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U.S. DEPARTMENT OF EDUCATION
fico of Eaueational Rasearch and Improvars

EDUCATIONAL RESOURCES INFORMATION
CENTER (ERIC)
This document has been reproduced as
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1 Minor changes have been made to
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i

Taking Stock

of Risk Factors for Child/Youth

Externalizing Behavior Problems

National Institute

DEPARTMENT OF HEALTH AND HUMAN SERVICES + PUBLIC HEALTH SERVICE * NATIONAL INSTITUTES OF HEALTH NIMH

CG032236

of Mental Health

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68


tendency to attribute hostile intentions to others
(Dodge, 1980; Dodge & Frame, 1982). This
attributional style increases the likelihood that
they will respond toward other children in a
retaliatory, aggressive manner (see Child
Characteristics section for more details).

Evidence exists that peer rejection associated with
aggression is malleable and can function as a
causal risk factor for externalizing behavior
problems. By specifically targeting children who
appear rejected because of their aggressive
behavior, interventions that provide anger
management skills and prosocial means of solving
peer conflicts have resulted in increased peer
acceptance and decreased child aggressive and
externalizing behavior problems (Conduct
Problems Prevention Research Group, 1999;
Lochman, Coie, Underwood, & Terry, 1993).

Victimization

In addition to the negative attributional biases
exhibited by rejected and aggressive children,
evidence shows that peers are more likely to
attribute hostile intentions and respond more
aversively when the perpetrator is considered an
aggressive youngster (Dodge, 1980; Dodge &
Frame, 1982). Rejected youth are more likely to be
treated negatively by their peers and are more
likely to be victims of peer attack and abuse
(Perry, Kusel, & Perry, 1988). Newer research has
documented that the victimization experienced by
socially rejected children includes not only
physical attacks but also acts that undermine
their relationships with other peers (i.e., relational
aggression) (Crick, Casas, & Ku, 1999; Crick &
Grotpeter, 1996). The correlation between peer
rejection and relational aggression victimization
has been found for children in preschool and
elementary school.

Adding to the work on early peer victimization is
the consistent correlation between being a victim
of crime and being a criminal offender (Esbensen
& Huizinga, 1991; Sampson & Lauritsen, 1990;
Singer, 1986). Adolescents who are offenders are
likely to be victims, and vice versa. It is not clear
whether criminal victimization predicts later
offending or whether early offending predicts later
victimization. Also, it is not known whether
criminal victimization in adolescence is predicted
by the experience of peer victimization in
elementary and middle school.

Peer Enhancement

Although aggressive children are at higher risk for
peer rejection, aggressive and rejected children do
have friends, and their friends also tend to be
aggressive (Cairns, Cairns, Neckerman, Gest, &
Gariepy, 1988; Haselager, Hartup, van Lieshout, &
Riksen-Walraven, 1998; Tremblay, Masse, Vitaro, &
Dobkin, 1995). As early as preschool, research has
documented aggressive children to be part of social
cliques that are particularly likely to be characterized
by aggression (Farver, 1996). Aggressive friendships
tend to be stable (Giordano, Cernkovich, & Pugh,
1986), and being a member of a group with other
aggressive children and/or adolescents is a predictor
of later conduct problems for both girls and boys
(Kupersmidt, Burchinal, & Patterson, 1995).

Selection of mutually aggressive and deviant
friends can expand in adolescence to pairings with
the opposite sex. Antisocial behavior is a strong
selection factor in couple formation. Individuals
with a history of antisocial behavior in adolescence
are likely to become partners with similar
individuals (Krueger, Moffitt, Caspi, Bleske, &
Silva, 1998). In turn, assortive pairing for
antisocial behavior is associated with continued
involvement in antisocial behavior during the adult
years (Yamaguchi & Kandel, 1993). In contrast,

83


an understanding of early childhood. Indeed,
some findings (on maternal age and maternal
smoking during pregnancy) suggest that research
may need to focus on pregnancy and the behavior
of young women that leads to early birth and
child rearing; this research would require an even
greater range of expertise and scientific
disciplines. Second, it is vital that research testing
experimental interventions targeting child factors
include both males and females, as well as
children from diverse ethnic backgrounds. The
ratio of males with conduct problems to females
with conduct problems is not as great as
previously suspected, It is essential to determine
whether risk factors for externalizing behavior
problems in girls are the same as or distinct-from
those for boys and whether these factors are
robust across ethnic groups.

Finally, it is important to note that there may be
several opportunities for testing the potential
causality of some child risk factors by partnering
with intervention research on related outcomes.
Current intervention trials that target maternal
smoking, drug use, and alcohol use and that
include long-term followup should be encouraged
to examine child externalizing behavior problems.
Similarly, intervention trials targeting early 10,
verbal abilities, and academic achievement should
be encouraged to include assessment of
externalizing behavior problems. This
recommendation extends to psychiatric
intervention trials focusing on the reduction of
oppositional behavior and ADHD in early life. It is
important to examine whether successful
modification of these behaviors can reduce the
incidence of conduct problems in later childhood
and adolescence.

References

Bates, J. E., Pettit, G. S., Dodge, K. A., & Ridge, B.
(1998). Interaction of temperamental resistance to
control and restrictive parenting in the
development of externalizing behavior.
Developmental Psychology, 34(5), 982-995.

Biederman, J., Faraone, S. V., Milberger, S., Jetton,
J. G., Chen, L., Mick, E., Greene, R. W., & Russell,
R. L. (1996). Is childhood oppositional defiant
disorder a precursor to adolescent conduct
disorders? Findings from a four-year follow-up
study of children with ADHD. Journal of the
American Academy of Child and Adolescent
Psychiatry, 35(9), 1193-1204.

Brennan, P. A., Grekin, E. R., & Mednick, S. A.
(1999). Maternal smoking during pregnancy and
adult male criminal outcomes. Archives of General
Psychiatry, 56, 215-219.

Brown, R. T., Coles, C. D., Smith, I. E., Platzman,
K.A., Silverstein, J., Erickson, S., & Falek, A.
(1991). Effects of prenatal alcohol exposure at
school age. II. Attention and behavior.
Neurotoxicology and Teratology, 13, 369-376.

Cadoret, R. J., Yates, W. R., Troughton, E.,
Woodworth, G., & Stewart, M. A. (1995). Genetic-
environmental interaction in the genesis of
aggressivity and conduct disorders. Archives of
General Psychiatry, 52, 916-924.

Caspi, A., Moffitt, T. E., Newman, D. L., & Silva, P.
A. (1996). Behavioral observations at age 3 years
predict adult psychiatric disorders. Archives of
General Psychiatry, 53, 1033-1039.

Christ, M. A. G., Lahey, B. B., Frick, P. J., Russo,
M. F., McBurnett, K., Loeber, R., Stouthamer-

Loeber, M., & Green, S. (1990). Serious conduct
problems in the children of adolescent mothers:

19


later become involved with drugs, and which
become prosocial and lose their aggressiveness?).
Given the richness of some of the existing
longitudinal studies, some of the questions may be
answerable through secondary data analysis.

This more dynamic view of externalizing behavior
problems already has had important implications
for studying risk factors. Etiology becomes more
complicated. A factor that leads to early aggressive
behavior may not have as great an effect on later
conduct problems. A factor that maintains conduct
problems may have had little to do with the initial
onset. A factor that leads to desistance from
delinquency may have had nothing to do with
either bringing about or maintaining the behaviors
in the first place. And a factor that puts one child at
tisk for externalizing behavior in one context may
actually protect another child from developing that
same behavior in another context.

Putting the Organism Back
Together in Considering
Individual Child Characteristics

A substantial number of studies have focused on
the question, what is it about individual children
that puts them at risk for engaging in externalizing
behavior? Researchers have studied a range of
individual characteristics that span multiple levels
of analysis within the child, including
neurotransmitters, neurohormones, physiology,
cognitive processes, expression of emotion, and
patterns of behavior. They have developed better
and better ways to study these various components
of child functioning and have greatly increased our
understanding of such characteristics. While such
work needs to continue, there is a growing need to
develop complementary studies that will expand
this focus in two directions.

First, most of the studies reviewed here examine
these individual child factors only in relation to

single points in time in the development of
externalizing behavior problems (e.g.,
difficult/irritable temperament in young childhood,
hostile attributional processes in elementary
school-aged children). A few studies have begun to
place these factors in a developmental context,
studying how such characteristics change with
development and are involved in trajectories for
externalizing behavior.

Second, most studies to date have restricted their
focus to one child characteristic, studying how that
characteristic is related to externalizing behavior
but providing no information about relationships
among different characteristics. Research that
attends to more than one characteristic will be
important for two reasons. When two or more
characteristics are implicated as risk factors,
understanding how these systems influence one
another is essential in learning how to treat or
prevent such behavior. For example, social
information processing may shape emotion
regulation, emotional regulation may shape social
information processing, or the two may reciprocally
influence one another or be controlled by a third
unknown process. Understanding the nature of
these links will help people ascertain whether
interventions that target social information
processing will be effective independent of any
attention to emotion regulation, or whether both
need targeting. The latter strategy may be essential
if these two systems influence one another.

In addition, cross-characteristic studies can help
identify risk factors that moderate other child
factors and account for meaningful increases in
tisk. For example, neural processes related to ADHD
may constrain social information processing,
which, in turn, increases the child’s risk for
externalizing behavior problems. Not only might
social information processing interventions be the
best way of approaching such cases, but such
interventions may require tailoring when used with
children with ADHD.

130

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NIH Publication No. 02-4938
November 2001

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36


conjunction. Lower SES, income inequality, and
deteriorated housing frequently occur together and, as
a cluster, are associated with high rates of crime and
delinquency. However, much of this research is
correlational and has focused on rates of problem
behavior across geographic regions rather than
individual variations in conduct. Also, social and
community variables are difficult to conceptualize as
“malleable” because altering income, housing, and
employment opportunities would require major social
change and incredible financial resources.

How then do we go about incorporating these
relevant variables into developmental models for
predicting and intervening with child and youth
conduct problems? One strategy frequently
employed by researchers is to use SES, income,
violent neighborhoods, and so forth as selection
criteria for determining high-risk groups and
targeting interventions. This way, such social and
community factors serve as contextual variables
and are conceptualized as factors that potentially
moderate the salience of other child, family, and
peer risk factors and processes (e.g., parental
monitoring, peer deviance). Although a useful
strategy (it increases the probability not only that
those most in need will be in the intervention but
also that it will be possible to detect a change), it
does little to help understand how such social and
community factors affect conduct problems.

This question of "how" has motivated researchers
interested in identifying variables that mediate the
association between social and community factors
and child/youth conduct problems. To date, two
important sets of factors have been identified as
mediators—family processes and a community
process known as collective social control. Lower-
SES families or families experiencing economic
distress are more likely to engage in harsh
discipline and provide less effective monitoring,
which, in turn, partially mediates the effect of these
broader variables on youth conduct problems.
Similarly, the research on collective social control
indicates that it partially mediates the relationship

104

107

between community disadvantage and rates of
delinquency and violent crime. Although research
on family processes has shown that parental
monitoring and discipline are causal risk factors
for child and youth conduct problems, additional
research is needed on collective social control to
determine its malleability and the resulting impact
on youth behavior. Studying the malleability of
collective social control is a critical next step that
could have profound implications for indicating
the causal potential of this variable and
developing more effective community-level
interventions to prevent youth problem behavior.
Given the number of child, family, and peer
processes reviewed in previous sections, it is clear
that much more research is needed to examine
how correlates, predictive risk factors, and causal
tisk factors at lower levels of analysis may either
mediate or be moderated by broader social factors.

The information reviewed here about school effects
on child and youth conduct problems also suggests a
range of important factors. School policies,
classroom placement, tracking, and classroom size
all could affect youth conduct. Although many of
these school variables have been related to academic
success and failure, surprisingly few studies have
examined these issues in relation to child and youth
conduct. Those studies that have examined
behavioral and conduct-related outcomes suggest
that school variables do correlate with problematic
behavior. However, more systematic research is
needed to establish the strength of these associations
and the degree to which school policies and practices
predict youth behavior.

Promising research has been conducted on
classroom aggression, teacher-student interactions,
and school bonding. Each of these school variables
has been related to child and youth conduct. In the
case of classroom aggression, levels of classroom
aggression in first grade reliably predicted
increased aggressive behavior in later grades for
children who were already showing some problem
behavior. Similarly, the research on early school


Family Factors
and Processes

This section focuses‘on children's immediate
social environment, including those who live with
and influence them on a regular and personal
basis. The primary focus is on qualities of family
social interaction that either increase or reduce
the risk of developing externalizing behavior
problems and conduct disorder. These interaction
qualities have been categorized into six domains:
engagement attentiveness versus disengagement’
inattentiveness; validation versus invalidation;
firm discipline and conflict management versus
harsh, inconsistent discipline and escalation of
conflict; effective problem solving versus
ineffective problem solving; structure versus lack
of structure in the learning environment; and
modeling of norm-maintaining behavior versus
modeling of antisocial behavior.

These domains were developed at a level
sufficiently general to characterize interaction
across development, spanning infancy,
toddlerhood, middle childhood, early adolescence,
and late adolescence. In many cases, the specific
behaviors that reflect a given domain will look
quite different across different periods of
development, because it is important to take into
account the growing sophistication and
contributions of the child in family interactions.

It is also important to note that each domain of
family interaction is shaped by and responds to a
number of other factors that have received
considerable attention, such as characteristics of
individual family members (attitudes, presence of

psychopathology) and characteristics of the social
context (family structure and transitions). These
factors can exert powerful effects. For example,
research on family structure and transitions has
shown that adolescents are at increased risk for
conduct problems if they live in single-parent
families or have experienced multiple transitions
in family composition or residence (Aneshensel &
Sucoff, 1996; Henry, Caspi, Moffitt, & Silva, 1996;
Patterson, Forgatch, Yoerger, & Stoolmiller, 1998;
Smith & Jarjoura, 1988). The reasons for these
effects, however, are not clear. Indeed, some
studies have shown these effects to be mediated
by more immediate and malleable family
processes (e.g., engagement, discipline) (Harnish,
Dodge, & Valente, 1995). Although such factors
help to identify potential target populations for
interventions, the focus of the present review will
be on family interaction qualities that either have
been shown to be or may be malleable risk
processes that would serve as targets for
interventions.

Another important context for family interaction
is that of culture. Indeed, some argue that
processes within the family are the primary means
by which culture is expressed. However, there is
limited research on cultural differences in family
processes related to externalizing behavior
problems. The most serious gap is in research with
Native American and Asian-American populations.
Also, very few studies with diverse samples have
included young children (ages 0-5). Finally,
available research with African-American and

43


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71


bonding has shown it to reliably predict decreases
in conduct problems in adolescence.

These important results need to be advanced to
determine ways to modify early classroom
aggression levels, improve school bonding, and
evaluate the impact of these changes on child
behavior. However, it is equally important that this
work be integrated with research reviewed in
previous sections—child characteristics, family
Processes, and peer factors. What are the
consequences of altering early classroom aggression
on child development of hostile attributions, peer
rejection, and bullying? By improving school
bonding, is one also influencing parental monitoring
of child behavior or structuring of the leaming
environment? Are school-based interventions more
or less effective in different neighborhood and
community contexts? Clearly, many important
questions remain to be investigated, questions
whose answers could have enormous impact on
the development of more effective preventive
interventions for child and youth conduct
problems.

