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Abnormal Psychology Fifth Edition Oltmanns and Emery PowerPoint Presentations Prepared by: Cynthia K. Shinabarger Reed This multimedia product and its contents are protected under copyright law. The following are prohibited by law: any public performance or display, including transmission of any image over a network; preparation of any derivative work, including the extraction, in whole or in part, of any images; any rental, lease, or lending of the program. Copyright © Prentice Hall 2007 Chapter Sixteen Psychological Disorders of Childhood This multimedia product and its contents are protected under copyright law. The following are prohibited by law: •any public performance or display, including transmission of any image over a network; •preparation of any derivative work, including the extraction, in whole or in part, of any images; •any rental, lease, or lending of the program. Copyright © Prentice Hall 2007 Chapter Outline • Externalizing Disorders • Internalizing and Other Disorders Copyright © Prentice Hall 2007 Overview • Viewing abnormal behavior within the context of normal development is important to understanding all abnormal behavior. • However, a developmental psychopathology approach is absolutely essential to disorders of childhood, because children change rapidly during the first 20 years of life. • Psychologists become concerned only when a child’s behavior deviates substantially from developmental norms, behavior that is typical for children of a given age. Copyright © Prentice Hall 2007 Overview • Psychological problems that commonly begin during childhood are listed in the DSM-IV-TR category Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. • Other than mental retardation and pervasive developmental disorders, the most important disorders in this category are the various externalizing disorders. • Externalizing disorders create difficulties for the child’s external world. Copyright © Prentice Hall 2007 Overview • Externalizing disorders are characterized by children’s failure to control their behavior according to the expectations of parents, peers, teachers, and/or legal authorities—for example, as a result of hyperactive behavior or conduct problems. Copyright © Prentice Hall 2007 Overview • Internalizing disorders are psychological problems that primarily affect the child’s internal world—for example, excessive anxiety or sadness. • DSM-IV-TR does not list internalizing disorders as separate psychological disorders of childhood; rather, the manual notes that children may qualify for many “adult” diagnoses, such as anxiety or mood disorders. Copyright © Prentice Hall 2007 Externalizing Disorders Symptoms of Externalizing Disorders • Many externalizing symptoms involve violations of age-appropriate social rules, including disobeying parents or teachers, violating social or peer group norms (e.g., annoying others), and perhaps violating the law. • Some misconduct is normal, perhaps even healthy, for children. • However, the rule violations in externalizing disorders are not trivial and are far from “cute.” Copyright © Prentice Hall 2007 Externalizing Disorders Symptoms of Externalizing Disorders (continued) • Externalizing behavior is a far greater concern when it is frequent, intense, lasting, and pervasive. • That is, externalizing behavior is more problematic when it is part of a syndrome, or cluster of problems, than when it is a symptom that occurs in isolation. Copyright © Prentice Hall 2007 Externalizing Disorders Symptoms of Externalizing Disorders (continued) • Children’s age is important to consider in relation to the timing as well as the nature of rule violations. • All children break rules, but children with externalizing problems violate rules at a younger age than is developmentally normal. Copyright © Prentice Hall 2007 Externalizing Disorders Symptoms of Externalizing Disorders (continued) • Psychologists distinguish between externalizing behavior that is adolescent-limited—that ends along with the teen years—and life-coursepersistent antisocial behavior that continues into adult life. • In fact, externalizing problems that begin before adolescence are more likely to persist over the individual’s life course than are problems that begin during adolescence. Copyright © Prentice Hall 2007 Externalizing Disorders Symptoms of Externalizing Disorders (continued) • Children with externalizing problems often are negative, angry, and aggressive. • Impulsive children act before they think. • They struggle with executive functioning, the internal direction of behavior. • Hyperactivity involves squirming, fidgeting, and restless behavior. • Hyperactive children are in constant motion, and they often have trouble sitting still, even during leisure activities like watching television. Copyright © Prentice Hall 2007 Externalizing Disorders Symptoms of Externalizing Disorders (continued) • Attention deficits are characterized by distractibility, frequent shifts from one uncompleted activity to another, careless mistakes, poor organization or effort, and general “spaciness” (for example, not listening well). • As with impulsivity, inattention is not intentional or oppositional; rather, it reflects an inability to maintain a focus despite an apparent desire to do so. Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders • The DSM-IV-TR divides externalizing disorders into three major types. • Attention-deficit/hyperactivity disorder (ADHD) is the problem that you may have heard called “hyperactivity” or perhaps “ADD.” • Oppositional defiant disorder (ODD) includes a wide range of problem behavior generally found among school-aged children. Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • Conduct disorder (CD) is a lot like what you may think of as juvenile delinquency, because CD involves rule violations that also are violations of the law. • Hyperactivity was distinguished from ordinary misbehavior about 100 years ago by British physician George Still, who speculated that the overactivity of some children he treated might be due to biological “defects.” Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • Since then, professionals have debated whether the misbehavior of school-aged children should be divided into two types. • Children with what we now call ADHD are assumed to have a biological problem best treated with medication. • Children with what we now call ODD are seen as having a psychological problem requiring psychological treatment. Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • Interest in what DSM-IV-TR calls conduct disorder also is about 100 years old but has a very different origin. • At the end of the nineteenth century, juvenile crime was distinguished from adult criminal behavior for the first time in American law. • The law adopted a compassionate view of juvenile delinquency, seeing the problem as a product of a troubled upbringing. Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • As a result, the state adopted a parental role in trying to help wayward youth, not just punish them. • Thus, the criminal behavior of juveniles came to be seen as a psychological problem, not just a legal one. Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • Attention-deficit/hyperactivity disorder (ADHD) is characterized by hyperactivity, attention deficit, and impulsivity. • The symptoms of hyperactivity and attention deficit each have been viewed as being the core characteristics of ADHD. Copyright © Prentice Hall 2007 Copyright © Prentice Hall 2007 Copyright © Prentice Hall 2007 Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • Oppositional defiant disorder (ODD) is defined by a pattern of negative, hostile, and defiant behavior. • The rule violations in ODD typically involve minor transgressions, such as refusing to obey adult requests, arguing, and acting angry. Copyright © Prentice Hall 2007 DSM-IV-TR Diagnostic Criteria for Oppositional Defiant Disorder A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present: 1. Often loses temper. 2. Often argues with adults. 3. Often actively defies or refuses to comply with adults’ requests or rules. 4. Often deliberately annoys people. 5. Often blames others for his or her mistakes or misbehavior. 6. Is often touchy or easily annoyed by others. 7. Is often angry and resentful. 8. Is often spiteful and vindictive. B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. Note: Consider a criterion only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level. Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • Professionals have long debated whether ADHD and ODD are the same or separate disorders. • The current consensus is that the two disorders are separate but frequently comorbid. • Not only are ADHD and ODD highly comorbid, but about 25 percent of children with each problem also have a learning disorder. Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • To a lesser extent, ADHD also is comorbid with internalizing disorders such as depression and anxiety. • Comorbid internalizing disorders are particularly common among girls with ADHD. Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • The subtyping of ADHD into the predominantly inattentive, predominantly hyperactive-impulsive, or combined types is another sometimes controversial distinction. • The predominantly inattentive subtype generally is accepted as an important diagnosis. • Some children have difficulty with inattention and information processing, but they exhibit little or no hyperactivity. Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • There is less support for the predominantly hyperactive-impulsive subtype. • Preschool children generally are classified in the predominantly hyperactive-impulsive group, while school-aged children fall into the combined type. • This implies that the two subtypes actually involve the same problems but are developmentally related. Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • Conduct disorder (CD) is defined primarily by a persistent and repetitive pattern of serious rule violations, most of which are illegal as well as antisocial—for example, assault or robbery. • DSM-IV-TR distinguishes the age of onset in defining conduct disorders—a distinction between adolescent-limited versus life-course patterns of antisocial behavior. Copyright © Prentice Hall 2007 Copyright © Prentice Hall 2007 Copyright © Prentice Hall 2007 Externalizing Disorders Diagnosis of Externalizing Disorders (continued) • Most of the symptoms of conduct disorder involve index offenses—crimes against people or property that are illegal at any age. • A few diagnostic criteria are comparable to status offenses—acts that are illegal only because of the youth’s status as a minor. • However, juvenile delinquency is a legal classification, not a mental health term. Copyright © Prentice Hall 2007 Externalizing Disorders Frequency of Externalizing Disorders • The National Academy of Sciences concluded that at least 12 percent of the 63 million children living in the United States suffer from a mental disorder, and the majority of these are externalizing disorders. • Between 3 and 5 percent of children in the United States are estimated to have ADHD at any point in time. Copyright © Prentice Hall 2007 Externalizing Disorders Frequency of Externalizing Disorders (continued) • Anywhere from 5 to 15 percent of youth in the United States may have ODD and/or CD. • After the first few years of life, from two to ten times as many boys as girls have an externalizing disorder. • Except for the normative increase during adolescence, the prevalence of externalizing behavior generally declines with age, although it declines at much earlier ages for girls than for boys. Copyright © Prentice Hall 2007 Externalizing Disorders Frequency of Externalizing Disorders (continued) • Externalizing disorders are associated with various indicators of family adversity, a fact highlighted by British psychiatrist Michael Rutter. • Rutter’s Family Adversity Index includes six family predictors of behavior problems among children: (1) low income, (2) overcrowding in the home, (3) maternal depression, (4) paternal antisocial behavior, (5) conflict between the parents, and (6) removal of the child from the home. Copyright © Prentice Hall 2007 Externalizing Disorders Frequency of Externalizing Disorders (continued) • Other epidemiological findings underscore the relationship between children’s externalizing problems and social disadvantage. • For example, psychological disorders are found in more than 20 percent of children living in inner city neighborhoods and are associated with divorce and single parenting. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders • Research on infants and toddlers indicates that a difficult temperament is a risk factor for later externalizing disorders. • Neuropsychological research suggests other biological contributions to externalizing disorders, particularly to ADHD. • Brain damage can produce overactivity and inattention, but hard signs of brain damage, such as an abnormal CT scan, are found in less than 5 percent of cases of ADHD. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • Neurological soft signs, such as delays in fine motor coordination (as may be evident in poor penmanship), also are more frequent among children with ADHD. • However, many children with ADHD do not show soft signs, while many normal children do. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • Minor anomalies in physical appearance, delays in reaching developmental milestones, and a history of mothers’ pregnancy and birth complications also appear more commonly among children with ADHD than normal children. • Still, researchers have yet to discover a specific marker of biological vulnerability. • One candidate is impairment in the prefrontal cortical-striatal network, an area of the brain that may control executive functions including attention, inhibition, and emotion regulation. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • Several studies show that genetic factors strongly contribute to ADHD. • Strong evidence on genetic contributions does not mean that ADHD is an “either you have it or you don’t” disorder, that is, a problem qualitatively different from normal. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • Genes contribute less to ODD and especially CD than to ADHD. • Genetic influence is stronger for early than late onset antisocial behavior. • Part of what is inherited may be a tendency to react more negatively to adverse environments. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • Specific problems in parenting also contribute to children’s externalizing problems. • One of the most important is psychologist Gerald Patterson’s concept of coercion, which occurs when parents positively reinforce a child’s misbehavior by giving in to the child’s demands. • Coercion describes a system of interaction in which parents and children reciprocally reinforce child misbehavior and parent capitulation. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • Sometimes children misbehave as a way of getting attention rather than as a way of getting what they want. • Negative attention refers to the idea that attempts at punishment sometimes accidentally reinforce children’s misbehavior. • Inconsistent discipline also is linked with children’s externalizing problems. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • Peer groups also can encourage delinquent and antisocial behavior, and among adolescents, peer influences may be stronger than parental ones. • Neighborhood and society also contribute to externalizing problems. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • There are no theories of how social factors play a unique role in the development of ADHD. • Mothers of children with ADHD are more critical, demanding, and controlling compared to the mothers of normal children. • However, research shows that problems primarily are a reaction to the children’s troubles, not a cause of them. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • Several investigators have found problems with self-control among children with externalizing disorders. • Low self-esteem, feelings of low worth, also is sometimes blamed as a cause of externalizing problems, but research shows, perhaps surprisingly, that children with ADHD overestimate rather than undervalue their competence. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • One area of research on self-control focuses on delay of gratification—the adaptive ability to defer smaller but immediate rewards for larger, long-term benefits. • In general, children with externalizing problems are less able to delay gratification and are more oriented to the present than are other children. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • Children with externalizing problems also may fail to exert self-control because they misinterpret the intentions of others, particularly in ambiguous social situations. • A related psychological issue concerns the “conscience” of children with externalizing problems. • Some evidence indicates that aggressive children follow the hedonic principles commonly used by children at younger ages. Copyright © Prentice Hall 2007 Externalizing Disorders Causes of Externalizing Disorders (continued) • Externalizing disorders have many causes, not one. • Biological, psychological, and social factors clearly interact in causing externalizing disorders. • The combination of a difficult temperament and family adversity may result in ODD and eventually conduct disorder, while a temperamentally “easy” child might turn out well-behaved despite growing up in difficult family circumstances. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders • Psychostimulants produce immediate and noticeable improvements in the behavior of about 75 percent of children with ADHD. • Traditionally, medication was discontinued in early adolescence, because it was believed that the problem was “outgrown” by that age. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • However, research shows that, while hyperactivity usually improves during the teen years, problems with inattention and impulsivity often continue. • Thus psychostimulants now are taken through the teen years, and perhaps into adulthood, as interest has grown in “adult ADHD,” inattention, impulsivity, and to a lesser extent, overactivity in adults. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • Numerous double-blind, placebo-controlled studies show that psychostimulants indisputably improve children’s attentiveness and decrease their hyperactivity. • More aggressive behavior therapies, including summer treatment programs, may produce notable benefits. • Still, the evidence establishes psychostimulant medication as the first-line treatment for ADHD. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • Although psychostimulants improve hyperactivity and impulsivity, their effects on attention and learning are less certain. • The side effects of psychostimulants can be troubling. • Some side effects are minor, such as decreased appetite, increased heart rate, and sleeping difficulties. • Other problems are more serious, such as an increase in motor tics in a small percentage of cases. • Evidence that psychostimulants can slow physical growth is also an important concern. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • Psychostimulants are an inexpensive and effective treatment for ADHD, especially in comparison with the alternatives. • Still, the benefits of medication are limited, various side effects are a source of concern, and, most importantly, there is no bright line between normal and abnormal behavior in diagnosing ADHD. • Thus, it is reasonable to ask whether we are overdiagnosing ADHD and overmedicating schoolchildren. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • Over the last decade, physicians tried antidepressants with many children with ADHD who do not respond to psychostimulants. • Antidepressants may affect ADHD symptoms directly for unknown reasons. • However, antidepressants clearly are a secondline treatment for ADHD. • Their use is justified only following the failure of psychostimulants. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • Behavioral family therapy (BFT) is a treatment based on learning theory principles that teaches parents to be very clear and specific about their expectations for children’s behavior, to monitor children’s actions closely, and to systematically reward positive behavior while ignoring or mildly punishing misbehavior. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • BFT is sometimes used as an adjunct or alternative to medication in treating ADHD, although it offers limited benefits for ADHD symptoms. • However, BFT is more promising as a treatment of ODD. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • Numerous programs have been developed to treat conduct disorders and juvenile delinquency. • Research indicates that conduct disorders among adolescents are even more resistant to treatment than are externalizing problems among younger children. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • Some BFT approaches have shown promise in treating young people with family or legal problems. • These treatments are based on principles similar to those in programs for younger children, except that negotiation—actively involving young people in setting rules—is central to BFT with adolescents. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • Multisystemic therapy (MST) is another intervention with conduct disorders that has received considerable attention. • In recognition of the diverse causes of externalizing behavior, MST combines family treatment with coordinated interventions in other important contexts of the troubled child’s life, including peer groups, schools, and neighborhoods. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • Several studies now document that MST therapy improves family relationships, and to a lesser extent, delinquent behavior and troubled peer relationships. • Many adolescents with serious conduct problems or especially troubled families are treated in residential programs outside the home. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • One of the most actively researched residential programs is Achievement Place, a group home that operates according to highly structured behavior therapy principles. • Achievement Place homes, like many similar residential programs, are very effective in improving aggression and noncompliance while the adolescent is living in the treatment setting. • Unfortunately, the programs do not prevent recidivism once the adolescent leaves the residential placement. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • Many delinquent youths are treated in the juvenile justice system, where rehabilitation is supposed to be the goal. • The philosophy of the juvenile justice system in the United States is based on the principle of parens patriae—the state as parent. • In theory, juvenile courts are to help troubled youth, not to punish them. • The juvenile justice system often creates delinquency instead of curing it, and recidivism is lower when delinquents are diverted away from the courts. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • Individually, therapists need to establish good relationships with troubled (and often difficult) children and youth, an important predictor of treatment outcome for externalizing problems. • Another key effort is preventing externalizing disorders from developing by easing the family adversity that creates them. Copyright © Prentice Hall 2007 Externalizing Disorders Treatment of Externalizing Disorders (continued) • For ADHD, hyperactivity generally declines during adolescence, while attention deficits and impulsivity are more likely to continue. • The continuity of symptoms into adult life for about half of children with ADHD is evident in the growing interest in adult ADHD. • Importantly, the prognosis of ADHD depends substantially on whether there is comorbid ODD or CD. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Symptoms of Internalizing Disorders • Children’s internalizing symptoms include sadness, fears, and somatic complaints, as well as other indicators of mood and anxiety disorders—for example, feeling worthless or tense. • DSM-IV-TR does not have a separate category for children’s internalizing disorders, but the manual does identify some unique ways in which children experience the symptoms. