Assessment and Treatment of Childhood Problems

ASSESSMENT AND TREATMENT OF CHILDHOOD PROBLEMS Second Edition

This page intentionally left blank

ASSESSMENT AND TREATMENT OF CHILDHOOD PROBLEMS A Clinician’s Guide SECOND EDITION

Carolyn S. Schroeder Betty N. Gordon

THE GUILFORD PRESS New York London

© 2002 The Guilford Press A Division of Guilford Publications, Inc. 72 Spring Street, New York, NY 10012 www.guilford.com All rights reserved Except as noted, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number:

9 8 7 6 5 4 3 2 1

LIMITED PHOTOCOPY LICENSE These materials are intended for use only by qualified mental health professionals. The Publisher grants to individual purchasers of this book nonassignable permission to reproduce those figures and appendices for which photocopying permission is specifically provided in a note on the opening page. This license is limited to you, the individual purchaser, for use with your own clients and patients. It does not extend to additional clinicians or practice settings, nor does purchase by an institution constitute a site license. This license does not grant the right to reproduce these materials for resale, redistribution, or any other purposes (including but not limited to books, pamphlets, articles, video- or audiotapes, and handouts or slides for lectures or workshops). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications.

Library of Congress Cataloging-in-Publication Data Schroeder, Carolyn S. Assessment and treatment of childhood problems : a clinician’s guide / Carolyn S. Schroeder, Betty N. Gordon. — 2nd ed. p. cm. Includes bibliographical references and index. ISBN 1-57230-742-0 1. Behavior disorders in children—Diagnosis. 2. Behavior disorders in children—Treatment. I. Gordon, Betty N. II. Title. RJ506.B44 S37 2002 618.92'858—dc21 2002005508

To the children and families with whom we have had the privilege of working over the years and, most especially, to our grandchildren, Zoe Margaret Schroeder, Elise Capen Ederle, and Margaret McBane Gordon, and their parents, whose love, encouragement, and dedicated parenting help ensure the well-being of the next generation

This page intentionally left blank

About the Authors

Carolyn S. Schroeder received her PhD in clinical psychology from the University of Pittsburgh in 1966. She is currently an Adjunct Professor at the University of Kansas, Lawrence. She previously held appointments in the Departments of Pediatrics, Psychiatry, and Psychology at the University of North Carolina at Chapel Hill. Throughout her career she has trained graduate students, interns, and postdoctoral fellows in the assessment and treatment of children and their families. She is widely recognized for the establishment of a model for psychologists’ participation in primary care pediatrics. Her publications reflect her interests in pediatric psychology, service delivery in primary care settings, and the assessment and treatment of children’s behavior problems. Betty N. Gordon received her PhD in developmental and child clinical psychology from the University of Washington, Seattle, in 1978. She is currently Associate Professor Emerita of Psychology at the University of North Carolina at Chapel Hill. She has taught graduate-level courses in child assessment and treatment and undergraduate courses in developmental psychopathology. In association with Chapel Hill Pediatric Psychology, she has been involved clinically in assessment and treatment of children for many years. Her research has focused on children who have been sexually and/or physically abused, with a primary interest in children’s memory for traumatic events.

vii

This page intentionally left blank

Preface

As with the first edition of this book, this second edition of Assessment and Treatment of Childhood Problems is based on our work in a primary health care setting. For almost 28 years our focus has been on enhancing children’s development, preventing problems, and helping parents to manage stressful life events and common but often persistent and troublesome behavior problems. The primary health care setting has provided us with a unique opportunity to follow children as they develop from birth through adulthood. We view this development as a function of the dynamic interaction among the characteristics of the child and the parents, the environment, and chance events, and understand psychopathology to be normal development gone awry. Although we recognize the importance of adolescence, the focus of this book is on the development of children ages 2–12 years and the problems that can occur during these ages. It has been 11 years since the publication of the first edition of this book and much has occurred during the intervening years. Of major importance is the emergence of the field of developmental psychopathology, with its focus on normal development and developmental variations throughout the life span. This interface between developmental psychology and clinical child psychology has greatly enhanced our understanding of when and how things can go wrong for children, and it provides guidance on developing effective preventive as well as assessment and intervention strategies. The advances of biological and genetic science have been enormous, and their influence on behavior and development has received an incredible amount of attention since the first edition was published. Theory and research in these areas have enhanced our understanding of the behavioral symptoms of problems such as depression, anxiety, and disruptive behavior disorders. We have learned, for example, that some behavioral disorders can be chronic and lifelong, thus requiring ongoing or periodic attention to maintain treatment gains. We have tried to reflect these advances in the literature reviews for each problem area, and it is our hope that this book will lead clinicians to a better understanding of the “state of the field” and will help guide them to a more empirically based approach to their work. The importance of a theoretical approach to the work of the child clinician cannot be overstated. Our thinking has been strongly influenced by behavioral, social learning, and cognitive-behavioral theorists. Approaches to assessment and intervention that reflect these orientations are emphasized. For each problem area presented, we have tried to describe treatment methods that are developmentally sensitive and have some documented efficacy for the ix

x

Preface

specific problem in question. The field continues to struggle, however, with how to transfer these treatments to community-based clinics—that is, the real world. Thus, the clinician must be creative in developing intervention strategies that have not been empirically validated for the majority of children with a specific problem but may be effective for an individual child or family. A theoretical aproach to guide the selection and/or development of these strategies is of critical importance. This book reflects the importance of a collaborative relationship between the child, the clinician, and parents in assessing and treating childhood problems. The clinician’s role is multifaceted, including that of educator, advocate, service provider, and case manager. He or she provides expertise based on knowledge of developmental processes and the empirical literature related to children’s problems. Parents, on the other hand, have the primary and ultimate responsibility for their children’s well-being and bring a unique understanding of their child and family. It is through this collaboration with parents that we are often able to change the trajectory of a child’s life, by enhancing parents’ abilities to deal with the tasks of parenting and by enabling them to help their children cope successfully with the stresses of growing up in an imperfect world. In this second edition we have attempted to provide a more complete picture of the problems that can occur between ages 2 and 12 years by adding three new chapters: eating problems, depression, and attention-deficit/hyperactivity disorder. We deleted the chapter on the development of the pediatric psychology practice at Chapel Hill Pediatrics since this information has been published elsewhere (e.g., Schroeder, 1996). The book is organized into three sections, with the first section providing a foundation for understanding specific problem areas and for developing assessment and intervention strategies. Chapter 1 provides an overview of child development with an emphasis on “where things can go wrong” in the developmental process. It also covers factors that can make children more resilient, or cause them to be more vulnerable to life stresses, as well as ways to use this information in the prevention of problems. Chapter 2 focuses on issues of diagnostic classification, prevalence of problems, steps in the assessment process, and treatment issues. The Comprehensive Assessment-to-Intervention System described in this chapter is used throughout the book as the framework by which clinicians can systematically gather the information necessary to understand and intervene in the problem areas covered in later chapters. The second section of the book deals with problems that can occur in childhood: eating problems, toileting problems, habits and tics, sleep difficulties, sexuality and sexual problems, fears and anxieties, depression, disruptive behavior, and attention-deficit/hyperactivity disorder. The final section of the book covers life events that can be sources of considerable stress for many children and parents during the course of growing up: siblings, divorce, and death. For each problem area or stressful event, we provide a brief review of the literature, a guide to comprehensive assessment, specific treatment options, and a case example that illustrates the central features of the problem. Finally, in the appendices we provide descriptions of published assessment instruments as well as a number of clinical forms and rating scales that are not commercially published. Who do we hope will read this book? It is written for all professionals who provide services to children. These include not only child psychologists but also pediatricians, family physicians, child psychiatrists, nurses, social workers, guidance counselors, and trainees in all of these and other health-related fields. We would like to thank the many people at The Guilford Press who helped shepherd this work to a final completion, most especially the production staff. There are many people who by their very presence greatly influenced our work: the parents and children with whom we

Preface

xi

have been fortunate to work and our colleagues at Chapel Hill Pediatrics and the University of North Carolina at Chapel Hill. Our husbands encouraged us to write a second edition and provided support and understanding throughout the process. Finally, our children, Mark and Matthew (CSS), and Sarah and Andrew (BNG), have taught us a great deal about parenting and resilience. When we completed the first edition of the book in 1991, they were in college or graduate school; in 2002, at the time of the second edition, they are young adults with families of their own. They have continued to teach us about development and developmental variations as they occur in their lives and our own.

Reference Schroeder, C. S. (1996). Psychologists and pediatricians in partnership. In R. J. Resnick & R. H. Rosensky (Eds.), Health psychology through the life span: Practice and research opportunities (pp. 109–132). Washington, DC: American Psychological Association.

This page intentionally left blank

Contents

PART I. THE FOUNDATION Chapter 1. Development of Psychopathology

3

Normal Development, 4 Vulnerability and Resilience, 18 Prevention of Problems, 30 Summary and Conclusions, 39

Chapter 2. Assessment to Intervention

40

Issues of Diagnostic Classification, 40 Estimates of Prevalence, 45 Planning the Assessment, 48 Assessment Case Example, 49 A Comprehensive Assessment-to-Intervention System, 50 Methods for Gathering Information, 56 Treatment Issues, 73

PART II. MANAGING COMMON PROBLEMS Chapter 3. Eating Problems

81

Normal Development of Feeding Behavior, 82 Eating Problems Related to Infant Feeding, 85 Obesity, 89 Assessment of Obesity, 90 Treatment of Obesity, 94 Case Example: Obesity, 99 Food Refusal Problems, 102 Assessment of Food Refusal Problems, 103 Treatment of Food Refusal Problems, 106 Case Example: Food Refusal Problem, 109

Chapter 4. Toileting: Training, Enuresis, and Encopresis Toilet Training, 115 Enuresis, 120 xiii

115

xiv

Contents Assessment of Nocturnal Enuresis, 123 Treatment of Nocturnal Enuresis, 127 Treatment of Mixed Enuresis, 132 Treatment Protocol for Enuresis, 133 Case Example: Enuresis, 137 Encopresis, 139 Assessment of Encopresis, 142 Treatment of Encopresis, 147 Treatment Protocols for Encopresis, 149 Case Example: Encopresis, 155

Chapter 5. Habits and Tics

159

Oral Habits, 159 Trichotillomania, 163 Other Habits, 164 Tics, 165 Assessment of Habits and Tics, 171 Treatment of Habits and Tics in General, 176 Treatment for Tourette’s Disorder, 180 Case Example: From Tics to Tourette’s Disorder, 182

Chapter 6. Sleep

186

Normal Sleep States and Patterns, 186 Sleep Disturbances, 189 Assessment of Sleep Problems, 199 Treatment of Sleep Problems, 204 Case Example: Night Waking, 211 Case Example: Nightmares, 214

Chapter 7. Sexuality and Sexual Problems

217

Normal Sexual Development, 217 Sexuality Education, 222 Sexual Problems, 225 Child Sexual Abuse, 231 Assessment of Sexual Abuse, 236 Treatment of Sexual Abuse, 247 Format for Immediate Short-Term Treatment When Abuse Has Been Substantiated, 251 Treatment in Cases Involving Nonsubstantiated Abuse, 257 Case Example: Substantiated Sexual Abuse, 258

Chapter 8. Fears and Anxieties Definitions, 262 Development of Fears and Worries, 264 Anxiety Disorders, 269 General Characteristics of Anxiety Disorders, 275 Assessment of Fears and Anxieties, 280 Treatment of Anxiety Disorders, 287 Case Example: School Refusal, 297

262

Contents

Chapter 9. Depression

xv

302

Definition and Classification, 303 General Characteristics of Depression, 305 Assessment, 315 Treatment, 322 Case Example: Subclinical Depression, 326

Chapter 10. Disruptive Behavior

331

Classification and Diagnosis, 332 General Characteristics of Disruptive Behavior Problems, 336 Development of Disruptive Behavior, 345 Assessment of Disruptive Behavior, 350 Treatment, 357 Case Example: Preschool Oppositional Behavior, 374

Chapter 11. Attention-Deficit/Hyperactivity Disorder

377

Diagnostic Criteria, 378 General Characteristics of ADHD, 381 Assessment, 393 Treatment, 402 Case Example: ADHD-C, 413

PART III. MANAGING STRESSFUL LIFE EVENTS Chapter 12. Siblings

419

Adjustment to the Birth of a Sibling, 420 Sibling Conflict, 424 Assessment of Sibling Conflict, 427 Treatment of Sibling Rivalry, 430 Case Example: Physical Conflict among Siblings, 433

Chapter 13. Divorce

440

Effects of Divorce on Children, 440 Assessment of Divorce-Related Issues, 450 Treatment of Divorce-Related Problems, 455 Case Example: Recommendations for a Child’s Living Situation, 462

Chapter 14. Bereavement

466

Children’s Understanding of Death, 467 Children’s Adjustment to Death, 468 The Terminally Ill Child, 470 Assessment of Death-Related Issues, 474 Treatment of Death-Related Issues, 477 Case Example: Death of a Parent, 480 Case Example: Death of a Sibling, 482

Appendix A. Description of Assessment Instruments Parent Rating Scales, 489 Teacher Rating Scales, 493

487

xvi

Contents Child Self-Report Measures, 495 Behavioral Observation Systems, 497 Structured Interviews, 498 Attention-Deficit/Hyperactivity Disorder Measures, 499 Depression, Anxiety, and Fear Measures, 500 Parent Characteristic Measures, 502

Appendix B. Assessment Instruments B.1. B.2. B.3. B.4. B.5. B.6. B.7. B.8. B.9. B.10. B.11. B.12. B.13.

505

General Parent Questionnaire, 507 Daily Log, 512 Specific Events Causing Concern, 513 Teacher Questionnaire, 514 Fear Survey Schedule for Children—Revised (FSSC-R) , 517 Screen for Child Anxiety Related Emotional Disorders (SCARED)— Child Version, 521 Screen for Child Anxiety Related Emotional Disorders (SCARED)— Parent Version, 523 Hopelessness Scale for Children, 526 Hopkins Motor and Vocal Tic Scale, 528 Children’s Eating Behavior Inventory (CEBI), 530 Child Attention Problems (CAP), 534 Academic Performance Rating Scale (APRS), 536 Therapy Attitude Inventory (TAI), 539

References

541

Index

615

PART

I

T H E F O U N D AT I O N

This page intentionally left blank

CHAPTER 1

Development of Psychopathology

M

ost children, in the process of growing up, will have emotional and behavioral problems that are transient in nature and are due to the stresses of development and adaptation to family and societal expectations. The primary task for parents is to enhance their children’s development by helping them gain control over normal developmental events such as toilet training, fears, learning about sexuality, being told “no,” and dealing with siblings and peers. Children and parents also must sometimes cope with negative life circumstances (e.g., poverty or parental unemployment) and stressful events, (e.g., a hospitalization, a divorce, a death, or the birth of a new baby). For all of this pressure to cope, it is heartening that epidemiological studies find that over the course of any one year, only about 20% of children suffer from an emotional or behavioral problem that is severe enough to interfere with their day-to-day functioning (Nottelmann & Jenkins, 1995). The goals of the child clinician are not only to assist this group of children who have major mental health problems, but also to help the other 80% of children and their parents manage the stresses of normal growth and development. Because of their rapid growth and development, children represent a unique population. Previously, the importance given to changes in development depended to a great extent on one’s theoretical perspective. Psychoanalytic theory, for example, emphasizes the emergence of independence and psychosexual development, whereas social learning theory focuses on the development of self-control and self-efficacy. However, the failure of any one theory to explain the full complexity of development across ages and areas has led to general acceptance of a transactional and/or ecological perspective of development, which attempts to account for factors within the child, family, and society that influence the child either directly or indirectly (Campbell, 1990). Within this perspective, developmental gains in each area (social, cognitive, motor, language, etc.) are thought to be related to progress in other areas. Moreover, competence or problems in any area of development early in life are seen as setting the stage for later development. Thus developmental change (both positive and negative) is the result of the transactional dialogue among each child with his or her unique biological/genetic makeup, the physical and social environment, and the cultural milieu into which he or she is born. Mash and Terdal (1997a) point out that the child clinician must recognize “the ebb and flow of this develop3

4

I. THE FOUNDATION

mental dialogue, because it has critical implications for the manner in which child behaviors are conceptualized, measured, classified, diagnosed, changed, and evaluated” (p. 22). Behaviors common at one age may be considered significant problems at another age, and many childhood problems may change both qualitatively and quantitatively as a child develops. In addition, the impact of stressful life events may vary with the child’s stage of development, the parent’s characteristics, and the social support system available to the family at that time. Knowledge of developmental norms is clearly essential for the child clinician to recognize which behaviors are excessive or deficient for children at a given developmental stage. An understanding of normal development is also important in choosing appropriate intervention techniques. Treatment of the school-age child, for example, will rely more heavily on cognitive and language skills, whereas use of concrete, situation-specific tasks and developmentally appropriate play activities will be more appropriate for the preschool child. The clinician must also have knowledge of the normal sequence of skill acquisition, in order to plan appropriate treatment for such problems as social skills deficits. In light of the importance of a developmental perspective for clinical work with children, this chapter first focuses on issues related to the normal development of children from birth to 10 years, and the factors that influence children’s later development (see Campbell, 1990, 1998, for excellent discussions of theoretical issues concerning development and behavior problems). Next, research related to the variables that contribute to the vulnerability or resilience of children is reviewed. Finally, models for prevention and early intervention are discussed.