References

Abbott, R. D., O'Donnell, J., Hawkins, J. D., Hill, K.
G., & Kosterman, R. (1998). Changing teaching
practices to promote achievement and bonding to
school. American Journal of Orthopsychiatry ,
68(4), 542-552.

Akerhielm, K. (1995). Does class size matter?
Economics of Education Review, 14(3), 229-241.

Almgren, G., Guest, A., Immerwahr, G., & Spittel,
M. (1998). Joblessness, family disruption, and
violent death in Chicago, 1970-90. Social Forces,
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Aneshensel, C. S., & Sucoff, C. A. (1996). The
neighborhood context of adolescent mental health.

Journal of Health and Social Behavior, 37,
293-310.

Bjerregaard, B., & Smith, C. (1993). Gender
differences in gang participation, delinquency,
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Criminology, 9(4), 329-355.

Burns, B. J., Costello, E. J., Angold, A., Tweed, D.,
Stangl, D., Farmer, E. M., & Erkanli, A. (1995).
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Bursik, R. J., & Grasmick, H. G. (1993). Economic
deprivation and neighborhood crime rates,
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Catalano, R., Novaco, R., & McConnell, W. (1997).
A model of the net effect of job loss on violence.
Journal of Personality and Social Psychology,
72(6), 1440-1447.

Conger, R. D., Conger, K. J., Elder, G. H., Lorenz, F.
O., Simons, R. L., & Whitbeck, L. B. (1992). A
family process model of economic hardship and
adjustment of early adolescent boys. Child
Development, 63, 526-541.

Costenbader, V., & Buntaine, R. (1999).
Diagnostic discrimination between social
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Costenbader, V., & Markson, S. (1998). School
suspension: A study with secondary school
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59-82.

Elliott, D. S., Wilson, W. J., Huizinga, D.,
Sampson, R. J., Elliott, A., & Rankin, B. (1996).
The effects of neighborhood disadvantage on
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Crime and Delinquency, 33(4), 389-426.

105

108


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127


predictive and possible causal relationship with
conduct problems.

Family Modeling of Norm-
Maintaining Versus Antisocial
Behavior

Family modeling of norm-maintaining behavior
involves exposing the child to prosocial behavior
versus rule-breaking and antisocial behavior by
other family members. Three different types of
evidence can be used to support the contribution
of family modeling in externalizing behavior
problems.

A sizable body of literature has examined whether
the presence of antisocial behavior, delinquency,
or criminal behavior in other family members
places children at increased risk for similar
behaviors. Much of this work has found increased
tisk when mothers, fathers, or siblings were rated
as more antisocial or had a history of delinquency
or criminal behavior (Farrington & Hawkins,
1991).

It is not known whether this increased risk stems
from modeling; from poorer parental discipline,
monitoring, and engagement; or from sharing
some common genetic predisposition.

A second body of literature concerns the
relationship between marital conflict and child
outcomes, where greater marital discord is
assumed to model behaviors relevant to
externalizing behavior problems in children.
Research over three decades documents modest to
moderate correlations between parental conflict
and children’s externalizing behavior problems.
Younger and older children appear to be
comparably influenced by parental conflict (Brody
et al., 1996; Jouriles et al., 1991). Family conflict
in more than one area (i.e., parent-parent, parent-
child, sibling-sibling) is correlated with child
aggression (Schwartz, Dodge, Pettit, & Bates,
1997). This pattern continues to be seen among

adolescents, where greater marital discord is
modestly correlated with increased delinquency
and problem behavior in both boys and girls
(Davies & Windle, 1997; Mekos, Hetherington, &
Reiss, 1996; Neighbors et al., 1997). Again, it is
not clear whether these effects are due to
modeling, disruptions in parenting behavior,
increased physiological dysregulation, or some
combination of these factors.

A third, more poorly documented area of literature
focuses on parental values, attitudes, or beliefs
concerning deviance and law-abiding behavior.
These few studies have found evidence of a
correlation between parental antisocial attitudes
and externalizing behavior problems/youth
offending (Gorman-Smith, Tolan, Loeber, &
Henry, 1998). However, additional research is
needed to examine these relationships for younger
children and to support predictive relationships.

Implications for Malleable
Family Risk Factors and
Developmental Processes

It is clear from the research that a number of
aspects of family interaction can increase the risk
for developing externalizing behavior problems
from early childhood through adolescence.
Specifically, lower levels of engagement, greater
use of invalidation, and harsh and inconsistent
discipline have all been identified as causal risk
factors for the development of externalizing
behavior problems. Although parental problem
solving, structuring of the learning environment,
and modeling of normative behavior show some
correlation with the development of conduct
problems, research on these processes has not
advanced to a level where inferences about
predictive or causal risk can be made soundly.

It is important to note that the three most
frequently studied family processes—engagement,

45

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Child Characteristics

A number of child characteristics have been
shown to be associated with high levels of
externalizing behavior problems. These
characteristics span multiple aspects of the
individual, including behavioral, emotional, and
cognitive functioning; autonomic,
neuroendocrine, and neurochemical systems; and
prenatal conditions and genetics. The conclusion
that emerges is that conduct problems likely
involve difficulties in regulation across
behavioral, emotional, cognitive, and biological
functioning. However, the extent to which
problems in regulation of one aspect of
functioning (e.g., emotional) affect the ability to
regulate another aspect (e.g., biological) or how
development of regulation in any one affects other
aspects is not known.

Behavioral and Emotional
Factors

A number of behavioral and emotional
characteristics have been hypothesized to play a
role in externalizing behavior problems. One
prospective longitudinal study found that the
display of empathic, sympathetic, and prosocial
behaviors in childhood predicts a lower risk of
conduct problems in early adolescence (Tremblay,
Pihl, Vitaro, & Dobkin, 1994). This work is
supported by research using concurrent designs
showing that children and youth with conduct
problems perform more poorly on measures of
empathy compared with normal children and
youth (Cohen & Strayer, 1996; Eisenberg et al.,
1996; Miller & Eisenberg, 1988).

Research on child emotionality has focused on
two forms of early emotional/behavioral
characteristics: difficult-irritable-oppositional and
shy-inhibited. Several longitudinal studies have
found that a pattern of difficult-irritable-
oppositional behavior during early childhood
predicts increased risk for later externalizing
behavior problems in childhood and adolescence
(Bates, Pettit, Dodge, & Ridge, 1998; Caspi,
Moffitt, Newman, & Silva, 1996; Guerin,
Gottfried, & Thomas, 1997). The strength of these
associations typically falls in the moderate range
(Cohen, 1988).

In addition, several longitudinal studies have
found that a pattern of inhibited behavior during
early childhood predicted decreased risk for later
antisocial behavior (Raine, Reynolds, Venables,
Mednick, & Farrington, 1998; Tremblay et al.,
1994). However, other studies have found that
behavioral inhibition in early childhood predicted
either later aggression or later increased antisocial
behavior (Caspi et al., 1996; Goldsmith, 1996).
Clearly, more research is needed on the influence
of early behavioral inhibition.

Complementing this work on emotionality is newer
research examining behavioral and attentional
regulation (i.e., a child's ability to maintain calm,
purposeful action and attention rather than acting
in daring, impulsive, and poorly controlled ways).
This research indicates that childhood daring and
impulsive behaviors (i.e., lack of regulation)
(Farrington & Hawkins, 1991), particularly when
combined with irritable emotionality, are predictive
tisk factors for later adolescent antisocial behavior
(Eisenberg et al., 2000). Both behavioral and

12


Table of Contents

Introduction 2... 6...
Development of Externalizing Behavior Problems . .

Early Childhood

Middle Childhood . . .
Adolescence

Child Characteristics ........ sees
Behavioral and Emotional Factors
Cognitive Factors
Autonomic Factors
Neuroendocrine Factors .
Neurochemical Factors
Prenatal Conditions and Genetic Factors .

Implications for Malleable Child Risk Factors and Developmental P Processes 13
Table 1: Child Characteristics—Research Summaries ......... 06.0.0 e cece ee eee eee 20
Family Factors and Processes ...............5+ bbe e eee eeee beeen eee BD

Engagement/Attentiveness Versus Disengagement/Inattentiveness . .
Validation Versus Invalidation
Firm Discipline and Conflict Management Versus Harsh Discipline and

Conflict Escalation ............0. 00000 s eee eee e eee
Family Problem Solving
Parental Structuring of the Learning Environment
Family Modeling of Norm-Maintaining Versus Antisocial Behavior
Implications for Malleable Family Risk Factors and Developmental Processes
Table 2: Family Factors and Processes—Research Summaries

Peer Influences .
Peer Rejection of Aggressive Behavior .
Victimization .....
Peer Enhancement .
Implications for Malleable Peer Risk Factors and Developmental Processes
Table 3: Peer Influences—Research Summaries .........-. 6.000 ee cee eee eee e eens 86



The impact of invalidation has been studied in
infants by measuring their response to hostile and
rejecting behavior. Evidence consistently shows
that such parental behavior is correlated with
externalizing behavior problems (Belsky, Hsieh, &
Crnic, 1998; Renken, Egeland, Marvinney,
Mangelsdorf, & Sroufe, 1989; Shaw et al., 1998).
This effect appears to be as robust for girls as for
boys, and for middle-SES as well as lower-SES
families. It has been found in both European-
American and African-American families. In much
of the work, parental hostility precedes the onset
of externalizing behavior problems. However,
some research indicates that parent hostility and
rejection may co-occur with child early disruptive
behavior and negative emotionality, reflecting a
more interactive and mutually escalating parent-
child interaction pattern (Shaw et al., 1998).

Parental warmth and hostility continue to show
moderate to strong effects during toddlerhood
(Campbell, Breaux, Ewing, & Szumowski, 1986;
Stocker, 1993) and middle childhood (Metzler,
Biglan, Ary, & Li, 1998), and a persistent but lower
effect in early adolescence (Conger & Conger, 1994;
Conger, Ge, Elder, Lorenz, & Simons, 1994). Parental
validation and warmth correlate and predict lower
levels of externalizing behavior and delinquency
(Feldman & Weinberger, 1994; Scaramella, Conger,
& Simons, 1999; Stocker, 1993), while parental
hostility, criticism, and rejection correlate with and
predict disruptive youth behavior (Campbell et al.,
1986; Conger & Conger, 1994). Although the effect
sizes tend to be small, parental
validationvinvalidation has been shown to be a
predictive risk factor across African-American,
European-American, and Hispanic families (Brody,
Stoneman, & Flor, 1996; Harnish et al., 1995;
Knight, Virdin, & Roosa, 1994; Lindahl, 1998).
Changes in parental warmth that accompany
changes in parental engagement, monitoring, and
discipline have been shown to lead to reductions in
child and adolescent conduct problems (Webster-
Stratton, 1998).

As in the case with young children, there is
evidence to support interactive effects between
parental hostility and middle childhood conduct
problems. However, as children move into early
adolescence, some evidence suggests that child
conduct problems predict reductions in parental
warmth but not the converse (Jang & Smith, 1997).
Thus, in childhood and adolescence, modest to
moderate predictive effects have been documented
for parental invalidation and problem behavior. In
addition, results of several intervention trials
indicate that parental validation, when combined
with other family processes, can be modified and
serve as a causal risk factor for child and
adolescent conduct problems (Borduin et al., 1995;
McNeil, Eyberg, Eisenstadt, Newcomb, &
Funderbunk, 1991; Patterson et al., 1982;
Tremblay et al., 1991; Webster-Stratton, 1998;
Webster-Stratton et al., 1988).

Firm Discipline and Conflict
Management Versus Harsh
Discipline and Conflict
Escalation

“Firm discipline” refers to parental strategies for
managing and controlling child behavior that
consistently use rules and set limits, provide
teasons for the rules, and offer nonpunitive
consequences for rule breaking. “Harsh discipline”
tefers to nonabusive parental strategies for
controlling child behavior that may involve
inappropriate or inconsistent use of rules, little
reasoning, and punitive or excessively negative
reactions to rule breaking. Frequently, these
parental strategies are studied within the context
of parent-child conflict and the ability to manage
calmly and resolve conflicts rather than engaging
in coercion and escalating conflict.

As early as age 2, parental use of coercion has
been identified as a predictive risk factor for

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73


behavior, it is not clear how these three forms of
peer influence interact or mutually develop over
time. Although research indicates that rejected
and aggressive children are more likely to be
victimized in grade school, it is not clear whether
these children are also at risk for victimization
during adolescence. Also, how does early
victimization affect peer acceptance and the
formation of social cliques? Are there
developmental events, child characteristics, or
family influences that increase vulnerability to
peer influence and, therefore, could be used to
more effectively target preventive interventions?
Some of the fundamental peer processes involved
in the development of externalizing behavior
problems have been established; research is
needed that pursues more complex interactions
and the developmental timing of peer influences
from early childhood through adolescence.

References

Bierman, K. L., Smoot, D. L., & Aumiller, K.
(1993). Characteristics of aggressive-rejected,
aggressive (nonrejected), and rejected
(nonaggressive) boys. Child Development, 64,
139-151.

Bierman, K. L., & Wargo, J. B. (1995). Predicting
the longitudinal course associated with
aggressive-rejected, aggressive (nonrejected), and
rejected (nonaggressive) status. Development and
Psychopathology, 7, 669-682.

Bjerregaard, B., & Smith, €. (1993). Gender
differences in gang participation, delinquency,
and substance use. Journal of Quantitative
Criminology, 9(4), 329-355.

Cairns, R. B., Cairns, B. D., Neckerman, H. J., Gest,
S. D., & Gariepy, J.-L. (1988). Social networks and
aggressive behavior: Peer support or rejection?
Developmental Psychology, 24(6), 815-823.

Chamberlain, P., & Reid, J. B. (1998). Comparison
of two community alternatives to incarceration for
chronic juvenile offenders. Journal of Consulting
and Clinical Psychology, 66(4), 624-633.

Coie, J. D., Terry, R., Lenox, K., Lochman, J., &
Hyman, C. (1995). Childhood peer rejection and
aggression as predictors of stable patterns of
adolescent disorder. Development and
Psychopathology, 7, 697-713.

Conduct Problems Prevention Research Group.
(1999). Initial impact of the Fast Track prevention
trial for conduct problems. I. The high-risk
sample. Journal of Consulting and Clinical
Psychology, 67(5), 1-15.

Crick, N. R., Casas, J. F., & Ku, H.C. (1999).
Relational and physical forms of peer
victimization in preschool. Developmental
Psychology, 35(2), 376-385.

Crick, N. R., & Grotpeter, J. K. (1996). Children's
treatment by peers: Victims of relational and overt
aggression. Development and Psychopathology, 8,
367-380.

Dishion, T. J., & Andrews, D. W. (1995).
Preventing escalation in problem behaviors with
high-risk young adolescents: Immediate and 1-
year outcomes. Journal of Consulting and Clinical
Psychology, 63(4), 538-548.

Dishion, T. J., Duncan, T. E., Eddy, J. M., Fagot, B.
I, & Fetrow, R. (1994). The world of parents and
peers: Coercive exchanges and children's social
adaptation. Social Development, 3(3), 255-268.

Dishion, T. J., Eddy, J. M., Haas, E., Li, F., &
Spracklen, K. (1997). Friendships and violent
behavior during adolescence. Social Development,
6, 207-223.

Dishion, T. J., McCord, J., & Poulin, F. (1999).
When interventions harm: Peer groups and

86


DOCUMENT RESUME

ED 473 561 CG 032 236

AUTHOR Hann, Della M., Ed.

