Externalizing Disorders in Children and Adolescents: Behavioral Excess and Behavioral Deficits
Abstract and Keywords
This chapter is a review of externalizing disorders in youth, with an emphasis on behavioral deficits, behavioral excesses and effective interventions. The term externalizing disorders refers to a broad topic that includes several clinically recognized disorders such as attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD). While specific chapters elsewhere in this volume cover each of these disorders, this chapter will investigate common similarities across several externalizing disorders, review their origins, and suggest evidence-based interventions for effective treatment. Academic intervention and academic assessment will not be addressed, because they are covered in two separate chapters. An emphasis will be placed on evidence-based practice interventions for externalizing disorders for the practicing school psychologist. It should be noted that by grouping ADHD, CD, and ODD under one label, externalizing disorders, the commonalities of these disorders will be highlighted, but in the process, some of their important differences will also be de-emphasized. (Mullin & Hinshaw, 2007).
Conceptualization of Externalizing Disorders
The term externalizing disorders refers to a child or adolescent whose behavior negatively affects persons (i.e., parents, other adults, and peers) who are external to them. The problematic behaviors are directed outward and commonly include noncompliance, aggression, impulsive behaviors, arguing, rule breaking, and property destruction. This is in contrast to internalizing disordered children and adolescents who inwardly direct their problematic behaviors, such as anxiety, fears, and somatic complaints.
The clinical term “externalizing disorders” is not found in any commonly accepted classification system such as the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV-TR) (American Psychiatric Association, 2000), International Classification of Diseases and Health Related Problems (ICD-10; World Health Organization, 2005), nor in the definitions for disabilities for the reauthorization of the Individuals with Disabilities Education Act (IDEA)–2004. The DSM-IV-TR combines externalizing behavior problems under disruptive disorders (e.g., ADHD, CD, and ODD). IDEA-2004 includes both externalizing disorders and internalizing disorders under the category of seriously emotionally disturbed; however, it specifically excludes “socially maladjusted” students from receiving services unless they are also severely emotionally disturbed. Some state educational agencies and school districts specifically equate socially maladjusted with externalizing disorders, and thus deny these students special education services ( Jenson, Olympia, Farley, & Clark, 2004).
Possibly the best research based origin for the concept of externalizing comes from the development of behavior rating scales such as the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2001) or the Behavior Assessment System for Children-II (BASC-II; Reynolds & Kamphaus, 2004). (p. 380) When behavioral items are developed for these rating scales and thousands of children are rated, two broad-band spectrum areas develop. One spectrum is made up of behaviors and sub-factors such as attention, delinquency, hyperactivity, conduct problems, and aggression, that are significantly associated with externally directed problem behaviors. This is as opposed to internally directed problem behaviors with sub-factors of depression, anxiety, withdrawal, and somatic problems. In a sense, with ratings by parents and teachers on thousands of clinically referred children, these individually rated behavior items intercorrelate and form the broad spectrums of externalizing and internalizing disorders.
There is also a clinical definition of externalizing disorders that goes beyond just the label and sub-factors (refer to Table 18.1). This definition describes externalizing
disorders as consisting of behavioral excesses and behavioral deficits (Rhode & Jenson, 2010; Gelfand & Drew, 2003). The behavioral excesses include behaviors frequently associated with externalizing disorders such as aggression (i.e., physical aggression, verbal aggression, revenge-seeking, property vandalism, engaging in bullying, and cruelty to animals), and noncompliance (i.e., not following directions, rule breaking, and arguing). However, this definition also includes substantial behavioral deficits such as lack of rule-governed behavior (i.e., does not internalize societal and behavioral rules that govern behavior) and poor social skills (i.e., has few friends, considered immature and demanding in social situations, constantly seeks attention), as well as deficits in academic skills and behaviors related to school success. These children are commonly described as “Tough Kids” because they are difficult to manage behaviorally and teach (Rhode et al., 2010). Defining externalizing disorders by describing core behavioral excesses and deficits is advantageous, particularly in designing interventions and prevention programs for these children. If only behavioral excesses are highlighted and treated, then the intervention programs for these externalizing students will frequently fail. Even if there is an initial decrease in behavioral excesses, externalizing students will frequently revert back to their old behavioral excesses to escape or avoid environments and situations that require skills they do not posses (Rhode & Jenson, 2010). For example, if noncompliance, arguing, and aggression decrease during a treatment program, and the student with academic deficits is then placed back into a demanding classroom environment that requires successful academic performance, this student will likely revert back to his old behavioral excesses to escape this setting. Good interventions for externalizing disorders must address both behavioral excesses and behavioral deficits.
Causes of Externalizing Disorders
There is no single cause for externalizing disorders (Gelfand & Drew, 2003; Rutter, 2003). Rather, this disorder has multiple causes that interact to produce externalizing behaviors. These causes include biological factors, genetics, family and parenting issues, learning coercive behaviors, and several other environmental factors. We do a disservice to students with externalizing disorders when we assume there is one single cause and one single treatment, and exclude other factors. When we do this, we miss the “bigger picture” of this disorder. There are many causes for externalizing disorders, and several avenues of treatment that should be recognized.
Genetics and Temperament
Biological factors play an important part in the etiology of externalizing disorders. Many researchers believe there is an inherited biological risk for the development of externalizing disorders (Dick, 2007; Hicks, Krueger, Iacono, McGue, & Patrick, 2004; Kendler, Jacobson, Myers, & Eaves, 2007). However, few researchers believe there is a single gene of transmission for externalizing behaviors. Rather, it is commonly assumed that there is a reciprocal influence between the genetic makeup and biology of a child, and such factors as inherited temperament, a “goodness of fit” between temperament style and the demands of the environment, parenting style, the community, and several other environmental factors (Carey, 1998; Smith, Barkley, & Shapiro, 2006; Gelfand, & Drew, 2003; McMahon, Wells, & Kotler, 2006; Patterson, 2002; Patterson, Reid, & Dishion, 1992).
The percentage of genetic influence on externalizing behaviors, especially antisocial behavior, is difficult to estimate. In 1994, Mason and Frick conducted a meta-analysis of several studies that included 3795 twin pairs and 338 adoptees, to estimate the influence of genetics on antisocial behavior. They concluded that approximately 50% of the variance in measures of antisocial behaviors was probably attributable to genetic effects. Baker, Bezdijan, and Raine (2006) reached a similar conclusion, “Heritability estimates suggest as much as one-half of the variation in propensity toward antisocial behavior can be explained by genetic differences among individuals” (p. 19). Rhee and Waldman (p. 381)
Table 18.1 Practical definition of a tough kid
Behavioral excesses: Too much of a behavior
Does not do what is requested
Does the opposite of what is expected
Is cruel to others
Behavioral deficits: Inability to adequately perform a behavior
Cannot delay rewards
Acts before thinking – impulsive
Shows little remorse or guilt
Will not follow rules
Cannot foresee consequences
Has few friends
Goes through friends fast
Noncooperative – bossy
Does not know how to reward others
Has few problem-solving skills
Constantly seeks attention
Generally behind in academics, particularly reading
Fails to finish work
Truant or frequently tardy
Forgets acquired information easily
From Rhode and Jenson’s The Tough Kid Book. Reprinted with permission of Pacific Northwest Publishing.
Although the study of general inheritability of externalizing behaviors has made advancements, pinpointing specific genes has been more difficult. Dick (2007) has reviewed the area and concluded there may be predisposition genes (i.e., GABRA2 and CHRM2); others (Beaver, Wright, Delisi, Walsh, Vaughn, Boisvert & Vaske, 2007) have found a gene x gene interaction (DRD2 X DRD4) that is related to the development of antisocial behaviors. These genes are “not specific to one externalizing disorder but will predispose individuals broadly to a spectrum of externalizing pathology” (Dick, 2007, p. 331).
Other researchers have found links with genetics and different levels of physiological arousal associated with thrill seeking, novelty seeking, and a decreased sensitivity to punishment and behavioral inhibition (Atkins, Osborne, Bennett, Hess, & Halperin, 2001; Sharp, Petersen, & Goodyer, 2008). These biological differences in physiological arousal may help explain the impulsive behaviors of externalizing children, and their failure to learn from aversive consequences for these behaviors. In a sense, these genetic differences produce under-arousal in some externalizing children, requiring them to seek exciting situations (e.g., rule breaking, aggression, taking chances) to maintain an optimal level of physiological arousal (Gelfand & Drew, 2003). These genes have been dubbed the (p. 382) “adventure genes” and have been associated with novelty seeking, impulsivity, exploratory behavior, and substance abuse (Ebstein & Belmaker, 1996; Lusher, Chandler & Ball 2001).
Temperament also appears to be an important factor in the development of externalizing disorders of childhood (Rettew, Copeland, Stanger, & Hudziak, 2004). Since the early research of Chess and Thomas (1984), and the publication of their longitudinal study of temperament in children, there has been a great deal of research linking temperament with externalizing disorders. Chess and Thomas studied 133 children from infancy to young adulthood. They found that 65% of the infants (2 to 3 months of age) in their sample could be categorized on nine behavioral characteristics into three distinct categories: easy temperament (40%), slow to warm up (15%), and difficult temperament (10%) infants. Difficult-temperament infants tended to be more emotional, irritable, active, fussy, and to cry more easily than other infants. Patterson et al. (1982) include a difficult temperament as one of several precursors that later leads antisocial behavior in children. Difficult-temperament children are also more vulnerable to abuse, school failure, and showed some of the poorest responses to childhood stressors such as divorce (Chess & Thomas, 1984). Other researchers have linked temperament with externalizing characteristics such as hyperactivity, novelty seeking, and aggression (Berdan, Keane, & Calkins, 2008; Rettew, et al., 2004).
Although temperament has a strong genetic link (Saudino, 2005; Torgerson & Kringlen, 1978), Chess and Thomas (1984) reported that a number of subjects in the population they studied changed temperament categories as they grew older. It is most likely the fit between a child’s temperament and the demands of the environment that significantly affect the development of problem behaviors. Chess and Thomas (1984) stated that “These findings suggest that poorness of fit between the child’s characteristics (i.e., temperament) and capabilities, and the demands and expectation of the environment, is sufficient to produce a behavior disorder by early childhood” (p. 58). Environmental and familial factors may play a role in changing temperament characteristics as a child grows older. With a good fit, the child is viewed as less difficult temperamentally; with a poor fit the child is viewed as more difficult. Biological factors such as genetic makeup and temperament may predispose a child to a general vulnerability, which is then triggered by a multiple set of familial and environmental factors, thus producing externalizing problem behaviors in children (Patterson et al., 1982; Rutter, 2003).
