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?