Samenvatting
Ontwikkelingspsychopathologie
Boek
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, Hoofdstuk 1 De ning Child Pathology
Factors that Complicate the Study of Child Psychopathology
In 1800’s, it was thought that children were less likely to su er from mental illness because of
not-fully developed brains.
Until fairly recently, knowledge of disorders of childhood was gathered by looking at disorders
in adulthood. However, there are key di erences, for example in the presentation of depression
in children and adults.
Developmentally sensitive systems need to be used; children are constantly changing. Often
child psychopathology study neglects the broader familial, social, and cultural context.
Another problem is that most forms of psychopathology in children overlap/coexist with other
disorders. I.e. overlap between; child maltreatment, violence, emotional and behavioral
disorders, substance abuse, delinquency, and learning di culties
Psychopathology in children di ers in degree from normal behaviour, rather than in kind of
behaviour. Judgement of deviancy depends on other child characteristics (age, sex,
intelligence), the situational appropriateness of a child’s behaviour, social and cultural context,
and characteristics of adults who make these judgements.
Contextual events have great in uence in producing child/adolescent disorders; sometimes
even greater than within-child factors.
Epigenetic e ects = Genetic in uences are not static, but moderated by regulatory processes,
some of which unfold in response to environment conditions.
Numerous risk markers for child psychopathology have been identi ed; genetic in uences,
temperament, etc. (see blz. 5 for a full list).
Many causes and outcomes of child psychopathology are interrelated and interact.
A speci c factor as a cause or outcome of child psychopathology usually re ects;
1.The point In an ongoing developmental process at which the child is observed
2.The perspective of the observer.
Early experiences may shape neural structure and function, which may then create dispositions
that direct and shape a child’s later experiences and behaviour.
Stigma plays a role in decreasing the likelihood that services are sought for children with mental
disorders; particularly in minority groups and cultures.
Current approaches view the roots of developmental and psychological disturbances in children
as the result of complex interactions over the course of development between the biology of
brain maturation and the multidimensional nature of experience
Child psychopathology has been commonly de ned as ‘’adaptional failure’’, such as deviation
from age-appropriate norms, exaggeration or diminishment of normal developmental
expressions; interference in normal developmental progress; failure to master developmental
tasks; failure to develop a speci c function or regulatory mechanism; and/or the use of non-
normative skills (e.g., rituals, dissociation) as a way of adapting to regulatory problems or
traumatic experiences.
Many current models have been based on faulty premises concerning singular pathways of
causal in uence. This does not capture the complexities of child psychopathology.
In this regard, many models explain child psychopathology in di erent ways:
-Evolutionary models: selection pressures operating on the human species
-Biological models: genetic mutations, neuroanatomy, and neurobiological mechanisms
-Psychodynamic models: intrapsychic mechanisms, con icts and defences
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, -Attachment models: importance of early relationships which provide foundational working
models of self, others, and relationships
-Behavioural/Reinforcement models: inadequate, or maladaptive reinforcement and/or
learning histories
-Social learning models: observational learning, vicarious experiences, reciprocal social
interaction
-Cognitive models: Distorted or de cient cognitive structures/processes
-A ective models: dysfunctional emotion-regulating mechanisms
-Family systems model: child psychopathology within a framework of intra- and
intergenerational family systems
There is a growing need to integrate these current models.
Psychology has conceptualised a continuum of dimension of characteristics and has focused
on the role of environmental in uences. In this way, psychology di ers from medicine, where
there is a more binary perspective (ill or healthy).
Signi cance of Child Psychopathology
Policy makers are generally not well acquainted with children’s mental health concerns, and
public policy has not kept up with the advances in the eld of child psychopathology. Strategies
to promote positive early development, as well as to prevent and treat early mental health
problems, will require not only signi cant investment on the part of governments but an
increased recognition that public policy should be shaped by empirical research.
There is a need for policy to:
-Support the training of individuals with the necessary expertise in children’s mental health
-Address the signi cant, ongoing obstacle faced by many parents of how to a ord such
expertise.
The growing attention to children’s mental health problems arise from di erent sources:
-1/3 of young people experience mental health problems that interfere with normal
development. The impact is huge: high risk of later development/clinical problems, also in
subclinical or undiagnosed youth.
-Signi cant portion of children do not grow out of childhood di culties, however the ways
in which they are expressed change. Failure to adjust in early developmental periods may
have lasting negative impact on later family, occupational, and social adjustment.
-Recent social changes such as chronic poverty, pressure of family breakup, single
parenting, traumatic events, homelessness, etc. increase the risk for the development of
disorders and more severe problems at younger ages.
