Externalizing Problems in School-Going Children

Mental health disorders (MHD) are prevalent in childhood and encompass a range of issues such as emotional-
obsessive-compulsive disorder (OCD), anxiety, depression, and disruptive disorders like oppositional defiance
disorder (ODD), conduct disorder (CD), and attention deficit hyperactive disorder (ADHD). Developmental disorders
such as speech/language delay, intellectual disability, and pervasive disorders like autism spectrum disorders are also
included. Emotional and behavioral problems (EBP) or disorders (EBD) can be classified as either “internalizing”
(e.g., depression, anxiety) or “externalizing” (e.g., ADHD, CD).

While mild, occasional naughty, defiant, and impulsive behaviors in preschool children are considered normal, more
extreme and challenging behaviors, such as unpredictable, prolonged, or destructive tantrums, are recognized as
behavior disorders. Community studies show that over 80% of preschoolers experience mild tantrums, but less than
10% have daily tantrums, considered normative misbehaviors at this age. Emotional problems like anxiety,
depression, and post-traumatic stress disorder (PTSD) typically emerge in later childhood and are often challenging
for parents and carers to recognize early due to children's limited vocabulary and comprehension for expressing
emotions.

Challenging behaviors, defined as "culturally abnormal behavior(s) of such an intensity, frequency, or duration that
the physical safety of the person or others is likely to be placed in serious jeopardy," can include self-injury,
aggression, non-compliance, environmental disruption, inappropriate vocalizations, and various stereotypies. These
behaviors can impede learning, restrict normal activities and social opportunities, and require substantial resources to
manage effectively. Many challenging behaviors may be seen as ineffective coping strategies for children, with or
without learning disabilities (LD) or impaired social and communication skills, attempting to control their
environment.

Environmental factors that increase the risk of challenging behavior include limited opportunities for choice, social
interaction, or meaningful activities. Adverse environments also include those with limited sensory input, excessive
noise, unresponsive or unpredictable carers, and where physical health needs and pain are not promptly addressed.
Rates of challenging behavior are significantly higher in hospital settings compared to schools for children with severe
LD. Aggression, a common challenging behavior, begins in childhood, with over 58% of preschool children
exhibiting some aggressive behavior. Aggression is linked to various factors, including individual temperaments,
disturbed family dynamics, poor parenting practices, exposure to violence, and attachment disorders. It is often
associated with other mental health problems such as ADHD, CD, ODD, depression, and autism.

Disruptive behavior problems (DBP), which include ADHD, ODD, and CD, are the most common externalizing
behavioral problems among children and young people (CYP). Evidence suggests that DBPs should be viewed as a
multidimensional phenotype rather than distinct subgroups. ADHD, the most common neurobehavioral disorder in
children and adolescents, has a prevalence of 5% to 12% in developed countries. It is characterized by excessive levels
of hyperactivity, impulsivity, and inattention relative to the child's age and development. The ICD-10 uses the term
"hyperkinetic disorder," equivalent to severe ADHD, while the DSM-5 identifies three subtypes: predominantly
hyperactive/impulsive, predominantly inattentive, and combined types.

Addressing Externalizing Problems in School-Going Children

Childhood externalizing behavior and juvenile delinquency are increasingly recognized as significant public health
concerns (Campbell, Harris, & Lee, 1995; Hann, 2002). In 1996, law enforcement agencies arrested 2.9 million
juveniles (Olds et al., 1998). Homicide is the second leading cause of death among 15- to 24-year-olds in the United
States and is the leading cause of death for young African-American males and females (National Center for Injury
Prevention and Control, 1996). Consequently, violence prevention has become one of the most urgent issues facing
society today (Campbell et al.; Gournay, 2001; Hann; Parker, McFarlane, Soeken, Silva, & Reel, 1999).

Understanding childhood externalizing behavior is crucial for professionals who specialize in child and adolescent
psychiatric and mental health. The construct of childhood externalizing behavior problems includes aggression,
delinquency, and hyperactivity. The biosocial model of childhood externalizing behavior serves as a conceptual
framework for research in this field, and clinical implications are briefly discussed.
A well-known distinction in child psychology and psychiatry is between “externalizing” and “internalizing” disorders
(Achenbach, 1978). Externalizing behavior problems refer to behaviors that are manifested in children's outward
actions and negatively affect the external environment (Campbell, Shaw, & Gilliom, 2000; Eisenberg et al., 2001).
These disorders include disruptive, hyperactive, and aggressive behaviors (Hinshaw, 1987). Key behavior problems
within this construct are aggression, delinquency, and hyperactivity. Other terms for externalizing behavior problems
include “conduct problems,” “antisocial,” and “undercontrolled” (Hinshaw).

Studies have shown that childhood aggression is a strong predictor of adult crime and violence. In contrast,
internalizing behavior problems such as withdrawal, anxiety, inhibition, and depression affect the child's internal
psychological environment. Terms for these problems include “neurotic” and “overcontrolled” (Campbell et al., 2000;
Eisenberg et al., 2001; Hinshaw, 1987). Although this dichotomy is not perfect, it provides a useful framework. For
example, a child's internalizing behavior problems can negatively impact others, and children with externalizing
problems may also suffer internally. There is substantial co-morbidity between externalizing and internalizing
behavior problems, meaning aggressive children may also experience anxiety, and depressed children may exhibit
conduct problems (Hinshaw).

The terms “externalizing behavior problems” and “antisocial” are often used interchangeably, but distinctions are
sometimes drawn. Shaw and Winslow (1997) state, “in most cases we use the term externalizing behavior rather than
antisocial behavior to discuss the less severe disruptive and destructive behavior of children” (pp. 148–149). Thus,
some researchers view externalizing behavior as a less severe form of antisocial behavior, especially in young
children. The externalizing construct includes hyperactivity, and some hyperactive children are not antisocial,
illustrating the difference between “externalizing” and “antisocial.” The construct also includes oppositional defiant
disorder (APA, 1994), characterized by negative, hostile, and defiant behavior, particularly toward parents and
teachers. These early behavior problems are generally less serious than aggression and delinquency and are seen as
precursors to more severe externalizing disorders such as conduct disorder.

Despite issues with definitions and co-morbidity, separating externalizing and internalizing behavior problems is
useful. Children with conduct disorder are more likely to become delinquent adolescents and violent adults
(Farrington, 1997). Hyperactive children are also more likely to become criminal, although this is not true for all
hyperactive children (Mannuzza, Klein, Konig, & Giampino, 1989). Similarly, children with internalizing problems
are more likely to grow up to be depressed and anxious.

In conclusion, addressing externalizing problems in school-going children involves understanding their multifactorial
nature and implementing effective management strategies that consider both environmental influences and individual
characteristics. This approach is vital for preventing the progression of these behaviors into more severe issues in
adolescence and adulthood.