NORMAL DEVELOPMENT General Comments The developmental tasks of children obviously change with age, and each stage of development presents unique challenges to children and parents. The ways in which significant adults help children through these difficult periods can have implications for children’s later development. A child who is having trouble with separation and individuation, for example, may have more trouble with social skills if the parents deal with separation issues in an angry or rejecting manner rather than with warmth and support. In considering normal development, the clinician should keep both inter- and intraindividual differences in mind. Individual differences in the rate of development are clearly apparent during the preschool years, and these differences often persist into the school-age years. Some children, for example, begin to speak before the age of 1, whereas other “normal” children have not acquired extensive language by age 3. Differences in physical growth become dramatically apparent in the late elementary school and early adolescent years, although each child may be developing along a normal continuum. At school age, academic standards typically reflect great differences among children. An individual child’s rate of development within various areas can vary as much as the rate of development among children. A child may be speaking in sentences at age 2 years, but may not begin hopping or skipping until much later than expected. Similarly, a child may be at the top of the class in reading, but may have difficulty participating in group play activities. Some of these inter- and intraindividual differences are primarily the result of genetic/biological factors; others seem to be more the result of environmental influences. Of course, the unique interaction of these two types of factors—the child’s and the environment’s—is what ultimately determines each child’s developmental course.

1. Development of Psychopathology

5

Because many types of learning take place rapidly and simultaneously during childhood, it is common for children who are not developing normally to be identified at this time (particularly during the preschool years), often because they fail to achieve an expected developmental milestone. It is usually the general pattern of development, rather than slower development in any specific area, that alerts adults to potential problems. Toilet training, for example, may be slower and more difficult; the child may be slower to learn to dress and eat independently; and constant supervision may be needed at a time when most children are becoming independent, helpful family members. If developmental problems are not noticed during the preschool years, they will almost inevitably be identified as a child enters school, when there are increased expectations to sit quietly, pay attention, process more complex language, read, do arithmetic, and deal with difficult social situations. The following discussion focuses on issues in normal development that are most relevant to understanding how psychopathology develops in children during the periods of infancy, toddlerhood, preschool, and school age. Table 1.1 provides an overview of normal development from infancy through school age, along with the associated parental tasks. The reader is referred to Davies (1999) and DiGirolamo, Geis, and Walker (1998) for more detailed descriptions of developmental milestones. In addition, we recommend three books for parents that cover developmental issues: Your Child (Pruitt, 1998); A to Z Guide to Your Child’s Behavior: A Parent’s Easy and Authoritative Reference to Hundreds of Everyday Problems and Concerns from Birth through 12 Years (Mrazek, Garrison, & Elliott, 1993); and Child Behavior: The Classic Childcare Manual from Gesell Institute of Human Development (Ilg, Ames, & Baker, 1992).

Infant Development (Birth–1 Year) Development during the first year of life is phenomenal, and by 12 months of age infants barely resemble the beings they were at birth. The main tasks of the first year can be summarized as follows: (1) to gain physiological stability; (2) to develop interpersonal attachments and strategies for maintaining them; (2) to regulate arousal and affect; (3) to develop and gain control over motor skills; (4) to begin to communicate needs and desires; and (5) to explore and learn about the external world (Davies, 1999; DiGirolamo et al., 1998). Brain development is most rapid during the first year of life, and this development makes all other functions (sensory, perceptual, emotional, regulatory, motor, and cognitive) possible (Davies, 1999). Development during infancy is also inseparable from the child’s relationship with his or her caregiver(s). Although the child is born with certain biological prerequisites, and his or her capabilities unfold in a regular progression, simple maturation is not sufficient to ensure normal progress (Davies, 1999). The infant is born with a capacity to organize his or her experiences, for example, but is dependent on adults to determine what those experiences will be and to provide appropriate stimulation and support so that the child can profit from these experiences (Davies, 1999). The types of experiences to which the infant is exposed influence which neural pathways will be strengthened, which will remain available, and which will atrophy (Davies, 1999). Thus issues of parenting are most critical during this early time of life. Problems during infancy typically come to the attention of pediatricians rather than mental health professionals (Campbell, 1998). However, clinicians should be knowledgeable about two areas of research most related to the development of later mental health problems: attachment and temperament. Both the quality of primary caregiver–infant attachment and the child’s temperamental characteristics can potentially influence the child’s future functioning,

TABLE 1.1. Issues of Normal Development and Associated Parental Tasks Toddlers (1–2 years)

• Brain develops rapidly • Weight triples, height doubles • Develops capacity for selfregulation • Physiological regularity increases • Becomes oriented to external world: sensory integration, visual and auditory acuity • Motor skills develop: rolling, sitting, crawling, standing, walking, reach and grasp, pincer grasp, hand to mouth, eye–hand coordination

• • • • •

• Needs environmental stimulation and exploration • Engages in sensory–motor actions and experiences • Learns about contingencies • Develops object permanence • Imitates adult behavior • Repeats pleasurable experiences • Anticipates familiar events • Begins goal-directed behavior

• Intense interest in exploring the world • Explores properties and functions of objects • Observation and imitation are key to learning • Develops expectations based on memory of past • Symbolic play and thinking begin • Conscious goals and plans • Views the world egocentrically

6

Infants (0–1 years)

Preschoolers (2–4 years)

Physical/motor development Stands and walks alone • Hops, skips, and jumps Imitates motor actions • Throws ball Goes up and down steps holding on • Dresses Stands on one foot • Undresses Uses implements (crayons, spoons) • Ties shoes • Copies shapes

Cognitive development • Memory capacity develops (processing and storage in place, good recognition memory, increase in ability to use retrieval strategies) • Uses verbally mediated thinking • Understands real vs. not real • Engages in pretend play • Understands consequences and rules • Views the world egocentrically • Uses magical thinking

School-age children (5–12 years) • Slow and steady growth • Increased eye–hand coordination • Sense of body position and gross motor function permit participation in organized sports

• Attention, persistence, and goaldirectedness allow formal schooling • Increased capacity to store, retain, and retrieve new information • Improved memory skills; uses retrieval strategies • Increasingly accurate perception of reality • Reversibility—can analyze events by thinking about them • Understands cause and effect • Spurt in cognition at 7 years: Spatial and visual organization, time orientation, seriation, auditory processing • Increase in executive processes: Problem solving, sustained attention

Language development • • • • • • •

Cries or smiles to communicate Orients to sound Babbles and vocalizes Imitates vocalization Learns turn taking Looks and points Understands single words and labels • Follows simple directions by end of first year

7

• Attachment develops • Uses strategies to maintain proximity • Uses caregiver to decrease arousal and regulate affect • Smiles responsively • Initiates play interactions • Cooperates in simple games (peekaboo) • Joint attention • Beginning sense of self • Cautious with new people • Responds to parents’ limit setting by end of first year

• Imitates single words • Uses single words to communicate needs • Combines words and gestures • Vocabulary of 10–100 words • Two- or three-word sentences

• • • • • • • • •

Social/emotional Balances desires for closeness with caregiver and for independence, exploration Plays independently and in parallel with others Imitates others and role-plays daily events Becomes self-assertive Bites or hits peers Expresses needs and feelings in gestures and words Has limited internal control Recovers quickly from upset Begins to understand social expectations

• Rapid development of grammar, syntax, and pronunciation • Uses language to understand the world • Asks questions • Follows three-step commands • Uses four-word complex sentences • Relates long stories and experiences • By age 5, 1,500- to 2,000-word vocabulary; grammar similar to adults’ development • Group play begins • Develops friendships • Follows rules • Plays cooperatively • Internalizes parental standards • Interacts appropriately with adults and peers • Uses language to express feelings • Uses words to control impulses

• Expression in written language begins • Vocabulary continues to increase • Uses language to express ideas and feelings, to plan for the future and remember the past, and to solve problems

• More consistent sense of self • Increased sense of identity based on gender, race, ethnicity and personal characteristics • Self-esteem based on sense of competence and status in peer group • Uses cognition to regulate internal arousal, to delay action, to attain goals, and to control behavior • Internalizes values, norms, and rules • Can see conflicting viewpoints and tolerates ambivalence • Identifies with parents as role models • Increased identification with samesex peers

(cont.)

8

TABLE 1.1. (cont.) Infants (0–1 years)

Preschoolers (2–4 years)

School-age children (5–12 years)

Parenting • Provide opportunities for exploration and motor activities • Talk to and describe child’s actions • Ensure child’s safety • Start setting limits • Use distraction to discipline

tasks • Be an authoritative parent • Be a good role model for appropriate behavior, expression of feelings, and relationships • Provide consistent daily routines and expectations • Be a good listener • Describe child’s actions and feelings

• Be an authoritative parent • Be a good role model • Encourage and model independent problem solving • Provide consistency • Be a good listener • Monitor and supervise child’s activities and friendships

I. THE FOUNDATION

8

• Scaffold or support child’s development • Adapt to child’s ongoing development • Be sensitive and responsive to child’s cues • Provide appropriate stimulation and experiences • Follow child’s lead/engage in joint attention

Toddlers (1–2 years)

1. Development of Psychopathology

9

and problems in either area are seen as risk factors for the development of behavioral or emotional problems. Attachment The formation of “attachment”—that is, an emotional bond between the infant and his or her primary caregiver(s)—occurs gradually over the course of the first year of life. As Campbell (1998) describes, the process begins as caregivers (usually parents) respond to the infant’s signals of hunger or other distress. The infant gradually learns that his or her needs will (or will not) be met consistently, and as a result develops expectations about adult behavior relative to his or her signals. At first any adult will do, but gradually, the infant begins to discriminate between and respond differently to familiar and unfamiliar people. As development progresses (usually by 6 or 7 months), the infant begins to engage in active attempts to maintain contact with familiar people (usually parents) and becomes upset when separated from them. By the end of the first year, the attachment figure is the infant’s main source of comfort and is used as a secure base from which the infant ventures out to explore the world (Waters & Cummings, 2000). Early in this process, the key to the formation of a secure emotional attachment between the infant and caregiver(s) is the ability of a caregiver to respond sensitively and promptly to the infant’s signals of distress (i.e., crying). As the child progresses through the first year, caregivers must adapt their behavior to the child’s rapidly changing needs while continuing to be sensitive and responsive to the child’s signals and to provide support for his or her development (Davies, 1999; DeWolff & van IJzendoorn, 1997; Thompson, 2000). As Campbell (1998) states: Mothers who are sensitive to their infants’ cues and responsive across a range of situations including feeding, responsiveness to crying, early face-to-face play, and the provision of opportunities to explore, foster the development of a secure attachment relationship. Mothers who respond to their infants abruptly, who are unresponsive, or who pace their behavior to their own needs and schedules foster the development of an anxious or ambivalent attachment characterized by excessive anger, clinging, and/or avoidance behavior of the part of the infant. (p. 13)

Infants who are securely attached to their caregivers have been shown to have more optimal development in a number of areas (Campbell, 1998). Main, Kaplan, and Cassidy (1985), for example, found that children who were securely attached at 12 months were more emotionally secure and better able to express their feelings at age 6; 6-year-olds who were insecurely attached at 12 months had great difficulty discussing their feelings and had few strategies for dealing with separation. Furthermore, children with secure attachments to their caregivers show more appropriate social adaptations over time (e.g., they are more popular, make more social contact, and are more helpful to others) than children with less secure attachments do (Hartup, 1989). Patterns of cognitive functioning, including more symbolic play, more internal control, and better problem-solving skills (Matas, Arend, & Sroufe, 1978), as well as increased task mastery (Baumrind, 1971) and higher school achievement (Estrada, Arsenio, Hess, & Holloway, 1987), are also associated with early secure attachment to caregivers. The quality of early attachment relationships has likewise been found to be important in emotional development, influencing popularity, number of social contacts, ability to offer support to others, and increased self-esteem (Cassidy, 1988; Sroufe & Fleeson, 1986).

10

I. THE FOUNDATION

Attachment relationships are not necessarily stable over time. Moreover, attachment is found to be less stable in higher-risk than in lower-risk families (Lamb, Thompson, Gardner, & Charnov, 1985). Attachment status probably fluctuates as a function of parental and environmental circumstances (Belsky, Campbell, Cohn, & Moore, 1996; Thompson, 2000). Thus securely attached infants may become insecure if their caregivers become less able to meet their needs because of divorce, onset of mental health problems, birth of a new baby, or other life stresses. Likewise, insecure infants may become more secure if their environments become more stable. The instability seen in some children’s attachment status may explain the inconsistency in research assessing links between quality of attachment and the later development of mental health problems (e.g., Bates & Bales, 1988). Moreover, environments that predispose children to insecure attachments also typically contain a wide range of other risk factors, so it is not always possible to determine whether adverse effects are due to poor-quality attachment or to other factors (Rutter, 1995). Nonetheless, it is reasonable to consider a disordered attachment, especially at extreme levels, as a risk factor for the development of problems later in life (Carlson, 1998; Rutter, 1995). Temperament The early work of Thomas and Chess (1977) demonstrated individual differences in “temperament,” or the behavioral style of a child’s interaction with the environment, as early as the first few weeks of life. Research in behavioral genetics suggests that many aspects of temperament may be inborn (Goldsmith, Buss, & Lemery, 1997; Plomin, 1989). Thomas, Chess, and Birch (1968) derived a cluster of traits (irregularity of biological functions or rhythmicity, withdrawal from novel stimuli, slow adaptation, intense responses, and predominantly negative mood) called “difficult temperament,” which was thought to be clinically significant. Since that time, research has demonstrated that the “difficult” infant is harder to parent and is at higher risk for developing behavior problems later in life than is the “easy” child (e.g., Bates, Maslin, & Frankel, 1985; Goldsmith et al., 1987; Kagan, 1997; Sanson, Oberklaid, Pedlow, & Prior, 1991). Moreover, an association between specific aspects of temperament and psychological symptoms has been found for school-age children. Lengua, West, and Sandler (1998), for example, reported that negative emotionality was associated with symptoms of depression, whereas impulsivity was related to conduct problems. Not all difficult children develop adjustment problems, however, and some easy children exhibit difficulties later in life. Thomas et al. (1968) introduced the concept of “goodness of fit” to account for this phenomenon. Thus difficult infants with highly stressed, unresponsive caregivers are considered at higher risk for later problems than difficult infants with responsive, sensitive, calm caregivers are (Campbell, 1990; Davies, 1999). Likewise, easy infants born into dysfunctional, highly stressed families may later develop problems, despite being easier to care for during infancy and early childhood. Goodness of fit is an important aspect of understanding the development of the caregiver– infant attachment relationship. As Campbell (1998) states, “Individual differences in the frequency and duration of crying, infant cuddliness and consolability, activity level, alertness, and self-quieting can have profound effects on parental behavior and the quality of the developing parent–infant relationship” (p. 11). The association between temperament and attachment is complex, however, with caregiver behavior and infant characteristics having both direct and indirect effects on attachment security (Susman-Stillman, Kalkoske, Egeland, & Waldman, 1996). Susman-Stillman et al. (1996), for example, found a negative relationship between in-

1. Development of Psychopathology

11

fant irritability and “maternal sensitivity” (used broadly to represent a number of maternal behaviors). They argue that the influence of temperament on attachment may be particularly important when maternal sensitivity is low, whereas high maternal sensitivity may mediate the effects of infant irritability. Although various aspects of the construct of temperament (stability, measurement, definition, etc.) continue to be debated, considerable research has demonstrated the relationship between specific dimensions of temperament and other aspects of later development, such as academic skills and IQ (Palisin, 1986), social relations (Keogh & Burstein, 1988), and adjustment to preschool and kindergarten (Parker-Cohen & Bell, 1988; Skarpness & Carson, 1987). Furthermore, temperament is currently being examined as one aspect of the ability to regulate one’s emotions and impulses, and as a mediator of children’s adjustment to a variety of stressful life events (e.g., parental divorce, death of a loved one). Thus consideration of temperamental characteristics in young children is clearly important to understanding many aspects of their development. Questioning parents or other caregivers about a child’s early temperament may shed light on current problems with behavior and interpersonal relationships. A recent book for parents, Understanding Your Child’s Temperament (Carey & Jablow, 1997), may be helpful in preventing problems related to child temperament.

