Externalising-disorders-among-Child-and-Adolescents

1. Externalizing disorders among
Children and Adolescents
DR. RICHARD S. MPANGO, PhD
SENIOR LECTURER , MENTAL HEALTH DEPARTMENT –
SCHOOL OF HEALTH SCIENCES, SOROTI UNIVERSITY.
PSYCHIATRIC EPIDEMIOLOGIST (PhD) AND CLINICAL PSYCHOLOGIST (MSc),
POST-DOCTORAL CHILD GR FELLOW, BROWN SCHOOL, WASHINGTON UNIVERSITY IN ST. LOUIS (WUSTL)

2. BACKGROUND
• Out of the 8 billion people worldwide, over 3 billion are younger than
25 years, making up 41.25% of the world population ; 2Billion children
(25%);1.3 billion adolescents (16%)-2023 (https://www.worldometers.info/world-population/)
• Africa has the youngest population in the world, with 70% of sub-
Saharan Africa under the age of 30 ( https://www.un.org/ohrlls/news/young-people%E2%80%99s-potential-key-
africa%E2%80%99s-sustainable-development)
• Over 226 M adolescents in SS Africa make the largest proportion of
the adolescent population of the world, with 23 % aged 10-19 years ;
20% of all adolescents globally; largest generation the region has ever had to
raise (Melesse DY, et al. BMJ Global Health 2020;5:e002231. doi:10.1136/bmjgh-2019-002231)

3. CHILD AND ADOLESCENT MENTAL
HEALTH PROBLEMS IN SSA
• Children and adolescents in SSA face health and socioeconomic
challenges that increase their vulnerability to mental ill-health (1)
• 50% of mental disorders have their onset before the age of 14 and
75% before 25 (2)
• 10–20% of children and adolescents worldwide experience mental health
problems. (2)
• In sub-Saharan Africa 1 out of 7 children(14.3%) and adolescents
experiences significant psychological challenges, ; almost 10% qualify for a
psychiatric diagnosis (2)

4. EXTERNALISING DISORDERS AMONG
CHILDREN / ADOLESCENTS WITH HIV AND
WITHOUT HIV
• Among children /adolescents with HIV/AIDS(CA-HIV),
prevalence of ‘any DSM-5 psychiatric disorder’ was 17.4%;
behavioural disorder = 9.6% ; most prevalent behavioural disorder
was attention deficit hyperactivity disorder (5.3%); (1) Kinyanda
et al, 2019
• A survey (3516 participants) within the region (TZ, Ethopia,
Burkina Faso), established that 1 in 10 i.e 9.2% C& A attending
school had externalizing problems ; (1), Shinde et al., 2023

5. Externalising (disruptive behaviour)
disorders among children and
adolescents
• According to the DSM-5, externalizing behavior and disruptive,
impulse-control, and conduct disorders include behaviors that “violate
the rights of others or bring the individual into significant conflict with
societal norms or authority figures” (American Psychiatric Association
2013, p. 461)
• Externalizing disorders , often specifically referred to as disruptive
behavior disorders
• Characterized by outward-directed behaviors
• Noncompliance, aggressiveness, overactivity, impulsiveness
• Includes attention-deficit/hyperactivity disorder, conduct disorder, and
oppositional defiant disorder

6. 1. Attention-Deficit/Hyperactivity Disorder
Excessive levels of activity
• Fidgeting, squirming, running around when
inappropriate, incessant talking
Distractibility and difficulty concentrating
• Makes careless mistakes, cannot follow instructions,
forgetful
May have difficulty with peer interactions

