Brief Lecture Notes for Unit 12
Revised as of 04/29/02
There are at least five compelling reasons for paying special attention to childhood disorders and child psychopathology:
1. The level of social responsibility that adults (not only parents and other caregivers, but society as a whole) have to care for children, on the assumption that they cannot care for themselves in the same manner that adults do (and are legally unable to enter into contractual relationships to seek care).
2. The presumably heightened vulnerability of children. For various reasons (see below) children are presumed to be more susceptible than adults to negative external influences that might be traumatic or pathology-inducing. (The high prevalence rate for all pathologies combined among the child population -- about 15% -- bears that out.) However, paradoxically, children are also likely more resilient than adults: more prone to short-term problems, but more likely to spontaneously recover from them: see below for why. Also see later in this unit for more information about the now trendy concept of resilience and the enhancement of resilience.
3. The notion that prevention (not after-the-fact cure or amelioration) should be the focus of any rational mental health intervention system. The earlier that adjustment difficulties can be identified and addressed, the better the chances (it can be presumed) that serious, intractable problems can be avoided.
4. The hope that our understanding of the etiology of pathology can be heightened by studying "simpler" forms of clinical phenomena such as might be encountered in children.
5. The high likelihood that childhood disorders are unique (categorically different from adult disorders) and thus require special attention and treatment in their own right. (Note that, in general, arguments #4 and #5 are opposite; it is difficult to see how both can be true.)
While the study of childhood pathology is important, it's also very difficult (as compared to the corresponding situation with adults) to make clear, consistent, reliable diagnoses. There are at least five reasons why:
1. The existence of self-report deficits (or obstacles) in children: either literal (lack of self-expressive or linguistic capabilities) or motivational (unwillingness to disclose directly to adults).
2. The thorny question of whether the "real patient" (appropriate unit of analysis) is the child her/himself, or the family system of which the child is a part.
3. The impact of the timetable of development: since what is "normal" is age-dependent, the same behavior could be evidence of pathology at one age but not at another.
4. The high probability of spontaneous remission (or spontaneous recovery) in children: most troublesome child behaviors are self-limiting or self-correcting, but some are not, so where do we draw the line?
5. The greater degree of situational specificity in child versus adult behavior: a child may exhibit a problem behavior (for instance) at home but not in school, or vice versa.
The vulnerability-resilience paradox
It often strikes students as paradoxical that children are both more vulnerable to external stresses (more likely to develop mental or emotional problems than adults) and more resilient (more likely to recover quickly from such problems). Here's a set of possible reasons why.
Five reasons why children may be more vulnerable:
1. Children's limited time horizon, meaning that because children live more "in the moment" than most adults do, when the present is black, it seems as if the child's whole world has caved in (where many adults can gain perspective by comparing a bleak present to a happy past and to prospects for future improvement, or can remind themselves that "this too shall pass").
2. Children's limited life experience (hence fewer opportunities to learn a "smorgasbord" of coping strategies). Obviously, the more coping strategies one has with which to handle life's stresses, the better.
3. Children's lesser cognitive capacity, which means that they are likely to run out of rational coping strategies sooner.
4. Children's lesser ego strength, not necessarily related to #2 or #3 above (intelligence and ego strength are only very slightly correlated), meaning that children are likely to be "swamped" or "overwhelmed" sooner or by less intense stressors.
5. Children's lesser social power, meaning that they have less of an ability to chart their own course in life, and must rely on others who may or may not be doing their job of serving as caretakers. In general, if we assume a positive correlation between autonomy/efficacy and self-esteem, children may feel frustrated, depressed, or inferior because they aren't allowed to make enough of their "own decisions" -- or so the argument runs.
Five reasons why children may be more resilient:
1. Children's limited time horizon -- hey, wait a minute, didn't we see this one on the previous list! Yes, but paradoxically, it has an upside: when the crisis is past, to a child who lives in the present, it's truly past... more likely to leave no residual effects in its wake. Adults, in contrast, are more prone to brood about the past or obsess about the future. Having a wider time horizon as adults do is a two-edged sword... it helps when times are tough, but may hurt when times are good.