The role of the parents and family in the development of externalizing disorders is well documented (Frick & Loney, 2002, Kendall, 2000; Patterson, 2002; Patterson, 1982; Snyder & Stoolmiller, 2002). These factors can take several forms, including parental deviance, parental rejection, coercive family interactions, lack of discipline or overly harsh discipline, marital conflict, divorce, and lack of supervision (Hetherington, Law, & O’Connor, 1993; Kendall, 2000; Snyder & Stoolmiller, 2002). Alcoholism, drug abuse, criminality, and psychiatric disorders in parents, all can contribute to the development of aggression, noncompliance, delinquency, and externalizing problems in children (Patterson et al., 1982; McMahon et al., 2006). Parental criminality and antisocial behavior has been linked to conduct disorders and oppositional defiant disorders in children (Frick, Lahey, Loeber, Tannenbaum, Van Horn, Christ 1993; Frick & Loney, 2002). Parental antisocial behavior may interfere with the development of positive parenting practices, while it also models deviant behaviors for their children (Capaldi, DeGarmo, Patterson, & Forgatch, 2002; Patterson et al., 1992). Criminality and antisocial behavior in parents may partially account for the trans-generation of antisocial behavior. In essence, one generation passes it to the next. Substance abuse and alcoholism may also have similar trans-generational effects for children with externalizing disorders (Hicks, et al., 2004; Schuckit, Smith, Pierson, Trim, & Danko, 2007). Alcoholism specifically can affect parenting ability by altering the parent’s perceptions of a child’s behavior, and contribute to inadequate monitoring and supervision, indulgence, and inconsistent or overly harsh parenting (McMahon et al., 2006).
Other family stressors such as divorce, marital distress, maternal depression, neighborhood risk, and low SES can also influence the development of externalizing disorders in children (Amato & Keith, 1991; Capaldi, et al., 2002; Cummings & Davies, 1994; Igoldsby & Shaw, 2002; Snyder, 2002). Research indicates that boys are more likely to develop the externalizing behaviors of noncompliance and aggression than girls following divorce (Amato, 2001; Amato & Keith, 1991; Malone, Lansford, Castellino, Berlin, Dodge, Bates, & Pettit, 2004). It should be recognized that a child’s antisocial behavior may also promote marital disharmony, (p. 383) which contributes to divorce, leads to a lower standard of living, and exacerbates maternal depression. It is a chicken and egg problem. The causal mechanism is unclear, of how much the family factors influence the development of externalizing behaviors in the child, or how much the child’s externalizing behaviors affect the discord in a family (Kazdin, 1995; Patterson, 1982; Patterson, et al., 1992).
Child rearing practices have an impact on the development of externalizing behaviors in children. However, these child rearing practices span a spectrum from harsh and abusive practices to inconsistent or negligent parenting practices (Burke, Loeber, & Birmaher, 2002; Patterson et al., 1992). Harsh, abusive, and punitive parenting that models parent aggression is associated with disruptive externalizing behaviors (Patterson, et al., 1992). This type of parenting focuses on what the child has done wrong, rather than teaching the child what he or she should do (Gelfand & Drew, 2003). On the other end of the spectrum are inconsistent parents who habitually have difficulty setting reasonable limits, and establishing family rules and consistent routines (Patterson, 1982; Patterson, et al., 1992). This type of parenting often leaves children confused about the exact limits and consequences for their behaviors. It is interesting to note that parents who use erratic control and are inappropriately permissive often revert to abuse, and are more likely to use aggression to discipline their child (Chamberlain, Reid, Ray, Capaldi, & Fisher, 1997; Jaffee, Caspi, Moffitt, & Taylor, 2004). These deficits in parenting and caregiving can also lead to attachment problems and difficulty with emotional regulation in a developing child (Guttmann-Steinmetz & Crowell, 2006). Some researchers have labeled this type of problem as a pattern of “insecure coercive attachment” (Devito & Hopkins, 2001). Families with high rates of conflict and coercive interactions make their children especially vulnerable to the development of externalizing, antisocial problem behaviors (Patterson, 1982; Patterson et al., 1992).
Coercion: The Aversive Cycle
Understanding the coercive family cycle and the role of noncompliance is essential for the successful treatment of externalizing behaviors in children. The coercion model (Patterson; 1976; Patterson et al., 1992) is an escalating cycle of aversive interactions between a parent and child. In the coercive process, escape from an ever escalating cycle of aversive behaviors is the motivating consequence that fuels externalizing behaviors such as aggression, arguing, temper tantrums, and noncompliance. For example, in a coercive interaction a parent may ask a child to clean his room. The child responds by ignoring the parent’s request. The parent then presses the request, and the child starts to whine. At this point, the parent may yell at the child, who then starts to argue with the parent about the unfairness of the request. Caught in the child’s argument, the parent may threaten the child with negative consequences for not following their directions. Next, the child may explode in a tantrum and become aggressive. The parent may then leave the room in frustration and, in effect, withdraw the original request to clean the room. In this model, the child has escaped the parent’s request by escalating his behavior from ignoring, whining, arguing, temper tantrumming and finally becoming aggressive. The parent likewise has avoided the child’s escalating string of aversive behaviors by walking away and withdrawing the original request. The child learns that his aversive behaviors can turn off the aversive parental behavior (i.e., parent request to clean his room). Both the parent and child are negatively reinforced through the coercive process. Coercion is a gradual learning process, which results in several deleterious consequences for the child. Gerald Patterson has described a child caught in an aversive interaction as a “victim and architect of the coercive system” (Patterson, 1976; Patterson, 1982).
By “victim” Patterson means that, although the child may have escaped an unwanted request from his parent, there were negative long-term consequences for engaging in this process. Patterson, (1982) hypothesized there are basically four progressive stages in the coercive process. The first stage is the learning process, where the child learns to use coercion to control others (i.e., parents, siblings, and other adults). Stage 1 is characterized by poor discipline, lax supervision, and parental inconsistency. It also puts the child at risk for child abuse, family disruption, and lower self-esteem. At Stage 2 the child learns to export the coercive process to peers and other adults such as teachers, thus leading to poor academic performance and rejection by peers. As the child gets older, Stage 3 begins with the coercive child seeking associations with other deviant peers, increased substance abuse, and delinquency. Stage 4 is the adult culmination of the coercive process, with chaotic employment experiences, disrupted marriage, legal problems, and possible institutionalization (i.e., incarceration).
The child is not only the victim in this process, but also the architect in the sense that coercion (p. 384) fundamentally changes family dynamics. However, the coercive child is not the only architect of this system. Both siblings and parents unknowing facilitate coercive family interactions (Patterson, 1982; Snyder, 2002). Overall, families of externalizing children that engage in coercion have much higher rates of aversive interactions such as yelling, threats, aggression, crying, whining, and noncompliance (Patterson, 1982). There does not appear to be a great deal of difference between the coercive child and his siblings. If grouped together, an uninformed observer would have difficulty picking out the clinically referred coercive child among the siblings. In essence, once the coercive cycle is initiated in the family, it tends to reverberate within the family and “once initiated these aversive events tend to snowball and have a life of their own” (Snyder, 2002, p. 73).
The Effects of Deviant Peers and Social Skills Deficits
There are other ramifications for the coercive process, which helps explain the behavioral deficit components (i.e., rule following, social skills and academic deficits) of the definition of externalizing disorders given earlier in this chapter. By learning the coercive process in the home, the externalizing child is likely to export it to the neighborhood and school. Externalizing children who use coercion are more likely to be rejected and disliked by their peers, and develop a negative reputation as being uncooperative, non-rule-following, and aggressive (Dishion, 1990; Coie & Kupersmidt, 1983; Snyder, 2002). These children do not learn the more sophisticated social skills needed to deal with disagreements, conflict, and competition with their peers. Rejection by a normal peer group often results in externalizing children looking for others that share similar behavioral characteristics (Snyder, 2002). Thus, they often form affiliations and friendships with other externalizing children, which add to their social problems. Externalizing children not only need to learn more sophisticated social skills, they also need appropriate contingencies to perform these skills.
It is important to note that the phenomena of seeking other children and adolescents with similar behavioral characteristics can produce a significant risk factor in treatment. Simply grouping externalizing students with each other in a treatment group or classroom setting can inadvertently foster antisocial behavior (Arnold & Hughes 1999). Dishion, McCord, & Poulin (1999) showed that grouping externalizing adolescents for prosocial skills training actually significantly increased their tobacco use and delinquent behavior as rated by teachers. Dishion et al. (1999) have named this phenomena “deviancy training.” When grouped together, through verbal and nonverbal communication, deviant peers positively reinforce each other for antisocial behavior; they learn new forms of deviant behavior; and they form friendships that extend beyond the group. This “iatrogenic” effect of making antisocial behavior worse through grouping occurs mostly with older externalizing youths. It is found more frequently when the groups are relatively unstructured, have little direction, and are poorly managed. This iatrogenic effect has important implications in treatment programs for externalizing youth. Arnold and Hughes (1999) have stated, “First, do no harm…” (p. 99) in reference to the harmful effects that can occur when externalizing students are grouped in treatment or skills training.
Academic and Self-Management Deficits
Academic problems are closely associated with externalizing disorders (Mullin & Hinshaw, 2007). These problems include disorganization, poor study skills, underachievement, grade retention, dropping out of school, and poor reading ability (Gelfand & Drew, 2003; Hinshaw, 1992; Walker, Ramsey, Gresham, 2004). Patterson, DeBaryshe, & Ramsey (1989) have indicated that the family coercive process is a major contributor to academic failure once school begins. Coercive students are at particular risk when their reading ability is low, and they constantly receive the negative message that they are a failure at school (Morgan & Jenson, 1988; Walker et al., 2004). This negative message is compounded each year when their negative reputations have preceded them with peers, teachers, and other school staff (Snyder, 2002). Externalizing students often have a general negative conditioning experience to school and academics, which follows them through each grade during their educational experience. The problem becomes one of not only academic remediation, especially in reading, but also of motivating the student to stay in school and continue to work academically (Rhode & Jenson, in press). Two chapters in this book address the core issues of academic interventions and assessment that are essential to the adjustment of the externalizing student to school.
The inability of externalizing children to self-manage and govern their behavior by following rules, develop empathy, and internalize societal values is a third major area of deficit (Smith et al., 2006; Rhode & Jenson, 2010). Skinner (1953) long (p. 385) ago outlined the developmental process of learning to be self-managed and rule governed by a three-step basic process. First, the child learns to be controlled (i.e., compliance to requests) by the language of others. Second, the child learns self-control through language and private speech. Finally, the child internalizes rules and creates new rules (i.e., problem solving) to govern his or her behavior in new and unsupervised settings. Normal children use internalized rules and problem-solving strategies to govern their behavior in novel situations. Externalizing children, especially coercive and impulsive children, are more contingency governed by the immediate environment, and have difficultly following rules and requests from parents and teachers (Snyder, 2002; Snyder & Stoolmiller, 2002).
This lack of self-management and rule governed behavior becomes a significant problem when externalizing children are not supervised nor monitored (Patterson, 1982).
Externalizing children are impulsive by nature, and controlled directly by what they encounter in their immediate environment. When externalizing children are left unsupervised in high-risk environments with deviant peers, they are far more likely to develop antisocial behaviors (Kilgore, Snyder, & Lentz, 2000; Patterson et al., 1992; Snyder, 2002). For externalizing children with poor rule governed behaviors, a major treatment focus is teaching self-management skills to the child, and increasing both parental and school staff monitoring of behavior. This issue is particularly problematic when externalizing students are unmonitored after school and on weekends. It is also a major argument against the expulsion and suspension of externalizing students ( Jenson, Rhode, Evans, & Morgan, 2006). When approximately 200 secondary students in Utah with externalizing problems were asked what type of disciplinary action they preferred, the vast majority indicated they would prefer out of school suspension (Evans, 2008). Simply putting externalizing youth on the streets of a community without supervision is asking for trouble, for the youth and for the community. Alternative positive supervision interventions are needed for externalizing students who are at risk for expulsion and suspension from schools.
