What does externalizing mean?

While anxiety and depression arise from internalizing problems, behavioural disorders are often the result of externalizing them. The term ‘behavioural problems’ refers to the general group of disruptive and antisocial behavioural problems. The terms behavioural disorder and disruptive behavioural disorder are used to refer to specific diagnostic groups. The term delinquency is mainly used in the legal system and refers to young people who exhibit antisocial behaviour or other behavioural problems. It refers to a minor who is caught performing an index crime (an act that is illegal for both adults and minors, such as theft) or a status crime (an act that is only illegal for minors, such as alcohol consumption).

Classification and description

Disruptive behaviour occurs at different moments in the development. Children of preschool age will beat, kick or bite other children. In the primary school period there is talk of bullying and various forms of aggression, which can definitely also be physical. In adolescence, young people display risky behaviour and / or use illegal drugs. The table below provides an overview of the types of behavioural problems that adults often describe as problematic and the DSM disorders associated with them.

The DSM category Disruptive Impulse control and Conduct disorders include, among other things, the diagnosis of ODD and CD, as well as, among others, kleptomania and antisocial personality disorder. The latter diagnosis applies to people who show a persistent pattern of aggressive and antisocial behaviour after the age of 18. This pattern must be present from the age of 15. In addition, there must have been a conduct disorder (CD) before the age of 15 .

What is Oppositional Defiant Disorder?

A certain degree of stubborn, disobedient and oppositional behaviour is part of normal development. Such behaviour is not always an indicator or predictor of clinical problems. To a certain extent, such behaviour is even conducive to the development of autonomy. Oppositional defiant disorder (ODD) is a behavioural disorder, in which there is an extreme pattern of an angry or irritated mood and negative, hostile and defiant behaviour. This pattern must be present for at least six months and at least four of the following symptoms must be displayed:

• Often loses patience
• Is easily annoyed
• Is angry easily and harbours resentment
• Often enters into discussion with adult or authority
• Often resists or refuses to obey adult requests or rules
• Irritates other people intentionally
• Blames others for their own mistakes or misconduct
• Is often envious and vengeful

The diagnostic criteria also state that behavioural problems significantly interfere with functioning.

When considering a diagnosis of ODD, it is important to distinguish between expected problem behaviour and problematic problem behaviour. A behaviour or emotional reaction must therefore occur more often than usual for a young person of the same age. In addition, the behaviour must interfere with the functioning of the child. There must therefore be a balance between over-diagnosing common problems of children and adolescents as disorders versus ignoring potentially serious problems that may be precursors of persistent antisocial behaviour.

What is Conduct Disorder?

The diagnosis conduct disorder (CD) is given when there is a more serious form of aggression and antisocial behaviour. The most important characteristic of CD is a repeated and persistent pattern of behaviour that violates the rights of others and important age-appropriate social norms. According to the DSM there can be;

• aggression towards people and animals,
• destruction of property,
• fraud and theft
• serious rule violations (for example, running away from home at night).

Different behaviours belong to each of these categories. To be diagnosed with CD, at least three of these behaviours must have been shown in the past year. At least one of these behaviours must have occurred in the past six months. The behaviour must also significantly interfere with social and academic functioning.

Depending on the onset of the behaviours, a distinction can be made between two subtypes: childhood onset and adolescent onset. Since only three of the different symptoms are required to be diagnosed with CD, children with CD form a heterogeneous group with different subtypes.

There are a number of issues related to the CD diagnosis. For example, it is unclear whether the diagnostic criteria are applicable to younger children. In addition, it is doubted whether the current criteria are applicable to girls, because they are largely based on sampling with men. The forms of aggression identified in the criteria are more characteristic of boys. Girls more often show relational aggression than physical aggression. In addition, research shows that girls with subclinical levels of CD symptoms do develop clinically significant problems.

Empirical approach

The empirical approach has found evidence for an externalizing syndrome.

Achenbach and Rescorla have tried to distinguish between two groups within this syndrome: aggressive behaviour (for example disobedience, fighting and destruction) and boundary crossing behaviour (for example lying, stealing and truancy). According to many studies, this distinction appears to be valid. In addition, there appear to be development differences between the two syndromes. The average score on the two syndromes decreases between the ages of 4 and 10. After the age of 10 the scores for the aggressive syndrome continue to decrease, while the scores for the rule-breaking syndrome increase. In addition, the aggressive syndrome is more stable than the boundary crossing syndrome. These findings suggest that it is important to distinguish between different types of externalizing behaviour.

