CHILD AND ADOLESCENT
PSYCHOPATHOLOGY
Fifth Edition
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CHILD AND ADOLESCENT
PSYCHOPATHOLOGY
A Casebook
Fifth Edition
Linda A. Wilmshurst
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Library of Congress Cataloging-in-Publication Data
Names: W ilmshurst, Linda, author.
Title: Child and adolescent psychopathology : a casebook / Linda A. W ilmshurst.
Description: Fifth edition. | Thousand Oaks, California : SAGE Publications, Inc., 2021. | Includes bibliographical
references and index. | Summary: “Child and Adolescent Psychopathology: A Casebook provides students
with an opportunity to gain deeper insight into a wide range of disorders within the context of the diagnostic
framework of the DSM-5. This supplemental textbook prov ides an abundance of “real life” cases which
demonstrate methods in assessing and treating a wide spectrum of child and adolescent psy chopathologies in
a variety of settings. Each case presents an opportunity to practice and develop clinical skills in the
assessment, diagnosis, and treatment of childhood disorders from a number of theoretical perspectives and at
various levels of interest and expertise. The book features current trends in assessment, diagnosis, treatment,
and research. It is an ideal hands-on resource for a child and adolescent psychopathology course. The fifth
edition includes a new case study on depression, expanded coverage of trauma-related disorders, a new
glossary, and updated assessment materials and references throughout”—Provided by publisher.
Identifiers: LCCN 2021028424 | ISBN 9781071822814 (paperback) | ISBN 9781071822845 (adobe pdf) | ISBN
9781071822821 (epub) | ISBN 9781071822838 (epub)
Subjects: LCSH: Child psychopathology —Case studies. | Adolescent psy chopathology—Case studies.
Classification: LCC RJ499 .W 46 2021 | DDC 616.8900835—dc23
LC record available at https://lccn.loc.gov /2021028424
Printed in the United States of America
This book is printed on acid-free paper.
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BRIEF CONTENTS
Preface
Acknowledgments
About the Author
1 Introduction: Understanding the Complexities of Child and
Adolescent Psychopathology
2 Introduction to Neurodevelopmental Disorders
Part A: Problems of Attention and Specific Learning
Disorders
Part B: Autism Spectrum Disorders (ASD) and Intellectual
Disabilities
3 Introduction to Disruptive Behavior Disorders
4 Introduction to Anxiety and Compulsive Disorders
5 Introduction to Problems of M ood: Depression and Bipolar
Disorders
6 Introduction to Disorders of Emotion and Behavior
Dysregulation
7 Introduction to Traumatic and Stress-Related Disorders
Appendix A: Supplemental Case Information
Appendix B: Systems of Classification
Appendix C: Guidelines to the Interpretation of Test Scores
and Assessment Information
Glossary
Glossary References
Index
DETAILED CONTENTS
Preface
Acknowledgments
About the Author
1 Introduction: Understanding the Complexities of Child and
Adolescent Psychopathology
1. Terry Hogan: The Avoidance Trap (10 years old)
Developing a Case Formulation
2. Jeremy Jones: M ommy and M e and Grandma M akes
Three (6 years old) Developing an Intervention Plan
3. Neesha Wilson: Phoenix Rising (10 years old) Risks,
Protective Factors and Psychological Well-Being
2 Introduction to Neurodevelopmental Disorders
Part A: Problems of Attention and Specific Learning
Disorders
4. Colby Tyler: Attention Problems or Distracted by
Life? (14 years old) ADHD; Gifted; Divorce
5. Thomas M cLearn: Read M e a Story (10 years old)
Dyslexia
6. Sandy Smith: M arching to the Beat of a Different
Drum (8 years old) Nonverbal Learning Disability
Part B: Autism Spectrum Disorders (ASD) and Intellectual
Disabilities
7. Dylan Bach: The World According to Dylan (6
years old) M ild Variant of ASD
8. Arthur Watson: Won’t or Can’t: A Case of M istaken
Identity (15 years old) Intellectual Disability; Parent
Denial; Academic and Behavior Problems
9. Brian Williams: M y Name Is Williams, Too (10
years old) Williams Syndrome
10. Bradley Hunter: Not Yet Diagnosed (5 years old)
Neurodevelopmental Symptoms
3 Introduction to Disruptive Behavior Disorders
11. Scott M ichaels: Boys Will Be Boys? (9 years old)
Oppositional Defiant Disorder; ADHD
12. Tyrone Wilson: The Gang’s All Here (15 years old)
Neesha’s Brother; M ultifinality; Learning and Behavior
Problems; Gang Activity; Forensic Assessments; Fetal
Alcohol Spectrum