The Role of Noncompliance
In discussing the coercive process for externalizing children, and its associated behavioral deficits, it is important to highlight the importance of noncompliance. Noncompliance is one of the most common behavior problems of childhood (Kalb & Loeber, 2003). Simply defined, noncompliance is not following a direction (i.e., from a parent or teacher) within a specific period of time (Forehand, 1977; Kalb & Loeber, 2003; Rhode & Jenson, in press). The reason noncompliance is so important because it is the “basic building block” of antisocial behavior that leads to more severe forms such as aggression and violence (Snyder, 2002). Children usually do not argue, tantrum, talk back, or make excuses in a vacuum. These aversive behaviors are generally exhibited to escape demanding situations, or request or commands from an adult. Thus noncompliance is core to the coercive process, and appears to be a behavior associated with all the major clinical conditions (i.e., ADHD, CD, and ODD) that make up the broad spectrum of behaviors that define externalizing disorders.
Noncompliance may be more than a core, but rather the “kingpin” that is central to coercion and holds the aversive behaviors together in the cycle. The kingpin is like an axle around which all the other behavioral excesses revolve as spokes. The externalizing child’s compliance to adult requests is approximately 40% to 50%, whereas normal children respond to approximately 80% to 85% of adult requests (Forehand, 1977; Rhode & Jenson, 2010). Research has shown that interventions focused on improving noncompliance in externalizing children will also collaterally improve the child’s aggression, arguing, and temper tantrums (Martinez & Forgatch, 2001; Parrish, Cataldo, Kolko, & Engle, 1986; Russo, Cataldo, & Cushing, 1981; Wells, Forehand, & Griest, 1980). In other words, interventions used to improve a child’s noncompliance will also improve other behavioral excesses and deficits, even though they are not the target of an intervention. Once the “kingpin” behavior of noncompliance is reduced, other antisocial behaviors in the coercive cycle will also improve. For externalizing children, a major focus of treatment should be the improvement of noncompliance in the home, in the neighborhood, and at school.
Stability and Developmental Nature of Externalizing Disorders
The changing nature of behavior as the child develops and grows older is an important concept for effective intervention with children with externalizing disorders. Figure 18.1 contains the compilation of hundreds of children ages 6 to 18 that have been rated on the Child Behavior Checklist (CBCL) by parents, self-reported on the Youth Report Form (YSR), and reported by teachers on the Teacher Report Form (TRF) (p. 386) (Achenbach & Rescorla, 2001) for externalizing behaviors. Open circles (boys) and squares (girls) represent nonreferred children, and closed circles and squares represent children referred for psychological problems.
It is easy to see from the parent, youth, and teacher ratings that externalizing problems are elevated and remain very stable and consistent across ratings, with teacher ratings more elevated. These data suggest that the behaviors that make up the constellation of externalizing disorders such as noncompliance and arguing are very stable over time, with some problem behaviors (e.g., truancy, substance abuse) gradually getting worse.
However, as children age and develop, there are stability differences between the clinical disorders (i.e., ADHD, CD, and ODD) that make up the externalizing grouping. For both CD and ODD, the problem behaviors appear to be very stable (e.g., boys), or get worse at about age 12 years (ratings of girls). In contrast, ratings for ADHD children (both parent and teacher ratings) appear to improve over time, but never fall within the normal range of nonreferred children.
Similarly, research literature has shown that as ADHD children age, the hyperactive-impulsive behaviors decline (Barkley, 1996). When an ADHD child is a preschooler, they exhibit higher rates of excessive motor activity, inattention, and impulsivity. When they enter school at about age 5–6, they are often recognized as being deviant from nondisabled peers. This is especially true for structured academic tasks that require sustained attention, problem solving, and sitting quietly (Barkely 1996). In adolescence, 43%–80% of these youths continue to have the disorder. When they approach young adulthood, this percentage falls to 30–50% (Barkley, 1996). Young adults with ADHD continue to have poorer outcomes than non-ADHD adults, including higher accident rates, substance abuse, more sexual partners, poor work histories, and more interpersonal problems (Weiss & Hechtman, 1993). However, the comorbidity of aggression and severe oppositional behavior with ADHD (i.e., 35%– 40%) produces significantly poorer outcomes (Smith, et al., 2006).
The stability and developmental issues of behaviors associated with ODD and CD are twofold. One issue is age of onset during childhood for these disorders. The second issue is the changing nature of the behaviors that make up the symptom clusters of ODD and CD as the child gets older. Both onset of the externalizing disorder and the changing nature of the CD and ODD have significant implications for treatment.
Externalizing children who have life-course paths (early starters) for antisocial behavior have a developmental course which persists from early childhood to young adulthood (Moffit, Caspi, Dickson, Silva, & Stanton, 1996). This pathway is similar to the early-onset CD described in the DSM IV-TR. This type of externalizing disorder has many of the problems and risks that were discussed earlier in this chapter. They are identified as being difficult-temperament infants, crying frequently, irritable, and hyperactive. It has been suggested that there may be early neurobiological deficits with these children that interfere with the development of inhibition, language, memory, and self-control (Moffitt, 1993; Moffitt, 2003). These children come from families that engage in coercion, the parents may exhibit antisocial behavior, there is martial distress, and maternal depression is more common, as is abuse (Patterson et al., 1992; McMahon et al., 2006). For life-course externalizers there appears to be a transition in antisocial behavior that moves them from overt ODD type behaviors to more covert CD based behaviors. Life-course pathway children may begin by “biting and hitting at age 4, shoplifting and truancy by age 10, selling drugs and (p. 387) stealing cars by age 16, robbery and rape by age 22, and fraud and child abuse by age 30” (Moffitt, 1993, p. 679). The life-path externalizing youth continue this pattern through childhood and adolescence and are at increased risk for more negative outcomes in adulthood (Moffitt, 2003).
The second basic type of externalizing disorder for children with CD type behaviors is the adolescent-limited pathway. This path generally starts in puberty when the youth is a teenager. The early history of an adolescent-limited externalizer is quite different from a life-path externalizer. Adolescent-limited youth engage in less deviant behavior and aggression in childhood, with less family problems, fewer temperament issues, and less academic failure (Moffitt, 1990; Moffitt, 2003). There is a sex ratio difference between males and females with a 10:1 ratio of males to females for life-course externalizers, and 1.5:1 ratio of males to females for adolescent-limited externalizers (Moffitt, & Caspi, 2001). Adolescent-limited externalizing youth are more susceptible to deviant peer influences that often result in violating societal norms and delinquency (Moffitt, 2003). They usually engage in less violent and aggressive behaviors, and engage in more status offences such as restricted adult privileges (i.e., alcohol, drug abuse, early sexual experiences, curfew violations). Many of the problem behaviors associated with adolescent-limited externalizers are rebellious in nature, and involve asserting independence from their parents (Moffitt, & Caspi, 2001). The long-term outcome in adulthood is much better for adolescent-limited pathway youth than for life-path externalizing youth, especially if the deviant behavior does not include getting caught in a societal “snare.” Societal snares are problems such as dropping out of school, substance abuse, incarceration, or arrests that preclude and cut off later adult opportunities, especially employment (McMahon et al., 2006). Many of the delinquent antisocial behaviors peak at around age 17, decrease during the 20s, and are reduced sharply (85%) by age 28.
As there are differences in life-path and adolescent-limited externalizing pathways, there is a difference in the very nature of the behaviors evolving from early childhood through adolescence. Loeber and Schmaling (1985) have proposed a bipolar one-directional development of problematic behaviors, ranging from overt behavior to covert type behaviors. Overt deviant behaviors include those that directly confront others, or cause the disruption of the environment (e.g., aggression, temper tantrums, defiance, and fighting). This is opposed to covert externalizing behaviors, which include behaviors that usually occur without the immediate awareness on the part of an adult (e.g., lying, vandalism, truancy, stealing, fire setting, and substance abuse) (McMahon et al., 2006). In a further analysis of the dimensions of externalizing behavior, Frick, Lahey, Loeber, Tannenbaum, Van Horn, & Christ (1993) found not only the bipolar dimensions of overt to covert behaviors, but also other dimensions of destructiveness and non-destructiveness. This analysis is given in Figure 18.2, which shows basically four subtypes of externalizing behavior—property violations, aggression, status violations, and oppositional behaviors.
This figure shows the early development of overt externalizing behaviors of opposition and aggression, which are then followed by more covert forms of behaviors of property violations and status violations. It is interesting to note that in this analysis, noncompliance is at the apex, or center, of the four behavior dimensions, indicating its central role as a kingpin behavior in the development of the four conduct problem dimensions (Loeber & Sschmaling, 1985). This finding of noncompliance as an apex or central behavior to the other dimensions of externalizing problem behaviors underscores the need for reducing noncompliance.
Assessment of Externalizing Disorders
Best practice assessment is a structured information gathering technique that leads to decisions about diagnosis, treatment, evaluation of that treatment, and research (Gelfand & Drew, 2003; Sattler, 2008). Structured information gathering means that the assessment instruments have been psychometrically standardized with good reliability and validity characteristics. For example, factor analyzed behavior rating scales, behavioral observations, curriculum based academic measurement, intelligence tests, and functional behavior assessments are all structured assessment approaches. This is opposed to nonstructured approaches such as anecdotal reporting, projective testing, or informal interviewing.
Best practice assessment for externalizing disorders should include multiple standardized assessment measures, multiple informants completing those measures, and the use of assessment measures across multiple environments (Morgan & Jenson, 1990; Rhode & Jenson, 2010). This type of assessment reduces bias, and averages out error that might come from the use of just one type of assessment measure, a biased informant, or missing behavior problems that occur in multiple environments. Best practice assessment can give a school psychologist a (p. 388) good estimate of the severity of the problem behavior, pinpoint problem behaviors for intervention, assess whether an implemented intervention has been effective, and possibly prevent exacerbation of externalizing behaviors.
Behavior Rating Scales
Behavior rating scales are basically checklists, with many items describing specific behaviors. Items are rated as a dichotomy—either the behavior exists “Yes” or it doesn’t exist “No.” Or, items are rated on a graded Likert Scale, such as no problem, somewhat of a problem, or a significant problem. When rating scales are developed and normed, hundreds of children are rated by parents or teachers on the individual behavior items or questions. When these behavior-rating scale items have similar structure and meaning, they intercorrelate highly and form broad bands of behaviors such as externalizing and internalizing, as previously described in this chapter. These broad bands (e.g., externalizing) are then made up of narrower bands or factors such as attention problems, aggressive behaviors, and delinquent behaviors (e.g., CBCL/6-18) (Achenbach & Rescorla, 2001).
One of the earliest behavior checklists was the Behavior Problem Checklist (Quay & Peterson, 1975), which was originally developed by Peterson in 1961. For the BPC, 400 cases referred to child guidance clinics and 831 elementary students were rated by parents and teachers. These items were then statistically intercorrelated (factor analyzed), and formed unitary behavioral dimensions (factors). Since 1961, work has continued on the Revised-BPC (1996), which has broad-band externalizing and internalizing behavior factors that include Conduct Disorder, Socialized Aggression, Attention Problems, Anxiety-Withdrawal, Psychotic Behavior, and Motor Excess. The Conduct Disorder factor is similar to the life-path externalizer; Socialized-Aggression corresponds to the adolescent-limited pathway, and Attentional (p. 389) Problems and Motor Excess correspond to ADHD. Together, these factors form the broad-band externalizing disorder, and Anxiety and Withdrawal factors form the broad-band internalizing disorder. Psychotic Behavior is a factor by itself.
