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Chapter 15 Developmental Psychopathology Learning Objectives When students have studied the material in this chapter, they will be able to answer the following: • Introduction 1. What issues are covered by developmental psychopathology? 2. How does a developmental approach enhance understanding of psychological problems? 3. What roles do heredity and environment play in the development of various psychological problems? 4. What problems should parents and teachers be particularly concerned about at each stage of development? • A developmental perspective on psychopathology 5. How do risk factors and protective factors in childhood predict adult psychological problems? 6. What forms do connections between childhood and adult psychological problems take? • Explaining psychopathology 7. What are the underlying assumptions of the medical, neurological and physiological, genetic, sociological, behavioral, psychodynamic, and family models of psychopathology? 8. How does a developmental perspective combine the assumptions of the other models? • Some childhood disorders 9. Discuss the symptoms, most likely causes, and most effective treatments for early childhood autism, conduct disorders, attention deficit/hyperactivity disorder, anxiety disorders, childhood depression, and anorexia nervosa. 10. Why is comorbidity common among children with psychological problems? • Childhood disorders and development 11. How does the study of developmental psychopathology shed light on the nature of more general developmental processes? 238 Developmental Psychopathology Chapter Summary Outline Note: Terms in bold print are chapter vocabulary words. Introduction • • • Developmental psychopathology is the study of the origins and course of disordered behavior. It includes the study of disturbed children, the developmental roots of adult disorders, and the patterns that disorders follow after they emerge. It also stresses the major themes of this book: importance of developmental contexts, interaction of genes and environment, role of past development in current developmental outcomes, and orderliness of development despite changes in a person over time. Studying psychopathology from a developmental perspective has enriched our understanding of emotional and behavioral disorders in several ways: 1. It has encouraged us to explore both the origins of abnormal behavior and the ways in which abnormal behavior changes over time. 2. It has focused attention on children who seem to be on a path to developing some disorder yet somehow manage not to develop it. 3. It encourages us to explore how disorders may have their roots in the ways individual resolve (or fail to resolve) the major developmental issues all people face. A Developmental Perspective on Psychoathology • • A major goal of developmental approaches to psychopathology is to understand why some children who are at risk for developing an emotional or behavioral disorder go on to develop it (what are the risk factors?), while others at similar risk do not (what are the protective factors?). Risk Factors and Protective Factors 1. Determining factors that place people at risk for developing an emotional or behavior disorder is a central task of developmental researchers. A risk factor is any factor that increases the likelihood of a negative developmental outcome. May be genetic, familiar, socioeconomic, cultural, or developmental. See Table 15.1 for a summary of risks. 2. The notion of risk is a statistical rather than a causal concept. It applies to groups of people, not to particular individuals. 3. Individual risk factors have limited predictive power, but the presence of multiple risk factors increases that predictive power dramatically. 4. Different combinations of risk factors can lead to the same disorder. 5. Whether risk factors lead to serious emotional or behavior problems is also influenced by the presence of protective factors—factors that promote or maintain healthy development. • Assessing Normal and Abnormal Behavior 1. In developmental psychopathology, normal and abnormal behavior must be considered together. Disorders often have their roots in the ways people handle the normal developmental issues we all face. 2. Some problem behaviors are quite common at certain ages, while others are not (e.g., hallucinations) and may predict later pathology. An example is poor peer relations, not pathological by itself, but the link between peer problems and later maladjustment is understandable. • Change and Stability over Time 239 Chapter 15 1. Although some childhood disorders show rather simple continuity with adult disorders, many do not. Some childhood problems typically disappear with time, while others evolve into quite different forms in later years. 2. There are, however, meaningful links between childhood problems and adult psychopathology. Explaining Psychopathology • • • Various models of psychopathology, or frameworks for explaining why things happen, have been proposed over the years. They focus on the etiology of psychological disorders (conditions that produce them). Most researchers believe that psychological disorders often involve a complex interplay of biology and environment. Researchers differ, however, in where they place their major emphasis—that is, in which factors they consider the primary determinants of a disorder. Biological Perspectives 1. The Traditional Medical Model According to this model, psychological disorders are mental illnesses to be diagnosed and cured, in much the same way as physical diseases. Psychological disturbance is assumed to be linked to an underlying structural or physiological malfunction. Certain mental disorders do fit the medical model (e.g., early childhood autism). 2. Modern Neurological and Physiological Models Chemical imbalances in the neurotransmitters in the brain have been found to be associated with various disorders but should probably not yet be viewed as causes of the disorders but as correlates or markers of a disorder. 3. Genetic Models Researchers who take a genetic perspective assume that some individuals inherit a predisposition to develop certain disorders. • Most of these predispositions must be polygenic, rather than being based on one defective gene. Environmental Perspectives 1. Sociological Models Sociological models of psychopathology stress the social context surrounding children who develop a disorder. Depression and attentional problems have been explored via these models. 2. Behavioral Models Behavioral models focus on specific rewards, punishments, modeled behaviors, and cognitive strategies that might contribute to disturbed behavior. They are based on the assumptions that disruptive responses persist because they are reinforced and that restructuring the environment can change the behavior. Early behavioral models assumed that the symptoms are the disorder; more recent versions take internal cognitive processes into account. 3. Psychodynamic Models Psychodynamic models have evolved from Freud's psychoanalytic theory. They assume that disturbed behavior results from underlying thoughts and feelings produced by life experiences and that merely treating the behavioral symptoms of a problem is not enough. 4. Family Models 240 Developmental Psychopathology • Family models hold that an individual's disturbed symptoms are a reflection of disturbance in the larger family system. Although one person may be labeled as the problem, signs of the family system's disturbance can usually be found in any member of the family. The Developmental Perspective 1. The developmental perspective draws upon and integrates all of the models of psychopathology discussed so far. It assumes that a variety of biological and environmental factors influence abnormal as well as normal development. 