4 Introduction to Anxiety and Compulsive Disorders
13. Winnie Kent: Silence Is Not Golden (5 years old)
Separation Anxiety Disorder; Selective M utism
14. Shirley Yong: Worried to Perfection (11 years old)
General Anxiety Disorder; Depression; Relational
Aggression; Cultural Conflict; Trichotillomania
15. Jordan Neeson: Let M e Count the Ways (9 years old)
Obsessive Compulsive Disorder
16. Sandra Silver: Shy or Social Anxiety Disorder (Social
Phobia) (15 years old) Social Anxiety Disorder
5 Introduction to Problems of M ood: Depression and Bipolar
Disorders
17. M aria Silva: Anxious and Sad (11 years old) or
Depression Bereavement
18. David Steele: Hopelessness and Despair (17 years
old) Adolescent Depression; Suicidal Ideation
19. M atthew M organ: Out of Control and In Control (9
years old) Child-Onset Bipolar Disorder/M ood
Dysregulation Disorder
20. Jenny Sloan: The All-American Girl (16 years old)
Bipolar Disorder; Suicide Attempt
6 Introduction to Disorders of Emotion and Behavior
Dysregulation
21. Alex Bishop: The Slippery Slope (15 years old)
Substance Use; M ultidimensional Family Therapy (M DFT)
22. Sarah Burke: Food for Thought (16 years old)
Disordered Eating and Eating Disorders
23. Tori Benson: Skin Deep: Cutting Through the Pain (16
years old) Self-M utilation; Borderline Personality Disorder
7 Introduction to Traumatic and Stress-Related Disorders
24. Juan Hernendez: The Crash (16 years old)
Posttraumatic Stress Disorder; Survivor Guilt
25. Jason Coleman: Disconnected Connections (16 years
old) Conduct Disorder; Attachment Disorder; Traumatic
Childhood
26. Ericka White: Not Yet Diagnosed (10 years old)
Appendix A: Supplemental Case Information
Appendix B: Systems of Classification
Appendix C: Guidelines to the Interpretation of Test Scores
and Assessment Information
Glossary
Glossary References
Index
PREFACE
Tell me and I’ll forget. Show me, and I may not remember. Involve me, and
I’ll understand.
—Nativ e American Proverb
The major goal of this casebook is to provide the reader with an opportunity to gain
deeper insight into the complexities of child and adolescent psychopathology and to
apply this knowledge within the context of the diagnostic framework of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013).
A case study approach is used to involve the reader in the simulated practice of
child psychopathology. As problems unfold, a dynamic illustration of a given child’s
problems can be observed during several different stages of development and from
the perspective of different theoretical viewpoints. Within a developmental context,
complex problems of child and adolescent adjustment become grounded in the
realities of family and school experiences. Case studies presented in this text are
especially relevant to the study of child and adolescent psychopathology because
all cases are based on actual clinical cases. Although the cases have been altered
to maintain confidentiality, they continue to represent actual living files and, as such,
provide a unique opportunity to capture the dynamics of child and adolescent
psychopathology in virtual presentations of life as the children develop and their
stories unfold before the reader’s eyes.
Cases have been selected to include a breadth of childhood and adolescent
psychopathology and are representative of the high rates of comorbidity
demonstrated in this population. Each case presents an opportunity to practice and
develop clinical skills in the assessment, diagnosis, and treatment of childhood
disorders from a number of theoretical perspectives and at various levels of interest
and expertise. The text is suitable for upper level undergraduate students in its rich
presentation of case materials that demonstrate applications of many of the core
concepts in child psychopathology (e.g., how therapists from differing theoretical
backgrounds would approach a given case). The text is suitable for graduate
students in providing opportunities to practice and hone clinical skills across a
breadth of clinical cases with opportunities for in-depth discussion and application in
specialty areas of concentration: assessment, diagnosis, and treatment. The text
can be a valuable resource for courses in child psychopathology, abnormal child
psychology, developmental psychopathology, school psychology, behavior
problems of childhood, child psychotherapy, child assessment, and case formulation
in child psychopathology.
