The influence of cortisol and internalizing problem behavior on
externalizing problem behavior in girls.
Masterscriptie Orthopedagogiek Pedagogische en Onderwijskundige Wetenschappen Universiteit van Amsterdam
A.Vermaas BSc 10459804 Mw. dr. M. Hoeve Mw. dr. I.B. Wissink Amsterdam, juni 2015
The influence of cortisol and internalizing problem behavior on externalizing problem behavior in girls.
Abstract. This study focused on basal cortisol levels and internalizing problem behavior as influential factors of externalizing problem behavior in girls. The sample included 78 girls who resided in a residential civil youth care institution in Amsterdam (age M = 15.43). Problem behaviors were measured with the RPQ, YPI and YSR. Saliva samples were collected to measure the basal cortisol levels. It was found that more internalizing problem behavior relates to more externalizing problem behavior, especially to impulsive/irresponsible traits. Second, it was found that lower basal cortisol levels are related to higher levels of callous/unemotional traits. This study shows that the relations found in all boys or mixed samples are not applicable to all girl samples and adjustments in theories, interventions and treatment are recommended.
Every intervention for youth with behavior problems used in Dutch residential and civil youth care has to be licensed before it can be implemented in youth care organizations (Nederlands Jeugdinstituut, 2015). The database with licensed interventions shows that there are more interventions targeting externalizing behavior in boys, while problem behavior in girls is not as unlikely as it may seem. For 5 to 10% of the boys who show externalizing problem behavior, there is 1 to 3% of the girls showing similar behavior (Costello et al., 1996; Lavigne et al., 1996; Moffit, 1993). A possible explanation of the scarceness of interventions that aim to reduce problem behavior in girls is that there is less literature available about externalizing problem behavior in girls than in boys. The present study will try to address this research gap. The focus is on basal cortisol levels and internalizing problem behavior as influential factors of externalizing problem behavior in girls. Insight into the influence of basal cortisol levels and internalizing problems on externalizing problem behavior in girls can be used to develop gender specific interventions for girls in residential youth care.
Externalizing problem behavior
Externalizing problem behavior refers to a set of behavioral characteristics that are considered to be undercontrolled and other-directed, such as antisocial, aggressive, oppositional, or overactive behaviors (Achenbach, 1991). These characteristics are perceptible in outward behavior that reflects the child’s negative behavior acting on the external environment (Campbell, Shaw, & Gilliom, 2000; Eisenberg et al., 2001). From a clinical perspective, child externalizing behavior can be operationalized in terms of psychiatric diagnoses: disruptive behavior disorder (covering both conduct disorder and oppositional defiant disorder) and attention deficit/hyperactivity disorder (American Psychiatric Association, 1994). The present study’s focus is on general externalizing problem behavior as well as on aggression and psychopathy which are more specific types of externalizing behavior.
Aggression appears to be a serious problem that is difficult to treat (Yorke, 1990). A meta-analysis of Huesmann, Eron, Lefkowitz and Walder (1984) showed that aggression is as stable as intelligence. Early aggressive behavior predicted antisocial behavior and delinquency, spouse abuse, traffic offenses and physical aggression later in life. Aggression was also shown to be intergenerationally stable and was not subjected to a certain situation, but appeared under different conditions. Aggression can be displayed in various situations and for different reasons (see Yorke, 1990 for an overview) and is often divided into reactive and proactive aggression (Raine et al., 2006; Steiner et al., 2011). Reactive aggression on the one hand is a resistant impulse that can be described as a hostile reaction towards a perceived
threat. Proactive aggression on the other hand can be defined as an aggressive action, stimulated by an external reward (Raine et al., 2006; Steiner et al., 2011). Both types of aggression are interrelated, but research has shown that different conditions provoke different types of aggression. For example, the meta-analysis of Card and Little (2006) showed that internalizing problem behavior can be related to reactive aggression, but not to proactive aggression.