2. This approach has been useful for uncovering the variety of factors that may contribute to a particular disorder and also for explaining patterns of change and continuity in the course of emotional problems (e.g., schizophrenia, juvenile depression). Some Childhood Disorders • • For most childhood disorders, both biological and environmental causes have been proposed. Autism is the one childhood disorder about which developmentalists are in agreement that biological factors are largely to blame. The other disorders discussed below are open to a number of explanations. Autism and Related Disorders 1. The core features of autism are a powerful insistence on preserving sameness in the environment, extreme social isolation, and severe speech deficits. Autism afflicts only 4 children in 10,000. 2. Autism is related to autistic spectrum disorders, a range of related pervasive developmental disorders with overlapping symptoms. The extreme syndrome affects 4 in 10,000 children, while autistic spectrum disorders affect every 6 in 1000 children. 3. Autistic children appear physically normal. There is general agreement that it has a biological basis, but it is not clear exactly what it is. 4. Biological bases: Brain imaging studies have found abnormalities in various lobes of the cortex, the cerebellum, and certain limbic structures. Many with autism show seizure disorders as they get older. There also is mounting evidence for genetic contributions. 5. Structured therapy programs can often improve autistic children's functioning, but the long-term outlook for them is not very positive. • Conduct Disorders 1. A conduct disorder is a persistent pattern of behavior that violates the basic rights of others or age-appropriate social norms. 2. There are several types of conduct disorders, distinguished by whether or not the child is aggressive and whether or not he or she can form normal bonds of affection. 3. It is one of the most frequent diagnoses given to children who are referred to mentalhealth centers, especially males. 4. When aggression and anti-social behavior begin early, they are very stable across childhood years and predict problems in adulthood. These disorders are referred to as life-course-persistent conduct disorders. In contrast, adolescence-limited conduct disorders are those that first appear in adolescence, and those who fit this generally do not go on to have chronic problems. 5. Several biological causes for conduct disorders have been suggested (e.g., testosterone levels), and studies have found a link between conduct disorders and a number of environmental factors (e.g., poverty, conflict, abuse). 6. Treatment is often difficult, especially if the disorder is allowed to persist into adolescence. Early intervention and prevention are key ingredients. Programs must last 241 Chapter 15 at least 2 years, provide high quality day care or preschool, provide emotional support for parents, and address the family’s broader context via educational and vocational counseling. • Attention Deficit/Hyperactivity Disorder 1. Children diagnosed with attention deficit/hyperactivity disorder (AD/HD) are a heterogeneous group, with the common thread being attention-related difficulties. 2. It is quite common (3-5% of all children), with the incidence being higher for males. 3. It is often quite difficult to distinguish AD/HD children from those with conduct disorders. As many as half the children fitting the diagnosis of AD/HD also fit that of conduct disorders, a situation referred to as comorbidity. 4. Causes of AD/HD Proving a particular cause is quite complex. Biological theories have received the most attention and support. There is some support for genetic contributions. There is also some evidence for differences between AD/HD and non-AD/HD children in functioning brain regions which support attention capacities, especially during tests of attention. 5. Treatment and Prognosis AD/HD is often treated with stimulants, which (due to a paradoxical drug effect) may increase a child's ability to concentrate but seem to have short-lived effectiveness. Some argue that it offsets a biochemical deficiency in the brains of children with AD/HD. Most popular prescription is Ritalin (methylphenidate); 1.5 million children and adolescents regularly use stimulant medications. • Stimulants may not produce a paradoxical effect, as these children do not slow down with stimulants. Also, just because children’s performance improves with stimulants does not suggest a biological need for them. And, there is reason to doubt the longterm effectiveness of stimulants. Behavioral therapy can be effective for AD/HD sufferers and has been successful in the classroom. This type of therapy with medication works better than medication alone. Many continue to have problems through adolescence, even if they have been treated for years with stimulants. It is important to evaluate the drugs’ long-term effects on the body. Anxiety Disorders 1. Anxiety disorders are less common than conduct disorders or AD/HD (up to 8%). Anxiety disorders include generalized anxiety disorder (very general and pervasive worries and fears) and separation anxiety disorder (excessive anxiety precipitated by separation from someone to whom the child is emotionally attached). 2. Anxiety disorders are more likely than conduct disorders or AD/HD to show spontaneous remission, and they usually do not predict serious problems in adulthood. 3. Only modest evidence exists to show that anxiety disorders are caused mainly by biological factors. 4. Family factors do make contributions to the onset of childhood anxiety disorders. 5. They are generally quite responsive to treatment with either behavioral or psychodynamic therapies. Focusing on the parents’ anxiety also seems useful in treating school anxiety. • Depression 1. It is now recognized that children suffer from depression, often showing such problems through somatic complaints, irritable mood, and social withdrawal rather than motor 242 Developmental Psychopathology slowing and obvious despondency. It is difficult to diagnose because it co-occurs with other problems such as anxiety disorders or AD/HD. 2. It may be distinct from adult onset depression. It is most strongly associated with a history of psychosocial adversity, including stress, anxious attachment, and physical or sexual abuse. • Anorexia Nervosa 1. Anorexia nervosa is a serious eating disorder characterized by extreme reduction in food intake, major weight loss (25% of original weight), and a distorted body image. Some anorectics go on eating binges, but then induce vomiting to avoid gaining weight— a practice called bulimia. This self-abuse can cause serious side effects, even death. 2. Anorexia nervosa is primarily a disorder of middle-class adolescent girls and young women (with perfectionistic tendencies). 3. Biological theories include the possibility of a dysfunctional hypothalamus—not much evidence to support this. 4. Psychological theories have emphasized early sexual abuse or overinvolved, overentangled families. Demand for compliance in return for nurturance. By adolescence, girls with this problem exert control over their bodies, over how much they eat. 5. Why do adolescent girls focus on food to assert their autonomy? Part of the answer is cultural. 6. It is difficult to treat because of the girl’s entrenched belief that she is not too thin and perhaps should become even thinner. Behavioral and family therapies have had some success. 7. 6 to 10 percent die from medical complications or suicide. • Comorbidity 1. Comorbidity is the rule for childhood psychological problems. For example, anorexia overlaps greatly with depression. Depression overlaps with other psychological disorders. 2. May have several causes: 1) limited ways in which children manifest problems (e.g., difficulty concentrating) and 2) childhood problems may not represent distinct syndromes at all. Childhood Disorders and Development • Each of the disorders discussed in this chapter underscores some of the processes of development and sheds light on normal development: 1. Autism marks a profound deviation from normal development and underscores the interrelationships among various areas of development. 2. Conduct disorders show notable stability over time, but their ultimate outcomes are not totally predictable; they predict a wide range of adult problems. 3. Attention deficit/hyperactivity disorder highlights the transformations that can occur over the course of development. 4. Anxiety disorders demonstrate what can happen when normal developmental issues are not successfully negotiated. 