7. Attention-Deficit/Hyperactivity Disorder
(ADHD)
‘A PERSISTENT PATTERN OF INATTENTION AND/OR HYPERACTIVITY-IMPULSIVITY
THAT INTERFERES WITH FUNCTIONING OR DEVELOPMENT, AS CHARACTERIZED
BY ATLEAST SIX SYMPTOMS OF INATTENTION, HYPERACTIVITY AND
IMPULSIVITY, PERSISTENTLY OCCURRING FOR AT LEAST SIX MONTHS TO A
DEGREE THAT IS INCONSISTENT WITH DEVELOPMENTAL LEVEL AND THAT
NEGATIVELY IMPACTS DIRECTLY ON SOCIAL AND ACADEMIC / OCCUPATIONAL
ACTIVITIES’ (AMERICAN PSYCHIATRIC ASSOCIATION, 2013)
Inattention Hyperactivity-Impulsivity
• Fails to give close attention to details
• Difficulty sustaining attention in tasks/play
activities
• Does not seem to listen when spoken to directly
• Often does not follow through on instructions and
fails to finish schoolwork, chores, or duties in the
workplace
• Often has difficulty organizing tasks and
activities
• Often avoids, dislikes, or is reluctant to engage
in tasks that require sustained mental effort
• Often loses things necessary for tasks or
activities
• Is often easily distracted
• Often forgetful in daily activities
• Quickly loses interest
Hyperactivity
• Often fidgets with or taps hands or feet or squirms in
seat
• Often leaves seat in situations when remaining seated
is expected
• Often runs about or climbs in situations where it is
inappropriate
• Often unable to play or engage in leisure activities
quietly
• Often is “on the go” or as if “driven by a motor”
• Talks excessively
Impulsivity
• Often blurts out answers before questions are
completed
• Often has difficulty waiting his or her turn
• Interrupts or intrudes on others

8. DSM-5 Criteria for
Attention-Deficit/Hyperactivity Disorder
• Either A or B:
A. Six or more manifestations of inattention present for at least 6 months to a maladaptive degree and greater than what
would be expected given a person’s developmental level, e.g., careless mistakes, not listening well, not following instructions,
easily distracted, forgetful in daily activities
B. Six or more manifestations of hyperactivity-impulsivity present for at least 6 months to a maladaptive degree and greater
than what would be expected given a person’s developmental level, e.g., fidgeting, running about inappropriately (in adults,
restlessness), acting as if “driven by a motor,” interrupting or intruding, incessant talking
• Several of the above present before age 12
• Present in two or more settings, e.g., at home, school, or work
• Significant impairment in social, academic, or occupational functioning
• For people age 17 or older, only five signs of inattention and/or five signs of hyperactivity-impulsivity are required to meet the
diagnosis.

9. Attention-Deficit/Hyperactivity Disorder
 Three specifiers in DSM-5 to indicate which
symptoms predominate
1. Predominantly inattentive type
2. Predominantly hyperactive-impulsive type
3. Combined type
 Combined is the majority of diagnoses
 Differential diagnosis
• ADHD or Conduct Disorder?
• ADHD
 More off-task behavior, cognitive and achievement deficits
• Conduct Disorder
 More aggressive, act out in most settings, antisocial parents, family hostility

10. BEHAVIORS IN ADOLESCENTS WITH
ADHD AND WITHOUT ADHD

11. ADHD
 ADHD often comorbid with anxiety and depression
 Prevalence estimates 8 to 11% worldwide ; Prev. among CA-HIV
=6%(Mpango et al., 2019); Prev. of in ADHD non-clinical school sample
of children and adolescents in a peri-urban setting in Entebbe =2.8%(
Nampijja et al.,2021); Prev. in Ethopia=9.9%(Aliye et al.,,2023)
 More common in boys than girls
• May be because boys’ behavior more likely to be aggressive
 Symptoms persist beyond childhood
• Numerous longitudinal studies show 65 to 80% still exhibit symptoms
• 60% of adults continue to meet criteria for ADHD in remission

12. Etiology of ADHD
 Perinatal and prenatal factors
• Low birth weight
 Can be mitigated by later maternal warmth
• Maternal tobacco and alcohol use
 Environmental toxins
• Limited evidence that food additives or food coloring can
have a small impact on hyperactive behavior
• No evidence that refined sugar causes ADHD
• Nicotine from maternal smoking
 Exposure to tobacco in utero associated with ADHD symptoms
 May damage dopaminergic system, resulting in behavioral disinhibition

13. ETIOLOGY OF ADHD
Parent-child relationship
• Parents give more commands and have more negative
interactions
• Family factors
 Interact with genetic [heritability, (Franke et al., 2009)] and
neurobiological factors
 Contribute to or maintain ADHD behaviors but do not cause
them
© 2015 JOHN WILEY & SONS, INC. ALL RIGHTS RESERVED.