Case studies provide diagnostic information at two levels. Case studies are
presented to illustrate the dual nature of diagnosis in its emphasis on diagnosis
as case formulation (an ongoing process of information gathering, problemsolving, and hypothesis testing) and diagnosis as the formulation of an
outcomes statement (the classification or conclusion).
Case studies provide comprehensive assessment information. Case
information is available from a variety of sources (case history, observations,
psychometric assessment, raw data, and clinical interviews) and developmental
contexts (individual child, family, school, and peers) to encourage students to
develop skills in integrating information from diverse sources.
Case studies provide opportunities to develop and practice skills in case
formulation. A semistructured flexible format for case formulation is presented
and demonstrated to emphasize how case formulation can apply to a wide
variety of theoretical perspectives and developmental contexts.
Each case provides an opportunity to develop case formulations that address
developmental issues relative to the case and to evaluate outcomes relative to
expectations.
Case studies provide information on current research findings and conceptual
issues. Questions posed at the end of each case will challenge the reader to
integrate information concerning conceptual issues or research findings with
material presented in each case.
Case studies provide information concerning evidence-based treatments. Each
case is accompanied by a discussion of current issues in treatment.
However, advanced students can also have the challenging opportunity of forging
new directions in integrating information from effectiveness studies in the
development of individual intervention plans and a “case-based” pragmatic approach
to treatment (Fishman, 2000).
Case studies provide opportunities to discuss issues in classification from a
variety of conceptual frameworks and different systems of service delivery.
Case studies demonstrate unique issues in the classification of childhood
disorders.
THE DSM-5 AND CHILD AND ADOLESCENT
PSYCHOPATHOLOGY
In the past, there has been considerable controversy regarding the suitability of
DSM diagnostic criteria for child and adolescent disorders. The main issues
concerned whether the categorical approach used by the DSM was suitable for
conceptualizing disorders from a developmental perspective that favored a
continuum of severity (dimensional approach) and one that recognized that
symptoms of disorders would manifest in different ways throughout development. In
addition, theories of developmental psychopathology often looked to family and
environmental factors that placed children at increased risk for psychopathology,
such as insecure attachment, family dysfunction, or social skills deficits. However, it
is important to note that the newly revised DSM-5 (APA, 2013) does represent
significant improvement in its conceptualization and applicability of disorders within a
developmental perspective in several important ways, with increased recognition
and emphasis on the following:
Developmental and lifespan considerations: The DSM-5 has been reorganized
around a lifespan orientation, progressing from disorders that have early onset
(neurodevelopmental disorders) to those most common in adolescence and
young adulthood (bipolar, depressive, and anxiety disorders) and ultimately
focusing on disorders most often associated with adulthood and later life
(neurocognitive disorders).
Comorbidity and clustering of disorders along internalizing and externalizing
dimensions: The DSM-5 represents a movement away from more traditional
emphasis on categorical classification toward increased emphasis on
dimensional aspects of diagnosis based on shared features, including “neural
substrates, family traits, genetic risk factors, specific environmental risk factors,
biomarkers, temperamental antecedents, abnormalities of emotional or
cognitive processing, symptom similarity, course of illness, high comorbidity,
and shared treatment response” (APA, 2013, p. 12). Within this context, the
DSM-5 framework is consistent with research supporting clustering of disorders
along dimensions of internalizing (anxiety, depressive, and somatic symptoms)
and externalizing factors (impulsive, disruptive, and substance use symptoms)
based on similarities in environmental and genetic risk factors for these two
dimensions.
Supporting diagnosis using dimensional cross-cutting symptoms measures. In
addition to the traditional diagnostic criteria available from the use of the
categorical symptom criteria, the DSM-5 also encourages the use of a
questionnaire targeting more general symptoms common to a number of
psychological disorders and difficulties (13 domains for adults, 12 domains for
children and adolescents). The adult form consists of 23 questions in a selfreport measure indicating the extent to which problems are evident, for the 13
domains, ranging from not at all (0) to severe (4). The parent/guardian symptom
measure is used for children aged 6–17 years.