5. Anorexia nervosa demonstrates a delayed attempt to establish autonomy—an issue usually addressed initially in toddlerhood; it also illustrates the complexity of developmental pathways. 6. Other disorders illustrate the complex interaction of risk factors and protective factors in the development of psychopathology, both biologically based and environmental ones. For all disorders, the total developmental context must be considered. 243 Chapter 15 Lecture Topics The following are lecture topic suggestions to complement Chapter 15 reading material. Topic 1: Assessing Emotional and Behavioral Problems in Children • • • • Research Questions: Where do we draw the line between the problems of normal children and those of children with serious psychological disorders? How does a developmental perspective help in making the distinction between normal and abnormal? Assessing whether a child is behaving abnormally and, if so, what specific disorder is involved, is an important part of the mental health professional's work. Some children show unquestionably disturbed behavior, such as chronic stealing, lying, fighting, overwhelming fears, or peculiar mannerisms such as finger-flicking. But other children have milder problems that are less obvious. Where do we draw the line between normal and abnormal behavior? Distinguishing between normal and abnormal behavior in children is particularly difficult because many behaviors that are perfectly normal at one age (e.g., tantrums, bed-wetting, separation anxiety, talking to an imaginary person) become increasingly abnormal as the child grows older. Childhood behavior problems become more frequent during two age periods—early childhood and early adolescence—but different problems are common at each age. For example, food finickiness, overactivity, and negativism are all fairly common in early childhood but not later on. In contrast, disturbing dreams, nailbiting, and mood swings are commonly reported adolescent problems that are not common earlier. Also, specific problems displayed are different for boys and for girls. Overaggressiveness is more likely to be reported for boys and shyness more likely to be reported for girls. Research Literature: 1. Achenbach, T. (1982). Developmental psychopathology (2nd ed.). New York: Wiley. 2. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. 3. Cicchetti, D. (1984). The emergence of developmental psychopathology. Child Development, 55, 1-8. 4. Cummings, E. M. (1995). Security, emotionality, and parental depression: A commentary. Developmental Psychology, 31, 425-427. 5. Nolen-Hoeksema, S., Wolfson, A., Mumme, D., & Guskin, K. (1995). Helplessness in children of depressed and nondepressed mothers. Developmental Psychology, 31, 377-387. 6. Sroufe, L. A. (1983). Infant-caregiver attachment and patterns of adaptation and competence. In M. Perlmutter (Ed.), Minnesota symposia in child psychology (Vol. 16). Hillsdale, NJ: Erlbaum. 7. Teti, D. M., Gelfand, D. M., Messinger, D. S., & Isabella, R. (1995). Maternal depression and the quality of early attachment: An examination of infants, preschoolers, and their mothers. Developmental Psychology, 31, 364-376. 8. Wenar, C. (1994). Developmental psychopathology from infancy through adolescence (3rd ed.). New York: McGraw-Hill. • Methods and Results: In judging whether any particular child's behavior is abnormal, a clinician must look at the child's overall patterns of behavior, not just a particular problem in isolation. A common set of criteria for judging a child's behavior includes the following: age-appropriateness of the problem behavior, its persistence, its intractability, the extent to which it interferes with the child's functioning, and how much distress it causes the child and others. 244 Developmental Psychopathology • • Many problems come and go without seriously impairing children's development. Others persist regardless of efforts to overcome them and have far-reaching implications for the child's adjustment. It is the latter that require professional treatment. For purposes of both research and treatment, it is useful to classify children's problems. Certain problems are often observed to occur together in more general syndromes. For instance, a child may be lethargic, weepy, and unable to take pleasure in life, at the same time showing a marked loss of appetite and complaining of feelings of worthlessness. Various causes might be responsible for each of these symptoms considered singly, but together they suggest that the child is suffering from the syndrome of depression. There are three major approaches to compiling descriptions of psychological syndromes: the clinical approach, the empirical approach, and the analysis of developmental profiles. 1. The clinical approach. This approach is based on the experience of clinicians with patients seeking treatment for a variety of psychological disorders. Categories for classifying psychological disorders are established by committees, based on consensus among clinical psychologists or psychiatrists. The American Psychiatric Association's (2000) Diagnostic and Statistical Manual (DSM-IV) is an example of such a system of categories. Clinically developed categories are often later used in research as well. Over time, syndromes that prove to be reliable are retained in the classification system, while undependable ones are discarded or modified. 2. The empirical approach. This approach is based on observation of very large numbers of children and their problems. From the data collected, researchers determine which problems go together empirically—that is, which problems are often observed to be associated with each other. These clusters of problems are then proposed as syndromes and retained if further research verifies their usefulness. The empirical approach is well represented by the work of Achenbach and Edelbrock (Achenbach, 1982). They collected data that consistently showed two dimensions to children's problems: internalizing behaviors, such as anxiety, shyness, and psychosomatic ailments, and externalizing behaviors, such as aggression and hyperactivity. These two dimensions have proven to be very robust; they appear in study after study and are stable for individual children over time. They also have clinical implications, in that externalizing behaviors tend to predict serious adult problems, but internalizing behaviors do not. They have developed checklists of behavioral problems for teachers and parents regarding individual children. A child's score can then be compared to the typical score of children known to have a psychological disturbance. 3. Analysis of developmental profiles. This approach focuses on different patterns of adaptation with respect to major developmental issues and makes use of findings from developmental research. One example is the three patterns of attachment during infancy described by Ainsworth. Successful and unsuccessful developmental adaptations have been identified during other periods as well. For example, some preschoolers adapt very well to the challenges of moving toward greater independence, developing early peer relations and self-management. Others fail to cope well with these developmental tasks and isolate themselves from potential playmates, behave aggressively toward peers, or show great passivity and inhibition. The developmental profiles approach is not really a system for classifying psychopathology. Instead, its major goal is to identify styles of engaging the environment, some of which seem to promote successful functioning and some of which do not. It is possible that some profiles of early behavior may place children at greater risk for particular disorders later on, although such predictions cannot now be made with any certainty. There is evidence, for example, that children who show the anxious-avoidant pattern of attachment during infancy are at risk for later problems with aggression and other conduct disorders. • Discussion Questions: Which of the three approaches for describing childhood syndromes seems to be the most useful? Does your answer differ according to who will be using the system? For example, are all three systems equally suitable for researchers, teachers, and clinical child psychologists? Explain. What are the long- and short-term ethical implications of using a diagnostic system to label children? 