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In its new policy on special education, the Quebec Ministry of Education (MEQ) clearly identified students with behavioural difficulties as a top priority (1). In 1998, nearly 25 000 such students received special educational services in Quebec public schools. Compared with other students with special needs, these children have lower rates of integration into regular classes and even lower graduation rates, since they tend to drop out at an early age (1). The problem is salient in elementary schools, where the proportion of students presenting with behavioural difficulties more than tripled over 15 years, from 0.78% in 1985 to 2.50% in 2000 (2). Surprisingly, there are relatively few data available on the nature and extent of the difficulties manifested by these young students, though this information is critical for defining and planning special educational services in schools. Regarding the nature of the difficulties, the MEQ proposed a definition, based on the presence of internalized or externalized behaviours (3). However, there is no consensus among schools on a method or instrument for assessing these problems. This may explain the paucity of data in this regard. Yet, notwithstanding the definition proposed by the MEQ, the difficulties seem to refer almost exclusively to symptoms that fall under the category of disruptive behaviour disorders, that is, oppositional defiant disorder (ODD) and conduct disorder (CD), as described in the DSM (4). For example, the Conseil supérieur de l’éducation (2) described students with behavioural difficulties as children who often argue with adults and refuse to comply with requests or rules, who are often truant from school, and who often bully, threaten, or intimidate others (2). Comorbidity of these behaviours with symptoms of attention- deficit hyperactivity disorder (ADHD) is also quite pronounced in these students (2,5). However, it is not known whether the difficulties in question are severe enough to meet the DSM criteria for any of these diagnoses. The main purpose of this descriptive study was to provide a general picture of the frequency of disruptive behaviour disorders (that is, ADHD, ODD, and CD) and of the comorbidity of these disorders in a representative sample of elementary school students receiving special educational services for behavioural difficulties. Further, given the MEQ’s focus on both internalized and externalized behaviours, we also explored the frequency of generalized anxiety disorder (GAD) and major depressive episode (MDE). We determined prevalence rates by sex and age group, with a view to defining better-adapted educational services. Though earlier studies conducted in the general population have observed higher rates of serious aggressive behaviours and delinquency (such as CD symptoms) in boys (6–9) and in older children (7,8,10), these findings might not apply to children in clinical samples with a higher level of impairment (11). Finally, as a substantial body of research has usually shown correlations across different informants to be modest at best, multiple sources are likely to provide unique, complementary, and meaningful data (12–16). The use of different informants remains a challenge, however. While the commonly accepted practice is to combine the data from each informant to formulate DSM diagnoses, studies have suggested that parent and teacher reports are better sources of information for documenting disruptive behaviour disorders in children than are child reports (6,14,15). Conversely, Jensen and others (14) observed that parent and child reports provide equally credible but complementary information on internalized disorders. In step with these findings, we chose to document disruptive behaviour disorders on the basis of data provided by parents and teachers and internalized disorders on the basis of data provided by parents and children. MethodParticipants and Procedure For reasons of confidentiality, school staff (generally psychoeducators) solicited the parents of eligible students to participate in the study. The psychoeducators removed 42 parents from the list either because they had never met them before or because they were afraid that contacting the parents might hamper their intervention with the child. Of the remaining 668 parents, 520 could be reached before the end of the school year, and 62.3% (n = 324) consented to study participation. This participation rate was deemed acceptable because it was comparable to those usually reported for longitudinal studies wherein the dependant variable is antisocial child behaviour or related areas (17). Further, data on the nonparticipants available from the schools showed that the final sample did not differ significantly from the original sample in terms of grade attended, sex, type of class (that is, regular or special), or school board. There were no significant differences in