Internalizing &

Externalizing Disorders

Akshara Pradeep
Externalizing Disorders
• Refers to a grouping of problems that are manifested in a child's
outward behavior and reflect the child acting negatively on the
external environment (Liu, 2004).

• Manifested by the person’s outward behaviors and related actions

(e.g., Achenbach, 1978 ; Campbell, Shaw, & Gilliom, 2000)

• Often act out toward their environment in a manner that violates

social rules of conduct and involves negative acts against others
and/or property
Disorders included are:

• Attention deficit hyperactivity disorder (ADHD)

• Conduct disorder (CD)

• Oppositional defiant disorder (ODD)

1. Intermittent explosive disorder (IED)
 Attention Deficit
Hyperactivity Disorder
3 COMPONENTS

• Inattention - difficulty getting on task, being in task and finishing them

• Hyperactivity - activity off task, out of seat, and disruptive. The activity is
developmentally inappropriate and is not goal directed or purposeful to
the task on hand.

• Impulsivity - inability to delay a response despite the anticipation of

negative consequences for the behavior. The difficulty in controlling
impulses is rated in comparison to others of the same age and gender.
Characteristics
Inattention
• Often fails to give close attention to details or makes careless mistakes in schoolwork,
work, or other activities
• Often has difficulty sustaining attention in tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental
effort (such as schoolwork or homework)
• Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils,
books, or tools)
• Is often easily distracted by extraneous stimuli
• Is often forgetful in daily activities
Hyperactivity
• Often fidgets with hands or feet or squirms in seat
• Often leaves seat in classroom or in other situations in which
remaining seated is expected
• Often runs about or climbs excessively in situations in which it is
inappropriate
• Often has difficulty playing or engaging in leisure activities quietly
• Is often “on the go” or often acts as if “driven by a motor”
• Often talks excessively
Impulsivity
• Often blurts out answers before questions have been completed
• Often has difficulty awaiting turn
• Often interrupts or intrudes on others
Subtypes

1. ADHD- IA
2. ADHD- HI
3. ADHD- C

• Diagnosed before the age of 12

Theories
Barkley's Theory of ADHD
• Barkley (1999) - fundamental impairment of ADHD is a deficit in
delayed responding.

• He developed a schema in which he illustrated how a deficit in

behavioral inhibition then leads to the other problems associated
with ADHD
Brown’s Model of ADD
•
Executive Dysfunction Theory of
ADHD
• Deficits in "higher-order" cognitive processes, such as planning, sequencing,
reasoning, holding attention to a task, working memory, inhibition of
inappropriate and selection of appropriate behaviors
• Executive functioning involves the operation of neural circuits that link the
frontal cortices with the basal ganglia, thalamus and parietal cortices
• Anatomical and functional studies have found evidence of structural
differences - significantly smaller volumes in the dorsolateral prefrontal
cortex, caudate, pallidum, corpus callosum, and cerebellum.
• Altered activation of the prefrontal cortex, fronto-parietal and fronto-striatal
circuits
• Dopaminergic and noradrenergic neurotransmitter
Dual Pathway
Dual Pathway: existence of two distinct subtypes ('pathways') within
combined type ADHD: one characterized by inhibitory deficits and the
other by delay aversion.
1. theory predicted that the pathway involving inhibitory deficits is
linked to the meso-cortical dopamine branch
2. In contrast, the pathway involving delay aversion is linked to the
meso-limbic dopamine branch and 'disturbances in reward centers'
Delay Aversion
• Described by Sonuga-Barke and colleagues in the early 1990s
• Delay Aversion: Inattentiveness and hyperactivity are considered to
reflect attempts to reduce subjective experience of delay in situations
where delay cannot be avoided
Causes
Biological
• High incidence of ADHD in first-degree relatives (Faraone &
Beiderman, 2013 )

• Brain of youth with ADHD matures more slowly than that of youth
without ADHD, particularly in brain regions associated with
attention, planning, and higher-level thinking (Shaw et al., 2007 ).
• Cortex of the brain develops more slowly in youth having ADHD
(Shaw et al., 2012 ), and there has been some evidence of abnormal
growth in the corpus callosum (Gilliam et al., 2011 )

• Impairments or dysfunction in areas of the prefrontal cortex in youth

with ADHD (e.g., Barkley, 1997 ; Pennington & Ozonoff, 1996 ; Schultz,
Tremblay, & Hollerman, 2000 ; Seidman, Valera, & Makris, 2005 ;
Willcutt, Doyle, Nigg, Faraone, & Pennington, 2005)
• Prenatal - maternal smoking during pregnancy, maternal alcohol
consumption, and use of non-prescribed drugs of abuse, prescribed drugs
such as anticonvulsants and anxiolytics, maternal stress, and maternal
hypothyroidism