245 Chapter 15 Topic 2: Research Strategies for Identifying Developmental Risk Factors • • • Research Questions: What research strategies are used to identify developmental risk factors for psychopathology? What are the advantages and disadvantages of each approach? Developmental psychopathologists are particularly interested in identifying patterns of behavior in childhood that can be used to predict disorders later in life. This is a difficult undertaking because not all such patterns appear disturbed in childhood, and some childhood behavior patterns that do appear disturbed do not predict adult disturbance. Two general types of studies have been used: outcome studies and longitudinal prospective studies. Research Literature: 1. Kety, S., Rosenthal, D., Wender, P., Schultzinger, F., & Jacobson, B. (1978). The biologic and adopted individuals who became schizophrenic. Prevalence of mental illness and other characteristics. In L. Wynne, R. Cromwell, and S. Matthysse (Eds.), The nature of schizophrenia. New York: Wiley. 2. Lyons-Ruth, K. (1995). Broadening our conceptual frameworks: Can we reintroduce relational strategies and implicit representational systems to the study of psychopathology? Developmental Psychology, 31, 432-436. 3. Robins, L. (1966). Deviant children grown up. Baltimore: Williams & Wilkins. 4. Seifer, R. (1995). Perils and pitfalls of high-risk research. Developmental Psychology, 31, 420424. 5. Zeitlin, H. (1982). The natural history of psychiatric disorder in children. Unpublished M.D. thesis, University of London. • Methods and Results: 1. Outcome studies. In outcome studies, researchers either examine the earlier records of disturbed adults (follow-back studies) or they start with children who are showing emotional and behavioral problems and continue studying them into adulthood. Outcome studies have shown some definite relationships between childhood problems and subsequent difficulties in adulthood, but these relationships are not as simple and direct as one might guess. Some of the most dependable signs that a child is likely to suffer future emotional problems turn out to be predictive of several adult disorders, not just one. As mentioned in the textbook, troubled peer relations in childhood are a good example. Having problems with peers is not necessarily a sign of current emotional problems, but it is an indication that a child is at risk of developing one of several adult disorders. One of the best-known outcome studies was the study conducted by Robins (1966) that is described in the textbook. That study was important because it provided clear evidence of the relationships between childhood and adult psychological disorders. In some cases (e.g., sociopaths), Robins found clear evidence of direct continuity between child and adult disorders. In others (e.g., childhood anxiety and shyness), she found no particular association with adult problems. In still others (e.g., schizophrenia), she found adult disorders linked with different sets of symptoms in childhood. Another example of an unexpected link between childhood and adult problems comes from a study conducted in England (Zeitlin, 1982). In this study, records of depressed adult patients who had attended a London clinic as children were examined. Typically, these people had not received a diagnosis of depression during childhood. Rather, they were described as having conduct disorders. What could explain this unexpected association? A deeper look revealed that emotional disturbance, including some depression, had also been present in these subjects as children, but apparently the "acting out" behavior so dominated the picture that the more subtle emotional problems tended to get lost in the diagnoses. What is important is the fact that a major adaptational failure in childhood predicted a later adult disorder. The connection is not as simple as stating that depressed children tend to become depressed adults, but the continuity in developmental problems is there nonetheless. 246 Developmental Psychopathology 2. Longitudinal prospective studies. In this type of study, researchers select a sample of children who do not yet show psychological disturbances. They then follow these children forward in time to find out which life histories are generally linked to good later adjustment and which are tied to later problems. One particular form of this approach is risk research, in which investigators select for study children known to have backgrounds that put them "at risk" for later psychological problems. "At risk" simply means that, given what we know about the antecedents of adult disorders, these children have a higher than average probability of developing some disorder in the future, even though they are currently free of symptoms. Since most psychological disorders are relatively rare in the general population, this strategy increases the efficiency of the research. Investigators need not study 1000 cases or more just to find 20 or 30 of particular interest to them. However, not all the subjects included in risk studies actually develop emotional or behavioral problems; many turn out to be well adjusted. Developmental psychopathologists are very interested in these resilient children. They want to know why, against negative odds, these youngsters manage to avoid psychological disorders. What protective factors are operating in these cases? The answers to these questions are not yet entirely clear, although features of the early caretaking environment seem to be increasingly implicated. Some of the most famous risk studies have been those of children born to schizophrenic mothers. In one such study, researchers followed a number of adopted youngsters, half of whom had a biological parent who was schizophrenic and half of whom had parents with no psychiatric disorders (Kety et al., 1978). A significantly higher percentage of those in the first group developed schizophrenia compared with those in the second group, suggesting a genetic component contributing to schizophrenia. Note, however, that the vast majority of children with schizophrenic parents or siblings do not themselves become schizophrenic. Researchers are currently very interested in what factors make some children of schizophrenic parents less vulnerable to developing the disorder than others. Of course, not all children of schizophrenic parents will inherit whatever genetic characteristic(s) it is that predisposes an individual to developing schizophrenia. But evidence suggests that even those who do inherit the predisposition are not bound to develop the disorder. Current research, mentioned in the textbook, is focusing on variations in family interaction that may play a role in determining an individual's actual outcome. • Discussion Questions: What are the advantages and disadvantages of each of the research strategies described above? What sorts of ethical dilemmas present themselves to researchers conducting risk research, especially with respect to the issues of intervention and prevention? Which developmental disorders do you think would be most fruitfully investigated using risk research? Which disorder do you think should be the most important research priority for developmental psychopathologists? Explain. Topic 3: Parental Depression and Distress—Implications for Development • • Research Question: What are the developmental consequences for children living with caregivers who have emotional, behavioral, and psychiatric problems, specifically depression and other affective disorders? Research Literature: 1. Campbell, S. B., Cohn, J. F., & Meyers, T. (1995). Depression in first-time mothers: Mother-infant interaction and depression chronicity. Developmental Psychology, 31, 349-357. 2. Cohn, J. F., Matias, R., Tronick, E. Z., Connell, D., & Lyons-Ruth, K. (1986). Face-to-face interactions of depressed mothers and their infants. In T. Field & E. Z. Tronick (Eds.), Maternal depression and child disturbance: New directions for child development, Vol. 34, (pp. 31-46). San Francisco: Jossey-Bass. 3. Field, T. (1992). Infants of depressed mothers. Development and Psychopathology, 4, 49-66. 