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Original Research
Frequency of Mental Health Disorders
in a Sample of Elementary School Students Receiving
Special Educational Services For Behavioural Difficulties

Michèle Déry, PhD1, Jean Toupin, PhD2, Robert Pauzé, PhD3, Pierrette Verlaan1
Objective: Despite being essential for defining and planning special
educational services, very few data are available in Quebec regarding
the nature and extent of behavioural difficulties presented by
children who receive special educational services at school. This
study provides a picture of the frequency of disruptive behaviour
disorders (that is, attention-deficit hyperactivity disorder [ADHD],
oppositional defiant disorder [ODD], and conduct disorder [CD]) and
internalized disorders (including generalized anxiety disorder [GAD]
and major depressive episode [MDE]) in a sample of elementary
school students receiving special educational services for behavioural
difficulties (n = 324).

Method: In this descriptive study, we established the presence of

mental health disorders according to teacher-, parent-, and child-
reported data that were obtained using structured diagnostic
interviews based on DSM-IV criteria. We also examined prevalence
rates by sex and age group.

Results: Three-quarters of the students met the criteria for ADHD,

one-half for ODD, and one-third for CD. About 14% of the students
presented with a GAD or met the criteria for an MDE in the past year.
Only 2% of the students presented with an internalized disorder
without a comorbid disruptive behaviour disorder.

Conclusions: Our results suggest that among students receiving

special educational services for behavioural difficulties, a large
proportion may have difficulties severe enough to meet the criteria
for at least one DSM-IV disruptive behaviour disorder. Such findings
may underscore the need to develop more collaboration between the
mental health and education sectors in rehabilitating these children.

(Can J Psychiatry 2004;49:769–775)

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 Clinical Implications

 The high prevalence rates of disruptive behaviour

disorders illustrate the extent to which students
receiving special educational services for
behavioural difficulties may comprise a severely
impaired group.
 Results suggest that these students may not
constitute a homogeneous group. This underscores
the need to consider the specificity of the disorders
presented by students, particularly with respect to
attention-deficit hyperactivity disorder.

 From our sample, internalized disorders seem to

rarely be considered by special educational
services in elementary schools, particularly if they
are not accompanied by a disruptive behaviour
disorder. This raises questions about special
educational services’ detection and rehabilitation of
children with internalized disorders.

Limitations

 Although our sample is distributed by grade, sex,

type of class, and school board, it may not fully
represent special educational students, since
ethical constraints prevented access to data on
special educational students who did not
participate in the study.
 We recruited the sample from school boards in 2
regions of Quebec. Findings should be generalized
cautiously to other school boards.

 We collected the data in the last term of the school

year. The rates reported here may underestimate
the frequency of disorders, because the
participants received special educational services
for their behavioural difficulties during the school
year.

Key Words: special educational services, elementary school

students, attention-deficit hyperactivity disorder, oppositional defiant
disorder, conduct disorder

Résumé : Fréquence des problèmes de santé mentale dans un

échantillon d’élèves de l’école primaire recevant des services
d’éducation spécialisée pour des difficultés de comportement
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.