2. Children's ability to depend on others (because society legitimates that), though a liability when the others don't do their job, is certainly an asset when they do... children don't have to pretend that they can be completely self-reliant, as adults (especially males) in our society are often taught they must do.
3. Children's ability to be openly expressive of feelings and emotions (because society legitimates that). Since emotional honesty and the freedom to "vent" are correlated with mental health, it's no surprise that children have an advantage over adults who often must "put on a happy face" or "keep a stiff upper lip" in the face of difficulty.
4. The relatively fewer pressures that children face may mean that their lives are actually easier than those of adults, though this could certainly be debated. At least during "overprotective" social eras, this is likely to be so for many children.
5. A greater degree of neurological plasticity, meaning that the brain can physically recover from stress or trauma, or that alternate brain pathways can be found; the adult brain is much less able to do these things.
While we're at it, what exactly is "resilience"?
Resilience
can be defined as the ability to make the best of changing conditions…
to bounce back after a defeat, loss, or setback… to survive tough times rather
than being overcome by them. It
means knowing how to cope with problems and difficulties, and how to turn them
into opportunities.
In
the adult world, for instance, studies indicate that resilience is one of the
best predictors of an employee’s capacity to be an effective contributor
and to add value to an organization. In
one study, 2/3 of all new hires failed within 2 years due to the lack of
resilience. Some of those failures
were obvious and outward (the employee was terminated or chose to leave the
organization to avoid termination). Others
were more subtle (lessened productivity, negative impact on employee morale,
resistance to change, cultivation of an entitlement mentality).
Resilience
is a cluster of skills, not one single capability.
In general, resilient individuals demonstrate:
Willingness
to take responsibility
for themselves, rather than blaming others or passing the buck
A
perception that problems are opportunities
rather than obstacles; “possibility
thinking”
Optimism
and trust regarding themselves, others, and circumstances
Solution-focused
thinking as opposed to
catastrophizing, worrying, or panic
A
“lifelong learning” orientation
that includes mental curiosity and a thirst for knowledge
Social
competence including a
recognition that others have value and that no one can make it alone
Resilience isn’t an all-or-nothing phenomenon.
It is a set of learnable skills and attitudes.
All of us can begin where we are to enhance our resilience and to help
those around us to do the same. (If
you recognize a lack of resilience in yourself, that’s an opportunity for
growth in disguise!)
Much recent research (too extensive to summarize here) has been exploring the question of how resilience in children can be enhanced through educational and family intervention initiatives.
Other paradoxes of childhood disorders
1. The continuity hypothesis
PSY 309 students know (or should know!) that the main theme of the course is the continuity hypothesis: that there is no clear-cut dividing line between normality and abnormality, but a continuous range of levels of adjustment that gradually blends into clinical syndromes. And, of course, PSY 360 students know (or should know!) that the main theme of the course is the seamless nature of human development: that (despite the existence of qualitatively different stages of development) the child is the father of the man (or the mother of the woman), that continuity as well as change mark the development of the human person and personality. Thus, the study of childhood pathology should suggest continuity of two sorts (normal -> abnormal and child -> adult) at the same time.
But in fact it's difficult in many cases to see the continuity exhibited in the childhood disorders. Many of them, as we'll see, have few adult parallels. It can be a challenge to find credible evidence of the kind of continuity we need and expect to find. (Look for these issues below.)
2. Axis I or Axis II?
As PSY 309 students know, the traditional (DSM-IV) classification system attempts to divide all clinical syndromes into either Axis I (acute, later onset, more specific, more disruptive) or Axis II (chronic, earlier onset, more general, less disruptive). We've previously studied the personality disorders as classic illustrations of the Axis II concept. But when we get to the childhood disorders proper (as opposed to adult Axis II conditions that, by definition, probably had their origin in early childhood), do they belong on Axis I or Axis II? If we look at their time of origin (obviously, by definition, "early" or in childhood), they appear clearly to fit Axis II. But if we look at other features, they fit Axis I. What's a diagnostician to do?