247 Chapter 15 4. Field, T., Fox, N. A., Pickens, J., & Nawrocki, T. (1995). Relative right frontal EEG activation in 3to 6-month-old infants of "depressed" mothers. Developmental Psychology, 31, 358-363. 5. Ge, X., Conger, R. D., Lorenz, F. O., Shanahan, M., & Elder, G. H., Jr. (1995). Mutual influences in parent and adolescent psychological distress. Developmental Psychology, 31, 406-419. 6. Goldsmith, D. F., & Rogoff, B. (1995). Sensitivity and teaching by dysphoric and nondysphoric women in structured versus unstructured situations. Developmental Psychology, 31, 388-394. 7. Nolen-Hoeksema, S., Wolfson, A., Mumme, D., & Guskin, K. (1995). Helplessness in children of depressed and nondepressed mothers. Developmental Psychology, 31, 377-387. 8. Pianta, R. C. & Egeland, B. (1994). The relation between depressive symptoms and stressful life events in a sample of disadvantaged mothers. Journal of Consulting and Clinical Psychology, 62, 1091-1095. 9. Tarullo, L. B., DeMulder, E. K., Ronsaville, D. S., Brown, E., & Radke-Yarrow, M. (1995). Maternal depression and maternal treatment of siblings as predictors of child psychopathology. Developmenal Psychology, 31, 395-405. 10. Teti, D. M., Gelfand, D. M., Messimger, D. S., & Isabella, R. (1995). Maternal depression and the quality of early attachment: An examination of infants, preschoolers, and their mothers. Developmental Psychology, 31, 364-376. 11. Zahn-Waxler, C. (Ed.). (1995). Parental depression and distress: Implications for development in infancy, childhood, and adolescence [Special section]. Developmental Psychology, 31, 347-436. • • Methods and Results: Children of depressed mothers display a variety of developmental outcomes, at least partly as a function of the family context and social support available to the mother and the severity and chronicity of the mother's depression. Further research is needed to determine the role played by individual difference factors, such as the child's temperament. Effects on infants. Infants of mothers with chronic depression are more likely than infants of nondepressed mothers to experience negative and intrusive caregiving (Cohn, Matias, Tronick, Connell, & Lyons-Ruth, 1986). Developmental and growth delays have been found in infants whose mothers' depression continues beyond the infants' 3rd month (Field, 1992). 1. Campbell, Cohn, & Meyers (1995) videotaped depressed and nondepressed first-time mothers interacting with their infants at home at 2, 4, and 6 months. (In contrast to studies utilizing highrisk clinical samples, they drew their subjects from a relatively low-risk community group of depressed women who met criteria for diagnosis but had not necessarily sought treatment. A demographically similar group of nondepressed women was used as a control group.) At the 2-month observation, there were no differences between depressed and nondepressed mothers during feeding, face-to-face interaction, and toy play. Those whose depressions lasted through 6 months, however, were less positive with their infants during these interactions than women whose depressions were more short-lived, and their babies were less positive during face-to-face interaction. A diagnosis of depression in the postpartum period is not necessarily associated with less optimal mother-infant interaction, but mothers whose depressions last through 6 months may provide their infants with less sensitive and responsive caregiving. Even among depressed mothers, there were differences in the ability to "pull themselves together for their infants and to get pleasure from this relationship" (p. 356). 2. Field, Fox, Pickens, and Nawrocki (1995) recorded brain electrical activity (EEG) in a sample of depressed and nondepressed mothers and their 3- to 6-month-old infants. Field et al. report that a greater number of depressed mothers and their infants versus nondepressed mothers and their infants displayed right frontal EEG asymmetry, indicating that the depressed affect exhibited by infants of depressed mothers is associated with a pattern of brain electrical activity similar to that found in inhibited infants and children, and in chronically depressed adults. Field et al. speculate that the right frontal EEG asymmetry they observed may be useful as a biological marker of infant vulnerability toward an anxious or fearful disposition. 248 Developmental Psychopathology 3. Teti, Gelfand, Messinger, and Isabella (1995) examined relations between maternal depression and attachment security among infant-mother and preschooler-mother dyads. They found that attachment insecurity was associated with maternal depression among infants and preschoolers: "Children without unitary, coherent attachment strategies tended to have more chronically impaired mothers than did children with coherent, organized attachment strategies" (p. 364). • Effects on children. 1. Nolen-Hoeksema, Wolfson, Mumme, and Guskin (1995) assessed helpless behaviors in 5- to 7year-old children of depressed and nondepressed mothers through direct observation, interviews, and teacher ratings. Nolen-Hoeksema et al. also observed the affective tone the mothers set in a joint puzzle task and their tendency to encourage mastery or become intrusive when their children became frustrated at the task. They found that depressed mothers set a more negative affective tone than nondepressed mothers during solvable puzzles, but there were few significant differences between the 2 groups of mothers and children. Overall, mothers—both depressed and nondepressed—who were more negative and hostile and less able to encourage mastery in their children had children who exhibited more helpless behaviors in the puzzle task, who were less likely to endorse active problem-solving approaches to frustrating situations, and whose teachers rated the children as less competent and more prone to helpless behaviors. 2. Goldsmith and Rogoff (1995) examined sensitivity of and teaching by dysphoric mothers (with mild depressive symptomatology) and nondysphoric mothers as they engaged in structured classification tasks and during unstructured activities with unrelated, unfamiliar 5- and 6-year-old children. Goldsmith and Rogoff found significant differences during structured classification tasks. Nondysphoric women were more sensitive to children's level of understanding than dysphoric women and were more likely to use a variety of teaching strategies. In addition, dyads with nondysphoric women were more likely to share decision making than dyads with dysphoric women. These findings suggest that children of depressed mothers may be less likely to experience the type of flexible, sensitive joint problem solving that a number of studies have shown assists children's cognitive development. 3. Tarullo, DeMulder, Ronsaville, Brown, and Radke-Yarrow (1995) examined longitudinally (from early childhood through early adolescence) treatment of sibling pairs by affectively ill and well mothers. Tarullo et al. assessed interaction on dimensions of maternal engagement and criticalirritable behavior. The researchers examined the relative contributions of maternal depression, the quality of maternal treatment, and differential treatment of siblings to each child's psychiatric status. Results showed that maternal bipolar or unipolar illness predicted older siblings' symptoms. Younger siblings' symptoms were predicted by maternal illness as well as maternal engagement and critical-irritable behavior in early childhood. Because "different pathways and different predictors may be significant" (p. 403), these findings highlight the need to study more than one child in a family. The results also underscore "the importance of combining approaches from developmental psychopathology and behavior genetics to understand within-family environments in both at-risk and well families" (p. 404). • • Effects on adolescents. Ge, Conger, Lorenz, Shanahan, and Elder (1995) examined mutual influences over a 3-year period in parent and adolescent distress (symptoms of depression, anxiety, and hostility) reported independently by 4 parent-child dyads: mothers-sons, mothers-daughters, fathers-sons, and fathersdaughters. They found that parent and adolescent distress were reciprocally related across time, with the strongest relations between mothers and sons and between fathers and daughters. Boys were more susceptible to parental distress during early adolescence, and a son's distress had more negative consequences for mothers than the reverse. Girls were more susceptible to parental distress during early to mid-adolescence, and mutual influences were more pronounced for girls who were experiencing the onset of menarche and for girls who had recently experienced a school transition. Discussion Questions: How does a child's developmental status influence the effects of maternal depression? What role is played by the family context in buffering or intensifying these effects? What are the intervention and prevention implications of studies of parental depression? 