Toddler Development (1–2 Years) Independence The hallmark of development in the second year of life is the child’s striving for autonomy and independence, at the same time that he or she still wants to be close to the primary attachment figure. Children at this age have an intense desire to explore the world and to master new and increasingly complex experiences, but they are still almost completely dependent on their caregivers. Davies (1999) summarizes the primary tasks of the toddler period as these: (1) to balance the need for closeness with exploration of the environment; (2) to become increasingly independent; (3) to begin to internalize parental standards; (4) to gain the ability to control emotions, impulses, and behavior; and (5) to begin to use mental representations in play and communication. Like infants, toddlers are rarely referred for mental health services, although parents frequently discuss problems with their pediatricians. Nonetheless, many later adjustment problems have their origins during this early period. As an example, some amount of defiance and noncompliance is to be expected during the second year of life, and for the first time behavior management becomes an important issue for parents. It is clear that inappropriate parental responses to children’s noncompliance or defiance can exacerbate problems, to the extent that negative reinforcement cycles may develop and persist (Patterson, 1976a). Thus it is not surprising that negative and conflicted parent–child relationships during the toddler period predict continued problems at school entry and beyond (Campbell, 1990; Campbell & Ewing, 1990). Whether the child’s defiance represents the self-assertion necessary to achieve independence or reflects anger and disturbance is the primary question for professionals (Campbell, 1998). Unfortunately, many parents have trouble making this distinction. They may interpret all toddler defiance as a threat to their authority, resulting in excessive punishment; conversely, they may have trouble setting appropriate limits on the child’s behavior, for fear of stifling the child’s initiative. Toddlers have limited internal control over their behavior and impulses; this

12

I. THE FOUNDATION

ability develops gradually during the preschool years, driven in part by the development of cognitive and language skills. As a result, a primary parental task is to provide external controls that ensure children’s safety while they are busy exploring their environment.

Preschool Development (2–4 Years) Child psychologists consider the preschool years (ages 2–4) to be among the most important developmental periods, because the foundation for later competence in many areas is laid during this time. The emergence of language, self-awareness, peer relationships, and autonomy/independence, as well as the increased complexity of cognitive, play, social, and motor skills, sets the stage for new and often intense interactions between the child and the environment. As a child’s capacity to interact with the environment increases, so do the problems and concerns of parents. Although most of these problems are transient, significant problems in any one developmental area can affect the development of other skills in other areas. Difficulty with language, for example, can influence cognitive development, or problems with self-control can affect self-esteem and social relationships. Because of their importance to the development of psychopathology, these two areas—language and self-regulation—are discussed in the next sections. Language Development The hallmark of development during the preschool years is the development of language. Although language obviously begins to develop during infancy, and the process continues throughout toddlerhood, the period between 2 and 6 years of age represents a time of enormous growth in children’s language abilities. Rapin (1996), in a synopsis of language development during the first 6 years of life, states that in the first year infants go from cooing vowel sounds to producing repetitive consonant–vowel syllables such as “mama” or “baba” to producing meaningful but imperfect words. In the second year, words are initially acquired one by one, and then vocabulary grows rapidly. After they acquire a few dozen single words, children start to produce two-word utterances. These utterances form the basis for grammar, which allows children to understand and produce meaningful sentences. During the third year, vocabulary increases to hundreds of words, whereas syntactic knowledge moves from the production of two-word utterances to full sentences. From then on, lanugage acquisition involves the comprehension and production of ever more complex sentences, as well as the acquisition of thousands more words. By school age, children start to master written language. Rice (1989) states that without explicit teaching, as many as 14,000 new word meanings may be acquired as children encounter them in meaningful situations and conversations; this phenomenon is the foundation for later reading skills. Moreover, preschool children begin to be able to use language to develop new cognitive skills, to facilitate their understanding of the world, to aid their remembering, to organize their thoughts, and to control their impulses (Rice, 1989). Hart and Risley (1995, 1999) have demonstrated the profound effect that parenting style has on a child’s acquisition of language. They found that children living in poverty, children born into middle-class families, and children with professional parents all had the same kinds of language experiences. Children born into homes with fewer economic resources, however, had fewer of these experiences. In other words, the amount of talking the parents engaged in with their children was a crucial factor in the children’s later language development. Increased frequency of talking provided greater language diversity, a proportional increase in the amount

1. Development of Psychopathology

13

of encouragement the children received, a greater opportunity to learn symbols for names and relations, and enhancement of verbal recall. Several other factors have been shown to enhance language development. These include (1) speaking “motherese,” which consists of such features as simple sentences focused on present events, slow rate of speech with pauses at significant words, and paraphrasing of the child’s utterances; (2) semantic contingency or joint attention, which involves immediate responses to the child’s utterances, and conversing about what the child is presently interested in; (3) reading to the child; (4) asking or suggesting rather than demanding; and (5) following the child’s lead during play interactions (Hart & Risley, 1995, 1999; Rice, 1989; Saxon, 1997). One factor that may impede language development is a controlling style of interaction with the child, characterized by many commands, directives, questions, and frequent attempts to shift the child’s attention to whatever the parent is interested in. Middle-ear disease, or otitis media, which is often accompanied by fluctuating hearing loss in preschool children, is associated with delays in language development (Simon, Larson, & Lehrer, 1988; Wallace, Gravel, McCarton, & Ruben, 1988), although this association has recently been found to be mediated by the communication style of caregivers, at least among children from low-socioeconomic-status (low-SES) environments (Wallace, Gravel, Schwartz, & Ruben, 1996). Wallace et al. (1996) found that the language of caregivers of children with and without otitis media did not differ. Among those children with otitis media, however, those whose caregivers used more directives, and fewer questions and informative utterances, had lower language skills. This style of caregiver language was associated with better language skills among low-SES children who did not have otitis media. Otitis media is a significant problem when one considers that as many as 40% of preschoolers’ visits to the pediatrician involve middleear disease (Teele, Klein, & Rosner, 1984). Delays in expressive language in children as young as 1 year with chronic middle-ear infections have been reported (Wallace et al., 1988). Furthermore, a longitudinal study by Feagans, Sanyal, Henderson, Collier, and Appelbaum (1987) indicated that middle-ear disease in the preschool years was related to attentional problems in elementary school, despite the fact that the language delays had resolved. The importance of language development is demonstrated by studies indicating that language mediates cognitive and social development (e.g., Simon et al., 1988; Toppelberg & Shapiro, 2000). Thus delays or disorders of language will impede development in other areas as well. Vallance, Cummings, and Humphries (1998), for example, argue that impaired communicative competence contributes to poor social skills, which may in turn lead to externalizing or internalizing symptomatology. Any of the major categories of speech and language disorders can be seen in children as young as the preschool years, including disorders of speech (articulation, voice quality, and fluency); disorders of language (understanding the symbol system, and production of words, meanings, and grammar); and disorders of communication or pragmatics (social uses of language as a communication system) (Vetter, 1980). Disorders of language and communication (but not speech disorders) are significantly associated with psychiatric disorders in childhood (Toppelberg & Shapiro, 2000) and adolescence (Beitchman et al., 2001). Cantwell and Baker (1991) have reported that as many as 50% of children with language disorders also have psychiatric diagnoses, about equally divided among behavioral and emotional disorders. Beitchman et al. (2001), for example, found that children with language impairments at age 5 years were significantly more likely to have anxiety (primarily social anxiety) and antisocial personality disorders at age 19 years. This association appears to be strongest for children who have problems with receptive language or comprehension. For example, comprehension delays at age 3 have been found to predict behavior problems at ages

14

I. THE FOUNDATION

7–11 (Silva, Williams, & McGee, 1987). In a review of 10 years of research on language disorders, Toppelberg and Shapiro (2000) conclude: “The presence of receptive or comprehension language disorders has proven to be the single most important consideration, as they are a highrisk indicator of more phonological, pragmatic, and psychiatric comorbidity, worsening social competence, and hyperactivity over the years and they are often not suspected or detected” (p. 150). Clearly, concerns about language should be referred immediately to the appropriate professionals for assessment and possible intervention. A national resource for parents of children with language problems is the American Speech–Language–Hearing Association, 10801 Rockville Pike, Rockville, MD 20852, 800-638-TALK, http://www.asha.org. Self-Regulation The expression of emotion during the preschool years is usually uninhibited, because the child is in the process of learning how to communicate emotions in socially acceptable ways. Anger is usually expressed behaviorally in response to an immediate stimulus (such as wanting a toy) by biting, scratching, or kicking, but is typically short-lived (Davies, 1999). Temper outbursts occur most often at about 2–3 years of age, and then gradually diminish during the later preschool years (Mesibov, Schroeder, & Wesson, 1977). Self-regulation (e.g., the ability to label emotions, to talk about emotions, and to use language about emotions to guide behavior) increases during the preschool years (Davies, 1999; Kopp, 1989). “Emotional regulation” is defined as “the process of initiating, maintaining, and modulating the occurrence, intensity, or duration of internal feeling states and emotion-related physiological processes” (Eisenberg, Guthrie, et al., 1997, p. 295). “Behavioral regulation” refers to the ability to control emotionally driven behavior (facial or bodily reactions, aggression, etc.). Children face many challanges in learning to regulate their emotions and behavior, including (1) tolerating frustration, (2) coping with fear and anxiety, (3) defending themselves and their property, (4) tolerating being alone. and (5) negotiating friendships (Cole, Michel, & Teti, 1994). How do children come to internalize parental standards and gain control over their emotions and their behavior? This is an important question for parents and professionals, as dysregulation is a common component of most forms of psychopathology. The inability to regulate one’s emotions is associated with behavior problems—externalizing problems for children who are underregulated, and internalizing problems for those who are overregulated (Cole et al., 1994; Eisenberg et al., 1996). Conversely, appropriate regulation is associated with more competent social functioning, both concurrently and in the future (Eisenberg, Guthrie, et al., 1997; Eisenberg, Fabes, et al., 1997). A longitudinal study of over 1,000 children by Caspi, Moffitt, Newman, and Silva (1996) exemplifies this work and highlights the importance of emotional and behavioral regulation in children’s development. In this study, children who were underregulated (i.e., who were irritable, impulsive, and lacking in persistence; had trouble sitting still; and had rough and uncontrolled behavior) at 3 years of age were more likely to qualify for a diagnosis of antisocial personality disorder and to be involved in criminal activity at 21 years of age. In contrast, overregulated or inhibited 3-year-olds were more likely to meet diagnostic criteria for depression at age 21. Controls for family SES did not change these long-term associations. Similarly, Shields and Cicchetti (2001) found that emotional dysregulation differentiated maltreated children who were either bullies or victims of bullying from maltreated children who were neither. The development of emotional regulation begins at birth with the infant’s inborn temperamental characteristics (Calkins, 1994; Kagan, 1994), especially ease and intensity of arousal

1. Development of Psychopathology

15

(Rothbart, Posner, & Boylan, 1990). These characteristics set the stage for how the infant will react to incoming stimuli. Experience (particularly the responses of parents or other caregivers), however, also plays a major role in moderating the infant’s reactions (Kagan, 1994). At first, the infant is almost completely dependent on his or her caregivers for regulation. Feeding, clothing, physical comforting, provision of regular and predictable routines, sensitive responding to the infant’s signals, and prevention of excessive stimulation or frustration all help the infant maintain a steady state (Calkins, 1994; Kopp, 1982). Later, parents or other caregivers promote regulation through their interactive styles, such as responsive and contingent versus insensitive, cooperative versus intrusive or controlling, reciprocal versus unilateral, supportive versus overprotective, and accepting versus neglecting (Calkins, 1994; Kochanska, 1995). Moreover, they directly teach regulation by modeling, disciplining, and reinforcing their children (Calkins, 1994; Denham, Mitchell-Copeland, Strandberg, Auerbach, & Blair, 1997). As an example, Kochanska (1995) argues that an inductive style of discipline (i.e., reasoning) elicits the optimal level of arousal in children, allowing them to attend to and process parental messages. Conversely, power-oriented or anxiety-arousing techniques may produce overarousal in a child, interfering with the child’s ability to learn; discipline completely lacking in pressure may not arouse children enough for them to pay attention to their parents or to motivate them to change their behavior. At the same time that parents are assisting the child to regulate his or her emotions and behavior, the child is developing better cognitive and language skills. These skills are critical to the ability to self-regulate, as children learn to communicate their needs and emotions more effectively, begin to understand social situations and the need to regulate their behavior, and gain the ability to apply regulation strategies intentionally (Calkins, 1994). Toddlers can comply with simple requests in familiar, predictable situations, but do not understand the rationale for compliance and do not generalize to new situations. Thus control is entirely external to the child at this age. By 24 months of age, true self-control begins to emerge, and a child has less need for external constraints (Kopp, 1982). Self-control at this age is still largely external, however, and is tied to concrete and specific situations. Parents provide control either by manipulating the child’s environment or by providing consequences for the child’s appropriate or inappropriate behaviors (Pope, McHale, & Craighead, 1988). By 3–4 years of age, children are better able to generalize rules from situation to situation and can recognize when other people behave inappropriately. They also begin to exercise more control by talking out loud about their own behavior. Verbal mediation of behavior increases rapidly during the preschool years. By 5–6 years, this verbal control begins to be internalized. The child then tends to control his or her own behavior by following the rules to get approval from others. At about age 6, the beginnings of moral behavior appear, with the child’s own conscience controlling behavior to avoid personal guilt rather than the condemnation of others. Although 4- and 5-year-olds become quite distressed in the presence of adult emotional expression and show different styles of coping (Cummings, 1987), the accurate interpretation of others’ emotional expressions does not develop until middle childhood (Covell & Abramovitch, 1987; Strayer, 1986). Environmental circumstances also play a role in how children learn to self-regulate. Chronically stressful occurrences, such as parental divorce, death of a loved one, or child abuse, can alter a child’s internal reactivity to emotion and subsequent coping behaviors (Kagan, 1994). Thompson and Calkins (1996) argue that children in these difficult circumstances often resort to nonoptimal regulatory strategies in their efforts to adapt to stressful environmental demands. They note that in some cases (e.g., ongoing parental conflict or abuse), there simply may not be a healthy way to cope.

16

I. THE FOUNDATION

School-Age Development (5–12 Years) The developmental tasks for school-age children (ages 5–12) involve the consolidation and refinement of the skills neccesary to meet the expectations of society. It is during this period that children develop new and more complex cognitive and language skills, and refine their fine and gross motor and attending skills. Socially and emotionally, they confront the challenges of dealing with increased numbers of adults and children in both structured and unstructured settings. Self-concept and the perceptions of others become increasingly abstract and consequently more accurate, leading to the development of social support networks outside the immediate family. The hallmarks of development during this period are increased cognitive skills, a more consistent and internalized sense of self, and the development of social relationships outside the home.