Proponents of the empirical approach argue that there are also other ways to distinguish between different behavioural problems within the broad externalizing syndrome:

• Based on the age at which the problems arise: an early-onset category with both aggressive and boundary crossing behaviour and a later-onset or adolescent-onset category with only boundary crossing behaviour.
• Salient symptom approach: distinction based on the primary behavioural problem that is shown.

The salient symptom approach can be expanded even further by making a wider distinction between open (overt) antisocial behaviour (for example physical fighting) and covert (covert) antisocial behaviour (for example stealing). These two categories can be further subdivided on the basis of destructive and non-destructive behaviour. Then there are four categories:

• Openly destructive behaviour: for example fighting and bullying
• Openly non-destructive behaviour: for example, arguing and oppositional behaviour
• Covertly destructive behaviour: for example lying and stealing
• Covert non-destructive behaviour: status crimes, such as running away from home and drug use, in which non-destructive is used as in ‘non-destructive to others than the person themselves’.

Sex differences

There are gender differences in prevalence, developmental progress and influences that contribute to the development of behavioural problems. Behavioural problems manifest themselves differently in boys and girls. It is often thought that boys exhibit more aggressive behaviour than girls. If aggression is only defined in terms of overt physical or verbal behaviour, it does indeed seem that boys are more aggressive. However, research shows that girls are more often relational aggression show. Relational aggression is intended to hurt someone or to damage other people's friendships. Examples of relational aggression are excluding people from a group or event and spreading gossip. Relational aggression is therefore secretive antisocial behaviour. Such behaviour is exhibited from preschool age up to and including adolescence and is related to rejection by peers, depression, anxiety, loneliness and feelings of isolation.

Violence

Violence is defined as an extreme form of aggression that does a lot of harm to someone else. Examples of this can be the following: robbing or raping people. Aggression can be defined as actions that cause less serious damage. A significant number of young people are involved in violent behaviour. In addition, they are often the victims of violence. Young people exposed to violence (as victims or witnesses) have an increased risk of developing both externalizing and internalizing and somatic problems.

Bullying

Bullying is characterized by an imbalance in power between two (or more) people. The offender deliberately and repeatedly tries to cause fear and suffering to the victim. Bullying starts to occur in the preschool years and is common in the primary school and high school period. Genetic and environmental factors contribute to which children become perpetrators, victims or both perpetrators and victims.

Boys bully more than girls but are also bullied more often than girls. In addition, boys are more often exposed to direct bullying, while girls are often bullied indirectly, for example through gossip. The typical perpetrator is aggressive towards both peers and parents. They are impulsive and have a positive attitude towards violence. They feel a strong urge to dominate others and are not very empathetic. Bullying can be part of a more general antisocial behavioural disorder. Perpetrators therefore have an increased risk of further behavioural problems.

The typical victim is anxious, insecure, sensitive, careful, quiet and not aggressive. However, victims may over time grow into bullies and portray contrary behviour.

In addition, victims often have low self-esteem. Bullied boys are often physically less strong than their peers are on average. Victims often have no close friend in class. Research shows that victims of bullying often feel depressed and lonely and have an increased risk of suicidal behaviour. The negative consequences for the victims point to the importance of early intervention.

Epidemiology

It is difficult to make an accurate estimate of the prevalence of ODD and CD, because different studies use different definitions and different research methods. The prevalence estimates for ODD range from 1-15% and CD from 2-10%.

Boys are more often diagnosed with ODD and CD than girls. The ratio boys: girls is 3: 1 or 4: 1. However, as previously discussed, the prevalence of ODD and CD in girls can be underestimated because the diagnostic criteria emphasize more masculine forms of aggression, such as physical aggression. The prevalence of behavioural disorders is increasing for both boys and girls with age. Some suggest that the sex ratio in middle adolescence diminishes due to gender-specific risks in the puberty period. Some researchers state that the prevalence of ODD decreases with age, but it is not clear whether this is true.