Aggression

Aggression is a key component of conduct disorder, characterized by physical or verbal behaviors that harm or
threaten others, including peers, adults, and animals (APA, 1994). It can be either appropriate and self-protective or
destructive to the self and others (Ferris & Grisso, 1996). Childhood aggression is a strong predictor of adult crime
and violence, with early onset being the most significant predictor of later convictions (Farrington, 2001; Moffitt,
1993). Boys are generally more physically aggressive, whereas girls are more likely to exhibit relational aggression,
such as social exclusion and slander (Hadley, 2003).

There are several types of aggression, with theoretical perspectives suggesting distinct subtypes (Dodge & Schwartz,
1997; Feshbach, 1971). One influential model differentiates between hostile and instrumental aggression (Feshbach,
1970). Hostile aggression is emotionally charged, reactive, and uncontrolled, often resulting in injury with little
benefit to the aggressor. In contrast, instrumental aggression is controlled, purposeful, and used to achieve goals, such
as domination (Atkins & Stoff, 1993; Dodge, 1991; Meloy, 1988). A multifactorial approach recognizes both
biological and social factors in understanding aggression. Studies on twins indicate that aggressive behavior has both
hereditary and environmental influences (Eley, Lichenstein, & Stevenson, 1999). Research has examined the roles of
social learning, family violence, school aggression, and media violence, among other factors (Campbell et al., 2000;
Feshbach & Feshbach, 1998; Fishbein, 2001). The biosocial interaction approach integrates biological and
psychosocial factors to explain the development of childhood aggression (Cicchetti & Lynch, 1993; Susman, 1993).

Delinquency

Delinquency encompasses various antisocial acts, including theft, vandalism, drug use, and violence (Farrington,
1987). While "juvenile delinquency" is a legal term, "delinquency" often refers more broadly to antisocial behavior.
This concept, as used in the Child Behavior Checklist (CBCL), includes behaviors such as lying, cheating, and
stealing (Achenbach, 1991; Achenbach & Edelbrock, 1983). Research suggests a strong overlap between aggressive
and nonaggressive antisocial behaviors, indicating that children exhibiting one are likely to exhibit the other (Quay,
1983, 1993). Environmental factors, such as exposure to violence and abuse, play significant roles in the development
of delinquency (Fogel & Belyea, 2001; Widom, 1997). Social learning theories also suggest that antisocial behaviors
are learned (Huesmann, 1997; Shahinfar, Kupersmidt, & Matza, 2001). Genetic influences have been implicated in
nonviolent antisocial behavior, with studies showing that such behaviors can be heritable (Rowe, 1983; Hutchings &
Mednick, 1975). Mednick, Gabrielli, and Hutchings (1984) found that adoptees with criminal biological parents were
more likely to commit crimes themselves, indicating a genetic component. However, violent offending does not
appear to be heritable, suggesting differences between violent and nonviolent antisocial behavior.

Hyperactivity

The term "hyperactivity" refers to two problems: excessive motor activity and attention deficits (Hinshaw, 1987).
DSM-IV uses the term "attention-deficit/hyperactivity disorder" (ADHD) to describe these issues, with three subtypes:
combined, predominantly inattentive, and predominantly hyperactive-impulsive (APA, 1994). Hyperactivity affects
3% to 5% of school-age children and is more common in boys (APA, 1994; Hinshaw, 1987). Hyperactive children
often have conduct problems, and those with both are the most seriously impaired (Barkley et al., 1990). Hyperactivity
is predictive of later antisocial behavior, with many hyperactive children developing conduct disorder (Mannuzza et
al., 1991; Lilienfeld & Waldman, 1990). Studies show that hyperactive children have higher rates of arrest and
criminal behavior in adulthood (Mannuzza et al., 1989; Satterfield et al., 1982).Comparison of Externalizing Problem
in Male and female School going Children:

Antisocial behavior and substance use disorders, collectively termed externalizing disorders, pose significant public
health and safety issues, with substantial societal costs (Cohen, Miller, & Rossman, 1994; Miller, Cohen, &
Wiersema, 1996; Rice, 1999; Room, Babor, & Rehm, 2005). Epidemiological studies on externalizing disorders reveal
three key patterns: high comorbidity rates (Kessler et al., 1994; Newman et al., 1996), higher prevalence in men
compared to women (Kessler et al., 1994; Newman et al., 1996), and an increase in prevalence during late adolescence
peaking in early adulthood, followed by a decline (Bachman, Wadsworth, O’Malley, Johnston, & Schulenberg, 1997;
Chassin, Flora, & King, 2004; Chen & Kandel, 1995; Harford, Grant, Yi, & Chen, 2005; Harpur & Hare, 1994;
Jackson, Sher, & Wood, 2000; Moffitt, 1993; Moffitt, Caspi, Rutter, & Silva, 2001; Sher & Gotham, 1999). This
investigation utilizes the externalizing (EXT) spectrum model to theoretically organize these observations.

Historically, disruptive, aggressive, and rule-breaking behaviors are seen as indicators of a common disposition to act
out, known as the externalizing dimension of child psychopathology (Achenbach & Edelbrock, 1984). Jessor and
Jessor (1977; Jessor, Donovan, & Costa, 1991) expanded this model to adolescence, incorporating behaviors such as
substance use and precocious sexual behavior. Etiological models suggest genetic, biological, environmental, and
developmental factors interplay to explain the co-occurrence of disinhibitory behaviors (Fowles & Kochanska, 2000;
Gorenstein & Newman, 1980; Patterson & Newman, 1993). Krueger et al. (2002; 2006) proposed the EXT spectrum
model to explain the high comorbidity rates among disorders such as conduct disorder (CD), antisocial personality
disorder (ASPD), and substance dependencies. This model posits a general liability to all these disorders, suggesting
individuals high on this liability are likely to express multiple disorders.

Confirmatory factor analysis studies support the EXT spectrum model, showing high comorbidity among
externalizing disorders (Krueger, 1999; Krueger, Caspi, Moffitt, & Silva, 1998; Vollebergh et al., 2001). Twin studies
estimate the heritability of this general EXT liability at approximately .80, indicating a significant genetic contribution
to comorbidity (Kendler, Prescott, Myers, & Neale, 2003; Krueger et al., 2002; Young, Stallings, Corley, Krauter, &
Hewitt, 2000). Hicks et al. (2004) further demonstrated that familial resemblance in externalizing disorders is due to
the transmission of the general EXT vulnerability rather than disorder-specific vulnerabilities. Statistical models have
found that conceptualizing externalizing disorders as a continuum of liability provides the best fit to the data (Krueger
et al., 2005; Markon & Krueger, 2005).