Cognitive Development Development of children’s cognitive skills advances rapidly during the school-age years and forms the basis for their development in other areas. From the age of about 6 onward, children no longer think egocentrically and develop increasingly mobile, flexible, reversible, and logical thought processes. By 7–8 years, children are able to use representational or internalized cognitive strategies in a systematic fashion to organize, order, and manipulate objects, numbers, and events. Later, a child is able to think of possibilities that do not exist in reality, to manipulate things mentally that are not actually present, and to see that reality is just a special case of what is possible. These advances in cognition allow for formal schooling and permit the child to master increasingly complex academic material. Moreover, increased cognitive skills allow a child better control over his or her impulses and behavior. Parental standards and rules become internalized, to the extent that the child can use these to guide behavior in the absence of authority figures. It is not surprising that school/academic problems are the most common referral concerns at this age (Campbell, 1998). The transition from preschool to elementary school is often difficult, and many children with learning and/or behavior problems are identified at this time. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994) estimates the general prevalence of learning disorders at 2–10% of school-age children; approximately 5% of students in public schools are identified as having learning disorders, which are more commonly found among boys than girls. According to DSM-IV, children with learning disorders evidence achievement in one or several academic areas (reading, writing, arithmetic, etc.) that is substantially below expectations based on their age, schooling, and intellectual abilities. Learning and behavior problems in school tend to coexist. Attention-deficit/hyperactivity disorder is most commonly associated with a learning disability (Durlak, 1992). Other associated behavior problems include aggression, social withdrawal, depression, poor self-esteem, and language and social skills deficits. Children with learning problems also tend to be rejected by their peers, and thus are vulnerable to the long-term consequences of social rejection, including delinquency, dropping out of school, and various psychiatric disturbances (Durlak, 1992). In general, school problems have been shown to vary with family circumstances; more severe problems are associated with greater family dysfunction. A fairly large number of chil-

1. Development of Psychopathology

17

dren are thought to be at risk for adjustment problems in school, with estimates as high as 30% of children in the United States. Durlak (1992) estimates that about 10% of school children have adjustment problems severe enough to interfere with their progress in school. Self-Concept and Self-Esteem Self-concept and self-esteem obviously develop throughout childhood and adolescence (and probably throughout life), but they become increasingly consistent and abstract during the school-age years. “Self-concept” refers to one’s view of oneself; “self-esteem” is defined as one’s self-evaluation, or the discrepancy between one’s actual self-concept and the ideal self (Harter, 1983a). Consistent with cognitive development, preschool chldren tend to view themselves in terms of concrete attributes, such as physical characteristics and possessions. Preschoolers also tend to think of themselves in either–or terms—for instance, as “nice” or “mean,” “good” or “bad” (Pope et al., 1988). At this time, self-concept and self-esteem are largely tied to feedback from parents and other significant adults. During the elementary school years, however, children begin to think of themselves in more abstract terms, and their sense of themselves becomes increasingly dependent on how they think others (especially peers) perceive them. Self-esteem plays a critical role in social and emotional development during the middle school years. Low self-esteem is associated with a number of psychiatric diagnoses (American Psychiatric Association, 1994), and also with poor academic achievement and peer relationship problems. High self-esteem, on the other hand, has been shown to buffer the effects of stress (O’Grady & Metz, 1987). Conversely, successful coping with stressful events can also foster a sense of mastery and thus can enhance self-esteem (Brazelton & Yogman, 1986). Therefore, the association between self-esteem and other factors is somewhat circular. Campbell (1990) states that adults have many opportunities to influence children’s self-esteem. They can reward, punish, or ignore their children’s successful experiences. They can also expose their children to mildly stressful experiences and help them to cope, or they can shield them from every adversity, denying them the experience of mastery and consequent self-confidence. Peer Relations The tasks of social development are complex for school-age children (Davies, 1999). Although parents remain important sources of support, other adults and peers play an increasing role in the child’s socialization. Many aspects of socialization, such as conflict resolution, problem solving, sharing, and behavioral regulation, are worked out in the context of the peer group. Social development is dependent on many other aspects of development, particularly cognitive and language development. Reasoning about the physical world, for example, provides the basis for reasoning about the social world. Social competence is in part a function of the development of specific cognitive skills, such as representational or symbolic thinking and social perspective taking (Howes, 1987), as well as language comprehension and communication skills. Research in behavioral genetics suggests that some aspects of social competence, such as sociability and extroversion, have a substantial genetic component (Plomin, 1989). Moreover, developmental research has shown that children’s experiences in early caregiving relationships provide the basis for the development of social competence (Jacobson & Wille, 1986; Park & Waters, 1989). Jacobson and Wille (1986), for example, demonstrated that the quality

18

I. THE FOUNDATION

of the caregiver–child attachment bond was related to the quality of a child’s later peer relationships: Securely attached children had happier, more harmonious, and less controlling peer relations than did insecurely attached children. Children’s friendships, as defined by reciprocity and commitment between individuals who are more or less equal, usually begin to develop during the preschool years with the onset of parallel play. Gradually play becomes more cooperative and reciprocal between 3 and 5 years of age (Howes, 1987), and by middle childhood competition becomes an important part of social relationships, especially for boys (Berndt, 1981). Children’s friendships are primarily same-sex at all ages from the preschool years through adolescence. They are based on common play interests and the attraction that emanates from similarities between self and others. In an excellent review of the development of social relationships, Hartup (1989) describes the importance of having both “vertical” relationships (i.e., attachments to individuals with greater knowledge and social power) and “horizontal” relationships (i.e., relationships in which individuals have equal amounts of social power). Whereas vertical relationships provide security and protection, horizontal relationships allow children to elaborate skills with individuals more or less similar to themselves. These relationships are seen as bidirectional, because both the children and the relationships change as a result of the interactions. As a child gets older, for example, the form of parent–child interactions changes from primarily physical to the parents’ giving verbal instructions to the parents’ sharing information. It is within the context of these relationships that the complexities of cooperation and competitiveness are mastered, and “intimacy” in social relationships is first achieved (Hartup, 1989). There is substantial evidence that having friends is a “developmental advantage” (Hartup, 1989); success with peers is associated in general with better psychological adjustment and school achievement (Campbell, 1998). Because of their intensity and equality, friendships provide optimal context for learning certain social skills, such as cooperation and intimacy. Hartup (1989) points out that although close relationships with other children may not be developmental necessities, being disliked by one’s companions is an important risk factor, because social rejection in childhood is consistently found to be related to later adjustment problems (Coie & Cillessen, 1993; Parker & Asher, 1987). Achenbach and Edelbrock (1981) report that 30–75% of children referred to guidance clinics are reported by their parents to have difficulties with peers. Given the importance of parent–child relationships in the socialization process, Putallaz (1987) suggests that intervention efforts for children with peer relationship problems should be directed at parent behavior as well as child behavior. She states that the parent–child interaction easily becomes cyclical, and if a parent does not change along with a child, the child’s original maladaptive behavioral repertoire will continue to be elicited in interactions with peers.

VULNERABILITY AND RESILIENCE Children are viewed as simultaneously extremely vulnerable and wonderfully resilient. Given their cognitive, physical, and social limitations, children are known to be especially vulnerable to adverse environmental conditions; as such, they are protected by laws against abuse, neglect, and exploitation, and provided with early intervention programs such as Head Start. On the other hand, children are also seen as behaviorally and emotionally resilient, in part because of the developmental process of continual change and adaptation that characterizes childhood. At this point, we might ask, “What makes some children more vulnerable or at risk for devel-

1. Development of Psychopathology

19

opmental and/or emotional/behavioral problems?” or, conversely, “Why do some children growup to be competent and productive adults, despite having experienced conditions and stresses that are known to have adverse effects on development?” The answers to these questions are difficult. We know that children with similar histories will have different outcomes, and that children with similar outcomes may reach them by different developmental pathways (Sameroff, 1985). This suggests that a multivariate, cumulative, and dynamic approach to vulnerability and resilience, in which various factors interact over time to exacerbate or moderate the effects of adversity at any given time, may be most helpful (Gordon & Jens, 1988). Rutter (1996) points out that what contributes to psychological vulnerability for an individual child is not an isolated life event or stressor, but rather an aggregated accumulation of stressful events. Similarly, it is recognized that protective factors are also on a continuum, and that when accumulated and present across time, these factors can increase the probability of a positive outcome for children in high-risk situations (Goodyer, 1990). Thus the accumulation and interaction of risk and protective factors, and the identification of areas of strength and vulnerability at any specific point in time, are the critical foci for assessment and treatment.

Risk and Protective Factors The field of developmental psychopathology merges our knowledge of normal development with clinical child psychology in order to give us a better understanding of the interplay of risk and protective factors during the course of children’s development. “Risk factors” in persons or environments result in a heightened probability for the subsequent development of a disease or disorder (Garmezy & Masten, 1986); conversely, “protective factors” are “those attributes of persons, environments, situations and events that appear to temper predictions of psychopathology based upon an individual’s ‘at risk’ status” (Garmezy, 1983, p. 73). One way of categorizing risk factors is to view them as (1) established risk, such as a frank genetic disorder (e.g., fragile-X syndrome, Down’s syndrome); (2) biological risk, such as poor prenatal care, drug and/or alcohol abuse by the mother during pregnancy, prematurity, anoxia, and low birthweight; and (3) environmental risk, such as poor responsivity or lack of sensitivity by a caretaker to a child, low level of language stimulation, or poverty (Odom & Kaiser, 1997). Protective factors can be categorized in the same way. This section focuses primarily on environmental risk and protective factors. Research in developmental psychopathology has identified many environmental factors that directly or indirectly affect children’s resistance or vulnerability to stress (Carta et al., 2001; Rolf, Masten, Cicchetti, Nuechterlein, & Weintraub, 1990). These are summarized in Table 1.2. The clinician must also understand the complex interplay between and among these risk and protective factors. Chronic life stress, for example, is associated with increased adjustment problems among children with few protective factors available to them, but has little effect on children with greater numbers of protective factors (Cowen et al., 1997; O’Grady & Metz, 1987). Moreover, the association between risk and protective factors and adjustment appears to be stronger for boys than for girls (Garmezy & Rutter, 1985; Greenberg, Lengua, Coie, Pinderhughes, & the Conduct Problems Research Group, 1999; McBride-Murry & Brody, 1999). The socioeconomic context of growing up plays an important role in determining the vulnerability or resilience of children. Socially and economically disadvantaged children, for example, are exposed to many more negative life events, and also are more adversely affected by these negative life events than are children from more affluent families (Ackerman, Kogos,

20

I. THE FOUNDATION

TABLE 1.2. Risk and Protective Factors in Child Development Risk factors

Protective factors Child characteristics

Medical problems Genetic disorders Birth complications Being male Difficult temperament Low intelligence Uneven development Extremes of activity level Attention deficit Language disorder or delay External locus of control Physical unattractiveness Being first-born Poor coping strategies Social skills deficits Insecure attachment Poor academic achievement Poor self-esteem

Good physical health Absence of genetic disorder Uncomplicated birth Being female Easy temperament High intelligence Even development Moderate activity level Developmentally appropriate attention Normal language development Internal locus of control Physical attractiveness Being later-born Flexible coping strategies Good social skills Secure attachment High academic achievement High self-esteem Family/environment characteristics

Single parent Many children Marital conflict Disagreement over child rearing Chronic poverty Poor social support network Unemployment or underemployment Inadequate child care resources Stressful life events Urban environment Chaotic home environment

Two parents Fewer children Family cohesiveness Consistent discipline Higher socioeconomic status (SES) Good individual and agency support Stable employment Adequate child care resources Low stress Rural environment Consistent, stable home environment Parent characteristics

Depression or schizophrenia Low intelligence Fewer years of education Teenage mother Insensitive/unresponsive parenting Unavailability Low self-esteem Poor parenting models Avoidance coping style (denial) Hypercritical Inappropriate developmental expectations Overly harsh or lax discipline Poor supervision of child Poor physical health Low expectations for child (behavior and academic performance)

Good psychological adjustment High intelligence More years of education Mature mother Sensitive/responsive parenting Availability High self-esteem Good parenting models Flexible coping style High nurturance/warmth Knowledge of developmental norms Authoritative discipline Close supervision and monitoring Good physical health High expectations for child

1. Development of Psychopathology

21

Youngstrom, Schoff, & Izard, 1999; McLoyd, 1998; Owens, Shaw, Giovannelli, Garcia, & Yaggi, 1999). On the other hand, a number of child and parent characteristics help buffer the effects of stress, even for those children who grow up in poverty. Masten and Coatsworth (1998), summarizing the research on resilence in children, state that the two variables most consistently found to differentiate resiliant from vulnerable children are good intellectual functioning and a close relationship with a caring parental figure. Other factors include an easy-going, sociable temperament; connections to an extended family support system; supportive contacts with adults outside the family; and participation in socially acceptable extracurricular activities. Parenting that involves consistent, highly structured, age-appropriate discipline combined with warmth and sensitivity, high expectations for behavior and academic achievement, and a strong sense of parenting efficacy has also been shown to buffer the effects of risk (Cowen et al., 1997; McLoyd, 1998; McBride-Murry & Brody, 1999). The parent–child relationship is a critical factor in determining both vulnerability and resilience among children. Viewed in a broad context, this relationship is influenced by child characteristics (such as sex, intelligence level, temperament, and biological status), which interact with parental, familial, and environmental chacteristics to predict the path of development for individual children. The child-rearing practices of parents certainly constitute an important component of this configuration: Parent behavior can set the stage for children to develop and use coping skills that make them more resilient, or, conversely, can place children at increased risk for problems (Blount et al., 1989). The next section reviews the work in this area.

Parenting Practices Determinants of Parenting Current work in the area of parenting practices has focused on the determinants of parenting styles and, not surprisingly, suggests that these determinants are numerous. Belsky (1984) describes three possible sources of influence on parenting: (1) characteristics of the parents, including their genetic and environmental origins and personal psychological resources; (2) characteristics of the child, especially his or her unique temperamental profile; and (3) characteristics of the environmental context of the parent–child relationship, including sources of stress or support (such as the marital or couple relationship and social networks). He and his colleagues argue that parenting is determined by the interaction among these sources of influence (Belsky, Woodworth, & Crnic, 1996). Others (Abidin, 1989; Clarke-Stewart, 1988; Kendziora & O’Leary, 1993) propose that it is also important to understand parents’ attitudes and beliefs about child rearing, because these can be critical motivational factors; that is, they can explain why parents behave toward their children in a particular manner. Kendziora and O’Leary (1993) and Martin (1975) have summarized the various determinants of parenting, and these are shown in Table 1.3. Research related to the most important of these is discussed next. Parents’ Developmental History. The influence of the developmental histories of parents, especially their own parenting histories, on parenting styles is demonstrated most clearly in studies of abusive parents. These show that parents who were mistreated during childhood are more likely than nonmistreated parents to mistreat their own children (Belsky, 1984). But the influence of parenting history has also been demonstrated for “normal” parents (Rodriguez & Sutherland, 1999). Parenting history may have a direct effect on current parenting behavior through modeling (we treat our children as we were treated by our parents) or inverse model-

22

I. THE FOUNDATION

TABLE 1.3. Predictors of Parenting Styles and Components of Dysfunctional and Optimal Parenting Predictors of parenting styles • • • •

• • •

•

Attitudes and expectations One’s own parenting models Education Characteristics of the child— conduct problems, activity level, and developmental changes Parental mental health (esp. depression) Marital relationship (esp. ongoing conflict) Social support (esp. insularity—few friends and frequent, highly aversive contact with relatives and helping agencies) Low SES

Components of dysfunctional parenting

Components of optimal parenting

• Uninvolved and not responding to child with sufficient warmth and stimulation • Overly harsh and controlling • Unable to set reasonable expectations and limits • Attends to and reinforces inappropriate behavior while not attending to appropriate behavior • Vague or attacking in communication with child • Doesn’t listen to child • Inconsistent and/or inept in handling situations that require punishment • Too gentle, lengthy, or delayed in dealing with misbehavior

• Enforces rules consistently • Has age-appropriate expectations • Reinforces appropriate behavior • Accepts and nurtures child • Models appropriate behavior • Assigns age-appropriate responsibilities • Provides developmentally appropriate stimulation • Monitors child’s activities • Provides reasons for rules/ limits

Note. The data are from Kendziora and O’Leary (1993) and Martin (1975).

ing (we are determined not to do to our children what our parents did to us) (Muller, Hunter, & Stollak, 1995; Simons, Whitbeck, Conger, & Chyi-In, 1991). Belsky (1984) argues that the influence of parenting history is more likely to be indirect; he states that “in general, supportive developmental experiences give rise to a mature, healthy personality, [one] that is then capable of providing sensitive parental care which fosters optimal child development” (p. 86). A study by Crockenberg (1987) illustrates how parenting history is important in determining current parent behavior. She found that adolescent mothers who had been rejected as children were more angry and punitive with their own children than nonrejected adolescent mothers were. The relationship between early rejection and punitive parenting practices was, however, moderated by current levels of social support: Rejected mothers with good support were less punitive than those with low levels of support. Crockenberg concluded that parenting history has an important but not necessarily a determining role in the way mothers care for their children; early negative experiences of parenting can be overcome by current supportive relationships. Parents’ Psychological Resources. Research on the effects of parental psychopathology, particularly maternal depression, on parenting behavior and child adjustment illustrates the importance of parents’ mental health status in determining how parents interact with their children. This work demonstrates that maternal depression is strongly associated with poor child adjustment. Maternal depression is relatively common among mothers of young children. In a nationally representative sample, McLennan, Kotelchuck, and Cho (2001) found that 24% of mothers of 1- to 2-year-olds and 17% of mothers of children between 2 and 3 years reported elevated depressive symptoms. Mothers who are depressed engage in a variety of negative parental behaviors: increased criticism, physical punishment, and aversive responses to chil-