Research has shown that there is a strong link between psychopathic traits and externalizing problem behavior in clinical as well as non-clinical samples (Dadds, Fraser, Frost, & Hawes, 2005; Frick, Cornell, Barry, Bodin, & Dane, 2003; Frick, O’Brien, Wootton, & McBurnett, 1994; Marsee, Silverthorn, & Frick, 2005). Youth with psychopathic traits are less sensitive for signals of fear and sadness of others (Blair, Budhani, Colledge, & Scott, 2005; Blair & Coles, 2000; Blair, Colledge, Murray, & Mitchell, 2001; Stevens, Charman, & Blair, 2001). However, these children do not differ from children without psychopathic traits in recognizing happiness, anger or being surprised; they only experience difficulties in recognizing sadness and fear (Blair, 1999). Because youth with high levels of psychopathic traits have a reduced sensitivity for these emotions, they are unable to activate the inhibition that regulates problem behavior making them more likely to react aggressive towards others.
Gender differences
The fact that previous research on externalizing problem behavior is based on mixed samples or all boy samples, does not mean that girls show no problems. Research on problem behavior in girls is mostly focused on internalizing problem behavior or, for example, relational or indirect aggression. Longitudinal and epidemiological studies have shown that approximately 5 to 10% of the boys display severe disruptive behavior in childhood against only 1 to 3% of the girls (Costello et al., 1996; Lavigne et al., 1996; Moffit, 1993). While this behavior is less often seen in girls, clinic-referred girls generally have more severe behavioral problems than boys (Kloosterman & Veerman, 1997; Webster-Stratton, 1996). In addition, research has shown that comorbidity is higher in adolescent girls (Costello, Armstrong & Erkani, 2000; Costello, Foley & Angold, 2006). Girls who showed disruptive behavior in childhood are likely to have more severe psychosocial problems in adulthood than boys, that is mental health problems, substance abuse and parental problems, which create a risk for next generations (Bardone, Moffitt, Caspi & Dickson, 1996; Chamberlain & Moore, 2002; Lewis, Yeager, Cobham-Portorreal & Klein, 1991; Odgers et al., 2008; Robins, 1986). The development of this behavior varies, starting with a different onset in girls than in boys. Girls are not as likely as boys to experience an early onset, but the problem behavior escalates
faster in adolescence (Côté et al., 2001; Galambos, Barker & Almeida, 2003; McCabe, Rodgers, Yeh & Hough, 2004; Moffit et al., 2001; Scaramella, Conger & Simons, 1999; Silverthorn, Frick & Reynolds, 2001). The differences in onset, pathways and outcomes suggest that a gender specific approach and treatment may be needed. Therefore, it is important to know which factors contribute to externalizing problem behavior in girls in order to be able to improve treatment.
Explanations of Externalizing Problem Behavior in Girls
A relatively new direction in research focuses on biological factors that may influence behavior in adolescents. The present study examined the potential influence of the basal cortisol level in girls, based on the hypothalamic-pituitary-adrenal axis (HPA-axis). The HPA-axis is part of the stress system that is supposed to preserve homeostasis in an ever-changing environment. The system exists of two components: the locus caeruleus (which produces noradrenalin) and the HPA-axis (see Gunnar & Quevedo, 2007 for an overview). The locus caeruleus can be found in the brain and is supposed to react directly on a threatening situation. The HPA-axis, consisting of the hypothalamus, pituitary gland, and adrenal glands, reacts somewhat later than the locus caeruleus and functions as a back-up system to recover the balance (homeostasis) in the body (Sapolsky, Romero, & Munck, 2000). After the first reaction of the locus caeruleus, the system of the HPA-axis starts a process in which the adrenal glands produce the hormone cortisol so the body can be restored to homeostasis (Chrousos & Gold, 1992; De Kloet, 1991; Sapolsky et al., 2000). Cortisol is produced in a circadian and is therefore present in rest or absence of stress as well. This basal cortisol level starts with an increase of cortisol after awakening and gradually decreases during the day (Edwards, Clow, Evans, & Hucklebridge, 2001).