TITLE Taking Stock of Risk Factors for Child/Youth Externalizing
Behavior Problems.

INSTITUTION National Inst. of Mental Health (DHHS), Rockville, MD.

REPORT NO No-02-4938

PUB DATE 2001-11-00

NOTE 138p.

AVAILABLE FROM For full text: http://www.nimh.nih.gov/childhp/
takingstock. pdf.

PUB TYPE Information Analyses (070) -- Numerical/Quantitative Data
(110) -- Reports - Descriptive (141)

EDRS PRICE EDRS Price MFO1/PC06 Plus Postage.

DESCRIPTORS *Adolescents; *Behavior Problems; *Children; Intervention;
*Mental Health; *Predictor Variables; Prevention

IDENTIFIERS *Risk Factors

ABSTRACT

Research on child and adolescent conduct problems has
proliferated over the past 15 years, resulting in an extensive array of risk
factors, processes, and targets for intervention. To capitalize fully on this
extensive research base and contribute effectively to public mental health,
the field now needs to take stock of what is known about child and youth
conduct problems. In 1998, The National Institute of Mental Health (NIMH
began a process known as “Taking Stock of Risk Factors for Child/Youth
Externalizing Behavior Problems.” “Externalizing behavior problems” refers to
a range of rule-breaking behaviors and conduct problems, including physical
and.verbal aggression, defiance, lying, stealing, truancy, delinquency
physical cruelty, and criminal acts. The “taking stock” process involves
three key objectives: (1) to identify and describe what is known about risk
factors and processes that contribute to externalizing behavior problems; (2)
to identify gaps in our knowledge about risk factors and processes; and (3)
to describe the kinds of research and research methodologies needed to
advance the field. This report provides a summary of the first of these
objectives--describing what is known about existing risk factors and
processes that contribute to externalizing behavior problems. This report
provides a summary of expert consensus and evaluation of what is currently
known about the factors and processes that contribute to the initiation,
enhancement, prevention, and termination of conduct problems in children and
youth. Specific information about the research studies that document these
findings can be found in the accompanying tables. (Contains 285 references
and 4 tables.) (GCP)

Reproductions supplied by EDRS are the best that can be made
from the original document.



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concerned with externalizing behavior problems are
moving beyond simple risk factor studies into the
study of risk and protective mechanisms that not
only explain variance in predicting outcomes, but
also suggest malleable processes that can be tested
for causality and become targets for intervention.
These risk mechanisms are developmental and
appear to involve more complex interactions
between organism and environment, which
themselves change in potency over the course of
development.

Acknowledging and truly taking into account this
complexity will be the task of the next generation
of risk research in externalizing behavior problems.
Indeed, several recent studies have moved in this
direction by studying how selected child factors
interact with specific environmental factors at
critical points in development and examining how
patterns among these factors affect the
development of externalizing behavior problems
(Conger et al., 1992; Deater-Deckard, Dodge, Bates,
& Pettit, 1998; Henry, Caspi, Moffitt, & Silva, 1996;
Pettit, Bates, Dodge, & Meece, 1999; Shaw, Owens,
Vondra, Keenan, & Winslow, 1996). These initial
studies are taking on the challenge of reducing the
now-overwhelming four-plus-dimensional matrix
(resulting from the intersection of child, family,
peer, broader social environment, and
development) to workable sets of multiple factors
that hold significant power for predicting risk and
revealing stronger groupings of causal risk factors
for externalizing behavior problems.

What can be used to guide this complex and
challenging work? The research reviewed here
suggests four strategies for advancing research on
risk factors and interventions for externalizing
behavior problems.

= Several important factors have been identified
as causal risk factors, including child hostile
attributional processes; parental engagement,

validation, and discipline; and peer rejection and

association with deviant peers. It is critical that
these findings be disseminated to the public and
that effectiveness research be conducted with the
intervention strategies known to affect these
factors to ensure appropriate implementation by
communities, schools, and mental health service
systems.

= The framework provided by Kraemer et al.
(1997) suggested that research on risk factors
televant to developing interventions can follow a
developmental course of its own. Once factors are
found to be correlated with outcomes, further
research should document the potential for
prediction and, ultimately, the potential for
causation. The current review identified a number
of predictive risk factors and concurrent
correlations with externalizing behavior problems.
Ivis critical that this research be advanced (i.e., that
concurrent correlations be tested for predictive risk
and effect size, and that potent predictive risk
factors be tested for potential causality). This type
of research will provide the foundation for
developing more effective interventions.

= Studying multiple factors simultaneously is
critical for furthering intervention and risk factor
research. Simple risk factor studies have played an
important role, but the field must advance to
describing, measuring, analyzing, and
experimentally intervening with child factors and
environments in more complex ways.

= A developmental perspective will need to be
incorporated into all research. Externalizing
behavior problems have a developmental course,
and it is likely that the risk factors and
mechanisms that lead to this development also
change over time. In particular, it is important to
know if there are particular points in development
when specific risk factors converge to substantially
increase vulnerability or when there are windows
of opportunity for intervention.

133

135


Contributing Experts

Robert Cairns, Ph.D.—University of North Carolina, Chapel Hill
John Coie, Ph.D.—Duke University
Rand Conger, Ph.D.—lowa State University
Nicki R. Crick, Ph.D.—University of Minnesota
Thomas Dishion, Ph.D.—University of Oregon
Nancy Eisenberg, Ph.D.—Arizona State University
Thomas Farmer, Ph.D.—University of North Carolina, Chapel Hill
Peggy Giordano, Ph.D.—Bowling Green State University
Nancy Gonzales, Ph.D.—Arizona State University
George Howe, Ph.D.—George Washington University
Sheppard Kellam, M.D.—Johns Hopkins University
Benjamin Lahey, Ph.D.—University of Chicago
Enrico Mezzacappa, M.D.—Judge Baker Children's Center
Debra Pepler, Ph.D.—York University, Ontario, Canada
John Reid, Ph.D.—Oregon Social Learning Center
Kenneth Rubin, Ph.D.—University of Maryland
Daniel Shaw, Ph.D.—University of Pittsburgh
Vincent Smerigilo, Ph.D.—National Institute On Drug Abuse
Howard Stevenson, Ph.D.—University Of Pennsylvania
Elizabeth Susman, Ph.D.—Pennsylvania State University
Terrence Thornberry, Ph.D.—State University Of New York, Albany
Farris Tuma, Sc.D.—National Institute Of Mental Health

Consulting Experts

Lawrence Aber, Ph.D.—National Center For Children In Poverty
Hendricks C. Brown, Ph.D.—University Of South Florida
Lindon Eaves, Ph.D., D.Sc.—Virginia Commonwealth University
Gary Gottfredson, Ph.D.—Gottfredson Associates


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conflict). Sorting out these confounding factors is
extremely difficult and requires caution in
drawing inferences about causal relationships.

Given these difficulties, there is substantial
evidence that offspring of mothers who give birth
earlier in life are more likely to have externalizing
behavior problems during childhood and
adolescence (Christ et al., 1990; Fergusson &
Lynskey, 1993; Spieker, Larson, Lewis, White, &
Gilchrist, 1997). This predictive association
between maternal age and child conduct problems
still holds even when maternal and paternal
conduct problems, substance use, perinatal
factors, demographic factors, parent-child
interactions, and related variables have been
controlled in regression analyses (Fergusson &
Lynskey, 1993; Wakschlag et al., 1997). Although
it is not clear how maternal age is related to child
behavior problems, at least two kinds of variables
can be hypothesized as mediators. First, having a
child earlier in life often restricts maternal
educational and occupational attainment and
related life circumstances, such as neighborhood
of residence, that are associated with youth
conduct problems and crime (see the Broader
Social Environment, Communities, and Schools
section). Second, less mature mothers may be
more likely to raise their children in ways that
may foster conduct problems, such as use of
harsh and inconsistent discipline (see Family
Factors and Processes section). Also, other as-yet-
unknown biological variables, environmental
variables, or both may mediate this relationship.

In addition to maternal age, consistent evidence
exists that prenatal maternal smoking is a
predictive risk factor for later child conduct
problems. Evidence from methodologically strong
epidemiological and clinical studies in several
countries has found maternal cigarette smoking
during pregnancy to predict inattention and
impulsivity during early childhood and conduct
problems and antisocial behavior during middle
childhood and adolescence (Brennan, Grekin, &
Mednick, 1999; Fergusson, Woodward, &

Horwood, 1998; Wakschlag et al., 1997;
Weissman, Warner, Wickramaratne, & Kandel,
1999), Even when potential mediators and
confounds are considered (e.g., maternal age,
drug use, psychopathology, SES, parent-child
interactions), the findings suggest linear
relationships between the number of cigarettes
smoked per day and the increased predictive risk
of child and adolescent conduct problems. As in
the research on maternal age, the reasons why
maternal smoking is related to child conduct
problems are not clear. It could be that maternal
smoking is a marker for some other set of risk
factors (e.g., parental behavior, neighborhood
effects [see respective sections on these topics]), or
that prenatal exposure to nicotine affects fetal
neurodevelopment, which in turn increases the
child's vulnerability to conduct problems, or that
these biological and social risk factors interact in
some way. Indeed, controlled animal studies
consistently show that exposure to low levels of
nicotine alters fetal neural development (Navarro
etal., 1989). Clearly, additional research is
needed to help explain why prenatal maternal
smoking is a predictive risk factor for later child
conduct problems.

Two other classes of prenatal insults that have
been related to later child conduct problems are
exposure to alcohol and exposure to illegal drugs.
Although research on prenatal exposure to alcohol
has shown robust effects on cognitive development
and neurodevelopment (e.g., attentional and
intellectual deficits) during childhood and
adolescence (Coles et al., 1991), research on
conduct-related behaviors among these children
suggests low to modest effects (Brown et al., 1991;
Coles et al., 1991; Olson et al., 1997). Similarly,
research on prenatal exposure to illegal drugs (e.g.,
cocaine) has found subtle and modest differences in
intellectual behavior and arousal regulation
between exposed children and nonexposed
comparison children (Eyler, Behnke, Conlon,
Woods, & Wobie, 1998; Lester, LaGasse, & Seifer,
1998). A recent study found prenatally exposed

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35

40


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48

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57


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classroom. Child Development, 64, 572-585.

McNeil, C. B., Eyberg, S., Eisenstadt, T. H.,
Newcomb, K., & Funderbunk, B. (1991). Parent-
child interaction therapy with behavior problem
children: Generalization of treatment effects to the
school setting. Journal of Clinical Child
Psychology, 20(2), 140-151.

Mekos, D., Hetherington, E. M., & Reiss, D. (1996).
Sibling differences in problem behavior and parental
treatment in nondivorced and remarried families.
Child Development, 67, 2148-2165.

Metzler, C. W., Biglan, A., Ary, D. V., & Li, F.
(1998). The stability and validity of early
adolescents’ reports of parenting constructs.
Journal of Family Psychology, 12(4), 600-619.

Neighbors, B. D., Forehand, R., & Bau, J. J. (1997).
Interparental conflict and relations with parents
as predictors of young adult functioning.
Development and Psychopathology, 9, 169-187.

Olds, D., Henderson, C. R., Cole, R., Eckenrode, J.,
Kitzman, H., Luckey, D., Pettit, L., Sidora, K.,
Mortis, P., & Powers, J. (1998). Long-term effects of

53


Peer Influences

Peers play an important role in child development.
Particularly as children mature into adolescents,
peers play a large role in shaping both appropriate
and inappropriate behaviors. However, newer
evidence indicates that as early as preschool,
peers begin to exert noticeable influences on child
aggressive behavior. Research on the influence of
peers on externalizing behavior problems can be
categorized into three domains—peer rejection of
aggressive behavior, peer victimization, and peer
enhancement of aggression and antisocial
behavior.

At first glance, the first and third domain may
appear contradictory. How can aggressive
behavior be rejected and also enhanced by peers?
This seeming contradiction is at the heart of peer
influence on externalizing behavior problems.
Aggressive behavior may be rejected by
conventional peers and at the same time
negatively and positively reinforced. Rejection by
conventional peers encourages similarly
aggressive and rejected children to find one
another, form friendships, and develop ways of
approving and accepting aggression. Although
much is known about predictive and causal risks
within each domain, the interdependence,
possible sequencing, and points of vulnerability
across domains of peer influence are not well
established.

Peer Rejection of Aggressive
Behavior

Peer rejection has been shown to be a middle-

childhood predictive risk factor for adolescent
conduct problems over and above its concurrent
correlation with childhood aggression. Several
longitudinal studies have documented that
children who are both rejected by their peers and
highly aggressive exhibit the poorest overall
adjustment in elementary school (Bierman &
Wargo, 1995; Lochman & Wayland, 1994). As
early as first grade, children who come from
families marked by higher amounts of conflict
and coercion are more likely to engage in
aggressive interactions with peers (Dishion,
Duncan, Eddy, Fagot, & Fetrow, 1994; Schwartz,
Dodge, Pettit, & Bates, 1997). In turn, aggressive
children who are rejected by their peers are at
increased risk for behavior problems prior to
middle school (Bierman, Smoot, & Aumiller,
1993; Bierman & Wargo, 1995). For boys, the
predictive relationship between early aggression
and peer rejection and later externalizing
behavior problems has been documented into
adolescence (Coie, Terry, Lenox, Lochman, &
Hyman, 1995).

To understand why peer rejection has such
negative effects for children, one must recall
research described in the Child Characteristics
section. Children who are both rejected and
aggressive show a more pervasive pattern of
behavioral and social deficits—including
inattention, argumentative and disruptive
behaviors, and poor prosocial behavior—unlike
children who are aggressive but not rejected or
rejected but not aggressive. Also, children who are
both rejected and aggressive are more likely than
their nonaggressive well-liked peers to develop
biased social information processing involving a

82


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89


externalizing behavior problems at school entry
(Crockenberg & Lourie, 1996; Fagot & Leve,
1998). Similarly, evidence indicates that negative
parental control and harsh parental discipline
during toddlerhood predict increased risk for child
aggression and externalizing behavior problems
one, two, and five years later (Campbell, 1994;
Campbell, March, Pierce, Ewing, & Szumowski,
1991; Campbell, Pierce, Moore, Marakovitz, &
Newby, 1996). Some of this work has examined
the role of early child negative emotionality and
finds that both child negativity and parental
coercion predict child behavior problems (Kingston
& Prior, 1995; Schwartz, Dodge, Pettit, & Bates,
1997).

In middle childhood, and in early and later
adolescence, consistent relationships between
highly conflictual, inconsistent, harsh, and
restrictive parenting and child externalizing,
delinquent, and antisocial behavior have been
found in research using concurrent correlational
designs (Knight et al., 1994; Sampson & Laub,
1994; Shumow, Vandell, & Posner, 1998).
Predictive longitudinal studies also indicate that
harsh and inconsistent parenting predicts later
youth conduct problems (Patterson et al., 1998;
Wasserman, Miller, Pinner, & Jaramillo, 1996).
However, the direction of this influence may
change over time, with a reciprocal relationship
between disciplinary style and antisocial behavior
in early and middle childhood, but fading
teciprocity as the child moves into adolescence
(with parental behavior predicting child behavior)
(Cohen & Brook, 1995). Also, there is some
evidence that the experience of parental punitive
discipline may more strongly predict early
childhood behavior problems than it does
adolescent conduct problems (Feehan, McGee,
Stanton, & Silva, 1991). It is important to note,
however, that modest to moderate effects of
parental discipline and parent-child conflict with
externalizing behavior problems still are detected
in adolescence (Neighbors, Forehand, & Bau,
1997;

43

Steinberg, Lamborn, Darling, Mounts, &
Dornbusch, 1994).

