Chapter 23: 19 Abnormal Behavior of Children and Adolescents - Abnormal Psychology (2022)

CHAPTER 19

Abnormal Behavior of

Children and Adolescents

Sensitivity to the differences between childhood psychological disorders and adult psychological disorders is a fairly recent development. Early theories tended to view children as small adults and did W-J not recognize the cognitive and emotional differences between the two age groups. The developmental processes of childhood and adolescence had not been studied closely, and it was therefore difficult to achieve an accurate understanding of what constituted normal and abnormal behavior for children. Since that time, theorists have acknowledged those processes, and substantial progress has been made in the study of childhood disorders. This increased understanding has led to improved treatment for children and to a more meaningful classification system for maladaptive behaviors. This is reflected in the difference between the DSM I, published in 1952, and the DSM-IV-TR, published in 2000, which is much more comprehensive in its description of conditions affecting children and adolescents. The need for this increased attention to abnormal childhood disorders is indicated by their prevalence, which most experts place at 13.3 percent of all children in the United States.

Chapter 23: 19 Abnormal Behavior of Children and Adolescents - Abnormal Psychology (1)SPECIFIC DIFFICULTIES IN STUDYING CHILDHOOD DISORDERS

Three possible difficulties in studying childhood disorders are considered here: the influence of adults; developmental considerations; and defining “abnormal.”

The Influence of Adults

It is impossible to understand a child’s behavior without understanding the role of the important adult figures in the child’s life. Children rarely seek help for their psychological problems on their own, so it is up to adults to act on behalf of the child. Parents, other relatives, and school personnel are the obvious key people. Parents can be reluctant to seek help for their child because they may feel that any problems reflect upon their ability as parents. They often view the difficulty as a phase through which the child is going, with the expectation that the child will soon outgrow this stage. This is particularly true of the less impairing disorders such as fears, simple phobias, and social anxiety. Sometimes, however, too much parental intervention can be a problem. By focusing undue or excessive attention on a difficulty, parents can exacerbate a problem that might be only transitory.

The start of school is frequently the time when a child’s psychological problems are first recognized. One reason for this may be that behavior that is acceptable at home cannot be tolerated in a school setting. Attention-deficit hyperactivity disorder (to be discussed in the “ATTENTION-DEFICIT AND DISRUPTIVE BEHAVIOR DISORDERS” section) is an example of this type of problem. Furthermore, teachers and other educational personnel are exposed to a broad range of children and can use this exposure, in addition to their training and experience, to assess abnormal behavior.

Developmental Considerations

The behavior of children must be evaluated within the developmental context in which the behavior occurs. Normal development involves the interaction of three areas of individual functioning: the cognitive-intellectual; interpersonal and emotional; and physical-motor areas. Development proceeds in these areas, with one improvement building upon an earlier improvement. Difficulties or disruptions at one stage can lead to more serious problems at a later time. It is therefore important to recognize and treat any developmental abnormalities as early as possible. A complicating factor in this process is that children often develop at varying rates, and it is often difficult to differentiate between what is just slow development and what is abnormal behavior.

What is “Abnormal”?

In most cases, the differences between normal and abnormal behavior are not as clearly defined in children as they are in adults. All children, at times, display maladaptive behavior, such as bedwetting or temper tantrums. Such behavior may be a result of specific stress and be a normal response to that stress for a child at a certain developmental stage. Most theorists in this area state that any behavior should be viewed as a problem if it occurs repeatedly and interferes seriously with the child’s, or another person’s, functioning. Experts in childhood psychological disorders carefully compare the intensity, frequency, and duration of problematic behavior to other children of that age or developmental level when deciding what is pathological and what is difficult but not atypical childhood behavior.

Classifying Children’s Disorders

Until relatively recently, diagnosis and classification of the psychological disorders of children have been a woefully neglected and confused area of abnormal psychology. For example, the first Diagnostic and Statistical Manual, issued in 1952, listed only two categories of children’s disorders: childhood schizophrenia and a catch-all type of category that was labeled “adjustment reaction of childhood.” Neither of these are diagnostic categories in the current DSM.

The DSM-IV-TR now lists ten categories of children’s disorders: mental retardation (discussed in Mental Retardation); learning disorders; motor skills disorders; communication disorders; pervasive developmental disorders; attention-deficit and disruptive behavior disorders; feeding and eating disorders of infancy or early childhood; tic disorders; eliminatory disorders; and other disorders of infancy, childhood, or adolescence. The major disorders within these categories are discussed in this chapter.

Chapter 23: 19 Abnormal Behavior of Children and Adolescents - Abnormal Psychology (2)ATTENTION-DEFICIT AND DISRUPTIVE BEHAVIOR DISORDERS

Under this heading, the DSM-IV-TR lists three subtypes of disruptive behavior: attentiondeficit/hyperactivity disorder (usually abbreviated as ADHD); conduct disorder (CD); and oppositional defiant disorder (ODD). All have in common the child’s infringement on the rights of and disturbing others.

Attention-Deficit/Hyperactivity Disorder

Behavior of the ADHD child is troublesome to parents and teachers and can cause distress for the child experiencing it. Because of its disruptive effect in the classroom, it is a frequently used (perhaps overused) diagnosis.