1. Development of Psychopathology

23

dren (Panaccione & Wahler, 1986; Webster-Stratton & Hammond, 1988); avoidance of confrontation and lack of success in controlling child behavior (Kochanska, Kuczynski, RadkeYarrow, & Welsh, 1987); and perceptions of increased child behavior deviance (Schaugnency & Lahey, 1985). The process by which maternal depression influences children’s behavior and/or development is theorized to be indirect. That is, depressed mothers perceive their children more negatively, which leads to increased criticism and punishment, resulting in child behavior problems (e.g., Forehand, Lautenschlager, Faust, & Graziano, 1986). Egeland, Kalkoski, Gottesman, and Erickson (1990) have suggested that maternal depression may indirectly affect children’s development through the home environment. Specifically, depressed mothers may be less organized and provide less stimulation than nondepressed mothers. It may also be the case, however, that the effects of depression on children are direct: Depressed mothers simply may not have the psychological resources necessary for effective parenting resulting in child behavior problems. In a longitudinal study of preschool children with behavior problems, Egeland et al. (1990) provided evidence for this direct link. They found that mothers whose levels of depressive symptomatology decreased over time had children whose functioning improved; conversely, mothers whose depression increased had children who functioned more poorly. These authors have also cited a substantial research literature linking maternal depression with non-nurturing caretaking behavior (e.g., emotional unavailability, poor communication, inconsistency, hostility, and overinvolvement). Campbell (1996) points out, however, that maternal depression and other forms of parental psychopathology often occur in a context of multiple risk factors, some or all of which may account better for children’s adjustment than parental mental health alone. Life stress and daily hassles can also have a negative influence on child adjustment by depleting the resources of parents (Crnic & Greenberg, 1990). The symptoms of irritability, sadness, hostility, and negativity found in depressed mothers are common among highly stressed parents who are not clinically depressed (Downey & Coyne, 1990). It is suggested that stress has a negative effect on parents’ mood, which leads to poor parenting and subsequent adverse child outcomes (Kendziora & O’Leary, 1993). Child Characteristics. The fact that children’s characteristics have an important impact on their relationships with their parents is well accepted. Mothers of infants born prematurely, for example, report more behavior problems in their infants and more parenting stress than mothers of full-term infants (Halpern, Brand, & Malone, 2001). Of all such characteristics that might influence the parent–child relationship, child temperament has engendered the most research. Not only are “difficult” infants more difficult to parent and “easy” infants easier to parent, but children with different temperamental characteristics also respond differently to the same environment. Crockenberg (1987), for example, demonstrated that irritable infants with angry, punitive mothers were more likely to be angry and noncompliant and to have lower self-confidence later than were easy infants with angry, punitive mothers. Child temperament alone, however, does not determine parent–child relationships. Rather, the “fit” among the unique characteristics of the child, the parent, and the environment is the critical factor in developmental outcomes. In a study of high-risk black children, McBride-Murry and Brody (1999) found that parenting protective factors, such as high expectations for child behavior and academic performance and consistent household routines, buffered the effect of difficult child temperament on the children’s ability to self-regulate their behavior. Consistent with this work, Tschann, Kaiser, Chesney, Alkon, and Boyce (1996) found that preschoolers

24

I. THE FOUNDATION

with difficult temperamental characteristics who lived in families with high levels of conflict had the most adjustment problems, both externalizing and internalizing. Easy children had fewer such problems, regardless of the level of family conflict. This research highlights the most important issue for prevention and/or intervention—that is, the interplay among the child’s unique temperamental characteristics, the parents’ capabilities and resources, and the broader environment’s ability to support the child’s development within this family context. Other characteristics of children that have been shown to have an effect on parenting are (1) the presence of conduct problems, (2) activity level, and (3) developmental changes (Kendziora & O’Leary, 1993). Anderson, Lytton, and Romney (1986) demonstrated that children with conduct problems elicited more negative feedback and were more noncompliant, regardless of with whom they were interacting (i.e., their own or someone else’s mother). Similarly, increased activity level (or underactivity in some circumstances) in children has been shown to result in increased parental harshness. Finally, parents must adapt to the developmental changes in their children (McNally, Eisenberg, & Harris, 1991). Parenting practices that are appropriate for a 2-year-old, for example, are not necessarily appropriate for older children (Socolar & Stein, 1996). Social Support Networks. The extent of parents’ social support networks—or, more precisely, the match between the support desired by parents and the support they actually receive—has also been shown to influence how parents care for their children. Positive perceptions of social support are associated with parents’ physical and mental well-being, which in turn affects parenting behavior (Cutrona, 1984; Heller & Swindle, 1983). Belsky (1984) argues that social support can have both direct and indirect effects on parenting behavior. Social support (e.g., being loved by a spouse or partner) can have a beneficial effect on parents’ mental health and sense of well-being in general; it can also provide concrete resources (financial help, child care, etc.) that enhance parenting abilities. Contact with friends and family members that is desired and is positively perceived functions to moderate the stresses of parenting (Crockenberg, 1987). Marital Relationship. For currently married parents, the marital relationship can be considered a source of either support or stress. In separated or divorced families, ongoing conflict between parents may provide a significant source of stress that interferes with their abilities to care for their children adequately. Many studies have documented the relationship among marital conflict (in either divorced or intact families), negative parenting behaviors, and child problems (e.g., Shaw & Emery, 1987; Stoneman, Brody, & Burke, 1989). Other work has shown that in intact families, support from one’s spouse may be a critical factor influencing parenting behavior (Brody, Pillegrini, & Sigel, 1986; Crnic, Greenberg, Ragozin, Robinson, & Basham, 1983; Crockenberg, 1987). Most interesting is a study by Howes and Markman (1989) showing that the quality of the marital relationship before the birth of the child influences the child’s functioning 3–5 years later! Abidin (1989) argues that the only aspect of the marital relationship that is relevant to child rearing is the alliance of the parents around child-rearing issues. Belsky (1984), however, points out that the marital relationship may also have an impact on parents’ general psychological well-being, and as such may exert an indirect but important influence on parenting skills. Homosexual Parents. Another factor of interest to child clinicians is the adjustment of children raised by gay or lesbian parents. It is estimated that between 6 million and 14 million

1. Development of Psychopathology

25

children have gay or lesbian parents. The majority of these children are born in the context of a heterosexual relationship in which one parent subsequently comes out as a homosexual; however, increasing numbers of lesbian and gay couples are seeking to adopt children, provide foster homes, or use artificial insemination to have children. Thus clinicians are increasingly being asked about the impact on children of living in these “nontraditional” households. Historically, the assumption was made that growing up with gay or lesbian parents would have a negative impact on children’s development in general and their psychosexual development in particular, including problems with gender identity, gender role behaviors, and especially sexual orientation. Moreover, these children were thought to be at risk for isolation from or rejection by peers, as well as a broad range of other emotional or behavioral problems. Although research addressing this question is limited, the data overwhelmingly and consistently indicate that children raised by homosexual parents are at no greater risk for these problems than are children growing up in more “traditional” households (Bailey, Bobrow, Wolfe, & Mikach, 1995; Chan, Raboy, & Patterson, 1998; Golombok & Tasker, 1996). In reviews of research related to the adjustment of children living with homosexual parents, C. J. Patterson (1992, 1997) has concluded that these children do not exhibit significant problems in their psychosexual development. They are happy with the sex to which they belong; they have no wish to be members of the opposite sex; and their interests in and preferences for activities are no different from those of other children. Furthermore, there is no evidence that the number of children raised by gay or lesbian parents who as adults identify themselves as homosexual exceeds that expected in the population at large. These children also have normal relationships both with their peers and with adults of both sexes. Finally, Patterson has found no evidence that children with homosexual parents are more vulnerable to being sexually abused, either by their parents or by the parents’ acquaintances, than are children with heterosexual parents. Not surprisingly, the quality of relationships within the family is more important than the sexual orientation of the parents in influencing children’s development (Chan et al., 1998; Patterson, 1995). If parents are open about their sexual orientation, for example, and this is accepted by other significant people, the mental health of both parents and children is improved (Patterson, 1997; Rand, Graham, & Rawlings, 1982). Children’s ability to accept their parents’ homosexuality is influenced by when they first learn about it, however. It is not surprising that children who are first told in early to middle adolescence have the most difficulty, as these children are in the process of exploring their own sexual identity (Huggins, 1989; Schulenberg, 1985). Physical Punishment The use of physical punishment as a disciplinary strategy has generated considerable controversy among both parents and professionals. Nonabusive corporal punishment is extremely common in the United States. Straus and Stewart (1999), in a survey of a nationally representative sample, found that almost all parents hit their children at some time during childhood. No fewer than 35% of parents reported hitting their infants (0 to 1 year), and the prevalence of corporal punishment increased to a peak of 94% among parents of children ages 3–4 years. Prevalence declined rapidly after age 5, but over half of the parents reported hitting their 12year-old children, and 13% said they hit their 17-year-olds! The severest form of punishment— hitting with an object (e.g., a belt or paddle)—was most common for children between the ages of 5 and 12 years (25% of parents), but physical punishment in general was most frequent

26

I. THE FOUNDATION

for 2-year-olds. Physical punishment was most prevalent among African American parents, those living in the South, and parents of boys. These data were replicated by Mahoney, Donnelly, Lewis, and Maynard (2000), who also found that parents of clinic-referred children were more likely to use corporal punishment (spank with bare hand; slap arm, leg, or hand; hit on bottom with hard object; pinch; shake; slap face, head, or ears) and two to three times more likely to use severe physical aggression (hit body with hard object; throw or knock down; hit with fist or kick hard; beat up; grab neck and choke; threaten with knife or gun) with their children than were parents of nonreferred children. As in the Straus and Stewart (1999) study, the use of corporal punishment in general declined with the age of the child; however, the prevalence of severe physical aggression in particular remained stable across development. Furthermore, although their use of corporal punishment declined with child age, parents of clinic-referred adolescents were twice as likely to use corporal punishment to control their children as parents of non-clinic-referred teenagers were. The debate about corporal punishment revolves around whether or not it has harmful effects on children’s development. Reviews of research have reported inconsistent results. Some studies find an association between corporal punishment of children and a variety of adverse effects, such as aggression, depression, and later spouse abuse (e.g., Straus, Sugarman, & GilesSims, 1997; Straus & Yodanis, 1996; Turner & Finkelhor, 1996); others have found no negative effects, at least when the punishment occurs in the context of a warm, supportive parental relationship (Baumrind, 1994, 1996; Rohner, Bourque, & Elordi, 1996). Rohner et al. (1996), for example, reported that corporal punishment had an adverse affect on children’s adjustment only when it was perceived as reflecting parental rejection. In contrast, Turner and Finkelhor (1996) found a significant association between physical punishment and child distress and depression even at low levels of punishment. Moreover, the association was strongest in the context of high parental support. Despite the inconsistency among studies, it seems clear that many children experience corporal punishment as highly stressful, and that for some it results in poor adjustment and increased aggressive behavior (Turner & Finkelhor, 1996; Straus, 1991; Straus & KaufmanKantor, 1994). Moreover, the risk of escalation from corporal punishment to severe physical aggression by parents who rely on physical discipline tactics to control their children or who have particularly difficult children is high (American Academy of Pediatrics, 1998). Mahoney et al. (2000) confirmed that the more parents of clinic-referred children perceived their children as being oppositional and antisocial, the more likely they were to use physical punishment. It is possible that frustrated parents resort to physical punishment because they feel that other methods of discipline have not worked to curb their children’s aversive behavior. However, the use of physical punishment may exacerbate a child’s aggressive and antisocial behavior. Mahoney et al. (2000) argue that their results are consistent with the concept of coercive cycles that develop and escalate in the interaction between parents and children with conduct problems (Patterson, 1982; Patterson, Reid, & Dishion, 1992); this suggests that causation is probably bidirectional. Perhaps a more important question is whether corporal punishment accomplishes what parents want it to. That is, does it teach children to behave in a more appropriate manner? Spanking certainly gets children’s attention, and initially it may stop inappropriate behavior. But research suggests that it is not effective over time. The more it is used, the less effective it becomes—in part because children habituate quickly, forcing parents to punish more frequently and more harshly. Parents who spank their children tend to spank them a lot, and many continue to spank as the children grow older, suggesting that children do not learn how to behave

1. Development of Psychopathology

27

as a result of physical punishment (Straus & Stewart, 1999). It is possible that this is the case because spanking does not teach children acceptable alternative behaviors; it simply teaches them what not to do (American Academy of Pediatrics, 1998). Moreover, physical punishment models an aggressive way of dealing with problems and indicates that it is OK for a bigger person to hit a smaller one. If the real issue is “How do we teach children appropriate behavior?”, learning principles suggest a number of methods that are more effective than physical punishment. These are discussed in detail in Chapter 10. Parenting practices that have been shown to promote more optimal adjustment in children are discussed next. Optimal Parenting Practices Despite the knowledge that many other factors influence children’s behavior, we know that parents remain a critical avenue through which child behavior and development are influenced. With the interrelated factors described above in mind, an important question for clinicians is “What can parents do to ensure more optimal development for their children?” Considerable research has addressed this question, and the major components of optimal parenting are summarized in Table 1.3. Baumrind (1967) first identified an association between “authoritative” parenting (warm, reasonable, nonpunitive, and firm) and positive child behavior. Conversely, overcontrolling or authoritarian discipline and undercontrolling or permissive discipline were associated with negative child behavior. Building on this work, Belsky (1984) has described the kinds of parenting at different ages that are thought to promote optimal child functioning. In infancy, cognitive and motivational competence and healthy socioemotional development are promoted by parents’ attentive, affectionate, stimulating, responsive, and nonrestrictive caregiving. For preschoolers, high levels of nurturance and affection, accompanied by firm control, foster the development of good social skills, resourcefulness, and achievement motivation. By school age, inductive reasoning, consistent discipline, and expressions of affection are positively related to self-esteem, internalized controls, prosocial orientation, and intellectual achievement. Pettit and Bates (1989) suggest that proactive parent behavior—characterized by monitoring children’s activities, providing anticipatory guidance, expressing affection toward the children, and teaching—function to prevent children’s misbehavior and thus reduce the need for parents to react punitively when children behave inappropriately. They found that in families where children were perceived as having behavior problems, mothers exhibited less proactive behavior than mothers in families with nonproblem children did. Dishion and McMahon (1998) propose monitoring as a critical skill that is relevant for parenting from infancy to adolescence, although the specific methods of monitoring will necessarily change with development. “Monitoring” is defined as “a set of correlated parenting behaviors involving attention to and tracking of the child’s whereabouts, activities, and adaptations” (p. 61). It is designed to enhance parents’ awareness of children’s activities and to communicate to children that their parents are concerned about and interested in what they are doing. Monitoring in infancy includes sensitive and responsive parenting, as well as joint attention to play activities. In the preschool years, monitoring ensures a child’s safety and can also be seen in joint attention, with verbal descriptions of the child’s activities. Monitoring a school-age child involves keeping track of school achievement, homework, and activities; knowing who the child’s friends are; and attending extracurricular activities, such as sports events, dance recitals, and school plays. During adolescence, monitoring means knowing where and with whom the child is, tracking school achievement, and attending extracurricular events in which the child is involved.

28

I. THE FOUNDATION

Recent work has examined the role that fathers play in their children’s development (e.g., Amato & Rivera, 1999; Coley, 1998; Tamis-LeMonda & Cabrera, 1999). This work indicates that the involvement of fathers and father figures (stepfathers, adult male friends, and relatives) with children is increasing as more mothers join the work force. A father is more likely to be positively involved with a child if he perceives the birth of the child as a desired event, has participated in the birth process and early care of the infant, has role models for father involvement, has a good relationship with the child’s mother, and has employment that is flexible enough to allow him to spend time with the child (Aldous, Mulligan, & Bjornason, 1998; Belsky, 1998; Brown & Eisenberg, 1995; Cox, Owen, Lewis, & Henderson, 1989). Tamis-LeMonda and Cabrera (1999) have reviewed the research in this area and found that for young children, fathers’ emotional investment, attachment to children, and provision of resources are all associated with the children’s well-being. For older children, fathers’ involvement (attending school meetings and/or parent–teacher conferences) is related to children’s academic performance. Moreover, fathers are particularly important in influencing children’s socialization and academic success. Specifically, Coley (1998) found that children who perceived their fathers as warm and as providing control had fewer behavior problems in school and engaged in more prosocial behaviors with peers. Dysfunctional parenting styles of both fathers and mothers, on the other hand, are clearly associated with a variety of child adjustment problems. The characteristics of dysfunctional parenting have been described by Kendziora and O’Leary (1993) and are summarized in Table 1.3.

