Externalizing disorders

Externalizing disorders are mental disorders characterized by externalizing behaviors, maladaptive behaviors directed toward an individual’s environment such as various acting out, disruptive, delinquent, hyperactive, and aggressive behaviors, which cause impairment or interference in life functioning ¹. Other terms used to describe externalizing behavior problems include “conduct problems,” “antisocial,” and “undercontrolled” (Hinshaw) ². Children with externalizing behavior disorders sometimes argue, are aggressive, or act angry or defiant around adults. A externalizing behavior disorder may be diagnosed when these disruptive behaviors are uncommon for the child’s age at the time, persist over time, or are severe.

Within the externalizing disorders, there are two major categories of behavior problems: (1) Problems of inattention, impulsivity, and hyperactivity associated with a diagnosis of attention-deficit hyperactivity disorder (ADHD); and (2) conduct problems and aggressive behavior associated with a diagnosis of oppositional defiant disorder (ODD) or conduct disorder. These two domains of externalizing disorders can be separated in factor analyses and exhibit different correlates. For example, ADHD is specifically linked with poor academic achievement, problems in executive functioning, and parental inattention and impulsivity, whereas conduct problems are specifically associated with socioeconomic disadvantage, dysfunctional family backgrounds, and parental criminality and antisocial behavior.

Externalizing disorders, however, are also manifested in adulthood. For example, alcohol- and substance-related disorders and antisocial personality disorder are adult externalizing disorders ³. Externalizing psychopathology is associated with antisocial behavior, which is different from and often confused for asociality.

Externalizing disorders are one of the most prevalent childhood behavior disorders and among the most common mental health disorders in the juvenile delinquency population. Childhood externalizing behavior is a major risk factor for later juvenile delinquency, adult crime, and violence ⁴. Childhood externalizing behavior and juvenile delinquency are being increasingly viewed as a public health problem ⁵.

Internalizing disorders are those mental health disorders in which the symptoms are primarily internal (keep inside) to the individual in ways such as social withdrawal, anxiety, negative thinking and beliefs and/or feelings of sadness and depression, problems that more centrally affect the child’s internal psychological environment rather than the external world. Other terms for this cluster of behavior problems include “neurotic” and “overcontrolled” ⁶. Inevitably, this dichotomy is neither perfect nor complete. For example, a child’s internalizing behavior problems can have a negative impact on others, including siblings, parents, peers, and teachers. Similarly, children with externalizing behavior problems not only may negatively affect their outside world, but also may be psychologically suffering internally. In fact, there is significant and substantial co-morbidity between externalizing and internalizing behavior problems ². In other words, children who are aggressive also may experience anxiety and, conversely, depressed children also may exhibit conduct problems ⁷.

The first step to treatment for disruptive behavior disorders is to talk with a healthcare provider. A comprehensive evaluation by a mental health professional may be needed to get the right diagnosis. Some of the signs of behavior problems, such as not following rules in school, could be related to learning problems which may need additional intervention. For younger children, the treatment with the strongest evidence is behavior therapy training for parents, where a therapist helps the parent learn effective ways to strengthen the parent-child relationship and respond to the child’s behavior. For school-age children and teens, an often-used effective treatment is a combination of training and therapy that includes the child, the family, and the school.

Externalizing behavior disorders

Oppositional Defiant Disorder

All children are oppositional from time to time, particularly when tired, hungry, stressed, or upset. They may argue, talk back, disobey, and defy parents, teachers, and other adults. Oppositional behavior is a normal part of development for two to three year olds and early adolescents. However, openly uncooperative and hostile behavior becomes a serious concern when it is so frequent and consistent that it stands out when compared with other children of the same age and developmental level and when it affects the child’s social, family, and academic life.

In children with Oppositional Defiant Disorder (ODD), there is an ongoing pattern of uncooperative, defiant, and hostile behavior toward authority figures that seriously interferes with the child’s day to day functioning. For example, when children act out persistently so that it causes serious problems at home, in school, or with peers, they may be diagnosed with oppositional defiant disorder (ODD). Oppositional defiant disorder usually starts before 8 years of age, but no later than by about 12 years of age. Children with oppositional defiant disorder are more likely to act oppositional or defiant around people they know well, such as family members, a regular care provider, or a teacher. Children with oppositional defiant disorder show these behaviors more often than other children their age.

Examples of oppositional defiant disorder behaviors include:

• Often being angry or losing one’s temper
• Often arguing with adults or refusing to comply with adults’ rules or requests
• Often resentful or spiteful
• Deliberately annoying others or becoming annoyed with others
• Often blaming other people for one’s own mistakes or misbehavior

Symptoms of oppositional defiant disorder may include:

• Frequent temper tantrums
• Excessive arguing with adults
• Often questioning rules
• Active defiance and refusal to comply with adult requests and rules
• Deliberate attempts to annoy or upset people
• Blaming others for his or her mistakes or misbehavior
• Often being touchy or easily annoyed by others
• Frequent anger and resentment
• Mean and hateful talking when upset
• Spiteful attitude and revenge seeking

The symptoms are usually seen in multiple settings but may be more noticeable at home or at school. One to sixteen percent of all school-age children and adolescents have oppositional defiant disorder. The causes of oppositional defiant disorder are unknown, but many parents report that their child with oppositional defiant disorder was more rigid and demanding than the child’s siblings from an early age. Biological, psychological, and social factors may have a role.

