Externalizing Disorders: Assessment, Treatment, and School-Based Interventions




© Springer Science+Business Media New York 2015
Rosemary Flanagan, Korrie Allen and Eva Levine (eds.)Cognitive and Behavioral Interventions in the Schools10.1007/978-1-4939-1972-7_9


9. Externalizing Disorders: Assessment, Treatment, and School-Based Interventions



Korrie Allen 


(1)
Innovative Psychological Solutions, Fairfax, VA, USA

 



 

Korrie Allen



Children with externalizing disorders (e.g., conduct disorder and oppositional defiant disorder) account for almost 25 % of all special services in schools and represent the most common reason for referral to pediatric and mental health clinics (Achenbach & Howell, 1993; Armbruster, Sukhodolsky, & Michalsen, 2004). Conduct problems often lead to increased use of psychiatric services and medication and are associated with significant emotional and physical distress in impacted children, families, and school personnel (Brosnan & Healy, 2011). The majority of children with an externalizing disorder receive few to no services, despite the high degree of impairment and poor prognosis (Lahey, Carlson, & Frick, 1997), and 70–80 % of those who do receive service use school-based services rather than services offered in the community (Burns et al., 1995). Schools represent the primary setting where children exhibit impairment and receive treatment (Ginsburg, Becker, Kingery, & Nichols, 2008). Providing evidence-based interventions in the school setting is therefore imperative to effectively prevent and treat externalizing disorders.

The purpose of this chapter is to review the developmental and environmental factors, assessment tools, and school-based interventions for children diagnosed with an externalizing disorder. The chapter focuses on conduct disorder and oppositional defiant disorder; the reader is referred to Chap. 8 to learn more about attention-deficit hyperactivity disorder. Conduct disorder (CD) is characterized by a long-standing pattern of rule violations and antisocial behavior. Approximately 6–16 % of boys and 2–9 % of girls meet the diagnostic criteria for conduct disorder (Esser, Schmidt, & Woerner, 1990; Kashani et al., 1987). Oppositional defiant disorder (ODD) is characterized by patterns of hostile and defiant behavior toward adults and other authority figures over a period of at least 6 months, and it occurs in about 1–16 % of the general population (American Academy of Child and Adolescent Psychiatry, 2007; Loeber, Burke, Lahey, Winters, & Zera, 2000). Certain features may overlap between the two disorders; however, there are important distinctions. Children with ODD, although argumentative, do not display significant physical aggression and are less likely to have a history of problems with the law as is common with CD. If left untreated, child conduct problems (irrespective of extent) intensify following entry into school, putting children with emergent behavior problems at increased risk for peer rejection, academic difficulties, substance abuse, delinquency, school dropout, and depression (Campbell, 1995).


Impact of Externalizing Disorders on the School Environment


Administrators and teachers face enormous pressure to ensure the academic success of all students. When students exhibit disruptive behavior, teachers are challenged with the arduous task of maintaining high academic standards while simultaneously managing problem behaviors (e.g., hitting, talking out, noncompliance) that are disruptive to the learning environment. Research indicates that teachers report spending almost 50 % of their class time managing behavior problems rather than focusing on educational instruction (e.g., Clapp, 1989). The management of problem behaviors has been identified as the most persistent issue facing schools (Center & McKittrick, 1987; Elam, Rose, & Gallup, 1992; Cotton, 1990; Colvin, Kame’enui, & Sugai, 1993). Teacher behaviors and school characteristics, such as low emphasis on teaching social and emotional competence, low rates of praise, and high student-teacher ratio, are associated with classroom aggression, delinquency, and poor academic performance (Webster-Stratton & Reid, 2010). Furthermore, aggressive children frequently develop poor relationships with teachers and are often expelled from classrooms (Webster-Stratton & Reid, 2010). Taken together, inadequate teacher support and exclusion from the classroom exacerbate social problems and academic difficulties.

Empowering school personnel to effectively treat behavior problems improves the overall educational environment for all students. This particularly needs to occur with early childhood education teachers, as externalizing behavior problems often start preschool. As a result, an increasing number of prekindergarten students are being expelled from early childhood education classrooms (Perry, Dunne, McFadden, & Campbell, 2008). Nationally, 6.67 prekindergarteners were expelled per 1,000 enrolled in early childhood education classrooms (Gilliam, 2005). Results from a national study of 3,898 prekindergarten classrooms revealed that 10.4 % of prekindergarten teachers reported that they expelled at least one student in the past 12 months with 19.9 % of those students being expelled more than once (Gilliam, 2005). Unfortunately, one of the main consequences of expulsion at the prekindergarten level is that it shifts the focus of early intervention and education away from the students who need it the most (Gilliam, 2008).