More recent behavior rating scales can be specific to particular disorders deficit areas such as ADHD (Conners, 1997), opositional defiant disorder (Hommersen, Murray, Ohan, & Johnson, 2006), autism (Schopler, Reichler, & Renner, 1988), Asperger’s syndrome (Gilliam, 2003), depression (Kovacs, 1992), social skills deficits (Gresham and Elliott,1990), and others. Behavior ratings scales have now evolved into comprehensive assessment systems that can include behavior rating scales from preschool through late adulthood, observation systems, and corresponding interviews. For example, the Achenbach System of Empirically Based Assessment (ASEBA; Achenbach & Rescorla, 2001) includes child behavior checklists (i.e., CBCL) from preschool (i.e., age 11/2–5), childhood-adolescence (6–18), adulthood (18–59), and older adults (59–90). The child and youth forms can be filled out by parents, teachers, and with some applications, a youth self-report form. This gives the assessment advantage of multiple raters (i.e., parent, teacher, and youth) across multiple environments (i.e., school and home). The individual items are rated on a Likert Scale of 0 = Not a Problem, 1 = Somewhat or Sometimes True, and 2 = Very True or Often True. The ASEBA system has been standardized on numerous cultures in several countries. There is a corresponding Direct Observation Form for classrooms and group activities, which is conducted in 10 minute increments, over 96 problem items, with an emphasis on on-task behavior. There is Semistructured Clinical Interview for Children and Adolescents (McConaughy & Achenbach, 2001) with eight syndrome scales that parallel the child behavior checklist’s (CBCL) behavioral factors and DSM IV-TR diagnostic categories.
When the CBCL behavior rating scale is completed by a parent or teacher, the items are scored and transferred to two profile sheets—one profile sheet for a Competence Scale Score, and one profile sheet for a Syndrome Scale Score. Both profile sheets are based on T-scores, with T-score of 50 being average, and with each increase of 10 points being one standard deviation from the mean. It is generally considered for the Syndrome Scale that a score of T-70 (i.e., two standard deviations above average T-50) is clinically significant, and at the 98th percentile. The Competence Scale Score shows adjustment to normal activities, social activities, and school performance. The Syndrome Scale is divided into several clinical factors (e.g., anxious depressed, withdrawal depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior, and aggressive behavior) depending on the age and sex of the child. The rule-breaking factor and aggressive behavior make up a special externalizing broad-band factor for the CBCL. School psychologists can obtain an estimate of the overall externalizing behavioral excesses of a child by first reviewing the T-score rating of the Externalizing Broad Band on the Syndrome Scale Profile (see Figure 18.3).
The second step is then to identify the narrow-band factors such as rule-breaking that have been scored over T-70. The third step is to review the specific items included under the narrow-band factors that have been individually highly rated with a 1 or 2, such as truant, bad friends, sets fires, and steals. This Syndrome Scale Profile analysis gives a school psychologist a good estimate of the particular behaviors and severity of the externalizing behavioral excesses of a child (e.g., scores above T-70). A fourth step of reviewing the Competence Scale Score profile gives an estimate of the externalizing child’s behavioral deficits, such as deficits in social activities, sports, friends, and school achievement and performance.
The ASEBA system has been used extensively in clinical and research settings for externalizing disorders (Gelfand & Drew, 2003; McMahon, et al., 2006). There are other comprehensive behavior rating systems such as the Behavior Assessment System for Children–Second Edition (BASC-II; Reynolds & Kamphaus, 2004), which is equally useful in assessing externalizing children. For school psychologists interested in an extensive review of available behavior ratings scales, the website (www2.massgeneral.org/schoolpsychiatry/schoolpsychiatry_checklists.asp) at the School Psychiatry Program of Massachusetts General Hospital is an excellent site. This site lists all of the major behavior rating scales as either preliminary screening checklists (i.e., CBCL, BASC-II) or checklists by specific disorders (i.e., ADHD, Aspergers, Depression, etc.), along with the age ranges, who completes the checklist, time to complete, and if there is a free version to view online.
Behavioral Observation Systems
Behavioral observation systems have several distinct advantages for school psychologists, particularly when assessing students with externalizing disorders. This is especially true when compared to (p. 390) anecdotal accounts and informal observations that are often conducted on externalizing-disordered children, but are of limited clinical use. Volpe and McConaughy (2005) discuss several advantages, including the following: they target specific behaviors; the behaviors are operationally defined; they follow standardized coding procedures; they yield quantitative scores; and they can be tested for reliability and validity. The major drawback of structured observation systems is that they seldom include a standardized comparison group, so comparing the severity of a behavior with a norm is difficult. Also, structured observation systems can be time consuming in comparison to other assessment approaches, such as behavior rating scales.
For assessing externalizing students in the classroom setting, there are several structured observations systems (Volpe, Diperna, Hintze, & Shapiro, 2005). These systems include the Behavioral Observation of Students in Schools (BOSS; Shapiro, 2004), ADHD School Observation Code (Gadow, Sprafkin, & Nolan, 1996), Classroom Observation Code (Abikoff & Gittelman, 1985); State-Event Classroom Observation System (Saudargas, 1997); and the Student Observation System (Reynolds & Kamphaus, 2004). These observation systems have the advantage of giving specific sampling of such externalizing behaviors as aggression (physical and verbal), out-of-seat behavior, talking out, off-task, hyperactive behavior, and noncompliance. Several of these systems are advantageous because the observational data can be directly entered into a laptop computer or handheld device, to collect and summarize.
The Behavioral Observation of Students in School (BOSS; Shapiro, 2004) is an excellent example of a school based observation system. It has been recommended for use with externalizing students (Volpe et al., 2005), and can be used to assess behavioral excesses in the classroom (i.e., leaving seat, throwing objects, talk-outs) and behavioral deficits (i.e., passive inattention, off-task). The BOSS gives a quantitative estimate of a student’s active engagement time (AET) when they are directly engaged in appropriate academic activities (i.e., reading aloud) and passive engagement time (PET; i.e., listening to (p. 391) the teacher). The observational data can be easily collected and entered into a handheld device. It also has the advantage that for every fifth interval of recording observational data on a referred child, data are also taken on a comparison peer in the classroom. This allows a direct comparison of the externalizing student’s behavior to a nonreferred peer’s behavior.
Other formal observation systems have been developed that can be used by school psychologists during test sessions and clinical interviews (McConaughy, 2005), and in clinic settings (McMahon et al., 2006; Roberts, 2001). The Behavioral Coding System (BCS; Forehand & McMahon, 1981) is particularly useful in structured situations (i.e., playroom) in which parents are guided (often with a radio “bug” in the ear) to interact with their child in a free play situation. For externalizing students, direct measures can be made on how parents give their child commands, compliance rates of the child, and the ability of parents to follow through with consequences (e.g., praise, timeout).
A simple approach to measuring one of the core problem behaviors for externalizing disorders, noncompliance, is the Compliance Test (Roberts & Powers, 1988). In a “clean up the toys” analog clinic setting, a parent is given a list of thirty 2-step commands (from an observing therapist behind a one-way mirror, with a radio bug device in the parent’s ear) to give to the child. For example, in the first step the parent gives the child the command to “Pick up the toy.” If the child complies, the parent then gives a second step command, “Now put it in the box.” If the child does not initially comply, the parent says, “Now pick up the toy and put it in the box.” Once the command is given by the parent, there is no verbal follow-up or consequence to the child. The child’s compliance or noncompliance behaviors are then coded. There is also a classroom version of the Compliance Test in which teachers give 30 common commands to an externalizing student (Jesse, 1989; Rhode et al., 2010). The advantage of either the clinic or school version of the Compliance Test is that is gives a direct estimate of noncompliance of an externalizing child (e.g., 50% compliance to request is considered clinically significant) and can be done in approximately 15 minutes. Research has shown that the Compliance Test accurately identifies and discriminates disruptive externalizing children from typical children (Filcheck, Berry, & McNell, 2004).
Another approach that is useful in observing externalizing students in classroom settings is the response discrepancy observation system (Alessi, 1980). A problem with most behavioral observation systems is that there is generally no comparison group of nondisabled students to use as a comparison standard. One solution for school psychologists using direct observations of externalizing students is the response discrepancy model (Rhode et al., 1992). With this model, during each observational time interval in which the externalizing student is observed, a nondisabled peer is also observed for the same time interval. Figure 18.4 gives an example of a response discrepancy observation sheet. There are ninety 10-second intervals on this sheet for a standard 15- minute observation. The method utilizes a momentary time sampling approach. With this approach, if the referred student exhibits any of the behaviors listed in the behavior code list (see Figure 18.4) that behavior is coded in the last second of the 10-second interval.
At the same time, for the same 10-second interval, a typical peer is also observed and his behavior is also is recorded. In the next 10-second interval, the referred student is observed again, however, now a different typical peer is also observed. At the end of the ninety 10-second observations in the 15-minute period, the observer has a good sample of the problem behaviors exhibited by the referred child. In addition, the school psychologist has a micronorm for comparison on the same problem behaviors exhibited by the typical peers in the same classroom.
The advantages of the response discrepancy observation system listed in Figure 18.4 are the normative comparison to peers, and the problem behaviors coded by the system. This approach focuses on the off-task behavior in the classroom, because off-task is a good index behavior of lower frequency externalizing problem behaviors, such as noncompliance (Barriga, Dorn, Newell, Morrison, Barbetti, & Robbins, 2002). Noncompliance, disruptive behaviors, and aggression occur at much lower rates and are thus harder to observe. However, off-task behaviors occur at a much higher rate and can easily be observed. There is a direct correlation between the occurrence of high-rate off-task behaviors and lower rate externalizing behaviors (e.g., noncompliance and disruption; Barriga et al., 2002; Rhode & Jenson, 2010). Knowing the rate of off-task behaviors is a good indicator of other low-rate externalizing behaviors. In addition, this observation system offers some unique coded behaviors associated with externalizing disorders, such as playing with an object, making noise with body, and inactive off task. The observation system can also be used to assess the (p. 392) positive and negative teacher interactions with the externalizing student, which are valuable when designing effective intervention strategies.
Functional Behavior Assessment and Externalizing Students
Functional behavior assessment (FBA) has gained widespread support for use with students with disabilities (Gelfand & Drew, 2003; March & Horner, 2002). The FBA concept is not new, and was first described by B. F. Skinner in 1953. Functional behavior assessment “is the process of identifying the events that reliably predict and maintain problem behavior” (March & Horner, 2002, p. 158). In essence, functional behavior assessment shows the functional relationship between a problem and the events that precede it (antecedents) and the variables that follow the behavior and maintain it (consequences).
