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 Table of Contents  
Year : 2016  |  Volume : 37  |  Issue : 2  |  Page : 46-52

Child abuse experiences in adolescents with externalizing disorders

Department of Psychiatry, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission27-Apr-2015
Date of Acceptance02-Aug-2015
Date of Web Publication2-Nov-2016

Correspondence Address:
Hala A El-Boraie
Department of Psychiatry, Faculty of Medicine, Mansoura University, Mansoura
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-1105.193021

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Objectives The purpose of this study was to explore the effect of experiencing childhood abuse on externalizing disorders in a sample of adolescents from Mansoura Adolescents Unit.
Patients and methods A total of 300 adolescents were included in the study; of them 100 were diagnosed as having externalizing disorders, whereas the other 200 were control adolescents from the outpatient clinic of Dermatology Department and Pediatric Hospital of Mansura University. The Mini International Neuropsychiatric Interview for Children and Adolescents was used for diagnosis, and a questionnaire on child abuse experiences was administered for assessment of parental abuse (physical and psychological) and sexual abuse. Finally, the modified Global assessment of functioning scale was used to assess the outcome of externalizing disorders.
Results Paternal psychological abuse is significantly associated with attention deficit hyperactivity disorder (combined type), conduct disorder (CD), and substance use disorders (SUDs), whereas paternal physical abuse is significantly associated with CD and SUDs. Maternal physical abuse is associated with CD and oppositional defiant disorder, whereas maternal psychological abuse and sexual abuse are significantly associated with CD and SUDs. Therefore, paternal physical abuse is considered the only predictor of externalizing disorders.
Conclusion This study has implications for the assessment of effect of childhood abuse on externalizing disorders during adolescence. Children physically abused, especially by the father in the sample, appeared to be at a greater risk for externalizing disorders. However, all types of child abuse were associated with externalizing disorders.

Keywords: adolescents, child abuse, child maltreatment, externalizing disorders

How to cite this article:
El-Baz RH, Abo-El-Ezz WF, El-Hadidy MA, El-Boraie HA. Child abuse experiences in adolescents with externalizing disorders. Egypt J Psychiatr 2016;37:46-52

How to cite this URL:
El-Baz RH, Abo-El-Ezz WF, El-Hadidy MA, El-Boraie HA. Child abuse experiences in adolescents with externalizing disorders. Egypt J Psychiatr [serial online] 2016 [cited 2023 Dec 11];37:46-52. Available from: https://new.ejpsy.eg.net//text.asp?2016/37/2/46/193021

  Introduction Top

Adolescence is the period during which there is an increased risk for several mental health problems. The extensive work of McConaughy et al. (1992) has led to the widely accepted differentiation between internalizing and externalizing problems of adolescents. Their classification categorized these behaviors into two broad dimensions: internalizing (overcontrolled) and externalizing (undercontrolled) behaviors (Nezhad et al., 2011). Externalizing disorders are generally disruptive, overt, and attention getting (Brook et al., 2012) and include attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), conduct disorder (CD), and substance use disorders (SUDs). In Egypt, behavior disorders represented 8.2% (in 1990) of diagnoses in all children attending the outpatient clinic of Ain Shams University Hospitals (Okasha, 1993). Child abuse is a major public health problem with a lifelong adverse effect on victims if there is no proper treatment. It is defined as any act(s) or failure of act(s) by parent or caregiver that results in actual or potential harm to a child's health or development, including neglect and physical, psychological, and sexual abuse (World Health Organization, 2014). Modern studies explain how child abuse interacts with genes and environmental factors to affect the developing brain and neuronal network (Hart and Rubia, 2012; Bair-Merritt et al., 2013).

A report published by UNICEF on studies conducted on child abuse in the Egyptian society revealed that 81% of children have been corporally punished at home and 91% corporally punished during the same period in schools (UNICEF, 2008). Multiple factors affect the impact of child maltreatment on victims; sex is one of the important factors.(Evans et al., 2008). Generally, male patients report more physical abuse compared with female patients (5–54 vs. 4–42%) (MacMillan et al., 2013), and female patients report more sexual abuse compared with male patients (16–22 vs. 4–11%) (Pereda et al., 2014). In addition, sex affects the level and type of impairment, as female adolescents are more prone to suffer from post-traumatic stress disorder, suicide (Thompson et al., 2004), depression (Moylan et al., 2010), and cardiovascular disease (Scott-Storey, 2013). The effect of cultural factors on the prevalence of child abuse is hard to determine due to variability in defining child maltreatment across countries (Al-Eissa et al., 2014). In general, Africa is considered to have the highest prevalence rate for all forms of child abuse, except for neglect, because of lacking data, whereas Asia has the lowest rate of sexual abuse (Stoltenborgh et al., 2013).

