Developmental Considerations In Clinical Child Psychology

September 5, 2006 PSYC 4930

Introduction

From Wenar & Kerig (2000) p. 2 “You are a clinical child psychologist conducting an initial interview with a mother who has brought her daughter into a child guidance clinic. “She has always been a sensitive child and a loner, but I thought she was getting along all right except that recently she has started having some really strange ideas. The other day we were driving on the highway to town, and she said, “I could make all these cars wreck if I just raised my hand.” I thought she was joking but

Introduction

She had a serious expression on her face and wasn’t even looking at me. Another time she wanted to go outside when the weather was bad, and she got furious at me because I didn’t make it stop raining. And now she’s started pleading and pleading with me every night to look in on her after she has gone to sleep to be sure her leg isn’t hanging over the side of the bed. She says there is some kind of crab creature in the dark waiting to grab her if her food touches the floor.

Introduction

What worries me is that she believes all these things can really happen. I don’t know if she’s crazy or watching too much T.V. or what’s going on.”

What is the first question you would ask?

Psychopathology is . . .

 “clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (DSM-IV-TR)  AKA, a mental disorder

Relevance of Development to Understanding Child Psychopathology

   We can only understand abnormal behavior with reference to normal behavior Child Psychopathology: “Normal development gone awry” (Wenar, 1982) Development can go awry in a variety of ways:   

Fixation

(Arrest of development at a particular stage)

Regression

(return to an earlier stage)

Failure to Develop

 

Exaggerated Behavior

(e.g., affect

Qualitatively Different Behaviors

What is Developmental Psychopathology?

 Sroufe & Rutter (1984)  The study of the origins and course of individual patterns of behavioral manifestation, whatever the age of onset, whatever the causes, whatever the transformations in behavioral manifestations, and however complex the course of the developmental pattern may be”  “the study of developmental processes that contribute to, or protect against, psychopathology” (Werner & Kerig, 2000)

Developmental Psychopathology

 Attempts to integrate what we know about normal development:  Cognitive development  Emotional development  Biological development  Moral development  In order to understand how they may contribute to psychopathology

Developmental Psychopathology: Key Concepts

 Organizational  Not linked to one theoretical orientation  Emphasizes the interaction between different developmental domains (i.e., motor, language, social)  Stage oriented  Tasks at each developmental stage must be confronted and mastered in adaptive or maladaptive ways

Developmental Psychopathology: Key Concepts

 Probablistic NOT deterministic  The likelihood of poor adjustment may increase, but psychopathology is not predetermined  Other factors may intervene  Normal-Abnormal Continuum  Psychopathology can be normal development gone awry  Not a disease process but a deviation from healthy development

Developmental Psychopathology: Key Concepts

 Risk and Resilience  Risk: any condition or circumstance that increases the likelihood that psychopathology will develop (e.g., biological factors, genetics, psychosocial factors)  Resilience: factors prevent/protect a child from psychopathology, despite the presence of risk factors (intelligence, family support)

Types of Biological Risk Factors

 Among the biological factors that can place the child at risk for later problems are factors operating before, during or after birth  E.g., neuronal migration problem, umbilical cord wrapped around neck, infection/high fever  In assessing children it is important to obtain information about any of these factors that may have contributed to the child’s presenting difficulties

Biological Risk Factors

 Age of the Mother  Poor Prenatal Nutrition  Maternal Use of Alcohol  Maternal Use of Tobacco  Use of Other Drugs  Prenatal and Postnatal Illnesses  Pregnancy and Birth Complications  Genetic Factors

Age of Mother

 

Research suggest that pregnancies in either very young or much older women are at greater risk for various types of complication One major risk factor with age is Down’s syndrome;



Rates vary with maternal age (Below 30 = 1 in 1,500; age 40 – 44 = 1 in 130; Over 45 = 1 in 65 births).



Optimal age for minimal complications seems to be between 23 and 28

Poor Maternal Nutrition

 Poor nutrition prior to and during the pregnancy can result in a range of developmental delays as well as specific types of physical conditions.