This functional relationship is described as the A (antecedent) B (behavior) C (consequence) model, or ABC model. The antecedents in this model set the occasion and precede the problem behavior, and are commonly events (e.g., changing classes, loud distracting sounds, class interruptions, requests), people (e.g., peers, teachers, parents), times (e.g., between classes, after school, late weekend nights), or places (e.g., alone in a car, behind the school with peers, at the shopping mall). The Bs in the ABC model are generally the behavioral excesses exhibited by externalizing students such as aggression, noncompliance, or arguing. However, the externalizing behaviors can also include such behavioral deficits as poor social skills or academic problems. The consequences that motivate and follow the behavior are positive reinforcing events that increase or maintain the behavior (e.g., attention, money, illegal substances), punishing events that suppress or reduce a behavior (i.e., timeout, loss of privileges, criticism), and negative reinforcing events, which increase or maintain a behavior to escape or avoid the consequence. Coercion, where a student increases his arguing, tantrums, and aggression to (p. 393) escape complying with an adult request, is a good example of a negatively reinforcing consequence.
There are several approaches and formal systems that can help a school psychologist collect the information for the ABC model, including interviewing, review of the student’s records, filling out ABC event sheets, plotting the behavior as a scatter plot, and direct observations. With a specialized type of FBA, functional behavior analysis, a mini-experiment is performed by the clinician in which antecedents and consequences are intentionally manipulated to see if they systematically affect the problem behavior being studied (Alberto & Troutman, 2006). There are formalized, commercially published functional behavior assessment systems that have generated a great deal of research and can be used clinically and educationally (Nelson, Roberts, & Smith, 1998; O’Neill, Horner, Albin, Sprague, Storey, & Newton, 1997; Witt, Daley, Noell, 2000). There is also a computerized functional behavior assessment system (Functional Behavior and Assessment System [FAIP], Jenson, Likins, Hofmeister, Morgan, Reavis, Rhode, & Sweeten, 1999) which guides the ABC interview, assesses and reports the antecedents and consequences, suggests interventions, and compiles a complete FBA report. This system has been shown to be as effective as more formalized FBA systems, and preferred by educators because it takes less time, prepares an FBA report, and suggests interventions for the problem behavior being studied (Hartwig, Tuesday-Heathfield, & Jenson, 2004).
Legislation in the United States (Reauthorization of IDEA-2004) now requires an FBA to be conducted when a student with a disability has been suspended from school for more than 10 days because of a problem behavior that is a direct manifestation of their disability. However, even if an FBA were not legally required, it is still one of the most informative assessment procedures for students with externalizing disorders. FBAs have been used to assess externalizing students for such problem behaviors as aggression and tantrumming (Erickson, Stage, & Nelson, 2006), for ADHD/being off task (Ervin, DuPaul, Kern, & Friman, 1998), running away (Kodak, Grow, & Northrup, 2004), and noncompliance (Wilder, Harris, Reagan, & Rasey, 2007). For externalizing students, some of the most common antecedents for problem behaviors are the presence of peers, or a poorly given command or request from an adult (Rhode et al., 2010). Conversely, some of the most common maintaining consequences are attention from peers, or escape or avoidance of an adult request. A simple approach for conducting an FBA is the use of ABC event sheets (Rhode et al., 2010). An example of an ABC event sheet is given in Figure 18.5. Multiple copies are made of the ABC event sheet. Each time the problem behavior occurs, the antecedents that precede the behavior and the consequences that follow the behavior are filled in on the ABC sheets.
Over time, when several ABC sheets have been completed, they can be compared to assess common antecedents and consequences for the externalizing student. The most frequently occurring antecedents described on the ABC sheets are the probable events that elicit or set the occasion for the problem behavior. The most frequent consequences that follow the behavior are the probable events that motivate the problem behavior.
Whole School Assessment of Externalizing Disorders
Assessments can be made of whole schools in which screenings are conducted to identify individual students with externalizing problems. In addition to identifying at-risk externalizing students, whole school assessment can pinpoint which types of problem behaviors are occurring most often in a school, where they are occurring, and at what specific times of the school day. Whole school assessments allow a school to be strategic in designing intervention programs. Whole school assessment can also be used to identify externalizing students and design early interventions and prevention programs before the behavior problems become exacerbated and entrenched.
The Systematic Screening for Behavior Disorders (SSBD; Walker & Serverson, 1990) is a multi-gated screening assessment system for children at risk for externalizing and internalizing disorders. Although the SSBD system screens for both externalizing and internalizing students, this discussion will focus only on externalizing students. The SSBD system was first standardized on elementary school children grades 1–6, but has been adapted for a downward extension of preschool students (Feil, Severson, & Walker, 1998), and an upward extension to middle and junior high school students (Caldarella, Young, Richardson, Young, & Young, 2008).
The SSBD system is a multiple gating assessment because it consists of a series of three interrelated assessment steps called gates (Walker, et al. 2004). With the first gate of the assessment process, a teacher is asked to nominate three students who meet the profile of an externalizing student. A written description is given to the teacher of a profile of a typical (p. 394) externalizing student who is aggressive, noncompliant, defiant, and argues. Using the written profile as a guide, the teacher lists three students who rank highest on the externalizing dimension in his class. With the second gate, the teacher is asked to rate these three highest ranking externalizing students on two brief rating scales. The first rating scale is the Combined Frequency Index which measures how frequently the student exhibits certain adaptive and maladaptive behaviors. The second scale is the Critical Events Index which includes 33 externalizing behaviors. The teacher is asked to rank the frequency of these behaviors by the student over the past 6 months. Students that exceed the norms on both of these steps in the second gate are referred for a third gate assessment. In the third gate, a professional trained observer, such as a school psychologist, is asked to complete two direct observations of all students who have made it past gates one and two. One observation is of student academic engagement while working on an independent assignment in the classroom. The second observation is of the student’s social behavior at recess or on the playground. Students who are identified, pass through all three gates, and exceed the norms, are those who are at most risk for developing significant externalizing problem behaviors (Caldarella, et al., 2008; Walker, Cheney, Stage, Blum, & Horner, 2005; Walker, Severson, Nicholson, Kehle, Jenson, & Clark, 1994).
Another schoolwide screening approach for externalizing students is based on the Positive Behavior Supports (PBS) model developed at the University of Oregon (Lewis & Sugai, 1999). The PBS system is based on the public health model for disease which includes primary, secondary, and tertiary levels of prevention and care. The PBS model is best visualized as a triangle. The broad base (or first tier) of the triangle represents 80% of the students in the school who are successfully managed with the primary management and discipline techniques already established in the school. The second tier of the triangle represents approximately 15% of the students who are at risk for significant behavior, academic, and social problems. The top tier of the (p. 395) triangle represents those students (5%) who are having significant discipline problems at school. The PBS model is a primary prevention model that emphasizes positive whole school management, the establishment of expectations through universal school rules, data based decision making, and the use of functional behavior assessment.
The data based decision making of the PBS model is based on the University of Oregon’s computerized School-Wide Information System (SWIS). With the SWIS system, office discipline referrals (ODRs) are entered into a computer data base. The ODR is the standard unit of measurement for discipline problems in the SWIS system. Over time, this system is capable of summarizing data on individual students, groups of students, or the whole student body. The 15% of students (Tier 2) who are at risk in the PBS triangle generally have two to five ODRs in a year, and about 5% of the students who are at most risk (Teir 3) have six or more ODRs (Scott, 2007). The at-risk students and most-at-risk students generally exhibit externalizing types of behaviors such as noncompliance, inappropriate physical contact, interrupting, etc. (Marchant, Anderson, Caldarella, Fisher, Young, & Young, 2008). Research has shown that PBS school management teams, given SWIS data on at-risk students, can reduce the overall number of ODRs in school in a year by approximately 50% with significant overall improvements in academic achievement (Scott, 2007).
Interventions for Externalizing Disorders: An Evidence Based Practice Approach
The term evidence-based practice (EBP) is frequently used today in relation to educational and psychosocial treatments for children and youth. Its frequency may be partially attributable to the reference 111 times to “researched based” or “research proven techniques” in the No Child Left Behind (United States Office of Education, 2002) federal legislation. However, EBP has roots that reach back to 1996 when Division 12 (Clinical Psychology) of the American Psychological Association published a state of the art summation and update of characteristics of empirically supported treatments (Chambless, Sanderson, Shoham, Johnson, Pope, Crits-Christoph, et al.,1996). Since then, EBP position papers and criteria have been published specifically for special education (Odom, Brantlinger, Gersten, Horner, Thompson, & Harris, 2005), behavior analysis (O’Donohue & Ferguson, 2006), school psychology (Stoiber & Kratochwill, 2000), and by the American Psychological Association (APA Task Force on Evidence-Based Practice, 2006) and the U.S. Office of Education, Institute of Education Science (Coalition Board of Advisors, 2003). There have been several intervention books published that focus exclusively on evidence based treatments and interventions: Treatments that Work with Children: Empirically supported strategies for managing childhood problems (Christophersen & Mortweet, 2002); Interventions: Evidence-Based Behavioral Strategies for Individual Students (Sprick & Garrison, 2008); School–Based Interventions for Students with Behavior Problems (Bowen, Jenson, & Clark, 2004); and Evidence-Based Psychotherapies for Children and Adolescents (Kazdin & Weisz, 2003). Recently, a special edition of the Journal of Child and Adolescent Psychology (2008) published an update of evidence-based psychosocial treatments for all of the major disorders in children (Silverman & Hinshaw, 2008). For externalizing disorders, there are two review papers of particular interest, one an EBP review of ADHD (Pelham, & Fabiano, 2008) and a second EBP review of disruptive disorders in children (Eyberg, Nelson, & Boggs, 2008).
The basic criteria for EBP include: a series of group or single-subject designed research studies; random assignment of subjects; well defined samples; conducted in independent research settings; statistically superior treatments (e.g., large effect sizes); and the inclusion of treatment manuals (see review by Silverman & Hinshaw, 2008).
Also gaining credence as a method for indentifying EBP treatments are meta-analytic studies. Meta-analyses study a particular intervention, for a specific population, over many years (e.g., 10 years) and yield effect sizes which are easily interpretable and show a magnitude of effect that is not based on the null hypotheses or simple p values (Jenson, Clark, Kircher, & Kritjansson, 2007). The effect sizes produced by meta-analytic studies indicate the magnitude of an effect with .0 = no effect, .2 = small effect, .5 = medium effect, and .8 = a large effect size (Cohen, 1988).
In this section, EBP standards will be used to judge the effectiveness of interventions for children with externalizing disorders. When meta-analytic studies are available, they will be used along with their reported effect sizes to judge the effectiveness and magnitude of specific interventions. The focus of the interventions will not be the traditional treatments associated with ADHD, CD, or ODD, because these are well reported in the literature (Eyberg, et al, 2008; Smith et al., 2006; McMahon, et al., 2006; Pelham, & Fabiano, 2008) and in this (p. 396) volume. Interventions that are associated with externalizing disorders in general, and are consistent with the definition of externalizing disorders given at the beginning of this chapter, will be reported. These include interventions for noncompliance, countering the negative effects of peers in groups, supervision and monitoring, parent training, and social skills training.
