Foundation Child Psychology
HER ROYAL HIGHNESS PRINCESS MARIA-ANNUNCIATA
Mankind owes to the child the best it has to give.
-UN Convention on the Rights of the Child (1989)
The past decade has produced extraordinary advances in understanding the special issues pertaining to abnormal child and adolescent psychology. Today, we have a much better ability to distinguish among different disorders of children and adolescents, which has given rise to increased recognition of poorly understood or under detected problems such as childhood depression and bipolar disorder, teen suicide and substance abuse, eating disorders, disruptive behaviour disorders, autism, learning disorders, and problems stemming from chronic health problems, abuse, and neglect. Similarly, the field is now more aware of the ways children’s and adolescents’ psychological disorders are distinguishable from those of adults, and how important it is to maintain a strong developmental perspective.
In a relatively short time, the study of abnormal child psychology has moved well beyond the individual child and family to consider the roles of community, social, and cultural influences in an integrative and developmentally sensitive manner. Similarly, those of us working in this field are more attuned to the many struggles faced by children and adolescents with psychological disorders and their families, as well as the demands and costs such problems place on the mental health, education, medical, and juvenile justice systems.
We believe that one of the best ways to introduce students to a particular problem of childhood or adolescence is to describe a real child. Clinical descriptions, written in an accessible, engaging fashion, help students understand a child’s problem in context and provide a framework from which to explore the complete nature of the disorder. In each text, we introduce case examples of children and adolescents with disorders from our own clinical files and from those of colleagues. We then refer to these children when describing the course of the disorder, which provides the student with a well-rounded picture of the child or adolescent in the context of his or her family, peers, community, and culture. In addition to clinical case material, we use extracts, quotes, and photos to help the student remain focused on the real challenges faced by children with disorders and their families. First-person accounts and case descriptions enrich the reader’s understanding of the daily lives of children and adolescents with problems and allow for a more realistic portrayal of individual strengths and limitations.
To reflect the expansion of this field, causes and effects of various childhood disorders are explained from an integrative perspective that recognizes biological, psychological, social, and emotional influences and their interdependence. This strategy was further guided by a consideration of developmental processes that shape and are shaped by the expression of each disorder. The broader contexts of family, peers, school, community, culture, and society that affect development are also important considerations for understanding child and adolescent disorders and are a critical feature of the texts.
We use both categorical and dimensional approaches in describing disorders because each method offers unique and important definitions and viewpoints. Each topic area is defined using DSM-IV-TR criteria, accompanied by clinical descriptions, examples, and empirically derived dimensions. The clinical features of each disorder are described in a manner that allows students to gain a firm grasp of the basic dimensions and expression of the disorder across its life span. Since children and adolescents referred for psychological services typically show symptoms that overlap into more than one diagnostic category, each chapter discusses common comorbidities and developmental norms that help inform diagnostic decisions.
To provide balance, we approach each disorder from the perspective of the whole child. Diagnostic criteria, therefore, are accompanied by an added emphasis on the strengths of the individual and on the environmental circumstances that influence the developmental course. Moreover, the developmental course of each disorder is followed from its early beginnings in infancy and childhood through adolescence and into early adulthood, highlighting the special issues pertaining to younger and older age groups and the risk and protective factors affecting developmental pathways. In this regard, we examine developmental continuities and discontinuities and attempt to understand why some children with problems continue to experience difficulties as adolescents and adults, whereas others do not.
The importance of recognizing diversity in understanding and helping children with problems and their families is emphasized throughout. New research continues to inform and increase our understanding of the crucial role that factors such socioeconomic status (SES), gender, sexual orientation, race, ethnicity, and culture play in the identification, expression, prevalence, causes, treatments, and outcomes for child and adolescent problems.
To sharpen our emphasis on these factors, we were fortunate to receive input from Sumru Erkut, PhD of Wellesley College, an expert in diversity and abnormal child development. As a result of Dr Erkut’s input, we examine differences related to SES, gender, race, ethnicity, and culture for each childhood problem under discussion. In addition, we also recognize the importance of studying distinct groups in their own right as a way of understanding the processes associated with specific problems for each gender, ethnic, or cultural group. While emphasizing new knowledge about diversity issues and childhood disorders, we also caution throughout these texts that relatively few studies have examined the attitudes, behaviours, and biological and psychological processes of children and adolescents with mental disorders and problems across different cultures, and we indicate places where this situation is beginning to change.
A distinguishing feature of these texts is its expansion and emphasis on several of the more recent and important areas of developmental psychopathology that do not easily fit into a deficits model or a categorical approach. These problems are sometimes referred to as relationship-based disorders because they illustrate the transactional nature of children’s behaviour in the context of significant relationships. Along with the recognition of the importance of biological dispositions in guiding development and behaviour, we discuss the strong connection between children’s behaviour patterns and the availability of a suitable child-rearing environment. Students are made aware of how children’s overt symptoms can sometimes be adaptive in particular settings or with caregiving relationships that are atypical or abusive, and how traditional diagnostic labels may not be helpful.
Treatment and prevention approaches are integral parts of understanding a particular disorder. Applying knowledge of the clinical features and developmental courses of childhood disorders to benefit children with these problems and their families always intrigue students and helps them make greater sense of the material. Therefore, we emphasize current approaches to treatment and prevention in each chapter, where such information can be tailored to the particular childhood problem. Consistent with the current health system demands for accountability, we discuss best practice guidelines and emphasize interventions for which there is empirical support.