No study has yet tested the EXT spectrum model to explain the gender differences in externalizing disorder
prevalence, with men exhibiting higher rates than women (average male-to-female ratio of 2.5:1) (Kessler et al., 1994;
Newman et al., 1996). This gender gap is seen in childhood precursors like CD, oppositional defiant disorder, and
ADHD (King, Iacono, & McGue, 2004; Lynskey & Fergusson, 1995; Moffitt et al., 2001). It narrows during
adolescence, particularly around menarche, and widens again in late adolescence and early adulthood (Bachman et al.,
1997; Chassin et al., 2004; Chen & Kandel, 1995; Harford et al., 2005; Harpur & Hare, 1994; Jackson et al., 2000;
Moffitt, 1993; Moffitt et al., 2001; Sher & Gotham, 1999).

A plausible hypothesis is that gender differences in externalizing disorders are due to differences in mean levels of
general EXT liability rather than disorder-specific factors. If confirmed, this hypothesis would shift the focus from
examining gender differences at the disorder level to the general factor level. Confirmatory factor models that
incorporate individual disorder means can estimate means on the latent EXT liability, aiding in theory building
regarding externalizing disorders' epidemiology. Additionally, these models can investigate the normative increase in
externalizing symptoms from late adolescence to early adulthood, providing insights into developmental patterns of
these disorders.

The study by Hicks et al. (2014) aimed to investigate gender differences and developmental changes in externalizing
disorders from late adolescence to early adulthood using a longitudinal twin study design. They utilized a sample of
over 1,000 twins from the Minnesota Twin Family Study, focusing on four specific externalizing disorders: adult
antisocial behavior, alcohol dependence, nicotine dependence, and drug dependence. The researchers employed
multiple statistical analyses including confirmatory factor analysis and biometric modeling to achieve their goals.

Their findings revealed several key insights. First, they observed significant gender differences in mean levels of
externalizing disorders, with men consistently exhibiting higher levels than women across all disorders, a difference
that widened from late adolescence to early adulthood. This increasing gap was attributed to a more pronounced
increase in symptoms among men compared to women over the study period.

The study also explored the developmental trajectories of these disorders. They found that the mean symptom levels
for all four disorders increased significantly from age 17 to age 24, indicating a general escalation in externalizing
behaviors during this developmental period. Moreover, individual-level analyses showed that a substantial proportion
of both men and women experienced increases in their externalizing symptoms, with more men than women
exhibiting significant increases. This suggests that while both genders showed increases in symptoms, men were
disproportionately affected, contributing to the widening gender gap observed.

In terms of stability over time, the researchers found moderate rank-order stability for each externalizing disorder
from late adolescence to early adulthood. This stability was particularly evident for the latent externalizing (EXT)
factor, which represents a general liability across the four disorders. The EXT factor exhibited greater stability
compared to the specific disorders, indicating that common underlying factors contribute significantly to the
persistence of externalizing behaviors over time.

Biometric analyses further elucidated the genetic and environmental contributions to these disorders. They found
notable gender differences in heritability estimates, with different patterns emerging between men and women across
the disorders. For instance, men showed increasing heritability for substance use disorders with age, while women
exhibited more variability in genetic and environmental influences across the disorders over time.

Externalizing problem Behaviour in Children with Specific Learning disorders:

Adolescents with Mild Intellectual Disabilities or Borderline Intellectual Functioning (MID-BIF), characterized by
IQs between 50 and 85, face heightened risks of developing behavior problems, particularly externalizing issues like
aggression and delinquency. This vulnerability exceeds that of their typically developing peers, as highlighted by
research (Dekker et al., 2002; Douma et al., 2007). Central to understanding and addressing these challenges is the
concept of emotion regulation, which involves managing emotions to adaptively respond to situations (Thompson,
1994).

For typically developing adolescents, difficulties in emotion regulation are strongly associated with externalizing
problems (Compas et al., 2017). Cognitive Behavioral Therapy (CBT), which focuses on improving emotion
regulation skills, has been effective in mitigating these issues among the general adolescent population (Garland et al.,
2008). However, there is a critical gap in knowledge concerning how emotion regulation functions specifically in
adolescents with both MID-BIF and externalizing problems (McClure et al., 2009). This gap impedes the development
of targeted interventions necessary for this vulnerable group.

Emotion regulation encompasses various strategies—cognitive (e.g., reappraisal) and behavioral (e.g., withdrawal)—
that can either help or hinder emotional well-being and mental health (Gratz & Roemer, 2004; Gross, 1998; Tull &
Aldao, 2015). Studies on typically developing adolescents indicate that difficulties in emotion regulation predict
increases in externalizing problems over time, particularly when maladaptive strategies dominate (McLaughlin et al.,
2011; Otterpohl et al., 2016). Adolescents with externalizing problems tend to rely more on maladaptive behavioral
strategies than cognitive ones (te Brinke et al., 2020).

In the context of MID-BIF, adolescents often exhibit delays in self-regulation and coping abilities due to cognitive
challenges (Bridgett et al., 2013; Hartley & MacLean, 2008). Consequently, they may experience heightened
difficulties in emotion regulation, potentially leading to increased externalizing behaviors (Nader-Grosbois, 2014;
Vieillevoye & Nader-Grosbois, 2008). However, it remains unclear whether these challenges in emotion regulation
are more pronounced in adolescents with both MID-BIF and externalizing problems compared to those with only
externalizing problems and average intelligence (AIQ). Executive functioning deficits, common in both groups with
externalizing problems, may contribute to similar challenges in emotion regulation (Granvald & Marciszko, 2016;
Lantrip et al., 2016). Adolescents with MID-BIF might tend to use behavioral rather than cognitive regulation
strategies due to their cognitive limitations (te Brinke et al., 2020).

Moreover, the study explores differences in levels and variability of angry mood between these groups. Angry mood,
which persists longer than transient emotions and influences behavior, is closely linked to emotion regulation
capacities and externalizing problems (Beauchaine & Cicchetti, 2019; Taylor, 2002). However, research specific to
adolescents with MID-BIF on angry mood levels and variability is limited, despite its relevance in understanding and
managing externalizing behaviors in this population (Argus et al., 2004; Neumann et al., 2011).

In conclusion, gaining insights into the complexities of emotion regulation and angry mood in adolescents with
externalizing problems and MID-BIF is essential for developing effective interventions. By elucidating these
relationships, the study aims to provide valuable information that can inform clinical practices and enhance support
for this vulnerable group.

The systematic review and meta-analysis by Enrica Donolato, Ramona Cardillo, Irene C. Mammarella, and Monica
Melby-Lervåg delve into the association between language and specific learning disorders (LLDs) in children and
their co-occurrence with internalizing and externalizing problems. This comprehensive study synthesizes findings
from diverse research to offer insights into how LLDs impact children's psychological well-being beyond academic
challenges.

