Chapter 15: Neurodevelopmental and Other Disorders of Childhood and Adolescence •

Know and understand the Externalising Disorders diagnosed in childhood. • Know and
understand the risk factors associated with the causes, development and maintenance of
the Externalising Disorders.

Introduction

Childhood and adolescence are crucial stages of human development marked by rapid
cognitive, emotional, and social changes. During this period, some children display persistent
behavioural patterns that violate social norms and disrupt family, school, and peer
relationships. These behaviours are known as externalising disorders, a group of mental
health conditions characterised by outward-directed behaviours such as aggression, defiance,
hyperactivity, and impulsivity. This essay explores the nature of externalising disorders,
including Attention-Deficit/Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder
(ODD), and Conduct Disorder (CD), and discusses the multifaceted risk factors involved in
their development and maintenance

Defining Externalising Disorders

Externalising disorders are behavioural disorders where the child’s actions are directed
outward, affecting the environment and others around them. Common symptoms include
aggression, disobedience, defiance, impulsivity, and rule-breaking. These behaviours
frequently interfere with the child’s ability to form and maintain healthy relationships and
succeed in academic or social settings. The three most common externalising disorders
diagnosed in childhood are ADHD, ODD, and CD.

Attention-Deficit/Hyperactivity Disorder (ADHD)

ADHD is a common childhood disorder that causes problems with paying attention, being too
active, and acting without thinking. There are three types: mostly inattentive, mostly
hyperactive-impulsive, or a mix of both. Children who have trouble paying attention may
find it hard to focus, follow instructions, or stay organized. Children who are hyperactive and
impulsive might talk a lot, be restless, and do things without thinking. This can make school
and social life difficult. In addition to the main symptoms of ADHD, children with ADHD
often have other problems, such as trouble with social skills, movement, and emotions. Many
are socially awkward—they may say or do the wrong things, misunderstand others, and act
bossy, which can lead to rejection by other children, even though they are often kind and
caring. They may also have trouble with movement and coordination, such as poor
handwriting or difficulty doing two things at once, like moving their arms and legs together.
However, not all are clumsy—some are very good at sports. Children with ADHD are usually
disorganised. They may lose their school bags, forget books, or struggle to start tasks. Many
also have low self-esteem because they often feel like they fail or get rejected, even when
they try hard

Comorbid Conditions in Children with ADHD

Many children with Attention-Deficit/Hyperactivity Disorder (ADHD) also have other

conditions at the same time, known as comorbid conditions, which can make their symptoms
more complex and harder to manage. A common comorbid issue is a specific learning
disability, where children struggle with reading, writing, or math despite having normal
intelligence. Between 40% and 60% of children with ADHD also show signs of Oppositional
Defiant Disorder (ODD), where they often argue with adults, refuse to follow rules, and
believe their behaviour is justified. Some also develop Conduct Disorder (CD), which
involves more serious rule-breaking and aggressive behaviour, often without guilt or remorse,
and may lead to early use of drugs or alcohol. Additionally, many children with ADHD suffer
from depression and anxiety due to repeated failures and feelings of rejection, which can
cause them to feel sad, withdrawn, or overly worried. Recognising and addressing these co-
occurring conditions is essential for effective treatment and support.

Oppositional Defiant Disorder (ODD)

Oppositional Defiant Disorder (ODD) is when children or teenagers often act angry, argue a
lot, and don’t cooperate. This happens more than usual for their age and can cause problems
at school, with family, and with their feelings. Kids with ODD lose their temper easily, get
annoyed fast, argue with adults, and refuse to follow rules. They might blame others, annoy
people on purpose, or act mean, but usually don’t hurt others physically or do serious crimes.
ODD is not just a phase and can lead to worse problems like Conduct Disorder if not treated
early.

ODD is diagnosed if these behaviours last for at least six months and happen often. The
behaviour is grouped into three types: angry/irritable mood (like losing temper),
argumentative/defiant actions (like refusing rules), and vindictiveness (being spiteful). The
behaviours should happen most days for children under five, or at least once a week for
children five and older. It must happen with people other than siblings to be diagnosed.
Conduct Disorder (CD)

Conduct Disorder (CD) is a serious behavioural problem seen in children and teenagers. It
involves a repeated pattern of breaking important rules, hurting others, and not respecting the
rights of people around them. Children with CD may act aggressively by fighting, bullying,
or being cruel to animals. They may also lie, steal, damage property, or break rules like
skipping school or staying out late without permission. If not treated early, CD can lead to
more serious problems in adulthood, such as criminal behaviour.

