Theories of Change and Mediators of Psychotherapy Effectiveness in Adolescents With Externalising Behaviours: A Systematic Review

BackgroundExternalising behaviours are becoming a remarkably prevalent problem during adolescence, often precipitating both externalising and internalising disorders in later adulthood. Psychological treatments aim to increase the social functioning of adolescents in order for them to live a more balanced life and prevent these negative trajectories. However, little is known of the intervening variables and mediators involved in these treatments' change mechanisms. We conducted a systematic review, exploring the available evidence on mediators of psychological treatments for externalising behaviours and symptoms amongst adolescents (10 to 19 years old).MethodsA systematic search was performed on Medline and PsycINFO databases, which identified studies from inception to February 23, 2020. Eligible studies included randomised controlled trials that enrolled adolescents with externalising symptoms and behaviours as, at least, one of the primary outcomes. A group of 20 reviewers from the COST-Action TREATme (CA16102) were divided into 10 pairs. Each pair independently screened studies for inclusion, extracted information from the included studies, and assessed the methodological quality of the included studies and the requirements for mediators, following Kazdin's criteria. Risk of bias of RCTs was assessed by the Mixed Methods Appraisal Tool. Extracted data from the included studies were reported using a narrative synthesis.ResultsFollowing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA), after removing duplicates, 3,660 articles were screened. Disagreements were resolved by consensus. In a second stage, 965 full-text articles were assessed for eligibility. A total of 14 studies fulfilled all inclusion criteria. The majority were related to systemic psychological treatment approaches. Two types of mediators were identified as potentially being involved in the mechanisms of change for better social improvements of adolescents: to increase healthier parent–adolescent relationships and parental discipline. However, there were significant and non-significant results amongst the same mediators, which led to discussing the results tentatively.ConclusionsFamily variables were found to be the largest group of investigated mediators, followed by relational, behavioural, and emotional variables. No cognitive or treatment-specific mediators were identified. Both adequate behavioural control of adolescents' peer behaviour and a better positive balance in their relationships with their parents seemed to buffer the effects of externalising behaviours in adolescents. Several methodological limitations concerning mediation testing design, outcome measures, and mediator selection have been identified.Ethics and DisseminationEthical approval was not required. PROSPERO registration number: CRD42021231835.

Associations between extracurricular arts activities, school-based arts engagement, and subsequent externalising behaviours: Findings from the Early Childhood Longitudinal Study

Introduction: Externalising behaviours during adolescence are associated with numerous long-term negative outcomes, although the majority of research is intervention-based as opposed to focused on risk reduction. Arts engagement has been associated with numerous beneficial factors linked to externalising behaviours, yet direct evidence linking them in longitudinal studies is lacking. Methods: Data from the Early Childhood Longitudinal Study were used, with baseline taken at 5th grade (aged 10-11 years) and outcomes measured at 8th grade (13-14 years). Ordinary least squares regression was used to examine individual-level associations between extracurricular and school-based arts engagement (number arts classes and adequacy of arts facilities) with externalising behaviours measured using the Strengths and Difficulties Questionnaire. Poisson regression was used to examine associations between school-level arts classes and facilities with an administrator-reported index of externalising behaviours in the school. All models were adjusted for sociodemographic factors. Individual-level analyses were clustered by school.Results: At the individual level, engaging in a greater number of extracurricular arts activities in 5th grade was associated with fewer externalising behaviours in 8th grade, although there was no association for school-based arts engagement. There were no school-level associations between arts classes or adequate arts facilities and externalising behaviours. Conclusions: Our results suggest extracurricular arts activities may be beneficial in reducing the risk for externalising behaviours, but the relationship is seen at an individual-level of engagement rather than based on school-level provision or facilities. Ensuring extracurricular access to the arts should be considered as a cost-effective way of preventing externalising behaviours while simultaneously promoting healthy emotional, coping, and social behaviours.