The meta-analysis reveals that children with LLDs exhibit higher levels of internalizing problems compared to their
peers without LLDs, with a moderate effect size (Hedges' g = 0.36). These internalizing problems encompass anxiety,
depression, and withdrawal behaviors, indicating that LLDs may contribute to heightened emotional difficulties in
affected children. Similarly, children with LLDs also demonstrate elevated levels of externalizing problems (Hedges' g
= 0.42) compared to controls. Externalizing problems typically involve behaviors such as aggression, defiance, and
conduct issues, highlighting that LLDs are associated not only with internalized emotional difficulties but also with
outwardly directed behavioral challenges.

The meta-analysis identifies several factors that moderate the relationship between LLDs and psychological problems.
The type of primary disorder within LLDs appears to influence the severity of internalizing problems, with children
diagnosed with language disorders showing a greater propensity for internalizing difficulties compared to those with
reading disorders. Gender also emerges as a moderating factor, influencing internalizing problems but showing
inconclusive results for externalizing problems. Clinical samples of children with diagnosed LLDs report higher levels
of internalizing problems compared to those with general difficulties or delays in learning and language, suggesting
that children formally diagnosed with LLDs may experience more pronounced socioemotional challenges. This
underscores the need for tailored interventions that address both academic and psychological needs.

The meta-analysis ensures robustness by considering various methodological factors such as informant (parent,
teacher, self-report), sample size, geographical area, and study quality. The consistent findings across these variables
enhance the reliability and generalizability of the results.

The implications of this meta-analysis for clinical practice are significant, particularly in the assessment and
intervention strategies for children with LLDs. Assessments should encompass not only academic performance but
also socioemotional functioning to identify and address internalizing and externalizing problems early. Interventions
should adopt a multifaceted approach that tackles both the academic challenges associated with LLDs and the
socioemotional difficulties highlighted in this study. Strategies focusing on enhancing socioemotional skills, coping
mechanisms, and self-regulation may be particularly beneficial. Given the variability in outcomes based on the type of
LLD and other moderating factors, interventions should be tailored to the specific needs and characteristics of each
child. For instance, children with language disorders might benefit from interventions that emphasize communication
skills and emotional expression. Effective management of LLDs requires collaboration between educators,
psychologists, speech therapists, and parents/caregivers, ensuring a holistic support system that addresses all aspects
of the child's development.

The study by Lysanne W. te Brinke, Hilde D. Schuiringa, and Walter Matthys explores emotion regulation and angry
mood among adolescents facing externalizing problems alongside Mild Intellectual Disabilities or Borderline
Intellectual Functioning (MID-BIF). This research fills a critical gap by shedding light on how these adolescents
manage their emotions compared to peers with average intelligence (AIQ) who also experience externalizing issues.

The findings indicate distinct patterns: adolescents with MID-BIF report fewer difficulties in emotion regulation
overall and employ fewer maladaptive regulation strategies compared to those with AIQ. Moreover, they exhibit
lower levels of angry mood, although variability in angry mood did not significantly differ between groups.
Importantly, adolescents with MID-BIF tend to rely more on behavioral rather than cognitive strategies for regulating
their emotions.

The implications underscore potential differences in emotion regulation processes between adolescents with MID-BIF
and their peers with AIQ when both groups face externalizing challenges. This suggests that while adolescents with
MID-BIF may report fewer difficulties in regulating their emotions, it's essential to consider potential limitations in
their ability to accurately report on internal processes like emotion regulation. Future research could explore
alternative methods such as parent or teacher reports to validate these findings further.

Additionally, the emphasis on behavioral rather than cognitive strategies in adolescents with MID-BIF implies that
therapeutic interventions targeting emotion regulation might benefit from adapting strategies that align with their
preferred methods of regulation. This approach could enhance the effectiveness of interventions aimed at improving
emotional awareness and regulation skills in this vulnerable population.

Despite its strengths in including a typically understudied population and employing multiple assessment methods, the
study also acknowledges limitations. These include the potential conceptual overlap between emotion regulation and
externalizing behaviors in measurement tools, the need for further validation of emotion regulation scales for
adolescents with MID-BIF, and the reliance on self-reporting which may be susceptible to social desirability bias.
Nevertheless, the findings provide a valuable foundation for tailoring interventions that address the unique emotional
and regulatory needs of adolescents with MID-BIF and externalizing problems, thereby contributing to more effective
therapeutic approaches and better outcomes for this population.

Comparison of Externalizing Problem in Male and female School going Children with Specific Learning
Disorders:

Learning disabilities often co-occur with various psychological issues, presenting a significant challenge for affected
children. Population-based surveys indicate that around 30% of children with learning disabilities also experience
behavioral and emotional problems, with the severity often increasing with age, especially among those with
nonverbal learning disabilities (Ekblad). For instance, children with dyscalculia may develop significant anxiety when
confronted with basic arithmetic tasks. Several studies underscore the link between learning disabilities and
psychological disturbances, highlighting the need for targeted interventions.

Shenoy and Kapur found that 21 out of 88 children with learning disabilities had a co-morbid psychological diagnosis,
emphasizing the prevalence of such dual challenges (Shenoy & Kapur). Similarly, Kishore et al. reported that 21 out
of 56 children with specific developmental disorders of scholastic skills exhibited co-morbid psychological disorders
(Kishore et al.). These findings are consistent with John's discovery that one-third of scholastically challenged
children had co-morbid psychological issues, including disorders of emotion and conduct (John). Moreover,
Muthukumar et al.'s retrospective study at the National Institute of Mental Health and Neurosciences in Bengaluru
revealed that 79% of children with learning disabilities had co-occurring psychological disorders, with internalizing
and externalizing disorders being prevalent (Muthukumar et al.). Bäcker and Neuhäuser's study on children with
dyslexia further illustrated a high rate of psychological co-morbidity, with adjustment disorders, hyperkinetic
disorders, and anxiety being the most frequent (Bäcker & Neuhäuser).

Externalizing disorders like Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD),
and Conduct Disorder (CD) are particularly common among children with learning disabilities. McGee et al. noted
that boys with reading disabilities were significantly more likely to have externalizing disorders, especially ADHD,
CD, or ODD, compared to their peers without reading disabilities (McGee et al.). This highlights the overlapping
challenges faced by children with both learning disabilities and externalizing disorders, necessitating specialized
clinical and educational attention.

The prevalence of ADHD in children with learning disabilities varies widely, ranging from 10% to 60%, depending on
the specific population studied (Willcutt & Pennington). The co-occurrence of ADHD and learning disabilities is
particularly notable, with attention deficits significantly impacting academic performance and overall well-being.

