Assessment and Treatment of Childhood Problems
A Clinician's Guide
By Carolyn S. Schroeder Betty N. Gordon The Guilford Press
Copyright © 2002 The Guilford Press
All right reserved. ISBN: 1-57230-742-0
Chapter One
Development of Psychopathology Most children, in the process of growing up, will have emotional and behavioral problems that are transient in nature and are due to the stresses of development and adaptation to family and societal expectations. The primary task for parents is to enhance their children's development by helping them gain control over normal developmental events such as toilet training, fears, learning about sexuality, being told "no," and dealing with siblings and peers. Children and parents also must sometimes cope with negative life circumstances (e.g., poverty or parental unemployment) and stressful events, (e.g., a hospitalization, a divorce, a death, or the birth of a new baby). For all of this pressure to cope, it is heartening that epidemiological studies find that over the course of any one year, only about 20% of children suffer from an emotional or behavioral problem that is severe enough to interfere with their day-to-day functioning (Nottelmann & Jenkins, 1995). The goals of the child clinician are not only to assist this group of children who have major mental health problems, but also to help the other 80% of children and their parentsmanage the stresses of normal growth and development.
Because of their rapid growth and development, children represent a unique population. Previously, the importance given to changes in development depended to a great extent on one's theoretical perspective. Psychoanalytic theory, for example, emphasizes the emergence of independence and psychosexual development, whereas social learning theory focuses on the development of self-control and self-efficacy. However, the failure of any one theory to explain the full complexity of development across ages and areas has led to general acceptance of a transactional and/or ecological perspective of development, which attempts to account for factors within the child, family, and society that influence the child either directly or indirectly (Campbell, 1990). Within this perspective, developmental gains in each area (social, cognitive, motor, language, etc.) are thought to be related to progress in other areas. Moreover, competence or problems in any area of development early in life are seen as setting the stage for later development.
Thus developmental change (both positive and negative) is the result of the transactional dialogue among each child with his or her unique biological/genetic makeup, the physical and social environment, and the cultural milieu into which he or she is born. Mash and Terdal (1997a) point out that the child clinician must recognize "the ebb and flow of this developmental dialogue, because it has critical implications for the manner in which child behaviors are conceptualized, measured, classified, diagnosed, changed, and evaluated" (p. 22). Behaviors common at one age may be considered significant problems at another age, and many childhood problems may change both qualitatively and quantitatively as a child develops. In addition, the impact of stressful life events may vary with the child's stage of development, the parent's characteristics, and the social support system available to the family at that time.
Knowledge of developmental norms is clearly essential for the child clinician to recognize which behaviors are excessive or deficient for children at a given developmental stage. An understanding of normal development is also important in choosing appropriate intervention techniques. Treatment of the school-age child, for example, will rely more heavily on cognitive and language skills, whereas use of concrete, situation-specific tasks and developmentally appropriate play activities will be more appropriate for the preschool child. The clinician must also have knowledge of the normal sequence of skill acquisition, in order to plan appropriate treatment for such problems as social skills deficits.
In light of the importance of a developmental perspective for clinical work with children, this chapter first focuses on issues related to the normal development of children from birth to 10 years, and the factors that influence children's later development (see Campbell, 1990, 1998, for excellent discussions of theoretical issues concerning development and behavior problems). Next, research related to the variables that contribute to the vulnerability or resilience of children is reviewed. Finally, models for prevention and early intervention are discussed.
NORMAL DEVELOPMENT
General Comments
The developmental tasks of children obviously change with age, and each stage of development presents unique challenges to children and parents. The ways in which significant adults help children through these difficult periods can have implications for children's later development. A child who is having trouble with separation and individuation, for example, may have more trouble with social skills if the parents deal with separation issues in an angry or rejecting manner rather than with warmth and support.
In considering normal development, the clinician should keep both inter- and intraindividual differences in mind. Individual differences in the rate of development are clearly apparent during the preschool years, and these differences often persist into the school-age years. Some children, for example, begin to speak before the age of 1, whereas other "normal" children have not acquired extensive language by age 3. Differences in physical growth become dramatically apparent in the late elementary school and early adolescent years, although each child may be developing along a normal continuum. At school age, academic standards typically reflect great differences among children.
An individual child's rate of development within various areas can vary as much as the rate of development among children. A child may be speaking in sentences at age 2 years, but may not begin hopping or skipping until much later than expected. Similarly, a child may be at the top of the class in reading, but may have difficulty participating in group play activities. Some of these inter- and intraindividual differences are primarily the result of genetic/biological factors; others seem to be more the result of environmental influences. Of course, the unique interaction of these two types of factors-the child's and the environment's-is what ultimately determines each child's developmental course.
Because many types of learning take place rapidly and simultaneously during childhood, it is common for children who are not developing normally to be identified at this time (particularly during the preschool years), often because they fail to achieve an expected developmental milestone. It is usually the general pattern of development, rather than slower development in any specific area, that alerts adults to potential problems. Toilet training, for example, may be slower and more difficult; the child may be slower to learn to dress and eat independently; and constant supervision may be needed at a time when most children are becoming independent, helpful family members. If developmental problems are not noticed during the preschool years, they will almost inevitably be identified as a child enters school, when there are increased expectations to sit quietly, pay attention, process more complex language, read, do arithmetic, and deal with difficult social situations.