After centuries of silence, misunderstanding, and outright abuse, children’s mental health problems and needs now receive greater attention, which corresponds to society’s recent concern about children’s well-being. Fortunately, today more people like you want to understand and address the needs of children and adolescents. Perhaps you have begun to recognize that children’s mental health problems differ in many ways from those of adults, so you have chosen to take a closer look. Maybe you are planning a career in teaching, counselling, medicine, law, rehabilitation, or psychology-all of which rely somewhat on knowledge of children’s special needs to shape their focus and practice. Whatever your reason is for reading this book, we are pleased to welcome you to an exciting and active field of study, which we believe will expose you to concepts and issues that will have a profound and lasting influence. Children’s mental health issues are becoming relevant to many of us in our current and future roles as professionals, community members, and parents and the needs for trained personnel are increasing.
Let’s begin by considering Georgina’s problems, which raise several fundamental questions that guide our current understanding of children’s psychological disorders. Ask yourself: Does Georgina’s behaviour seem abnormal, or are aspects of her behaviour normal under certain circumstances? How would you describe Georgina’s problem? Is it an emotional problem? A learning problem? A developmental disability? Could something in her environment cause these strange rituals, or is she more likely responding to internal cues we do not know about? Would Georgina’s behaviour be viewed differently if it occurred in a boy or in a child from an African American or Hispanic background? Will she continue to display these behaviours and, if so, what can we do to help?
When seeking assistance or advice, parents often ask questions similar to these about their child’s behaviour, and understandably need to know the probable course and outcome. These questions also exemplify the following issues that research studies in abnormal child psychology seek to address:
• Defining what constitutes normal and abnormal behaviour for children of different ages, sexes, and ethnic and cultural backgrounds
• Identifying the causes and correlates of abnormal child behaviour
• Making predictions about long-term outcomes
• Developing and evaluating methods for treatment and/or prevention
How you choose to describe the problems children show, and what harm or impairments such problems may lead to, is often the first step toward understanding the nature of their problems. Georgina’s symptoms fi t the diagnostic criteria for obsessive-compulsive disorder. This diagnostic label, although far from perfect, tells a great deal about the nature of her disorder, the course it may follow, and the possible treatments.
Georgina’s problems also illustrate important features that distinguish most child and adolescent disorders:
• When adults seek services for children, it often is not clear whose “problem” it is. Children usually enter the mental health system as a result of concerns raised by adults- parents, pediatricians, teachers, or school counselors-and the children themselves may have little choice in the matter. Children do not refer themselves for treatment. This has important implications for how we detect children’s problems and how we respond to them.
• Many children and adolescent problems involve failure to show expected developmental progress. The problem may be transitory, like most types of bedwetting, or it may be an initial indication of more severe problems ahead, as we see in Georgina’s case. Determining the problem requires familiarity with normal, as well as abnormal, development.
• Many problem behaviours shown by children and youths are not entirely abnormal. To some extent, certain problem behaviours are shown by most children and youths. For instance, worrying from time to time about forgetting things or losing track of thoughts is common; Georgina’s behaviour, however, seems to involve more than these normal concerns.
Thus, decisions about what to do also require familiarity with known psychological disorders and troublesome problem behaviours.
• Interventions for children and adolescents often are intended to promote further development, rather than merely to restore a previous level of functioning. Unlike interventions for most adult disorders, the goal for many children is to boost their abilities and skills, not only to eliminate distress.
Before we look at today’s definitions of abnormal behaviour in children and adolescents, it is valuable to discover how society’s interests and approaches to these problems during previous generations have improved the quality of life and mental health of children and youths. Many children, especially those with special needs, fared poorly in the past because they were forced to work as coal miners, field hands, or beggars. Concern for children’s needs, rights, and care require a prominent and consistent social sensitivity and awareness that simply did not exist prior to the 20th century. As you read the following historical synopsis, note how the relatively short history of abnormal child psychology has been strongly influenced by philosophical and societal changes in how adults view and treat children in general.
Counting for Safety
At age 10, Georgina’s strange symptoms had reached the point where her mother needed answers-and fast. Her behaviour first became a concern about 2 years ago, when she started talking about harm befalling herself or her family. Her mothers recalled how Georgina would come home from the third grade and complain that “I need to finish stuff but I can’t seem to,” and “I know I’m going to forget something so I have to keep thinking about it.” Her mother expressed her own frustration and worry: “As early as age 5, I remember Georgina would touch and arrange things a certain way, such as brushing her teeth in a certain sequence. Sometimes I’d notice that she would walk through doorways over and over, and she seemed to need to check and arrange things her way before she could leave a room.” Georgina’s mother had spoken to their family doctor about it back then and was told, “It’s probably a phase she’s going through, like stepping on cracks will break your mother’s back. Ignore it and it’ll stop.”
But it didn’t stop. Georgina developed more elaborate rituals for counting words and objects, primarily in groups of four. She told her mom, “I need to count things out and group them a certain way-only I know the rules how to do it.” When she came to my office, Georgina told me, “When someone says something to me or I read something, I have to count the words in groups of four and then organize these groups into larger and larger groups of four.” She looked at the pile of magazines in my office and the books on my shelf and explained, matter-of-factly, that she was counting and grouping these things while we talked! Georgina was constantly terrified of forgetting a passage or objects or being interrupted. She believed that if she could not complete her counting, some horrible tragedy would befall her parents or herself. Nighttime was the worst, she explained, because “I can’t go to sleep until my counting is complete, and this can take a long time.” (In fact, it took up to several hours, her mother confirmed.) Understandably, her daytime counting rituals had led to a decline in her schoolwork and friendships. Her mother showed me her report cards: Georgina’s grades had gone from above average to near failing in several subjects.