14. NEGATIVE OUTCOMES ASSOCIATED
WITH ADHD
• CA with ADHD likely to perform poorly in school than those without
ADHD; similar findings [1,2,3]
• CA with ADHD more likely to have disciplinary school problems than those
without ADHD; similar findings [1,2]
• CA with ADHD is associated with worse social functioning than CA-HIV
without symptoms of ADHD [1,2]
• CA with ADHD are at increased risk for negative outcomes, including
emotional, behavioral problems and social adaptation [1]

15. TREATMENT OF ADHD
 Stimulant medications (Ritalin, Adderall, Concerta,
Strattera)
• Reduce disruptive behavior
• Improve interactions with parents, teachers, peers
• Improve goal-directed behavior and concentration
• Reduce aggression
• Effective in about 75 percent of children with ADHD but there are side effects
 Loss of appetite, weight, sleep problems
 Medication plus behavioral treatment (MTA study)
• Slightly better than meds alone
• Improved social skills whereas meds alone did not
• Three-year follow-up found superior benefits of meds did not persist

16. TREATMENT OF ADHD
Psychological treatment
• Parental training
• Change in classroom management
• Behavior monitoring and reinforcement of appropriate
behavior
Supportive classroom structure
• Brief assignments
• Immediate feedback
• Task-focused style
• Breaks for exercise

17. ASSESSMENT INSTRUMENTS /
MEASURES FOR ADHD
• Behavior Assessment System for Children (BASC-3), designed for people aged 2 to 21.
• National Institute for Children's Health Quality (NICHQ) Vanderbilt Assessment Scale, intended for ages 6 to 12.
• Conners Comprehensive Behavior Rating Scale (CBRS), intended for ages 6 to 18.
• Vanderbilt Attention Deficit Hyperactivity Disorder- Parent Rating scale
• Standardized DSM-5 referenced rating scale, the parent version (5–18 years) of the Child and Adolescent Symptom
Inventory-5 (CASI-5) ; https://doi.org/10.1177/0049475517724688 ;Mpango et al.,2017
• Child & Adolescent Symptom Inventory-Progress Monitor (CASI-PM)
https://doi.org/10.1080/17450128.2019.1686672 ; Mpango et al.,2020
• Disruptive behavior scale (45 items)
• Vanderbilt Attention Deficit Hyperactivity Disorder- Parent Rating scale
• Swanson, Nolan, and Pelham ADHD Rating Scale (SNAP-IV)

18. 2. CONDUCT DISORDER (CD)
 Pattern of engaging in behaviors that violate social
norms and the rights of others, and are often illegal
• Aggression
• Cruelty towards other people or animals
• Damaging property
• Lying
• Stealing
• Vandalism
• Often accompanied by viciousness, callousness, and lack of
remorse

19. SYMPTOMS OF CONDUCT DISORDER(1)
• Presence of three (or more) of the following 15 criteria in the past 12 months
from any of the categories below, with at least one criterion present in the
past 6 months:
• Aggressive behavior toward others and animals.
• Frequent physical altercations with others.
• Use of a weapon to harm others.
• Deliberately physically cruel to other people.
• Deliberately physically cruel to animals.
• Involvement in confrontational economic order crime- e.g., mugging.
• Has perpetrated a forcible sex act on another.

20. SYMPTOMS OF CONDUCT DISORDER(2)
• Property destruction by arson.
• Property destruction by other means.
• Has engaged in non-confrontational economic order crime- e.g., breaking and entering.
• Has engaged in non-confrontational retail theft, e.g., shoplifting.
• Disregarded parent's curfew prior to age 13.
• Has run away from home at least two times.
• Has been truant before age 13.
The preceding criteria is accompanied by the following:
• 1. The behaviors cause significant impairment in functioning and 2. If the individual over age 18 the criteria for
APD is not met.

21. DSM-5 CRITERIA FOR
CONDUCT DISORDER
• Repetitive and persistent behavior pattern that violates the basic rights of others or conventional social norms as
manifested by the presence of three or more of the following in the previous 12 months and at least one of them in
the previous 6 months:
A. Aggression to people and animals, e.g., bullying, initiating physical fights, physically cruel to people or animals,
forcing someone into sexual activity
B. Destruction of property, e.g., fire-setting, vandalism
C. Deceitfulness or theft, e.g., breaking into another’s house or car, conning, shoplifting
D. Serious violation of rules, e.g., staying out at night before age 13 in defiance of parental rules, truancy before age
13

22. FURTHER QUALIFIERS ARE:
• 1. Child, Adolescent, or Unspecified onset.
• 2 Limited prosocial emotions, - lack of remorse or guilt, lack of
empathy, callousness, unconcerned about performance, shallow or
deficient affect
• 3. With mild, moderate, or severe levels of severity (American
Psychiatric Association, 2013).