Contextual factors, such as poverty and living in a criminal neighbourhood, increase the risk of a behavioural disorder. Behavioural disorders are more common in urban areas than in rural areas. The influence of ethnic and socio-economic factors on behavioural problems in children and adolescents is probably mediated by their influence on factors such as the ability of parents to educate effectively.

Comorbidity

The average age at which ODD occurs is 6 years and for CD 9 years. This suggests that ODD is a precursor to CD. However, ODD does not always result in CD. However, most young people with CD also meet the criteria of ODD.

ODD and CD co-occur regularly with ADHD. If this is the case, ADHD is often a precursor to ODD or CD. Some parents may not be able to cope with ADHD, which may play a role in the development, maintenance or worsening of ODD or CD. Parent-child relationships are just one example of the mechanisms by which ADHD increases the risk of ODD and CD.

Young people with behavioural disorders also often experience other problems, such as problems with drug use, rejection by peers, poor school performance, verbal deficits and executive deficits. Internalizing disorders, such as an anxiety disorder or depression, also occur above average in young people with behavioural disorders. The relationship between ODD or CD and depression may be explained by the fact that one disorder increases the risk of another disorder. Another possible explanation for the link is that there are shared genetic and environmental influences.

What is the developmental process?

Some, but not all, young people with behavioural disorders continue to display aggressive and antisocial behaviour over time. When behavioural disorders occur relatively early, this is associated with more serious and persistent antisocial behaviour. A distinction can be made between two development patterns:

• Behavioural disorder from childhood (child-onset): Moffitt also calls this pattern life-course persistent antisocial behaviour , because the behavioural problems are fairly stable. Young people with a child-onset pattern often show various problems from pre-school age, such as ADHD, neurobiological deficits and academic problems. These problems can be the starting point for a developmental pattern that is characterized by an early start and persistent disruptive and antisocial behaviour. For some, this pattern leads to an antisocial personality disorder and other negative outcomes. Despite the stability of the behavioural problems, behavioural problems can manifest themselves differently at different moments in the development. A child can particularly have tantrums at a young age, while the same child is involved in vandalism in high school.
• Behavioural disorder from adolescence (adolescent onset): this pattern is more common than the child-onset pattern. With this pattern, antisocial behaviour does not develop until adolescence. The antisocial behaviour usually decreases after adolescence, so Moffitt also calls this pattern adolescence-limited .

Loeber developed a model to show how antisocial behaviour can develop. This model has three paths, each with three levels. The less serious behaviours (lower levels) are precursors of the more serious behaviours (higher levels). Progress on a developmental path is characterized by increasing diversification of behaviour: children and adolescents who are advancing exhibit new types of antisocial behaviour and continue to exhibit their previous behaviour (so they are not replaced). The model consists of three paths:

The open path:

1. Some aggression, such as bullying others
2. Physically fighting
3. Violence

The secret path:

2. Small covert behaviours, such as shoplifting and lying
3. Damage to property, such as vandalism and arson
4. Moderate to severe delinquency, such as theft and fraud

The authority conflict path (before age 12):

3. Stubborn behaviour
4. Disobedience and rebellion
5. Avoidance of authorities, such as truancy and running away from home

Individuals can advance on one or more paths. However, not every individual goes to a higher level or treads on a path at all. Children enter the authority conflict path at a younger age than one of the other two paths.

Aetiology

The development of behavioural problems is the result of an interaction between various factors:

• Child factors: for example impulsive behaviour and hyperactivity
• Family factors: for example antisocial behaviour of parents, poor parenting practices, abuse or neglect by parents, low socio-economic status
• School factors: for example dealing with deviant peers or rejection by peers
• Living environment and social factors: for example poverty, the availability of weapons and the way violence is discussed in the media

Children can learn aggressive behaviour by being endorsed in it. They can also learn it by imitating aggressive models, such as parents who physically punish their child for errors. The way in which parents treat children also influences a child's behaviour. Parents of disobedient children generally demand a lot from their child and are very critical. It appears that children become more obedient when they are rewarded for appropriate behaviour and punished for disobedient behaviour. The problematic parenting characteristics of antisocial families is partly explained by the transfer of poor parenting practices from one generation to another. In addition, there is a link between stressors outside the family, such as financial problems, discrimination and parenting practices. Parental psychopathology is also associated with poor parenting practices.