A meta-analysis from Alink et al. (2008) showed that there is a small, but significant association between cortisol and externalizing problem behavior in general. Lower levels of cortisol are related to higher levels of externalizing problem behavior. It is known that children who are exposed to higher levels of stress have a higher chance of developing externalizing problem behavior. Because of endured stress, the basal cortisol level increases in early childhood leading to some kind of habituation and the HPA-axis becomes less sensitive to stress, which leads to lower cortisol levels in children between ages of 6 to 12. The level of cortisol has to be activated externally (by impulses from the environment) to achieve homeostasis. Zuckerman (1979) related the lower basal cortisol levels to underarousal. So-called sensation seeking compensates lower cortisol levels: the tension that arises stimulates the increase of cortisol. Raine (1996) focused on low levels of fear: a person
could experience low levels of fear and therefore that person will have no knowledge of negative or aversive consequences of fear (such as punishment and regarding pain of others by own matter). This person is not able link the negative consequences to externalizing actions and therefore it is more likely for this person to get involved in physical fights or conflicts. These theories are based on research focusing on boys or mixed samples. Therefore it is rather unknown whether these theories apply to girls.
Not only biological processes influence externalizing problem behavior. Earlier research from Zoccolillo (1992) showed that externalizing problem behavior in youth coheres with emotional problems, such as depression and fear. Research has shown that these emotional, or internalizing problems, are relatively common in girls in residential facilities, who also show high levels of externalizing behavior. Internalizing problem behavior is specifically related to reactive aggression, according to the frustration-anger model (Dollard et al., 1939; see Vitaro et al., 2006 for a review). This model points out that reactive aggression is used as a reactor on the anger and frustration stimulus to eliminate the threat. Therefore, reactive aggression could be related to negative affectivity (the tendency to feel negative emotions and to express them as a reaction on the environment) and specifically the emotions that perceive frustration or irritation and threat. Underlying factors of negative affectivity are frustration and anger as well (Murris & Meesters, 2008; Whittle et al., 2008). Dodge et al. (1997) discovered that children showing reactive aggression are more often depressed than children showing proactive aggression. Research from Raine et al. (2006) added that adults who mainly tend to react in a reactive aggressive way are more often socially fearful. Finally, the meta-analysis from Card and Little (2006) showed that reactive aggression is related to internalizing problem behavior and inadequate emotion regulation in contrast with proactive aggression. This can be explained by earlier research showing that adults with specific externalizing problem behavior tend to have difficulties with processing information because hostile attribution of others is not correctly interpreted (Crick and Dodge, 1996; Dodge and Coie, 1987; Orobio de Castro et al., 2005). Because of this, internalizing problem behavior will be addressed in this paper.
The Present Study
The present study first examined the link between basal cortisol levels and internalizing problem behavior on the one hand and (different types of) externalizing behavior on the other hand. Second, the interaction between cortisol levels and internalizing behavior was examined in relation with girls’ externalizing behavior. Based on the literature, it was expected that lower basal cortisol levels would be more strongly related to proactive
aggression and callous/unemotional traits. Next, the relation between internalizing problem behavior and reactive aggression and impulsive/irresponsible traits was expected to be stronger than the relation with proactive aggression. Finally, it was expected that low basal cortisol levels and more internalizing problems would interact and produce a worsening course of externalizing problem behavior in girls.
Methods Participants
The sample included 78 girls, who resided in a civil youth care institution in a residential setting in Amsterdam between March 2010 and June 2013. The girls were between 13 and 18 years old (M = 15.43, sd = 1.19) at the start of their treatment. Roughly a third (38.5%) of the girls had the Dutch nationality or ethnic background (n = 30), and 26.9 percent of the girls had a non-Dutch nationality (n = 21). Of the total sample, 7.7 percent (n = 6) were Surinamese, 6.4 percent (n = 5) were Moroccan, and 13 percent (n = 10) had a different ethnic background, including a Turkish, Antillian, Armenian, Dutch/Suriname, African, Dutch/Moroccan, Iraqi or Ghanaian background. The nationality of the remaining participants (34.6%, n = 27) was unknown. The average time in treatment was 261 days (M = 260.89, sd = 111.99). The saliva samples were taken from 78 girls on an average of 82 days (M = 81.9, sd = 51.54) after they entered the institution. The set of questionnaires was fully completed by 54 girls.