Victims of childhood maltreatment are at increased risk for a wide range of externalizing problems (Pears et al., 2008) such as ADHD (Cohen et al., 2001), CD (Murray and Farrington, 2010), ODD (Cohen et al., 2001), delinquency (Williams et al., 2010), and antisocial behavior (Jonson-Reid et al., 2010).

  Rationale of the study Top

The need for this study stems from many observations. The first is that the Egyptian adolescent population is huge and constitutes nearly 40% of the Egyptian population (Central Agency for Public Mobilization and Statistics, 1992). Second, although extensive research has been conducted in the USA, less is known about adolescent mental health and its key correlates in developing nations, such as in our country Egypt. Third, studies on risk factors, such as child abuse, for psychiatric disorders in adolescents are given little attention.

  Patients and methods Top

The study was conducted at the outpatient clinic of Adolescent Unit of Psychiatry Department in Mansoura University Hospital, which serves Dakahlia Governorate and surrounding areas. It took place during the period from November 2012 to March 2014. This was a case–control cross-sectional study. Written informed consent was obtained from the adolescents and their parents. Adolescents were informed about the objectives of the study and they had the right to refuse to participate. The study included two groups: the patient group included 100 adolescents, whereas the control group included 200 adolescents from the outpatient clinic of Dermatology Department and Pediatric Hospital, Mansoura University Hospital. The research was approved by the research and ethics committee.

Inclusion criteria for the patient group

Adolescents from the outpatient clinic diagnosed as having one of the externalizing disorders (ADHD, CD, ODD, and SUDs) based on Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (DSM-IV-TR) (American Psychiatric Association, 2000), those between 10 and 19 years of age, having IQ more than 80, and of both sexes were included in the study.

Exclusion criteria

Exclusion criteria were as follows: participants with IQ scores below 80 (because they were uncooperative and unable to complete some tools), presence of severe neurological disabilities, those who were illiterate, and those who refused to join the study.

Inclusion criteria for the control group

Individuals with acute and short-term medical illness that did not interfere with the psychological state, those with no history of psychiatric or neurological disorders, and of both sexes with age range of 10–19 years, similar to that of the patient group, were included in the study and were subjected to the same scales and tools as the patient group.


  1. Clinical assessment was carried out with a semistructured psychiatric interview based on the psychiatric sheet for children and adolescents of Mansoura University Hospital and then Mini International Neuropsychiatric Interview for Children and Adolescents was used (Sheehan et al., 1998). It screens for 17 axis I disorders. The Arabic version of Mini International Neuropsychiatric Interview for Children and Adolescents was used (Ghanem et al., 2000).
  2. The Arabic version of the Wechsler Intelligence Scale for Children was used (Ismael and Malekal, 1993) to assess IQ. It is a battery comprising 11 subtests – each is scored individually – which is divided into two parts: the Verbal Scale Subtest for verbal IQ and the Performance Scale Subtests for performance IQ. The scores of both yield the average index of general intellectual functioning.
  3. Assessment of childhood maltreatment was conducted using the questionnaire of child abuse experiences during childhood (Arabic version) (Mukheimar and Razeq, 2004). It is a self-administered questionnaire comprising 32 items about the father and the same for the mother; both include 16 items for physical abuse and 16 items for psychological abuse, and separate 10 items for sexual abuse. The items are scored as follows: always true = 4; sometimes true = 3; rarely true = 2; almost never true = 1.
  4. For measuring the outcome of externalizing disorders, the modified Global assessment (mGAF) (Smith et al., 2011) of functioning scale was used. Therefore, this scale gives a more detailed criteria and scoring system (0–90). Lower scores indicate severe impairment and a midrange score of 50 represents ‘serious symptoms’ or ‘serious impairment in social, occupational, or school functioning’.
  5. Income was measured with the average annual Egyptian household income, according to the Central Agency for Public Mobilization and Statistics (2012).

Statistical analysis

The collected data were computed and analyzed using Microsoft excel program and statistical package for social science program, version 22 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. IBM Corp, Armonk, NY). The results were tabulated, grouped, statistically analyzed, and described using descriptive and analytical statistics using the following tests:

  1. mean and SD (1 ± SD) was used for continues variables;
  2. absolute and relative frequencies for quantitative variables;
  3. one-way analysis of variance test was used when comparing the several means to determine the interaction of several independent variables with each other and the effect on a dependent variable. The Bonferroni post-hoc test method is used for performing multiple comparisons and for controlling the pairwise error rate;
  4. Pearson's correlation coefficient was used to correlate variables with each others; and
  5. multiple linear regression (multivariable linear regression) was carried out to study the relationship between a dependent variable and one or more explanatory variables (or independent variable).