Reconceptualization of childhood disorders and unique diagnostic criteria for
some disorders with onset in early childhood: The previous category of
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
originally housed disorders of mental retardation, learning disorders, motor skills
disorder, communication disorders, pervasive developmental disorders,
attention deficit and disruptive behavior disorders, feeding and eating disorders
of infancy or early childhood, tic disorders, elimination disorders, and other
disorders of infancy childhood or adolescence (separation anxiety disorder,
selective mutism, reactive attachment disorder, stereotypic movement
disorder). This category has been removed and a new category –
Neurodevelopmental Disorder – has been added which includes intellectual
disabilities, communication disorders, autism spectrum disorder, attention
deficit/hyperactivity disorder, specific learning disorder, motor disorders, and
other neurodevelopmental disorders.
Separation anxiety disorder and selective mutism are now both parts of the
category of Anxiety Disorders, while reactive attachment disorder can currently
be found in the category of Trauma- and Stressor-Related Disorders, which
also contains disorders of posttraumatic and acute stress disorders, as well as
the adjustment disorders. Obsessive compulsive disorder has been moved
from the anxiety disorders to a new category of Obsessive Compulsive and
Related Disorders, which also includes such disorders as body dysmorphic
disorder, hoarding, and trichotillomania. In addition to these reorganizational
features, the DSM-5 now includes unique diagnostic criteria for posttraumatic
stress disorder (PTSD) for children 6 years of age and younger and a new
diagnostic category “disruptive mood dysregulation disorder,” which has been
developed as a potential alternative diagnostic category for symptoms of
pediatric bipolar disorder featuring severe recurrent (three or more times,
weekly) temper outbursts (verbally or behaviorally). Within the category of
Feeding and Eating Disorders, a new diagnostic category of
“avoidant/restrictive food intake disorder” has been added, with onset most
likely in early childhood. This new disorder replaces the previous category of
Feeding Disorder of Infancy or Early Childhood.
Conduct disorder and oppositional defiant disorder can be found in the
category of Disruptive, Impulse-Control, and Conduct Disorders which also
includes intermittent explosive disorder.
Risk and prognostic factors: In addition to providing information concerning
prevalence, development, and course, the DSM also includes specific sections
on comorbidity, and any available information regarding temperamental,
environmental, and genetic/physiological factors.
Clinical case formulation: The DSM emphasizes that “it is not sufficient to
simply check off the symptoms in the diagnostic criteria” and that developing a
clinical case formulation requires the ability to recognize the constellation of
“predisposing, precipitating, perpetuating, and protective factors” that have
contributed to the development of psychopathology and utilizing this
information for effective treatment planning (p. 19).
This casebook can provide the materials necessary to develop and enhance clinical
skills in all the areas listed previously; however, the reader should not lose sight of
the fact that, ultimately, each case study in this text is a story about a lost child. In
these “living files,” the children have lost the path to normal development. Based on
clues provided in the story, the reader’s goals are to determine a child’s current
path relative to normal adjustment and redirect the child’s course in the right
direction. With these goals in mind, read their stories and develop your expertise so
that you can be better prepared to help the next child who may find you.
OVERVIEW OF THE CASEBOOK
Chapters 1–7: Cases of Child and Adolescent
Psychopathology
Children and youth depicted in the 26 case studies in these chapters manifest
symptoms of several comorbid disorders, as is often seen in real life. The case
studies provide an in-depth look at the multiple pathways that can lead to
maladaptive behaviors and how children can be buffered from harm or become
increasingly more vulnerable based on individual and environmental factors. Cases
are presented as they appear in the newly revised DSM-5 and are clustered into
chapters that allow for extensive discussion of how the case studies represent
similar but different disorders within a given category. Each chapter begins with an
introduction to the types of disorders discussed within that chapter. The introduction
will also provide information regarding any changes to the DSM criteria that may
have altered symptom criteria or how the disorder is to be conceptualized in the
future. Each case study is presented in the same format and includes the following
information:
Overview
Introduction
Developmental History/Family Background
Reason for Referral
Assessment Results
Issues, Trends, and Treatment Alternatives
Post-Case Questions
References
At the end of each case study, there is a discussion of relevant issues or trends
and a review of the latest empirical findings regarding developmentally appropriate
treatment programs. Finally, a number of post-case questions challenge the reader
to apply theory and research to case-based practice. The following is a brief
summary of the content and cases discussed in each of the seven chapters.