Procedure
This project was approved by the board of the Medical Ethic Commission from the VU University Medical Center. Anonymity and proper use of information about participants was guaranteed. Diagnostic interviews and self-report questionnaires were part of the regular program in the residential youth care institute. The collection of neurobiological measures was explicitly approved by the participants. When the girls granted permission after a verbal explanation, they were handed an information brochure and signed an informed consent. Parents were informed by phone after the participants filled out the consent form. When parents gave their permission, the neurobiological measuring took place. Saliva was gathered respectively 0, 30, and 60 minutes after awakening. The participants were asked to remain awake and were not allowed to eat, smoke or brush their teeth in the meantime. The saliva was collected on a regular school day in the institution, starting at 7:30 AM. During this hour, the researcher stayed with the participants to ensure the correctness of the collection and to answer questions. The samples were kept in a freezer (temperature of -20°C) until analysis. Instruments
Cortisol. This study uses the Area Under the Curve with respect to ground (AUCG) method (to measure the Cortisol Awakening Response (CAR). This method is commonly used to measure the basal cortisol level in saliva samples (Fekedulegn et al., 2007). In this study, the AUCG measures the intensity or magnitude of the response directly after awakening (Fekedulegn et al., 2007). AUCG is the total area under the curve of all measurements. In this study, only the first measurement (directly after waking up) was used to determine the basal hormonal output of the participants.
Behavioral problems. The Youth Self Report (YSR; Achenbach, 1991b) was used to assess behavioral and emotional problems in children and adolescents. The YSR is a self-report questionnaire for assessing problems in 6- to 18-year-olds (Ferdinand, 2008) and consists of 120 items on behavioral or emotional problems during the last 6 months. The items are rated on a 3-point Likert scale ranging from 0 = ‘not true’ to 2 = ‘very or often true’. The reliability and validity were confirmed to be acceptable for the Dutch version (Verhulst, Van der Ende & Koot, 1997). The YSR consists of the following scales: anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, rule-breaking behavior and aggressive behavior. These scales can be divided into two higher order factors: internalizing and externalizing problems. The reliability of the scales in this study was .909 for internalizing problem behavior, .912 for externalizing problem behavior, and .946 for the total problem behavior score.
Psychopathy. The Youth Psychopathic traits Inventory (YPI; Andershed, Kerr, Stattin & Levander, 2001) measures the interpersonal, affective and lifestyle dimensions of psychopathic traits in adolescents (Hillege, Das & De Ruiter, 2010; Andershed et al., 2001). The YPI is a self-report questionnaire consisting of 50 items rated on a four-point Likert scale ranging from 1 = ‘does not apply at all’ to 4 = ‘applies very well’. Higher scores indicate more psychopathic characteristics. The interpersonal dimension is captured in the grandiose/manipulative dimension consists of the subdimensions dishonest charm (e.g., “When I need to, I use my smile and my charm to use others”), grandiosity (e.g., “I am more important and valuable than other people”), lying (e.g., “Sometimes I lie for no reason, other than because it's fun”), and manipulation (e.g., “To get people to do what I want, I often find it efficient to con them”). The affective dimension, the callous/unemotional traits, consists of the subdimensions remorselessness (e.g., “I seldom regret things I do, even if other people feel that they are wrong”), unemotionality (e.g., “What scares others usually doesn't scare me”), and callousness (e.g., “When other people have problems, it is often their own fault, therefore, one should not help them”). Finally, the impulsive/irresponsible dimension consists
of the subscales thrill seeking (e.g., “I get bored quickly by doing the same thing over”), impulsiveness (e.g., “I prefer to spend my money right away rather than save it”), and irresponsibility (e.g., “I have cut classes more than most other people”). The reliability for the main scales in this sample was .729 for
Table 1.
Descriptive statistics
M SD Min. Max.