Evidence exists that the effects of parental
discipline and conflict management may vary as a
function of ethnicity and community context.
Several studies have documented concurrent
correlations and predictive risk between harsh or
inconsistent parental discipline, or both, and
child/adolescent conduct problems in African-
American and Hispanic samples (Knight et al.,
1994; Lindahl, 1998), but other studies have
found different effects. For example, harsh
discipline had different effects on European-
American and African-American children. In a
study of children in early elementary school,
physical discipline (e.g., spanking) predicted
increased externalizing behavior for European-
American but not for African-American children
(Deater-Deckard, Dodge, Bates, & Pettit, 1996).
These differences, however, were significant only
in the nonabusive range of corporal punishment;
physically abusive parenting is associated with
antisocial behavior for both African-American and
European-American children (Dodge, Pettit, Bates,
& Valente, 1995; Shumow et al., 1998). In
adolescence, unilateral parental decision making
was related to fewer conduct problems among
African-American youth and was unrelated to
externalizing behavior problems among European
Americans, Hispanics, and Asian Americans
(Lamborn, Dornbusch, & Steinberg, 1996).

Parental discipline and conflict management have
been primary targets for many intervention
programs. These trials have consistently
documented that improvement in these aspects of
parenting leads to improvements in child and
adolescent conduct (Webster-Stratton, 1998).
Beginning in toddlerhood, through middle
childhood and adolescence, interventions that
include improvement in parental discipline, in
addition to monitoring and validation, show
reductions in youth conduct problems and
antisocial behavior (Bank et al., 1991; Patterson

47


Studying Correlated
Environments

This review found that a wide range of
environmental factors from a variety of social
contexts are likely to influence the developmental
course of externalizing behavior problems. Single
variables by themselves do a poor job of describing
the environments that influence developmental
pathways. In addition, the variables we use to
describe these environments often co-occur with
one another, both within and between social
contexts. Recent literature uses terms such as
“correlated constraints,” “correlated
environments,” or “bundled risk factors” to
describe such co-occurrence. These findings have
important implications for research and effective
intervention.

= Simple risk factor studies have played an
important but more preliminary role in the field.
They provided initial evidence about where
attention needed to be focused. Now, research on
environmental risk factors needs to move to
describing environments in more complex ways.
Indeed, this review organized environmental
factors into three primary areas—family, peer, and
the broader social environment. Many correlations
and predictive risk factors were identified in each
area, as well as several noted causal risk factors.
Research now must build on this foundation by
examining how factors within and across these
areas converge to increase or decrease risk for
conduct problems at various phases of
development.

= Interventions that focus on single
environmental risk factors are very likely to be
compromised by hidden constraints, threshold
problems, and even boomerang effects. Hidden
constraints are linked risk factors that are
overlooked. For example, parent training programs
may fail to change important parenting behaviors

because they fail to appreciate the constraints on
parenting imposed by parental depression,
interparental conflict, work, or economic
conditions. Threshold problems occur when
interventions fail to target a broad enough array of
important factors. For example, programs that
target only reductions in conduct problems may not
teach a threshold for effectiveness if they do not
also include training in how to carry out prosocial
alternatives. Boomerang effects occur when
interventions to reduce one risk factor actually
enhance other risk factors. For example,
interventions that bring children with conduct
problems together in groups to work on social skills
may inadvertently enhance the formation of self-
reinforcing deviant peer groups.

Recent studies have made some headway,
suggesting important directions for studying
correlated environments and their effects.

= Studies involving more comprehensive
assessments of the child's developmental context
find important continuities across aspects of the
environment. For example, various dimensions of
parenting behavior tend to co-occur (validation,
monitoring, engagement, discipline) (Barnes,
Farrell, & Banerjee, 1994; Farrington & Hawkins,
1991; Haapasalo & Tremblay, 1994; Patterson,
Chamberlain, & Reid, 1982; Sampson & Laub,
1994; Scaramella, Conger, & Simons, 1999;
Simons, Johnson, Conger, & Elder, 1998;
Wasserman, Miller, Pinner, & Jaramillo, 1996).

= Studies that include measurement of more than
one social context also find cross-context links
(Borduin et al., 1995). For example, parenting
patterns are related to peer relationships (Aseltine,
1995; Dishion, Duncan, Eddy, Fagot, & Fetrow,
1994; Schwartz, Dodge, Pettit, & Bates, 1997), and
communities may reinforce local friendship
networks that enhance the operation of these
effects (Brody et al., 2001; Sampson, Raudenbush,
& Earls, 1997).

131

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126


Synthesis and Epilogue

This review of empirical studies was guided by two
objectives: (1) to identify the significant risk factors
associated with externalizing behavior problems;
and, (2) to estimate the likelihood that each factor
influences the occurrence of externalizing behavior
problems. In pursuing these objectives, an evaluative
framework developed by Kraemer et al. (1997) was
used to categorize factors as correlates, predictive
tisk factors, or causal risk factors based on the
scientific evidence to date. Three important lessons
were learned quickly. First, research in this area has
blossomed in the past decade, resulting in hundreds
of empirical papers covering a wide range of possible
factors. Second, while a number of significant causal
risk factors have been identified (i.e., child hostile
attributional processes; parental engagement,
validation, and discipline; peer rejection and
association with deviant peers), a number of factors
have empirical support as predictive risk factors and
many more have been identified as concurrent
correlations. Third, many researchers have moved
beyond a simple risk-factors perspective, driven by
findings that pointed to a more complex and richly
textured view of children and how they develop from
infancy through early adulthood.

The preceding sections of this report have, with
some exceptions, stayed close to the original
objectives, focusing in turn on each of the many
factors discussed in this literature. It is important,
however, to expand on these objectives to take into
account the complexity of externalizing behavior
problems and to encourage the next generation of
empirical studies. This expansion includes: (1) the
importance of defining externalizing behavior in
developmental terms; (2) the need to “put the

organism back together” in considering individual
child characteristics as they relate to risk and
protection; (3) the problem of “correlated
environments” and their implications; and (4) the
necessity of studying child characteristics and
environmental factors in concert.

Defining Externalizing Behavior
in Developmental Terms

The past decade has seen a movement from
defining externalizing behavior problems as
isolated acts or static traits to defining
externalizing behaviors as an organized system of
responses that emerges, grows, and changes over
the course of development. These responses are
multifaceted, including not just overt actions but
also patterns of thinking and feeling (e.g., hostile
attributions, irritability). To completely characterize
externalizing behavior problems, researchers must
describe not only the kinds of actions, thoughts,
and emotions involved, but also how they are
interrelated and how these interrelated patterns
develop and change over the months and years
from infancy through childhood, adolescence, and
early adulthood. While a number of recent
longitudinal studies have given some initial picture
of these developmental “trajectories,” “pathways,”
or “reorganizations,” a great many questions
remain unanswered. For instance, there are
questions about continuity and discontinuity
(Which young children remain aggressive
throughout childhood, and which do not?) and
questions about reorganization of behavior (Which
aggressive children later become bullies, which

129

134


Taking Stock

of Risk Factors for Child/Youth

Externalizing Behavior Problems

Editor
Della M. Hann, Ph.D.
Associate Director for Research Centers, Training & Coordination
Division of Mental Disorders, Behavioral Research, and AIDS
National Institute of Mental Health

Associate Editor
Nicolette Borek, Ph.D.
Psychologist
Division of Mental Disorders, Behavioral Research, and AIDS
National Institute of Mental Health

DEPARTMENT OF HEALTH AND HUMAN SERVICES + PUBLIC HEALTH SERVICE + NATIONAL INSTITUTES OF HEALTH N MI

National Institute
of Mental Health


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on the move: Residential and educational mobility
in American's schools. Sociology of Education, 72,
54-67.

Thornberry, T. P., Krohn, M. D., Lizotte, A. J., &
Chard-Wierschem, D. (1993). The role of juvenile
gangs in facilitating delinquent behavior. Journal
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55-87.

Thurlow, M. L., Ysseldyke, J. E., Wotruba, J. W., &
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305-315.

107

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prevention of special classroom placement may be
even more effective.

Changing schools frequently is associated with a
variety of problems, including lower academic
performance, worse behavior in school, lower
grade retention, school dropout, and serious
disciplinary problems (Rumberger & Larson,
1998; Swanson & Schneider, 1999; Tucker, Marx,
& Long, 1998). Based on data collected by the
National Educational Longitudinal Survey,
changes that occur during the early school years
have little impact on child behavior problems.
However, school changes during high school were
correlated with a moderate increase in behavioral
problems (Swanson & Schneider, 1999). The
importance of number of school changes may be
mediated by family structure. In families with two
biological parents, excessive mobility (eight or
more moves) correlated with school problems.
However, for all other family configurations, any
move was associated with problematic youth
behavior (Tucker et al., 1998). Also, school
changes and dropout were predicted by high rates
of absenteeism, misbehavior, and low-educational
expectations (Rumberger & Larson, 1998).

Another school variable considered relevant to
child conduct is the type of disciplinary practices
invoked for misbehavior. Although disciplinary
practices are aimed at reducing problem behavior
in schools, surprisingly few studies have directly
examined the relationships between school
discipline and the development and maintenance of
externalizing behavior problems. Given the
growing trend of adopting zero-tolerance policies,
this lack of data is cause for concern. In a survey
on school suspension, the majority of middle
school and high school students who received
suspensions did not consider this form of discipline
to be very helpful in solving problems (Costenbader
& Markson, 1998). Data on less punitive forms of
school discipline also are limited. However, there is
some evidence that use of less punitive forms of
school discipline in elementary school (e.g.,

105

102

Teminders to be safe and respectful) did result in
reduced problem behavior (Lewis, Sugai, & Colvin,
1998).

Another school practice that has received
attention is tracking (i.e., the arrangement of
students in classrooms by levels of ability).
Tracking is a complex factor, as it is intertwined
with other characteristics of students, families,
friends, and schools in ways that seem to solidify
differences among students. Students who come
from low-SES backgrounds, attend low-SES
schools, are members of ethnic-minority groups
(Jones, Vanfossen, & Ensminger, 1995), and
display behavior problems (Farmer, 1993) are
over-represented among low-ability tracks. Being
placed in a low-ability track is associated with
less effective instruction, more disruptive off-task
behavior by students, and lower than expected
academic attainment (Gamoran, Nystrand,
Berends, & LePore, 1995).

Public concerns about class and school size have
grown with concerns about violence in the schools
and poor pupil performance. Yet educational
researchers have had difficulty determining whether
reduced class size positively affects student
performance and behavior. Part of this difficulty
comes from the fact that schools do not randomly
assign students to classes (e.g., there is tracking) and
that there are state and federal regulations that limit
the size of special education classes. However, when
special education restrictions are taken into account,
smaller class size does correlate with enhanced
performance (Akerhielm, 1995). Research on the size
of schools has focused on academic outcomes rather
than behavioral outcomes (Lee & Smith, 1997;
McGiverin, Gilman, & Tillitski, 1989). This research
indicates that the most effective high schools serve
600-900 students. Neither small schools (< 300)
nor large schools (> 2,100) are associated with
strong learning environments. Similarly, the effect of
school size is more profound in schools with lower-
SES students and in schools with higher
concentrations of minority students (Lee & Smith,


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Esbensen, F.A., & Huizinga, D. (1993). Gangs,
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Farmer, E. (1993). Externalizing behavior in the
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\
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106

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attentional regulation contribute to this finding,
and the pattern of relations, while low-moderate in
predictive strength, has been found in the United
States (Lengua, West, & Sandler, 1998) and New
Zealand (Henry, Caspi, Moffitt, & Silva, 1996).

Cognitive Factors

Research on ADHD provides further information
about the role of attention and other cognitive
processes in the development of externalizing
behavior problems. A number of studies have
documented that boys who meet criteria for ADHD
in childhood are at increased risk for conduct
disorder and antisocial behavior in adolescence
and early adulthood (Mannuzza et al., 1991).
However, when comorbid oppositional defiant
behavior is measured, some evidence suggests
that increased risk for conduct disorder is
correlated with early oppositional defiant behavior
rather than ADHD (Biederman et al., 1996;
Moffitt, 1990). Thus, while the evidence indicates
an association between ADHD and conduct
problems, it is not clear whether ADHD operates
as a predictive risk factor or a moderator.

In trying to clarify the implications of ADHD,
researchers are incorporating indices of basic
cognitive functioning and development,
specifically executive function and inhibitory
control processes. Executive function refers to the
ability to take in information, formulate plans of
action and thinking, and execute behaviors
consistent with these plans. Involved in this
process is the ability to exert inhibitory control,
that is, to inhibit other sources of information and
other incompatible behaviors.

There is some debate as to whether executive
function and inhibitory control are relevant to
conduct disorder or whether they are best thought
of as related to ADHD and, therefore, pertinent only
in instances of comorbid conduct disorder and

ADHD. However, recent studies using improved
measures of these cognitive processes and refined
sampling techniques have indicated that
inhibitory control is correlated with conduct
disorder, even in the absence of ADHD
(Oosterlaan, Logan, & Sergeant, 1998; Oosterlaan
& Sergeant, 1996). Children with more persistent
or pervasive conduct problems seem more likely to
demonstrate deficits in executive function and
inhibitory control. These associations appear to be
relatively independent of IQ and other cognitive
functions, such as memory (Seguin, Boulerice,
Harden, Tremblay, & Pihl, 1999). This
independence of effect from IQ is particularly
important because a large number of studies have
found lower IQ and verbal abilities to be predictive
risk factors for later antisocial behavior
(Fergusson & Horwood, 1995; Stattin &
Klackenberg-Larsson, 1993; White, Moffitt, &
Silva, 1989). Note, however, that much of the
research on executive function is based on
concurrent assessments of cognitive functioning
and problematic behavior. Additional research is
needed to identify the predictive associations and
potential causality of these processes for conduct
problems.

Related to IQ and verbal abilities is a young
person's academic achievement. Research
consistently documents low correlations between
poor academic performance and externalizing
behavior problems (Maguin & Loeber, 1996).
Again, it has been difficult to determine if this
association holds for children who show conduct
problems in the absence of ADHD; several studies
show correlations among poor academic
achievement, conduct, and attention problems, but
weak or no relationships between poor academic
achievement and conduct problems alone (Frick et
al., 1991). However, children who develop conduct
problems in middle childhood are at increased risk
of later negative educational outcomes, including
early school dropout (Fergusson & Horwood,
1998). Thus, the direction of effects between
academic achievement and externalizing behavior

13


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81


problem behavior. American Psychologist, 54(9),
755-764.

Dodge, K. A. (1980). Social cognition and
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Dodge, K. A., & Frame, C. L. (1982). Social
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87


generally occurs through associations with
deviant peers. Initial data on these “late starters”
suggest that much of their antisocial behavior
tends to be nonaggressive and that they are more
likely to desist in problem behaviors as they
become older. However, other ongoing research is
suggesting that some late starters may be
involved in highly aggressive and problematic
behaviors. Additional research is needed to fully
understand the pathways and outcomes for late
starters.