 For example, it has been estimated that the standard 400 mg dosage of Folic acid that comes in most daily vitamins is capable of reducing the rates of spina bifida by a full 50%

Maternal Alcohol Use

     Heavy alcohol use by the mother during pregnancy can result in Fetal Alcohol Syndrome (FAS) Over 40% of women who drink heavily with have children with FAS (but not all) FAS results in developmental delays, growth retardation, facial dysmorphisms, learning disabilities, behavioral disorders, cognitive impairments Lower levels of alcohol intake during pregnancy can also lead to significant development delays No “safe” level of alcohol intake in pregnancy has been determined

Maternal Tobacco Use

    Can result in premature birth and associated low birth weight, miscarriages, and subtle developmental delays There are also data to suggest that heavy smoking may relate to later risk for both cancer and conduct disorder in the child Several, but not all, studies have found a significant association between smoking during pregnancy and ADHD There is also some evidence that paternal as well as maternal smoking can have effects of the child

Other drug use during pregnancy

 Children born to mothers who use narcotics can be born addicted  Children of drug abusing mothers often show developmental delays, problems with emotional regulation, and problems with attention and activity level  In such cases there are often problems in the quality in early mother-child interaction patterns  Drug effects are often confounded by living in an environment where drug abuse is common, as well as genetic predispositions.

Pre or Postnatal Illnesses and Injuries

    Viral illnesses like Rubella during the first trimester can result in a range of problems including deafness, heart problems, cleft palate, and mental retardation.

Congenital Rubella has also been shown to significantly increase the rates of infantile autism.

Head injuries and childhood illnesses with high fevers have also been show to relate to learning problems, developmental delays and ADHD.

It has also been suggested that early strep infections can also be associated with OCD like features or tic disorders in children ( P.A.N.D.A.S. – Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections)

Pregnancy and Birth Complications

 A variety of pregnancy and birth complications (e.g., anoxia, prematurity, toxemia, low birth weight, meconium aspiration) have been found to be associated with a wide range of childhood problems  General developmental delays  Speech and language problems  School difficulties  Attention-Deficit/Hyperactivity Disorder (ADHD)

Genetic Factors

 Disorders with significant genetic loadings include Autism, ADHD, Tourette’s, Schizophrenia, and Bipolar disorder  Genetics may interact with environmental factors  The significant role of genetic contributions to childhood disorders makes it necessary to thoroughly assess family history of mental illness when conducting interviews with parents

Biological Risk/Resilience



Childhood temperament

can be thought in terms of inborn individual differences in

behavioral style

that are reflected in the child’s interaction with his/her environment.

 A child’s temperament makeup can make him or her either easy or difficult to parent.

Childhood Temperament

      Temperament refers to basic dimensions of personality that are grounded in biology Thomas and Chess (1968) conducted the New York Longitudinal Study Attempted to delineate individual differences in the behavioral style of infants and young children Studied 141 children from infancy through adolescence Found 9 dimensions of temperament that differentiated children as young as 2 - 3 months of age These were assumed to reflect biologically based individual differences in temperament

9 Temperament Dimensions in New York Longitudinal Study Model

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2.

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7.

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9.

Rhythmicity

 Degree of regularity of repetitive biological functions, sleeping, waking, feeding, elimination

Approach-Withdrawal

 Nature of initial response to a new stimulus, such as new food, toys, people

Adaptability

 Sequential course of the child’s responses to new stimuli or altered situations

Intensity of Response

 Energy level of response

Quality of Mood

 Amount of pleasant, joyful, friendly behavior as contrasted with unpleasant, crying, unfriendly behavior

Activity Level

 Level, tempo, and frequency of motor functioning

Distractibility

 Effectiveness of extraneous environmental stimuli in interfering with or altering the direction of ongoing behavior

Persistence

 Continuation of an activity in the face of obstacles to its continuation and length of time an activity is pursued

Threshold of Responsiveness

 Level of extrinsic stimulation necessary to evoke a noticeable response, regardless of the nature of the response  “Difficult” infants are harder to parent, and are at increased risk for future behavior problems

Temperament Dimensions

   Easy vs. Difficult Temperament 1.

Five distinguishing dimensions: Difficult temp.

Rhythmicity (irregularity of biological functions) 2.