249 Chapter 15 Topic 4: ADHD Information and Controversy • Reference Information: Many children from preschool through high school are diagnosed with attention-deficit disorder with hyperactivity. With the controversy about misdiagnosis and overdiagnosis of ADHD in this country, many parents and educators are wondering how to properly diagnose the disorder, and furthermore, how to treat the disorder in the event that the child actually suffers with ADHD. Easy to access Web sources exist on this topic. 1. One is from the National Institute of Mental Health and is a three-part information booklet that provides an in-depth summary of the disorder including its diagnosis, treatments, coping strategies, and medication options. It has an extensive list of books and organizations. This threepart booklet can be accessed at http://www.kidsource.com/kidsource/content2/add.nimh.html. 2. A second Web resource on the topic is from the National Information Center for Children and Youth with Disabilities at http://www.kidsource.com/NICHCY/ADD1.html. • Russell Barkley is a well-known researcher and clinician in the ADHD domain and has a number of books available on the topic. He sees ADHD as a neuropsychological disorder of executive functions and a developmental deficit in self-regulation and behavioral inhibition. Some of his publications are: 1. ADHD and the Nature of Self-Control (1997) from Guilford Press. 2. ADHD in Adolescents (1998) with Arthur L. Robin from Guilford Press. 3. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (1998) from Guilford Press. 4. Attention-Deficit Hyperactivity Disorder: A Clinical Workbook (1998) with Kevin Murphy from Guilford Press. • • There has been a backlash to the medication option for ADHD as over two million children are treated with Ritalin for ADHD. Many have countered that there are more natural approaches to treating this disorder and several books on the topic have appeared over the past few years. For instance, Dr. Mary Ann Block (1997) wrote a book called No More Ritalin: Treating ADHD Without Drugs by Kensington Publication Corporation. She advocates a drug-free approach. Discussion Questions: Why is ADHD so overdiagnosed in the U.S? Why are we inclined to place children on medication, even at such young ages, and for such an extended period of time? Who should parents listen to and why? Are the drug-free approaches safe? Is Ritalin safe? Classroom Discussion Topics and Activities 1. Eating Disorders: Students can watch a Nova program at the PBS Web site titled “Dying to Be Thin” and then comment on the program. It is at http://www.pbs.org/wgbh/nova/thin/program.html. Students can read the transcript at http://www.pbs.org/wgbh/nova/transcripts/2715thin.html. Hesse-Biber discusses the fact that 1 in every 250 women between the ages of 13 and 22 years suffers from an eating disorder. She explores the reasons why eating disorders are so prevalent in females in our society in her book Am I Thin Enough Yet?: The Cult of Thinness and the Commercialization of Identity (1997) from Oxford University Press. Other books: a. Anorexia and Bulimia (1998) by Paul R. Robbins from Enslow Publishers. For young adults. b. The Body Image Workshop: An 8-Step Program for Learning to Like Your Looks (1997) by Thomas Cash, Ph.D. from New Harbinger. c. Exacting Beauty: Theory, Assessment, and Treatment of Body Image Disturbance (1999) by Thompson, Heinberg, Altabe, and Tantleff-Dunn from APA. 250 Developmental Psychopathology d. Handbook of Treatment for Eating Disorders (1997) by Garner and Garfinkel from Guilford Press. e. Information on eating disorders is available from http://www.anred.com/toc.html Have students discuss why they believe eating disorders occur more frequently in females and do not strike all subgroups within North America equally. What can we do about this growing problem? Which model of psychopathology do they believe deals most effectively in explaining the why of eating disorders? Where can you go for help (see above references to share)? 2. Medicating Children: A Frontline program on “Medicating Kids” is available for students to watch at the PBS Web site http://ww.pbs.org/wgbh/pages/frontline/shows/medicating/watch. Before watching the show, students should make note of their position on medicating children for various mental health challenges (the video pertains to ADHD, ADD, and comorbidity with depression). After the viewing, students should note whether they changed their position, and why. This assignment can overlap discussions of ADHD. 3. ADHD Library Assignment: Understanding the origins of Attention Deficit Hyperactivity Disorder has implications for treatment and educational practices for children and adolescents with ADHD. However, the scientific community is somewhat divided about the origins ADHD. This activity involves students in an informal debate about the origins of ADHD. Students will be divided into two groups in this debate after they have read two articles (min.) that the instructor has placed on library reserve. Two great articles to outline the debate are: Joseph, J. (2000). Not in their genes: A critical review of the genetics of attention deficit hyperactivity disorder. Developmental Review, 20(4), 539–567. Farone, S., & Biederman, J. (2000). Nature, nurture, and attention deficit hyperactivity disorder. Developmental Review, 20(4), 568–581. Have students prepare for one week for the debate. Then have them address questions such as: What are the advantages and disadvantages of each author’s perspective for parents of children with ADHD? What conclusions can be drawn from this activity regarding the nature-nurture debate? What are the advantages and disadvantages to biological explanations for behavior? How might treatment approaches for ADHD differ depending on the two authors’ perspectives on the origins of ADHD? 4. Alcohol Use and Abuse: Many adolescents have tried alcohol and some have crossed the line into abuse of alcohol. For this activity, the instructor will show students an on-line test for alcohol problems and discuss with them important variables to consider when evaluating one’s own drinking behavior. Students will be encouraged to obtain their own personal profile by taking the on-line survey. The Alcohol Use Disorders Identification Test (AUDIT), developed by the World Health Organization in 1999 to screen for dangerous drinking patterns, is available from the following site: http://www.alcoholscreening.org/screening/index.asp. Be sure to address contributing factors to alcohol abuse by adolescents, college students, and persons in various cultures. Students may have some concerns about their drinking patterns, and information should be posted regarding the counseling center’s number and location on or near your campus. 