Oregon Model

Patterson developed the Oregon Model: an intervention for families with aggressive and antisocial children. This intervention is based on a social interaction learning perspective and emphasizes the social context. Patterson developed coercion theory to explain how a problematic behaviour pattern arises. He argues that aggressive behaviour in a child does not stand alone, but that the child behaves in this way to control its family members. This process is called coercion . If parents have little good parenting techniques, coercive family interactions increase, and this leads to openly antisocial behaviour. Negative reinforcement and the reinforcement trap play an important role in the process of coercion. An example is that a child has a tantrum in the supermarket because he or she wants her mother to buy  chocolate. The mother is ashamed of this behaviour being displayed so publicly and given is by buying chocolate (positive confirmation of the child's behaviour). The consequence of this in the short term is that the tantrum of the child has ended (negative confirmation of mother's behaviour). In the long term, however, the consequences for the mother are negative: the behaviour of the child is positively confirmed, which increases the chance that the child will continue to show the behaviour in the future. In addition, the behaviour of mother has been negatively confirmed, which increases the chance that she will also give in to the child in the future. So mother ran into the negative reinforcement trap.

Patterson states that antisocial behaviour of the child is the result of, but also influences two parenting practices:

• Parental discipline: closely following and classifying problem behaviour, ignoring trivial coercive events and linking consequences to behaviour. Parents of children with behavioural problems more often regard behaviour as problematic, are not well able to ignore low levels of coercive behaviour and are unable to link behaviour to consequences.
• Parental control (monitoring): there is a positive relationship between the amount of time children spend without parental control and antisocial behaviour.

What can have an influence?

Marriage disputes

Divorces and conflicts between parents often occur in families of children with behavioural disorders. When a divorce is characterized by few conflicts and good cooperation between parents, this causes fewer problems for the children. If there is aggression between parents, the chance of disturbances is greater than would be expected based on the presence of only marital conflicts. The relationship between marital conflicts and behavioural disorders can be explained in different ways:

• Parents who argue a lot and are aggressive to each other serve as role models for their children.
• The stress that marriage conflicts entail can interfere with parenting practices, such as monitoring the child's behaviour.
• Hostility and anger can influence the development of emotion regulation of the child, which can contribute to behavioural problems.
• The relationship between marital conflicts and behavioural problems can be reversed or oppositional: the child's behavioural problems can contribute to marital conflicts.
• The relationship is explained by a third variable, such as an antisocial personality disorder of one of the parents.

Mistreatment

Early abuse, in particular physical abuse, is a risk factor for serious behavioural problems. The relationship between abuse and behavioural problems can be explained in different ways:

• The child learns a coercive interaction style in the family.
• Through physical abuse, the child learns problematic cognitive and social information processing patterns. He or she interprets unclear social cues as threatening, which means that he or she will react aggressively the next time.

However, not all abused children exhibit behavioural problems. The relationship can be influenced by various factors, such as individual differences (for example, in the functioning of the sympathetic and parasympathetic nervous system).

Relationships with peers

When children are exposed to aggressive peers from an early age, this increases the chance that they themselves will show aggressive and antisocial behaviour even at a young age. In addition, it increases the chance of later association with deviant peers, which can contribute to the maintenance and escalation of such behaviour.

Children with behavioural problems are often rejected by peers, which increases the risk of social, academic and psychological problems. Some aggressive children have friends who also exhibit aggressive and antisocial behaviour. Dealing with deviant peers plays a role in the development, maintenance and aggravation of antisocial behaviour.

Influences of peers are not independent of other contextual factors. Dealing with deviant peers is associated with various individual factors (for example genetic vulnerability), family factors (for example conflicts between parents), cultural factors and community factors (for example a poor living environment).

Cognitive-emotional influences

Social, cognitive and emotional processes are part of the development and maintenance of antisocial behaviour. Antisocial children, for example, have difficulty seeing things from someone else's perspective, have little problem-solving skills and are unable to control their own emotions and behaviour. According to Dodge, cognitive processing consists of several steps:

• Encoding (searching for and paying attention to) social and emotional cues
• Interpreting social and emotional cues
• Searching for possible responses to social and emotional cues
• Choosing a specific response
• Performing the selected responses

Children with behavioural disorders have poor social problem-solving skills and have cognitive deficits in various parts of this process. For example, they may mistakenly think that other people have hostile intentions. These children also think that aggression will lead to positive results.