these variables between the participants and the 42 cases excluded by the psychoeducators. Girls comprised 20% of the final sample—a proportion comparable to that usually reported for elementary school children receiving services for behavioural difficulties (2). Also, 26% of the sample attended special classes, which was consistent with the percentage usually reported for these students in Quebec schools (1). Parents and children were interviewed at home, separately, by trained graduate students; the interview could not be completed for 8 children. Teachers who agreed to act as informants (n = 306) were interviewed by telephone. Thus we obtained a complete paired data set for disruptive behaviour disorders from 306 parents and teachers and for internalized disorders from 316 parents and children. Measurement of Disorders We used the Dominic Interactive with the children to document the presence of internalized disorders (that is, GAD and MDE) (20). This instrument is a computerized pictorial questionnaire, specially designed to screen for the most common disorders in primary school children according to DSM-IV criteria. The instrument’s psychometric properties have been deemed acceptable (20,21). Analysis ResultsFrequency of Disruptive Behaviour Disorders
Prevalence rates varied significantly across age groups for ADHD (according to parents), for ODD (according to either informant), and for CD (according to teachers). More specifically, the lowest rates obtained for ADHD and ODD were for students aged 11 to 13 years. For CD, the highest prevalence obtained was for the group aged 6 to 8 years, a result that remained significant when the 2 categories of informants were considered jointly. There was no significant sex effect or sex by age group interaction for the 3 disorders. Comorbidity of Disruptive Behaviour Disorders Frequency of Internalized Disorders
Only 2% of students presented with an internalized disorder without a comorbid disruptive behaviour disorder (not shown in the table). Finally, about 15% of the students did not present with any of the disorders assessed in the study. DiscussionThe behavioural difficulties presented by most students in our sample were severe enough to meet the criteria for at least one DSM-IV disruptive behaviour disorder (that is, ADHD, ODD, or CD). The high prevalence rates obtained illustrate the extent to which students receiving special educational services for behavioural difficulties may constitute a severely impaired group. This may raise questions about the adequacy and sufficiency of school services to cope with certain behavioural difficulties. However, the rates reported here must be interpreted with a certain degree of caution. Above all, the representativeness of the sample remains uncertain, despite its distribution by grade, sex, type of class, and school board. Unfortunately, owing to ethical constraints, we did not have access to data on the problems manifested by the nonparticipants. Insofar as families of antisocial children are more inclined to refuse their participation in studies (17), the high rates reported here could even underestimate the frequency of ODD and CD in the sample. Further, as the data were collected in the last term of the school year, the rates reported here may also underestimate the frequency of disorders that could have decreased with the special educational services that participants received during the school year. Keeping in mind these limitations, we were nevertheless surprised by the very high rates of ADHD (74%) in the sample. Of the students who received a diagnosis of ODD or CD, only a slight fraction did not have comorbid ADHD. Further, nearly one-quarter of the students were diagnosed with ADHD only. Similar studies conducted in other countries have also reported very high rates of ADHD alone or in conjunction with ODD or CD among elementary school students receiving special educational services for emotional and behavioural difficulties (22,23). These results, in addition to the fact that teacher reports yielded higher rates of ADHD than did parent reports, suggest that the school context is particularly sensitive to this disorder. They support the idea that, in practice, the manifestation of ADHD symptoms is crucial to receive special educational services in elementary school. Children with ADHD and ODD or CD (one-half the students in this sample) have often been described in the literature as exhibiting more aggressive behaviours and a wider range of difficulties than do children with ODD, CD, or ADHD only (24) and are more likely to continue CD manifestations over the years (25). From this perspective, the school environment’s sensitivity to ADHD may simply reflect the detection of children with more serious disruptive behaviours. Our findings also suggest that, in practice and despite the MEQ’s definition of behavioural difficulties, children with internalized disorders rarely receive