The following discussion focuses on issues in normal development that are most relevant to understanding how psychopathology develops in children during the periods of infancy, toddlerhood, preschool, and school age. Table 1.1 provides an overview of normal development from infancy through school age, along with the associated parental tasks. The reader is referred to Davies (1999) and DiGirolamo, Geis, and Walker (1998) for more detailed descriptions of developmental milestones. In addition, we recommend three books for parents that cover developmental issues: Your Child (Pruitt, 1998); A to Z Guide to Your Child's Behavior: A Parent's Easy and Authoritative Reference to Hundreds of Everyday Problems and Concerns from Birth through 12 Years (Mrazek, Garrison, & Elliott, 1993); and Child Behavior: The Classic Childcare Manual from Gesell Institute of Human Development (Ilg, Ames, & Baker, 1992).
Infant Development (Birth-1 Year)
Development during the first year of life is phenomenal, and by 12 months of age infants barely resemble the beings they were at birth. The main tasks of the first year can be summarized as follows: (1) to gain physiological stability; (2) to develop interpersonal attachments and strategies for maintaining them; (2) to regulate arousal and affect; (3) to develop and gain control over motor skills; (4) to begin to communicate needs and desires; and (5) to explore and learn about the external world (Davies, 1999; DiGirolamo et al., 1998). Brain development is most rapid during the first year of life, and this development makes all other functions (sensory, perceptual, emotional, regulatory, motor, and cognitive) possible (Davies, 1999). Development during infancy is also inseparable from the child's relationship with his or her caregiver(s). Although the child is born with certain biological prerequisites, and his or her capabilities unfold in a regular progression, simple maturation is not sufficient to ensure normal progress (Davies, 1999). The infant is born with a capacity to organize his or her experiences, for example, but is dependent on adults to determine what those experiences will be and to provide appropriate stimulation and support so that the child can profit from these experiences (Davies, 1999). The types of experiences to which the infant is exposed influence which neural pathways will be strengthened, which will remain available, and which will atrophy (Davies, 1999). Thus issues of parenting are most critical during this early time of life.
Problems during infancy typically come to the attention of pediatricians rather than mental health professionals (Campbell, 1998). However, clinicians should be knowledgeable about two areas of research most related to the development of later mental health problems: attachment and temperament. Both the quality of primary caregiver-infant attachment and the child's temperamental characteristics can potentially influence the child's future functioning, and problems in either area are seen as risk factors for the development of behavioral or emotional problems.
Attachment
The formation of "attachment"-that is, an emotional bond between the infant and his or her primary caregiver(s)-occurs gradually over the course of the first year of life. As Campbell (1998) describes, the process begins as caregivers (usually parents) respond to the infant's signals of hunger or other distress. The infant gradually learns that his or her needs will (or will not) be met consistently, and as a result develops expectations about adult behavior relative to his or her signals. At first any adult will do, but gradually, the infant begins to discriminate between and respond differently to familiar and unfamiliar people. As development progresses (usually by 6 or 7 months), the infant begins to engage in active attempts to maintain contact with familiar people (usually parents) and becomes upset when separated from them. By the end of the first year, the attachment figure is the infant's main source of comfort and is used as a secure base from which the infant ventures out to explore the world (Waters & Cummings, 2000).
Early in this process, the key to the formation of a secure emotional attachment between the infant and caregiver(s) is the ability of a caregiver to respond sensitively and promptly to the infant's signals of distress (i.e., crying). As the child progresses through the first year, caregivers must adapt their behavior to the child's rapidly changing needs while continuing to be sensitive and responsive to the child's signals and to provide support for his or her development (Davies, 1999; DeWolff & van IJzendoorn, 1997; Thompson, 2000). As Campbell (1998) states:
Mothers who are sensitive to their infants' cues and responsive across a range of situations including feeding, responsiveness to crying, early face-to-face play, and the provision of opportunities to explore, foster the development of a secure attachment relationship. Mothers who respond to their infants abruptly, who are unresponsive, or who pace their behavior to their own needs and schedules foster the development of an anxious or ambivalent attachment characterized by excessive anger, clinging, and/or avoidance behavior of the part of the infant. (p. 13)
Infants who are securely attached to their caregivers have been shown to have more optimal development in a number of areas (Campbell, 1998). Main, Kaplan, and Cassidy (1985), for example, found that children who were securely attached at 12 months were more emotionally secure and better able to express their feelings at age 6; 6-year-olds who were insecurely attached at 12 months had great difficulty discussing their feelings and had few strategies for dealing with separation. Furthermore, children with secure attachments to their caregivers show more appropriate social adaptations over time (e.g., they are more popular, make more social contact, and are more helpful to others) than children with less secure attachments do (Hartup, 1989). Patterns of cognitive functioning, including more symbolic play, more internal control, and better problem-solving skills (Matas, Arend, & Sroufe, 1978), as well as increased task mastery (Baumrind, 1971) and higher school achievement (Estrada, Arsenio, Hess, & Holloway, 1987), are also associated with early secure attachment to caregivers. The quality of early attachment relationships has likewise been found to be important in emotional development, influencing popularity, number of social contacts, ability to offer support to others, and increased self-esteem (Cassidy, 1988; Sroufe & Fleeson, 1986).
Attachment relationships are not necessarily stable over time. Moreover, attachment is found to be less stable in higher-risk than in lower-risk families (Lamb, Thompson, Gardner, & Charnov, 1985). Attachment status probably fluctuates as a function of parental and environmental circumstances (Belsky, Campbell, Cohn, & Moore, 1996; Thompson, 2000). Thus securely attached infants may become insecure if their caregivers become less able to meet their needs because of divorce, onset of mental health problems, birth of a new baby, or other life stresses. Likewise, insecure infants may become more secure if their environments become more stable. The instability seen in some children's attachment status may explain the inconsistency in research assessing links between quality of attachment and the later development of mental health problems (e.g., Bates & Bales, 1988).
Continues...
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