It is important to note that the early starter/late
starter model of two developmental pathways for
externalizing behavior problems is controversial.
Several research groups are actively examining
data to detect other potential pathways, as well as
distinct developmental patterns related to child
gender. However, this two-pathway model is
important because it incorporates the notion that
behaviors exhibited by children with conduct
problems differ with development and changes in
the social environment. The basic forms of
externalizing behavior problems evident in early
childhood, middle childhood, and adolescence are
summarized below.

Early Childhood

Most children engage in rule-breaking and defiant
behaviors during early childhood (ages 2-6);
therefore, this is the stage of life at which
externalizing behaviors are at their peak. During the
early years, the primary manifestations of
externalizing behavior problems include
noncompliance, oppositional behaviors, and overt
physical and verbal aggression. With developing
cognitive, language, and social abilities, most
children replace their aggressive problem-solving
strategies with prosocial ones. A small minority of
children continue to engage in high rates of
externalizing behavior and exhibit these behaviors
(e-g., coercive interactions with parents, hitting
young peers) in home and school settings. Children

who show early and persistent externalizing
behavior problems and who experience additional
psychiatric and academic problems (e.g., attention
deficit hyperactivity disorder [ADHD)}) are at
highest risk for developing serious delinquency
and engaging in juvenile crime in adolescence.
Thus, children who, from an early age, show
persistent externalizing behavior problems appear
to be developing along the early onset pathway
for conduct problems, failing to learn prosocial
ways of interacting with others, and laying the
foundation for continuing problematic behaviors.

Middle Childhood

With the increased cognitive and social
sophistication of middle childhood (ages 7-13),
children expand their repertoire of conduct
problems from those that are evident to observers
(i.e., overt, direct) to those that are hidden or
secretive (i.e., covert, indirect, relational). Both
boys and girls who are aggressive are at risk for
being actively rejected and marginalized by their
peers. When evaluating their social encounters,
these children are often likely to attribute hostile
intent to others. Although coercive family
interactions may continue and escalate, processes
within the peer group gain in importance in
continuing the development of externalizing
behavior problems.

Adolescence

Externalizing behavior problems can intensify
during adolescence, when peer influences enhance
the diversity of rule-breaking behaviors to include
delinquent and antisocial behaviors (e.g.,
vandalism, theft, assault), substance use, and, in
some cases, gang involvement and drug dealing.
For many antisocial young men and women, there
is a developmental acceleration into precocious


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115


Implications for Malleable Peer
Risk Factors and Developmental
Processes

Research on peer influences shows that,
beginning in elementary school, peers can have
profound causal effects on externalizing behavior
problems. Within the first years of school, one can
see peer rejection of aggressive children,
aggressive children beginning to form
relationships with similarly aggressive children,
and peers beginning to attribute greater hostile
intent and aversion to aggressive classmates. At
the same time, aggressive children are more likely
to engage in and escalate their aggressive
behavior with aggressive peers, to develop hostile
attributional styles for interpreting social
encounters with others, to be the victim of peer
attacks, and to bully others. This vicious cycle of
early peer rejection, hostile attributional
processes, and increased aggressive behavior,
however, is malleable. Interventions that target
early aggressive behavior by providing anger
management skills and prosocial means of solving
peer conflicts and reducing hostile intent toward
others have resulted in increased peer acceptance
and decreased externalizing behavior problems.

It is critical to expand on these important results
in two ways. First, the outcomes from these
interventions should be expanded beyond peer
rejection and hostile intent to include indices of
peer victimization and formation of peer cliques.
Are the skills learned through intervention
generalizable to these domains of peer influence?
Also, long-term effects need to be documented. If
these early interventions are successful in
deterring the formation of aggressive and
antisocial cliques, this could have profound effects
during adolescence by deterring association with
deviant peers and preventing the escalation of
serious antisocial behavior. Clearly, long-term
followup of these interventions is needed.

82

The second way to expand these interventions is
through research to determine ways of effectively
translating the interventions for use by
communities, schools, and mental health service
systems. School policies, classroom structure, and
classroom management also may correlate with
externalizing behavior problems (see the Broader
Social Environment, Communities, and Schools
section), which could intensify or constrain
interventions. Critical issues will need to be
addressed: who will receive the intervention (all
children or only targeted high-risk children), when
in development the intervention will be most
effective (e.g., early versus late elementary
school), for whom the intervention should
continue, who should administer and deliver the
intervention, and what should administering and
delivering the intervention cost? However, the
potential gain of decreased externalizing behavior
problems is well worth the effort.

Although the potential for early peer interventions
to affect adolescent association with deviant peers
tequires further empirical testing, the current data
on deviant peers are quite clear: association with
deviant peers during adolescence is a significant
causal risk factor for antisocial behavior.
Grouping similarly deviant adolescents together,
even in the presence of therapeutic interventions,
serves only to maintain and possibly enhance
antisocial behavior. This finding is in direct
conflict with many educational, community, and
state policies and services that group troubled
youth together in classrooms or in group homes.
Clearly, these policies deserve re-examination
given these research findings. Also, there needs to
be more research that examines alternatives to
group placement (e.g., therapeutic foster care) and
that addresses ways of preventing association
with deviant peers during pre- and early
adolescence (e.g., after-school programs,
increased parental monitoring).

In looking over the research on peer rejection,
victimization, and enhancement of aggressive

85


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on”: Residential mobility and children's school
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Uehara, E. S., Chalmers, D., Jenkins, E. J.,&
Shakoor, B. H. (1996). African American youth

encounters with violence. Journal of Black Studies,

26(6), 768-781.

Van Acker, R., Grant, S. H., & Henry, D. (1996)
Teacher and student behavior as a function of risk
for aggression. Education and Treatment of
Children, 19(3), 316-334.

Vitaro, F., Brendgen, M., & Tremblay, R. E.
(1999). Prevention of school dropout through the
reduction of disruptive behaviors and school
failure in elementary school. Journal of School
Psychology, 37(2), 205-226.

Wallace, R. (1990). Urban desertification, public
health and public order: ‘Planned shrinkage’,
violent death, substance abuse and aids in the
Bronx. Social Science Medicine, 31(7), 801-813.

Wehby, J. H., Dodge, K. A., Valente, E., & Conduct
Problems Prevention Research Group (1993).
School behavior of first grade children identified
as at-risk for development of conduct problems.
Behavioral Disorders, 1, 27-39.

Xie, H., Cairns, R. B., & Cairns, B. D. (1999).
Social networks and configurations in inner-city
schools: Aggression, popularity, and implications
for students with EBD. Journal of Emotional and
Behavioral Disorders, 7(3), 147-155.


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56


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55


supportive, nondeviant partners are a source of
protection, breaking the continuity in antisocial
behavior between adolescence and adulthood
(Quinton, Pickles, Maughan, & Rutter, 1993).

Peers also serve to reinforce aggressive behavior,
particularly for children who have difficulty with
aggression (Snyder, Horsch, & Childs, 1997).
Young (preschool- and elementary school-aged)
aggressive children are much more likely to
initiate, reciprocate, and persist with aversive
behavior with their peers than are nonaggressive
children (Snyder & Brown, 1983). In elementary
school, research on bullying (the assertion of
power through aggression, repeated over time and
intended to cause harm) has found the peer group
to be critical in maintaining, exacerbating, and
terminating bullying. Peers tend to give positive
attention to bullies by watching, cheering, and
sometimes joining the bully. The positive
attention has been correlated with longer bouts of
bullying (O'Connell, Pepler, & Craig, 1999). Also,
boys who bully in early adolescence have been
shown to be at higher risk for antisocial behavior
in adulthood (Farrington, 1993). Although several
antibullying programs have been developed for
schools, these interventions have not specifically
targeted peer processes in bullying.

The role of peers in enhancing delinquent and
antisocial behavior in adolescence is well
established. Most of the externalizing behavior
problems of adolescents—including violent acts
toward others—occur in deviant peer groups. For
elementary- and middle school-aged boys,
association with deviant peers is not only
correlated concurrently with conduct problems but
is also a predictive risk factor for increased
involvement over time (Elliott, Huizinga, &
Menard, 1989; Keenan, Loeber, Zhang,
Stouthamer-Loeber, & Van Kammen, 1995;
Patterson, 1993; Vitaro, Tremblay, Kerr, Pagani, &
Bukowski, 1997). Deviant peers also engage in
forms of deviancy training in which antisocial talk
(e.g., bragging about physical assaults, discussing

delinquent acts) meets with approval and positive
reinforcement (Dishion, Eddy, Haas, Li, &
Spracklen, 1997). In highly deviant groups (i.e.,
juvenile street gangs), group membership is
correlated with increased delinquent behavior
(Bjerregaard & Smith, 1993). Studies following
youth before, during, and after their gang
membership show that rates of delinquency,
especially violent delinquency, are substantially
higher when a young person is a member of a
gang than either before or after membership
(Esbensen & Huizinga, 1993; Thornberry, Krohn,
Lizotte, & Chard-Wierschem, 1993).

The most powerful evidence for documenting peer
enhancement of conduct problems as a causal risk
factor comes from failed interventions that
involved grouping together high-risk youth.
Interventions that group together high-risk youth,
even in the presence of therapeutic intervention,
have been shown to result in increasing
delinquent behavior (Dishion & Andrews, 1995;
Dishion, McCord, & Poulin, 1999). In contrast,
research on therapeutic foster homes for
delinquent youth that involve definitive changes
in parenting and strict enforcement of no contact
with deviant peers shows that these interventions
result in decreased delinquency (Chamberlain &
Reid, 1998).

Clearly, peer enhancement of conduct problems is
a significant causal risk factor for antisocial
behavior. By adolescence, the only established
way to effectively reduce this influence is to
remove contact with deviant peers. It is not
known whether interventions aimed at reducing
early peer reinforcement of aggressive behavior or
bullying also may be effective in reducing conduct
problems and deterring development of delinquent
behavior. Nor is it known whether interventions
designed to decrease peer rejection also may
decrease peer enhancement of aggressive
behavior. Given the strength of evidence about the
role of peers in externalizing behavior problems,
these questions appear ripe for investigation.

81

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boys to show more problems with undercontrolled
behavior compared with nonexposed children
from similar environmental backgrounds
(Delaney-Black et al., 2000). Much of this work is
ongoing and has so far followed children only
through middle childhood; thus, the effects on
adolescent behavior are not known.

A distinct yet equally challenging area of research
concerns the study of genetic contributions to
externalizing behavior problems. Generally,
studies in this area can be subdivided into two
categories: those examining the genetics of
conduct disorders and those examining the
genetics of behaviors that are relevant to the
development of conduct problems. These
behaviors are potentially important because they
typically emerge earlier than conduct problems
and may be developmental precursors.

In studying the genetic influences on conduct
disorder, it has become clear that accurate
description and subtyping of phenotypic behaviors
are essential. Research has shown that levels of
genetic and environmental influence appear to
differ markedly for different patterns of conduct
problems (Edelbrock, Rende, Plomin, &
Thompson, 1995; Silberg et al., 1995). In the
early starter pattern, adolescent boys with an
earlier age of onset tend to be highly oppositional,
to exhibit comorbid ADHD, and to engage in
physical aggression, property crimes, and truancy.
In the late starter pattern, boys with onset during
adolescence typically do not have ADHD and
restrict their problematic behavior to property
crimes and truancy. Initial research examining
concordance between twins suggests that early
starter conduct disorder may be more strongly
influenced by genetic factors than the
developmental type of conduct problems that
emerges during adolescence (Silberg et al., 1995).

A number of adoption studies, however, provide
evidence for more complex relationships among
genetic and environmental factors. The likelihood of

conduct problems in adopted-away offspring of
antisocial parents (i.e., parents with criminal
records) is significantly lower if they were raised by
well-adjusted adoptive parents (Cadoret, Yates,
Troughton, Woodworth, & Stewart, 1995). However,
the ability to parent such children also may be
affected in that genetically influenced characteristics
of the child can evoke parenting behaviors that in
turn increase the risk of developing externalizing
behavior problems. Several studies of adopted
offspring of antisocial parents have shown gene-
environment evocative effects; adolescent
externalizing behavior problems partially mediate
the relationship between biological parent antisocial
behavior and adoptive parent harsh/inconsistent
discipline (Ge et al., 1996; O'Connor, Deater-Deckard,
Fulker, Rutter, & Plomin, 1998). These results are
supported by behavioral genetic studies of twins
showing that the correlation between harsh
parenting behavior and adolescent antisocial
behavior problems is partially accounted for by
variations in the adolescent's genetic background
(Neiderhiser, Reiss, Hetherington, & Plomin, 1999).
Thus, parenting and other environmental features
appear to interact in complex ways with genetic
dispositions in relation to youth conduct problems.

In addition to research on the genetic influences of
conduct disorder, there has been research
examining genetic influences on behaviors related
to conduct disorder. Of the many childhood
characteristics considered to be likely
developmental precursors to serious conduct
problems, two characteristics—ADHD and difficult-
irritable-oppositional behavior—have been
examined in a number of twin studies. Collectively,
these studies indicate substantial genetic influence
on attention problems and ADHD (Edelbrock et al.,
1995; Gjone, Stevenson, & Sundet, 1996; Levy,
Hay, McStephen, Wood, & Waldman, 1997;
Sherman, McGue, & Iacono, 1997) and difficult-
irritable-oppositional behavior (Cyphers, Phillips,
Fulker, & Mrazek, 1990; Goldsmith, Buss, &
Lemery, 1997), with heritability estimates generally

17


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59


Broader Social Environment, Communities, and Schools ......................045 99

Broader Social Environment -. 99
Communities and Neighborhoods . . . . « 100
Social Environment and Community Influences on Families and Children .. » 100
Schools 101
Implications for Malleable Community Risk Factors and Developmental Processes ....... 103
Table 4: Broader Social Environment, Communities, and
Schools—Research Summaries ....... 2... eee eee cece etree eee eet e eee 109
Synthesis and Epilogue .......... 00... cc cece cece eee ene n tent e eens 129
Defining Externalizing Behavior in Developmental Terms ..................-5 . 129
Putting the Organism Back Together in Considering Individual Child Characteristics . 130

Studying Correlated Environments .......... 00000 e cece eee e teen eee eee see » 131
Studying Child Characteristics and Environmental Factors in Concert . 132
Implications for Future Research » 132



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63

67


G. R. Bock (Ed.), Genetics of criminal and
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et al., 1982; Tremblay et al., 1991; Wahler et al.,
1993). For adjudicated youth, improvements in
parental discipline have stronger effects on youth
conduct when parents are supported to intervene
in peer and academic settings outside the home
(Borduin et al., 1995). Also, therapeutic foster
home placements that emphasize effective
parental discipline have shown significant
reductions in delinquency among adjudicated
youth (Chamberlain & Reid, 1998). Thus, there is
substantial evidence that parental discipline and
conflict management are causal risk factors for
child and youth externalizing behavior problems
and conduct problems.

Family Problem Solving

“Family problem solving" refers to behaviors that aid
in exploring a given problem and that generate
potential solutions. For young children this also
includes parental exploration of problems, helping to
give structure to the situation and encourage
prosocial means of understanding the situation.
Although a relatively large body of research has
examined basic family problem solving, little of this
research has been directed toward understanding
externalizing behavior problems. This is striking
because many family-based interventions use
training in problem solving as part of the
intervention package.