special educational services in elementary schools, particularly if their symptoms are not accompanied by a disruptive behaviour disorder. Other studies (22,23) have reported low rates of internalized disorders in students with emotional and behavioural difficulties. Considering the extent to which these students are identified primarily because of behaviour problems and in respect to the MEQ’s policies, our results militate in favour of changes in screening and mandates of special educational services. The relatively small size of our sample may have affected the power to detect group differences and interaction. Nevertheless, this study tends to show that the frequency of disruptive behaviour disorders is higher in younger students than in older ones for certain diagnoses and informants. This result stands in contrast to the observations made in community samples with respect to ODD or CD. Where ADHD is concerned, however, a higher prevalence was also found in younger children from community samples (6). This finding may reflect the efforts made by schools to screen children who need special educational services at an early age. In other words, the age of children with disruptive disorders may constitute another factor that favours the selection of children for such services. Another unexpected result concerns the rates of disruptive behaviour disorders observed in girls, which were as high as those observed in boys. Despite this similarity, the ratio of boys to girls in our sample is 5:1, similar to ratios usually reported for elementary school children receiving services for behavioural difficulties (2). This finding clearly suggests that the same selection criteria are applied in schools to select girls and boys for eligibility for special educational services—the manifestation of disruptive behaviours, in particular, determines eligibility for such services. However, the difficulties demonstrated by the girls in our sample also appeared more complex, owing to a higher rate of internalized disorders among girls than among boys. Researchers who have examined externalizing and internalizing disorders related to CD in boys and girls have repeatedly supported this finding (26). Our sample was recruited in school boards from 2 regions in Quebec. Findings should be replicated with other samples from other regions before they can be generalized. Despite this limitation, the results suggest that students receiving special educational services for behavioural difficulties are not a homogeneous group. Though a large part of the special services provided in elementary schools should be directed toward curbing disruptive behaviours, our findings also underscore the need to take into account the specificity of the disorders presented by students. Moreover, the results suggest that greater attention must be paid to internalized disorders in children and that intensive programs must be put forth for younger children. Generally, our findings raise questions about the capacity of elementary schools to independently assume the burden of educating children with severe and multiple disruptive behaviours. This may underscore the need to develop more collaboration between the mental health and education sectors in the rehabilitation of these children. In our view, the systematic collection of data on children and families should provide the basis for organizing multilevel services and agencies that may be required for these students. Future studies will need to document the stability of these disorders across the child’s development and to describe the educational, social, and medical services received. Research efforts will have to examine continuity of services and factors associated with remission. Funding and SupportThis work was supported by the Social Sciences and Humanities Research Council of Canada (grant nr 410-201-1353), the Conseil québécois pour la recherche sociale (grant nr RS-3338 ), and a team grant from the University of Sherbrooke. AcknowledgementThe authors thank Dr Jacques Joly for his help with data preparation and analysis. References1. Ministry of Education. Adapting our schools to the needs of all students: policy on special education. Quebec: MEQ; 1999. 2. Conseil Supérieur de l’Éducation. Les élèves en difficulté de comportement à l’école primaire: comprendre, prévenir, intervenir. Québec:CSE; 2001. 3. Ministry of Education. Élèves handicapés ou élèves en difficulté d’adaptation ou d’apprentissage (EHDAA) : Définitions. Québec: MEQ; 2000. 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington (DC): American Psychiatric Association; 1994. 5. Fortin L, Strayer FF. Caractéristiques de l’élève en troubles du comportement et contraintes sociales du contexte. Revue des Sciences de l’Éducation 2000;26:3–16. 6. Breton JJ, Bergeron L, Valla JP, Berthiaume C, Gaudet N, Lambert J, and others. Quebec Child Mental Health Survey: prevalence of DSM-III-R mental health disorders. J Child Psychol Psychiatry 1999;40:375–84. 