There are different types of CD depending on when the behaviours start and how the child
acts. If symptoms begin before the age of 10, it is called childhood-onset CD. If they start
after age 10, it’s called adolescent-onset CD. In some cases, it’s hard to tell when the
behaviours began. The severity can also vary—mild cases might include lying or staying out
late, while severe cases may involve violence or serious trouble with the law.

Children with CD often do not feel guilty for their actions. They may blame others, refuse to
take responsibility, and sometimes start using drugs or alcohol at a young age. Based on
behaviour, CD can be further grouped. Under socialised types have poor relationships and
often act selfishly without guilt. Socialised types might have friends but still break rules,
often through gang activity. Aggressive types are involved in physical violence. Non-
aggressive types break rules without using violence, such as running away or vandalism.

According to the DSM-5, a child must show at least three out of 15 specific behaviours in
the past year, with at least one happening in the last six months, to be diagnosed with CD.
These behaviours fall into four categories:

1. Aggression to people or animals (e.g., bullying, fighting, cruelty).

2. Destruction of property (e.g., setting fires or vandalism).

3. Deceitfulness or theft (e.g., lying or stealing).

4. Serious rule-breaking (e.g., running away, skipping school).

These behaviours must cause serious problems at home, school, or with peers. Also, if
someone is 18 or older, they cannot be diagnosed with CD if they meet the criteria for
antisocial personality disorder instead
Risk factors

The development of externalising disorders is influenced by an interplay of genetic,

neurological, psychological, and environmental factors. These risk factors do not act in
isolation but interact in complex ways across different systems in the child’s life.

Genetic and Biological Influences

. Genetic studies, Studies show that genetics play an important role in causing ADHD and
Conduct Disorder (CD). For example, if one identical twin has ADHD, the other twin often
has it too, which means it can run in families. Children are also more likely to develop CD if
their parents have certain mental health problems, like depression, ADHD, or drug and
alcohol issues. This means that some children may be born with a higher risk of having
these behaviour problems because of their family history.

Neurological Risk Factors

Children with ADHD often have problems with brain chemicals called dopamine and
noradrenalin. These chemicals help with focus and controlling behaviour. When there isn't
enough dopamine, children get distracted easily. If noradrenalin levels are too low, they may
become quiet and withdrawn, but if it's too high, they may become hyperactive and
impulsive.

Also, their brains don’t filter out unimportant sights and sounds properly, which means they
can get overloaded with too much information. This makes it hard for them to stay focused
and respond in an organised way

Family Environment

Family does not directly cause ADHD or Conduct Disorder, but it can affect how these
problems grow. Children with ADHD can cause a lot of stress at home, and parents may feel
like they’re not good at parenting. Even though bad parenting doesn’t cause ADHD, it can
make the behaviour worse. Parents may become stricter or argue more with their child.

For children with Conduct Disorder, parents often give more negative feedback, don’t watch
their children closely, or think their child is being bad on purpose. These families may have
more problems, like poor problem-solving or even neglect. Things like divorce, single-parent
homes, or big families can add extra stress and increase the chances of children developing
serious behaviour problems.
Socio-economic factors

Socio-economic factors can have a big impact on children’s behaviour. In South Africa, many
children grow up in poverty and face difficult living conditions. Although not all of them will
develop behaviour problems, research shows that living in poor areas with high crime rates
increases the risk of developing Conduct Disorder. This means that children in tough
environments are more likely to show serious behaviour issues like aggression, rule-breaking,
and trouble with the law.

Personal and emotional factors

Children with Conduct Disorder often have personal and emotional difficulties that affect
their behaviour. They usually don't see their own mistakes and often blame others. They may
act without thinking and take part in risky activities. These children get upset easily and have
trouble controlling their emotions.

They also struggle to understand social situations and often misread what others mean, which
can lead to fights or arguments. Their temperament (natural personality) plays a role too.
Many are outgoing and focus only on what they see or feel, which makes it hard for them to
follow rules in different situations. Problems can get worse if the child’s personality is very
different from their parent’s, as this can lead to more conflict and less understanding at home.

Diet

In 1973, Dr. Benjamin Feingold thought that what children eat might affect how hyperactive
they are. But many studies have shown that diet does not cause ADHD. Some foods can make
some kids more active and upset, but diet is not the main cause of ADHD

In conclusion externalising disorders such as ADHD, ODD, and CD represent significant

mental health challenges in childhood and adolescence. These disorders are marked by
behaviours that negatively impact relationships, academic performance, and overall
development. While each condition has distinct features, they often co-occur and share
overlapping risk factors, including genetic, neurological, familial, socio-economic, personal,
and environmental influences. These disorders often happen at the same time and can get
worse if not treated. To help children with these problems, it’s important for parents, teachers,
and health workers to work together and support the child in all areas of life. Early help can
make a big difference.