Dodge distinguishes between two types of aggressive behaviour:

• Reactive aggression: an angry reaction to an observed provocation or frustration.
• Proactive aggression: is not associated with anger and is characterized by intentional, hostile behaviours such as bullying and fighting. These behaviours are aimed at achieving specific goals.

Both types of aggression are associated with different social-cognitive deficits. Reactive aggressive youngsters in particular show deficits in the early stages of the social-cognitive process, while proactive aggressive children mainly show deficits in the later stages of the process. The two types of aggression are also related to different outcomes.

What are the biological influences?

Genetic influences

Aggressive and antisocial behaviour is partly genetically determined. The heredity component is probably greater for problems that occur already in childhood than for problems that only arise in adolescence. It has also been suggested that delinquency in adolescence has a smaller genetic component than criminal behaviour in adulthood. This is explained by the fact that delinquency in adolescence often does not persist into adulthood, while criminal behaviour often originates in childhood. Genetic influences interact with environmental influences, such as family factors and social learning experiences.

Neurobiological influences

There is a connection between both the sympathetic and parasympathetic aspects of the autonomic nervous system and behavioural problems. There are differences between, for example, heart rate and cortisol levels between young people with and without behavioural problems.

Grey states that a distinction can be made between two brain systems, each with separate neuroanatomical and neurotransmitter systems:

• Behavioural Inhibition System (Behavioural Inhibition System; BIS): is related to emotions such as fear and tends to inhibit (inhibit) actions when situations are new or scary or behaviour can be punished.
• Behavioural approach system (BAS): is related to the search for rewards and pleasant emotions. The BAS tends to activate behaviour in the presence of confirmation.

A poor balance between BIS and BAS would result in a predisposition that, in combination with negative environmental conditions, causes behavioural problems. Quay states that an underactive BIS in combination with an overactive BAS can play a role in the development of persistent behavioural disorders.

Other scientists think that aggressive behaviour is the result of the combination of an underactive BIS and an underactive BAS. An underactive BAS leads to chronic under arousal. In that case, aggressive behaviour can be seen as a way to seek excitement or activation.

According to Grey, the fight or flight system can also be involved in behavioural disorders. This system mediates defensive reactions under circumstances of frustration, punishment or pain. Stimuli that are experienced as threatening, therefore activate the F or F system. Young people with behavioural problems have a lower threshold for activating this system (they activate it faster) than children without behavioural problems. In general, the BIS and BAS are considered as motivational systems, while the F or F system is considered as an emotion regulation system.

Structural and functional deficits of the brain are also associated with behavioural problems. The frontal lobes in particular can play a role through shortages in verbal and executive function, such as emotion regulation.

Drug use

A distinction is made between illegal drugs (such as cocaine) and legal drugs (such as alcohol) . Many young people experiment with drugs. The DSM distinguishes between two types of drug-related disorders: drug use disorder and drug-induced disorders. In drug use disorder , there are four symptom clusters namely: risky use, pharmacological criteria, poor control over use and limitation on normal social functioning.

For drug-induced disorders, we are talking about symptoms and syndromes caused by recent use of a specific drug.

The DSM criteria for adolescents are the same for both diagnoses as for adults. However, the question is to what extent these criteria are applicable to adolescents. Adolescents, for example, often show symptoms that just do not meet the diagnostic criteria. In addition, they are overestimated in the case of, for example, withdrawn behaviour after use.

Epidemiology

It is not clear how drug use relates to ethnicity, socio-economic status (SES) and gender, because studies often use different definitions and different research methods. Most studies show that men make more use of illegal drugs than women. With regard to SES, drug use appears to be more common among young people with both lower and higher SES than average.

Drug-related disorders are related to other problems, such as the use of multiple types of drugs, academic problems, family problems, anxiety disorders and mood disorders. In addition, many young people who misuse drugs meet the diagnostic criteria for ODD and CD.