-Many mental health problems in children go untreated, and received help may not be
optimal. This is related to factors like lack of screening, inaccessibility, cost, lack of
perceived need of parents, parental dissatisfaction with services, and stigmatization and
exclusion.
-Many children with unassisted/unidenti ed mental health problems end up in criminal
justice or mental health systems as young adults; great risk of school dropout.
-Many children in NA experience child maltreatment, this is associated with
psychopathology in childhood and as adults.
Epidemiological Considerations
Prevalence
Disorders of childhood appear common. Estimates; 20 – 40% of children worldwide have a
clinically diagnosable disorder.
Overall lifetime prevalence of childhood problems: 36%, however, rates may vary per age, sex,
SES and ethnicity.
Age Di erences
No signi cant age di erences for children 4 – 16 in total number of DSM diagnoses.
Externalizing problems show a decline with age.
Many disorders of childhood decrease by age 12, while disorders of adolescence have not yet
emerged in that age.
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, Answers to the question: Do problem behaviours decrease/increase with age?
Are complicated by;
1.A lack of uniform measures of behaviour that can be used across a wide range of ages
2.Qualitative changes in the expression of behaviour with development
3.Interactions between child age and sex
4.The use of di erent informants across development
5.The speci c problem behaviours of interest
6.The clinical status of the children being assessed
7.The use of di erent diagnostic criteria for children of di erent ages
Socioeconomic Status
Mental health problems are overrepresented among the very poor.
However, e ect sizes between SES and child psychopathology are small.
The e ects of SES on aggression can be explained partly by stressful life events and by beliefs
that re ect a tolerance or acceptance of aggression. Others suggest that relationship between
SES and externalizing problems may be related to poor parents being less able to monitor their
children.
Associations between socioeconomic disadvantage and children’s mental health derive from
the fact that SES is a marker of many potential sources of negative in uence; such as low
maternal education, low level of employment, single pareting, parental psychopathology, limited
resources, negative life events (such as poor nutrition and violence).
Sex Di erences
Psychopathology in girls has received less research attention than in boys. Until recently, girls
were often excluded from the sample. Inclusionary diagnostic criteria are often derived from
studies with boys.
There are di erences in prevalence, expression, accompanying disorders, underlying
processes, outcomes, and developmental course in boys versus girls.
Boys: More ADHD, ASS, CD/ODD, learning and communication disorders. More externalizing
symptoms
Girls: More anxiety disorders, adolescent depression, eating disorders. Internalizing symptoms
increase more rapidly during adolescence.
Similar rates of internalizing symptoms in boys and girls.
The meaning of sex di erences is poorly understood.
For example, it is di cult to determine whether observed sex di erences are functions of
referral or reporting biases, the way in which disorders are currently de ned, di erences in the
expression of a disorder (e.g., direct vs. indirect aggressive behavior), sex di erences in the
genetic penetrance of disorders, sexual selection e ects/evolutionary processes, or sex
di erences in biological characteristics and environmental susceptibilities.
Mechanisms and causes of sex di erences may vary for di erent disorders and di erent ages.
Di erences in problem behaviours between sexes is small in preschool age, but becomes more
common with age.
Although there are more externalizing problems in boys and internalizing problems in
adolescent girls in children who are referred for treatment, sex di erences in externalizing
versus internalizing problems are minimal in nonreferred samples.
Comparisons of behavioural and emotional problems in boys and girls over time can provide
useful information about sex-related characteristics. However, taken in isolation, this does not
address di erences in;
-Expressions of psychopathology in boys versus girls
-The processes underlying these expressions
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, -The long-term consequences of certain behaviours for boys versus girls
-The impact of certain environmental events on boys versus girls
It seems likely that “the pathways from childhood to adolescence and adult pathology are age
and gender speci c and that these di erences may be the result of di erent social contexts
that nurture the development of health or pathology for female and male individuals.
There may also be di erences in the processes underlying the expression of psychopathology
and distress in boys versus girls.
For example; the types of child-rearing environments predicting resilience to adversity may
di er for boys and girls.
Gender paradox of comorbidities = Although the prevalence of disruptive behaviour is lower in
girls than boys, the risk of comorbid conditions such as anxiety is higher in female samples.
girls’ heightened level of interpersonal sensitivity, caring, and empathy may be a protective
factor with respect to the development of antisocial behavior. At the same time, girls’
heightened sensitivity to the plight of others, and their reluctance to assert their own needs in
situations involving con ict and distress, may elevate their risk for the development of
internalizing problems.
However, relation between gender and comorbidity likely vary between disorder, age, source of
referral, and other factors.
Rural versus Urban Di erences
Research ndings are inconsistent regarding di erence in rates of child behaviour disorders in
Urban vs. Rural areas.
In analysis that controlled for SES and ethnicity, few di erences were found; however there was
higher delinquency in urban regions.