  Results Top

In this study, the mean age of the cases with externalizing disorders (n = 100) was 13.79 ± 3.10 years and that of controls (n = 200) was 15.28 ± 2.38 years. In the patient group, the percentage of male patients (n = 84) was 84% [odds ratio (OR) = 1.85, 95% confidence interval (CI) = 1.551–2.197] and that of female patients (n = 16) was 16% (OR = 0.249, 95% CI = 0.184–0.468), whereas in the control group the percentage of male participants (n = 91) was 45.5% and that of female participants (n = 109) was 54.5%, as the male population was 1.85 times more prone to externalizing disorders compared with the female population. Our study declared that 26% of externalizing disorders were from urban areas, whereas 74% were from rural areas. In the control group 53.5% of them were from urban areas and 46.5% were from rural areas ([Table 1]).
Table 1 Sociodemographic data of the whole sample

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The most prevalent diagnoses of the externalizing disorder group were ADHD-combined type (30%), CD (23%), SUDs (20%), and ADHD-inattentive type (10%). Further, 13% of cases showed comorbidity of externalizing disorders (7% ADHD-combined type comorbid with CD, 4% ADHD-inattentive type comorbid with CD and 2% CD comorbid with SUDs) ([Table 2]).
Table 2 Externalizing disorders in the patient group

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On using the analysis of variance test for comparing the means of child abuse experiences in different diagnoses in the patient group, we found that ADHD (combined type) is significantly associated with paternal psychological and physical abuse. However, CD is significantly associated with all types of child abuse experiences, paternal psychological and physical abuse, maternal psychological and physical abuse, and sexual abuse. However, SUDs are significantly associated with paternal physical and psychological abuse, maternal psychological abuse, and sexual abuse. In contrast, ODD is associated only with maternal physical abuse, and ADHD-inattentive type is not significantly associated with any type of child abuse ([Table 3]).
Table 3 Childhood abuse experiences among patients with externalizing disorders

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A correlational analysis was performed between the explanatory variables and dependent variables ([Table 4]). All measured child abuse types are positively and significantly intercorrelated with each other, whereas they all negatively and significantly correlated with mGAF of externalizing disorders, except maternal physical abuse.{Table 4}

Multiple regression analysis was performed to explore childhood maltreatment as a risk factor associated with externalizing disorders. In the analysis, F (1,94) = 13.389 with P < 0.001 which indicates a significant effect of paternal physical abuse on the outcome of externalizing disorders (mGAF) (b = 0.353, P < 0.001), whereas other types of child maltreatment revealed no significant effect on externalizing disorders ([Table 5]).
Table 5 Multiple regression analysis of child abuse experiences

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  Discussion Top

In the current study, we adopted the hypothesis that there is an association between externalizing problems in adolescents and experiences of childhood abuse. An adolescent's experience of childhood abuse is an important factor that affects psychological and mental health. Child abuse or maltreatment, including physical, sexual, and psychological abuse, which may be due to watching violence between parents and multiple forms of neglect such as low parental supervision or lack of appropriate monitoring (UNICEF, 2008).

In this study, there is a significant difference between the age of the externalizing disorder group (13.79 ± 3.10, P < 0.001) and the control group (15.28 ± 2.38, P < 0.001). Externalizing disorders are more common during young age, because youngsters have a greater tendency to express their emotions and react to stresses through greater impulsivity and misbehavior. The male population was 1.85 times more prone to externalizing disorders compared with the female population (OR = 1.85, 95% CI = 1.551–2.197, P < 0.001). In the sample, the ratio of boys-to-girls was 4 : 1 for risk of externalizing disorders. This may be attributed to the fact that boys mature more slowly compared with girls and are more likely to have difficulty regulating their thoughts, feelings, and impulses, and tend to express their emotions externally that makes them more likely to have externalizing disorders.

Similar to the results reported in this study, various researchers (Prinzie et al., 2006; Burt et al., 2009) have suggested that boys present more externalizing problems compared with girls. Studies conducted in Brazil (Bandeira et al., 2006; Nunes et al., 2013) and Iran (Sajjadi et al., 2013) also reported that boys exhibit behavioral problems more frequently compared with girls. However, some studies found that there was no sex difference identified in externalizing problems (Marturano et al. 2005; Saud and Tonelotto, 2005; Nunes et al., 2013; Korhonen, 2014).

Residence is one of the important factors affecting the emergence of psychiatric morbidity. In the current study, 26% of participants from the patient group were from urban areas (OR = 0.486, 95% CI = 0.341–0.693), whereas 74% were from rural areas (OR = 1.591, 95% CI = 1.319–1.922). We claimed that externalizing disorders are more prevalent in rural than in urban areas and may be due to ignorance, negative attitude, and stigma about mental illness and seeking medical or psychiatric consultation lately.

