavioral disorders are psychiatric illnesses , which means they affect the brain and how it functions. These kids aren’t trying to be difficult (conduct disorder may be an exception). They need help and support so they experience life more positively and, by default, so others in their lives can experience life more positively, too.

Professional mental health help is essential for these children. To help with school success, many kids with emotional and behavioral disorders qualify for special education services. In addition to these professional supports, the more you as a parent or caregiver understand about emotional and behavioral disorders and the types and characteristics, the better able you’ll be to understand your child and help them get through times of strong emotions and undesirable behaviors.

article references

APA Reference Peterson, T. (2022, January 11). What Are Emotional and Behavioral Disorders in Children?, HealthyPlace. Retrieved on 2024, September 9 from https://www.healthyplace.com/parenting/behavior-disorders/what-are-emotional-and-behavioral-disorders-in-children

Medically reviewed by Harry Croft, MD

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Emotional and Behavioral Disorders in the Classroom

“Emotional and Behavioral Disorder” is an umbrella term under which several distinct diagnoses (such as Anxiety Disorder, Manic-Depressive Disorder, Oppositional-Defiant Disorder, and more) fall. These disorders are also termed “emotional disturbance” and “emotionally challenged.” According to the Individuals with Disabilities Education Act (IDEA), children with emotional and behavioral disorders exhibit one or more of these five characteristics:

• An inability to learn that cannot be explained by intellectual, sensory, or health factors.
• An inability to build or maintain satisfactory interpersonal relationships with peers and teachers.
• Inappropriate types of behavior or feelings under normal circumstances.
• A general pervasive mood of unhappiness or depression.
• A tendency to develop physical symptoms or fears associated with personal or school problems.

IDEA guarantees students access to a Free and Appropriate Public Education (FAPE) in the Least Restrictive Environment (LRE) possible. As such, students diagnosed with emotional disorders (ED) are often included in general education classrooms. However, severe cases often require students to be taught in special education “cluster units,” self-contained programs, or even separate schools.

Under the umbrella term of Emotional and Behavioral Disorders, there are two categories: Psychiatric Disorders and Behavioral Disabilities.

Psychiatric Disorders

This category encompasses a wide range of conditions. Psychiatric disorders are defined as mental, behavioral, or perceptual patterns or anomalies which impair daily functioning and cause distress. Some of the most common examples of these diagnoses include:

• Anxiety Disorder
• Bipolar Disorder (aka Manic-Depressive Disorder)
• Eating Disorder (such as anorexia, bulimia, and binge-eating disorder)
• Obsessive-Compulsive Disorder
• Psychotic Disorder

From a teacher’s perspective, psychiatric disorders present a profound challenge for a number of reasons. For one, schools are not hospitals, and teachers can not be expected to “treat” these disorders. Students who struggle with these sorts of challenges are often undergoing treatment and may be receiving medication. Medication can affect people in unexpected ways and, because medical information is confidential, teachers may be unaware why students are acting the way they are. This makes it difficult to respond appropriately to certain behaviors. Additionally, students suffering from these conditions may be simply unable to meet academic and behavioral expectations. In such cases, students need to receive special education interventions of some sort, and may need to be moved into a special education classroom.

Behavioral Disabilities

Children with behavioral disabilities engage in conduct which is disruptive to classroom functioning and/or harmful to themselves and others. To be diagnosed as a behavioral disability, the behaviors must not be attributable to one of the aforementioned psychiatric disorders.

There are two categories of behavioral disabilities: oppositional defiant disorder and conduct disorder.

Oppositional defiant disorder is characterized by extreme non-compliance, negativity, and an unwillingness to cooperate or follow directions. Children with this condition are not violent or aggressive, they simply refuse to cooperate with adults or peers.

Conduct disorder is much more severe. This disorder is characterized by aggression, violence, and harm inflicted on self and others. Students with conduct disorder typically need to be taught in special education classrooms until their behavior has improved enough to allow contact with the general education population.

Strategies for Teaching Students with Emotional and Behavioral Disorders

As with other conditions, students with emotional and behavioral disorders need a positive, structured environment which supports growth, fosters self-esteem, and rewards desirable behavior.

Rules and Routines

Rules need to be established at the beginning of the school year, and must be written in such a way as to be simple and understandable. The wording of rules should be positive: “Respect yourself and others” is a better rule than “Don’t hurt anyone.” Keep it simple: 6 rules or less.

Consequences for breaking rules should also be established at the beginning of the school year, and applied consistently and firmly whenever the rules are broken. The consequences must be consistent and predictable. When administering consequences, provide feedback to the student in a calm, clear manner. That way, the student understands why the consequence is necessary. Try to avoid becoming emotionally reactive when rules are broken. Emotional reactivity gives the student negative attention, which many children find very rewarding. Remain calm and detached, be firm yet kind. It’s a difficult balance to achieve, but crucially important for positive results.

Routines are very important for classroom management. Students with emotional and behavioral disorders tend to struggle with transitions and unexpected change. Going over a visual schedule of the day’s activities is an effective way to start the day, and helps the students feel grounded.

Techniques for Supporting Positive Behavior

Students with emotional and behavioral disorders often need to receive instruction in a special education setting because their behavior is too maladaptive for a general education classroom. Here are a few ideas to guide and support growth towards more positive, adaptive behavior:

• Token Economy – Students earn points, or tokens, for every instance of positive behavior. These tokens can then be used to purchase rewards at the token store. In order for a token economy to be effective, positive behavior must be rewarded consistently, and items in the token store must be genuinely motivating for the student. This takes a fair amount of preparation and organization, but has proven to be quite effective.
• Classroom Behavior Chart – A chart which visually plots the level of behavior of every student in the classroom. Students who are behaving positively progress upwards on the chart; those who are behaving negatively fall downwards. This makes every student accountable, and helps you monitor and reward progress. This won’t work if difficult students perpetually stay on the bottom of the chart. Focus on the positive to the fullest degree possible, and keep them motivated.
• Lottery System – Similar to the token economy, students who behave in positive ways are given a ticket with their name on it. These tickets are placed in a jar, and once or twice a week you draw one out. The winner of the lottery is rewarded with a prize.
• Positive Peer Review – Students are asked to watch their peers, and identify positive behavior. Both the student who is behaving positively and the student who does the identifying are rewarded. This is the exact opposite of “tattle-telling,” and fosters a sense of teamwork and social support in the classroom.

Teaching children with emotional and behavioral disorders can be extremely challenging. Remember: fostering and rewarding positive behavior has proven to be vastly more effective than attempting to eliminate negative behavior. Punishment and negative consequences tend to lead to power struggles, which only make the problem behaviors worse. It is not easy to remain positive in the face of such emotionally trying behaviors, but don’t give up. Your influence could mean a world of difference to these students who are struggling with an incredibly difficult condition.

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