23. CONDUCT DISORDER (CD)
• Onset; can appear as early as the preschool years, Middle
childhood to middle adolescence
• Common premorbid condition with ODD (Oppositional Defiant
Disorder), which may progress to Conduct Disorder.
• Rejection by more prosocial peers and association with delinquent
peers with reinforcement of conduct disordered behaviors my
occur (American Psychiatric Association, 2013)

24. CONDUCT DISORDER
 Substance abuse common
• Unclear whether it precedes or is concomitant with disorder
 Comorbid with anxiety and depression
• Comorbidity rates vary from 15 to 45%
• CD precedes anxiety and depression
 Prevalence ; ranges 2% to 10%
• Boys
 4 to 16%
• Girls
 1.2 to 9%
• Prevalence among CA-HIV-psyc. Dx 1.2%,/ Psyc.Prob.3.9%(Kinyanda et
al.,2019); prev. CA attending school in SSA=34.5% (1)

25. CONDUCT DISORDER (CD)
 Two distinct CD types (Moffitt, 1993)
1. Life-course-persistent pattern of antisocial behavior
• 10 – 15x more common in boys than girls
2. Adolescence-limited
• Maturity gap between physical maturation and rewarding adult behaviors
 Follow-up longitudinal studies of life-course-persistent type
show more severe problems into early adulthood, including:
• Academic underachievement
• Neuropsychological deficits
• ADHD
• Family psychopathology
• Poorer physical health
• Lower SES
• Violent behaviors

26. DISORDERS RELATED TO CONDUCT
DISORDER
 Intermittent explosive disorder: recurrent verbal or
physical aggressive outbursts that are out of proportion to
the circumstances.
• Aggression is impulsive and not preplanned
 Oppositional Defiant Disorder (ODD) behaviors do not meet criteria
for CD (especially extreme physical aggressiveness) but child
displays pattern of defiant behavior
• Argumentative, loses temper, lack of compliance, deliberately aggravates
others, hostile, vindictive, spiteful, or touchy, blames others for own
problems
 Comorbid with ADHD, learning and communication disorders
• Disruptive behavior of ODD more deliberate than ADHD
 Most often diagnosed in boys but may be as prevalent in girls

27. RISK FACTORS
• Under controlled temperament, low verbal IQ, parental rejection and neglect,
child maltreatment ( including sexual abuse) and inconsistent parenting.
• Parental history of ADD/ADHD and conduct disorder is also identified as a
risk factor (APA, 2013),
• Parental drug and alcohol abuse and dependence (Haber et al., 2010).
• Parental overindulgence (i.e development of a sense of entitlement, lack of
concern for others, self absorption unrealistic expectations, and frustration
when these expectations are not delivered (Fogarty, 2009)

28. IMPACT ON FUNCTIONING
• STI's, (Sexually Transmitted Infections), unwanted pregnancy
• Juvenile justice system involvement
• Family strife, and injuries from accidents or fighting (APA, 2013;
Bonin, et al 2011).
• Profound impact on parents( including self-blame of their child’s/
teens condition, guilt, shame, anxiety, social embarrassment
financial problems, conflicts within the family, interruption of
work, and fatigue (Meltzer, Ford, Goodman, & Vostanis, 2011).

29. ETIOLOGY OF CONDUCT DISORDER

30. ETIOLOGY OF CONDUCT DISORDER
(CD)
 Genetic factors
• Heritability likely plays a part
• Twin study data show mixed results
• Adoption studies focused on criminal behavior, not conduct disorder
 Meta-analysis of twin and adoption studies suggest 40 –
50% of antisocial behavior is heritable
• Genetics a stronger influence when behaviors begin in childhood
rather than adolescence
 Genetics and environment interact
• Abuse as a child PLUS low MAOA activity most likely to develop CD