The limited work that has been conducted
suggests that parental problem solving, from the
early years of child development through
adolescence, is correlated with less problematic
child and adolescent behavior. In early
childhood, parental exploration of child
emotional experiences, particularly anger and
sadness, has been correlated with fewer behavior
problems (Hooven, Gottman, & Katz, 1995;
Zahn-Waxler, lannotti, Cummings, & Denham,
1990). There is some evidence that poorer family
problem solving in middle childhood may predict
later delinquent behavior (Coughlin &

Vuchinich, 1996; Vuchinich, Wood, & Vuchinich,
1994). However, it tends to be associated with
other problems in parenting (e.g., engagement,
discipline) and, in general, accounts for less of the
variance in externalizing behavior outcomes than
engagement, discipline, and validation. Some
research indicates, however, that changes in
family problem solving can lead to reductions in
child aggression (Sayger, Horne, Walker, &
Passmore, 1988).

Parental Structuring of the
Learning Environment

Parents and families can structure children’s time
in ways that enhance access to learning
opportunities in the home, neighborhood, or
community and protect children from negative
environmental influences. Although this concept
is theoretically and practically relevant, there is
little research regarding the influence of family
structuring of children’s time and activities on
externalizing behavior problems.

Research to date, conducted with school-aged
children and adolescents, suggests that families
that encourage involvement with school and
maintain contact with the school have children
who show fewer problematic behaviors than do
families that are less involved with school (Jenkins,
1997; Ketsetzis, Ryan, & Adams, 1998). Also,
parents who provide firm discipline and
monitoring of their adolescents tend to have
children who become involved with peers with
similar parental discipline styles (Fletcher, Darling,
Steinberg, & Dornbusch, 1995). Being involved in
networks of this type appears to be protective
against delinquency, because parental monitoring
protects against association with deviant peers
(Aseltine, 1995). These few findings suggest that
parental structuring correlates with child conduct;
however, more research is needed to determine the

44

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35


Moffitt, T. E. (1993). Adolescence-limited and life-
course-persistent antisocial behavior: A
developmental taxonomy. Psychological Review,
100(4), 674-701.

Patterson, G. R., Reid, J. B., & Dishion, T. J.
(1992). Antisocial boys. Eugene, OR: Castalia
Press.

Stoff, D. M., Breiling, J., & Maser, J. D. (Eds.).
(1997). Handbook of antisocial behavior (Vol. 22).
New York; John Wiley & Sons.

U.S. Department of Health and Human Services.
(2001). Youth violence: A report of the Surgeon
General. Rockville, MD: U.S. Department of Health
and Human Services, Center for Disease Control
and Prevention, National Center for Injury
Prevention and Control; Substance Abuse and
Mental Health Services Administration, Center for
Mental Health Services; and National Institutes of
Health, National Institute of Mental Health.


validation, and discipline—also tend to correlate
strongly with one another. This is to say that
parents who are less engaged also tend to be less
validating and to use harsher and less consistent
discipline. Thus, it is not surprising that
empirically driven family-focused intervention
trials typically target all three processes. These
trials have provided evidence for the malleability
of these processes and the causal nature of the
relationship by demonstrating that intervention
can substantially decrease child extern:
behavior problems. Interventions beginning
during pregnancy and extending into the second
year of life have shown consistent effects on these
parenting processes. Indeed, one such early
intervention trial has shown long-term effects on
serious delinquent behavior during adolescence.
Also, a number of randomized trials have tested
interventions aimed at families of preschoolers
and young children in elementary school. These
trials have consistently shown both immediate
and longer term reductions in externalizing
behavior problems. Similarly, in later childhood
and adolescence, randomized trials aimed at
family processes have shown effects.

Given these important intervention results, it is
imperative that strategies for enhancing family
interactions be transported and implemented in
community services and mental health practice.
Research is needed that identifies opportunities
within communities for providing effective
interventions, explains how to provide the
interventions cost-effectively, and develops
community infrastructure and buy-in for
sustaining the interventions. In many cases, this
process will involve building collaborative
relationships with community leaders and
policymakers, as well as people in other scientific
disciplines such as community psychology,
sociology, and social work.

46

In addition to the effectiveness and dissemination
research needed on established risk factors and
interventions, further research is needed on the
predictive and potentially causal role of family)
problem solving, structuring of the learning
environment, and family modeling. Do these
processes significantly contribute to conduct
problems over and above the effects of
engagement, validation, and discipline? Are there
developmental periods in which some family
Processes are more influential than others? When
family processes are disrupted, does this increase
the child's vulnerability to being affected by
factors in other domains, such as characteristics
of the child, the peer group, the school, and the
neighborhood? This last question is particularly
challenging, given the wide array of factors that
could be influential at any given time. However,
considering these interaction effects—which
involve the child, the family, the peer group, and
the broader social environment—may prove to be
the most insightful for developing interventions
for real-world settings.

Whether conducting future research on the
effectiveness and dissemination of interventions
or studying basic processes of family problem
solving, structuring of the learning environment,
or modeling, scientists must address cultural
issues. The research to date on cultural effects has
suggested some interesting distinctions,
particularly in the study of parental discipline. It
is essential for future research on family processes
relevant to conduct problems to include diverse
ethnic samples and methodologies sensitive to
potential cultural distinctions. These efforts will
provide not only a richer empirical understanding
of how risk factors are similar or differ across
ethnic groups but also a much stronger base on
which to develop interventions relevant to the
world's diverse population.

50


sexual activity and sexual promiscuity. Of these
antisocial youth, a small proportion will intensify
their aggressive behaviors and commit serious
violent offenses.

Given what is known about the developmental
course of externalizing behavior problems, it is
clear that behaviors targeted for intervention, as
well as the immediate expected outcomes from
such interventions, will differ depending on the
age of the children involved. Also, because
externalizing behavior problems have not been
found to be attributable to a single source or
situation, interventions for changing these
behaviors need to focus on multiple risk factors
across multiple settings. Similarly, the relative
contribution of individual risk factors may change
with development, suggesting different targets for
interventions at different ages. What are the
multiple risk factors and situations that should be
targeted in interventions? Are there additional
developmental pathways other than the early and
late starter pathways? These are questions of
tremendous importance to the field, with equally
important ramifications for public mental health.
To advance this research, however, it is important
to review and take stock of what is known
currently about the many risk factors for
externalizing behavior problems and to use this
information when considering which
combinations and interactions of factors hold
greatest promise for understanding and
decreasing child and adolescent externalizing
behavior problems. The sections that follow
summarize what is currently known about risk
factors in four domains: child characteristics;
family factors and processes; peer influences; the
broader social environment, communities, and
schools,

References

American Psychiatric Association. (1994).
Diagnostic and statistical manual of mental
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Bartusch, D. R. J., Lynam, D. R., Moffitt, T. E., &
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general theory versus a developmental theory of
antisocial behavior. Criminology, 35(1), 13-48.

Cairns, R. B., & Cairns, B. D. (1994). Lifelines and
risks: Pathways of youth in our time. Cambridge,
England: Cambridge University Press.

Coie, J. D., & Dodge, K. A. (1997). Aggression and
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Hinshaw, S. P., Lahey, B. B., & Hart, E. L. (1993).
Issues of taxonomy and comorbidity in the
development of conduct disorder. Development
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Kraemer, H. C., Kazdin, A. E., Offord, D. R.,
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Loeber, R., Farrington, D. P., Stouthamer-Loeber,
M., Moffitt, T. E., & Caspi, A. (1998). The
development of male offending: Key findings from
the first decade of the Pittsburgh youth study.
Studies on Crime and Crime Prevention , 7(2),
141-171.

19


Hispanic populations is almost exclusively based
on low-income, inner-city, high-risk samples.
Where available, cultural generalizability and
distinctions will be mentioned in the following
review of family processes.

The first three domains of interaction—
engagement, validation, and discipline/conflict—
account for the lion's share of studies to date.
Many of the studies measured more than one
aspect of parenting, and there is substantial
evidence that engagement, validation, and
discipline/conflict tend to correlate with each
other. This point has not gone unnoticed in
intervention work. It is typical for interventions
targeting family processes to emphasize more
than one process, such as engagement, validation,
and discipline. Research in this area has not
tested experimentally the effects of interventions
aimed at distinct domains of interaction before
building comprehensive preventive interventions.

Engagement/Attentiveness
Versus Disengagement/
Inattentiveness

In infancy and toddlerhood, the concept of
engagement has been studied in terms of mother-
infant responsiveness and infant attachment
security (i.e., quality of the affective bond between
infant and caregiver). Evidence indicates that the
quality of early parental engagement predicts
infant attachment security and that both parental
engagement and infant attachment predict the
development of early onset externalizing problems
(Lyons-Ruth, Alpern, & Repacholi, 1993; Shaw,
Keenan, & Vondra, 1994; van den Boom, 1994).
Maternal unresponsiveness during infancy has
been shown to predict later child externalizing
behavior problems (Shaw et al., 1994). Also, there
is evidence that avoidant and disorganized
attachments during infancy predict later parental
and teacher reports of externalizing behavior

problems in preschool (Erickson, Sroufe, &
Egeland, 1985; Shaw, Owens, Vondra, Keenan, &
Winslow, 1996). This result also has been
demonstrated among higher risk samples (e.g.,
low income, parental psychopathology) (Lyons-
Ruth et al., 1993).

Additional work indicates that the relationship
between parental responsiveness and infant
attachment security and child behavior problems
may be moderated by child gender and negativity.
Several studies have found the impact of maternal
responsiveness and attachment security to be more
pronounced for boys than girls (Shaw et al., 1994).
Other work indicates that it is the combination of
infant negative emotionality and attachment security
that places children at greater risk for externalizing
behavior problems rather than attachment security
alone (Shaw et al., 1996).

Several early intervention programs with a
primary focus on changing mother-infant
responsiveness and engagement have provided
evidence suggesting that these early family
processes are causal risk factors for child conduct
problems. Through intervention, early maternal
unresponsiveness can be changed, and this
change, in some cases, was related to more secure
infant attachment (van den Boom, 1994; van
Ijzendoorn, Juffer, & Duyvesteyn, 1995;
Wendland-Caro, Piccinini, & Millar, 1999). In
addition, a well-known early intervention that
included changes in early maternal engagement,
validation, and problem solving (in addition to
other forms of maternal support) showed long-
term effects on reducing conduct problems in
adolescence (Olds et al., 1998).

Interestingly, the issues of parental responsiveness
and engagement have received less attention in
preschool-aged children. The limited research
suggests that lack of parental supervision and
attention during this period of development predicts
increased aggression and delinquency in grade
school boys (Haapasalo & Tremblay, 1994).

40

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121

124


environment correlations in late childhood and
early adolescence: Antisocial behavioral problems
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Olson, H. C., Streissguth, A. P., Sampson, P. D.,
Barr, H. M., Bookstein, F. L., & Thiede, K. (1997).
Association of prenatal alcohol exposure with
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Olweus, D., Mattsson, A., Schalling, D., & Low, H.
(1988). Circulating testosterone levels and
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Oosterlaan, J., Logan, G. D., & Sergeant, J. A.
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Oosterlaan, J., & Sergeant, J. A. (1996). Inhibition
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Pine, D. S., Coplan, J. D., Wasserman, G. A.,
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Raine, A., Reynolds, C., Venables, P. H., Mednick,
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Raine, A., Venables, P. H., & Mednick, S. A.
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Raine, A., Venables, P. H., & Williams, M. (1995).
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American Journal of Psychiatry, 152(11),
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Rubin, K. H., Bream, L. A., & Rose-Krasnor, L.
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Seguin, J. R., Boulerice, B., Harden, P. W.,
Tremblay, R. E., & Pihl, R. O. (1999). Executive
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Sherman, D. K., McGue, M. K., & Iacono, W. G.
(1997). Twin concordance for attention deficit
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and mothers' reports. American journal of
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Silberg, J., Meyer, J., Pickles, A., Simonoff, E.,
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behaviours: Findings from the Virginia Twin
Study of Adolescent Behavioural Development. In

23


above .50. Unfortunately, most twin studies of
difficult-irritable-oppositional behavior have
confounded its measurement with aggressive
behavior. Other child characteristics relevant to
conduct disorder include lowered levels of
empathy and lowered levels of harm
avoidance/behavioral inhibition (Cyphers et al.,
1990; Emde et al., 1992; Goldsmith et al., 1997).
Twin studies consistently indicate low to
moderate heritability of these behaviors, as well.

It is important to note, however, that behavioral
genetic studies frequently are limited by their small,
nonrepresentative samples and by methodological
problems associated with restriction of range. A
preponderance of the studies in Table 1 used
Caucasian samples, with little attention to
description or variations related to SES.

Implications for Malleable Child
Risk Factors and Developmental
Processes

The term child factors refers to characteristics of
children that increase or decrease their risk for
externalizing behavior problems. Such factors
frequently have not been considered candidates
for demonstrating “causal” relationships because
they typically are conceptualized more as static
traits or “unmalleable” predispositions. Our
growing knowledge about development and the
tremendous interplay among biology,
environment, and behavior, however, challenges
this thinking and suggests that many child
factors may indeed be malleable, particularly
during early development. An example of this
social information processing, including hostile
attributional bias. Interventions targeting these
processes have shown that hostile attributions
are malleable and that decreasing those-
attributes decreases child externalizing
behaviors. Additional child factors reviewed here
that similarly could serve as experimental targets

for preventive interventions are child empathy,
moral reasoning, and social problem solving.

Even if child factors are not malleable, greater
attention to these factors could be of great value
to prevention research by improving the ability to
focus interventions on children who are most at
risk. A number of child factors reviewed here
could be evaluated in terms of their usefulness as
selection factors for high-risk studies, including
individual differences in executive function, early
academic difficulties, and early impulsivity and
irritable emotionality, particularly when these
characteristics co-occur with environmental risk
factors.

In addition to highlighting targets for intervention,
the current review indicates that additional
research is needed to confirm the potential
predictive risk of some child characteristics,
particularly individual differences in autonomic
activity, neuroendocrine factors, and
neurochemical factors. Similarly, there is little to no
existing information about the potential interactive
effects among different child characteristics. For
example, it is not known how individual differences
in autonomic regulation relate to differences in
cortisol regulation, emotional regulation, or both.
Also, no one knows how interactions among such
characteristics may vary across age groups or how
family, peer, and other social environmental factors
may affect these patterns. Research is needed to
examine such interactions and investigate how the
accumulation and interaction of child risk factors
and environmental factors affects the
developmental course and severity of conduct
problems.

Future research on child characteristics related to
conduct problems should consider two important
issues. First, many potentially malleable child
factors appear early in life, so researchers need to
focus on an earlier part of the lifespan. Advancing
such research may require collaborations between
psychiatrists and developmental researchers with

18


Introduction

Research on child and adolescent conduct
problems has proliferated over the past 15 years,
resulting in an extensive array of risk factors,
processes, and targets for intervention. To
capitalize fully on this extensive research base
and contribute effectively to public mental health,
the field now needs to take stock of what is
known about child and youth conduct problems.
In 1998, The National Institute of Mental Health
(NIMH) began a process known as “Taking Stock
of Risk Factors for Child/Youth Externalizing
Behavior Problems.” “Externalizing behavior
problems” refers to a range of rule-breaking
behaviors and conduct problems, including
physical and verbal aggression, defiance, lying,
stealing, truancy, delinquency, physical cruelty,
and criminal acts. A diagnosis of conduct disorder
can be made when these conduct problems
become repetitive and persistent and occur in a
variety of settings, such as home, school, or
community (American Psychiatric Association,
1994). The “taking stock” process involves three
key objectives: (1) to identify and describe what is
known about risk factors and processes that
contribute to externalizing behavior problems; (2)
to identify gaps in our knowledge about risk
factors and processes; and (3) to describe the
kinds of research and research methodologies
needed to advance the field.

