Lecture 22 Childhood Psychopathology: Overview Lecture Outline I. Introduction II. Special Issues A. Development B. Environmental Factors C. The Effects of Labelling D. Child Rights III.Internalizing vs. Externalizing Disorders A. Internalizing Disorders B. Externalizing Disorders IV. Conclusion ------------------------------------------- I. Introduction Up to this point we have been examining psychological disorders that typically affect adults. In the next four lectures, we will look at psychopathology and childhood. Childhood psychopathology is an entire field in its own right, so needless to say our discussion will be brief and woefully incomplete. An entire course could be, and often is, devoted to this topic. Nevertheless, I will attempt to introduce you to some of the key issues involved in the study of child psychopathology, and then we will briefly examine some specific childhood disorders. II. Special Issues As we have discussed with adult psychopathology, defining abnormality is very difficult. The problems in defining and classifying what's abnormal in children is in many respects even more difficult (Gibbs, 1982). Let us look at the case of six-year-old Tommy (Gibbs, 1982): Tommy is having bad dreams, is fearful of dogs, and has wet the bed once a week for the past five weeks. Tommy's mother is worried and brings him to a child guidance clinic. During the evaluation, Tommy expresses fearful and violent fantasies, especially concerning his parents. Tommy is accepted into treatment and is diagnosed with Adjustment Disorder with anxious mood. But, is Tommy an abnormal child?: Are his problems different in kind or intensity from those of other children? Might he quickly outgrow his present symptoms? How do other parents view similar behavior? If untreated, will he grow up to be abnormal? Will treatment help his present symptoms and reduce the likelihood of later problems? How will the experience of being labelled abnormal affect him? A broad perspective, encompassing numerous factors, needs to be taken to fully understand childhood psychopathology. Indeed, the biopsychosocial model is particularly apt here - a model of pathology, if you recall, that calls for such a broad perspective: biological, psychological, and social factors in an overarching, mutually influencing system. Certainly some of these questions could apply to adults as well, but children present special considerations when we look at psychopathology. The study of child psychopathology is complicated by a host of factors that influence problem definition, course, and outcome, as well as treatment (Campbell, 1983). Let us examine some of these issues in more detail. A. Development Perhaps the most important aspect of childhood psychopathology is that it must be viewed in a developmental context. Until relatively recently, theory and classification of child disorders were merely extensions of work with adults (Campbell, 1983). The important and often profound changes that occur in physical and psychological development were often overlooked. 1. Chronological age: At the most basic level, problem definition depends on the age of the child. Behaviors that would be considered abnormal at one age level, might be perfectly appropriate at another age level. For example, bed wetting, inability to read, fear of strangers, anxiety and distress when left alone are certainly problems if they occur in a 12-year-old, but these same behaviors are normal with a 1- or 3-year-old (Campbell, 1983; Gibbs, 1982). 2. Cognitive-developmental level: The child and the adolescent clearly have different cognitive capabilities. Problem solving, the ability to take another person's point of view, self-concept, morality...all these develop through time. For example, some of you are probably familiar with the work of Piaget, the Swiss psychologist who proposed a series of stages that all children go through as their cognitive abilities develop. His theory illustrates how we all move from primitive and very limited abilities in our early years, to increasingly complex and sophisticated abilities as we move through childhood. The point is this: how a particular behavior is perceived, interpreted, and labelled by adults (ie: normal vs abnormal) will depend in large part on the child's level of cognitive development. For example: Parental interpretations of aggressive behavior vary with the age of the child. Aggressive behavior in 2- and 3- year-olds is rarely seen as a problem requiring treatment. This is because it is largely understood that at this age, the child does not "mean" to hurt another person. S/he has not reached the stage of cognitive development that permits him/her to take the perspective of another person. Thus, s/he is not able to connect his/her behavior with the inflicting of pain. Aggression at this age is frequently over possession of a toy, reflecting the ego-centric ("self-oriented") nature of their cognitive processes. The egocentrism/lack of perspective taking which is normal at this age leads adults to see such behaviors as less problematic at this age level (Campbell, 1983). Indeed, many "problems", especially those of the first few years of life, are often transitory: as the child matures, the problems will fade away. At a later age, say 8 years-old, similar behavior would begin to become a concern. At this stage of development, although still largely egocentric, the child's cognitive abilities are increasing: s/he is able to use and understand language to a much greater degree, symbolic thought increases, s/he is able to follow rules to a certain extent...all of which suggests the child's ability to "think about what they are doing". Parents will no longer overlook aggressive behavior; they will try to teach their child "proper" behavior. Excessive aggressive behavior may lead to a referral for treatment of some sort. At an even older age level, say 13 years, these same aggressive behaviors would be considerable cause for concern. In addition to treatment, the juvenile legal system may begin to be involved. At this age, the adolescent is at a developmental level where it is expected that s/he can take another person's point of view, that s/he can fully think about his/her own actions and their outcomes. 3. Prognostic implications: Factors such as age and cognitive level determine, in part, whether or not a particular behavior problem spells trouble for the future. Although the child may be having difficulties presently, does that mean s/he will continue to have problems? Diagnosing a child implies stability, which, as we have seen, may not be warranted. Many of the problems seen in childhood have "little if any predictive value for adult functioning" (Harris, 1979, p.45). The question then is at what point does a problem behavior become a legitimate target for inclusion in a diagnostic system (Harris, 1979). B. Environmental factors: Children are dependent on others. This fact has important implications in our analysis of psychopathology. 