Method

Participants and Procedure

The transversal data used to estimate the frequency of disorders were drawn from the first year of
an ongoing longitudinal study on the persistence of behavioural difficulties. The students who
participated in this study attended public elementary schools from 3 school boards in 2
administrative regions of Quebec (that is, the Eastern Townships and Montérégie). Teachers had to
be in contact with the students for at least the past 6 months to be eligible as informants; thus the
data were collected in the last term of the school year. Eligible participants included children in
Grade 1 through Grade 6 who were on the list of students receiving special educational services at
school for behavioural difficulties; who did not have a physical, sensorial, or intellectual deficiency;
and who lived with at least one parent (n = 710).
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 French translation of the Diagnostic Interview Schedule for Children (DISC, 18),
developed and validated for the Quebec Child Mental Health Survey (6,19) with parents and
teachers as informants on children’s disruptive behaviour disorders. We also used 2 sections on
internalized disorders (that is, GAD and MDE) with parents. As this instrument was based on DSM-
III-R criteria, we added certain questions not included in the earlier version of the manual to probe
for DSM-IV symptoms. No additions were necessary in the section concerning MDE because the
DSM-III-R and DSM-IV criteria for this disorder coincide. Kappa values calculated for the disorders
identified with both the DSM-III-R–based DISC and the DSM-IV–based DISC were good or very
good. When teachers were the informants, the kappa values calculated were 0.67 for ADHD, 0.87
for ODD, and 0.90 for CD. Those calculated when parents were the informants were 0.73 for ADHD,
0.88 for ODD, and 0.65 for CD. As per the DSM-IV criteria, CD symptoms were assessed over a
period of 12 months with parents and over a period of only 6 months with teachers, a practice that
is consistent with the DSM-III-R criteria. This may explain the higher kappa values for CD reported
by teachers. The kappa value calculated for GAD (from the parent informant) was 0.74; this
calculation excluded the section on autonomic hyperactivity that appeared only in the DSM-III-R
version of the DISC.
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
We divided the students into 3 age groups (6 to 8 years, 9 to 10 years, and 11 to 13 years),
corresponding approximately to the 3 academic cycles of the elementary school curriculum in
Quebec. The first cycle includes the first and second grade, the second cycle includes the third and
fourth grade, and the third cycle includes the fifth and sixth grade. Boys and girls were similarly
distributed in each group (2 = 1.26, df 2, ns). Although there were no significant differences
between the characteristics of the final sample and those of the original sample, we weighted the
data regarding academic cycle, sex, and school board to eliminate any potential bias attributable to
these variables. We computed and adjusted a design effect of 1.02 through a weighting procedure
before running statistical analyses and calculating the 95%CI (assessed by the normal
approximation) for prevalence rates. We considered informant reports both separately and jointly.
When we used reports jointly, a disorder was said to be present when the diagnosis could be
formulated on the basis of data provided by either informant. ODD diagnoses were made whether or
not CD criteria were met. These 2 disorders were combined for the comorbidity analyses. We used
McNemar’s test to compare the rates of disorders obtained on the basis of the informants’ reports.
Comparisons by sex and age group were carried out with the chi-square statistic. Given that a
binomial distribution (that is, presence vs absence of disorders) tends toward a normal distribution,
we used 2 x 3 analyses of variance (that is, sex by age group) to estimate interactions between
variables.

Results

Frequency of Disruptive Behaviour Disorders

For each informant category, the most prevalent disruptive behaviour disorder identified in the
sample was ADHD, followed by ODD and CD (Table 1). Teacher reports yielded higher rates of
ADHD (McNemar’s test P < 0.001) and of CD (McNemar’s test P < 0.05) than did parent reports.
When teacher and parent reports were considered jointly, three-quarters (74.3%) of students
received a diagnosis of ADHD, one-half (52.5%) received a diagnosis of ODD, and one-third
(34.8%) received a diagnosis of CD.

Table 1 Rates of disruptive behaviour disorders across sex and age groups according to parents and (or)
teachers (n = 306; n = 300a)
Disorder, Sex Age group in years 95%CI Disorder  age group Disorder  sex
informant

6–8 9–10 11–13 All 2 value (df 2) 2 value (df 1)

(n = 77) (n = 122) (n = 306) (n = 316)