Chapter 1: Introduction to Understanding the Complexities of Child
and Adolescent Psychopathology
The opening chapter poses 10 important questions that clinicians ask to guide their
determination of whether a behavior is typical or atypical based on their
understanding of normal development. Initial discussions will evolve around
developing a case formulation and the three stages that are involved in the process
(problem identification, problem explanation, and treatment planning). Case
formulations can be influenced and guided by assumptions that are derived from a
variety of theoretical frameworks. There are a number of theoretical approaches
available to assist our understanding of the nature of child and adolescent
psychopathology (how disorders develop and why they persist) and inform us as to
potential treatment alternatives. The decision-making process is strengthened by
drawing on information from five theoretical models (biological, behavioral, cognitive,
psychodynamic/attachment, and parenting/family systems) which can assist in
understanding maladaptive behaviors from a developmental perspective. Ultimately,
these perspectives can be integrated into an overarching transactional
biopsychosocial framework that considers the influences of child characteristics
(genetics, temperament) and environmental factors (immediate and distal contexts,
such as family, teachers, peers, extended family, and culture) in the etiology and
maintenance of maladaptive behaviors. Using the different models as a guide,
learners will be given an opportunity to develop case formulations and intervention
plans for three cases presenting with a variety of comorbid issues. Finally, the
chapter will conclude with a discussion of the risks and protective factors
associated with the different levels of influence in Bronfenbrenner’s ecological
biopsychosocial model, including child characteristics (genetic and temperament
factors) and the immediate (family, school, peers, neighborhood) and more distal
influences (exosystem and macrosystem).
In the first chapter, readers are introduced to three cases which have been
specifically selected to provide opportunities for readers to develop and apply
important skill sets, including developing a case formulation from a variety of
theoretical perspectives, developing a specific behavioral intervention plan, and
developing an increased awareness of risks and protective factors that can
influence child outcomes.
The first case, Terry Hogan (Case 1), presents a complex set of mental health
issues that prompt the reader to investigate case formulations along a number of
theoretical perspectives. For the second case, Jeremy Jones (Case 2), readers are
introduced to a young boy who is raised by his mother and maternal grandmother.
The case affords further opportunities to examine case formulations from a number
of different angles and provides the added bonus of involving the reader in the
process of conducting a functional behavioral assessment with the goal of
developing a behavioral intervention plan for Jeremy that can be used in the home
by his mother and grandmother. Finally, the third introductory case, Neesha Wilson
(Case 3), serves as the spokesperson for resilience as her case presentation
highlights the importance of considering risks and protective factors that influence
the trajectory of child development. However, although Neesha’s path is one of
resilience, outcomes for her brother Tyrone (Case 12) provide a powerful lesson in
the concept of multifinality illustrating that despite sharing similarities in their
environments, the two siblings, experiences result in very different outcomes.
Case 1: Terry Hogan developing a case formulation
Case 2: Jeremy Jones developing a behavioral intervention plan
Case 3: Neesha Wilson focusing on risks and protective factors
Chapter 2: Introduction to Neurodevelopmental Disorders
Neurodevelopmental disorders are disabilities that are associated primarily with
dysfunction of the neurological system and brain. There are many disorders that
can be classified within this category, including attention deficit/hyperactivity
disorder (ADHD), the learning disorders, autism spectrum disorder (ASD), disorders
of intellectual disability (formerly known as mental retardation), communication
disorders, and motor disorders. The introduction to this chapter will provide updated
versions of diagnostic criteria for the cases to be discussed, as outlined in the
DSM-5. Children with neurodevelopmental disorders can often experience
difficulties with speech and language, motor skills, learning and memory, or other
functions related to neurological dysfunction. Children who experience
neurodevelopmental disorders can demonstrate problems in processing information
about their social and academic world that have far-reaching implications for the
trajectory of their future development. Although individuals who meet criteria for
neurodevelopmental disorders share many comorbid features, the cases in this
chapter will be clustered around two themes: cases involving problems of attention
and specific learning disorders and cases addressing issues of intellectual disability
and ASD.