Aetiology

There are various factors involved in the origin and maintenance of drug use:

1. Individual factors: for example genes, neurobiological characteristics, temperament, self-regulation, problem-solving skills and cognitive-affective components (attitudes, expectations, intentions and ideas about control).
2. Family factors: attachment, family conflicts, parenting practices, modelling.
3. Peer factors: perceived drug use by peers, observed approval by peers.
4. School factors: school performance, involvement in school activities.
5. Factors in the living environment: poverty.
6. Greater socio-cultural factors: availability of drugs, social norms regarding drug use.

There are various models that explain how risk and protective factors contribute to the development of drug use. Social learning theory emphasizes processes such as imitation, expectation and consequences. Another model views adolescence as a period of increasing freedom and exploration, in which adolescents want to behave in a way that is appropriate for adults, but not for adolescents. An example of this is alcohol consumption.

Other scientists argue that drug use should be viewed in relation to stress. Young people who experience many negative events (and have few skills to deal with them) have an increased risk of drug use. Drug use is then considered a coping strategy for dealing with negative emotions and stress. However, this doesn’t take the use of ‘party-drugs’ into account.

The gateway theory states that the use of legal drugs, such as alcohol, precedes the use of illegal drugs. The use of one drug therefore increases the chance of using the other drug. However, not all young people are going to use other drugs. It is true thought that the younger a person starts with one drug, the bigger the chance that he or she will start using another drug.

Genetic factors can also influence drug use, this is more the case with clinical use than with use typical of adolescence. In the second, environmental factors have a greater influence.

Assessment

The assessment of behavioural problems must be focused on various problems and on the child's environment. Interviews, behavioural observations, self-reports and questionnaires can be used.

What is the treatment of behavioural disorders?

Parent training and child training

Parent training is one of the most effective ways to reduce aggressive, antisocial and disobedient behaviour in children. Parent training often has the following characteristics:

• We mainly work with the parents. The parents learn to change the interactions with the child with the aim of increasing prosocial behaviour and decreasing deviant behaviour. Young children can participate in the sessions to change the interactions. Older young people can participate in negotiation and behavioural change programs.
• Parents learn new ways to identify, define and observe behavioural problems.
• Parents learn social learning principles and related procedures such as empowerment and time outs.
• Treatment sessions are used to practice techniques.
• Treatment often focuses, among other things, on the child's functioning at school.

Other treatments focus more on the aspects of the child's functioning rather than family functioning. For example, some interventions focus on social-cognitive deficits. Children learn social and problem-solving skills here. It is best to combine parent training with cognitive treatments.

Community based treatment

Young children often benefit more from the above treatments than adolescents and chronically delinquent young people. Seriously behavioural or delinquent youths are sometimes placed in institutions that are part of the criminal justice system. However, the effectiveness of this is doubted. In addition, this exposes young people to a surrounding with only more deviant behaviour, which reinforces the problem behaviour of the young person. These concerns have led to the development of community-based programs such as the Teaching Family Model (TFM).

Difficulties have been encountered in the transition to the normal pattern. The Multidimensional treatment foster care (MTFC) works with smaller groups and also focuses more on the upcoming normal life.

Multisystemic treatment

Multisystemic therapy is a family and community-based approach based on Bronfenbrenner's socio-ecological model. Multisystemic therapy focuses not only on the child and family, but also on influences outside the family, such as peers, school and the living environment. There is a lot of empirical evidence for the effectiveness of this form of treatment.

Pharmacological treatment

Children with behavioural disorders can be treated with medication, such as mood stabilizers. There is, however, limited evidence of its effectiveness. Children with both (ODD or CD) and ADHD can benefit from taking medication. From a scientific perspective, evaluations of pharmacological treatments for ODD or CD should check whether or not the effectiveness is due to the presence of ADHD symptoms. Many studies have not checked for this. If medication is used to treat behavioural problems, this should be part of a multimodal treatment that also includes parent training and other psychological interventions.

Prevention

The above treatment methods (with the exception of pharmacological treatment) can also be used as a prevention strategy. There are also other programs that have been specifically developed for prevention purposes. Such programs can, for example, be used at a day-care centre or at school. Prevention programs can be used universally or selectively.