DSM-IV puts most (but, annoyingly, not quite all) childhood disorders on Axis I on the grounds of their acute, specific, disruptive nature. But this is far from an obvious choice, especially since some childhood disorders appear to lead, in adulthood, not to an adult Axis I disorder as one might expect, but to an Axis II condition! For instance, unresolved oppositional defiant disorder (Axis I) in a child might become or lead to antisocial personality disorder (Axis II) in an adult! This makes little sense.
An overview of representative disorders
It's not my intention to exhaustively cover all the childhood disorders, but we will be taking a look at the classification schema used today, as well as representative examples of disorders that fall into each category. Classifying childhood disorders is difficult, but the current schema divides them into four general categories or clusters:
1. Conduct or disruptive behavioral disorders (e.g., attention deficit disorder, oppositional defiant disorder) that are characterized by hostility, aggression, acting out, or deficits in impulse control; these are "undercontrolled" disorders
2. Emotional disorders (e.g., school phobia, anaclitic depression) that are characterized by negative affective states (anxiety, sadness, insecurity); these are "overcontrolled" disorders
3. Habit disorders (e.g., enuresis, eating disorders) include a rather wide range of repetitive maladaptive or dysfunctional behaviors directed more toward the self than toward others
4. Developmental disorders (e.g., autism, learning disorders) involve generalized or specific deficiencies in the normal acquisition of cognitive or socio-relational skills
This fourfold division is imperfect. Some disorders do not clearly fit into only one category; the third category is particularly vague and broad, tending to serve as a "catchall" or "default" category for disorders not easily classified elsewhere. But it's the standard system in use today.
Some important comparisons and contrasts can be made using categories 1 and 2 specifically. First, category 1 is highly predictive of adult pathology (only 17% of a group of children diagnosed with a category 1 disorder were later, in a longitudinal study, symptom-free as adults) while category 2 is not. (Can you think of reasons why this might be so?) Because of the oppositional (over- vs. undercontrolled) nature of behaviors in these two categories, it's unlikely that a child would fall into both categories, suggesting two different developmental pathways. Adult parallels of category 1 and 2 disorders are common, while there are few if any adult parallels to category 3 and 4 disorders. Hence the latter categories may be more likely thought of as conditions specific to childhood.
An example of a disruptive disorder: ADHD
This is the most frequently diagnosed disruptive disorder and actually involves two major variants (the primarily "inattentive" type vs. the primarily "impulsive" type), with of course a combined or catchall category in between. ADHD has been a highly controversial diagnostic category for 20 years or more. At one time (early 1980's) many clinicians were skeptical about whether the disorder really existed at all! Today few would take that view, but some still think the diagnosis is overused.
Inattentiveness (or difficulties in mentally focusing, particularly as evidenced by increased difficulty when direct efforts to focus are made), weak impulse control, hyperactivity, disruptive (though not combative or hostile) behavior, and difficulties with follow-through are signal symptoms. While ADHD is not itself a learning disorder or learning disability, some 20% of ADHD children also have a learning disability; this high a degree of comorbidity suggests a neurological link between the two kinds of conditions (probably related to prefrontal cortex underactivity as discussed earlier in class). The fact that (paradoxically to some) the use of stimulant drugs such as Ritalin improves functioning in some 80% of ADHD children also suggests the correctness of this general model. (However, the sixfold increase in the use of these drugs over the past five years may well be cause for some concern and skepticism; are we "drugging" some normal children in a sort of psychiatric overreach?) Also, the fact that ADHD is much more likely (5 to 6 times more likely) with boys than girls may suggest a fundamental biochemical link (remember earlier discussions of sex-linked traits as related to gender differences in vulnerability).
Behavioral and cognitive treatments for ADHD do exist and should not be neglected. Behavioral approaches are straightforward and involve the direct rewarding of non-hyperactive behaviors along with the extinction of hyperactive ones. Cognitive approaches involve the use of cognitive models to coach children about how to use metacognitive strategies to check their impulsivity and to better maintain mental focus.