Symptomatology

The behavior of children diagnosed as having attention-deficit/hyperactivity disorder is characterized by impulsiveness, inattention, and/or physical hyperactivity that is inappropriate for the child’s age. ADHD is divided into three subtypes: predominately inattentive; predominately hyperactive/impulsive; and combined. The predominately inattentive type is diagnosed more frequently in females and adults. These highly distractible children have difficulty remaining still and will race from one activity to another. Nothing seems to hold their attention for very long. They frequently act with little thought of the consequences of their actions and are disruptive when engaged in social activities. In the classroom, they often do not attend to directions, are frequently out of their seats, and will call out at inappropriate times. In school, these children frequently perform below their cognitive abilities and often exhibit specific learning disabilities. Because of their poor scholastic achievement and social difficulties, children with ADHD often display low self-esteem. In addition, their relationships with their parents frequently are strained by their inability to follow rules and their high level of motor activity.

One study (Anderson et al., 1987) reports the prevalence of this disorder at about three to five percent of all preadolescents. As with many childhood disorders, the number of boys diagnosed as ADHD greatly exceeds the number of girls receiving this diagnosis.

Prognosis

There has been controversy regarding the course of ADHD as children mature. In girls, a decrease in observable hyperactive behavior is frequently seen, but restlessness, inattention, and impulsivity may continue. Additionally, many individuals with ADHD still experience symptoms in adulthood. Although outward behavior changes, there are subtler signs and the internal experience of inattention, hyperactivity, and impulsiveness.

ADHD has been correlated with other disruptive behaviors that may continue through life. Many researchers believe that when evaluating long-term prognosis, it is important to differentiate between subjects who exhibit pure ADHD symptoms and those who also display aggressive symptoms. A study by Satterfield (1982) initially demonstrated that hyperactive boys were twenty times more likely to be in trouble with the law than was a sample of “normal” boys. He then divided the hyperactive group into two subgroups, one with aggressive symptoms and one without, and determined that the nonaggressive group had no more legal problems than did the normal population.

Additionally, research suggests that children with ADHD are at increased risk for substance abuse. However, with appropriate treatment of ADHD, that risk decreases significantly. Hence, it appears that children with ADHD are not homogenous. Presence of more symptoms than necessary to make a diagnosis and lack of appropriate treatment appear to be associated with less adaptive outcomes. Conversely, with appropriate treatment and support as needed throughout life, adults with ADHD typically are successful.

Causes of Attention-Deficit/Hyperactivity Disorder

No one definitive cause of ADHD has been discovered. There is evidence (Greenhill, 1990), however, for a biological basis for ADHD. The study determined that participants with ADHD utilized 12 percent less glucose, a source of fuel for the brain, than did non-ADHD participants. The brain area most deprived of glucose was an area associated with attention and motor control, which are the central problems of ADHD children. Subsequent research also implicates lowered activity levels in the parts of the brain responsible for behavioral inhibition. This seems to fit with findings of the effectiveness of stimulant medication, which increases activity in these areas.

Another possible factor is a genetic, or hereditary, basis. ADHD is more common in family members of individuals with the disorder. From this research, a possible genetic basis for the disorder is hypothesized.

Treatment

There are two main treatment approaches for ADHD. These are pharmacological and psychosocial.

THE OF

The use of drugs to treat the symptoms of ADHD is probably the most common form of treatment. The drugs most frequently used are central nervous stimulants such as Ritalin and Dexedrine. Studies (for example, Ottenbacher & Cooper, 1983) indicate that these drugs achieve their results without impairing the child’s cognitive abilities. School performance is often improved. Not all children with ADHD respond to stimulant medication; about 35 percent of this population receive no benefits. Some researchers believe that those children who also exhibit symptoms of conduct disorder in addition to ADHD are also those who are least likely to benefit from medication. Some children who do not benefit from stimulant medication improve with the use of a newer, nonstimulant ADHD medication, Strattera. This medication also is helpful for children who experience significant negative side effects from stimulant medication.

There are many critics of the use of drug therapy. Gadow (1986) questions the long-term benefits of medication, especially when underlying psychosocial causes of the disorder are neglected. In most instances, when the medication is discontinued, the symptoms reappear. A troublesome result of medication is the physical side effects they produce, such as insomnia, slowed growth, and impaired appetite. These side effects occasionally result in parents opting for “medication vacations,” where the child is not medicated during times when school is not in session. Furthermore, the long-range physical effects of these medications upon children have not been studied fully.

PSYCHOSOCIAL

The use of behavior modification techniques has proven slightly helpful in the treatment of ADHD. These include token economy systems, which involve providing a clear explanation of expected behavior to the child, and then a tangible reward system for satisfactory performance. Behavior modification systems have achieved some positive results (Barkley et al., 2002). A criticism of this technique is that it can have a negative impact on the child’s belief that he or she can control his or her own behavior (Horn, 1983). Furthermore, there is evidence that children with ADHD respond less positively to consequences (the basis of behavior modification) in comparison to their nonaffected peers.