5. What is normal?: Have your students comment on what is and is not “normal” or “normative” behavior in our society. Have them comment on what types of “abnormal” behaviors of the past are not seen as “abnormal” in present day society. Along with this discussion, have students comment on the DSM. What are the pros and cons to having this manual, now in its text-revised (2000) fourth edition? Have students consider what difference taking a developmental approach to explaining and treating psychopathology might make. What practical implications does such an approach have? Ask students to consider whether cross-cultural studies might shed light on the causes of psychological disorders. Encourage the class to list and explore all of the ways in which crosscultural research might illuminate environmental and biological factors contributing to specific 251 Chapter 15 disorders. In addition, ask them to reflect on whether some disorders might be more universal (i.e., found in all cultures) than others and to explain their answers. (A good "starter" example for this question might be anorexia nervosa.) Combine this discussion with item 1 above. Invite a clinical psychologist or a pediatric psychiatrist to discuss the issue of non-normative developmental issues in childhood and adolescence. Have students organize questions to ask pertaining to one particular mental health challenge that interests them. 6. Suicide Risk in Adolescence: Invite a speaker or several (if available in your area—larger cities will have this option) to address issues of adolescent suicide, particularly as it relates to depression, drug abuse, and/or sexual orientation. Have hotline information available for students to take with them. In anticipation of the speaker(s) presentation, have students consider risk factors that they believe are prevalent in adolescent suicide. Perhaps the movie listed under the video resource list on “Teen Suicide” could be shown, as it discusses the risk factors associated with this tragedy. Other resources can be obtained from http://www.aap.org/advocacy/childhealthmonth/prevteensuicide.htm. 7. Discussion of the Neurological Model: Have your students comment on what they like and do not like regarding the modern neurological and physiological models of psychopathology. To add substance to this discussion, you may wish to share information from an article in Time magazine of September 29, 1997 called “The Mood Molecule” by Michael D. Lemonick. In this article is a digestible discussion of serotonin drugs and how they treat everything from depression to overeating, but there can be risks. • Obtain a copy or two of recent books regarding natural remedies for psychological disorders for discussion of alternative views to the neurological/physiological models of disorders, and have students discuss the pros and cons to alternative treatments. Are we a pill-happy society? If we listen more to our bodies and take more time to treat our bodies well, might we need fewer medications to boost our moods? Some examples of books available on the topic are: Beyond Prozac: Brain-Toxic Lifestyles, Natural Antidotes and New Generation Antidepressants by Dr. Michael Norden (1996) from Harper Collins. Natural Prozac: Learning to Release Your Body’s Own Anti-Depressants by Dr. Joeal C. Robertson (1998) from Harper Collins. Potatoes Not Prozac by Dr. Kathleen DesMaisons and Candace Pert (1999) from Simon and Schuster. Films, Videos, and Internet Resources Films and Videos: • Asperger Syndrome: Living Outside the Bell Curve (2001, 18 min., Insight Media). Featuring the expertise of Tina Iyama, this video describes the causes and symptoms of Asperger Syndrome and examines a range of coping strategies. It profiles twelve-year-old Andrew, revealing that, with appropriate support, it is possible for a student with Asperger’s to flourish outside the social and educational bell curve. • Autism and Asperger’s Disorder (CD-ROM) (2002, Insight Media).This CD-ROM takes an in-depth look at Autism and Asperger’s Disorder, describing the characteristics of each condition, associated learning styles, and communication weaknesses. It also presents effective intervention strategies. • Depression: A Teenager’s Guide (18 min., Films for the Humanities and Sciences). Today more than two million teenagers suffer from clinical depression—which can lead to substance abuse and even suicide—but only 40% seek help. In this fact-filled, down-to-earth program, medical professionals and six young men and women speak out about depression: what it is, what it feels like, how to identify it, what its triggers and symptoms are, and how to treat it. This candid guide is an indispensable part of any teen-oriented depression awareness program. 252 Developmental Psychopathology • • • • • • • • • • • Childhood Depression (2000, 28 min., Insight Media). Between four and eight percent of American children experience depression. For girls, the numbers are twice as high. Featuring the commentary of a child psychiatrist and child psychologist, this video shows how swift intervention can interrupt potential patterns of repeated depression later in life, improve school performance and socialization, and prevent substance abuse and suicide. Childhood Depression (19 min., Insight Media). This program profiles a three-year-old boy and his parents, who all have depressive disorders. The mother discusses how depression has affected her all her life and how she fears that her son may face the same problems. Mother and son visit Dr. Donald McKew, author of Why Isn’t Johnny Crying: Coping with Depression, who explains how genetic disorders and chemical imbalance can lead to mood disorders. The program emphasizes the importance of encouraging young people to express their feelings. Coping with Attention Deficit Disorder (1995, 20 min., Films for the Humanities and Sciences). Not so long ago, Andy might have been labeled a problem, a hyperactive child. In fact, he has one of the most common behavioral disorders among American children—Attention Deficit Hyperactivity Disorder, ADHD. This program explains what ADD and ADHD are: causes, symptoms, proper evaluation and diagnosis, and approaches to treatment. The emotional impact of ADD and ADHD on those suffering from the disorder and on their families can be devastating, and the program offers expert advice on coping with this challenge. Counseling and Parenting Difficult Teens (1995, 25 min. each, Insight Media). This three-part set teaches counselors and parents how to resolve conflicts with teenagers by improving communication. Presenting dramatizations involving defiant teenagers, gang members, and substance abusers, the program explores issues within each crisis and shows how to resolve them. Eating Disorders (1994, 19 min., Films for the Humanities and Sciences). This program covers the personality profiles of the likeliest anorectic individuals and shows how anorexia develops and can be cured. Hidden Scars, Silent Wounds: Understanding Self-Injury (2002, 23 min., Insight Media). Self-injury refers to a pattern in which a person cuts or burns parts of the body to relieve pent-up emotional stress. Typically, sufferers have endured traumatic or abusive events or family situations and have resorted to self-injury as an unhealthy coping mechanism. This video explains and demystifies the problem and includes candid interviews with sufferers and their families. Identifying and Responding to Trauma in Ages 6 to Adolescence (2002, 29 min., Insight Media). Older children suffering from the effects of emotional trauma are frequently misdiagnosed as having attention deficit disorder or chronic depression. This video addresses the common trauma-related problems for adolescents and explains how to help them form positive attachments and overcome their anxieties and feelings of distrust. It includes information applicable to the traumatic terrorist attacks of September 11, 2001. Kids Under the Influence (1989, 58 min., Films for the Humanities and Sciences). Examines the longterm psychological and physical disorders caused by alcohol consumption among adolescents. Managing Oppositional Youth (1997, 53 min., Insight Media). Reviewing many of the causes of oppositional, strong-willed behavior, this video outlines effective, practical strategies for managing hard-to-manage children and teens. It includes expert commentary to help viewers better understand how to improve outcomes at home and at school, as well as how to handle difficult parent-child and teacher-student interactions. Misunderstood Minds (2002, 1 hr. 30 min., PBS). Follow the compelling personal stories of five children struggling with learning differences and their families in this remarkable 90-minute documentary. As parents, educators, clinicians, and other professionals help the kids better understand their learning profiles, they gain strategies and solutions that lead toward success both in and out of the classroom. Reviving Ophelia: Saving the Selves of Adolescent Girls (1998, 35 min., Insight Media). Psychologist Mary Pipher examines the role of media and popular culture in shaping the identities of teenaged girls. She discusses teen pressures, sexuality, relationships, and issues of freedom. 