3.

4.

5.

Approach-Withdrawal (withdrawal from novel stimuli) Adaptability (slow adaptation) Mood (negative mood) Intensity of Response (high intensity)  Slow-to-Warm-Up Low activity, tendency to withdraw, and slow to adapt; may show negative mood but with low intensity

Temperament Dimensions

 Distributions of temperament in children:  More Easy than Difficult Children  In the 141 children in the New York Longitudinal Study (

NYLS

)  10% Difficult Temperament  30% Easy Temperament  15% Slow-to-Warm-Up Temperament

Temperament as a Risk Factor



Relationship to adjustment problems:



70% of difficult temperament children in the NYL study developed behavior problems in adolescence

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Only 18% of easy children developed problems in adolescence

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Follow-up into adulthood documented a significant relationship between temperament at age 3-5 and adult psychiatric disorder

 Still dimensions of temperament are subject to change with maturation, environment, and experience

Temperament: Goodness-of-Fit

   “The greatest contribution of the NYLS was the emphasis on "goodness of fit," that is, that the temperament of the child alone was not the most important consideration in the child's growth and development, but the extent to which that temperament fit with the values, expectations, and style of the child's family.” (Doreen Arcus, Ph.D. University of Massachusetts Lowell) The Concept of Goodness-of-Fit:  “the meshing between the child’s temperament style and the demands the environment places on the child” Clinical Child Psychologists: Intervening with children with difficult temperaments

Psychosocial Risk Factors

 Effects of Cumulative Life Stress  Effects of Divorce  Marital Violence  Physical Abuse  Sexual Abuse  Parenting Style

Cumulative Life Stress

 Experiencing numerous life changes within a restricted period of time has been found to be associated with a range of child health and adjustment problems:  Anxiety  Depression  Drug Use  Recurrent Abdominal Pain  Poor health status for children with diabetes  General Problems with Health and Adjustment

Cumulative Life Stress

   There is also evidence that high levels of stress in expectant mothers can impact offspring Animal Studies – Stressed rats have longer pregnancies and more spontaneous abortions.

Expectant mother’s show links between life stress and pregnancy and birth complications  There is also some evidence to suggest links between stress during pregnancy and the development of difficult temperament and delays in motor and mental development

Divorce

   Divorce is not a single event A range of associated stressors/transitions can impact the child:     Changes in Residence Changes in School Loss of Friends Possible Separation From One Parent    Possible Economic Hardships Continued Parental Conflict Possible Remarriage and new Step-family All of these can serve as significant risk factors that can impact the child in multiple ways

Divorce: Short Term Effects

 Short term effects usually take the form of Emotional Problems and Behavioral Difficulties  This may elicit anger and possibly guilt  Also, many of the rules that have previously served to control the child’s behavior may have been disrupted

Divorce: Long Term Effects

 Wallerstein notes that, as children grow older, they often continue to view their parents divorce as the single most formative experience in their lives, with major divorce-related issues arising as they approach adulthood.

 Divorce, which involves a major falling apart of the prototypic relationship of the child’s early life can have negative and pervasive effects that may affect the child’s view of relationships and the world

Domestic Violence

 Observing violence between parents can have a significant impact on the child and his/her behavior:  Increase overall adjustment problems  Increase anxiety, depression and other internalizing problems such as fearfulness and insecurity  Children who have been abused themselves show:  Increased levels of aggression  Greater willingness to use violence as a means of resolving conflict themselves

Effects of Child Abuse

 Effects can include:  Impaired self esteem  Decreased empathy  Anxiety and depression  Aggressive behavior  Post-Traumatic Stress Disorder (PTSD)  Abuse, like divorce, can also impact on the child’s general view of relationships and of the world

Sexual Abuse Statistics

 1/4 to 1/3 of females and 1/10 of males experience sexual abuse of some type before adulthood  Most common age is between 8 and 12  Perpetrators most often males  Seldom an isolated occurrence

Effects of Sexual Abuse

 Some evidence that younger children have more internalizing problems while older children have more externalizing problems  Findings suggest that 40-60% of sexually abused children show evidence of emotional/behavioral disturbance with around 15-20 % displaying severe disturbance