Day Care as a Risk Factor General Effects of Day Care Concerns about the effects of day care on the development of children have soared as increasing numbers of mothers join the work force. These concerns revolve around the question of whether day care should be considered a risk factor for children’s development. That is, have negative effects of day care on children’s development been documented—and if so, what areas of development are affected, and what factors mediate or moderate these effects? Research on the effects of day care has focused on children’s emotional, social, and intellectual development. With regard to emotional adjustment, Clarke-Stewart (1989) concludes from a comprehensive review of this research that little consistent evidence exists for detrimental effects of day care on children’s emotional adjustment, as measured by the mother– child attachment relationship. She argues that studies showing that children in day care are less securely attached to their mothers have failed to consider that Ainsworth’s Strange Situation (the most common method of measuring attachment) may not be a valid assessment method for these children; they may not perceive it as a very stressful situation and thus may not exhibit attachment behaviors. Other reviews concur with this reasoning (Hoffman, 1989; Scarr, Phillips, & McCartney, 1990; Scarr, 1998). One recent study, however, has indicated that children are particularly vulnerable to attachment problems at certain ages if they enter day care during these times (Varin, Crugnola, Molina, & Ripamonti, 1996). In this study, children who started day care between 6–12 months and 18–23 months of age had more attachment difficulties and lower tolerance for frustration than those who entered either earlier or later. Research focusing on the effects of day care on children’s social adjustment has consistently documented greater levels of aggression and noncompliance in day care children than in children raised at home (Clarke-Stewart, 1989; Haskins, 1985; Scarr et al., 1990). Other

1. Development of Psychopathology

29

studies, however, suggest that these behaviors may be primarily a function of the curriculum content of the day care program or of specific activities or toys. That is, when the curriculum is modified (e.g., by teaching prosocial behaviors) or activities and toys are changed (e.g., enough trucks are provided so that each child can play with one), levels of aggression and noncompliance decrease (Finkelstein, 1982). With regard to cognitive development, Clarke-Stewart (1989) concludes that day care may give intellectually average children a “head start,” but that children reared at home catch up quickly when they enter school. Among economically and socially disadvantaged children, however, the day care experience may serve to prevent a decline in intellectual functioning that results from a lack of early intellectual stimulation (Ramey & Campbell, 1984). Research on the effects of maternal employment, which almost always involves placing children in out-of-home care, is consistent with that discussed above: No short- or long-term adverse effects of maternal employment on child adjustment have been found (Harvey, 1999). However, Clark, Hyde, Essex, and Klein (1997) demonstrated a relationship between length of maternity leave and the quality of mother–infant interactions; shorter leave was associated with less sensitive parenting. This relationship was mediated by mothers’ symptoms of depression and infant temperament. Clark et al. (1997) suggest that mothers who experience symptoms of depression, and also have infants who are more difficult to care for, may find early return to work very stressful. This stress in turn affects their relationships with their infants and places the children at risk for later adjustment problems. In summarizing research related to mothers’ working, Hoffman (1989) states that “maternal employment is not so robust a variable that it can be related to child outcomes. It operates through its effects on the family environment and the child care arrangements, and these are moderated by parental attitudes, family structure, and other variables” (p. 289). The effects of day care on children’s development thus seem to be mediated by many of the same familial and environmental factors that influence the development of any child (Howes, 1988). These include a mother’s attitudes, beliefs, and perceptions of child rearing; her general sense of well-being; the support she receives from her spouse/partner and/or her family; her level of education; and her child-related behaviors. Factors unique to working mothers and day care that influence children’s development are mothers’ feelings about working and about their child care arrangements, and, most important, the quality of the care provided (Peterson & Peterson, 1986). The quality of day care is a critical factor. Quality of care can be evaluated on two levels: structural and process. High structural quality includes (1) age-appropriate caregiver–child ratios, which are related to increased safety and better cognitive and language stimulation; and (2) smaller group size, which is related to less caregiver time spent in management tasks and more spent in social, educational, and cognitive activities. High process quality consists of (1) sensitivity and responsiveness to the children’s needs; and (2) provision of developmentally apropriate stimulating activities, both of which are associated with caregiver training. A third important aspect of quality is the stability of care or low staff turnover, which gives children the opportunity to form emotional attachments with their substitute caregivers. Quality of care is consistently related to various areas of child development (but see Scarr, 1998, for a different opinion). Moreover, the positive effects of high-quality care during the preschool years have been shown to last well into elementary school (Broberg, Wessels, Lamb, & Hwang, 1997). Burchinal and colleagues (Burchinal, Roberts, Nabors, & Bryant, 1996; Burchinal et al., 2000), for example, have found that quality of care (specifically, child–adult ratio and teacher education) is positively related to children’s cognitive, language, and com-

30

I. THE FOUNDATION

munication skills during the first 3 years of life. Similarly, Volling and Feagans (1995) reported an association between quality of care and children’s social competence, nonsocial play, and positive interactions with caregivers. Furthermore, high-quality day care reduced the incidence of social problems for children who were temperamentally vulnerable (i.e., rated by their mothers as socially fearful). The effects of quality of care are thought to be most important for children who live in impoverished environments (Scarr, 1998). High-quality day care for these infants and preschoolers has been used as a form of early intervention and has been shown to improve their school achievement and social behaviors later in life (Ramey & Ramey, 1992, 1998). Sexual Abuse in Day Care Settings Parents often worry that they have placed their children at increased risk of sexual abuse by leaving them in the care of others. Finkelhor, Williams, and Burns (1988) addressed this concern through a survey of 270 day care settings across the United States in which sexual abuse was substantiated during 1983–1985; these authors concluded that in reality, young children are at greater risk of sexual abuse in their own homes than in day care settings. This study did not include informal small-scale child care operations, however, and thus it may have somewhat underestimated the risk of sexual abuse for children in day care. A study by Margolin (1991) described cases of sexual abuse by nonrelated caregivers in informal arrangements or working in unlicensed, unregistered facilities. In 31% of the sample of 325 cases, the abuse was committed by a caregiver hired by parents, often caring for a child in the parents’ own home. The perpetrators in these cases were more likely than expected to be female (36%) and adolescent (mean age was 16.9 years). Other perpetrators were adult friends of children or parents (18% of cases), relatives of caregivers (16%), ad hoc caregivers (8% of cases), live-in caregivers (8%), or parents of the children’s friends (6%). Most disturbing about these cases is the finding that parents often were extremely careless in choosing a caregiver (e.g., they had reason to believe the caregiver had a history of molesting children, left the child with someone they did not know, or left the child with someone who was intoxicated); did not attend to the child’s discomfort with or dislike of a caregiver; or did not change caregiving arrangements when the child told them about being molested. Provision of adequate and affordable day care for all families who need it is an enormous problem. Although high-quality care is available, it is costly, and many families are forced to rely on less than adequate arrangements. Moreover, the difficulty of finding any child care— much less affordable, good-quality care—is often so great that parents may be tempted to overlook signs that a child is suffering. Finkelhor et al. (1988) discuss the role that parents can play in the early detection, follow-up, and prevention of sexual abuse in day care settings. Their suggestions are summarized in Table 1.4.

PREVENTION OF PROBLEMS Children are prime targets for prevention programs, because many have not yet experienced significant damage from threats to their mental and physical health. The literature contains descriptions of a wide variety of prevention programs for children, including programs to prevent child abuse and accidents; programs to alleviate fears of medical and dental procedures; programs to prevent emotional/behavioral problems for children of divorce or chronically ill

1. Development of Psychopathology

31

TABLE 1.4. What Parents Can Do to Prevent Sexual Abuse in Day Care Settings 1. Visit frequently and at irregular times (e.g., pick up the child early or drop off late). 2. Insist on free access to all areas of the day care center. Locked doors, and rules about when parents can visit, are grounds for suspicion. 3. Participate in the program as much as possible. 4. Interview people who live in or visit regularly the home of the day care provider. 5. Be equally suspicious about day care in “good” and “high-risk” neighborhoods. 6. Be alert to signs of distress in your child, and seek advice from your primary health care provider. • Persistent not wanting to go, and eagerness to leave when picked up. • Significant changes in behavior (e.g., nightmares, toileting problems, general fears, whininess) that resolve when the child is absent from day care for a period of time. • Unusual sexual behaviors. • Physical complaints (e.g., genital rashes, itching, bruising). 7. Discuss the possibility of sexual abuse with your child. • “Nothing that happens should be a secret, no matter what you are told.” • “Tell me immediately if anyone does anything mean.” • “Once you are home, you are safe. Day care staff have no power to harm families.” 8. Teach your child about appropriate and inappropriate behaviors in the bathroom. 9. Teach your child about the intimidation tactics often used to ensure children’s silence. • “If anyone threatens you in any way, tell me right away.” • “Mom and Dad are more important and powerful than any day care teacher. We will always protect you.” Note. Data from Finkelhor, Williams, and Burns (1988). Reprinted from Gordon and Schroeder (1995). Copyright 1995 by Plenum Press. Reprinted by permission.

children; parent education programs; and educational programs for disadvantaged children (Lorion, Myers, Bartel, & Dennis, 1994). Most recently, programs to prevent school-based violence by promoting social competence have been developed (Henrich, Brown, & Aber, 1999). The critical issues for any prevention program are (1) demonstration of the program’s effectiveness in actually preventing the targeted behavior(s) or disorder(s), and (2) its cost– benefit ratio. Price, Cowen, Lorion, and Ramos-McKay (1989) reviewed 300 prevention programs and summarized the components shared by programs with demonstrated effectiveness. Effective programs (1) targeted a specific group of people; (2) were designed to alter the life course trajectory of the participants (i.e., they aimed for long-term rather than short-term effects); (3) strengthened the support systems available in the family, community, and school; and (4) provided extensive, carefully designed research to document their success. Price et al. (1989) state that cost–benefit analyses are rarely done in evaluating prevention programs, despite the critical information these can provide for policy makers and taxpayers. They note two factors to consider in doing such analyses: (1) Benefits may not be apparent in the short term, but rather may increase over often lengthy periods of time; and (2) policy makers and taxpayers want to know who will gain or lose from the program, as well as the size of the gain or loss. Finally, Price et al. (1989) note that although some programs may never be completely costeffective, they may have great value in promoting human dignity or relieving human suffering. Recent work indicates that prevention programs also need to be modified in order to be most effective with children from different cultural groups or ethnic backgrounds (Podorefsky, McDonald-Dowdell, & Beardslee, 2001). The need for prevention programs for children is highlighted by the American Psychological Association Task Force on Prevention, which cites the increasing discrepancy between

32

I. THE FOUNDATION

the number of children who need mental health services and the number of providers of those services (Price et al., 1989). Despite increasing interest in prevention among professionals, Rickel and Allen (1987) argue that competition between prevention and direct services for scarce resources, particularly funding and staff time, has inhibited the development of prevention programs to the extent thought to be necessary. This situation will change only when professionals concerned with the welfare of children bring knowledge from the research community to the attention of legislators and others who shape public policy (Rickel & Allen, 1987). Child clinicians can play an important role in this process by advocating on a local, state, or national level for the needs of children.

Parent Education Programs In an attempt to prevent the common problems of childhood from persisting and/or becoming increasingly severe, professionals have focused on providing parents with information about child development and training in behavior management techniques. Parent education or parent training programs have become increasingly popular, and child clinicians can play an important role by offering these programs to parents in their communities. A distinction is made between “parent education” and “parent training”: Parent education focuses on preventing the development of dysfunctional child behavior, whereas parent training attempts to resolve serious child disturbances (Schaefer & Briesmeister, 1989). Thus parent education is seen as “universal” prevention, whereas parent training is viewed as “selective” or “indicated” prevention. Both types of programs, however, share such techniques as provision of information, teaching behavioral and learning principles, building parenting and communication skills, and developing problem-solving skills. Parent training programs can be viewed broadly as the primary focus in the treatment of young children’s maladaptive behavior. The parents are in fact the ones who must carry out a sleep program or a habit reversal program, or who must change their behavior or the environment to support a child’s learning new skills or decreasing negative behavior. Moreover, many of the parent training programs that focus on teaching specific management techniques also provide parents with techniques that can foster optimal development in many areas. For example, teaching parents how to use reflective comments can foster a child’s language development and self-esteem. Teaching parents how to use time out contributes to an authoritative parenting style (warmth with firm limits). Learning to use contingent reinforcement provides a child with opportunities to develop positive self-esteem and learn new skills in other areas. Parent education has received increased attention from child clinicians. Schultz and Vaughn (1999), for example, surveyed parents attending an urban pediatric primary care clinic about their need for information. Most parents had questions about child rearing and indicated that parent handouts, parent groups, and videotapes shown in the clinic waiting room would all be desirable methods of disseminating information. What should be the focus of programs employing these methods, however? The content and theoretical views of parent education programs are extremely varied, and many do not reflect current research and thinking in child development (Dangel & Polster, 1984; Taylor & Biglan, 1998). As previously stated, it is difficult to identify specific causal mechanisms in the development of childhood disorders, and equally difficult to delineate the specific factors contributing to or mediating outcome (Campbell, 1990). We can, however, share with parents our knowledge about factors that increase vulnerability or resilience in children, including specific parenting styles and practices as outlined in Table 1.3. Teaching parents specific parenting practices that have been shown

1. Development of Psychopathology

33

to increase positive parent–child interactions, and assisting parents in setting limits and providing consistent consequences for inappropriate behavior, would constitute a reasonable approach to parent education programs. To be effective, parent education programs not only should focus on specific information about child development and management techniques, but also should take into account the broader personal needs of the family members. We know, for example, that maternal depression or anxiety, a poor social support network, and marital discord are all associated with the development of behavior problems among children (Bush & Cockrell, 1987; Panaccione & Wahler, 1986; Stoneman et al., 1989). Parents with these problems are less likely to access parent education programs than are better-functioning parents. Moreover, it is important to consider child characteristics in planning for effective parent education, because children respond differently to different parenting techniques. Thus parent education programs should provide information on the relationship of these risk factors to child behavior, as well as guidelines for when parents should seek professional help. Clarke-Stewart (1988) calls for clinicians to provide parent training programs for non-clinic-referred parents that are similar to those designed for parents of behavior-disordered children, and Webster-Stratton (1982) presents evidence that such programs can be effective in changing mothers’ attitudes and behaviors in a costeffective manner. Taylor and Biglan (1998) review the components of parent training programs that have empirical support for their effectiveness. These are discussed in detail in Chapter 10. Taylor and Biglan argue that many popular parenting programs, such as Parent Effectiveness Training (Gordon, 1970) and Systematic Training for Effective Parenting (Dinkmeyer & McKay, 1976), lack any evaluation of effectiveness; some of these programs also strongly advise parents against using certain proven behavioral techniques, such as praise or time out. In contrast to these programs, Taylor and Biglan (1998) recommend several books for parents that offer empirically supported advice for parents. These include Parenting the Strong-Willed Child (Forehand & Long, 1996) and The Incredible Years: A Trouble-Shooting Guide for Parents of Children Aged 3–8 (Webster-Stratton, 1992b). We also like the following books for parents: How to Talk So Kids Will Listen and Listen So Kids Will Talk (Faber & Mazlish, 1999); The Confident Child: A Practical, Compassionate Guide (Apter, 1997); and Hyper-Parenting: Are You Hurting Your Child by Trying Too Hard? (Rosenfeld & Wise, 2000). In summary, this research indicates that the expertise is available to design and implement more effective parent education programs. Further research is needed, however, to examine the relative efficacy of different contents, teaching methods, and instructors for different samples of parents and children.

Prevention of Accidental Injuries Another form of prevention that is receiving increasing interest is the prevention of children’s accidental injuries. The normal developmental chacteristics of children (e.g., mouthing objects, high activity levels, curiosity, and exploratory behavior) place them at high-risk for injuries (Baker, O’Neill, Ginsburg, & Li, 1992). This is reflected in the very high incidence of injuries among children. Data from the National Center for Injury Prevention and Control (1999) indicate that “each year between 20–25% of all children sustain an injury sufficiently severe to require medical attention, missed school and/or bed rest.” Whether a child’s injury is considered accidental or intentional is often difficult to determine; thus data on intentional and nonintentional injuries are often combined. These two types of injury account for more childhood deaths than the next six most frequent causes of death combined. Christophersen notes

34

I. THE FOUNDATION

that there has been a dramatic increase in the number of childhood deaths due to both accidents and violence over the last 50 years, in part reflecting a general increase in violence in U.S. society. The relationship between physical abuse and childhood injuries is complex. Garbarino (1988) has classified childhood injuries on a continuum from random accidents to preventable accidents to negligence to assault, although there is some overlap between these categories (e.g., injuries resulting from automobile accidents would once have been considered random accidents, but now are considered preventable). Furthermore, whether or not an injured child is reported for physical abuse is related to socioeconomic and racial factors. Specifically, black and low-SES white parents who seek medical attention for their children’s injuries are more likely to be reported for child abuse than are white parents from higher-SES backgrounds (Daniel, Hampton, & Newberger, 1983). Injuries that occur in the home are responsible for the majority of childhood deaths, and boys are more vulnerable to these injuries than girls, presumably because of behavioral differences (Christophersen, 1989). Matheny (1986), however, found that characteristics of the mother and the environment were more closely related to injuries than child characteristics were. Toddlers whose mothers were more emotionally stable, active, and energetic; whose mothers had more education; and who lived in better-organized, less cluttered homes were less vulnerable to accidental injury. Poor parenting, particularly a lack of appropriate supervision or monitoring of the child, plays a critical role in the occurrence of childhood injuries (Dishion & McMahon, 1998; Garbarino, 1988). DiLillio and Peterson (2001) outline various approaches to injury prevention, which include passage of laws requiring people to change their behavior (e.g., laws requiring use of seat belts) and passive control by redesign of products and the environment (e.g., safety caps for medicine bottles). Other successful approaches to prevention of accidental injuries have utilized principles of reinforcement. Roberts and Turner (1986), for example, rewarded parents with lottery tokens redeemable for prizes for using child safety seats, and reported significantly increased usage during a 2-week period. Still other approaches have taught parents to use standard behavior management techniques to decrease dangerous behavior in their children (Matthews, Friman, Barone, Ross, & Christophersen, 1987). Of most relevance to the child clinician is research cited by Christophersen (1989) demonstrating that information given to parents before the birth of a child is more effective in changing parents’ child-safetyrelated behavior than information given when the child is a preschooler. Parents are apparently more receptive to child-related information during pregnancy than after the child is born (when they probably are too busy and too tired to pay attention!). This suggests that other types of prevention programs for parents should begin prenatally, at which time parents could be given information designed to prevent a variety of childhood problems.