Severe behavior problems manifesting in childhood have long been considered precursors to juvenile delinquency and adult criminality (e.g., Broidy et al., 2003). The period from infancy to preschool is one of the most critical periods in the development of learned aggressive patterns (Aguilar, Sroufe, Egeland, & Carlson, 2000; Bor, Duncan, & Owen, 2001; Farrington, 1994). For instance, longitudinal studies examining preschool children have shown that almost 50 % of children exhibiting aggressive behavior problems in the preschool years will continue to experience similar problems in middle childhood and into adolescence (Campbell, 1995; Cummings, Iannotti, & Zahn-Waxler, 1989). More specifically, empirical studies that track the development of behavior problems over time have found continuity between aggressive, noncompliant behaviors measured between 1 and 3 years of age and externalizing behavior problems measured at 5 years of age (e.g., Cummings et al., 1989). Additionally, preschool children identified as aggressive at 5 years of age are five times more likely to be aggressive at age 14 and that 86 % of children identified with conduct and oppositional defiant behaviors at age 7 tend to display these same behaviors at age 15 (e.g., Moffitt, 1993). Nagin and Tremblay (1999) found that physical aggression in early childhood is a distinct risk factor for later violent offending independent of other disruptive behavior problems. Broidy et al. (2003) indicated that chronic physical aggression during the elementary school years among boys markedly increased their risk of demonstrating physical violence during adolescence.


Contextual Social-Cognitive Model


Violent and aggressive behavior rarely occurs spontaneously. It usually has a long developmental pathway impacted by many environmental variables (Rappaport & Thomas, 2004). The child’s environment tends to either promote or buffer conduct problems. Aggressive, impulsive, and violent behavior is often the end result of a complex interaction among many different types of causal mechanisms, including individual vulnerabilities (e.g., poor impulse control, low intelligence), problems in the rearing environment, and stressors in the larger social ecology (Frick, Bodin, & Barry, 2000). Lochman and colleagues (2012) developed the contextual social-cognitive model which is based on empirically identified risk factors associated with antisocial behavior. The model provides a framework to understand how conduct problems develop and worsen over time and includes malleable risk factors such as family, peer groups, community and neighborhood, and the child’s social-cognitive processes and emotional regulation abilities that can guide intervention efforts (Lochman & Wells, 2002a, 2002b).


Family


Parental discord, criminality, antisocial family values, and unemployment are often associated with ODD and CD. Children with conduct problems tend to reflect the dysfunction, conflict, and maladaptive processes within the family (Kazdin, 1996). Parents of children with conduct problems often have limited skills to manage the child’s behavior appropriately and often inadvertently end up reinforcing the child’s negative behavior. They tend to engage in harsh and inconsistent discipline, poor monitoring and supervision, and low levels of warmth and involvement (e.g., Patterson, Reid, & Dishion, 1992). Children’s behavior also influences parenting, as youth who present challenging behaviors may elicit less effective parenting (Fite, Colder, Lochman, & Wells, 2006). Though difficult and often resistant to change, parenting style is important to understand and assess as the family plays a primary role in the development and maintenance of conduct problems.


Social Cognition


The most common behavioral problem exhibited by children with externalizing disorder is aggression. Aggression is typically the reason for referral, suspension, and other negative outcomes. Aggressive behavior is complex and associated with social, emotional, and cognitive factors (Feindler & Engel, 2011). Aggressive children typically have underdeveloped social skills (Glick, 2003) due to cognitive distortions and deficiencies that often interfere with accurate encoding and appraisal of social information (Powell et al., 2012). Specifically, children with ODD and CD appear to excessively recall hostile cues and to inaccurately attribute hostile intent to other’s motives (Lochman & Dodge, 1994). This “antisocial belief system” justifies their aggressive responses and perceived injustices (Glick, 2003) and, not surprisingly, delinquent youth function at lower levels of moral reasoning than their nondelinquent peers (Feindler & Engel, 2011; Glick, 2003; Kohlberg, 1981, 1984; Nelson, Smith & Dodd, 1990).