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Frequently, behavioral therapy focuses not on ADHD, but on the surrounding challenges, such as self-esteem, social relations, and academic difficulties. In these cases, therapy provides skills training and support, which cannot be attained from medication alone. For example, social skills training has been shown to improve appropriate assertive behavior in children with ADHD (Antshel & Remer, 2003). Parent training has been used to teach parents how to effectively support their children and has resulted in improved behavior in children with ADHD (Anastopoulos & Farley, 2003). Many researchers report that the use of drug therapy, in conjunction with behavioral techniques, is most effective in treating ADHD and its associated difficulties (Gittelman-Klein et al., 1980).

Conduct Disorder

This diagnosis is considered a more extreme type of disruptive disorder than ADHD and includes antisocial and delinquent behavior.

Symptomatology

The DSM-IV-TR defines conduct disorder as “a persistent pattern of conduct in which basic rights of others are violated or major societal norms are violated.” The characteristics include problems at home and in school and the destruction or theft of the property of others. These children often are involved in physical fights and are at increased risk for developing early substance abuse and precocious sexual activity. It is not unusual for a child with conduct disorder to suffer from emotional problems, particularly depression.

Estimates of prevalence rates vary, but are 6 percent to 16 percent for boys and 2 percent to 9 percent for girls. For some individuals with conduct disorder, the onset is in childhood and tends to be gradual. For others, the onset is in adolescence and tends to be more acute.

Prognosis

Unfortunately, conduct disorder often persists into late adolescence and adulthood. One study (Kazdin 1987) reports that children with conduct disorder in many cases continue the pattern of criminal activities later on as adults. As adults, they have difficulty maintaining employment and frequently experience marital problems. Another study reports that a child diagnosed as conduct-disordered is significantly more likely to become an alcoholic or to develop antisocial personality disorder as he or she grows older than are children with other emotional problems (Rutter & Garmezy, 1983).

Many theorists believe that the diagnosis of conduct disorder more accurately predicts impaired adult functioning than does any other factor or diagnosis, except for childhood psychosis or developmental disabilities.

Causes of Conduct Disorders

The family environment is viewed as an important factor in the development of conduct disorders. These families are often disrupted by marital problems, emotional instability, and inconsistent displays of affection and support. Discipline is often inappropriate and is characterized by particularly harsh or extremely lenient methods. Patterson (1986) addressed the matter of disciplining techniques in a study of children with conduct disorder. His results indicated that the parents of these children were inconsistent in punishing misbehavior and failed to teach skills necessary for social and academic success.

Another social factor in conduct disorder is peers. Children with conduct disorder tend to have peers who engage in delinquent behavior. It is difficult to tease out whether one causes the other, but it is clear that an antisocial peer group can serve to maintain conduct-disordered behavior.

There is some support for the role of genetic factors in the development of conduct disorders. Mednick (1986), in a comprehensive study of more than 14,000 adopted children, concluded that adopted children are more likely to have engaged in criminal behavior if their biological parents were criminals, even if they had never lived with their biological parents.

Treatment

Because family influences are important in the development of this disorder, many treatment methods focus on treating the family unit. These include teaching effective parenting techniques and family therapy to reduce discord in the home. Given the problems and stresses in many of these families, this approach has had limited success.

Educating the child with conduct disorder in the use of cognitive-behavioral skills is another treatment approach. These skills include the identification of problems, the use of self-statements to modify behavior, and the development of more appropriate behavior. The method appears to be more effective with preadolescent children. Generally speaking, earlier intervention is correlated with greater success.

It often becomes necessary to remove the child with conduct disorder from the home and place him or her in a residential treatment setting. This is most common with adolescents. Many of these settings utilize behavior management techniques and control the child’s complete environment. The child must comply with rules and demonstrate appropriate behavior in order to achieve specific privileges and rewards. It is also important, through the use of various methods such as role playing, to teach new ways of behaving and important social and academic skills. Unfortunately, the effects of such treatment facilities tend to fade after discharge.

Currently, the most effective (and cost effective) treatment for conduct disorder is a multimodal approach. There are a number of such programs that provide intensive, multimodal services, including in-home family therapy, individual therapy, collaboration with school staff and legal authorities, and interventions in the community. By intervening in all of the areas that contribute to or support conduct disordered behavior, changes are made. However, earlier intervention is still more effective than waiting for problems to escalate.

Oppositional Defiant Disorder

The diagnosis of ODD is used for children who show negative, argumentative, or hostile behavior. Such children lose their tempers frequently, object to directions, and ignore rules. The behavior is most frequently expressed in family settings, but may also be carried over to school or other settings involving authority figures. Occasionally, the child will be relatively subdued at home and act out his or her disruptive behavior only elsewhere, usually in the classroom.

Unfortunately, without successful treatment, children with oppositional defiant disorder frequently go on to develop conduct disorder. Treatment of oppositional defiant disorder typically focuses on increasing warm, positive interactions with parents and guiding parents in developing consistent, effective discipline strategies.