Early Intervention Programs Yet another form of prevention that interests child clinicians is the early intervention program. Early intervention programs have primarily targeted high-risk children; they include educational programs such as Head Start, model programs such as the Abecedarian Project (Horacek, Ramey, Campbell, Hoffmann, & Fletcher, 1987; Ramey & Campbell, 1984), and interventions in the family system (Heinicke, Beckwith, & Thompson, 1988). Of most concern to child clinicians is family-focused early intervention.

1. Development of Psychopathology

35

Family-focused early intervention is directed at changing parental functioning so that permanent negative effects on children are minimized (Heinicke et al., 1988). This type of intervention is typically “selective” or “indicated.” Intervention can be directed at developing positive child-rearing techniques, improving parents’ abilities to cope with stress, and/or promoting children’s adaptive behaviors. The goal is not only to forestall events that are harmful to children’s development, but also to enhance the children’s ability to cope with difficulties that occur in the normal course of development (Wolfe, Edwards, Manion, & Koverola, 1988). As an example of family-focused early intervention, Sanders (1999) describes a multilevel parenting and family support program that was designed to reduce the prevalence of behavioral and emotional problems in preadolescent children. Components of the program ranged from “universal” to “indicated” prevention and included the following: 1. Media and promotional strategies, such as television and radio advertisments, newspaper columns dealing with common parenting issues, and 13 episodes of a 30-minute “infotainment” television show. 2. A brief 20-minute consultation for parents with specific concerns about a child’s behavior or development, a series of parenting “tip sheets,” and four brief videotape programs. 3. Four 20-minute sessions that presented information, and allowed parents to practice specific skills and selective use of parenting tip sheets. 4. Ten 90-minute individual sessions with home visits for some high-risk individuals, eight group sessions with follow-up telephone contact for other high-risk parents, and telephone-assisted and self-directed parent training for those who could not come to the clinic. 5. Family intervention targeted toward families with additional risk factors that did not change as a result of lower levels of intervention. Each of the components of this program has been evaluated, and all are reported to be successful in meeting their individual goals. In another example, Burns, Hoagwood, and Mrazek (1999) reported long-term (i.e., 15-year!) benefits of a prevention program targeted at highrisk pregnant women. Those who received the most intense and longest intervention (home visits every 2 weeks during pregnancy, continued home visits until a child was 24 months old, free transportation to the health care clinic, and developmental screening at 1 and 2 years of age) demonstrated the most benefit from the program. Benefits noted included less use of welfare, better education, and less drug use. In a review of 20 early intervention studies with high-risk families, Heinicke et al. (1988) found that 15 (75%) showed at least one significant positive effect. The studies reviewed included work with parents during pregnancy, immediately after a child’s birth, and ongoing sessions from the age of 1 month to school entrance. The number of sessions varied from 1 to over 1,000 contacts. Those programs producing a more pervasive effect—that is, those that influenced children’s functioning in a greater number of areas—had 11 or more contacts with each family, which began before or shortly after the birth of the child and continued for up to at least 3 months of age. Heinicke et al. (1988) concluded that this is the length of time needed to develop a trusting relationship with high-risk families and to help them identify and resolve core issues. Although this in no way means that the direct impact on the parent–child relationship is not significant, it does indicate that intervention may be primarily leveraged through

36

I. THE FOUNDATION

the relationship between the intervenor(s) and the family, rather than through direct work with the child. More recently, Ramey and Ramey (1998) have summarized the early intervention research focused on improving children’s cognitive skills. Based on the results of many studies across four decades, they propose six principles that should guide development of successful early intervention programs: 1. Developmental timing. Interventions that begin earlier in a child’s life and continue longer are more effective. 2. Program intensity. Programs that are more intensive (e.g., more visits, more hours, more days per week, more weeks per year) are more effective. Moreover, parents and children who participate more regularly and actively show greater positive results. 3. Direct provision of learning experiences. Children who receive direct intervention show larger and longer-lasting benefits than do children in programs that rely on intermediary intervention, such as training parents in ways to enhance their children’s cognitive development. 4. Program breadth and flexibility. More comprehensive programs that use multiple methods to affect child development are more effective than those with a narrower focus. 5. Individual differences in program benefits. Some children will show greater benefits than others. In some cases those at highest risk benefit most, whereas in other cases the opposite is true. 6. Ecological dominion and environmental maintenance of development. Initial positive effects tend to diminish over time, to the extent that environmental supports to maintain the child’s gains are lacking. Thus programs that involve parents, teachers, and other important adults are likely to be more beneficial. The success of early intervention programs that focus primarily on children has been directly linked to parental involvement. Haskins (1989), in a review of the efficacy of preschool education programs, concluded that although model programs (those included in a national consortium of outstanding early intervention programs) and the Head Start program both have immediate positive effects on the intellectual performance and social competence of children, this effect declines for Head Start children in the first few years of public schooling. In contrast, the evidence for improvement on long-term measures of school performance (e.g., special education placement) and “life success” measures (e.g., teen pregnancy, delinquency, use of welfare, and employment) is substantial for the model programs; there is no evidence linking Head Start attendance with any of these variables. Among the outstanding features of the model programs is parent and teacher involvement, which no doubt accounts for some of these differences. Haskins (1989) describes one program that included 90-minute home visits by teachers each week!

Prevention of Child Abuse Prevention of Physical Abuse Because child physical abuse typically involves the interplay of a wide variety of risk factors, the goals of prevention programs targeted at this problem are necessarily complex. Wolfe, Repucci, and Hart (1995) state that prevention of child abuse involves “establishing the parents’ ability to cope with external demands and provide for the developmental and socialization needs of their children while reducing the barriers of stress that [im]pose upon the family”

1. Development of Psychopathology

37

(p. 6). These authors reviewed research related to prevention programs for physical abuse. Programs that targeted at-risk parents were found to be effective (at least in the short term) in improving parents’ attitudes and behavior, as well as the overall adjustment of mothers. No particular approach was found to be essential, except that fairly intensive group and home visit components were associated with effectiveness. Programs that targeted new and expectant parents (including high-risk low-SES groups) were beneficial even if they provided only brief home visits, if the participants were considered to be at lower risk of abuse; high-risk participants did not benefit from less intense interventions. Programs for adolescent parents required more intensive home visits to demonstrate effectiveness. Wolfe et al. (1995) conclude that multilevel programs offering escalating services over time, depending on the needs of families, are necessary with this diverse population of parents. Programs that continue for 1–3 years and are personalized (i.e., home visits) are most successful with higher-risk parents. Moore, Armsden, and Gogerty (1998) describe an early intervention/prevention day care program for abused and high-risk children ages 1 month to 5 years. The program’s goals were to decrease the long-term adverse effects of maltreatment and to reduce the likelihood of recidivism. Parents and siblings of the targeted children also received services. The 12-year follow-up data indicated that the children who received treatment had fewer behavioral and emotional problems, more positive home environments, and better parent–child relations than a group of abused children who received community services. Furthermore, the treatment group was significantly less prone to violence, aggression, and anger, and had fewer disciplinary actions in school. Prevention of Sexual Abuse With the increase in reports of sexual abuse of children, teaching children personal safety skills has become important. Reviews of research on the effectiveness of child sexual abuse prevention programs find that in general these programs result in knowledge increases (albeit in some cases very small ones) among the participants (Davis & Gidycz, 2000; Wolfe et al., 1995). Active involvement of children is one factor that has been strongly associated with success. Some studies have found that older children benefit more from prevention, whereas others suggest that because older children may know something about sexual abuse prior to participation, they show smaller gains in knowledge than do younger participants. Other work indicates that programs for very young children (i.e., preschool and early elementary school) must be sensitive to the developmental needs of the children in order to be effective. That is, prevention programs must recognize differences in how children at various developmental levels conceptualize sexual abuse (Kolko, 1988; Repucci & Haugaard, 1989). Preschoolers, for example, have difficulty understanding that someone they love could hurt them, and they may not be able to discriminate “good” from “bad” physical contact. Younger elementary-school-age children are often unsure about the nature of sexual abuse and tend to view perpetrators as “bad people,” strangers, or someone close to their own age; preadolescent children understand that sexual abuse involves sexual touching, but view perpetrators as older “mentally ill” or “sexually deviant” people (Wurtele & Miller, 1987). Evaluation research indicates that prevention programs can be successful even for preschool children when they include such behavioral techniques as modeling, guided practice, and reinforcement of appropriate responses (Wurtele, 1990; Wurtele, Kast, Miller-Perrin, & Kondrick, 1989). Wurtele and Miller-Perrin (1992) have summarized the important components of sexual abuse prevention programs for very young children. These programs should

38

I. THE FOUNDATION

focus on teaching simple rules such as protection of private parts, rather than “good touch,” “bad touch,” and “confusing touch,” as the latter concepts are beyond the capabilities of preschool children (Miller-Perrin & Wurtele, 1988). Teaching the importance of disclosure (“Tell someone”) is also considered a critical component of programs for young children, because it is unlikely that all children will be able to get away or say “No” (Kolko, 1988). Finally, the effectiveness of prevention programs for young children increases as the time, effort, and oneon-one practice that are provided increase. “Booster” sessions may be essential for maintaining effectiveness over time (Garbarino, 1988). Involving parents, in combination with teaching behavioral skills (e.g., use of role play, modeling, reinforcement to teach personal protection, recognition of exploitive situations, etc.), has been demonstrated to be a good way to approach sexual abuse prevention, especially for preschool children (e.g., Wurtele, Kast, & Melzer, 1992; Wurtele, Currier, Gillispie, & Franklin, 1991). It is important to note, however, that parents of children who are most at risk for sexual abuse (e.g., children from dysfunctional families, socially isolated youngsters) are least likely to participate in such programs. Furthermore, although parents may be willing to participate in teaching abuse prevention skills to their children, it is likely that they will need information about what to teach. For example, many parents do not know, or do not know how to tell their children, that most sexual abuse is perpetrated by someone known to the child (Wurtele et al., 1991). Providing parents with the information they need to educate their children can improve the parents’ ability to protect their children (e.g., providing better supervision, changing sleeping arrangements, checking on day care centers, etc.), as well as increase the children’s personal safety skills (Wurtele & Miller-Perrin, 1992). Moreover, parents need to know that children who have good self-esteem, problem-solving skills, and sexual knowledge are better able to protect themselves from sexually exploitive situations. It is important to recognize that even the most effective sexual abuse prevention programs do not demonstrate that all children acquire all the information and skills taught. Moreover, there is no ethical way to demonstrate that children actually use the skills they have learned in abusive situations. Fryer, Kraizer, and Miyoshi (1987a, 1987b) engaged 5- to 7-year-olds in an interesting abduction analogue situation following their participation in an abuse prevention program. A research assistant (stranger) approached each child in the school yard and asked the child to accompany him or her to a car to pick up some materials. All but four of the children who participated in the prevention program refused to go (88%), whereas only half of the controls refused. Retraining for all children plus the control group resulted in refusal by everyone but two of these four original participants. Actual abuse situations are very complex, and it is not possible to predict what children will do if and when they are confronted with such a situation. Consequently, it is important for professionals to begin targeting other aspects of the child sexual abuse phenomenon (Wolfe et al., 1995). A review of the epidemiological characteristics of child sexual abuse by Wurtele and Miller-Perrin (1992) suggests several potential targets: 1. Potential perpetrators of sexual abuse. One prevention program, for example, was designed to teach adolescents who were at risk of abusing children about the nature and causes of child sexual abuse. In addition, empathy, anger management, problem solving, decision making, and impulse control skills were taught (Committee for Children, 1989). 2. Sociocultural attitudes and beliefs. Societal attitudes about children, male socialization, sexuality, and male–female relationships contribute to a social context that supports sexual abuse of children (Wurtele & Miller-Perrin, 1992).

1. Development of Psychopathology

39

3. Mass media and pornography. Although a direct connection between erotic portrayals of children and child sexual abuse has not been consistently documented (Murrin & Laws, 1990), it seems reasonable to assume that such films, advertising, and other media may contribute to an increased sexual interest in children and decreased inhibitions about sexual contacts with children.

SUMMARY AND CONCLUSIONS Given the increasing discrepancy between the number of children needing mental health services and the number of providers and funds for these services, child clinicians and researchers must begin to focus on prevention programs. Taken together, the research on parenting styles, as well as that focused on other risk and protective factors, provides guidelines for planning early intervention or prevention programs for families that can enhance children’s development. These programs are based on the assumption that if children are reached early enough, their life course trajectory can be significantly changed for the better. These programs should attempt not only to forestall harmful effects on children’s development, but also to enhance the children’s ability to cope with the difficulties that occur over the normal course of development. This presents a great challenge, given the complex interplay between risk and protective factors: Multiple risk factors may combine and potentiate each other, whereas certain protective factors may buffer the effects of risk and stress. Child biological factors and other characteristics, the social and environmental context, and parental characteristics all must be weighed in the assessment of risk and protective factors. Access to children, however, is necessarily through parents. Reviews of current early intervention programs have suggested that parental involvement in the intervention process is critical to these programs’ effectiveness in preventing child problems. Although there is much to be learned about the processes involved in parent–child interaction and the factors causing and mediating positive outcomes for children, we have the methodology, knowledge, and experience to implement more and better parent education programs, family-focused early interventions, and other prevention programs to enhance the development of children. In doing this, however, the quality of the programs and qualifications of the intervenor(s), as well as documentation of outcome relative to cost, must be carefully considered.

40

I. THE FOUNDATION

CHAPTER 2

Assessment to Intervention

T

he primary task of the child clinician is to identify and treat those children who suffer from emotional and/or behavioral problems that significantly interfere with their development or functioning and are likely to persist without intervention. The first step in accomplishing this complex task is a careful assessment of the presenting problem. The assessment process helps the clinician determine which problems are clinically significant and might benefit from treatment, and which are only annoying and/or transient. The second step, intervention, is necessarily dependent on the quality of the assessment. In addition to determining whether particular behaviors are clinically significant, the assessment process must determine what factors contribute to the problem and what the target areas for intervention should be. Furthermore, a careful assessment informs the clinician about which treatment methods are developmentally appropriate for each child and family. In order to accomplish this task, the clinician must take into account the developmental level of the child; the potential biological influences on the child’s functioning; and the broader ecological factors (familial, social, and cultural) that interact with children’s characteristics. Moreover, the clinician must have knowledge of empirically validated treatment approaches, as well as of ways to document treatment progress for individual cases. In this chapter, we focus on the assessment-to-intervention process in general. First, we discuss issues of diagnostic classification, and review estimates of prevalence for childhood problems. Next, we present a comprehensive assessment-to-intervention system that is adapted to specific problems as they are covered in later chapters. Methods of assessment that we have found most useful in clinical practice are also discussed. Finally, issues central to the treatment process are covered.

ISSUES OF DIAGNOSTIC CLASSIFICATION Assessment and diagnostic classification are parts of a single process. Assessment identifies the distinguishing features of an individual case, whereas classification groups cases according to these features (Kamphaus & Frick, 1996). Some of the benefits of classification systems include (1) promotion of communication among professionals, since each system of classification defines the rules for distinguishing a particular disorder from normal functioning and facilitates reporting of data; (2) translation of research into practice, since classification allows 40

2. Assessment to Intervention

41

one to determine how the features of an individudal case relate to other cases for which research has identified similiar features; and (3) documention of the need for such services as special education, for staff in a particular setting, or for reimbursement of services. In contrast to these advantages, there are inherent problems in any classification system. First, there is no clear way to determine when a behavior should be considered pathological. Second, there is a high degree of overlap between various forms of psychopathology, making categorization of cases difficult. Third, a stigma is often associated with the “label” derived from classification. The labels “mental retardation” or “attention-deficit/hyperactivity disorder” (ADHD), for example, can cause people to treat children differently from their unlabeled peers. In an attempt to deal with this problem, it has recently become standard practice to use classification labels to describe the psychological construct rather than the person (e.g., “a child with ADHD” vs. “an ADHD child”). Although the benefits of classification outweight the disadvantages, it is important that the clinician have a clear understanding of the limitations of different classification systems, that the labels or classification categories be used cautiously, and that classification be used only when there is a clear purpose for doing so (Kamphaus & Frick, 1996). Furthermore, for a classification system to be useful, it must be simple and have explicit rules so that it can be used reliably by different raters over time. It must also be meaningful—that is, valid in terms of the etiology and course of the problem, associated features, or treatment approaches.