Gender differences also play a crucial role in the manifestation of externalizing problems among children with
learning disabilities. Research indicates that boys with reading disabilities are more likely to exhibit externalizing
behaviors such as aggression and hyperactivity compared to girls (Heiervang et al.; Willcutt & Pennington). Boys may
externalize their frustrations and difficulties more overtly, whereas girls with reading disabilities might internalize
their struggles, showing less pronounced externalizing behaviors (Nelson & Gregg; Carroll et al.).

In contrast, the relationship between math disabilities and externalizing problems shows mixed findings regarding
gender differences. Some studies suggest that girls with math disabilities may exhibit more externalizing behaviors
due to increased frustration with numerical tasks (Wu et al.). However, other research points to higher rates of
internalizing problems among boys with math disabilities, indicating a nuanced interplay between gender and the
expression of psychological difficulties (Graefen et al.).

Overall, understanding these complex relationships between learning disabilities, gender, and psychological problems
is crucial for developing effective interventions. Tailored approaches that address both academic challenges and
psychological well-being are essential to support the diverse needs of children with learning disabilities and mitigate
the impact of associated psychological issues.

Concept of Behaviour therapy:

Behavior therapy has significantly shaped the treatment landscape across a broad spectrum of human afflictions and
disabilities, reflecting its effectiveness under skilled practitioners. Over the past decade, the field has witnessed
substantial growth in literature and organizational memberships, underscoring its expanding influence. Originally
focused on correcting behavioral distortions, behavior therapy has evolved to encompass internal mental processes
and psychophysiological conditions while maintaining a steadfast commitment to the principles of experimental
psychology (Lazarus & Fay, 1984).

Central to behavior therapy is its systematic approach to clinical issues, employing a testable conceptual framework
with treatment methods that are objectively measurable and replicable. It emphasizes validated outcome criteria and
evaluative procedures to assess the effectiveness of specific interventions tailored to individual problems (Lazarus,
1984). The scope of its applications spans a wide array of conditions including affective disorders, alcoholism,
asthma, back pain, cardiac problems, depression, insomnia, obesity, phobias, and schizophrenia.

Rooted in a behavioral learning model of psychopathology, behavior therapy prioritizes observable behavior over
hypothesized personality structures or subjective experiences (Phillips & Kanfer, 1969). It focuses on modifying
behavior through empirical research and experimental psychology, avoiding speculative interpretations of events
while acknowledging the utility of individuals' self-reported experiences. The approach targets current environmental
stimuli and behavioral responses that perpetuate maladaptive behaviors in the present rather than delving into their
historical origins.

Behavior therapy operates on the foundational belief that maladaptive behaviors are learned and therefore can be
unlearned through structured interventions that reverse the initial learning process (Eysenck, 1960a). Techniques such
as classical and operant conditioning, modeling, and related concepts are employed to modify behavior, cognition,
emotions, drives, and physiological processes. For instance, the classic case study of M. Jones (1924a) illustrates how
a child's fear of animals, stemming from a rabbit bite, was systematically extinguished by associating the rabbit with
pleasant emotions induced by appetizing foods.

In its modern form, behavior therapy builds on these foundational principles by integrating contemporary learning
theories, particularly classical (Pavlovian) and operant (Skinnerian) conditioning (Hilgard, 1956). It distinguishes
itself from psychodynamic therapies by de-emphasizing the exploration of formative experiences or historical
antecedents of current issues. Instead, it focuses on immediate stimuli and autonomic responses to alleviate fear and
anxiety or expand behavioral repertoires through reinforcement towards specific therapeutic goals (Wolpe & Lazarus,
1966). This pragmatic, data-driven approach has positioned behavior therapy as a valuable therapeutic modality for
addressing emotional challenges resistant to traditional insight-oriented therapies, particularly in cases involving
developmental delays, schizophrenia, psychopathy, and addictive behaviors.

Types of Behaviour therapy:

Childhood disruptive behaviors, such as anger outbursts and aggression, frequently lead to outpatient mental health
referrals due to their association with disorders like Oppositional Defiant Disorder (ODD), Conduct Disorder (CD),
ADHD, anxiety, and mood disorders. Effective treatment is crucial for improving outcomes for both children and
families. Two established interventions for managing these behaviors are Cognitive Behavioral Therapy (CBT) and
Parent Management Training (PMT).

CBT is highly effective in helping children manage anger, irritability, and aggression by addressing both
dysfunctional thought patterns and maladaptive behaviors. It has shown significant success across various disorders,
particularly in reducing symptoms of ODD and other externalizing behaviors. Meta-analytic studies consistently
demonstrate substantial improvements in ODD symptoms (effect size: -0.879) and broader externalizing symptoms
(effect size: -0.52) following CBT interventions. Key techniques include cognitive restructuring to challenge irrational
thoughts fueling anger, skills training in techniques like deep breathing and problem-solving, and exposure techniques
to reduce emotional reactivity over time. CBT not only targets immediate symptoms but also enhances attentional
control, diminishes aggressive behaviors, and alleviates internalizing symptoms such as anxiety and depression. By
equipping children with lifelong coping strategies and emotional regulation skills, CBT fosters improved social
interactions and overall well-being.

PMT, on the other hand, focuses on enhancing parenting strategies to manage childhood disruptive behaviors. It
emphasizes positive reinforcement to encourage desirable behaviors and consistent discipline to address negative
behaviors effectively. Parent-Child Interaction Training within PMT aims to improve family interactions by enhancing
communication skills and fostering a supportive environment. Research underscores PMT's effectiveness in reducing
parental stress (effect size: -0.607) and enhancing parenting skills (effect size: -0.381), leading to reductions in
aggressive and oppositional behaviors among children with conditions like ADHD. PMT not only addresses
immediate behavioral concerns but also cultivates a nurturing family environment conducive to long-term positive
outcomes for children.

Additionally, play therapy offers a valuable therapeutic approach for children with externalizing behaviors,
particularly those with developmental language disorders. By providing a safe space for emotional expression and
social interaction through play, this approach enhances emotional regulation, social competence, and self-regulation
skills. Studies consistently highlight the efficacy of play therapy in improving behavioral outcomes and supporting
holistic development.

For severe aggression and complex cases, combining CBT and PMT with medication management has proven
effective. Multimodal treatments that address multiple risk factors, including both parent and child symptoms, show
promise in producing sustained benefits. A transdiagnostic approach to CBT acknowledges that symptoms like anger
and irritability cut across various psychiatric disorders, enhancing the flexibility and applicability of CBT principles
across different populations of children with disruptive behaviors.

In conclusion, evidence-based behavioral therapies such as CBT and PMT play pivotal roles in managing childhood
disruptive behaviors like anger, irritability, and aggression. These therapies not only improve child outcomes by
reducing symptoms but also enhance parenting skills and family dynamics. Combined with medication and
multimodal treatments, they offer comprehensive strategies for effectively addressing challenging behaviors in
children, underscoring the importance of tailored, psychosocial interventions in clinical practice.