Interventions for Noncompliance
Noncompliance is one of the most common behavior problems of childhood, and a leading reason for referrals for intervention and treatment (Gelfand & Drew, 2003; Kalb & Loeber, 2003; Patterson et al., 1992). It is also one of the most common problematic behaviors found across all the major externalizing conditions (e.g., ADHD, ODD, and CD; see McMahon et al., 2006; Smith, et al., 2006). As we have reported earlier, noncompliance is a core characteristic of externalizing disorders, and a kingpin behavior (Patterson, 1982; Forgatch, & DeGarmo, 2002). Improvements in noncompliance will often result in collateral improvements in other nontreated problematic behaviors (Martinez & Forgatch, 2001; Parrish, Cataldo, Kolko, & Engle, 1986; Russo, Cataldo, & Cushing, 1981; Wells, Forehand, & Griest, 1980).
Noncompliance has been defined as the refusal to initiate a requested behavior from another person (generally an adult) within a specific period of time (5 to 10 seconds) (Forehand & McMahon, 1981; Yeager & McLaughlin, 1995; Rhode et al., 2010). The exact normative rates of compliance are difficult to establish because of differences due to the age and sex of the child, clinically versus nonclinically referred children, what type of requests are given, and several other factors. However, in an early review paper, Forehand (1977) reported compliance rates for nonclinically referred children as 70% to 80%, and for clinically referred children as approximately 30% to 40%.
Noncompliance is developmental in nature, frequently starting to increase in the early preschool years and decreasing about age five (Patterson, 1976). Many parents view their toddlers in these early years as “extremely noncompliant” (Kalb & Loeber, 2003). In the Pittsburg Youth Study, noncompliance before school age was not considered to predict later poor outcomes in childhood unless it was accompanied by aggression, impulsivity, and hyperactivity (Kalb & Loeber, 2003). However, by school age, boys at age 7 with persistent noncompliance were at greater risk for developing significant behavior problems. One study (Hämäläinen & Pulkkinen, 1996) found that noncompliance at age 8 was also correlated with aggression at age 8, and then correlated with aggression and norm-breaking at age 14. By the time a child enters school, noncompliance—especially when associated with aggression, impulsivity, and negativism—can lead to significant social and school adjustment problems. Early effective intervention is important in stemming problems that can lead to school failure, social rejection, family disruption, and delinquency.
Evidence-based interventions for problematic noncompliance can be viewed through an ABC model of antecedent control, consequence control, and approaches that include both antecedent and consequence control. The best predictor of a child’s noncompliance to a request is the antecedent event occurring immediately before the child’s noncompliant behavior (Williams & Forehand, 1984). This “antecedent event” is generally an adult caregiver (e.g., parent or teacher) who issues the command. The manner in which the request or command is given can affect student compliance rates by 20% to 40% (Hamlet, Axelrod, Kuerschner, 1984; Matheson & Shriver, 2005). Much of the antecedent control research for noncompliant behavior has been pioneered by Forehand and McMahon (Forehand, 1977; McMahon & Forehand, 1981). These antecedents include proximity or closeness to the child (Forehand, 1977; Kalb & Loeber, 2003); giving a direct command rather than indirect request (implied or suggested) (Elrod, 1987; Matheson & Shriver, 2005); specific rather than vague commands (Dumas & Lechowicz, 1989); making eye contact when giving the command (Hamlet et al., 1984; Kapalka, 2004); allowing enough time (e.g., 5 seconds) for compliance (Forehand, 1977; Matheson & Shriver, 2005), not interrupting the initial command in the 5-second window by repeating the command (Forehand, 1977); stating the command in a quiet and positive voice (Matheson & Shriver, 2005); giving fewer commands and waiting for compliance (Forehand, 1977); giving more positive initiation “do” commands than negative cessation “don’t” commands (Neef, Shafer, Egel, Cataldo, & Parrish, 1983); not using a question formatted command (e.g., Wouldn’t you like to……?) but rather a positive direct command (e.g., Please do…; Faciane, 2005; Reed, 1985); and preceding a low-probability compliance request (40% or lower) with a high-probability compliance request (70% or higher), which is referred to as behavior momentum (Mace, & Belfiore, 1990). A summary of the antecedent (p. 397) events associated with effective request-making is given in Table 18.2.
Some researchers have formalized the antecedent variables listed above into a two-part request with a “signal” or warning word (MacKay, McLaughlin, Kimberly, & Derby, 2001; Musser, Bray, Kehle, & Jenson, 2001; Rhode et al., 2010; Yeager & McLaughlin, 1995). The two-part request is, “Please (request behavior),” allowing a 5-second time period for the child to comply, followed by praise and attention if the child complies. If the child does not comply, the request is followed by a “You need to (request behavior).” The word “need” is the discriminative stimulus that if the child does not comply with the original request, then a reductive consequence will follow. Reductive consequences have included timeout, loss of a favored toy, or loss of points (MacKay, et al., 2001; Muesser, et al., 2001; Rhode et al., 2010, Yeager & McLaughlin,
Table 18.2 Strategies for improving compliance
Do not use a question format for a request
Give time for compliance (approximately 3 to 5 seconds)
Get close to the child when giving the request (approximately 3 feet)
Use the child’s name when giving a request
Do not give repeated commands (approximately 2 commands)
Look the child in the eye when you give a request
Give a direct request rather than an indirect command (i.e., a suggestion)
Give a clear and specific request rather then a vague request
Give the request in a quiet, positive voice
Give more “Do” requests rather than “Don’t” requests
Give high probability compliance request immediately before a low probability request
Socially reward the child for following the request
Interventions for Inappropriate Peer Influences in Group Settings
As reviewed earlier in this chapter, research has shown (Arnold & Hughes, 1999; Dishion et al., 1999) that grouping externalizing students together in instructional or treatment groups can lead to negative peer deviancy training. In essence, peers in these groups teach and reinforce deviant forms of behavior to each other. With this deviancy training, “adolescents derive meaning and values from the deviancy training process that provides the cognitive basis for motivation to commit delinquent acts in the future…” (Dishion et al., 1999, p. 762). It is estimated (Buehler, Patterson, & Furiness, 1966) that in institutional settings, the peer reinforcement to adult reinforcement rate is 9:1, indicating strong peer influence and an undermining of adult control. When antisocial youth are paired in groups, the training sequence involves the rule-breaking talk of one youth, which is followed by reinforcing laughter from another youth, and then an escalation in antisocial behavior for that pair of youth and others in the group (Dishion, Spracklen, Andrews, & Patterson, 1996). If behavioral control is lost in a group setting, with rule breaking and peer reinforcement for deviant behavior, then the intended purpose of instruction or treatment in the group is defeated.
Several variables can mediate this negative peer influence (Arnold & Hughes, 1999; Dishion et al., 1999). Age of the student is one variable, with younger students showing less of a negative peer effect. The nonhomogeneous grouping of youth, where externalizing youth are mixed with prosocial youth can have a dampening effect on inappropriate peer influences. However mixing prosocial and externalizing youth may be an unrealistic procedure. (p. 398) Behavior management procedures that control group behavior may have a distinct advantage when the grouping of externalizing students is necessary. A group contingency is a system that delivers an incentive (a reward or reductive consequence) to the entire group based on the behavior of the individuals in that group ( Jenson & Reavis, 1996). Evidence-based practice meta-analytic research has shown that group contingencies are the most effective intervention in reducing disruptive behavior in public education settings (Stage & Quiroz, 1997). Group contingencies are particularly effective when there is both overt and covert peer support for inappropriate behavior, and there is a need to foster positive peer cooperation (Morgan & Jenson, 1989).
The effectiveness of group contingencies has been shown to be effective in the control of disruptive classroom behavior (Theodore, Bray, Kehle, & Jenson, 2001), problematic bus riding behavior (Greene, Bailey, & Barber, 1981), inappropriate behavior in lunchroom settings (Fabiano, Pelham, Karmazin, Kreher, Panahon, & Carlson, 2008), disruptive library behavior (Fishbein & Wasik, 1981), class transition times (Campbell & Skinner, 2004), swearing behavior (Kazdin, 2005), and several other areas. There are basically three types of group contingencies: dependent, independent, and interdependent (Litow & Pumroy, 1975). In a dependent group contingency, the whole group’s incentive is based on the performance or behavior of one (or a few) individual(s). This is the most pressuring type of group contingency, and adverse effects can occur if the identity of the individual is known. It should be used with extreme caution or not at all with externalizing students. In an independent group contingency, each member of the group who meets a preset criteria is rewarded. The incentive is based on each student’s own performance in meeting the criteria. All the students meeting the criteria are rewarded; all the students that do not meet the standard are not rewarded. In an interdependent group contingency, the students in the group receive an incentive dependent upon the behavior or performance of the whole group. The interdependent group contingency is possibly the most powerful in managing inappropriate peer reinforcement and behaviors, because all students are dependent upon each other.
One of the best known and most studied group contingencies is the Good Behavior Game developed by Barrish, Saunders, and Wolf (1969). The Good Behavior Game utilizes team cooperation, peer influence, and an interdependent group contingency to increase rule following and decrease disruptive behaviors. It is especially effective in reducing inappropriate peer reinforcement for deviant behavior. With the Good Behavior Game, the group is split into teams which compete against themselves or a preset criterion for a reward. In the original study, conducted in a classroom of disruptive students, the team with the lowest number of behavioral infractions (i.e., rule-breaking) or less than 5 rule infractions won a group incentive. In this way, one team could win (i.e., lowest rule infractions) or all the teams could win (i.e., each team with less than 5 infractions). The Good Behavior Game has been well researched in a variety of settings, and its effectiveness documented over a 33-year period of time (Tingstrom, Sterling-Turner, & Wilczynski, 2006). It is especially effective in reducing subtle peer reinforcement for inappropriate and deviant behaviors. As in the original study (Barrish et al., 1969), if a particularly difficult peer refuses to participate and continues to disrupt, that individual is placed on a team by himself.
The randomized group contingency is a new form of group contingency that has been shown to be especially effective in controlling peer deviant behavior in group settings (Coogan, Kehle, Bray, & Chafouleas, 2007). With the mixed group contingency, the type of group contingency (i.e., dependent, independent, or interdependent), the type of problem behavior, the criteria for reinforcement, and the reinforcement to be earned can be all randomized. For example, Kelshaw-Levering, Sterling-Turner, Henry, and Skinner (2000) used a mixed group contingency with a veteran second grade teacher to control her disruptive classroom. The teacher had 27 years of teaching experience and described the class as “the worst class she has ever taught.” The mixed group contingency utilized four jars that were placed on the teacher’s desk. The first jar contained slips of papers labeled Behaviors, which specified the behaviors (e.g., off-task) and criteria that were to be judged for compliance. The second jar was labeled the Contingency Jar, with slips of paper with the terms Whole Class or Individual Name. The third jar was labeled Names, and contained all the students’ names in the classroom. The fourth jar was labeled Reinforcers which contained slips of paper with various reinforcers that could be earned.
Baseline observations in the classroom had shown that disruptive behaviors occurred 60 times during a 75-minute block of time (almost one per (p. 399) minute). The day was divided into three evaluation periods. At the end of an evaluation period a slip was drawn from the Behavior jar, which stated the behavior and criteria to be evaluated. Then a slip was drawn from the second Contingency jar, either a whole class slip or an individual student slip. If it was an individual student slip, then a student’s name was drawn from the third jar, Names. That student’s performance was then compared to the behavior and criteria selected from the Behavior jar. If the randomly selected slip from the Contingency jar was Whole Class, then the whole class’ performance was compared for the behavior selected from the Behavior jar. If the criteria were met (either by the whole class, or by an individual student, depending on the contingency), a reinforcer was randomly selected from the fourth Reinforcer jar for the whole class. After using this procedure, disruptive behaviors decreased dramatically from approximately 40% of the measured intervals in the baseline to less than 4% of the intervals in treatment.