This report provides a summary of the first of
these objectives—describing what is known about
existing risk factors and processes that contribute
to externalizing behavior problems. To accomplish
this objective, four primary domains of risk were
identified: child characteristics; family factors and
processes; peer influences; the broader social
environment, communities, and schools.

Within each domain, leading experts were
convened in small groups (typically six to eight
experts) to summarize the risk factors and
processes. (A list of experts involved in these
groups is included at the beginning.) Each group
met for a day and a half to discuss which factors
were most well-documented and “known” by the
field. Through a consensus process, each small
group “took stock” and identified the most well-
established risk factors and processes in a given
domain. To document these factors, each expert
was asked to identify, evaluate, and summarize a
minimum of three key references for each factor.
All evaluations used a framework developed by
Kraemer et al. (1997) to describe three types of
tisk factors. At the most basic level, factors can be
correlates when shown to occur concurrently with
externalizing behavior problems. Next, factors
that are found to reliably precede behavior
problems can be described as predictive risk
Jactors. Finally, factors that can be manipulated
through experimentation or-intervention and
shown to lead to changes in behavior problems
can be described as causal risk factors. It is
important to note that this framework also
implies a “developmental course" to risk factor
research. Once factors are found to be correlated
with outcomes, further research should document
the potential for prediction and, ultimately, the
potential for causation. Causal risk factors then
become the empirical foundation for building
effective interventions.

This report provides a summary of expert
consensus and evaluation of what is currently
known about the factors and processes that
contribute to the initiation, enhancement,

“Zz


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Haapasalo, J., & Tremblay, R. E. (1994). Physically
aggressive boys from ages 6 to 12: Family
background, parenting behavior, and prediction of
delinquency. Journal of Consulting and Clinical
Psychology, 62(5), 1044-1052.

Henry, B., Caspi, A., Moffitt, T. E., & Silva, P. A.
(1996). Temperamental and familial predictors of
violent and nonviolent criminal convictions: Age 3
to age 18. Developmental Psychology, 32(4),
614-623.

134,

136


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23


problems may be complex and may change across
development.

In contrast to research on basic cognitive
functioning and academic achievement, strong
evidence exists about the role of social information
processing as both a predictive and a causal risk
factor for externalizing behavior problems. Findings
from prospective longitudinal studies (Dodge,
Bates, & Pettit, 1990; Dodge, Pettit, Bates, &
Valente, 1995) and intervention studies (Hudley &
Graham, 1993) provide clear evidence that biased
social information processing—that is, the
tendency to attribute hostile intentions to
others—predicts and is a causal risk factor for the
development and maintenance of physically
aggressive behavior patterns. Similarly, initial
studies suggest that biased social information
processing may be involved in the development of
other forms of aggressive behavior (e.g., relational
aggression) (Crick, 1995). The work on relational
aggression, however, has progressed only to the
extent of finding concurrent associations.

Consistent evidence also documents modest
correlations between conduct problems and
problems in moral reasoning and social problem
solving. When faced with interpersonal conflicts or
social dilemmas in an experimental situation,
aggressive preschool and elementary school-aged
children are more likely than their nonaggressive
age-mates to recommend using aggressive,
manipulative, and/or commanding strategies for
resolving problems (Rubin, Bream, & Rose-Krasnor,
1991; Rubin, Moller, & Emptage, 1987). Among
older youth and adults, delinquent and antisocial
behavior is correlated with poorer and less
sophisticated moral reasoning abil! (Gregg,
Gibbs, & Basinger, 1994; Nelson, Smith, & Dodd,
1990; Trevethan & Walker, 1989). Additional
research is needed to determine whether social
problem solving and moral reasoning abilities
predict or follow externalizing behavior problems or
whether improvements in these abilities can lead to
improvements in externalizing behaviors.

Autonomic Factors

Another aspect of child functioning that has been
related to emotional and behavioral regulation is
the autonomic system, particularly indices of heart
tate. Lowered heart rate and dampened heart rate
variability are consistently correlated with
disruptive and antisocial behaviors from early
childhood through adolescence and adulthood
(Mezzacappa et al., 1997). These autonomic
measures have been found to predict later
aggression in childhood (lower heart rate or vagal
tone) (Raine, Venables, & Mednick, 1997), and the
ceasing of antisocial behavior in young adulthood
(higher heart rate) (Raine, Venables, & Williams,
1995). These data, however, are limited to males,
because only a few studies have examined links
between heart rate and externalizing behavior
problems in girls. Additional research is needed to
document whether heart rate regulation indices
predict the onset and persistence of diagnosed
conduct disorder.

Neuroendocrine Factors

Hormones produced by the hypothalamic-pituitary-
adrenal axis appear to be related to the
pathophysiology of externalizing behaviors, based
on correlational studies. Basal levels of cortisol
tend to correlate negatively with indices of
childhood externalizing behavior (McBurnett,
Pfiffner, Capasso, Lahey, & Loeber, 1997; Moss,
Vanyukov, & Martin, 1995). Also, there is evidence
that increased cortisol reactivity (changes in level)
predicts conduct problems one year later among
adolescents (Susman, Dorn, Inoff-Germain,
Nottelmann, & Chrousos, 1997). Additional
research is needed that employs consistent
methods and procedures for collecting basal cortisol
and monitoring cortisol reactivity (a likely
contributor to inconsistent findings) in long-term
longitudinal studies to determine the direction of
effects.

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28


Broader Social

Environment, Communities,

and Schools

Research on the impact of community and broader
social environmental factors differs from research
discussed in other areas of this report in several
fundamental ways. First, many of the community
and social environmental features that elevate
tisk for externalizing behavior problems operate
in a cluster. That is, while one can statistically
identify distinct factors (e.g., minority group
membership, economic disadvantage), in reality,
tisk of youth conduct problems is particularly
elevated in social areas characterized by a
confluence of these structural features

Second, in the other sections of this report,
assessments of risk are associated with individual
variation in externalizing behavior problems and
conduct problems. However, research examining
the influence of community and broader social
environment factors traditionally has focused on
rates of violence and crime across particular
geographic entities rather than on individual
variation. For example, neighborhoods
characterized by high rates of unemployment
often have a high overall crime rate. These
variables may not be strong in predicting which
youth will exhibit externalizing behavior
problems. However, the “strain” associated with
the inability to achieve along traditional
educational and occupational lines may be an
important contextual factor influencing antisocial
behavior.

Broader Social Environment

Within the broader social environment, two key
factors have been related to aggression and
delinquent behavior—culture and SES. Indeed, it
can be very difficult to distinguish the effects of
these two factors because SES is frequently
confounded with ethnic membership. As noted
above, it may be the interaction of culture and
SES that is most germane to youth conduct
problems. Given this caveat, cross-cultural
research on aggression and violence has shown
American culture to be more accepting of
aggressive behavior (Hartz, 1995; Kumagai &
Straus, 1983) compared with other cultures. This
can be particularly striking within some U.S.
subcultural groups (Heimer, 1997), such as street
gangs (Bjerregaard & Smith, 1993; Esbensen &
Huizinga, 1993; Thornberry, Krohn, Lizotte, &
Chard-Wierschem, 1993). Research on lower SES
and poverty consistently shows these variables to
correlate with elevated rates of crime (Heimer,
1997). Rates of crime are likely to increase where
there is a decline in access to jobs or where
unemployment is high (Almgren, Guest,
Immerwahr, & Spittel, 1998; Catalano, Novaco, &
McConnell, 1997).

Economic discrimination also is associated with

increased violence (Messner, 1989). In the criminal
justice system, lower SES and minority youth were

102


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The hypothalamic-pituitary-gonadal axis is
responsible for producing gonadotropin-releasing
hormones (LHRH), the gonadotropins (luteinizing
hormone and follicle stimulating hormone), and sex
steroids (testosterone, estrogen, and progesterone).
The findings for these hormones and sex steroids
vary across ages and studies. Specifically, no single
study or group of studies establishes the relationship
between LHRH and gonadotropins and externalizing
behavior problems. There is evidence that higher
testosterone correlates with greater aggression and
irritability during adolescence (Olweus, Mattsson,
Schalling, & Low, 1988). In one randomized double-
blind experiment with youth experiencing pubertal
delay, boys and girls who were administered mid-
level doses of testosterone and estrogen, respectively,
showed increased aggressive behavior compared
with those receiving placebo (Finkelstein et al.,
1997). However, developmental differences were
suggested, with stronger patterns of association
found between testosterone and externalizing
behavior in older adolescents boys than in younger
adolescents. Given the small sample size for this
study, additional research is needed to clearly
understand potential effects. In addition, few studies
have included measurement of estrogen and other
sex steroids.

Neurochemical Factors

In comparison to many of the other areas of
influence discussed in this report, evidence for the
influence of regulation of brain neurochemicals on
externalizing behaviors is not as clear or abundant.
Two neurochemical systems, serotonin and
dopamine, have been studied. Serotonin is a
regulatory neurotransmitter that can be involved in
inhibitory responses to stimuli. Evidence relating
the serotonergic system with externalizing behavior
is derived from both animal and human studies.
There is some indication that enhanced
serotonergic activity in early childhood correlates

with increased externalizing behavior (Halperin et
al., 1997; Kruesi et al., 1992; Pine et al., 1997).
This statement, however, is only tentative. Few
studies have been done with children and young
adolescents. The studies to date have included
small and unrepresentative samples. Also, this
tesearch is complicated by differences in
measurement strategies across studies
(cerebrospinal fluid indexes versus peripheral
indexes following pharmacological challenge) that
make cumulative interpretations difficult.

The empirical evidence to support the role of
dopamine in externalizing behavior in humans
also is not well developed. Limited studies with
children provide unclear findings. Lower levels of
homovanillic acid (the metabolite of dopamine)
(Limson et al., 1991) and lower levels of
dopamine beta-hydroxylase (DBH, the enzyme
facilitating conversion of dopamine to
norepinephrine) were correlated with
externalizing behavior (Galvin, Stilwell, &
Shekher, 1997). However, a positive relationship
was found between plasma DBH and disinhibition
and sensation seeking (Kuperman, Kramer, &
Loney, 1988). Overall, the functioning of the
dopaminergic and serotonergic systems has not
been sufficiently researched to draw conclusions
about their contribution to externalizing behavior
problems.

Prenatal Conditions and
Genetic Factors

Several prenatal conditions associated with adverse
reproductive outcomes also have been associated
with externalizing behavior problems in offspring.
These include young maternal age, smoking, and
alcohol and drug use during pregnancy. It is
important to note that this area of research is
challenged by the extent and complexity of co-
occurring factors (e.g., low socioeconomic status
[SES], violence in the environment, family

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1997). It is not known, however, whether these
same effects would be useful indicators of student
behavior and conduct.

Within schools, youth develop social hierarchies
and groups that, in some cases, can set the tone
for conduct problems and delinquency. Students
in high-status cliques can wield considerable
social power with peers and classmates. Recent
research has shown that aggressive behavior by
boys can enhance the likelihood of their obtaining
prominent positions in social structures (Xie,
Cairns, & Cairns, 1999), particularly when
accompanied by high athleticism or above-average
academic performance (Rodkin, Farmer, Pearl, &
Van Acker, 2000). Additional research, however,
is needed to understand how social cliques and
hierarchies develop and contribute to student
conduct in schools.

Two features of the classroom also have been
related to child externalizing behavior
problems—the level of classroom
disruption/aggression and teacher-student
interactions. One study has documented that the
overall level of classroom aggression can have
significant effects on individual children’s risk for
aggression over time (Kellam, Ling, Merisca,
Brown, & lalongo, 1998). More aggressive boys
who were assigned to first grade classrooms that
were high in disruption and aggression were at
markedly increased risk for continuing to be
aggressive over the next years of elementary
school. This was in comparison with aggressive
boys who were not placed in aggressive/disruptive
classrooms. In addition, recent research on teacher-
student interactions indicates that teachers interact
differently with students who have externalizing
behavior problems. Students with behavior problems
receive more teacher reprimands and fewer
opportunities to respond appropriately to teacher
requests (Van Acker, Grant, & Henry, 1996;
Wehby, Dodge, & Valente, 1993). To some extent,
lowering teacher-student ratios, particularly in
special education classrooms, can mitigate these

106

103

teacher-student interactions (Thurlow, Ysseldyke,
Wotruba, & Algozzine, 1993).

Complementing research on the impact of schools
on children and youth is research that examines
how children and youth feel about their schooling
experience. “School bonding" consists of
attachment to school, commitment to educational
pursuits, and belief in the fairness of school rules.
Evidence shows that school bonding is related to
delinquency in middle school, with decreased
bonding associated with increased rates of
delinquency (Jenkins, 1997). Further,
interventions designed to modify elementary
school teaching practices to increase school
bonding showed bonding to be a predictive risk
factor for externalizing behavior problems in
adolescence. Through an intervention designed to
modify teacher behavior, successful changes in
school bonding were associated with improved
academic achievement (Abbott, O'Donnell,
Hawkins, Hill, & Kosterman, 1998). Long-term
effects of this intervention program, when
combined with parent training and social
competence training for the children, showed that
the package of interventions provided throughout
elementary school had enduring modest effects in
reducing self-reported violent behavior, heavy
drinking, and sexual intercourse before age 18
among multiethnic urban children (Hawkins,
Catalano, Kosterman, Abbott, & Hill, 1999).

Implications for Malleable
Community Risk Factors and
Developmental Processes

Existing research on the broader social
environment, communities, and schools indicates
that many factors affect the development and
likelihood of youth conduct problems. As noted at
the beginning of this section, many of the social
and community factors that have been associated
with youth conduct problems operate in


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Disentangling confounded correlations. Journal of
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840-844.

Cohen, D., & Strayer, J. (1996). Empathy in
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Cohen, J. (1988). Statistical power analysis for the
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Coles, C. D., Brown, R. T., Smith, I. E., Platzman,
K. A., Erickson, S., & Falek, A. (1991). Effects of
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Crick, N. R. (1995). Relational aggression: The
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Cyphers, L. H., Phillips, K., Fulker, D. W., &
Mrazek, D. A. (1990). Twin temperament during
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Journal of the American Academy of Child and
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Delaney-Black, V., Covington, C., Templin, T.,
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L., Czerwinski, R. H., & Sokol, R. J. (2000).
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Dodge, K. A., Pettit, G. S., Bates, J. E., & Valente,
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15

20 BEST COPY AVAILABLE


more likely to be referred to court and to receive
more intensive police scrutiny than higher SES
and Caucasian youth (Sampson, 1986).

Communities and Neighborhoods

Studying the impact of communities and
neighborhoods on children, researchers have
examined three major features: (1) structural and
demographic features, (2) exposure to situations
or events, and (3) community-level processes and
forms of social control. In terms of structural and
demographic features, research on the extent to
which neighborhoods are characterized by
deteriorating housing (Spelman, 1993),
overcrowding (Wallace, 1990), greater population
density, and greater numbers of female-headed
households (Harries & Powell, 1994; Smith &
Jarjoura, 1988) consistently shows correlations
with neighborhood crime rates and violence.