Even in studies in which rural versus urban di erences have been found, for the most part these
di erences were associated with economic and cultural di erences between sites, and not with
urbanization per se
Ethnicity and Culture
Ethnicity
Until recently, research in child psychopathology has been insensitive to di erences in
prevalence, age of onset, developmental course, and risk factors related to ethnicity as well as
to the considerable heterogeneity within speci c ethnic groups
Studies have reported no or very small di erences related to ethnicity when SES, sex, age, and
referral status were controlled.
Unfortunately, African American and Hispanic American children are much less likely to receive
specialty mental health services
Culture
Culture structures the way in which people and institutions react to a child’s problems. Cultural
attitudes in uence diagnostic and referral practices. For example, in western cultures, shyness
is associated with maladjustment, but with leadership in Chinese culture.
In research of 11 – 15 year old children:
Kenyan children were rated particularly high on overcontrolled problems (e.g., fears, feelings of
guilt, somatic concerns), due primarily to numerous reports of somatic problems. Whites were
rated particularly high on undercontrolled problems (e.g., “arguing,” “disobedient at home,”
“cruel to others”).
The rates of expression of some disorders, particularly those with a strong neurobiological
basis (e.g., ADHD, ASS), may be less susceptible to cultural in uences
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, Greater social connectedness and support in more traditional cultures and greater access to
resources and opportunities in industrialized societies are examples of mechanisms that may
alter outcomes across cultures.
Key Concepts in Child Psychopathology
Several recurrent and overlapping issues have characterized the study of psychopathology in
children, including:
1.Di culties in conceptualizing psychopathology and normality
2.The need to consider healthy functioning and adjustment
3.Questions concerning developmental continuities and discontinuities
4.The concept of developmental pathways
5.The notions of risk and resilience
6.The identi cation of protective and vulnerability factors
7.The role of conceptual factors
Psychopathology versus Normality
Establishing boundaries about what is normal and abnormal is arbitrary. However, these
boundaries can be informative.
Childhood disorders have most commonly been conceptualized in terms of deviancies involving
breakdowns in adaptive functioning, statistical deviation, unexpected distress or disability, and/
or biological impairment.
Harmful Dysfunction = An overarching concept of mental disorder, which encompasses a
child’s physical and mental functioning, and includes value- and science-based criteria.
A child’s condition is viewed as a disorder only if:
-It causes harm or deprivation of bene t to the child, as judged by social norms
-It results from the failure of some internal mechanism to perform in its natural function
What is normal? Categories of mental disorder stem from human-made boundaries. However,
clear distinctions do not necessarily need to exist for categorical distinctions to have utility.
Categorical distinctions are still useful as long as they adequately predict which children will be
most likely to bene t from access to special education, treatment, or disability status.
Healthy Functioning
Attention to developmental processes in childhood is useful, because:
-Judgments of deviancy require knowledge of normative developmental functioning, both
with respect to a child’s performance relative to same-age peers and with respect to the
child’s own baseline of development
-Maladaptation and adaptation often represent two sides of the same coin, in that
dysfunction in a particular domain of development (e.g., the occurrence of inappropriate
behaviors) is usually accompanied by a failure to meet developmental tasks and
expectations in the same domain (e.g., the nonoccurrence of appropriate behaviors).
-In addition to the speci c problems that lead to referral and diagnosis, disturbed children
are likely to show impairments in other areas of adaptive functioning.
-Most children with speci c disorders are known to cope e ectively in some areas of their
lives. Knowing child’s strengths can be implemented in treatment
-Children move between pathological and nonpathological forms of functioning over the
course of their development: ups & downs over time
-Many behaviours that are not classi ed as deviant may nevertheless represent less
extreme expressions or a disorder, or early expressions of a later progression to deviant
extremes.
-No theory of a childhood disorder is complete if it cannot be linked with a theory of how
the underlying normal abilities develop and what factors go awry to produce the disordered
state
Adaptation involves the presence and development of psychological, physical, interpersonal,
and intellectual resource
Developmental Continuities and Discontinuities
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, A central issue in child psychopathology concerns the continuity of disorders between
childhood, adolescence, and adulthood. Some disorders persist into adulthood (ASS,
intellectual disability), and others go away (enuresis/encopresis).
Most disorders (mood disorders, schizophrenia, GAS) can occur in childhood and adulthood.
And di er in degree of continuity.
Mechanisms underlying the relationship between early maladaption and later disordered
behaviour can operate in direct and indirect ways.
Direct relationships include:
-The development of a disorder during infancy/childhood, which persists over time
-Experiences that alter a child’s physical status (i.e. neural plasticity) which in turn
in uences later functioning
-The acquisition of early patterns of responding (e.g. compulsive compliance, dissociation)
that may be adaptive in the light of a child’s current developmental level and circumstances,
but may result in later psychopathology when circumstances change and new
developmental challenges rise.