7. Lahey BB, Schwab-Stone M, Goodman SH, Waldman ID, Canino G, Rathouz PJ, and others. Age and sex differences in oppositional behavior and conduct problems: a cross-sectional household study of middle childhood and adolescence. J Abnorm Psychol 2000;109:488–503. 8. Offord DR, Boyle MH, Szatmari P, Rae-Grant N, Links PS, Cadman DT, and others. Ontario Child Health Study: II. Six-month prevalence of disorders and rates of service utilization. Arch Gen Psychiatry 1987;44:832–6. 9. Stranger C, Achenbach TM, Verhulst FC. Accelerated longitudinal comparisons of aggressive versus delinquent syndromes. Dev Psychopathol 1997;55:17–29. 10. Loeber R, Farrington DP, Stouthamer-Loeber M, van Kammen W. Antisocial behavior and mental health problems: explanatory factors in childhood and adolescence. Hillsdale (NJ): Erlbaum; 1998. 11. Goodman SH, Lahey BB, Fielding, B, Dulcan, M, Narrow W, Regier D. Representativeness of clinical samples of youths with mental disorders: a preliminary population-based study. J Abnorm Psychol 1997;106:3–14. 12. Achenbach TM, McConaughy SH, Howell, CT. Child/adolescent behavioral and emotional problems: implications of cross-informant correlations for situational specificity. Psychol Bull 1987;101:213–32. 13. Bird H, Gould M, Staghezza B. Aggregating data from multiple informants in child psychiatry epidemiological research. J Am Acad Child Adolesc Psychiatry 1992;31;78–85. 14. Jensen P, Rubio-Stipec M, Canino G, Bird H, Dulcan M, Schwab-Stone M.E, and others. Parent and child contributions to diagnosis of mental disorder: are both informants always necessary? J Am Acad Child Adolesc Psychiatry 1999;38:1569–79. 15. Mitsis EM, McKay KE, Schulz KP, Newcorn JH, Halperin, JM. Parent-teacher concordance for DSM-IV attention-deficit/hyperactivity disorder in a clinic-referred sample. J Am Acad Child Adolesc Psychiatry 2000;39:308–13. 16. Verhulst FC, Van der Ende J. Assessment of child psychopathology: relationship between different methods, different informants and clinical judgment of severity. Acta Psychiatr Scand 1991;84:155–9. 17. Capaldi D, Patterson GR. An approach to the problem of recruitment and retention rates for longitudinal research. Behavioral Assessment 1987;9:169–78. 18. Shaffer D, Schwab-Stone M, Fisher P, Cohen P, Piacentini J, Davies M, and others. The diagnostic interview schedule for children-revised version (DISC-R): I. Preparation, field testing, interrater reliability, and acceptability. J Am Acad Child Adolesc Psychiatry 1993;32:643–50. 19. Breton JJ, Bergeron L, Valla JP, Berthiaume C, St-Georges M. The Diagnostic Interview Schedule for Children (DISC 2.25) in Quebec. Reliability findings in the light of the MECA study. J Am Acad Child Adolesc Psychiatry 1998;37:1167–74. 20. Valla JP, Bergeron L, St-Georges M, Berthiaume C. Le Dominique Interactif: présentation, cadre conceptuel, propriétés psychométriques, limites et utilisations. Revue Canadienne de Psycho-Éducation 2000;29:327–47. 21. Valla JP, Kovess V, Chee CC, Berthiaume C, Vantalon V, Piquet C, and others. A French study of the Dominic Interactive. Soc Psychiatry Psychiatr Epidemiol 2002;37:441–8. 22. Kershaw P, Sonuga-Barke E. Emotional and behavioural difficulties: is this a useful category? The implications of clustering and co-morbidity–the relevance of a taxonomic approach. Educational and Child Psychology 1998;15:45–55. 23. Place M, Wilson J, Martin E, Hulsmeier L. The frequency of emotional and behavioural disturbance in an EBD school. Child Psychol Psychiatry Rev 2000;5:76–80. 24. Hinshaw SP, Lahey BB, Hart EL. Issues of taxonomy and comorbidity in the development of conduct disorder. Dev Psychopathol 1993;5:31–49. 25. Toupin J, Déry M, Pauzé R, Mercier H, Fortin L. Social and cognitive contributions to conduct disorder in children. J Child Psychol Psychiatry 2000;41:333–44. 26. Robins LN. The consequence of conduct disorder in girls. In: Olweus D, Block J, Radle-Yarrow M, editors. Development of antisocial and prosocial behaviour. Harcourt Brace Jovanovich; 1986 p 385–414. Author(s)Manuscript received July 2003, revised, and accepted August 2004. 1. Professor of Developmental Psychology, Research Centre on Childhood’s Behavior Disorders, Department of Psychoeducation, University of Sherbrooke, Sherbrooke, Quebec. 2. Professor of Child and Adolescent Psychopathology, Director of the Research Centre on Childhood’s Behavior Disorders, Department of Psychoeducation, University of Sherbrooke, Sherbrooke, Quebec. 3. Child and Family Therapist, Professor of Psychotherapy, Research Centre on Childhood’s Behavior Disorders, Department of Psychoeducation, University of Sherbrooke, Sherbrooke, Quebec. Address for correspondence: Dr M Déry, Department of Psychoeducation, University of Sherbrooke, 2500 Boulevard de l’Université, Sherbrooke, QC J1K 2R1 e-mail: Michele.Dery@USherbrooke.ca
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