Age at start treatment 15.43 1.19 13.16 17.78
Cortisol Area Under the Curve (ground) 1131.02 331.33 304.50 1852.50 Youth Self Report
Internalizing problem behavior 58.97 10.74 30 82
Externalizing problem behavior 61.65 10.09 37 81
Youth Psychopathic traits Inventory
Grandiose/manipulative 10.65 8.83 0 36 Callous/unemotional 13.13 7.09 3 35 Impulsive/irresponsible 19.55 8.77 3 42 Reactive-Proactive Aggression Questionnaire Reactive aggression 12.90 4,83 2 36 Proactive aggression 5.85 5.20 0 22
Note. Total N = 78, AUCG n = 73, YSR n = 71, YPI n = 74, RPQ n = 58.
callous/unemotional, .848 for impulsive/irresponsible and .874 for grandiose/manipulative and .914 for the YPI total score.
Aggression. The Reactive-Proactive Aggression Questionnaire (RPQ; Raine et al., 2006) is an instrument which measures reactive and proactive aggression. The RPQ consists of 23 items: 11 items which measure reactive aggression (e.g., “Gotten angry when others threatened you”) and 12 items which measure proactive aggression (e.g., “Had fights with others to show who was on top”) (Cima, Raine, Meesters & Popma, 2013). The items are rated on a three-point Likert scale with 0 = ‘never’, 1 = ‘sometimes’ and 2 = ‘often’. The range of item-total correlations of the proactive subscale is .41-.57, .45-.58 for the reactive subscale and .41-.60 for the total scale (Raine et al., 2006). The Cronbach’s alphas in this
study were .908 for the total scale, .831 for the reactive subscale and .873 for the proactive subscale of the RPQ.
Results
Table 1 presents the descriptive statistics for the variables used in the present study. Almost all of the girls ceded a saliva sample (n = 73). All girls reported a certain level of problem behavior in the Youth Self Report (internalizing minimum = 30, externalizing
Table 2. Pearson’s correlations 1 2 3 4 5 6 7 8 1. AUCG - 2. YSR - Internalizing -.059 - 3.YSR - Externalizing .009 .636** - 4. YPI – GM -.049 .225 .346** - 5. YPI - CU -.244* .059 .170 .563** - 6. YPI – II -.054 .467** .599** .534** .225 -7. Reactive aggression -.139 .206 .501** .303* .356** .319* -8.Proactive aggression .016 .114 .455** .439** .305* .422** .676** -Note. AUCG = Area Under the Curve with respect to ground.
GM = Grandiose/manipulative, CU = Callous/unemotional, II = Impulsive/irresponsible. *p < .05 level; **p < .01.
minimum = 37). For psychopathic traits and aggression girls reported a wider range of scores with maximum scores three standard deviations higher than the means.
Preliminary analyses showed the relationship to be linear with both variables normally distributed, as assessed by Shapiro-Wilk test (p > .05). No outliers were detected. A Pearson’s product-moment correlation was computed to assess the associations between variables (see Table 2). A moderately negative relation was found between basal cortisol level and callous/unemotional traits, r(69) = -.244, p = .044. Internalizing problem behavior was strongly correlated with externalizing problem behavior, r(71) = .636, p < .001. Internalizing problem behavior also correlated with impulsive/irresponsible traits, r(71) = .467, p < .001. The various types of externalizing problem behavior (YSR externalizing scale, various YPI and RPQ scales) were mutually correlated.
A multiple regression model was used to determine how much of the variation in externalizing problem behavior could be explained by AUCG and internalizing problem behavior. The assumptions of linearity, independence of errors, homoscedasticity, unusual points and normality of residuals were met. A step-wise approach was used. The first model showed that AUCG alone did not contribute significantly to externalizing problem behavior, F(1, 64) = .005, p = .942, adj. R2 = -.016. The second model in which both basal cortisol levels and internalizing problem behavior were included was significant, F(2, 63) = 21.870, p < .001, adj. R2 = .391. Next, the interaction of basal cortisol level and internalizing problem Table 3.