253 Chapter 15 • • • • • • • The Secret Life of Mary Margaret: Portrait of a Bulimic (1993, 30 min., Ambrose Video). HBO awardwinning video about a bulimic young American woman. Street Gangs of Los Angeles (1994, 44 min., Films for the Humanities and Sciences). This program looks at the thrills and dangers of life for Black and Hispanic gang members and their parents to stand up for their own rights. Muslim girls, in particular, are unhappy when their parents try to prevent them from becoming part of Western culture. Teenage Suicide (1994, 19 min., Films for the Humanities and Sciences). This documentary explores some of the reasons teens commit suicide and the recent increase in suicide. It also describes some of the behavior patterns of which family and friends should be aware. Trouble in Mind (1999, 30 min. each, Insight Media). Each video in this set focuses on a common mental disorder, describing typical behavior and showing how to spot and interpret symptoms. The disorders include Alzheimer’s disease, anti-social personality disorder, ADHD, bipolar disorder, delirium, depression, eating disorder, obsessive-compulsive disorder, panic disorder, PTSD, postpartum depression, psychosomatic disorder, and schizophrenia. Understanding Attention Deficit Hyperactivity Disorder (1996, 20 min., Films for the Humanities and Sciences). Found in both children and adults, Attention Deficit Hyperactivity Disorder is looked upon by some as having a physiological cause while others see it as a psychological disorder. This program offers diverse and candid opinions from both sides of the debate. Is medication the best treatment, or is behavior modification combined with increased structure and discipline the preferable course? A classroom teacher, a social worker, a behavior specialist, a pediatrician, and a parent with twins who have ADHD offer their insights. A Meridian Production. (20 minutes, color) Understanding Eating Disorders (2002, 24 min., Insight Media). Introducing three major eating disorders (anorexia nervosa, bulimia, and binge eating), this program describes warning signs, side effects, and emotional and psychological underpinnings. It presents the stories of Mindi, Josh, and Kristen who reveal that eating disorders can happen to anyone, male or female, and, in the worst case scenario, can be fatal. It addresses related issues of personality, self-esteem, and body image. Understanding the Defiant Child (1997, 34 min., Insight Media). Offering a clear picture of children who routinely demonstrate negative, hostile, and defiant behavior, this video illuminates the nature and causes of ODD and explains its relationship to ADD. Russell Barkley explains how to recognize ODD and distinguish it from less severe misbehavior. A-V Resource List Information: • List of providers for most of the videos listed above: 1. Ambrose Video at www.ambrosevideo.com or 800-526-4663 2. Davidson Films at www.davidsonfilms.com or 888-437-4200. 3. Films for the Humanities and Sciences at www.films.com or 800-257-5126. 4. Insight Media at www.insight-media.com or 212-721-6316. 5. Magna Systems at 708-382-6477. 6. Public Broadcasting Service at 1-800-949-8670 or www.shop.pbs.org 7. Yale University Films at 203-432-0148. Additional Internet Resource Options for Chapter 15: http://www.mhhe.com/dehart5 A variety of teaching tools for this textbook are available from the Web site for McGraw-Hill. 254 Developmental Psychopathology http://www.nimh.nih.gov/publicat/autism.cfm National Institute of Mental Health Autism information http://web.nami.org/helpline/depression-child.html National Association for the Mentally Ill—facts and information on childhood depression http://www.symptoms-of-depression.com/html/children_and_teens.php3 Information on mood disorders in children and adolescents. http://www.childhoodanxietynetwork.org/htm/td1.htm A guide into the world of childhood anxiety and related childhood disorders. It is an up-to-date site with the newest research and information about: ADHD, OCD, Panic, Selective Mutism, Separation Anxiety, Depression, Generalized Anxiety Disorder (GAD), Social Anxiety, PTSD, Trichotillomania, Specific Phobia, etc. http://www.nmha.org/infoctr/factsheets/74.cfm National Mental Health Association fact sheets and information on conduct disorders. http://www.nimh.nih.gov/publicat/helpchild.cfm National Institute on Mental Health information on ADHD. http://www.mentalhealth.com/dis/p20-ch01.html Internet Mental Health, with numerous links to information about attention-deficit hyperactivity disorder. http://www.psych.org/public_info/child.cfm American Psychiatric Association’s listings of information on various childhood disorders. http://www.aap.org/advocacy/childhealthmonth/prevteensuicide.htm Suicide is the eighth leading cause of death for all persons regardless of age, sex or race; the third leading cause of death for young people aged 15 to 24; and the fourth leading cause of death for persons between the ages of 10 and 14. http://www.aacap.org/publications/factsfam/eating.htm Information on eating disorders from the American Academy of Child and Adolescent Psychiatry. http://www.anred.com/toc.html This site gives statistics, definitions, and descriptions of eating disorders, including obesity. Links to additional sources of information are also available. http://education.indiana.edu/cas/adol/adol.html Adolescence Directory On-Line (ADOL) is an electronic guide to information on adolescent issues. It is a service of the Center for Adolescent Studies at Indiana University. Educators, counselors, parents, researchers, health practitioners, and adolescents can use ADOL to find Web resources for a variety of topics such as: conflict and violence (prevention and peer mediation), mental health issues (e.g., AD/HD, depression, eating disorders), health and health risk issues (e.g., alcohol and other drugs, obesity, AIDS, sexuality, acne), counselor resources (professional organizations, links to other resources), and teens only (teen zines, homework help, sports, penpals, and games). http://www.talkwithkids.org/twk-press-release-030199.html This survey found that kids in families who talk openly about sex and relationships are more likely to say they would turn to a parent first if faced with a crisis. Read more details about this interesting survey and examine related charts and graphs which go with it. (The survey was conducted by the Kaiser Family Foundation and Children Now.) http://www.personal.psu.edu/faculty/n/x/nxd10/adolesce.htm 255 Chapter 15 This site links to articles on peer pressure, the popularity issue, the decreasing influence of parents, and the increasing influence of the peer group. Information on cliques and crowds, adolescent dating, and additional readings are accessible from the site. http://journals.cec.sped.org/EC/Articles/Article%203.pdf Critical Social Skills for Adolescents With High Incidence Disabilities: Parental Perspectives. This qualitative research explored parental views about critical social skills for adolescents with high-incidence disabilities. Parents in this study shared their beliefs that emotional intelligence and character play critical roles in the social and emotional development of their children. Findings indicate that although parents agree that academic performance is important, they want their children to develop skills in two major areas: (a) interpersonal and intrapersonal skills, which include skills such as communicating, listening, interpreting, and discerning; and (b) moral development, which includes areas of character, empathy, and perseverance/motivation. Only members of the Council for Exceptional Children can view this page. 256