1305Early chronic inflammation and behavioural problems in children at age two: a longitudinal study

Background Inflammation has been suggested to contribute to the pathogenesis of adult mental illness and been implicated mechanistically in childhood behavioural problems like internalising and externalising symptoms. High-sensitive C-reactive protein (hsCRP) and glycoprotein acetyls (GlycA) are biomarkers of chronic low-grade inflammation. We aimed to investigate whether hsCRP and GlycA, and environmental factors that influence these inflammatory biomarkers, were associated with internalising and externalising behaviours in early childhood. Methods The Barwon Infant Study is a population-derived birth cohort recruited using an unselected antenatal sampling frame in Victoria, Australia. Infant bloods collected at birth and 12-month were analysed for hsCRP by ELISA and GlycA by NMR. Environmental factors were derived from questionnaires undertaken antenatally to four years postnatally. Internalising and externalising behaviours at age two were measured by the Child Behaviour Checklist. Associations between inflammatory biomarkers and behavioural outcomes were assessed by multivariable regression analyses adjusted for relevant factors. Results Increased GlycA levels at birth (GlycAbirth)(β = 5.22 T-score units; 95% confidence interval (CI)(1.22, 9.21; P=0.01) and decreased GlycA levels at 12 months (GlycA12months)(β=-6.47 T-score units; 95% CI(-11.44, -1.50); P=0.01) were associated with increased internalising behaviours at age two. Association persisted for GlycAbirth, but not for GlycA12months when adjusted for GlycA at both time points within the same model. Weak associations were observed for hsCRP at both time points and externalising behaviours at age two. Conclusions Our findings document an association between increased GlycAbirth and greater internalising behaviours in children aged two years. Elevated early chronic inflammation may be an important pathway in adverse behavioural development in children. Key messages Increased GlycA levels at birth is associated with greater internalising behaviours in children at age two years.

Adverse childhood experiences—household stressors and children’s mental health: a single centre retrospective review

ObjectiveTo determine the prevalence of reported ‘household stressor’ adverse childhood experiences (ACEs) in families of children presenting with neurodevelopmental, behavioural or emotional difficulties and to determine whether family vulnerabilities, individually or cumulatively, were associated with particular clinical symptomatology.DesignRetrospective chart review followed by statistical analysis of family stressors and clinical symptomatology.SettingA community paediatric clinic in Australia.ParticipantsAll 267 children who attended an initial paediatric appointment during 2018.Results162 (60.7%) children had been exposed to one or more household stressor ACEs, including 116 (43.4%) children exposed to parental mental illness. Behavioural disturbance occurred in 144 (53.9%) children and externalising behaviours (other than attention deficit hyperactivity disorder) were more frequent than internalising behaviours. Externalising and internalising behaviours were associated with individual and cumulative household stressor ACEs. Most other symptomatology apart from genetic/neurological conditions, autistic symptoms and some developmental delays appeared to be partially associated with ACEs.ConclusionHousehold stressor ACEs were common, frequently occurred concurrently, and were associated with much of the symptomatology, in this cohort. Parental mental illness was the most prevalent stressor and behavioural disturbance the most prevalent symptomatology. These findings may have implications for clinical practice and service provision.

Externalising Behaviour in Children: An Integrative Model Between Health and Education

Background: Externalising behaviours are the most common mental health disorder of childhood and adolescence. They are defined as attention deficit and hyperactivity disorder (ADHD) and conduct disorder (CD). CD is associated with high societal and economic burden. Yudi Gunyi School caters for students aged 10-16 years with problematic externalising behaviour. A multidisciplinary health assessment has been developed. This evaluation aimed to see if this model of care improved the outcomes for children with externalising behaviour.Methods: A retrospective evaluation of all students attending the health assessment between 26 July 2016 and 14 May 2019 using de-identified data was conducted. Descriptive statistics (proportion, mean, SD, and range) were used. A student’s t-test was used to assess change in SDQ scores.Results: Prior to the assessment 22.8% had a paediatrician but 33.3% were not engaged with the paediatrician. Similarly, mental health services were involved in 27.8% but 18.2% were not engaged. Child protection services had previous involvement with 43% and current involvement with 32.9%.Attendance was high (failure to attend 7.6%; cancellation 8.9%). New diagnoses of ADHD (3.8%), autism (1.3%), CD (1.3%) and ODD (1.3%) were made. Other issues identified included learning difficulties (12.7%), medical diagnoses (10.1%), emotional concerns (16.5%), domestic violence (12.7%), OOHC (7.6%), trauma background (27.8%), the death/loss of a close relative/friend (8.9%), parental separation (31.6%) and substance use (19%). SDQ teacher reports showed a statistically significant decrease in total difficulties scores (M = 6.2, SD = 6.165, p < 0.05, eta squared = 1.013 (large effect)) and all subsets including behavioural/conduct difficulties (M = 1.8, SD = 2.4, p <0.05, eta squared = 0.741 (medium effect)), hyperactivity and concentration difficulties (M = 2.8, SD = 2.4, p <0.05, eta squared 1.15 (large effect)) and impact scores (M = 1.636, SD = 1.8, P <0.05, eta squared = 0.909 (large effect)).There were no significant differences in the parent and self-reported SDQs. Conclusions: The multidisciplinary model between health and education offered mechanisms to reduce barriers to care for children experiencing externalising behaviours.