Effectiveness of Behaviour therapy for Externalizing Problem Behaviour:

Play therapy

Play therapy has proven highly effective in addressing a wide range of behavioral and emotional challenges in
children, particularly externalizing behaviors such as aggression, noncompliance, and hyperactivity. Research
consistently highlights the unique therapeutic benefits of play therapy, leveraging play as a natural medium for
emotional expression, social skill development, and behavioral regulation.

A meta-analysis conducted by Bratton et al. (2005) underscored the positive outcomes of play therapy across various
behavioral domains. The analysis synthesized findings from multiple studies, consistently demonstrating reductions in
aggressive behaviors and improvements in social skills among children engaged in play therapy sessions. This
comprehensive review provides robust empirical support for the efficacy of play therapy in mitigating externalizing
behaviors through its emphasis on emotional expression and social interaction (Bratton et al., 2005).

Further empirical evidence from Leblanc and Ritchie (2001) reinforces the effectiveness of structured play therapy
interventions in reducing externalizing symptoms in children. Their study documented significant improvements in
behavioral outcomes, including decreased aggression and enhanced compliance with rules and directions. It
underscores play therapy's role in teaching children alternative, adaptive ways to manage their emotions and behaviors
effectively (Leblanc & Ritchie, 2001).

Moreover, studies like that of Toseeb et al. (2020) indirectly support the therapeutic value of play therapy by
highlighting the importance of social interactions and prosocial behaviors in mitigating externalizing problems,
particularly in children with developmental language disorders. Although not focused directly on play therapy, this
research underscores the broader principles that play therapy integrates to foster positive behavioral adjustments over
time (Toseeb et al., 2020).

Practically, play therapy engages children in a non-threatening and enjoyable activity where they can freely express
and resolve their emotions. By using play as a therapeutic tool, practitioners facilitate learning of new interpersonal
skills, conflict resolution strategies, and impulse control techniques. Involving parents in play therapy sessions extends
these benefits into the home environment, promoting consistency in behavior management and reinforcing positive
changes observed during therapy. Play therapy emerges as a highly valuable intervention for addressing externalizing
behaviors in children. Its effectiveness in promoting emotional regulation, enhancing social skills, and fostering
overall behavioral adjustment is supported by substantial empirical evidence. This makes play therapy a promising
approach for clinicians and educators alike, offering practical and effective strategies for supporting children
experiencing behavioral challenges.

Cognitive behavioral therapy

Cognitive Behavioral Therapy (CBT) has established itself as a cornerstone in treating externalizing disorders among
children and adolescents, supported by a robust empirical foundation. While initial evidence predominantly stemmed
from controlled efficacy studies conducted in university settings, the translation of CBT interventions into routine
clinical care settings has become a focal point of investigation. This meta-analysis sought to address this gap by
examining the effectiveness of CBT specifically for Attention Deficit Hyperactivity Disorder (ADHD), Conduct
Disorder (CD), and Oppositional Defiant Disorder (ODD) in non-university clinical settings.

The meta-analysis systematically reviewed 51 treatment effectiveness studies published up to May 2020,
encompassing a total of 5,295 patients across diverse clinical contexts. The findings revealed a significant average
within-group effect size of g = 0.91 post-treatment, indicating substantial clinical improvements. Particularly
noteworthy were the large effect sizes observed for ADHD (g = 0.80) and CD/ODD (g = 0.98), underscoring the
efficacy of CBT in addressing these challenging externalizing behaviors. Of significant clinical relevance were the
remission rates reported in the studies: 38% of patients with ADHD and 48% with CD/ODD achieved remission by
the end of treatment. These outcomes underscored CBT's capacity to bring about meaningful symptom reduction and
functional improvement in real-world clinical settings. Despite challenges, such as an average attrition rate of 14%
across studies, the effectiveness metrics closely mirrored those observed in controlled efficacy studies conducted
within university settings.

Comparative analysis against efficacy studies conducted in controlled environments highlighted that CBT delivered in
routine clinical care settings demonstrated similar remission rates, effect sizes, and attrition rates. This convergence
suggests that CBT can maintain its therapeutic efficacy and achieve clinically significant outcomes when implemented
outside highly controlled research environments. The meta-analysis underscores the robustness and generalizability of
CBT as a treatment option for externalizing disorders in diverse clinical settings. Its effectiveness in achieving
substantial clinical improvements and high remission rates supports its integration into community-based mental
health services. This finding advocates for the widespread adoption of CBT in routine clinical practice, emphasizing
its potential to deliver meaningful and lasting benefits for children and adolescents struggling with externalizing
behaviors.

Parental management techniques

The meta-analysis conducted by Maughan et al. (2005) systematically examined the effectiveness of Behavioral
Parent Training (BPT) in treating externalizing behaviors and disruptive behavior disorders among children and
adolescents. Spanning 79 outcome studies from 1966 to 2001, the analysis included diverse experimental designs such
as between-subjects, within-subjects, and single-subject experimental designs. Key findings from the meta-analysis
revealed substantial overall mean weighted effect sizes across different study designs: 0.30 for between-subjects
designs, 0.68 for within-subjects designs, and notably high effect sizes in single-subject design studies, with a mean
weighted effect size of 0.54 using ITSACORR and 1.56 using the No Assumptions method. These effect sizes indicate
the significant impact of BPT in reducing externalizing behaviors and managing disruptive behavior disorders in
children and adolescents across various experimental methodologies The meta-analysis underscored that the method
of intervention, specifically BPT's structured approach, significantly influenced its effectiveness across different study
designs. BPT typically involves teaching parents specific behavior management techniques and strategies, which
consistently yielded positive outcomes in reducing problem behaviors. Implications from these findings highlight the
robustness of BPT as an evidence-based intervention for addressing externalizing behaviors and disruptive behavior
disorders. By targeting parenting practices and interactions within the family context, BPT not only improves child
behavior but also enhances parent-child relationships and overall family functioning.
Furthermore, Maughan et al.'s study contributes updated insights and comparisons with prior meta-analyses on BPT,
reaffirming its relevance and effectiveness in clinical practice and research settings. The findings advocate for the
integration of BPT into comprehensive treatment plans for children and adolescents struggling with externalizing
behavior issues. In conclusion, Behavioral Parent Training emerges as a pivotal intervention for managing
externalizing behaviors and disruptive behavior disorders, supported by strong empirical evidence across diverse study
methodologies. Its structured approach and focus on enhancing parenting skills underscore its role in promoting
positive developmental outcomes for youth, advocating for its widespread adoption in clinical and educational settings
alike.