Chapter 23: 19 Abnormal Behavior of Children and Adolescents - Abnormal Psychology (3)EMOTIONAL DISORDERS

Emotional difficulties exhibited by children differ in several ways from disruptive disorders. Children with emotional disorders rarely cause difficulties for others. The incidence of emotional disorders is about equal for boys and girls in childhood and becomes more common in girls during adolescence, as opposed to disruptive behavior disorders, which are more common in boys.

Children are subject to a variety of disturbing emotional disorders, some of them similar to adult psychiatric illnesses; for example, depression, anxiety disorders, and even preoccupation with bodily symptoms, as in hypochondriasis (see Somatoform and Dissociative Disorders). However, children typically do not have the insight into the disorders expected in adults. For example, children typically do not acknowledge the irrationality of their phobias. Furthermore, children’s expressions of mood states may vary; for example, children may express depressed affect through irritable behavior rather than verbal reports of feelings of sadness. It also is important to note that children continue to act like children, even when experiencing emotional disorders. That is to say, children with depression often will still play—this is simply typical child behavior, not a sign that everything is going fine for the child.

In the following sections, we consider emotional disorders to which children may be subject: separation anxiety; fears and phobias; and reactive attachment disorder.

Separation Anxiety Disorder

Some degree of emotional pain at being separated from parents is shown by many children, especially in close-knit families in which the child has developed an emotionally dependent relationship with his or her parents. However, when excessive anxiety, to the point of panic, that is not age appropriate is shown by the child, he or she is said to be suffering from a separation anxiety disorder. Extreme manifestations of the illness are shadowing the parent around the house, refusing to stay alone in a room at home, extreme difficulty in falling asleep without a parent being in the same room, and the appearance of physical symptoms when threat of separation from parents exists. Physical symptoms may range from stomach disorders to heart palpitations and dizziness. The DSM-IV-TR comments that the disorder is “apparently not uncommon,” occurring among 4 percent children and young adolescents. They also report it as much more common in girls than in boys.

Antianxiety medications can be used to treat children; however, there are less invasive strategies that tend to have better long-term results with less risk of side effects. Such behavioral therapies as modeling and systematic desensitization are considered helpful psychotherapeutic approaches (see Behavioral, Cognitive, and Biogenic Therapies).

Fears and Phobias

Fearfulness about many things is a common problem in childhood. There are three age periods during which specific kinds of fear are most characteristic: 1) Preschool children often develop fears of insects and animals; for example, spiders and dogs. 2) During preadolescence, their fears shift from the concrete and visible to the hidden and imaginative; for example, in the dark, frightening shadows may be imagined as ghosts or hidden, perhaps murderous villains. During this period, there also may be fears of possible disasters in elevators or airplanes or severe weather. 3) Soon after puberty, when social life becomes important, their fears come closer to resembling those of insecure adults; they worry about not being accepted by “the group” and fear new social situations. They may also suffer lowered self-esteem and develop concern about their self-identity.

Unless those emotional reactions seriously disrupt a child’s functioning, they can be dealt with by parental understanding and reassurance. Rational explanations and protected direct experiences with the encouragement of parents and the support of childhood friends can reduce the intensity of the child’s fears.

When the fears are disabling, professional help may be needed. Anderson and colleagues (1987), in a comprehensive discussion of children’s disorders, report that 2 to 3 percent of children develop real phobias. The most effective therapy is modeling in imitation of other children of the same age, who may or may not be friends. With adolescents, the therapist may attempt systematic desensitization (see Behavioral, Cognitive, and Biogenic Therapies).

Reactive Attachment Disorder

Reactive attachment disorder is one of the few diagnoses in the DSM with a specified etiology. The disorder is characterized by a failure to form appropriate attachments due to grossly pathogenic care. The failure to form appropriate attachment is evidenced in disrupted social relationships that follow one of two patterns: diffuse bonds, indicated by indiscriminate affection that does not result in a true attachment; or avoidance of bonds, which may result in hypervigilant, ambivalent, disorganized, or inhibited social relationships. Pathological care can result from physical or emotional neglect or frequent changes in caregivers. In order to meet diagnostic criteria, the onset of symptoms must be prior to the age of five.

The disorder is relatively rare. Without intervention, difficulties persist throughout life. With early support and appropriate care, much improvement can be seen. However, treatment after early childhood becomes very difficult and has low success rates.

Chapter 23: 19 Abnormal Behavior of Children and Adolescents - Abnormal Psychology (4)SPECIFIC SYMPTOM DISORDERS

Here are grouped a number of behavior disorders that have in common three characteristics: 1) the disorder is expressed in a single symptom and does not usually involve a pervasive maladaptive pattern of behavior; 2) that symptom is a troublesome physical expression in the eliminatory function in speech, motor behavior, or eating; and 3) most often, the symptom is troublesome to the individual because it tends to embarrass him or her and bring on social tensions that interfere with the young person’s normal development.

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In the following sections, we discuss briefly the eliminatory problems of enuresis and encopresis and selective mutism.

Eliminatory Problems

There are two: enuresis, which is urinating in clothes or bed; and encopresis, which is having bowel movements in culturally inappropriate ways.