Indirect associations:
-Early predispositions that eventually interact with environmental experiences (stressors),
the combination leads to dysfunction.
-Experiences (e.g. peer rejection) that contribute to an altered sense of self-esteem, or
negative cognitive set, which leads to later di culties
-Experiences providing various opportunities or obstacles that then lead to the selection of
particular environmental conditions, and by doing so guide a child’s course of development
Although research supports the notion of continuity of disorders, it does not support the
continuity of identical symptoms over time. E.g. expression of behavioural patterns change over
course of development.
Another example of a consistent pattern of organization involves early attachment quality and
the development of internal working models that children carry with them into their later
relationships. Internal working models of self and relationships may remain relatively stable over
time, while the behavioral expressions of these internal models change with development
Developmental Pathways
A developmental pathway de nes the sequence and timing of behavioural continuities and
transformations and summarizes the probabilistic relationships between successive behaviours.
In attempting to identify developmental pathways as deviant or not, it is important to recognize
that:
-Equi nality: Di erent pathways may lead to similar expressions of psychopathology
-Multi nality: Similar pathways may result in di erent forms of dysfunction, depending on
the organization of the larger system in which they occur.
Example of a developmental pathway: the diagnosis of conduct disorder typically precedes the
initiation of use of various substances, and this use in turn precedes the diagnosis of alcohol
dependence in adolescents. This can, in turn, exacerbate risk for persistant antisocial behavior
by virtue of the reciprocal in uences of alcohol dependence on antisocial behavior and vice
versa
Risk and Resilience
Resilience = Successful adaptation in children who experience signi cant adversity.
Many factors can provide turning points whereby success in a particular developmental task
(e.g., educational advances, peer relationships) shifts a child’s course onto a more adaptive
trajectory.
The term ‘’Resilience’’ is generally used to describe children who:
-Manage to avoid negative outcomes and/or to achieve positive outcomes despite being at
signi cant risk for the development of psychopathology
-Display sustained competence under stress
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, -Show recovery from trauma
Vulnerable children: Children who are predisposed to develop psychopathology, and who show
a susceptibilty to negative developmental outcomes under high-risk conditions. Genetics
makeup and temperament contribute to this.
One problem in research on resilience has been an absence of agreed-upon criteria for de ning
positive developmental outcomes. Debate on if this should be based on external criteria
(academic performance), internal criteria (subjective well-being) or a combination.
Resilience is not indicative of any rare or special qualities of a child per se (as implied by the
term “the invulnerable child”), but rather is the result of the interplay of normal developmental
processes such as brain development, cognition, personality development, caregiver–child
relationships, regulation of emotion and behavior, and the motivation for learning
Protective and Vulnerability Factors
Protective- and Vulnerability factors include factors within the child, family and community; see
blz. 22 for examples.
Common risk factors encompass acute stressful situations and chronic adversity.
Example of a protective factor: a child’s ability to self-regulate via self-soothing, focused
attention, and organized and goal-directed behavior—can bu er children from the increases in
internalizing symptoms associated with exposure to parental marital con ict.
Contextual In uences
Any consideration of child psychopathology must consider and account for 3 sets of contextual
variables:
1.The child as context: the idea that unique child characteristics, predispositions, and traits
in uence the course of development
2.The child of context: the notion that the child comes from a background of interrelated
family, peer, classroom, teacher, school, community, and cultural in uences
3.The child in context: The understanding that the child is a dynamic and rapidly changing
entity; and that descriptions taken at di erent point in time or in di erent situations my yield
very di erent information.
Extrasituational events can in uence the child indirectly, such as a parent’s work-related stress.
Child outcomes may vary as a function of:
-The con guration of circumstances over time
-When and where outcomes are assessed
-The speci c aspects of development that are a ected.
De ning Child Psychopathology
There has been a lack of consensus concerning how psychopathology in children should be
de ned; oftentimes the DSM or ICD are used. However, DSM use raises a few questions:
1. Should child psychopathology be viewed as a disorder that occurs within the individual
child (e.g., disorder of the brain, psychological disturbance), as a relational disturbance, as
a reaction to environmental circumstances, or (as is likely) some combination of all these?
2. Does child psychopathology constitute a condition qualitatively di erent from normality, an
extreme point on a continuous trait, a delay in the rate at which a normal trait would
typically emerge, or some combination of the three? How are “subthreshold” problems to
be handled?
3. Can homogeneous disorders be identi ed? Or is child psychopathology best de ned as a
con guration of co-occurring disorders or as a pro le of traits and characteristics?
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