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?