Biological Factors


Genetic factors account for about 50 % of the variance in aggressive/antisocial behavior (Nelson, Finch, & Ghee, 2012). Research demonstrates that aggression may be a function of the behavioral activation system, which stimulates behavior and responses to signals of reward or non-punishment, coupled with deficits in the behavioral inhibition system, which is responsible for anxiety and inhibiting behavior (Nelson et al., 2012). Recently, researchers have begun studying the association between aggression in youth and fluctuations in testosterone, cortisol, and neurotransmitters (Rappaport & Thomas, 2004); however, at this time no definite mechanisms have been identified. There is some evidence to suggest that there is a correlation between higher levels of testosterone and physical aggression in boys (Scerebo & Kolko, 1994). Additionally, other studies have found that the neurotransmitter serotonin may modulate aggressive behavior in youth (Conner, 2002; Clarke, Murphy, & Constantino, 1999).


Peers


Rejection from prosocial peers can lead aggressive youth to congregate, forming deviant peer groups (Miller-Johnson et al., 1999). In addition, research demonstrates that associating with deviant peers raises the likelihood of more serious conduct problems (Fite, Colder, Lochman, & Wells, 2007).


Complexity of Assessment and Diagnosis


The diagnostic criteria for oppositional defiant disorder and conduct disorder have largely remained the same in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed . (DSM-5), as in the prior edition. In order to make the diagnosis of oppositional defiant disorder, the behavioral disturbances must cause significant impairment in the child’s social, academic, or occupational functioning, and the behaviors must not occur exclusively during the course of a psychotic or mood disorder. Additionally, the child must not meet criteria for conduct disorder, which is a more serious behavioral disorder. If the youth is 18 years or older, he or she must not meet criteria for antisocial personality disorder. Conduct disorder is the repetitive and persistent pattern of behavior that violates societal norms or the basic rights of others, covering four symptom areas: (1) aggressive behavior that threatens or causes physical harm to other people or animals, (2) nonaggressive conduct that causes property loss or damage, (3) deceitfulness or theft, and (4) serious violation of rules (e.g., truancy).

The assessment and diagnostic process for ODD and CD is complicated by high rates of comorbidity and symptom overlap with other conditions. ODD and CD are associated with increased risk of other mental disorders during childhood (e.g., Burke, Loeber, Lahey, & Rathouz, 2005). For instance, Nock, Kazdin, Hiripi, and Kessler (2007) found that 42.3 % of children with ODD develop CD and 25 % develop attention-deficit hyperactivity disorder (ADHD). ADHD is found to influence the development, course, and severity of CD. Youth with comorbid ADHD have a much earlier age of onset of disruptive behavior than youths with CD alone (Moffit, 1990). Furthermore, studies have reported that ODD and CD are associated with elevated rates of mood and anxiety disorders (Nock, Kazdin, Hiripi, & Kessler, 2007; Burke et al., 2005). Biederman and colleagues (1996) found that a diagnosis of ODD doubles the risk of both severe major depression and bipolar disorder.

In addition, children with externalizing disorders tend to exhibit many anger outbursts. This is typically the primary reason for referral. Angry students tend to see themselves as victims of injustice and, consequently, often reject the goal of eliminating their anger. Once children with behavior problems enter school, negative academic and social experiences escalate the development of conduct problems (Webster-Stratton & Reid, 2010).

For many of these children, anger and aggression occur with high rates of noncompliant behavior. McMahon and Forehand (2003) describe noncompliance as refusing to follow instructions or established rules and arguing with adults during day-to-day activities. As described above, noncompliance is one of the core features of ODD and CD. Examples of noncompliance in the school setting include refusing to follow teacher commands or follow expected behaviors such as completing classwork, arguing, whining, and refusing to “take no” for an answer. Typically noncompliance and aggressive behavior occur simultaneously; however, they represent different types of disruptive behavior and may require separate treatments (Sukhodolsky, Cardona, & Martin, 2005). The complexity of ODD and CD makes diagnosis and determination of long-term outcomes difficult. The majority of children with internalizing and externalizing disorders exhibit disruptive behavior, aggression, and irritability.


Assessment Methods


School practitioners should use a battery of assessment tools when evaluating children for ODD and CD due to the heterogeneous nature of the disorders. Similar to all other psychosocial problems, it is important to use multimethod, multi-informant, multisetting approach and to use multiple data collection points (Nelson et al., 2012). Comprehensive assessment of the family characteristics, culture, and preferences helps the school psychologist understand the scope of the problem and implement effective interventions (Nelson et al., 2012). In the school setting, the depth of the assessment is often impacted by practical factors such as time and availability of measures. When assessing conduct problems, it is important to look at the context of observable behavior problems, interaction styles, and environmental factors (Lochman, Powell, Whidby, & FitzGerald, 2012).