Children and young people who live in deteriorating
neighborhoods with higher crime rates are more
likely to be exposed to and witness robberies,
assaults, and murders. Experiencing their
neighborhood as dangerous, young people may
become anxious, depressed, defiant, and/or
aggressive (Aneshensel & Sucoff, 1996; Gorman-
Smith & Tolan, 1998; Greenberg, Lengua, Coie, &
Pinderhughes, 1999; Griffin, Scheier, Botvin, Diaz, &
Miller, 1999). Children who have seen or been the
victim of violence are more likely to perceive
themselves as vulnerable to violence and are more
likely to report carrying weapons to school (Simon,
Dent, & Sussman, 1997; Uehara, Chalmers, Jenkins,
& Shakoor, 1996).

A newer line of research has begun to examine how
community-level processes and forms of social
control may be related to youth delinquency. Studies
have shown that the extent of collective social
control (e.g, the extent to which members of the
community have local friendship networks and

100

share collective willingness to intervene in youth
misbehavior, such as skipping school, painting
graffiti, showing disrespect to adults) correlates
with decreased rates of delinquency and problem
behaviors and partially mediates the relationship
between community structure variables and
delinquency (Bursik & Grasmick, 1993; Elliott et
al., 1996; Sampson, 1997; Sampson & Groves,
1989; Sampson, Raudenbush, & Earls, 1997).

Social Environment and
Community Influences on
Families and Children

Another strategy for assessing the impact of the
broader social environment and community is to
examine how these broader contextual factors
influence group and individual processes (e.g.,
family, peer, or child individual characteristics).
The basic notion is that structural or demographic
variables—such as SES, culture, and community
deterioration—probably influence everyday social
routines and ways of relating, which may in turn
affect the risk of antisocial behavior.

Compared with lower-SES parents, those in
middle-class families are more likely to monitor
their children's friendships and less likely to use
harsh discipline (Heimer, 1997); both are
parenting behaviors shown to be causal risk
factors for child externalizing behavior problems
(see Family Factors and Processes section).
Additional research has documented that higher
levels of perceived economic stress are associated
with parental distress, which in turn increases
parental hostility, decreases parental monitoring,
and subsequently increases youth externalizing
behavior (Conger et al., 1992). Other research has
documented differences between children of
middle-SES families and children of lower-SES
families; middle-SES children show less physical
aggression and more cooperative interactions with
peers (Ramsey, 1988).

163


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20

BEST COPY AVAILABLE


nurse home visitation on children's criminal and
antisocial behavior. Journal of the American
Medical Association , 280(14), 1238-1244.

Patterson, G. R., Chamberlain, P., & Reid, J. B.
(1982). A comparative evaluation of a parent-

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Patterson, G. R., Forgatch, M. S., Yoerger, K. L., &
Stoolmiller, M. (1998). Variables that initiate and
maintain an early-onset trajectory for juvenile
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Patterson, G. R., & Yoerger, K. (1995). Two
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Schwartz, D., Dodge, K. A., Pettit, G. S., & Bates, J.

E. (1997). The early socialization of aggressive

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pathways in the development of early disruptive
behavior problems. Development and
Psychopathology, 8, 679-699,

Shaw, D. S., Winslow, E. B., Owens, E. B.,
Vondra, J. I., Cohn, J. F., & Bell, R. Q. (1998). The
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changes in adjustment and competence among

50

54 BEST COPY AVAILABLE


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37

32


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G. (1998). A test of latent trait versus life-course
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24


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61


= Studies that include assessment of broader
social factors, such as regional economic
conditions or density of local friendship networks,
find that these factors can place constraints on peer
and family contexts in ways that are related to
externalizing behavior problems. In some cases,
these constraints can even eliminate the
association between such context factors and
externalizing. For example, there is evidence for
cultural variation in the effects of parenting on
externalizing, such that some parenting variables
are related to externalizing in Caucasian families
but not in African-American families (Deater-
Deckard, Dodge, Bates, & Pettit, 1996)

Studying Child Characteristics
and Environmental Factors in
Concert

While the study of child factors and environmental
tisk factors has proliferated, evidence is emerging
to suggest that these two domains must be studied
together. Three sets of findings demonstrate this,
suggesting important directions for future work.

Child behavior both shapes the child's
environment and is @ response to that environment.
A number of recent studies suggest that trajectories
of child development are shaped by patterns of
reciprocal influence between the child and the
child's social context. Negative emotionality in the
infant and young child increases the likelihood of
parental hostility and rejection, which in turn
increases negative emotionality (Shaw et al.,

1998). Conduct problems in middle childhood
reduce effective parenting (discipline, monitoring,
validation), which reinforces antisocial behavior
(Simons et al., 1998). Reduced parental monitoring
and warmth in late childhood increases the risk of
delinquency, and increased delinquency reduces
monitoring and warmth (Jang & Smith, 1997).
Recent studies of evocative gene-environment
correlations further support the thesis that a range

of child characteristics both shape and are shaped
by social context (Ge et al., 1996; O'Connor, Deater-
Deckard, Fulker, Rutter, & Plomin, 1998),

= Social contexts can have different effects on the
developmental trajectories of different children,
depending on what the children bring to the
context. Several studies now suggest that specific
environmental factors may be risk factors for some
children, have no effect on others, and be protective
factors for still others. For example, high levels of
parental control appear to increase risk for children
with one temperament but protect children with a
different temperament (Bates, Pettit, Dodge, &
Ridge, 1998). Again, these patterns also appear in
behavioral genetics studies, indicating that
heritable child characteristics and particular
environmental factors interact in influencing the
developmental trajectories of externalizing behavior
problems (Cadoret, Yates, Troughton, Woodworth,
& Stewart, 1995).

= These two patterns, reciprocal effects and child-
environment interaction effects, must also be
considered in a developmental context. There is
evidence that the reciprocal effects between child
conduct problems and lax parental monitoring are
strongest before age 15 and that in later
adolescence it is delinquency that leads to lax
monitoring (Jang & Smith, 1997). Similar fading of
reciprocal effects may occur for conduct problems
and poor parental disciplinary practices, with the
latter much more likely to drive the former in late
adolescence (Cohen & Brook, 1995). This change
may also be concomitant with increasingly
reciprocal effects among antisocial adolescent
peers.

Implications for Future Research
The four issues discussed above reflect the progress

of a scientific field as it grapples with the
complexities of human development. Investigators

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120


prevention, and termination of conduct problems
in children and youth. Specific information about
the research studies that document these findings
can be found in the accompanying tables.
Although in some cases more than or fewer than
three references were evaluated, in general, the
tables were limited to three entries per factor.

It is important to note that this summary is not
intended to be a complete literature review of all
factors related to externalizing behavior problems
and conduct disorder. Instead, the summary
provides an integrated overview of what experts
in the field regard as the most well-studied factors
and processes and further evaluates these factors
in terms of their status as correlates, predictive
risk factors, or causal risk factors. The objective of
the summary is to document what is known about
externalizing behavior problems and conduct
disorder in order to highlight what causal risk
factors are already known and can be used in
interventions, as well as which factors need
further research to document their potential for
prediction and causation. The expert consensus
and evaluation process used to develop this
summary was considered a richer and more
expeditious route to accomplishing this objective
than a comprehensive literature review. In
addition, this summary is limited to research on
child and adolescent externalizing behavior
problems and conduct disorder. Although there is
some overlap between externalizing behavior
problems and violence, the current summary is
not intended as a complete review of all forms of
youth aggression, violence, and antisocial
behavior. Readers interested in this broader field
of research are referred to recent reviews and
edited volumes (Coie & Dodge, 1997; Loeber &
Farrington, 1998; Stoff, Breiling, & Maser, 1997;
U.S. Department of Health and Human Services,
2001).

Development of Externalizing
Behavior Problems

Before reviewing the status of risk factors, it is
important to consider how externalizing behavior
problems change over development. In the past 20
years, several longitudinal studies have provided
a picture of the changing forms of aggression and
conduct problems from early childhood through
adolescence (Cairns & Cairns, 1994; Loeber,
Farrington, Stouthamer-Loeber, Moffitt, & Caspi,
1998; Patterson, Reid, & Dishion, 1992). Their
findings converge to suggest that no single child
characteristic or situation can account for the
development of externalizing behavior problems.
Rather, these problems result from interactions
between characteristics of the child and situations
within the family, peer group, school, and
community. Some research suggests that there are
two entry points to developing externalizing
behavior problems—in early childhood and in
early adolescence—with potentially different
patterns of risk factors associated with each
(Bartusch, Lynam, Moffitt, & Silva, 1997;
Hinshaw, Lahey, & Hart, 1993; Moffitt, 1993).
Children who exhibit persistently high levels of
externalizing behavior problems early in their
lives are at high risk for intensifying to lying,
bullying, and fighting in middle childhood, and
more serious behaviors such as cruelty to
animals, vandalism, and aggressive criminal
behaviors in adolescence. A significant number of
these antisocial youth continue to exhibit
correlated problem behaviors (e.g., drug use,
precocious sexual activity) throughout
adolescence and into adulthood, although the
types of difficulties experienced by antisocial boys
and girls tend to diverge with development.

In contrast to children with an early onset of
externalizing behavior problems, some youth
begin to exhibit problem behaviors during early
adolescence. Their entry into conduct problems


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iz9


Schools

Recently, incidents of school violence have drawn
people’s attention to the nature of schools and the
identification of educational policies, educational
practices, and student behavior that can
contribute to child and youth conduct problems
and violence. It is important to note that the
majority of youth who receive any help fora
mental health problem receive interventions
through their school (Burns et al., 1995).
However, such services tend to be brief
(approximately one visit per quarter for outpatient
or three days for inpatient) and are more typical
for younger children (Farmer, Stangl, Burns,
Costello, & Angold, 1999).

A number of school policies may affect youth
conduct. These policies include zero-tolerance
practices (the suspension and expulsion of students
for problem behaviors), proficiency testing
(requiring students to pass standardized exams to
qualify for graduation), full inclusion (providing
uniform services in the general classroom
regardlcss of the intcnsity of the problem), and usc
of the social maladjustment clause of the federal
definition of students with serious emotional
disturbance, which indicates that students who are
socially maladjusted are not eligible for special
education services and civil rights protections
unless it is determined that they have an emotional
disturbance. Little systematic research, however,
has examined how these school policies affect
youth conduct. Limited research examining the
impact of the social maladjustment clause indicates
that this policy may be extremely difficult to apply
appropriately. Current rating scales for
discriminating between social maladjustment and
emotional disturbances have been found to be
unreliable (Costenbader & Buntaine, 1999).
Similarly, research on teacher assessments of those
in need of special education services has shown
that while students with externalizing behavior
problems are deemed troubled, many are not
identified for special education services (Farmer,

164

101

Rodkin, Pearl, & Acker, 1999). However, in another
study, boys recommended for special services
showed higher rates of conduct disorder than boys
who were referred but not recommended (Mattison,
Morales, & Bauer, 1992). This unreliability and lack
of clear identification can have profound
implications under the social maladjustment
clause. By not identifying children with
externalizing behavior problems as emotionally
disturbed, schools are able to suspend and expel
these children without invoking any of the civil
rights protection practices that are required for
students with identified disabilities.

Even when children are identified as emotionally
disturbed, the impact of placement into special
classrooms is difficult to assess. Placement into
special services is governed by legal mandates,
and students placed in more restrictive settings
are expected to have more intensive needs than
those placed in less restrictive settings. Thus,
special placements cannot be experimentally
manipulated, and studies comparing outcomes of
students in different settings must be conducted
with nonequivalent groups. Given these
limitations, research indicates that interventions
designed to decrease disruptive classroom
behavior do result in desired outcomes in both
special services classrooms and typical
classrooms, with children in restricted classrooms
mote likely to evidence reduction in disruptive
behavior than students in regular classrooms
(Stage & Quiroz, 1997). Interestingly,
interventions designed to prevent school dropout
found that correlated reductions in conduct
problems in youth ages 9, 10, and 11 also helped
to prevent placement in special classrooms, which
in turn reduced the risk of dropping out of school
(Vitaro, Brendgen, & Tremblay, 1999).
Cumulatively, these results suggest that special
classroom placement supplemented with
interventions to reduce disruptive behavior may
be effective. However, it is not clear whether these
effects are similar for children and youth in
elementary, middle, and high school or whether


Similarly, interventions that have addressed parental
engagement (as well as validation, discipline, and
problem solving) during toddlerhood have been
successful in decreasing later childhood externalizing
behavior problems (Sheeber & Johnson, 1994;
Webster-Stratton, 1998; Webster-Stratton, Kolpacoff,
& Hollinsworth, 1988). Thus, evidence exists that
parental engagement continues to be a causal risk
factor during toddlerhood.

In middle childhood and early adolescence, the
concept of engagement has been studied in terms
of the amount of time spent with the child, the
degree of attentiveness, and monitoring of the
child's activities. Consistent evidence indicates
that greater involvement, stronger focus of
attention, and higher levels of monitoring are
related concurrently to lower levels of conduct
problems and predict lower risk for developing
delinquency or criminal activity (Farrington &
Hawkins, 1991; Fridrich & Flannery, 1995). There
is some evidence that the lack of parental
monitoring may be of particular importance in
middle childhood; it was found to be a stronger
predictor of early arrests (prior to age 15) than of
later arrests (Farrington & Hawkins, 1991;
Patterson & Yoerger, 1995). Also, some research
indicates possible reciprocal effects between
monitoring and delinquency in the period from 13
to 15 years, with weak monitoring promoting
delinquency, which, in turn, further erodes
monitoring (Jang & Smith, 1997).

Monitoring and involvement continue to show
effects on conduct problems into adolescence.
During middle and late adolescence, engaged
parenting has been related to a reduction in
antisocial behavior over time (Aseltine, 1995;
Barnes, Farrell, & Banerjee, 1994; Simons,
Johnson, Conger, & Elder, 1998). Although the
total effect of engagement is low to moderate, the
fact that it continues to have a direct impact is
important in light of the impact of peer
characteristics, personal characteristics, and other
environmental factors operating at this period of

development. Moreover, even small reductions in
rates of serious conduct problems can yield very
significant economic, health, and social benefits.

The concurrent and predictive associations of
parental engagement during middle childhood
and adolescence also are seen in research with
African-American and Hispanic families
(Forehand, Miller, Dutra, & Chance, 1997; Fridrich
& Flannery, 1995). Although the effects range
from mild to moderate, the consistency of findings
indicates that poor parental engagement is a
significant predictive risk factor for youth conduct
problems in African-American and Hispanic
families. A number of intervention trials have
included parental monitoring among the family
process variables to target in intervention
(Patterson, Chamberlain, & Reid, 1982; Wahler,
Cartor, Fleischman, & Lambert, 1993). During
middle childhood and adolescence, results of these
programs consistently show parental monitoring
as a causal risk factor for reducing adolescent
conduct problems (Bank, Marlowe, Reid,
Patterson, & Weinrott, 1991; Tremblay et al.,
1991), with stronger effects found when parents
are encouraged to extend their supervision and
monitoring to the peer and academic setting
(Borduin et al., 1995). Although interventions
that include improved parental monitoring also
have shown effects for youth already involved in
criminal behavior, stronger effects are found in
therapeutic foster homes where parental
monitoring is enhanced (Chamberlain & Reid,
1998).

Validation Versus Invalidation

“Validation” refers to behavior likely to comfort
children, increase their sense of security, or
communicate that they are valued and valuable.
“Invalidation” refers to behavior that is physically
painful, increases a sense of insecurity, or
communicates to children that they are deficient,
defective, or not valuable.

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