Different Components of Behaviour therapy for the management of Different Externalizing Problem
Behaviour:

ADHD

The study by Hornstra et al. (2021) investigated the efficacy of Behavioral Parent Training (BPT) techniques tailored
for children diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). Conducted as a randomized controlled
microtrial, the study enrolled 92 children aged 4 to 12 years along with their parents, comparing antecedent-based
techniques (AC) and consequent-based techniques (CC) against a waitlist control group. Results indicated that both
AC and CC effectively reduced daily parent-rated problem behaviors compared to the control group. Immediate post-
training assessments showed medium to large effect sizes, with AC demonstrating significant improvements in daily
rated problem behaviors (d = 0.56), sustained up to two weeks (d = 0.65), while CC showed significant improvements
at the two-week follow-up (d = 0.53). AC proved more immediately effective, whereas CC required more time to
demonstrate significant effects.

Regarding ADHD symptom reduction, both techniques effectively reduced hyperactivity-impulsivity symptoms at the
two-week follow-up. AC showed superior effectiveness in reducing symptoms of inattention compared to CC,
underscoring the differential impact of antecedent-based versus consequent-based techniques on specific ADHD
symptoms. Notably, the study did not find significant reductions in symptoms of Oppositional Defiant Disorder
(ODD) based on DSM-IV criteria, although improvements were noted in specific daily rated oppositional defiant
behaviors. The low attrition rate (4%) indicated strong parent engagement and acceptability of the short, focused BPT
interventions, suggesting their feasibility as primary treatments without additional mental health care or medication.

Miranda and Presentación (2000) conducted a study assessing cognitive-behavioral therapy (CBT) for children with
ADHD, comparing self-control therapy alone versus combined self-control therapy with anger management training.
Thirty-two children, divided into aggressive and non-aggressive subgroups, participated in either self-control therapy
alone or the combined approach. Both interventions involved cognitive-behavioral techniques such as self-
instructional training and behavioral contingencies, supplemented by anger management strategies to regulate
emotions. Results indicated significant improvements across all treated groups, with slightly greater improvements
observed among aggressive children receiving the combined therapy. This finding suggested that integrating anger
management strategies into CBT may enhance outcomes for hyperactive-aggressive children with ADHD.

Sprich et al. (2016) examined the efficacy of CBT for adolescents with persistent ADHD symptoms despite
medication. Forty-six adolescents received either immediate CBT or were placed on a waitlist control. Those in the
CBT group showed significant reductions in ADHD symptom severity compared to controls, as assessed by parents
and adolescents themselves. CBT also improved overall distress and impairment, highlighting its role as an adjunctive
therapy to medication in managing ADHD symptoms and enhancing adolescent functioning.

Barzegary and Zamini (2011) investigated play therapy, specifically using the "watch ring" technique, for boys with
ADHD. The randomized study included 14 boys assigned to either play therapy or a control group. Results indicated
significant reduction in ADHD symptoms among boys in the play therapy group compared to controls, supporting the
efficacy of play therapy as a non-pharmacological intervention for managing ADHD symptoms in children.

These studies collectively underscore the effectiveness of tailored behavioral interventions such as BPT, CBT, and
play therapy in managing ADHD symptoms and improving behavioral outcomes in children and adolescents. Each
intervention approach offers distinct benefits, highlighting the importance of individualized treatment strategies in
addressing the diverse needs associated with ADHD.

Oppositional Defiance Disorder

The study by Heshmati et al. (2023) investigated the effectiveness of child-centered play therapy (CCPT) in reducing
symptoms of Oppositional Defiant Disorder (ODD) among preschool-aged children. Using a randomized pretest,
posttest, follow-up (RPPF) design with a control group, 24 children aged 5-7 years were selected based on CSI-4
cutoff scores and randomly assigned to either an experimental group receiving CCPT or a control group without
intervention. Over a 12-week period, the experimental group participated in CCPT sessions, while the control group
did not receive any treatment. Repeated measures ANOVA indicated a significant difference (P < 0.05) between the
groups in terms of ODD symptoms, demonstrating that CCPT effectively reduced these symptoms in preschool
children. Follow-up evaluations over 6 months further showed a sustained decrease in symptoms among the
experimental group, highlighting the lasting impact of CCPT as a therapeutic approach for managing ODD symptoms
in young children.

Similarly, Zarra-Nezhad et al. (2023) conducted a study to assess the efficacy of child-centered group play therapy
(CCGPT), narrative therapy, and their combination in reducing separation anxiety disorder (SAD) and enhancing
social-emotional behaviors among preschool-aged children (2.5-4 years old). This randomized controlled trial
involved 48 children displaying symptoms of SAD, divided into a control group and three intervention groups:
CCGPT alone, narrative therapy alone, and combined CCGPT with narrative therapy. Pre-test and post-test measures
indicated that both CCGPT and the combined therapy significantly reduced levels of separation anxiety compared to
the control group. Additionally, all intervention groups showed decreased behavioral problems and increased
prosocial behaviors relative to controls. These findings underscore CCGPT and narrative therapy as effective
interventions for improving social-emotional competencies in young children, particularly in alleviating symptoms of
SAD and enhancing overall behavioral outcomes.

Furthermore, Calub et al. (2020) presented a case study focusing on a preschool-aged girl diagnosed with Oppositional
Defiant Disorder (ODD) to evaluate a multimodal cognitive-behavioral treatment approach. Over a 4-month period
involving 18 sessions, the treatment combined individual CBT sessions with the child, behaviorally-based parent
training, and consultation with the classroom teacher. Post-treatment assessments and a 2-month follow-up revealed
significant reductions in physical aggression and property destruction, along with improvements in parent and teacher-
reported internalizing and externalizing symptoms. This case study underscores the efficacy of a tailored, multimodal
treatment approach integrating CBT techniques with behaviorally-based parent and teacher training to effectively
manage and reduce aggression and other behavioral symptoms associated with ODD in preschool-aged children. It
highlights the importance of comprehensive intervention strategies across different settings to achieve significant
improvements in behavior and functioning.

These studies collectively emphasize the effectiveness of child-centered play therapy, group play therapy, narrative
therapy, and multimodal cognitive-behavioral treatments in addressing externalizing behaviors and disruptive
behavior disorders in preschool-aged children. Each intervention approach offers valuable insights into tailored
therapeutic strategies that can support young children experiencing developmental challenges, contributing to the
broader understanding and implementation of evidence-based interventions in clinical practice.

Conduct disorder

The study conducted by Paul Rohde and colleagues (2004) examined the efficacy of Cognitive-Behavioral Treatment
(CBT), specifically the Adolescent Coping With Depression (CWD-A) course, in adolescents diagnosed with both
Major Depressive Disorder (MDD) and Conduct Disorder (CD). This research aimed to evaluate how CWD-A could
alleviate depression among adolscents grappling with these challenging psychiatric conditions.