Enuresis

Involuntary voiding of urine may occur in the daytime or at night. Occasional involuntary daytime voiding, often referred to in the family as “an accident,” is common soon after the child has been toilet trained, most often when the child is absorbed in a pleasant activity that the he or she chooses not to leave or during a time of emotional or otherwise exciting play. Enuresis is not diagnosed until symptoms have been present for three months and the child is at least five.

Frequently in enuresis, the problem is nighttime bedwetting (nocturnal enuresis). Enuresis is more prevalent among boys (7 percent), double that of girls at early ages (five or six years of age). It remains higher, at a diminishing rate, through young adulthood.

CAUSES OF

Beyond physical causes or urological problems, a couple of psychological factors have been associated with enuresis. None is given special prominence. Among possible causes of enuresis are: 1) regression on the birth of another child; 2) frequent emotional upheavals in the child’s home life; 3) faulty learning experiences.

TREATMENT TO

Two notably successful treatment programs are available to the parents of the child with enuresis. The first and simpler method, commonly referred to as the bell-and-pad technique, was developed by Mowrer in 1938. It requires a special bed pad that, when moistened by the child’s urine, sets off a loud signal, waking the child and sending him or her off to the toilet. Smaller alarms that are placed in a pocket attached to the child’s underpants also are available.

The second method uses a form of aversive therapy and requires only a very short training period, usually less than a week. Azrin and colleagues (1974), who developed the program, prefer that an outside trainer rather than the parents implement the program. Before any training, the dry bed program is explained to the child and parents. In phase one, the child drinks a preferred beverage, lies down in his or her bed, and counts to fifty; then, in an unhurried fashion, the child walks to the toilet and tries to urinate. After several such trials, in phase two, the child is given more to drink and told that he or she will be awakened hourly to urinate. Accidents result in the child being required to change the sheets and to begin training all over again. In the Azrin report on outcome, the group reports that all trained children were continent for at least six months after four nights of training. In both behaviorally oriented therapies, a success rate of 90 percent has been regularly reported.

Medication is sometimes used to treat enuresis. There are several different types of medications that may be used with each having a different method of action. They do have the effect of preventing urination during the night while in use. However, enuresis typically returns upon stopping the medication.

Encopresis

A habit disorder that is much less common than enuresis, encopresis is said to exist if a child older than four years passes feces in inappropriate places, including his or her clothing, at least once a month for 3 or more months. The problem occurs in 1 percent of five-year-olds, more frequently in boys than in girls.

When involuntary rather than deliberate (a determination that is not always easy to make), the cause may be constipation or a tendency to retain fecal matter. When it is deliberate, there is the possibility of oppositional tendencies or even more severe pathology. Whether involuntary or deliberate, a physical examination is in order to identify any organic problem that may be present.

Inconsistent or overly rigid toilet training or painful constipation may contribute to development of this problem. Although there is a paucity of research on encopresis, Levine and Bakow (1975) do report a better than 50 percent success rate when they combined medical and behavioral therapy. Frequently, treatment focuses on alleviating constipation and helping the parent to implement a behavior plan to reward the child for bowel movements in the toilet. The DSM-IV-TR reports laconically that the disorder “rarely becomes chronic.”

Selective Mutism

As a child grows beyond infancy, speech becomes a principal tool in the child’s developing social life. When speech is seriously impaired, there will be upsetting limitations in the child’s social life; and when that impairment persists to school age, it can impair classroom performance. In the case of selective mutism, the child is able to speak, but does not do so in specific social situations. This must occur for at least one month, causing significant impairment, and not be due to language difficulties. The disorder is rare. It is typically treated through behavioral interventions that shape and reward talking in the situations where it had not been occurring.

Chapter 23: 19 Abnormal Behavior of Children and Adolescents - Abnormal Psychology (5)PERVASIVE DEVELOPMENTAL DISORDERS

Developmental disorders are some of the most serious of psychiatric disorders affecting children. They have a pervasive effect on every aspect of the child’s behavior and do not go away with time or treatment. The two principal classes of developmental disorders are mental retardation (discussed in Mental Retardation) and pervasive developmental disorders. Pervasive developmental disorders include such conditions as autistic disorder and Asperger’s Disorder.

Autism

Among the saddest and most devastating of the childhood disorders is autism. Fortunately, it is a relatively rare disorder; two to five children in ten thousand develop autism. Onset is very early in the life of the child and is indicated by a marked delay in motor development and a failure to show responsiveness to physical affection.

Because of its extreme impact on a child’s behavior and the disheartening plight of the parents of a child with autism, researchers in the field of childhood behavior have devoted considerable research effort to understanding its etiology. Despite that effort, there is much yet to be learned about causative factors. Treatment is most uncertain, although certain therapies, largely behavioral, have been found somewhat effective in reducing the more extreme symptoms of autism. The DSM-IV-TR reports that one child in six of those affected will make an adequate social adjustment and will be able to do some kind of regular work by adulthood; another one in six makes only a fair adjustment; but two-thirds remain severely handicapped and are unable to lead independent lives.