An example of an emotional disorder: Separation anxiety disorder
This disorder is defined in terms of excessive need for contact with a primary attachment figure. (PSY 309 students: if you don't know what attachment is, click here.) Since attachment behavior is more or less universal in children around age 1-2, this syndrome only comes into play if the child does not "outgrow" such behavior by age 4. Typical symptoms include clinging, worry about catastrophic events (to self or to the attachment figure) during separation, panic upon separation, nightmares with themes of separation, "wheedling" or other manipulative behavior to prevent separation. The disorder has an approximately 4% prevalence rate and is about twice in common in girls as in boys. Often though not always it is precipitated by a traumatic or quasi-traumatic event (e.g., death of a family member or of a pet, parental separation or divorce).
Treatments vary widely and include desensitization, behavioral modeling, positive reinforcement for independent behavior, and cognitive reframing.
An example of a habit disorder: Anorexia
Anorexia (and its sister illness, bulimia) is almost exclusively a female disorder; 19 of every 20 anorexics are female. About 1% of female Americans have the disorder, a three- or fourfold increase in the prevalence rate over the past four decades.
Defined as self-starvation or extremely restricted food intake for nonmedical reasons in the absence of any objective need for weight loss, anorexia usually involves various specific food aversions, food or eating phobias, and food-oriented rituals or compulsions.
Socioculturally, the demographics of anorexia strongly suggest a link to culturally mediated messages about ideal body image and its relationship to self-worth. The recent increase in the prevalence of the disease almost exactly tracks a change, over the same four decades, in the cultural body ideal for women (in the direction of increasing thinness).
Psychodynamically, there is appreciable evidence that most anorexics come from families that are overinvolved, emotionally restrictive, perfectionistic, and controlling. The disorder may thus have its roots, not only in low self-esteem, but in bids for autonomy/control on the part of the sufferer, who sees in this behavior a way to gain control over an aspect of her life that parents cannot alter, to obtain attention and possibly positive "strokes", and perhaps even to express anger in an indirect (passive-aggressive) manner.
Of course, biochemical changes in the brain as the result of self-starvation lead to cognitive distortions, weakened reality testing, tunnel vision, mental narrowing, behavioral perseveration, and the like, making it all the harder for the anorexic to break out of the destructive cycle.
Family therapy based treatments are for choice, followed by cognitive reframing methods. Recidivism is moderate. Many anorexics who do recover struggle with excess weight afterwards due to changes in the body's "set point".
An example of a developmental disorder: Autism
Among the most serious, yet fortunately most infrequent, of childhood disorders, autism has a vanishingly low incidence rate of 0.04% (1 in every 2,500), and is three times as prevalent in boys than in girls. Defined by a cluster of symptoms that include failure to develop normal social and linguistic responses, it usually is evident by age 3. Symptoms include a lack of interest in or apparent aversion to social stimuli, lack of language development including distortions such as echolalia or echopraxia, OCD-like sterotypies of behavior, and often the presence of savant-like intellectual abilities.
While etiology is debatable, psychodynamic models have largely been discredited in favor of theories that emphasize various forms of brain dysfunction. Treatments usually involve highly structured behavioral and psychoeducational interventions, including controversial ones like "facilitated communication". Outcomes are variable at best, and correlated with the child's overall intellectual capacity.
For PSY 309 students only: If you email me no later than 5/3 correctly identifying Ken Marquard's Big Five profile, you can glean 2 extra credit points. If you don't know who Ken is, you missed out... too bad.
Study Guide Questions
1. State five reasons why psychologists should concern themselves with child psychopathology; five reasons why diagnosis is more difficult with children than with adults.
2. Explain the vulnerability-resilience paradox and offer reasons for each phenomenon.
3. Summarize other paradoxes or dilemmas surrounding child psychopathology as explained in lecture.
4. Explain the fourfold classification system and how it relates to the overcontrolled-undercontrolled dimension. Give a specific example of a disorder in each category and discuss symptomatology, etiology, and treatment.