Multiple Regression Analysis
Externalizing Callous/unemotional Impulsive/irresponsible
B SEB β B SEB β B SEB β Intercept 61.618 4.572 18.936 3.084 20.281 3.874 AUCG .000 .004 .009 -.005 .003 -.237 + .000 .003 -.010 Internalizing .551 .083 .641** .049 .073 .082 .346 .081 .475** AUCG x Int -.000 .000 -.020 .000 .000 -.854 .000 .000 -.750 Note. B = unstandardized regression coefficient; SEB = standard error of the coefficient; β=
standardized coefficient; AUCG = Area Under the Curve with respect to ground. +p < .10, *p < .05, **p < .01
behavior was added to the model, but this did not significantly explain externalizing problem behavior, F(3, 62) = 14.394, p < .001, adj. R2 = .381 (see Table 3).
Further, a multiple regression model analyzed how much of the variation in callous/unemotional traits could be explained by the AUCG and internalizing problem behavior. The assumptions of linearity, independence of errors, homoscedasticity, unusual points and normality of residuals were met. These variables did not significantly contribute to callous/unemotional traits; Model 1 with AUCG alone, F(1, 64) = 3.806, p = .055, adj. R2 = .041; Model 2 with Internalizing problem behavior added, F(2, 63) = 2.112, p = .129, adj. R2 = .033; Model 3 with AUCG x Internalizing problem behavior added, F(3, 62) = 1.774, p = .161, adj. R2 = .034 (Table 3). None of the scales explained callous/unemotional traits significantly.
A final multiple regression model was computed to determine how much of the variation in impulsive/irresponsible traits could be explained by the AUCG and internalizing
problem behavior. The assumptions of linearity, independence of errors, homoscedasticity, unusual points and normality of residuals were met. The first model showed that AUCG alone did not contribute significantly to impulsive/irresponsible traits, F(1, 64) = .007, p = .935, adj. R2 = -.016. AUCG and internalizing problem behavior significantly contributed to impulsive/irresponsible traits in the second model, F(2, 63) = 9.130, p < .001, adj. R2 = .200. No interaction effect of internalizing problem behavior and basal cortisol levels on impulsive/irresponsible traits was found in the third model, F(3, 62) = 6.428, p = .001, adj. R2 = .200 (Table 3).
Discussion
The main focus of this study was whether basal cortisol levels and internalizing problem behavior could explain externalizing problem behavior in girls. First, it was found that more internalizing problem behavior relates to more externalizing problem behavior, especially to impulsive/irresponsible traits. Second, it was found that lower basal cortisol levels are related to higher levels of callous/unemotional traits. Finally, it was found that there was no interaction effect for internalizing problem behavior and basal cortisol levels.
Prior research showed that there is a strong association between externalizing problem behavior and emotional problems (e.g., Dadds, Fraser, Frost & Hawes, 2005; Frick, O’Briend, Wootton & McBurnett; 1994). The findings of the present study are in line with these prior results. However, a relation between internalizing problem behavior and (reactive) aggression was expected to be found, but this was not found in this population of girls in residential youth care. This is remarkable because there are multiple theories stating that internalizing or emotional problems are related to reactive aggression. In this study it was found that internalizing problem behavior has a strong influence on externalizing problem behavior for girls in a residential setting.
Next, a relation between internalizing problems and impulsive/irresponsible traits was found. This relation was not found in all boys or mixed samples. The theory of Blair (1999) stated that youth with high levels of psychopathic traits have a reduced sensitivity for emotions such as sadness. Because they are unable to activate the inhibition that regulates problem behavior, we expected to find a relation with aggression. However, derived from this theory it may carefully be assumed that girls in a residential setting with internalizing problem behavior do not react in an aggressive way, but may have resulted in impulsive/irresponsible behavior. The present study adds to previous research in that it confirms the association between internalizing and externalizing behavior in girls and, more specifically, it shows that
internalizing behavior is not related to any type of externalizing behavior but to impulsive and irresponsible behavior in particular.