A child presenting with oppositional defiant disorder symptoms should have a comprehensive evaluation. It is important to look for other disorders which may be present, such as attention-deficit hyperactivity disorder (ADHD), learning disabilities, mood disorders (depression, bipolar disorder), and anxiety disorders. It may be difficult to improve the symptoms of oppositional defiant disorder without treating the coexisting disorder. Some children with oppositional defiant disorder may go on to develop conduct disorder.

Oppositional defiant disorder treatment

Treatment of oppositional defiant disorder may include:

• Parent Management Training to help parents and others manage the child’s behavior
• Individual Psychotherapy to develop more effective anger management
• Family Psychotherapy to improve communication and mutual understanding
• Cognitive Problem-Solving Skills Training and Therapies to decrease negativity
• Social Skills Training to increase flexibility and improve social skills and frustration tolerance with peers

Medications may be helpful in controlling some of the more distressing symptoms of oppositional defiant disorder as well as the symptoms related to coexistent conditions such as ADHD, anxiety, and mood disorders.

A child with oppositional defiant disorder can be very difficult for parents. These parents need support and understanding. Parents can help their child with oppositional defiant disorder in the following ways:

• Always build on the positives, give the child praise and positive reinforcement when s/he shows flexibility or cooperation.
• Take a time-out or break if you are about to make the conflict with your child worse, not better. This is good modeling for your child. Support your child if s/he decides to take a time-out to prevent overreacting.
• Pick your battles. Since the child with oppositional defiant disorder has trouble avoiding power struggles, prioritize the things you want your child to do. If you give your child a time-out in his room for misbehavior, don’t add time for arguing. Say “your time will start when you go to your room.”
• Set reasonable, age appropriate limits with consequences that can be enforced consistently.
• Maintain interests other than your child with oppositional defiant disorder, so that managing your child doesn’t take all your time and energy. Try to work with and obtain support from the other adults (teachers, coaches, and spouse) dealing with your child.
• Manage your own stress with healthy life choices such as exercise and relaxation. Use respite care and other breaks as needed.

Many children with oppositional defiant disorder will respond to the positive parenting techniques. Parents may ask their pediatrician or family physician to refer them to a child and adolescent psychiatrist or other qualified mental health professional who can help diagnose and treat oppositional defiant disorder and any coexisting psychiatric condition.

Conduct Disorder

“Conduct disorder” refers to a group of repetitive and persistent behavioral and emotional problems in youngsters. Children and adolescents with conduct disorder have great difficulty following rules, respecting the rights of others, showing empathy, and behaving in a socially acceptable way. Conduct disorder is diagnosed when children show an ongoing pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These rule violations may involve breaking the law and result in arrest. Children with conduct disorder are more likely to get injured and may have difficulties getting along with peers.

Examples of conduct disorder behaviors include:

• Breaking serious rules, such as running away, staying out at night when told not to, or skipping school
• Being aggressive in a way that causes harm, such as bullying, fighting, or being cruel to animals
• Lying, stealing, or damaging other people’s property on purpose

Children and adolescents with conduct disorder are often viewed by other children, adults and social agencies as “bad” or delinquent, rather than mentally ill. Many factors may lead to a child developing conduct disorder, including brain damage, child abuse or neglect, genetic vulnerability, school failure, and traumatic life experiences.

Children or adolescents with conduct disorder may exhibit some of the following behaviors:

• Aggression to people and animals
  • bullies, threatens or intimidates others
  • delights in being cruel and mean to others
  • starts physical fights
  • has used a weapon that could cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife or gun)
  • is physically cruel to people or animals
  • steals from a victim while hurting them
  • forces someone into sexual activity
  • shows no genuine remorse after an aggressive episode
• Destruction of property
  • deliberately engaged in fire setting with the intention to cause damage
  • deliberately destroys other’s property
• Deceitfulness, lying, or stealing
  • has broken into someone else’s building, house, or car
  • lies to obtain goods, or favors or to avoid obligations
  • steals items without confronting a victim (e.g. shoplifting, but without breaking and entering)
• Serious violations of rules
  • often stays out at night despite parental objections
  • runs away from home
  • often stays away from

Children who exhibit these behaviors should receive a comprehensive evaluation by an experience mental health professional. Many children with a conduct disorder may have coexisting conditions such as mood disorders, anxiety, post-traumatic stress disorder (PTSD), substance abuse, ADHD, learning problems, or thought disorders which can also be treated. Research shows that youngsters with conduct disorder are likely to have ongoing problems if they and their families do not receive early and comprehensive treatment. Without treatment, many youngsters with conduct disorder are unable to adapt to the demands of adulthood and continue to have problems with relationships and holding a job.