In a similar study, Theordore et al., (2001) used a randomized group contingency to control the disruptive behavior of five inner city high school students in a self-contained classroom for students with severe emotional disturbance. The randomized group contingency reduced overall disruptive behavior in this classroom from an average of 42% of the baseline intervals to just 4% of the treatment phase intervals. Both of these studies show that a random mixed group contingency is very effective in reducing disruptive behaviors that are reinforced by deviant peers.
Supervision and Monitoring Externalizing Students
The importance of supervising and monitoring externalizing students has been highlighted earlier in this chapter. Externalizing students left unmonitored often develop problem behaviors, especially if the environment is high risk and populated with deviant peers. The areas that are most problematic in schools include transitions in the hallways, bunching of students near lockers, bathrooms, and stairwells, transition to school, and other areas where students can be easily unmonitored. One of the most high-risk times for students is the period of time right after school, before they reach home (Pettit, Laird, Dodge, & Bates, 1997). It is difficult for school psychologists to monitor all the high-risk areas in a school. However, teachers can be urged to stand by their doors during class transitions, and staff can be assigned times to randomly enter bathrooms, to walk in the halls, or stand at the top of stairwells. For externalizing students, there are also researched, structured supervision programs that are positive and effective in monitoring students’ high-risk behaviors.
The Check and Connect program was developed at the University of Minnesota to monitor and assist high-risk students (Anderson, Christenson, Sinclair, & Lehr, 2004; Christenson, Sinclair, Thurlow, & Evelo, 1999). The program has two basic components. The Check component is a continuous assessment of a student’s progress through a set of indicators that includes school attendance, grades, credits, disciplinary problems, and suspensions. The Connect component is a regular meeting (at least once a month, and often weekly) with an appointed monitor. During the Connect meeting, the mentor provides social skills instruction, academic support (homework assistance and tutoring), recreational and community service opportunities, and mediation with other school staff on the student’s behalf. The Check and Connect program emphasizes the continuous monitoring of at-risk students, and the relationship between the student and appointed mentor. The Check and Connect program has been extensively researched and recognized by the U.S. Office of Education What Works Clearing House (2006) as effective in helping students stay in school and make meaningful academic progress. Todd, Campbell, Meyer, and Horner (2008) have recently reported the effectiveness of the Check and Connect program in significantly lowering problem behaviors in four elementary schools in Oregon.
Another monitoring program is the Behavior Education Program (BEP; Crone, Horner, & Hawken, 2004) developed at the University of Oregon. The BEP is a check-in and check-out program for high-risk students who have received three to five office referrals for discipline problems in one academic year. The BEP program is commonly used with such behaviors as noncompliance, disruptive behavior, inappropriate language, and classroom talk-outs.
With the BEP, a student checks in with a supervising adult at the beginning of the school day and checks out again at the ending of the day. The program emphasizes that the adult checking the student in and out should be positive, supportive, and a person the student trusts. The student initially develops a BEP contract with the supervising adult that lists the behaviors that will be tracked and monitored across the day. During this contracting process, the student also negotiates a list of rewards he (p. 400) can earn by making progress. At the morning check-in, the student picks up his Daily Progress Report (DPR) card with a list of behaviors (e.g., follows directions, keeps hands and feet to self) or academic tasks (e.g., completing work, being prepared). The student then carries the (DPR) card across the day, and his progress is monitored and rated by his teachers. At the end of the day the DPR card is rated by the supervising adult and feedback is given, and the student’s progress is graphed. The student has a chance to earn points that are later exchanged for back-up reinforcers.
Over time, the supervising adult enters the student’s DPR ratings into a spreadsheet to monitor student progress. The student’s progress is regularly monitored by the school’s BEP team. If problems occur, or a student does not seem to be making progress, the school’s BEP team can suggest program adjustments or conduct a functional behavior assessment (FBA) and develop a formal Behavior Support Plan. Parents are also given an orientation to the BEP program, and receive copies of the DPR card.
The research on the BEP program has documented its effectiveness in reducing problem behaviors with reductions of approximately 50% in office disciplinary referrals (Fairbanks, Sugai, Guardino, & Lathrop, 2007; Filter, McKenna, Benedict, Horner, Todd, & Watson, 2007; Hawken, MacLeod, & Rawlings, 2007). The program is designed for students who are at risk and externalizers, but not for the most extreme violent or destructive students.
Social Skills Training for Externalizing Students
Social skills deficits are a defining deficit of externalizing students. These students are commonly shunned by other youth, and seek other externalizing students for social affiliation (Gresham, 1998; Patterson et al., 1992). These social problems may be a function of not knowing how to perform essential social skills (i.e., a deficit) or performance problems (i.e., knowing how to perform the skill, but not doing so; Gresham, 1986; Gresham, Sugai, & Horner, 2001). Performance problems may be a function of anxiety in performing the skill, negative reactions from other deviant youth, or the inability to generalize the skill from the training environment to actual social situations. Performance problems can undermine the generalization of newly learned social skills from the training environment to the general social environment of the externalizing youth.
There are several different types of social skills training programs which focus on teaching social skills for general social interaction skills, making friends, and using problem solving in social situations. These programs include Skill Streaming the Elementary School Child (McGinnis & Goldstein, 1997), The Prepare Curriculum (Goldstein, 1988), The ASSET Program (Hazel, Bragg, Schumaker, Sherman, & Sheldon-Wildgen, 1981), The ACCEPTS Program: A Curriculum for Children’s Effective Peer and Teacher Skills (Walker, McConnell, Holmes, Todis, Walker, & Golden, 1983), and The Tough Kid Social Skills Program (Sheridan, 1995). These general social skills programs are frequently standalone programs, where students are “pulled out” of their regular school activities and placed in a special social skill training group for instruction. This instruction generally includes a rationale for using the social skill, task analysis teaching of the steps involved in the skill, demonstration of the skill through modeling, role playing the skill, and coaching of the skill (Walker, Ramsey, & Gresham, 2004). Some programs include behavior management strategies, homework, and generalization techniques.
The overall effectiveness of general social skills programs for externalizing youth is mixed. Several meta-analytic studies have shown that general social skills programs are ineffectual, with limited supporting research (Forness & Kavale, 1996; Quinn, Kavale, Mathur, Rutherford, & Forness, 1999; Smith & Travis, 2001). The externalizing youth may learn the skills in an instructional environment, but fail to use them in social situations where they are needed. DuPaul and Eckert (1994) have described this phenomena as “the effects of social skills curricula: now you see them and now you don’t” (p. 13). DuPaul and Eckert (1994) suggest that the problem of not using newly learned social skills in the general social environment is a “generalization” problem, and gives several suggestions (e.g., train sufficient exemplars, modify consequences, use self-mediated stimuli) to improve generalization. Other researchers (Cook, Gresham, Kern, Barreas, Thornton, & Crews, 2008), in a reanalysis of the meta-analytic research on social skills training for secondary students, have reported more promising results. However, even in this extensive reanalysis of the meta-analytic research, the effect size for treatment effectiveness for general social skills programs is still only a modest .32.
Other specialized social skills programs involve a more comprehensive training program that includes training the externalizing students, their parents, (p. 401) and their teachers. The Incredible Years Parents, Teachers, and Children Training Series (http://www.incredibleyears.com) is one such program (Webster-Stratton & Reid, 2003). This program has an extensive curriculum, video modeling tapes, behavior management, and dinosaur puppets for instruction of toddlers through elementary students diagnosed with ADHD, CD, or ODD. The evaluation of the Incredible Years social skills program (i.e., Dino Dinosaurs) has been extensively researched, with significant reductions in aggression at school and home (Webster-Stratton & Reid, 2003). Another program is the Problem-Solving Skills Training (PSST; Kazdin, 2003), which focuses on teaching problem-solving skills for real-life social problems. The model is based on an information processing model that includes problem identification, generating solutions, making a decision, and evaluating the outcome. This program also includes a parent training component and therapeutically planned activities outside the training session, called “super solvers,” for practice and generalization of the problem-solving skills. The PSST has been evaluated compared to placebo controls, a supportive relationship therapy group, and client-centered relationship therapy (Kazdin, Bass, Siegel, & Thomas, 1989; Kazdin, Esveldt-Dawson, French, & Unis, 1987). The PSST approach was significantly superior to the supportive relationship and client-centered relationship therapy groups, as measured by CBCL and the TRF, with maintenance at a one-year follow-up evaluation.
There are specialized social skills training programs that focus on anger management and bullying. These programs are multi-component programs that can include self-management procedures, direct interventions, and prevention components.
Anger Coping Training (Lochman, Barry, & Pardini, 2003) is designed as a social information processing intervention for externalizing elementary children. In the program, children discuss anger-based social encounters with peers, the anger-provoking cues, and the possible motives of the peers. The children are taught cognitive-behavioral techniques to reduce their anger, including anger reducing self-talk, problem solving, negotiation, and other skills. In addition to the school based training program, the Anger Coping Training program also includes a parent training component. Lochman and Wells (2003) have shown that the Anger Control Training leads to a reduction in substance abuse, and improved children’s social competence when compared to a no-treatment control group. A similar program is Anger Replacement Training (ART; Goldstein, Glick, Reiner, Zimmerman, Coultry, & Gold, 1987). ART is a multi-component program for externalizing adolescents that involves teaching moral reasoning, basic social skills training, self-coaching, and an ABC-functional assessment model of dealing with anger. The student learns the antecedent cues for their anger (triggers), stress reduction, and anger control strategies, and maintains a Hassle Log of their difficult anger interactions with adults and peers. The effectiveness research on ART has shown improvements in global ratings of anger, and reductions in arrests (Goldstein & Glick, 1994). However, in residential treatment center evaluation of Aggression Replacement Training, there was a reported improvement of the knowledge in how to manage anger, but no significant changes in overt behavior of externalizing adolescents (Coleman, Pfeiffer, & Okland, 1991). In an effort to determine the overall effectiveness of evaluation of cognitive-behavioral interventions for anger management, a meta-analysis was conducted by Sukhodolsky, Kassinove, and Gorman in 2004. This included 51 intervention studies, and yielded only a medium magnitude effect size of .67.
Anit-bullying programs can be viewed as a specialized social skills program to reduce bullying behaviors, primarily from externalizing students. Bullying is often defined as an “intent to do harm, the repeated aspect of the harmful acts, and the power imbalance between bully and victim” (Merrell, Gueldner, Ross, & Isava, 2008, p. 26).