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Symptoms of Internalizing Disorders (continued) • When diagnosing major depressive episodes among children and adolescents, for example, the clinician is allowed to substitute “irritable mood” for “depressed mood.” • DSM-IV-TR offers only a few, scattered developmental considerations in diagnostic criteria. • This is due in large part to the fact that the course of children’s normal emotional development is not well charted. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Symptoms of Internalizing Disorders (continued) • The assessment of depression in children can be particularly difficult. • For example, in one study of children hospitalized for depression, clinicians found a correlation of zero between children’s and parents’ ratings on identical measures of the children’s depression. • Parents systematically underestimate the extent of depression reported by their children and adolescents. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Symptoms of Internalizing Disorders (continued) • In assessing children’s internalizing problems, mental health professionals must obtain information from multiple informants—parents, teachers, and the children themselves. • When assessing children directly, child clinical psychologists are sensitive to different signs that may be indicative of depression at different ages. • Depression in children and adolescents often is comorbid both with externalizing problems and with anxiety. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Symptoms of Internalizing Disorders (continued) • As with depression, children often have trouble identifying their anxiety, but they are more aware of their fears, which are immediate and have a clear environmental referent. • Research on the development of children’s fears is more advanced than it is for their anxiety. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Symptoms of Internalizing Disorders (continued) • Three findings from fear research are important to note. • First, children develop different fears for the first time at different ages, and the onset of new fears may be sudden and have no apparent cause in the child’s environment. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Symptoms of Internalizing Disorders (continued) • A second finding is that some fears, particularly fears of uncontrollable events such of disasters, are both common and relatively stable across different ages. • Third, many other fears, especially specific ones like fears of monsters or normal worries about death, become less frequent as children grow older. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Symptoms of Internalizing Disorders (continued) • DSM-IV-TR contains a diagnosis for separation anxiety disorder, which is defined by symptoms such as persistent and excessive worry for the safety of an attachment figure, fears of getting lost or being kidnapped, nightmares with separation themes, and refusal to be alone. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Symptoms of Internalizing Disorders (continued) • Separation anxiety disorder is especially problematic when it interferes with school attendance. • School refusal, also known as school phobia, is characterized by an extreme reluctance to go to school, and is accompanied by various symptoms of anxiety, such as stomachaches and headaches. • Children with internalizing or externalizing problems often have troubled peer relationships. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Symptoms of Internalizing Disorders (continued) • A number of troubling symptoms of children’s psychological disorders are best understood as specific developmental deviations, significant departures from ageappropriate norms in some specific area of functioning. • In fact, some developmental deviations are considered disorders in their own right. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Diagnosis of Internalizing and Other Disorders • In 1896, the psychologist Lightner Witmer established the first psychological clinic for children in the United States. • Despite the early origins of child clinical psychology, children were largely ignored in early classifications of mental disorders. • DSM-I contained only two separate diagnoses for children, and DSM-II listed only seven childhood disorders. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Diagnosis of Internalizing and Other Disorders (continued) • DSM-III recognized a much wider range of childhood disorders, and in fact, contained a proliferation of diagnostic categories, 40 in all. • Although laudable, the new effort was overly ambitious. • Many of the new diagnoses were severely criticized and subsequently were dropped. Copyright © Prentice Hall 2007 Copyright © Prentice Hall 2007 Copyright © Prentice Hall 2007 Copyright © Prentice Hall 2007 Internalizing and Other Disorders Diagnosis of Internalizing and Other Disorders (continued) • Pica is the persistent eating of nonnutritive substances, such as paint or dirt. • Many infants and toddlers put nonnutritive substances in their mouths, but the feeding disorder pica is rarely diagnosed, except among mentally retarded children. • Rumination disorder, the repeated regurgitation and rechewing of food, is another infrequent feeding disorder. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Diagnosis of Internalizing and Other Disorders (continued) • Tourette’s disorder is a rare problem (4 to 5 cases per 10,000 people) that is characterized by repeated motor and verbal tics. • Stereotypic movement disorder is selfstimulation or self-injurious behavior that is serious enough to require treatment, as may occur in mental retardation or pervasive developmental disorder. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Diagnosis of Internalizing and Other Disorders (continued) • Selective mutism involves the consistent failure to speak in certain social situations (for example, in school) while speech is unrestricted in other situations (for example, at home). • Reactive attachment disorder is another rarely diagnosed problem, although it may be more prevalent than we would hope. • Reactive attachment disorder is characterized by severely disturbed and developmentally inappropriate social relationships. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Diagnosis of Internalizing and Other Disorders (continued) • Encopresis and enuresis are common problems. • The terms refer, respectively, to inappropriately controlled defecation and urination. • According to DSM-IV-TR, enuresis may be considered abnormal beginning at age 5, as most children have developed bladder control by this age. • Encopresis, a much less common problem, may be diagnosed beginning at age 4. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Diagnosis of Internalizing and Other Disorders (continued) • Beginning with DSM-III, the manual became overinclusive in its listing of childhood disorders, and included too many “disorders” that are not in fact mental disorders. • Many “disorders” have been dropped, but there seem to be other “childhood disorders” that are not disorders. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Diagnosis of Internalizing and Other Disorders (continued) • Children’s behavior is intimately linked with the family, school, and peer contexts. • Because of this, some experts have suggested that diagnosing individual children is misleading and misguided. • Instead, children’s psychological problems could be classified within the context of key relationships, particularly the family. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Frequency of Internalizing Disorders • The prevalence of externalizing disorders generally decreases as children grow older, but the opposite is true for internalizing disorders. • Depression increases dramatically during preadolescence and adolescence, especially among girls. • Anxiety disorders also are very common, and may occur among as many of 5 to 10 percent of all young people. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Frequency of Internalizing Disorders (continued) • Suicide is the third leading cause of death among teenagers, trailing only automobile accidents and natural causes. • In comparison to adult suicide attempts, suicide attempts among adolescents are more impulsive, are more likely to follow a family conflict, and are more often motivated by anger rather than depression. • Cluster suicides also can occur among teenagers. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Causes of Internalizing Disorders • Most research on the causes of mood and anxiety disorders among children is based on the same theories of etiology we have discussed in relation to adults. • Evidence simply is lacking or inadequate on the development of many other psychological problems of childhood. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Causes of Internalizing Disorders (continued) • Except for some research documenting genetic influences on childhood onset obsessive– compulsive disorder, few behavior genetic studies have been conducted on children’s internalizing disorders. • In the few studies completed to date, widely different estimates of genetic contributions are obtained based on children’s versus parents’ reports. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Causes of Internalizing Disorders (continued) • Jerome Kagan and colleagues have conducted some important basic research that suggests a more general, biological predisposition to anxiousness. • Extreme parental neglect deprives infants of the opportunity to form a selective attachment. • Such neglect can cause reactive attachment disorder, or what attachment researchers sometimes call anaclitic depression—the lack of social responsiveness found among infants who do not have a consistent attachment figure. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Causes of Internalizing Disorders (continued) • A number of longitudinal studies have demonstrated that anxious attachments during infancy foreshadow difficulties in children’s social and emotional adjustment throughout childhood. • However, an insecure attachment does not seem to result in the development of any particular emotional disorder. • Rather, insecure attachments predict a number of internalizing and social difficulties, including lower self-esteem, less competence in peer interaction, and increased dependency on others. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Causes of Internalizing Disorders (continued) • Separation or loss is another threat to attachment, one that clearly causes distress among children, in the short run. • However, research fails to find a relationship between childhood loss and depression during adult life. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Causes of Internalizing Disorders (continued) • Emotion regulation is a process in which children learn to identify, evaluate, and control their feelings based on the reactions, attitudes, and advice of their parents and others in their social world. • Our understanding of children’s emotional development is far from complete, and only scattered research has linked troubles with emotion regulation to children’s internalizing disorders. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Treatment of Internalizing Disorders • Relatively few treatments for anxiety or mood disorders have been developed or studied specifically as they apply to children. • For example, medications known to alleviate depression in adults have rarely been studied among children and adolescents, and may be no more effective than placebos in treating their depression. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Treatment of Internalizing Disorders (continued) • Researchers already have begun to correct the neglect of treatment research on children’s internalizing disorders. • Some forms of cognitive behavior therapy and interpersonal therapy show promise for treating children’s depression, and cognitive behavior therapy and family therapy have produced positive results in treating children’s anxiety. Copyright © Prentice Hall 2007 Internalizing and Other Disorders Treatment of Internalizing Disorders (continued) • Until recently, psychologists believed that children “outgrew” internalizing problems. • Prospective research demonstrates, however, that some internalizing disorders persist over time. Copyright © Prentice Hall 2007