Effects of Sexual Abuse

 Common Responses to Sexual Abuse Include:  Anger and hostility  Guilt and depression  Physical and somatic complaints  Problems in school and social functioning  Effects on sexuality  Highly sexualized behaviors  Fearful/inhibited behaviors

Effects of Sexual Abuse

 Without treatment, effects often continue into adulthood  Studies have suggested that:  One-half of women requesting therapy in outpatient crisis centers and over two-thirds of women seen in psychiatric emergency rooms have been sexually abused  Diagnoses of delayed PTSD are not uncommon  Affects future social relationships and influences how the person deals with issues of trust and both physical and emotional intimacy

Parenting Style: Risk or Resilience?

   Baumrind (1991)   Two parenting dimensions: Warmth/support Control/structure 1.

Four parenting styles: Authoritarian “Do what I say because I say so”  High on structure, Low on warmth  Can lead to aggression, low self-esteem

Parenting Style: Risk or Resilience?

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3.

4.

  Permissive/Indulgent Parent: Low on structure, High on warmth May lead to dependent, irresponsible child   Neglectful Parent: Low on structure, Low on warmth May lead to antisocial behavior    Authoritative Parent: High on structure (firm & consistent) High on warmth May lead to self-reliant, secure child

Parenting Style: Risk or Resilience?

 Using Baumrind’s system, research has found that:  Adolescents with authoritative parents faired best, those with neglectful parents faired worst  Adolescents with authoritarian parents were doing well in school and avoiding problem behaviors, but had poor self-concepts  Those with permissive parents perceived themselves positively, but engaged in misconduct and performed poorly in school  These findings may not apply to ethnically diverse samples

Risk Factors: The Big Picture

 The presence of one or more risk factors does not always lead to child psychopathology  Biological, genetic, psychosocial, and other factors can also promote resilience, which may help a child overcome risk factors  Intelligence  Easy temperament  Authoritative parents  Social support  Self-esteem

Developmental Considerations: “Normal Problems”

 The difficult infant  The defiant toddler  The aggressive or withdrawn preschooler  The oppositional adolescent  The overly dramatic/impulsive youth  The egocentric teenager

Developmental Course of Psychopathology

 Psychopathology may present differently depending on the age of the child:  ADHD –hyperactivity  Conduct Disorder —delinquent behaviors  Depression —withdrawal, somatic complaints, irritability vs. hypersomnia, depressed mood  Phobias —may be transient in children

Other issues before we continue . .

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A note on terminology as: —in recent years the trend has been to discontinue the use of phrases such    Autistic child Depressed teenager Schizophrenic It is thought that this terminology does not consider the individual, but only defines them by their mental disorder Thus, it is more accepted to use:    Child with autism Teenager with depression Patient with schizophrenia

The DSM

 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR)  the system of classification of mental disorders used by most psychologists  First published in 1952  Early editions were strongly influenced by psychoanalytic theories: “Phobias are generally attributed to fears displaced to the phobic object or situation from some other object of which the patient is unaware” (APA, 1968, p. 60)

The DSM

 Beginning with the DSM-III (1980), the diagnostic categories were:  Atheoretical  Based upon explicit criteria (e.g., certain number of criteria must be met)  The Multiaxial system was also introduced

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II.

III.

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V.

The DSM: Multiaxial System

Clinical Syndromes Personality Disorders and Mental Retardation General Medical Conditions Psychosocial and Environmental Problems Global Assessment of Functioning

The DSM

 Strengths:  Systematic classification is good for patients and helps with insurance reimbursement  Allows for well-controlled research and the integration of this research into clinical practice  Multiaxial system emphasizes importance of other factors (e.g., physical symptoms, situational factors)  Can help guide treatment

The DSM

 Weaknesses:  Categories do not always reflect scientific research, but sometimes social mores:  Homosexuality was a mental disorder in DSM-I and II, and III (if it caused “marked distress)   Premenstrual Dysphoric Disorder (DSM-IV) Negative social stigma – Danger of Labels  Poor reliability??

 Evolving and Not Definitive  DSM-IV – 1994 – In current use