31. ETIOLOGY OF CONDUCT DISORDER
(CD)
 Neurobiological factors
• Poor verbal skills
• Difficulty with executive functioning
• Low IQ
• Lower levels of resting skin conductance and heart rate
suggest lower arousal levels
 Psychological factors
• Deficient moral development, especially lack of remorse
• Modeling and reinforcement of aggressive behavior
• Harsh and inconsistent parenting
• Lack of parental monitoring
• Cognitive bias: Neutral acts by others perceived as hostile

32. DODGE’S COGNITIVE THEORY OF
AGGRESSION

33. ETIOLOGY OF CONDUCT DISORDER
(CD)
 Peer influences associated with CD
• Rejection by peers
• Affiliation with deviant peers
 Sociocultural factors
• Poverty
• Urban environment
 Higher rates of delinquent acts among
children / adolescents living in poorer
neighborhoods rather than race

34. TREATMENT OF CONDUCT DISORDER
Family interventions
• Evidence based parenting programs
• Parental management train (PMT)
 Teach parents to reward prosocial behavior
Multisystemic therapy
• Deliver intensive community-based services
• Treatment programs; Supervision, clear expectations for behavior,
accountability, and consequences for inappropriate behavior are
part of a quality treatment program.

35. MULTISYSTEMIC TREATMENT OF
CONDUCT DISORDERS (CD)

36. ASSESSMENT INSTRUMENTS /
MEASURES FOR CONDUCT DISORDER
• Strengths and Difficulties Questionnaire (SDQ)
• Disruptive Behavior Disorder Rating Scale
• Iowa Connors and Impairment Scales
• Youth Conduct Problems Scale
• Standardized DSM-5 referenced rating scale, the parent version (5–18 years) of the Child and
Adolescent Symptom Inventory-5 (CASI-5) ; https://doi.org/10.1177/0049475517724688
;Mpango et al.,2017
• Child & Adolescent Symptom Inventory-Progress Monitor (CASI-PM)
https://doi.org/10.1080/17450128.2019.1686672 ; Mpango et al.,2020

37. 3. OPPOSITIONAL DEFIANT DISORDER
• Criterion A, pattern of angry/irritable mood, argumentative/defiant behavior, or
vindictiveness lasting at least 6 months w/4 or more DSM-5 Criteria:
• Often loses temper
• Often argues with adults
• Often actively defies or refuses to comply w/rules
• Often deliberately annoys others
• Often blames others for his/her mistakes or behavior
• Often touchy or easily annoyed by others
• Often angry and resentful
• Often spiteful or vindictive

38. ODD ;DSM-5; CRITERION B &C
• Criterion B. Disturbance in behaviour is associated with distress in
the individual or others in his or her immediate social context (e.g.
- family, peer group, work colleagues), or it impacts negatively on
social, educational, occupational, or other important areas of
functioning.
• Criterion C; Behaviours do not occur exclusively during the
course of a psychotic, substance use, depressive, or bipolar
disorder. Also, the criteria are not met for disruptive mood

39. MNEMONIC
• The mnemonic REAL BADS can be used to remember the symptoms of ODD:
• R - Resentful
• E - Easily annoyed
• A - Argues with adults
• L - Loses temper
• B - Blames others
• A - Annoys people deliberately
• D - Defies rules or requests
• S - Spiteful

40. EPIDEMIOLOGY
• Rates vary (2 – 16% reported; overall 5%); prev. among CA-
HIV(Psyc. Dx= 2.2%; Psych.Problem=4.1%(Kinyanda et
al.,2019)
• Rate decreases with age
• Diagnostic Stability:
• Greater stability with more severe ODD/CD
• Stability as high or higher for females vs. males

41. NATURAL HISTORY
• Gender differences don’t emerge until after 6 y/o
• More prevalent in males prior to puberty-more prevalent in males than in females
(1.4:1 ratio) ; rates equalize (m:f) after puberty
• Usually evident by 8 y/o
• Symptoms often emerge at home but generalize with time
• Earlier onset  worse prognosis
• Onset is typically gradual over months or years
• ODD can be relatively benign but sometimes lies on a continuum with CD (30 –
40% of individuals move from one stage to the next: ODD  CD  APD)

42. ASSOCIATED FEATURES
• During school years there may be low self-esteem (or over
inflated self-esteem), mood lability, low frustration tolerance,
swearing, and precocious use of alcohol / drugs
• Common Comorbidities:
• ADHD, Learning D/O, & Communication D/O
• 50% of kids w/ADHD have ODD or CD
• 70% of kids w/ODD or CD have ADHD