This study revealed that lower basal cortisol levels are related to higher levels of callous/unemotional traits. When adjusted for internalizing problem behavior, the relationship is less strong, but remains a trend. This finding was expected based on the meta-analysis by Alink et al. (2008), showing that lower levels of cortisol are related to higher levels of externalizing problem behavior such as callous/unemotional traits are. The underarousal theory of Zuckermann (1979) assumes that antisocial behavior deriving from the callous/unemotional traits gives a certain amount of tension that stimulates the increase of cortisol to maintain homeostasis. The tension arising from this sensation seeking behavior leads to the stimulation of the adrenal glands to produce cortisol and, in this case, to restore homeostasis by rising the basal cortisol levels. It is remarkable that lower levels of cortisol are specifically associated with callous/unemotional traits and not with any other type of externalizing problem behavior. It was expected that lower levels of cortisol were also related to proactive aggression, but this relation could not be supported. Aggression as a whole does not cohere with lower levels of cortisol. The theory of Raine (1996) states that a person with lower basal cortisol levels could experience low levels of fear. Therefore, this person could easier get wrapped up in a fight because he cannot relate the negative consequences to externalizing actions. In this study however, expressing proactive aggression was not linked to lower levels of cortisol. This study shows that the relations found in all boys or mixed samples are not fully applicable to all girl samples and only the relation between basal cortisol levels and callous/unemotional traits can be endorsed.
Limitations
This study has several limitations. The design of this research was cross-sectional. Therefore, this study cannot clarify whether the lower cortisol levels or internalizing problem behavior are the cause or the consequence of the externalizing problem behavior. Only longitudinal studies can resolve the issue of the direction of causality. Second, this sample was recruited in a clinical youth care institute in Amsterdam, which makes the outcomes generalizable to girls with severe problem behavior in urban agglomeration in western countries. It could be interesting to investigate if the relationships are transferrable to a wider range of girls and non-clinical samples. It should be noted that there is a lot of ethnic diversity, which makes the results generalizable to multiple ethnicities, but has to be interpreted with caution if applied on Dutch girls with the Dutch nationality. Furthermore, the Youth Self Report was used, which is a self-report instrument. Therefore, the answers may be
socially desirable and the results may not be representable (Muris, Meesters & Van den Berg, 2002). Finally, the collection of saliva was not always conducted following the strict procedure; some girls ate or fell asleep in between the collecting of the saliva samples. Nonetheless, no notable outliers were detected.
Theoretical and Clinical Implications
This study aimed to discover if basal cortisol levels and internalizing problem behavior are related to externalizing problem behavior in girls. It was found that most of the literature focusing on externalizing problem behavior is based on a boy or mixed sample and just a small amount of literature focused on girls. This study shows that the relations found in all boys or mixed samples are not one-on-one applicable to all girl samples, which is an indication that the gender specific treatment as meant to form with this study is just. On the basis of the outcomes of this study, it is recommended that the existing theories concerning the relation where more internalizing problem behavior relates to more externalizing behavior (e.g. impulsive and irresponsible traits) are adjusted to suit the female population better. In addition, theories with a focus on lower basal cortisol levels should add a focus on higher levels of callous/unemotional traits when concerning girls.
The results provide a new insight in the explanation of specific types of externalizing problem behavior. While impulsive and mainly the irresponsible behavior from the psychopathic aspect is linked with biological causes like heredity or developmental aspects as childhood neglect, a relationship with internalizing problem behavior was found. This implicates that girls showing this type of behavior could be experiencing internalizing problem behavior instead of psychopathy. This means that it is important to examine the causes of externalizing problem behavior.
It was found that there is a strong influence between internalizing and externalizing problem behavior. This is in line with prior research and implies that girls in residential settings should receive treatment for both externalizing and internalizing problems. The finding that internalizing problem behavior has a strong association with impulsive/irresponsible behavior, suggests that effective treatment of internalizing problems might relate to reductions of impulsive and irresponsible behavior. This study pleads for more research and a new focus on the design of specific interventions for girls showing externalizing problem behavior.
Based on this study it seems that lower levels of cortisol are related to specific psychopathic traits. If these results are replicated in larger scale studies, in the future, it might be possible to develop biological screening procedures with the aim to eventually select the
best possible treatment. Further, this study provides a starting point to focus on psychopharmacological treatment for girls with an elevated biological risk.
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