Categorical Approach The most commonly used categorical classification system in the United States is the Diagnostic and Statistical Manual of Mental Disorders, presently in its fourth edition (DSM-IV; American Psychiatric Association [APA], 1994). (The text of DSM-IV has recently been revised [DSM-IV-TR; APA, 2000], but the basic criteria sets remain the same.) Another example of the categorical approach is the similar International Classification of Diseases, currently in its 10th revision (ICD-10; World Health Organization, 1992). In both these systems, an individual either meets or does not meet criteria for a particular disorder. The DSM system illustrates many of the problems with the categorical approach to diagnosis. First, diagnostic categories and criteria for defining each disorder are chosen by committees of mental health experts. Hence clinical experience, inferences from the existing empirical literature, and the various orientations of committee members all contribute to the categories that are finally selected for inclusion. As a result, the criteria for many of the diagnostic categories for childhood disorders have changed with each new edition of DSM; children who met the criteria for a particular diagnosis in one edition often fail to qualify for the diagnosis in the next edition, and vice versa (Achenbach, 1998). Second, the assessment process for determining the diagnostic criteria does not always specify what instruments should be used, what informants should be included, and how the rating for presence and severity of the criteria should be made (Cantwell, 1996). A related concern is that there is no systematic method of determining the extent to which symptoms interfere with children’s functioning. This is problematic because impairment of functioning is a key criterion for making a DSM diagnosis, but the evaluation of impairment is currently left to “clinical judgment” (Bird et al., 2000). A third problem with the DSM approach is that the reliability and validity of classifications for infants and toddlers has not been adequately demonstrated (DelCarmen-Wiggins & Carter, 2000). As the criteria for diagnosis became more detailed in DSM-III (APA, 1980) and later DSM editions, structured interviews designed to give yes–no answers about whether a child meets

42

I. THE FOUNDATION

each criterion for each specified category or disorder became increasingly popular (McClellan & Werry, 2000). Structured interviews do not take into account the importance of such factors as the natural history, biological correlates, psychosocial correlates, familiality, and response to treatment, however (Cantwell, 1996). Cantwell (1996) also points out that individual diagnoses in DSM-IV differ widely in the extent to which empirical evidence to substantiate their external validity is available; few childhood and adolescent disorders are fully validated. The DSM-IV childhood disorders for which there is a satisfactory amount of external validation include ADHD, conduct disorder, Rett’s disorder, autistic disorder, Tourette’s disorder, obsessive– compulsive disorder, and anorexia nervosa (Cantwell, 1996). Other questions that are difficult to answer with a categorical approach to classification include (1) how to handle problems that are subthreshold or just miss the criteria or cutoff score for a disorder (the “not otherwise specified” category tends to lump together all disorders that do not meet criteria); (2) how to discriminate one disorder clearly from another disorder; (3) how to deal with comorbidity (i.e., are disorders distinct, or is there something unique about the co-occurrence?); and (4) how to determine whether disorders differ qualitatively or quantitatively from “normal” (Cantwell, 1996) . The use of the DSM classification system can be particularly problematic with children, whose ever-changing development makes it difficult to determine which behaviors are transient developmental problems and which are clinically significant (Campbell, 1990). Although DSM-IV encourages the clinician to view individuals with a particular disorder as heterogeneous and to gather information that goes beyond the diagnosis, it does not provide adequate guidelines for determining the developmental and clinical significance of the symptomatic behaviors that define a problem during early and middle childhood. In addition, although both parent–child and sibling relational problems can be coded as “other conditions that may be a focus of clinical attention” (APA, 1994, p. 675), the diversity of these problems and their importance to the diagnosis of children’s problems are not adequately taken into account (Volkmar & Schwab-Stone, 1996). Despite these difficulties, DSM-IV has the advantage of describing a variety of discrete clinical features in a single term or diagnosis that facilitates communication with others in both clinical and research work (Cantwell, 1996). This latest revision also provides the user with basic scientific information supporting the various categories, including (1) the characteristics of associated features; (2) age, gender, and cultural trends; (3) prevalence; (4) course; and (5) familial patterns (APA, 1994). In addition, there are five DSM-IV sourcebooks (e.g., Widiger, Frances, Davis, & First, 1994) that provide information on the scientific bases for the disorders. Another recently published categorical diagnostic system is the Diagnostic and Statistical Manual for Primary Care (DSM-PC; Wolraich, Felice, & Drotar, 1996), published by the American Academy of Pediatrics. The academy’s goal was to develop a comprehensive and developmentally appropriate categorical diagnostic system in order to help primary care pediatricians recognize, manage, and refer a wide spectrum of children’s behavioral and developmental problems, as well as to take into account stressful family and environmental situations (Drotar, 1999). Some of the critical underlying assumptions of the DSM-PC system include the following: (1) Symptoms are viewed along a continuum from normal variations to severe mental disorders, which is divided into clinically meaningful graduations; (2) the quality of children’s environment is recognized as having a critical impact on their mental health and is taken into account in assessing problems; (3) children’s expression of symptoms and responses to stressful environmental situations vary as a function of age and level of development; and (4) the system is based on objective data where possible and on professional consensus in cases

2. Assessment to Intervention

43

where data are not yet available. In addition, the system was developed to be fully compatible with DSM-IV (APA, 1994) and ICD-10 (World Health Organization, 1992). Although this system is not yet in wide clinical use, and much research must be done to validate it, it holds promise in describing children’s problem behavior and its significance within a particular developmental and environmental context. A fourth system has been developed specifically for the youngest children: the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC 0-3) (Zero to Three, 1994). Although its reliability and validity have not yet been widely studied, the DC 0-3 shows potential for categorizing disorders in the early years, including parent–child relational disturbances.

Dimensional Approach In contrast to the categorical approach, a dimensional or multivariate approach to studying childhood problems assumes that behavior occurs along a continuum (from normal to pathological) rather than dichotomously (an individual either has or does not have a disorder), and bases classification on patterns of behavior covariation (Achenbach, 1998; Kamphaus, Petoskey, Cody, Rowe, & Huberty, 1999). Examples of dimensional systems include the Child Behavior Checklist (CBCL; Achenbach, 1991a, 1992) and the Behavior Assessment System for Children (BASC; Reynolds & Kamphaus, 1992). In the dimensional approach, pools of items are selected for reporting behavioral and emotional problems that are felt to be important among children. These items are then scored for large normative and clinical samples as assessed by different informants (i.e., parent, teacher, child) to determine how well they discriminate between children who are considered in need of help and those who are considered relatively normal (Achenbach, 1998). Factor analysis and principal-component analysis are used to identify sets of problems that co-occur; these sets or patterns of problems are viewed as syndromes, but no assumptions are made about why they covary. Data from the normative samples provide a frame of reference for judging problems reported for individual children. Standard scores or percentiles are used to determine whether a child’s scores on each syndrome are relatively low, medium, or high compared to nonreferred peers and as reported by each of the different informant sources. Thus a dimensional system of classification allows one to describe multiple behavior patterns for an individual child, with cutoff scores used to determine the clinical significance of specific behaviors for different age groups as rated by different respondents. The use of a dimensional approach has some advantages, in that it takes into account a full range of child behavior versus just categories of disorders. It thus provides information about prevention and early intervention for emerging problems, such as depression. Moreover, it considers deviant behavior as a matter of degree rather than as being present or absent, and the inclusion of adaptive scales gives information about protective factors and optimal development (Kamphaus et al., 1999).

Categorical versus Dimensional Approaches Although there has not yet been much research comparing the DSM-IV system with the empirically derived syndromes of dimensional systems, studies with the DSM-III (APA, 1980) or DSM-III-R (APA, 1987) have shown that many common DSM diagnoses for children’s behavioral/emotional problems have counterparts among the empirically based syndromes of the CBCL (Achenbach, 1998; Chen, Faraone, Biederman, & Tsuang, 1994). Achenbach (1998)

44

I. THE FOUNDATION

cautions, however, that the empirically based assessment instruments were designed to measure relatively common behavioral/emotional problems occurring during a particular period of time (i.e., the past 6 months), as reported by different informants who see the child under different conditions. The instruments are not designed to address important relational issues, age of onset, the length of time the behavior has occurred, or the behavior’s impairment of a child’s functioning, all of which are included in the DSM criteria for many disorders. The dimensional approach also is not designed to assess for extremely rare behaviors such as autism. One syndrome that has been found with the CBCL system but is not reported in the DSM system is the cross-informant “social problem syndrome” (e.g., “acts too young for age,” “too dependent,” “doesn’t get along with other kids,” “gets teased a lot,” “not liked by other kids,” “clumsy,” and “prefers being with younger children”). This syndrome appears to represent an important pattern of behavior, and there is empirical evidence to support its high heritability (Edelbrock, Rende, Plomin, & Thompson, 1995), developmental stability (McConaughy, Stanger, & Achenbach, 1992), cross-informant agreement (Sawyer, 1990), and good discrimination between referred and nonreferred children (Achenbach, 1991a, 1991b). Arend, Lavigne, Rosenbaum, Binns, and Christoffell (1996) compared the DSM approach with a dimensional one based on the CBCL and its Profile (Achenbach, 1991a, 1992). Focusing on 510 children ages 2–5 selected from pediatric primary care settings, they compared DSMIII-R (APA, 1987) diagnoses derived from semistructured parent interviews, parent questionaires, play observation, and developmental testing to parent ratings on the CBCL. The greatest convergence between the two approaches was found when there was clearly no problem. Children who received scores below the clinical cutoff on the CBCL but were given a DSM diagnosis were compared with those who scored below the CBCL cutoff but did not receive a DSM diagnosis. These two groups differed in the severity of their behavior and in the number of situations in which the behavior occurred. Arend et al. (1996) also found that children’s lack of cooperation across settings indicated a greater likelihood of more severe behavior problems resulting in a DSM diagnosis. So the addition to the CBCL parent questionnaire of questions regarding the crosssituational nature of the child’s behavior, or having both the teacher and the parent complete the CBCL, should enhance the utility of the CBCL dimensional diagnostic system in identifying children with significant problems that otherwise might be missed. It is remarkable that 28 different DSM-III-R diagnoses were used for this sample of preschoolers (Arend et al., 1996). The prevalence of behavior problems on the CBCL was 8.3%, as compared to 21.4% “probable” diagnoses (9.1% “severe”) with the DSM-III-R. These results differ from those for a sample of older children from pediatric primary care, in which use of the CBCL indicated a prevalence rate of 25% (Costello et al., 1988). The different prevalence rates for older versus younger children raise the question of the DSM categories’ ability to differentiate children’s problems during the preschool years. Although Arend et al. (1996) indicate that interviewing parents and observing a child’s behavior may provide a greater amount and richness of information with which to make a categorical diagnosis, they also point out that the utility of the diagnosis depends on the validity of the DSM-III-R diagnosis for the individual in question. This is an important cautionary note, particularly with preschool children, who exhibit a significant number of problem behaviors that are age-appropriate and transient. One must also be aware that studies identifying preschool children with the DSM versus the CBCL are very likely to represent different samples of children (i.e., clinic-referred vs. community samples) (Keenan, Shaw, Walsh, Delliquadri, & Giovannelli, 1997). Arend et al. (1996) indicate that their data do not lead them to recommend either the categorical or the dimensional approach, but it seems clear that clinical judgment regarding the presence of a signifi-

2. Assessment to Intervention

45

cant problem is enhanced when information is gathered through multiple methods, from several sources, and across situations. Both the authors of the DSM-IV and the developers of dimensional approaches stress the importance of including different types of data in the assessment process, such as medical evaluation, cognitive assessment, physical assessment, parent and child interviews, and direct assessment of the child behavior (e.g., Achenbach, 1998; Bernet, 1999; Kamphaus & Frick, 1996). Research indicates that both the categorical approach and the dimensional approach to classification have problems, which should discourage exclusive reliance on one versus the other (Kamphaus & Frick, 1996). In reality, a combination of these approaches is probably most useful. For example, the categorical distinctions between severe and moderate mental retardation, and between these and normality, are useful for planning services as well as for determining etiology and prognosis. The dimensional aspect of the intelligence level, however, is a very useful indicator within both the normal and abnormal ranges for planning specific educational and rehabilitation programs. Our assessment system, which is discussed later in this chapter, uses a variety of assessment methods to obtain an understanding of the child in comparison to other children the same age. The child’s family, social and ecological factors, and the ways in which the child’s behavior is viewed by the child’s family and others in the child’s environment are also important pieces of information in our approach to assessment. This information leads to a judgment about the significance of a behavior problem and, if necessary, the appropriate areas to be considered for treatment. It can also result in the diagnosis of a specific DSM-IV disorder.

ESTIMATES OF PREVALENCE The prevalence of behavioral and emotional problems among children is difficult to determine because of the various nonstandardized criteria used to identify the presence of a particular problem, as well as the varying labels and definitions of problem behaviors. In addition, the wide developmental and behavioral variability among children from infancy to adolescence makes it difficult to say that a certain behavior or set of behaviors represents a clinical disorder except in extreme cases. Specific behaviors increase and decrease with age (Campbell, 1998). For example, fears, worries, nightmares, toileting problems, and tantrums decrease with age in preschool and school-age children. Disruptive behaviors decrease in the preschool years and increase again as children move toward adolescence. Moreover, many behaviors that might be considered symptoms of psychiatric disorders are surprisingly common in nonclinical samples of children (Campbell, 1998). Table 2.1 indicates prevalence rates for the DSM-IV disorders that have their onset during infancy, childhood, or adolescence. More generally, in a recent review of epidemiological studies conducted in various countries after 1980, Bird (1996) estimated that between 12.4% and 51.3% of children 6–18 years of age have a diagnosable disorder. When only clinically significant or severe disorders are included, estimates of prevalence drop to between 5.9% and 19.4% of children. The wide variation in these rates is thought to be due to cultural factors rather than to methodological differences among studies. In the United States, prevalence of disorders among children and adolescents in the general population is estimated at approximately 17.6%–22% (Nottelmann & Jansen, 1995). Prevalence rates for DSM diagnoses of preschool children are consistent with those for older children, although the types of disorders evidenced may vary. As noted above, Arend

46 I. THEFirst FOUNDATION TABLE 2.1. DSM-IV Disorders Usually Diagnosed in Infancy, Childhood, or Adolescence Disorders

Age of onset

Prevalence

Mental retardation Learning disorders Reading disorder Mathematics disorder Disorder of written expression Motor skills disorders Developmental coordination disorder Communication disorders Expressive language disorder Mixed receptive–expressive language disorder Phonological disorder

Birth

1%

6–9 years 6–10 years 7–? years

4% 1% Unknown

Preschool

6% of 5- to 11-year-olds

3 years Before 4 years

3–5% of school-age children 3% of school-age children

Preschool

2–3% of 6- to 7-year olds; 0.5% of 17-year-olds 1% of preadolescents; 0.8% of adolescents

Stuttering

2–7 years

Pervasive developmental disorders Autistic disorder Rett’s disorder Childhood disintegrative disorder Asperger’s disorder

Before 3 years 5–48 months Before 10 years Preschool to early school age Attention-deficit and disruptive behavior disorders Attention-deficit/hyperactivity disorder Before 7 years Conduct disorder Pre- and early adolescence Oppositional defiant disorder Before age 8—not later than early adolescence Feeding and eating disorders Pica Infancy (?) Rumination disorder 3–12 months Feeding disorder of infancy or early Before 6 years childhood Tic disorders Tourette’s disorder Before 18 years Chronic motor or vocal tic disorder Before 18 years Transient tic disorder Before 18 years Elimination disorders Encopresis At least 4 years Enuresis At least 5 years

Other disorders Separation anxiety disorder Selective mutism Reactive attachment disorder of infancy or early childhood Stereotypic movement disorder

Before 18 years Before 5 years Before 5 years All ages

Note. The data are from American Psychiatric Association (1994).

2–5 cases per 10,000 Uncommon; only females Very rare Unknown; more common in males

3–5% of school-age children 6–16% of males < 18 years 2–9% of females < 18 years 2–16% of children

Unknown Unknown 0.5–2.5% of pediatric hospital admissions 4–5 per 10,000 4–5 per 10,000 4–5 per 10,000 1% of 5-year-olds Age 5: 7% male, 3% female Age 10: 3% male, 2% female Age 18: 1% male 4% of children and adolescents Rare;