Leo Kanner (1971), who specialized in the treatment of autism, offers this plaintive portrait of a child with autism as he appeared in the doctor’s office: “He wandered aimlessly about for a few moments, then sat down, uttering unintelligible sounds, and abruptly lay down, smiling. Questions and requests, if reacted to at all, were repeated in echolalic fashion. Objects absorbed him, and he showed good attention in handling them. He seemed to regard people as unwelcome intruders. When a hand was held out before him so that he could not possibly ignore it, he played with it as if it were a detached object. He promptly noticed the wooden form boards and worked at them spontaneously, interestedly and skillfully.”

The remainder of this section considers the symptomatology of autism, the present status of our understanding of its etiology, and therapies used for the treatment of autism.

Among children with autism, 75 percent are mentally retarded, many severely so, with IQs below 50. The DSM-IV-TR lists six diagnostic criteria, the first of which is onset before three years. A description of the other criteria follows:

1. Disturbance in relating to others: Children with autism demonstrate significant problems with nonverbal behavior, do not develop age-appropriate peer relationships, do not spontaneously seek to share experiences with others, and seem to lack the interest or ability for bidirectional social and emotional relationships. One father describes his child’s behavior in this sentence: “When Robert turned to you, he looked through you as if you were transparent” (Kaufman, 1976, p. 11). A particularly disconcerting aspect of their behavior is their unwillingness (perhaps inability) to maintain eye contact. Some of the least handicapped children later on develop a sham and deceptive sociability; for example, they may run along with a group of other children, but they nevertheless remain aloof from them.

2. Delayed language development. About 50 percent of children with autism remain mute or use only three or four necessary phrases, which may later disappear. The remaining 50 percent of the autistic group are limited to echolalic expression, repeating words someone has said to them in parrot-like fashion. There is difficulty in sustaining conversations and lack of pretend or imitative play. Children with autism often confuse pronouns; for example, using “you” for “I.” Parents must learn that repeating the parental question, “Do you want your dinner?” means “Yes, I do.” Children who have autism may use parts of an object or event for the whole, referring to dinner, for example, as milk. When they do use words or react to them, they will be very literal in their usage. Their language may be allegorical, such as the use of a prohibiting command learned from parents; for example, “Don’t crayon the walls,” as a universal expression for “No” or “Don’t do that.” Speech may be high-pitched and monotonous, with inappropriately emphasized words. Idiosyncratic or odd responses to the environment are common.

3. Restricted movements, behavior, and interests. Included are tiptoeing around the room, sudden starts and stops, flapping of their arms, body rocking or whirling, head rolling, and playing with their fingers pulled up close to their eyes. Objects may be endlessly twirled or fingered in detail. Children with autism may play with pieces of a game but actually play no game. They may develop peculiar attachments to inanimate objects; for example, carrying around a toy mechanized truck as a normal child might carry around a cuddly teddy bear, or exhaustively fingering a light switch. With surprising perceptual acuity and spatial memory, children with autism will order and reorder their world to maintain things as they were, frequently going into temper tantrums when changes caused by others are first noticed. The need for sameness may carry over to the food they choose to eat, the toys with which they play, and the arrangement of their room or bed. Often there is an intense focus on parts of objects rather than the whole.

Asperger’s Disorder

Asperger’s disorder is occasionally referred to as a milder version of autism. It is associated with interpersonal difficulties and restricted patterns of interests seen in autism, but there is no language delay. Furthermore, most individuals with autism have significant cognitive deficits; conversely, those with Asperger’s disorder tend to have average or even above average cognitive abilities.

Causative Factors in Pervasive Developmental Disorders

Little is known about the etiology of autism. There is evidence of a biogenic cause, in particular genetic factors in pervasive developmental disorders.

Biological Differences

Research indicates a wide variety of neurological factors loosely associated with autism. For example, there has been some evidence of abnormal levels of serotonin, seizures, higher rates of abnormal brain waves, and signs of general neurological difficulties. Also, unusually large brain size (5-10 percent) in toddlers—not always evident at birth and only sometimes in adolescence—has been suggested as a possible correlate of autism (see for example, Fombonne et al., 1999; Volker et al., 2004). General signs of neurological difficulties also are seen in Asperger’s disorder.

Genetic Factors

Research consistently suggests a genetic component to pervasive developmental disorders. Family studies imply a genetic component to both autism and Asperger’s disorder. Recent genetic-linkage analysis research has implicated a segment of chromosome 3 in autism.

(Video) Chapter 33 PERSONALITY ASSESSMENT

Although much good research has been directed at understanding autism, much about the disease is not yet known. In a general way, what we do know about it can be summarized in the two statements that we quote here. One set of authorities in the field (Goldstein et al., 1986) put it this way: “The autistic child quite likely enters the world biologically different in some ways [from other children], but the biological consequences probably vary with the way the child’s environment, especially his mother, responds to that difference.” It is a statement with which most clinicians are likely to agree. DeMyer, Hingtgen, and Jackson (1981), in concluding their studies, express the thought less definitely and with a somewhat different emphasis: Children with autism are “beings with an inborn defect or defects in brain functioning, regardless of what other causal factors may subsequently become involved.”