Behavior Rating Scales


The use of a behavior checklist is a quickly and easy method to understand the breadth and severity of the problems (Lochman, Powell, Whidby & FitzGerald, 2012; McMahon & Forehand, 2005). A commonly used rating scale to assess for clinically significant externalizing behaviors (e.g., ODD and CD) is the Behavior Assessment System for Children -Second Edition (BASC-2; Reynolds & Kamphaus, 2004). The BASC-2 aids in the identification and differential diagnosis of emotional/behavioral disorders (in accordance with special education laws) among children and adolescents based on a 4-point Likert scale ranging from “never” to “always.” Additional rating scales include the Achenbach Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001), Eyberg Child Behavior Inventory (Eyberg & Pincus, 1999), and Revised Behavior Problem Checklist (RBPC; Quay & Peterson, 1996).


Interviews and Behavioral Observations


Interviews with the child, parent, and teacher can be helpful in identifying variables related to the occurrence of disruptive behavior. In the school setting, it is important to determine the function of the behavior. The reader is referred to Chap. 2 for a detailed review of conducting functional behavior assessments. Overall, identifying the antecedents and consequence of the behavior will help the teachers effectively modify the behavior in classroom.


Impairment and Other Areas of Functioning


Longitudinal studies have demonstrated that persistent difficulty in adulthood is better predicted by functional impairment than by diagnostic symptoms (Pelham et al., 2005). Children’s Impairment Rating Scale (CIRS; Fabiano et al., 2006) is a brief measure which assesses impairment in important areas. The scale has parent and teacher versions which ask about the degree to which the child has problems that warrant treatment, intervention, or special services in specific areas of functioning. The measure assesses the following areas of functioning: peer, sibling, parent, teacher, academics, self-esteem, classroom/family, and global performance. In addition, peer ratings are often helpful in identifying a subgroup of aggressive, socially rejected children who exhibit a combination of risk factors that point to possible situational factors related to their experience of frustration and aggressive outbursts (Lochman, Powell, Boxmeyer, Andrade, Stromeyer & Jimenez-Camargo, 2012).


Interventions for Youth with Externalizing Behavior Disorders


The research indicates that school-based interventions for children with externalizing disorders have yielded mixed results. In some instances, especially in urban high-risk schools, some intervention programs were found to be ineffective or even iatrogenic (Farahmand, Grant, Polo, & Duffy, 2011; Franklin, Kim, & Tripodi, 2009). Children with ODD and CD exhibit disruptive behavior that negatively impacts classroom instruction, other students, and the child’s ability to function. Due to the complex nature of ODD and CD, interventions require a multifaceted approach that includes school mental health providers working with teachers, parents, and the student. This section includes three intervention modalities: (1) manualized programs for school personnel and families, (2) individual skill building techniques, and (3) teacher consultation.


Evidence-Based Manualized Treatments


There are several evidence-based treatments already in use for the treatment of ODD and CD in the school setting. Due to the heterogeneity of the disorder and sensitivity to environmental variables, most programs include a school and parent training component, although implementing the parent component is not always feasible in school settings. Research indicates that of the two types of evidence-based treatments for youth with ODD—(1) individual approaches with a focus on problem-solving skills and (2) family interventions with a focus on parent management training—parent management programs have the greatest amount of empirical support (American Academy of Child and Adolescent Psychiatry, 2007).

Most parent management interventions adhere to four main principles: (1) reduce positive reinforcement for negative or disruptive behaviors, (2) increase positive reinforcement for appropriate behaviors, (3) establish consequences or punishment for negative or disruptive behaviors, and (4) provide consistent, predictable responses to behaviors (American Academy of Child and Adolescent Psychiatry, 2007). Brestan and Eyberg (1998) identified ten treatments for ODD that had sufficient research outcome reports to designate them as probably efficacious. Pardini and Lochman (2006) outlined several of these treatments, including Incredible Years Program and Dinosaur School, Montreal Delinquency Prevention Program, Anger Coping and Coping Power programs, and Problem-Solving Skills Training. The major components of these programs are presented briefly because they each contain a school component.