1. Stability: Children's behavior is much less stable than adults' behavior, because it is more responsive to environmental changes and manipulations (Gibbs, 1982). A child's behavior can vary dramatically from one situation to another. What the adults are doing in the child's environment, and simply which adults are present, can have a profound impact on the child's behavior. For example: the problem may occur only in the presence of certain people (an overly permissive parent). Therefore, it may be as important to assess the child's environment as it is to assess the child's "problem". 2. Referral: Children are rarely self-referred: their parents or other adults decide the child needs help and seeks it out. The first task of a clinician working with children is to determine whether or not a problem actually exists. Intolerance, ignorance, and misconceptions on the part of the adult may be the reason for the referral (Campbell, 1983). Indeed, parents' referral of their child may be more a factor of their own emotional state (Shepherd, Oppenheim & Mitchell, 1971). Other problems in referral is that certain behaviors may be overlooked. Parents, teachers, and other adults who refer a child for help, may underidentify children with certain disturbances because those disturbances are less salient or troublesome to them (Knopf, 1984). For example: the child who withdraws from social contact will not be as salient as the child who disrupts class, and so may not be identified as needing help. 3. Locus of Problem: This leads us to the question "Whose Problem Is It?" For example, the child's dependency means s/he is more likely to be scapegoated by other family members as the cause of problems within the family (Gibbs, 1982). In reality, then, the problem may not be the child's per se. There are various ways of conceptualizing "the problem": - Child-centered: The problem is the child's; there is something wrong with him/her. - Dyadic model: The problem is in the nature of the child's interaction with another person (eg: father). Various interaction patterns may be leading to problems for the child (Gordon & Davidson, 1981). A common faulty interaction pattern is the overreliance on coercion by a parent as a child management technique. Nevertheless, relationships tend to be reciprocal: behavior by one person tends to be reciprocated by the other (Patterson & Reid, 1970). And so, coercion begets coercion. - Psychological well-being of parents: Other problems may lie beyond the overt dyadic interaction, and have more to do with the cognitive and emotional problems other family members are having (Gordon & Davidson, 1981). For example: - the mother may feel guilty about having a retarded son, and this adversely effects how she treats all her children. - the father may be angry at having a child, perhaps unplanned for. - parental psychopathology can effect the child's behavior. In other words, the problem may have to do with the psychological well-being of each parent. - Family Systems model: Other problems experienced by the child may actually represent conflict and other difficulties elsewhere in the family, usually the marital relationship (Gordon & Davidson, 1981). For example: the parents may be angry at each other, but they take it out on the child. In a sense, the child's problems may actually be a "symptom" of distress elsewhere in the family. C. The Effects of Labelling: Given the dependent nature of children, and (especially for younger children) the fact that they are not really able to "speak for themselves" as it were, labelling a child with a diagnosis can have a profound impact on him/her; perhaps more so than with adults who are labelled (Weiner, 1982). Labelling can lead to stigma/prejudice/discrimination exaggerate the severity of the child's problem exaggerate the stability of the problem ignore environmental influences lead others to have negative expectations regarding the child (and so they treat the child accordingly...insuring a self- fulfilling prophecy, perhaps) D. Child Rights: Adults at least can speak out, and be heard. Adults have advocates, they have regulations and laws, all of which protect their basic rights. In addition, adults have the ability to self-refer: that is, an adult (not all adults, its true) knows when s/he is having a problem. Children, as we've seen often do not have this ability. Until recently, children have had very few advocates or laws etc that will protect their rights. Because children (especially young children) may not have the ability to know that they are having problems or that they need help or what help is available, we as adults have an important ethical responsibility: to identify those children who need help. But, as we've seen, there are numerous factors which makes this quite difficult to do. In addition, there are numerous beliefs in our society that make it very difficult for a third-party to "intrude" into the life of a child and his/her family (see Handout 22-1). III. Internalizing vs Externalizing disorders Although certain problem behaviors often diminish with time, children who show multiple problems seem to be truly at risk for long- term problems. In general, clusters of problem behaviors are more indicative of psychopathology than are single behaviors (Mash & Terdal, 1981). Numerous researchers have found that children with multiple problems have problems that cluster into at least two general groups (see Achenbach, 1982): A. Internalizing Disorders Certain problems appear to be related to problems "within the self", such as fears, physical complaints, worrying, shyness (Handout 22-2). Historically, these types of disorders were termed the "neuroses". They have also been called "overcontrolled", overinhibited" and "shy-anxious" problems (Achenbach, 1982). Children with these types of disorders seem to deal with problems internally, rather than acting them out in the environment. Internalizing disorders usually cause more distress to a child than do the externalizing disorders, although this is not always the case (Wicks-Nelson & Israel, 1984) B. Externalizing Disorders The other cluster of problem behaviors is characterized by behaviors directed outward, typically toward other people. Examples include disobedience, aggression, delinquency, temper tantrums, and overactivity (Handout 22-2 lists additional examples of this class of behaviors). These type of behaviors typically involve conflict with other people. Not surprisingly, this class of behaviors has also been called "conduct disorder", "undercontrolled", and simply "aggressive". IV. Conclusion In the next few lectures, we will examine some examples of internalizing and externalizing disorders, as defined in the DSM-III-R. It will be important to keep in mind during our discussions the complexities involved in dealing with childhood psychopathology. As we continue on with this topic, and as you read the chapter in your text, keep in mind a number of questions: How are these disorders unique compared to the adult disorders we have been discussing? How is our study of these disorders affected by the special issues we have discussed today? What implications do these issues have for treatment?