Treatment of Pervasive Developmental Disabilities

Beginning with the work of Bruno Bettelheim at the Orthogenic School at the University of Chicago, clinicians working with children who have autism have developed a variety of treatment approaches, a number of which report at least partially successful results. Despite their efforts, the prognosis for the child with autism still is considered bleak. Typical of that opinion is the estimate of Cardon et al. (1988) that less than one-fourth of the children with autism who receive treatment attain even marginal adjustment later in life. Rosenhan and Seligman (1989), while agreeing that treatment is slowly improving, nevertheless predict that most young adolescents and young adults with autism still will need access to intensive support services.

Response to treatment is correlated directly with measured IQ and with the presence of intelligible language before the age of five. Those factors are, of course, related, and both indicate a less severe form of autism. What the relationship between those two factors and response to therapy means is that children with mild to moderate autism may respond to treatment. But even for those treatable children, the course of treatment is prolonged (two to three years) and intense (in some programs, as many as forty hours a week). The cost of such programs is out of the reach of many, perhaps most, families without significant assistance. In line with this finding, individuals with Asperger’s disorder who, by definition, do not have significant language impairment and have higher IQs, tend to respond more positively to treatment. Although there is life-long impairment, most individuals with Asperger’s disorder are able to function independently and many are quite successful.

Rutter, in an early review (1968) of treatment approaches to autism, reports that insight therapy of a psychodynamic nature has not proven effective. On the other hand, there are many reports of success with a variety of behaviorally oriented treatment efforts that focus intensively on the correction of specific deficits in the child’s behavior. Examples of such approaches are teaching specific sounds and identifying them with specific objects; helping a child give up objects to which he or she has become pathologically attached; and helping children make even rudimentary physical contact with others. That type of training makes extensive use of behavioral principles; for example, reinforcing desired responses, even though they move only generally or slightly in the right direction (see the “Shaping” section in Behavioral, Cognitive, and Biogenic Therapies).

Some therapists use graded educational approaches adapted to the specific needs of the child in an attempt to remove specific perceptual, cognitive, or motor deficits. Almost all of the successful programs make use of one-on-one, long-term treatment approaches that build warm, loving, and accepting interaction between therapist and patient. Despite the occasional reports of successful treatment, experts on autism advise caution in adopting too optimistic an outlook on outcome of treatment.

Chapter 23: 19 Abnormal Behavior of Children and Adolescents - Abnormal Psychology (6)SUMMARY

Recognition of the presence of mental disorders among children and adolescents and research on those disorders has lagged behind the efforts at understanding adult mental disorders. Not until the DSM-III-R was an adequate listing of disorders of children and adolescents presented.

Three special difficulties exist in trying to understand the mental disorders of the young: 1) attitudes of adults in the home who so significantly shape their children’s personalities and often deny the existence of problems; 2) developmental considerations, which would cause behavior considered normal at one age to be considered abnormal at a later age; and 3) the great difficulty in delineating between the normal and the abnormal in children, who as a whole are prone to occasional behavioral difficulties.

The DSM-IV-TR now lists ten categories of children’s disorders; for convenience and clarity, the chapter has discussed them under four principal headings.

Disruptive behavior disorders: There are three such disruptive behavior disorders. They are attention-deficit hyperactivity disorder (ADHD), which is characterized by inattention and/or impulsiveness and hyperactivity inappropriate for the age of the child; conduct disorder, which includes repeated violation of major rules, norms, and the rights of others; and oppositional defiant disorder, which is manifest in negative, argumentative, or hostile behavior.

Emotional disorders: Three types of emotional disorders are discussed in this chapter. They are separation anxiety disorder, in which the child shows emotional pain, sometimes extreme, when separated from home and family; anxiety disorders, which also occur in adults but are not characterized by the insight achieved by adults and may be more fanciful; and reactive attachment disorder, which results in attachments that are either diffuse or nonexistent and are due to pathological care.

Specific symptom disorders: These disorders are usually limited to a specific troublesome symptom that handicaps the child in social and educational life. The principal symptom disorders discussed in this chapter are the eliminatory disorders of enuresis and encopresis and selective mutism. This category of disorders also includes tic disorders, learning disorders, communication disorders, and feeding disorders.

Pervasive developmental disorders: There are two primary pervasive developmental disorders. They are autism, which is a relatively rare but serious childhood mental disorder in which the child shows marked impairment in communication and interpersonal relating and restricted behavior, interests, or activities, and Aspserger’s disorder, in which the individual evidences interpersonal difficulties and restricted behaviors and interests, but not language delays.

Chapter 23: 19 Abnormal Behavior of Children and Adolescents - Abnormal Psychology (7)SELECTED READINGS

Barkley, R. A. (2000). Taking charge of ADHD: The complete, authoritative guide for parents. New York: Guilford Press.

Gupta, V. B. (2004). Autistic spectrum disorders in children. New York: Marcel Dekker.

Hill, J. & Maughan, B. (eds.). (2000). Conduct disorders in childhood and adolescence. Cambridge, UK: Cambridge University Press.

McHolm, A. E., Cunningham, C. E. & Vanier, M. K. (2005). Helping your child with selective mutism: Steps to overcome a fear of speaking. Oakland, CA: New Harbinger Publications.