The Incredible Years Program (3–8 years) includes a teacher and parent training program. Though most of the research focuses on the teacher program which consists of six workshops focusing on building positive relationships with children and families, providing encouragement and incentives, teaching effective discipline, and supporting the development of children’s emotion regulation, social skills, and problem-solving abilities (Webster-Stratton & Reid, 2010), research shows that children in the program demonstrate reduced behavior problems in the classroom and improved prosocial skills with peers and that teachers demonstrate improvements in classroom management skills (Webster-Stratton & Reid, 2010).

The Montreal Delinquency Prevention Program (Tremblay, Masse, Pagani, & Vitaro, 1996) is designed as a 2-year program for children in early elementary school and also involves both parent and child components. In the child component, small groups of children meet for 45-min weekly sessions, totaling to nine sessions during the first year and ten during the second year. The groups of children consist of equal numbers of target children with ODD and typical children, and these children work together to learn social skills and self-control techniques.

The Anger Coping program consists of both school-based and outpatient programs for children in fourth through sixth grade (see Larson & Lochman, 2013). There are 18 sessions lasting between 45 and 90 min, and the program employs both a point system for compliant behavior and a goal-setting aspect, in which the children identify areas of their behavior that need improvement; they monitor their progress through weekly progress reports. The program also involves segments for anger management, perspective-taking, social problem-solving skills, and role-playing. The Coping Power program is a more comprehensive, lengthier version of the Anger Coping program, extending it to 33 sessions, and includes additional topics such as emotional awareness, managing peer pressure, social and personal goals, relaxation techniques, and social skills enhancement (Lochman et al., 2008; Wells, Lochman, & Lenhart, 2008). The extension of this program is designed to improve long-term effects. Moreover, the Coping Power program includes a parent component of sixteen 2-h sessions extended over the same period of time as the child component. In these sessions, parents are taught to effectively manage problem behaviors, set house rules, and reinforce the skills and techniques learned in the child component.

The Problem-Solving Skills Training and Parent Management Training is a well-researched form of cognitive-behavioral therapy (CBT) designed for children aged 7–13 years and involves 25 weekly individual sessions, each lasting about 50 min (Kazdin, 2010). This program teaches children prosocial problem-solving skills and techniques for managing difficult interpersonal relationships. Therapists work with the children to practice these skills through role-playing, reinforcement, modeling, and feedback. Parents are taught and encouraged to help their children with these new skills at home. The Parent Management Training aspect consists of 16 individual 2-h sessions over the course of 6–8 months, during which parents are instructed on techniques to use when managing problematic behaviors at home. This parent training aspect also employs role-playing and modeling to reinforce techniques. Parents are also taught school-based reinforcement to improve their children’s performance in school through goal-setting and positive reinforcement.


Skill Building Strategies


The above programs were selected because they include school-based components or individual/group techniques that are easily translated to the school setting. However, administering a comprehensive program may not be feasible in the school setting due to financial, environment, and time constraints. Please see Chap. 14 for additional methods to adjust programs to the school setting. Children with ODD and CD often lack the skills to effectively identify triggers or cope with perceived threats. There are additional skill building strategies that are beneficial for children with ODD and CD. The key goal of teaching new strategies is to help the students develop and use skills during a conflict. This review only covers a few of the several research-based interventions, primarily focusing on those that are amenable to the school setting. These include self-monitoring and problem-solving skills . For a more extensive review of common treatment components for children with conduct problems, see Eyberg, Nelson and Boggs (2008) and Lochman, Powell, Boxmeyer, and Jimenex-Camargo (2012).


Emotion Awareness and Self-Monitoring


Students with conduct disorder typically do not perceive their behavior as problematic. Often the first phase of change involves helping the child to identify their destructive behaviors and to understand the triggers for their behaviors (Lochman et al., 2012). Improving the child’s ability to recognize negative emotions helps the child identify conditions where they are prone to engage in negative behavior. This involves teaching students to identify physiological sensations, behaviors, and cognitions. One technique to achieve this is the use of a “Hassle Log ,” a self-monitoring tool, designed to identify variables associated with both the antecedent and consequent conditions surrounding anger provocations and aggressive behavior (Feindler & Engel, 2011). The Hassle Log provides information that helps children determine the triggers for their behaviors and to create scripts for role-play and practice. It also teaches self-observation and self-evaluation and encourages self-reinforcement for instances of effectively managed anger (Feindler & Engel, 2011).

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Jun 29, 2017 | Posted by in PSYCHOLOGY | Comments Off on Externalizing Disorders: Assessment, Treatment, and School-Based Interventions

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