ADHD

Parent Boys 51.6 52.3 33.7 44.9

Girls 50.0 35.7 26.9 33.9 9.92**

All 51.3 50.0 31.7 42.9 37.2 to 48.5 6–8; 9–10 > 11–13 2.24

Teacher Boys 62.9 52.8 57.9 57.6

Girls 80.0 50.0 42.3 54.5

All 66.2 52.4 54.5 57.0 51.3 to 62.6 3.85 0.17

Either Boys 80.6 73.0 72.6 75.0

Girls 86.7 71.4 61.5 71.4

All 81.8 72.8 70.2 74.3 69.3 to 79.2 3.16 0.31

ODD

Parent Boys 27.9 44.3 34.7 36.5

Girls 53.3 42.9 26.9 39.3

All 32.9 44.1 33.1 36.9 31.4 to 42.4 3.40 0.15

Teacher Boys 40.3 37.5 29.8 35.1

Girls 40.0 21.4 26.9 29.1

All 40.3 35.3 29.2 34.0 28.6 to 39.4 2.66 0.72

Either Boys 48.4 62.5 45.7 52.2

Girls 73.3 57.1 42.3 53.6 6.13*

All 53.2 61.8 45.0 52.5 46.8 to 58.21 9–10 > 11–13 0.03

CD
 Parent Boys 12.9 17.0 13.7 14.7

Girls 33.3 7.1 30.8 25.0

All 36.4 15.7 17.4 16.6 12.3 to 21.9 0.14 3.50

Teacher Boys 37.1 13.6 23.4 23.7

Girls 31.3 13.3 26.9 25.0 12.64**

All 35.9 13.6 24.2 23.8 19.0 to 28.7 6–8 > 9–10; 11–13 0.04

Either Boys 42.6 28.4 32.6 33.6

Girls 53.3 14.3 46.2 40.0 6.11*

All 44.7 26.5 35.5 34.8 29.5 to 40.4 6–8 > 9–10 0.81

a
n corrected for design effect
* P < 0.05 ** P < 0.01
ADHD = attention-deficit hyperactivity disorder; CD = conduct disorder; ODD = oppositional defiant disorder
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
The comorbidity of ADHD and ODD or CD was considered according to either informant. Not
surprisingly, one-half the sample (50.7%) presented with this particular constellation of disorders,
while 23.6% presented with ADHD only, and 8.7% presented with ODD or CD only. (These rates are
not shown in the table.) Merely 17.1% of the students did not qualify for a diagnosis of disruptive
behaviour disorder. This distribution did not vary significantly across sex ( 2 = 1.13, df 3, ns) or age
group (2 = 8.85, df 6, ns). The age by sex interaction also proved nonsignificant.
Frequency of Internalized Disorders
Parent and child reports yielded similar prevalence rates for GAD (Table 2), but child reports yielded
higher rates of MDE than did parent reports (McNemar’s test P < 0.005). When parent and child
reports were considered jointly, the prevalence of GAD was 13.8% and that of MDE was 8%. Girls
obtained higher rates of GAD than did boys, according to either informant. Girls also obtained a
higher prevalence rate for MDE, according to parent reports. There was no significant age group
effect or sex by age group interaction.

Table 2 Rates of internalized disorders across sex and age group according to parents and (or) children
(n = 316; n = 310a)

Disorder, Sex Age group in years 95%CI Disorder  age group Disorder  sex
informant

6–8 9–10 11–13 All 2 value (df 2) 2 value (df 1)

(n = 80) (n = 107) (n = 129) (n = 316)

GAD
 Parent Boys 3.1 5.6 7.0 5.5

Girls 13.3 7.1 14.3 12.3

All 5.1 5.8 8.6 6.7 3.9 to 9.5 1.18 3.35

Child Boys 9.2 4.5 7.1 6.3

Girls 13.3 7.1 17.2 13.8

All 10.0 4.9 9.4 7.8 4.8 to 9.9 2.14 3.66

Either Boys 12.3 10.1 14.0 11.9

Girls 20.0 13.3 27.6 22.4

All 13.8 10.6 17.1 13.8 9.9 to 17.6 2.18 4.37*

MDE

Parent Boys 1.5 0 2.0 1.2

Girls 0 7.1 10.3 6.9

All 1.3 1.0 3.9 2.1 0.5 to 3.7 1.68 6.99**

Child Boys 7.8 4.5 6.0 5.9

Girls 6.7 0 17.2 10.3

All 7.6 3.9 8.5 6.7 3.9 to 9.4 2.08 1.46

Either Boys 9.4 4.5 7.1 6.7

Girls 6.7 7.1 17.2 12.3

All 8.9 4.9 9.4 8.0 4.9 to 10.9 1.76 1.99

a
n corrected for design effect;
* P < 0.05; ** P < 0.01
GAD = generalized anxiety disorder; MDE = major depressive episode
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.

Discussion

The 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 Support

This 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.

Acknowledgement

The authors thank Dr Jacques Joly for his help with data preparation and analysis.

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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