Morris, T. L. & March, J. S. (eds.). (2004). Anxiety disorders in children and adolescents (2nd ed.). New York: Guilford Press.

Schaefer, C. E. (1993). Childhood encopresis and enuresis: Causes and therapy. Lanham, MD: Jason Aronson.

Walker, E. C. & Roberts, M. C. (eds.). (2001). Handbook of clinical child psychology (3rd ed.). Hoboken, NJ: Wiley.

Williams, D. (1992). Nobody nowhere: The extraordinary autobiography of an autistic. New York: Times Books.

Test Yourself

1) What disorder frequently is treated with stimulant medication and cognitive-behavioral therapy?

a) attention-deficit/hyperactivity disorder

b) conduct disorder

c) oppositional defiant disorder

d) reactive attachment disorder

2) What disorder is treated with intensive (sometimes as much as 40 hours per week) behavioral therapy?

a) autistic disorder

b) encopresis

c) oppositional defiant disorder

d) selective mutism

3) What disorder is the direct result of pathological care?

a) autistic disorder

b) conduct disorder

(Video) The History of Abnormal Psychology

c) reactive attachment disorder

d) separation anxiety disorder

4) What disorder is likely due to the interaction of a genetic predisposition and social influences such as inconsistent discipline and delinquent peers?

a) Asperger’s disorder

b) conduct disorder

c) encopresis

d) separation anxiety disorder

5) What disorder is characterized by urinating in bed or one’s clothes?

a) autistic disorder

b) Asperger’s disorder

c) encopresis

d) enuresis

6) What disorder has symptoms of significant difficulties in interpersonal relationships and restricted interests, behaviors, or activities, but not delayed language?

a) autistic disorder

b) Asperger’s disorder

c) oppositional defiant disorder

d) reactive attachment disorder

7) What disorder is characterized by negativistic and hostile behavior?

a) conduct disorder

b) oppositional defiant disorder

c) encopresis

d) selective mutism

8) Which of the following disorders is characterized by apprehension and extreme distress concerning the absence of a caregiver?

a) enuresis

b) oppositional defiant disorder

c) separation anxiety disorder

d) selective mutism

9) Approximately 13.3 percent of children have a psychological disorder. True or false?

Test Yourself Answers

1) The answer is attention-deficit/hyperactivity disorder often is treated with a combination of stimulant medication, such as Ritalin or Adderall, and cognitive-behavioral therapy focusing on psychoeducation, skill building, and self-esteem.

2) The answer is autistic disorder. Autism frequently is treated with intensive, one-on-one behavioral therapy that focuses on teaching rudimentary communicative, social, and self-care skills and alleviating behavioral difficulties.

3) The answer is reactive attachment disorder. Reactive attachment disorder is one of the few disorders in the DSM with a specified cause. It is characterized by disturbed attachments (diffuse or nonexistent) due to pathological care such as physical or emotional neglect or frequent changes of caregivers.

4) The answer is conduct disorder. While the exact cause of conduct disorder has not been pinpointed, evidence suggests an interaction between genetic and environmental factors. There is evidence of abnormalities of brain activity, which may be passed from generation to generation. Additionally, inconsistent discipline and delinquent peer groups fail to provide appropriate socialization and, in fact, can encourage the violations of major rules and norms seen in conduct disorder.

5) The answer is enuresis. The primary symptom of enuresis is urinating, intentionally or unintentionally, in one’s clothes or the bed after the age of 5. When it occurs during waking hours, it is specified diurnal enuresis; when sleeping, nocturnal enuresis.

6) The answer is Asperger’s disorder. Sometimes referred to as high functioning autism, individuals with Asperger’s disorder have the interpersonal difficulties and restricted behavior and interests associated with autism, but not the communication difficulties. Additionally, many individuals with autism exhibit mental retardation, but those with Asperger’s disorder typically have average to above average intellectual abilities.

7) The answer is oppositional defiant disorder. The symptoms of oppositional defiant disorder include a pattern of frequently: losing one’s temper; arguing with adults; not following requests or rules; purposefully annoying others; blaming others; being easily annoyed; and being angry, resentful, spiteful, or vengeful.

8) The answer is separation anxiety disorder. This excessive fear of separation from caregivers can be evidenced in the expression of distress in anticipation of the caregiver’s absence, obsessive worry about the caregiver’s well-being or being separated from caregiver, refusal to be alone or go places without the caregiver (including sleeping without the caregiver near), nightmares about separation, and physical complaints in anticipation of separation from the caregiver.

(Video) Symptoms of Child Behavior Disorders | Child Psychology

9) The answer is true. At any one time, approximately 13.3 percent of children and adolescents meet diagnostic criteria of a psychological disorder.

Videos

1. Models of Abnormality (Explaining Mental Illness) | Psyched with Setmire
(Psyched with Setmire)
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4. Psych 102 Chapter 15 Mindtap Before the Class Questions
(Ahmed Ali)
5. Abnormal Psychology- Chapter 11, Eating Disorders
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6. HISTORICAL PERSPECTIVE ON ABNORMAL BEHAVIOURS - 1
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