Conduct disorder treatment

Treatment of children with conduct disorder can be complex and challenging. Treatment can be provided in a variety of different settings depending on the severity of the behaviors. Adding to the challenge of treatment are the child’s uncooperative attitude, fear and distrust of adults. In developing a comprehensive treatment plan, a child and adolescent psychiatrist may use information from the child, family, teachers, community (including the legal system) and other medical specialties to understand the causes of the disorder.

Behavior therapy and psychotherapy are usually necessary to help the child appropriately express and control anger. Special education may be needed for youngsters with learning disabilities. Parents often need expert help to develop and carry out special management and educational programs in the home and at school. Home-based treatment programs such as Multisystemic Therapy (MST) are effective for helping both the child and family.

Treatment may also include medication in some youngsters who may have difficulty paying attention, impulse problems, or depression.

Treatment is rarely brief since establishing new attitudes and behavior patterns takes time. However, early treatment offers a child a better chance for considerable improvement and hope for a more successful future.

Attention-Deficit Hyperactivity Disorder (ADHD)

Attention-Deficit Hyperactivity Disorder (ADHD) is one of the most common neurodevelopmental disorders of childhood. It is usually first diagnosed in childhood and often lasts into adulthood. Children with ADHD may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result will be), or be overly active.

Any child may show inattention, distractibility, impulsivity, or hyperactivity at times, but the child with ADHD shows these symptoms and behaviors more frequently and severely than other children of the same age or developmental level. ADHD occurs in 3-5% of school age children. ADHD typically begin in childhood but can continue into adulthood. ADHD runs in families with about 25% of biological parents also having this medical condition.

There are three different types of ADHD, depending on which types of symptoms are strongest in the individual:

1. Predominantly Inattentive presentation also sometimes called Attention Deficit Disorder (ADD): It is hard for the individual to organize or finish a task, to pay attention to details, or to follow instructions or conversations. The person is easily distracted or forgets details of daily routines.
2. Predominantly Hyperactive-Impulsive presentation: The person fidgets and talks a lot. It is hard to sit still for long (e.g., for a meal or while doing homework). Smaller children may run, jump or climb constantly. The individual feels restless and has trouble with impulsivity. Someone who is impulsive may interrupt others a lot, grab things from people, or speak at inappropriate times. It is hard for the person to wait their turn or listen to directions. A person with impulsiveness may have more accidents and injuries than others.
3. Combined presentation: Symptoms of the above two types are equally present in the person.

Because symptoms can change over time, the presentation may change over time as well.

Signs and symptoms of ADHD

It is normal for children to have trouble focusing and behaving at one time or another. However, children with ADHD do not just grow out of these behaviors. The symptoms continue, can be severe, and can cause difficulty at school, at home, or with friends.

A child with ADHD often shows some of the following:

• trouble paying attention
• daydream a lot
• forget or lose things a lot
• squirm or fidget
• talk too much
• inattention to details and makes careless mistakes or take unnecessary risks
• easily distracted
• have a hard time resisting temptation
• have trouble taking turns
• have difficulty getting along with others
• loses school supplies, forgets to turn in homework
• trouble finishing class work and homework
• trouble listening
• trouble following multiple adult commands
• blurts out answers
• impatience
• fidgets or squirms
• leaves seat and runs about or climbs excessively
• seems “on the go”
• talks too much and has difficulty playing quietly
• interrupts or intrudes on others

A child presenting with ADHD symptoms should have a comprehensive evaluation. Parents should ask their pediatrician or family physician to refer them to a child and adolescent psychiatrist, who can diagnose and treat this medical condition. A child with ADHD may also have other psychiatric disorders such as conduct disorder, anxiety disorder, depressive disorder, or bipolar disorder. These children may also have learning disabilities.

Without proper treatment, the child may fall behind in schoolwork, and friendships may suffer. The child experiences more failure than success and is criticized by teachers and family who do not recognize a health problem.

ADHD treatment

In most cases, ADHD is best treated with a combination of behavior therapy and medication. For preschool-aged children (4-5 years of age) with ADHD, the American Academy of Pediatrics recommends parent training in behavior management as the first line of treatment, before medication is tried. For children 6 years of age and older, the recommendations include medication and behavior therapy together — parent training in behavior management for children up to age 12 and other types of behavior therapy and training for adolescents. Schools can be part of the treatment as well. What works best can depend on the child and family. Good treatment plans will include close monitoring, follow-ups, and making changes, if needed, along the way.

Research clearly demonstrates that medication can help improve attention, focus, goal directed behavior, and organizational skills. Medications most likely to be helpful include the stimulants (various methylphenidate and amphetamine preparations) and the non-stimulant, atomoxetine. Other medications such as guanfacine, clonidine, and some antidepressants may also be helpful.

Other treatment approaches may include cognitive-behavioral therapy, social skills training, parent education, and modifications to the child’s education program. Behavioral therapy can help a child control aggression, modulate social behavior, and be more productive. Cognitive therapy can help a child build self-esteem, reduce negative thoughts, and improve problem-solving skills. Parents can learn management skills such as issuing instructions one-step at a time rather than issuing multiple requests at once. Education modifications can address ADHD symptoms along with any coexisting learning disabilities.

References

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