Is frontoamygdalar connectivity in the resting brain linked with externalising behaviours during development?

Externalising problems tend to vary over the course of development, but often peak in late adolescence. Data suggest that the frontoamygdalar brain circuitry (involved in emotion regulation) might have an important role in mediating externalising behaviour.

Facial emotion recognition in children with externalising behaviours: A systematic review

Difficulties in facial emotion recognition (FER) are associated with a range of mental health and antisocial presentations in adolescents and adults. Externalising behaviours in children are often one of the earliest signs of risk for the development of such difficulties. This article systematically reviews the evidence (from both group and correlational studies) for whether there is a relationship between FER and externalising behaviours in pre-adolescent children (aged 12 and under), both across and within externalising behaviour domains (hyperactivity, conduct problems, callous-unemotional traits, and aggression). Four electronic databases were searched producing 1,296 articles. Articles were included if they used validated measures of FER and externalising behaviours. Sixteen articles met criteria for inclusion in the review. Overall, the results suggested FER problems are present in ADHD, CP and callous-unemotional presentations, and in samples of children with higher levels of externalising problems rather than in community samples. However, there was no consistent evidence for specific emotions being implicated in the studies reviewed. Clinically, the findings suggest that FER difficulties are commonly associated with externalising behaviours, and hence this review offers some support that FER deficits could be a relevant target of intervention for externalising behaviours. However, more longitudinal studies are required, that control for other variables that might underlie FER difficulties (e.g. IQ or basic Theory of Mind abilities), to inform our knowledge of whether FER difficulties are a causal factor in externalising behaviours.

Sleep Problems in School Aged Children: A Common Process across Internalising and Externalising Behaviours?

Sleep problems are common in childhood and impact cognitive, psychological and physical wellbeing. The current study investigated the association between sleep problems and internalising and externalising behaviour in 114 school-aged children (5–12 years) from four primary schools in Melbourne, Australia. Data were collected using the Sleep Disorder Inventory for Students to measure sleep and the Conners Behavior Rating Scale to assess behaviour, both by parent report. Hierarchical regression analysis, controlling for socioeconomic status and age, identified moderate associations between sleep problems and emotional distress, aggressive behaviour and hyperactivity/impulsivity. Findings suggest screening for sleep problems in children presenting clinically with behavioural issues is a potentially important clinical practice. Additionally, results support the elaboration of transdiagnostic theory, whereby sleep problems are a common process in both internalising and externalising behaviour in children.

Assessment of Behavioural Disorders in Children with Functional Constipation

BACKGROUND: Functional constipation (FC) is a common health problem in paediatrics that causes significant physical and emotional distress to patients and their families. AIM: In the current work, we assessed the presence of behavioural problems in children with functional constipation and their pattern and relation to various demographic and disease-associated factors. METHODS: A cross-sectional case-control study was conducted, including 55 consecutive children aged 4-16 years diagnosed with functional constipation and 55 healthy age and sex-matched controls. Psychological assessment was done using the Pediatric Symptom Checklist – 17 (PSC-17). RESULTS: Twenty-six (47.3%) patients with FC had positive total PSC-17 scores while none of the controls had positive scores (p-value < 0.001). Positive internalising and externalising behaviours scores and attention problems were found in 36 (65.5%), 15 (27.3%) and 12 (21.8%) of the patients respectively in contrary to controls where only 6 (10.9%) had positive scores in internalising behaviour, and non-showed externalising behaviour and 4 (7.3%) were inattentive. Older age, longer duration of illness, residency in rural areas and presence of encopresis were found to have a significant association with the presence of such problems. CONCLUSION: Children with FC have more behavioural disorders compared to healthy controls. Integration of psychosocial aspects and their management is recommended during dealing with patients with FC.

A parenting intervention for middle childhood: An expansion of a Circle of Security intensive individual protocol

The intensive Circle of Security intervention is an attachment-based program that utilises video feedback to support parents to understand and respond to their children’s attachment needs. The original group format was developed into an individual protocol for flexible delivery and broad dissemination. This protocol, described elsewhere, has been previously meaningfully applied to caregiver-child dyads up to preschool age. The present case study describes an expansion of the protocol’s applicability to dyads in middle childhood by demonstrating its use with a mother who presented with difficulties managing the externalising behaviours of her 8-year-old daughter.