Spanning from 1998 to 2001, the study recruited 93 adolescents aged 13-17 from a county juvenile justice department,
all meeting criteria for both MDD and CD. Participants were randomly assigned to either receive the CWD-A
intervention or a control condition involving life skills and tutoring. Evaluations occurred post-treatment with follow-
ups at 6- and 12-month intervals.
Results indicated significant differences in Major Depressive Disorder recovery rates post-treatment, with 39% of
adolescents in the CWD-A group achieving recovery compared to 19% in the control group. This finding, supported
by an odds ratio of 2.66 (95% confidence interval = 1.03–6.85), highlights the efficacy of CWD-A in treating
depression in this population. Moreover, adolescents undergoing CWD-A reported substantial reductions in depressive
symptoms as measured by the Beck Depression Inventory-II and Hamilton Depression Rating Scale, along with
improvements in social functioning compared to peers in the control group. Despite these positive outcomes,
differences in MDD recovery rates between groups were not sustained at the 6- and 12-month follow-ups, suggesting
challenges in maintaining long-term treatment gains.

Conversely, regarding Conduct Disorder, the study did not find significant differences between the CWD-A and
control groups post-treatment or during the follow-up periods. This underscores the complexity of treating co-
occurring disorders separately and indicates the need for targeted interventions addressing the distinct symptoms and
challenges associated with each condition. In summary, the study provides robust evidence supporting CBT,
specifically through the CWD-A course, as an effective acute treatment for depression in adolescents with comorbid
MDD and CD. It emphasizes the importance of interventions targeting immediate depressive symptoms and
enhancing social functioning. However, it also underscores ongoing challenges in achieving sustained long-term
outcomes, highlighting the necessity for continued research to optimize treatments for adolescents navigating complex
psychiatric comorbidities.

Effectiveness of Behaviour therapy for management of different Externalizing problem behavior in Children
with Specific Learning Disorders:

Research on the effectiveness of interventions for managing externalizing behavior problems in children with Specific
Learning Disorders (SLD) is crucial given the challenges these children face in academic and social domains.
According to meta-analytic findings (McCart et al., 2006), behavioral parent training (BPT) and cognitive behavioral
therapy (CBT) have shown moderate efficacy in addressing externalizing behaviors in children and adolescents with
average intelligence. Specifically, McCart et al. (2006) reported mean effect sizes (ES) of 0.47 for BPT and 0.35 for
CBT, indicating their potential benefits in reducing disruptive behaviors.

The study by Nagihan Saday Duman, Özgür Öner, and Ayla Aysev aimed to investigate the impact of educational
therapy on self-esteem and externalizing behaviors in children diagnosed with Specific Learning Disability (SLD).
Conducted with 150 children aged 9-11 years, the research utilized the Wechsler Intelligence Scale for Children-
Revised (WISC-R) and an SLD test battery to confirm diagnoses. Additionally, the Piers-Harris Children’s Self-
Concept Scale and the Child Behavior Checklist (CBCL 6-18) were employed to assess self-esteem and externalizing
behaviors. Results indicated that children with SLD exhibited lower self-esteem levels and higher scores for
externalizing behaviors compared to typically developing children. Following educational therapy, significant
improvements were observed in the SLD test battery scores for children in the therapy group compared to those on the
waiting list. Moreover, the therapy group demonstrated increased self-esteem and reduced externalizing behavior
scores post-therapy. These findings suggest that educational therapy effectively enhances self-esteem, mitigates
externalizing behaviors, and addresses symptoms of SLD in children. However, the study recognizes the influence of
various psychosocial factors on children’s overall well-being and underscores the necessity for further research to
comprehensively understand these complexities.

Moreover, studies have highlighted the synergy of combining BPT with CBT, showing superior outcomes compared
to single-focus interventions (Kazdin et al., 1992; Lochman and Wells, 2004; Webster-Stratton and Hammond, 1997).
This combined approach has been effective in enhancing behavior management skills in children with externalizing
problems, suggesting its relevance for children with SLD who may also exhibit these challenges.

However, there remains a notable gap in understanding whether such combined interventions are equally effective for
children with SLD, who often struggle with learning and adaptive skills. Children with SLD, characterized by
difficulties in reading, writing, or mathematics despite average or above-average intelligence, are known to experience
higher rates of externalizing behavior problems compared to their peers without learning disorders (Baker et al., 2002;
Dekker et al., 2002). These behavioral issues can lead to academic underachievement and social difficulties,
underscoring the need for targeted interventions.
Current literature indicates limited intervention studies focusing specifically on children with SLD and externalizing
behavior problems. Most existing research has explored preventive programs primarily targeting parents of preschool
children, without direct intervention for the children themselves (Hand et al., 2012; McIntyre, 2008a, b; Plant and
Sanders, 2006; Roberts et al., 2006; Tellegen and Sanders, 2013). While initial findings from parenting programs are
promising (Matson et al., 2009), methodological limitations such as small sample sizes and lack of control groups
challenge the generalizability of these results (Einfeld et al., 2013).

Furthermore, the application of CBT specifically tailored for children with SLD and externalizing problems remains
underexplored. Existing randomized trials have predominantly focused on adults with intellectual disabilities, showing
effectiveness in improving anger control (Willner et al., 2013). However, empirical data on the adaptability and
effectiveness of CBT techniques in children with SLD are lacking, particularly in terms of addressing their unique
cognitive profiles and learning needs.

The theoretical feasibility of applying CBT with children with SLD hinges on the adaptation of cognitive tasks to their
cognitive abilities, such as language processing, attention span, and working memory (Sturmey, 2004; Joyce et al.,
2006; Van Nieuwenhuijzen et al., 2009). Despite concerns about cognitive demands, proponents argue that evidence-
based cognitive techniques can be effective if appropriately adapted to accommodate these children's cognitive
limitations (Kazdin and Whitley, 2006).

Given these gaps and theoretical considerations, there is a critical need for rigorous, large-scale randomized trials to
evaluate the effectiveness of multimodal interventions like Standing Strong Together (SST) adapted from the Coping
Power Program (Lochman et al., 2008; Van de Wiel et al., 2007). SST integrates BPT and CBT components to target
both parenting practices associated with externalizing behaviors and social information processing deficits in children
with SLD. By employing a cluster-randomized design comparing SST with care as usual (CAU), researchers aim to
assess its impact on reducing externalizing behaviors and improving parent-child relationships in this population.

In summary, while existing evidence supports the efficacy of BPT and CBT in managing externalizing behaviors in
children with average intelligence, the applicability of these interventions to children with SLD requires empirical
validation. This study seeks to address this gap by examining whether SST can effectively mitigate externalizing
behavior problems in children with SLD, thereby contributing to the development of targeted interventions tailored to
their unique needs and challenges.

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