The basic focus of many anti-bullying programs is at the whole-school level, by raising awareness of bullying behavior for students and staff. Other components can include special training for victims, and interventions for identified bullies. The Olweus Bully Prevention Program (Olweus, 1993) from Norway is possibly the best researched anti-bullying program. This program is divided into core components which include several school-level anti-bullying components (e.g., develop schoolwide rules against bullying, form of a Bully Prevention Coordinating Committee, and develop specific consequences for bullying); a classroom-level component (e.g., classroom training to increase knowledge of bullying and empathy for victims, informational meetings with parents); and an individual-level component (e.g., interventions for children who bully and their victims, and discussions with parents of involved students). (See www.clemson.edu/olweus/). This program has been evaluated in several large Norwegian studies, including 2,500 children grades 4–7 in Norway (Olweus, 1991) and in the United (p. 402) States, including 18 middle schools in South Carolina (Limber, 2004) and 12 elementary schools in Philadelphia (Black, 2003). Reductions in bullying by student self-reports in these studies are approximately 50%. Other bullying programs have been developed in the United States, such as Bully-Proofing Your School (Garrity, Jens, Porter, Sager, Short-Camilli, 1993), the Expect- Respect Program (Whitaker, Rosenbluth, Valle, & Sanchez, 2003), and the Tough Kid Bully Blockers program (Bowen, Ashcraft, Jenson, & Rhode, 2008).
The evidence-based practice research on anti-bullying programs is mixed. One problem with the anti-bullying programs is that the outcome data is primarily based on student and teacher self-reports. Few evaluation studies have actually utilized outcome measures based on behavioral observations, or reductions in disciplinary office referrals for bullying. Smith, Schneider, Smith, and Anaiadou (2004) conducted a meta-analysis of 14 studies and concluded, “the majority of programs evaluated to date have yielded nonsignificant outcomes on measures of self-report victimization” (p. 547). Ferguson, Miguel, Kilburn, and Sanchez (2007) conducted a meta-analysis of 45 anti-bullying studies, reaching the similar conclusion that anti-bullying programs are not practically effective in reducing bullying behavior or violence in the schools. In a third meta-analysis of 16 anti-bullying programs over a 25-year period based on 15,386 students K–12 grades, Merrill et al. (2008) found that only one-third of the effect sizes reflected meaningful and clinically important effects. The majority of effect sizes showed no meaningful positive effects. The authors concluded that bullying programs “are more likely to influence knowledge, attitudes, and self-perception rather than actual bullying behaviors” (p. 26).
Parent Training for Externalizing Students
Behavioral parent training is also known by several other names, such as behavioral family therapy (Griest & Wells, 1983), parent-interaction therapy (Bell & Eyberg, 2002), or parent management training (Patterson, Reid, Jones, & Conger, 1975). Essentially, these programs focus on teaching parents needed skills to effectively manage their child’s problem behaviors. These parent programs are not “talk therapy” or communication based programs; rather, they teach specific skills to manage misbehavior.
There are several common skills that are included in most behavior parent training programs. These skills generally involve teaching parents to specifically define and pinpoint target behaviors to be changed, focusing on positive reinforcement and effective praise; establishing home rules, learning to give effective commands, and learning to effectively use reductive consequences such as timeout and response cost for problem behaviors (Maughan, 2004). Some parent training programs (Jenson, Rhode, & Hepworth, 2003; Patterson, 1974) work exclusively by training the parents without the child being present. The parents learn and practice the skills with the therapist, and then apply the techniques as homework assignments with their child. Other programs (Forehand & McMahon, 1981; 2003; Hanf, 1969) train parents with the child present under controlled clinic conditions, such as one-way mirror training rooms and radio “bug in the ear” with real-time instructions to the parents given by an observing therapist. Both approaches have proven effective in managing externalizing students (McMahon et al., 2006; Eyberg, et al., 2008).
Patterson (1974; 1982) introduced the Parent Management Training Oregon Model to train parents to manage their externalizing children who had been referred for treatment from juvenile courts, schools, and mental health centers. Patterson et al. (1973) used programmed teaching manuals, Living with Children: New Methods for Parents and Teachers (Patterson & Gullion, 1968), or Families: Applications of Social Learning to Family Life (Patterson, 1971), to train parents to pinpoint behaviors, construct behavioral contracts, and apply contingencies for problem behaviors. In one study with 27 externalizing boys (Patterson, 1974), the program significantly reduced the frequency of deviant behaviors (approximately by 50%) for 2 out of 3 boys, with a time investment of 31.4 hours of training and 1.9 hours for a follow-up booster session.
Forehand and McMahon (1981) developed a treatment model, Helping the Noncompliant Child (Forehand and McMahon, 2003), that was based on the earlier parent training model of Hanf (1969; 1970). This model consists of two phases. In the first phase (differential attention), the parent is trained to break out of the coercive cycle by increasing positive attention to the child’s appropriate behaviors while ignoring inappropriate behaviors. The parent learns to positively describe the child’s behavior as they play a game in a controlled therapy room with “bug in the ear” instructions from a therapist. In the second phase of the intervention (compliance training), the parent is trained to give precise and direct commands (Alpha Commands) to the child, and refrain from imprecise and vague (p. 403) commands (Beta Commands). If the child complies with the parental command, he or she is socially rewarded and praised. If the child is noncompliant, the parent learns to effectively use reductive consequences such as a timeout procedure. The effectiveness of the Forehand and McMahon (2003) model has been documented and extensively reviewed (Eyberg, et al., 2008; McMahon, et al., 2006). The effects of significantly reduced deviant behaviors generalize over time, and appear independent of the families’ socioeconomic levels.
Other training programs for parents of externalizing children appear equally effective, with reductions in problematic behavior for Parent-Child Interaction Therapy (Brinkmeyer & Eyberg, 2003), the Incredible Years Program (Webster-Stratton, 1984), and the Tough Kid Parent Training Program (Jenson, Rhode, & Hepworth, 2003; Kuhn, 2004). The evidence-based practice research for the effectiveness of parent training has been established (Eyberg, et al., 2008). Two meta-analytic studies have also validated the effectiveness of parent training. Serketch & Dumas (1996) analyzed 26 behavioral parent training studies for children with antisocial behaviors (e.g., aggression, temper tantrums, and noncompliance). ADHD children were excluded from this study. The overall effect sizes for the reduction of externalizing behaviors were large (i.e., parent report, .84, independent observer, .85, and teacher report, .73). In essence, 80% of the children improved when their parents were trained. Maughan, Christensen, Jenson, Olympia, and Clark (2005) conducted a meta-analysis of 79 studies on parent training for externalizing children. This study did include ADHD children along with other externalizing children. For group designed research studies (between- and within-group), the effect sizes for reduction of externalizing behaviors ranged between .30 and .69, indicating that 62% and 76% of children whose parent(s) had received training did better than nontreated children. For single subject design studies, the effect size was very large, 1.56, indicating the children of trained parents were 95% better than nontreated children. The differences in meta-analytic studies and effect sizes are probably due to the selection of the externalizing children (i.e., exclusion or not of ADHD), the type of research designs (i.e., between group, within group, or single subject design), and whether the effect sizes were weighted for sample size. From the meta-analytic evaluation studies, it appears that training the parents of externalizing children is an effective intervention. The studies have shown significant reductions in behavioral excesses and disruptive behavior such as noncompliance, and improvement in positive family interactions and reductions in parent stress (Kuhn, 2004; Maughum et al., 2005).
Externalizing disorders represent one of the largest groups of children and adolescents referred for clinical and educational services. This group commonly includes children labeled as AttentionDeficit/Hyperactivity Disorder (ADHD), Conduct Disorder (CD), Oppositional Defiant Disorder (ODD), Severely Emotionally Disturbed (SED), and Behavior Disordered (BD). Primarily, these children have behaviors that are directed outward (externally) and affect others such as teachers, adult caretakers, and peers. In this chapter, we have chosen to define an externalizing disorder as a condition with behavioral excesses and behavioral deficits. The behavioral excesses include several behaviors such as noncompliance, aggression, impulsivity, arguing, tantrumming, property destruction, and bullying. The behavioral deficits include such areas as lack of self-control, poor social skills, and deficits in academic skills and school related behaviors. We have emphasized research that shows noncompliance as one of the defining characteristics of externalizing disorders. It is a “kingpin” behavior that is implicated in almost all the other behavior excesses, such as arguing, aggression, and tantrumming. It is also implicated in the causation of many of the behavioral deficits in the academic and social behavior of externalizing children. Research has shown that treatments that lead to significant reductions in noncompliance, collaterally lead to improvements in untreated externalizing behavioral excesses and behavioral deficits.
We have reviewed the literature for externalizing disorders, and have stressed several points about this disorder. First, externalizing disorders have multiple causes that include biological, familial, and environmental factors. The biological factors tend to result in a general vulnerability that put a child at risk for developing externalizing problems. Other factors include the development of the coercive cycle in families, which then leads to the development of more robust externalizing behaviors. This aversive cycle within a family negatively reinforces and shapes externalizing behaviors such as noncompliance and aggression. The child then learns and transfers coercive behaviors to other environments, including school and neighborhood settings. Academic failure and rejection by peers often compounds the problems (p. 404) of the externalizing child. This type of externalizing disorder is considered a “life path” externalizing disorder that starts early in a child’s life and then continues throughout adolescence and adulthood, as opposed to an “adolescent path” externalizing disorder that is characterized by a non-affected childhood and an onset in adolescence.
Research has shown for the “life path” externalizing disorder that early in childhood these behaviors are overt (e.g., aggression, opposition, defiance) and easily observed. However, as the child ages and enters adolescence they change into more covert behaviors (e.g., stealing, running away, substance abuse), which are more clandestine in nature. For the “adolescent path” there is a less problematic childhood, which is followed by antisocial behaviors developing in adolescence.
There are other important environmental factors that contribute to externalizing behavior problems. One area of particular concern is the influence of peers in high-risk unsupervised environments. Since externalizing children are commonly shunned and excluded by non-affected peers, they frequently seek other antisocial children for peer associations. These antisocial peers provide deviancy training, and directly reward antisocial behavior in each other. Grouping externalizing students for treatment or instruction without effective behavioral control can exacerbate externalizing problem behaviors.
Successful treatment approaches for children with externalizing disorders must be comprehensive to be successful. By comprehensive we mean that the treatment must successfully manage behavioral excesses and remediate behavioral deficits. We have limited our discussion in this chapter to only evidence-based treatments that can be commonly used with externalizing disorders. Some of the most promising treatments focus on reducing noncompliance, utilizing antecedent interventions such as precision requests. Other treatments emphasize increasing the supervision of externalizing disordered children, such as check-in and check-out monitoring programs. Still other interventions focus on peer management, especially when externalizing students are put into groups for instruction and treatment. Group contingencies that utilize randomized criteria and consequences have been notably successful in reducing deviant and disruptive behaviors in peers when they are grouped.
Some promising approaches such as social skills training, anger management, and bully prevention programs, have only been moderately successful. This is especially true of “pull out” training programs, where children are pulled out of their everyday environments and placed in special groups for social skills training. If social skills training programs are to be successful, then they must include systematic generalization procedures to ensure transfer of the skills to the child’s natural environment.
Possibly one of the most successful interventions for externalizing problems is training parents to use specialized behavior management techniques. These techniques include pinpointing and targeting specific behaviors for change, increasing reinforcement and rewards for appropriate behaviors, leaning antecedent control techniques such as making effective requests, and designing consequences for problem behaviors. Research has shown that this type of parent training is effective in reducing such problems as noncompliance and aggression, while improving social behaviors in externalizing children. Parent training is cost effective, focuses on the family, and emphasizes the development of appropriate behaviors and social skills.
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