This study found that low average income is related to externalizing disorders. In a study conducted on African children up to grade 8, Ayer and Hudziak (2009) found that low socioeconomic status is associated with externalizing disorders; Bøe et al. (2014) also reported similar results. In contrast, Korhonen (2014) revealed that there were no socioeconomic differences between groups.

Child abuse in this study was measured by means of five categories (paternal physical abuse, paternal psychological abuse, maternal physical abuse, maternal psychological abuse, and sexual abuse). All these types are significantly associated with externalizing disorders in adolescents, but only paternal physical abuse is considered a significant predictor of externalizing disorders. The current study revealed that ADHD (combined type) is significantly associated with paternal psychological and physical abuse. However, CD, is significantly associated with all types of child abuse experience. SUDs are significantly associated with paternal physical and psychological abuse, maternal psychological abuse, and sexual abuse. In contrast, ODD is associated only with maternal physical abuse, and ADHD-inattentive type is not significantly associated with any type of child abuse.

Child abuse can lead to increased aggression that is mediated by inability of the child to regulate emotions (Ayer and Hudziak, 2009). Maltreatment is considered a severe early stress, and repeated stressful events can affect gene expression (Bøe et al., 2014) and brain development, thus increasing risk for numerous psychological health problems (Heim et al., 2010).

Similar relations between physical abuse, ranging from spanking to more severe and harsh physical punishment, and externalizing problems have been reported in other countries such as in Sub-Saharan Africa (McEwen, 2012; Choi and Oh, 2014; Leyton and Stewart, 2014) and other countries worldwide (Ani and Grantham-McGregor, 1998; Hermenau et al., 2011).

A study by Hecker et al. (2014) on 409 children (52% boys) from grade 2 to 7 had a mean age of 10.49 (SD = 1.89) years. Nearly all children had experienced physical abuse at some point during their lifetime both in family and school contexts. Half of the respondents reported having experienced corporal punishment within the last year from a family member. This study revealed that physical abuse by parents or by caregivers was positively related to children's externalizing problems.

Physical abuse correlated positively with all externalizing disorders, whereas correlated negatively with prosocial behavior (Leyton and Stewart, 2014). Longitudinal studies suggest that physical abuse of a child predicts aggression and antisocial behavior during adolescence and adulthood (Ani and Grantham-McGregor, 1998; Hermenau et al., 2011). This association may be due to the imitation of parental behavior and internalizing it, followed by expression of this aggressive behavior. Different types of child abuse (physical, psychological, and sexual) were associated with numerous psychiatric disorders, including externalizing disorders (Hecker et al., 2014) and may be related to criminal activity in adulthood (Connor et al., 2004; Schilling et al., 2007).

The relation between ADHD and childhood maltreatment is bidirectional as a history of child abuse increases ADHD symptoms, as well as ADHD increases risk for maltreatment due to externalizing behaviors and dysfunctional peers and family relations (Aebi et al., 2014). ADHD-inattentive type that is not associated with any type of child abuse may emphasize the effect of biological causes rather than psychological causes (Briscoe-Smith and Hinshaw, 2006).

A history of physical and/or sexual abuse is also linked with adolescent SUDs (Bukstein and Lutka-Fedor, 2007). Some researchers have identified increased symptoms of substance use in maltreated versus normally treated youth, (Odgers et al., 2008) but others have not observed this pattern (Cohen et al., 2001). Many researchers have proposed that childhood maltreatment may play a role in the etiology of antisocial personality disorders and persistent adult antisocial behavior (Caspi et al., 2002), and, in young adults, it is associated with higher psychopathy scores (Horwitz et al., 2001). Physical abuse appears to be more strongly related to adult antisocial behavior than is neglect or emotional abuse (Cohen et al., 2001). The effects of maltreatment may be mediated by other environmental risk factors, such as other stressful situations.

The difference in types of child abuse that affect externalizing disorders during adolescence may explain the core of psychodynamics of each disorder, which confirms the variance in the nature of these disorders even if they are included in the same category.


  1. More extensive studies are required using longitudinal design, which are more relevant and are used to confirm causality.
  2. Using multiple informants (adolescent, parents, and teachers) in gathering data instead of single informant.
  3. This study may be beneficial in encouraging early detection and prevention efforts as regards adolescents’ psychopathology. Findings reported in this study showed that externalizing disorder outcomes are correlated with all types of child abuse.
  4. Preventive programs are more effective by family and public awareness. They may be required to help prevent adolescents from developing externalizing disorders. Preventative strategies could focus on positive parenting and nonviolent caregiving measures.


Conflicts of interest

None declared.

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  [Table 1], [Table 2], [Table 3], [Table 4]EgyptJPsychiatr_2016_37_2_46_193021_t4.jpg, [Table 5]

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