43. RISK FACTORS
• ODD is more common in families where child care is disrupted by
a the presence of ;
• multiple different caregivers or
• families in which harsh, inconsistent, or
• neglectful child-rearing practices are common (APA,2013)

44. INVESTIGATIONS
• A biopsychosocial “investigation” to understanding aggressive behaviour is
important. A child diagnosed with ODD or ADHD may all have these factors
contribute to their symptoms:
• Parenting and family factors: Parenting behavior, Parent-child attachment
• Peer relationships: Peer rejection, Deviancy “training” (getting trained to be
“unliked” by others)
• Child-level mental processes: Callous-unemotional traits (degree of empathy
in the child), Emotional regulation, Executive functions and language (think
learning disorders), Social cognition

45. INVESTIGATE ;RISK FACTORS
• Predisposing Factors: Trauma, Raised up in the orphanage
• Precipitating Factors: Recently punched by student, Recently
moved, Recent death in family
• Perpetuating Factors: Recurring social/family/school conflicts

46. PROGNOSIS
• Symptoms of ODD can result in frequent conflicts between the
individual and parents, teachers, supervisors, peers, and/or
romantic partners.[4]
• Increased risk for antisocial behavior, impulse-control problems,
substance abuse, anxiety, and depression, when they enter
adulthood(5) APA,2013
• Increased risk for suicide attempts.[6]

47. TREATMENT
• Behavioural Modification; a therapeutic and treatment approach designed to
change a undesirable negative behaviour. By using a system of positive or
negative consequences, an individual learns the correct set of responses for
any given stimulus
• Parent training / parent management training (PMT) / behavioural parent
training (BPT) ; are training programs that aim to change parenting behaviors
and teach positive reinforcement methods for improving children and
adolescent behaviour problems.; It is commonly used for ODD & CD [1][2]

48. ODD ASSESSMENT INSTRUMENTS /
MEASURES
• Iowa Conners Scale
• Child Adolescent Disruptive Behavior Inventory (CADBI)
• https://mightier.com/resources/oppositional-defiant-disorder
• Standardized DSM-5 referenced rating scale, the parent version (5–18 years)
of the Child and Adolescent Symptom Inventory-5 (CASI-5) ;
https://doi.org/10.1177/0049475517724688 ;Mpango et al.,2017
• Child & Adolescent Symptom Inventory-Progress Monitor (CASI-PM)
https://doi.org/10.1080/17450128.2019.1686672 ; Mpango et al.,2020

49. Prevention and Early Intervention
important
• Universal programs
– Broad behavioral health
• Selective programs
– Increased risk but no diagnosis
• Indicated programs
– High score on risk factors could be helpful to guide early
intervention

50. Conclusion
Promising areas for growth include:
• Longitudinal research for risk factors
• Studies about Gene-environment interactions
• Exploring the therapeutic potential of ‘Peer
interactions’
• Development of locally appropriate treatments
• Community /general population studies

51. WAY FORWARD
• School mental health programs important since many children in
schools may be battling with mental health problems that are not
recognised(Currie & Bray,2019)
• Child and adolescent mental health policy in Uganda recommends
screening for mental, neurological and substance problems among
school-going children and adolescents (MoH,2017)
• Determine the epidemiology / burden of mental health problems in the
non-clinical / non-vulnerable population of children and adolescents
attending schools in Uganda and offer CAMHS to the identified
children /adolescents ; Early intervention services

52. WAY FORWARD
• Adapt / develop locally appropriate instruments for screening and monitoring
emotional and behavioural problems in youth, ; Our team developed a Ugandan
specific CASI-Progress Monitor (30-item questionnaire that can assess for the 8
commonest youth PD; developed from the CHAKA data using correlational analysis;
Sprafkin et al, 2010;- Mpango et al., Published by the journal of Vulnerable Children
and Youth Studies; October 2019 10.1080/17450128.2019.1686672
• Pilot interventions (selection will be guided by the formative work) to assess for
feasibility, acceptability and trends to efficacy
• Operationalize the Uganda GOVT policy to establish youth friendly corners at all
public Health Centres

53. THANK YOU
.