• Perinatal - low birth weight, prematurity, and obstetric complications

• Postnatal - an inadequate diet, iodine deficiency and major B vitamin

deficiencies, iron and lead poisoning, high exposure to industrially
contaminated areas, old paint, and soft-water areas where lead water pipes
are common
Disruptive Behavior
Disorders
 Disruptive Behavior Disorders

ODD CD
Oppositional Defiant
Disorder
• Oppositional defiant disorder (ODD) refers to a recurrent pattern of
negative, defiant, disobedient and hostile behavior toward authority
figures lasting at least six months.

• ODD is more common in boys than in girls

Conduct Disorder
Conduct disorder (CD) involves more serious behaviors including
aggression toward people or animals, destruction of property, lying,
stealing and skipping school. The behaviors associated with CD are
often described as delinquency.

• ODD can develop into CD if not managed promptly

Common Characteristics
• Often loses temper
• Often argues with adults
• Often actively defies or refuses to comply with adults’ requests or
rules
• Often deliberately annoys people
• Often blames others for his or her mistakes or misbehavior
• Is often touchy or easily annoyed by others
• Is often angry and resentful
• Is often spiteful or vindictive
Etiology
Biological
• Genetic contributions are higher for antisocial behavior in the presence of
inattention and hyperactivity (Thapar et al., 2013), callous unemotional
traits (Viding et al., 2008) or high levels of physical aggression (Burt, 2009)

• Maternal alcoholism and smoking during pregnancy can lead to increased

antisocial behavior as part of the fetal alcohol syndrome

• Fairchild et al. (2011) found lower amygdala volume in both early-onset and
adolescent-onset ODD/CD, regions associated with the processing of socio-
emotional stimuli reduced right insula volume in the adolescent-onset
subgroup
Temperament
• Traits usually identified are negative emotionality, poor emotional
self-regulation, inattention, and restlessness.

• A “difficult” temperament becomes more likely to lead to disruptive

behavior problems when it interacts with a harsh inconsistent
parenting style (Bradley & Corwyn, 2008; Bornovalova et al., 2014)
IQ
• Conduct disordered children, delinquent adolescents, and adult
antisocial individuals show poor performance on standardized tests of
verbal ability, and in tests of IQ, poor verbal ability; performance
scores are lower too, but usually not as much as verbal ones

• Low IQ can contribute to academic difficulty which in turn mean that

school becomes unrewarding, rather than a source of self-esteem and
support, low school attainment further adds to the probability of
ODD/CD developing
Executive Dysfunction
• Children and adolescents with conduct problems have been shown consistently
to have poor executive functions. These comprise those abilities implicated in
successfully achieving goals through appropriate, effective actions

• For e.g. learning and applying contingency rules, abstract reasoning, problem
solving, self-monitoring, sustained attention, and concentration, relating
previous actions to future goals, and inhibiting inappropriate responses

• Fairchild et al. (2009) found that children with ODD/CD were more likely to take
risky decisions and were less sensitive to punishment.
Information Processing Theory
Family
• Harsh inconsistent discipline, low warmth and involvement, and high criticism (Rutter et
al., 1998)

• 2 ways in which behaviors are attained

a) Positive overtures and behaviors by children are ignored and so become extinguished
b) Negative behavior attracts parental attention, which even though it is usually critical
and hostile, is nonetheless reinforcing where the overall context is one of being
ignored
c) Negative reinforcement trap: a parent responds to mild oppositional behavior by a
child with a prohibition to which the child responds by escalating his behavior and
mutual escalation continues until the parent backs off, thus teaching the child that if
he gets more aggressive, his parents will back of and he will get his way
Attachment
• Insecure attachment patterns, especially disorganization, strongly
associated with antisocial behavior
Social Learning
• Children’s aggression may be increased because they imitate
aggressive behavior modeled by their parents and may learn that
aggression is a normative part of family relationships which is an
effective way of controlling others, and that it is sanctioned, not
punished.
Environmental
• Rejection by healthy peers is that from as young as 5 years,
aggressive-antisocial children tend to associate with other deviant
children

• Poor economic background ( low SES)

• Young people with ODD/CD disproportionately live in inner-city areas

characterized by physical deterioration, neighborhood disorganization
and high residential mobility
THANK YOU