Part A: Problems of Attention and Specific Learning Disorders
This part of the chapter will provide an overview of the nature of diagnostic criteria,
etiology, and course of disorders that can influence a wide range of academic and
social concerns: attention deficit/hyperactivity disorder (ADHD) and the learning
disorders. This section will address how these disorders can impact learning
through difficulties with executive functions (ADHD) and information processing
(specific learning disorders). The discussion will also include any conceptual
changes or modifications to the criteria for these disorders in the DSM-5. Three
cases will be introduced that address difficulties in the diagnosis and treatment of
these disorders, as well as the importance of recognizing other comorbid disorders
that often coexist with these problems.
From a developmental perspective, children with ADHD and learning disorders often
can go undiagnosed and not recognized as having problems, until the academic
difficulties become more obvious, around the third or fourth grade. Colby Tyler
(Case 4) is a young adolescent who is gifted and living in a home situation that has
just been shattered by his parents’ divorce. All this would have been difficult to
contend with for any teen; however, Colby also has ADHD and his unsettled
conditions have taken their toll on his academic progress. Thomas M cLearn (Case
5) is an 8-year-old boy who is talented athletically and a natural go-getter.
Everything seemed to be going his way, until his parents discover the secret that
Thomas had been keeping for years. Thomas has learned to cope with his inability
to read by memorizing his favorite books. Despite all his natural talent and innate
intelligence, Thomas has dyslexia and he cannot read. Finally, Sandy Smith (Case
6) presents with a different set of problems. Although she is able to read very well,
she has other subtle problems that seem to go unnoticed, until she is asked some
very basic questions about money or time. She also seems to take everything
literally and as a result can be the brunt of jokes and peer ridicule. Sandy is very
awkward and socially has very few friends. Sandy has a rare form of specific
learning disorder known as a nonverbal learning disability.
Case 4: Colby Tyler attention deficit/hyperactivity disorder (ADHD) and gifted
Case 5: Thomas M cLearn dyslexia
Case 6: Sandy Smith nonverbal learning disability
Part B: Autism Spectrum Disorder and Intellectual Disability
Children like Dylan Bach (Case 7) and Bradley Hunter (Case 10) represent
extremes in symptom presentations manifesting symptoms that at times can result
in poor ability to engage in social reciprocity, yet at other times may exhibit islands
of insight that are well beyond their years. Although some children with intellectual
disabilities (general patterns of cognitive deficits) are readily diagnosed due to more
obvious delays, others like Arthur Watson (Case 8) may manage to escape
detection due to behavioral problems that overshadow their disability, resulting in
caregivers setting expectations far beyond the level that the child is able to master,
resulting in frustration and escalation of behavioral issues. Other children with
intellectual disabilities, like Brian Williams (Case 9) who has Williams syndrome,
may demonstrate special talents, like musical ability, or heightened motivations to
engage in social situations, although they may be significantly limited in areas of
cognitive functioning.
Case 7: Dylan Bach autism spectrum disorder (ASD; mild variant)
Case 8: Arthur Watson intellectual disability
Case 9: Brian Williams intellectual disability (Williams syndrome)
Case 10: Bradley Hunter not yet diagnosed; possible neurodevelopmental
disorder
Chapter 3: Introduction to Behavioral Disorders
Children who exhibit symptoms of externalizing disorders, such as oppositional
defiant disorder (ODD) or conduct disorder (CD), can be a very disruptive force in
their surroundings through their behaviors which may be highly visible, intrusive, and
unsettling. Children with ODD or CD may demonstrate poor ability to regulate
behaviors and emotions, resulting in responses to emotionally charged situations
that escalate out of control, regardless of whether these events are positive or
negative (Rydell, Berlin, & Bohlin, 2003). While children with ODD can present as
willfully disobedient and defiant of authority, adolescents with CD often violate the
rights of others in behaviors that are either overt (bullies, initiates fights, cruelty) or
covert (break and enter, cons others, theft) in nature. Family characteristics can be
an important underlying dynamic in developing a case formulation for children and
adolescents with disruptive behavior disorders, such as Scott M ichaels (Case 11),
while peer influences can be an important contributing factor for adolescents with
these tendencies, such as Tyrone Wilson (Case 12).
Case 11: Scott M ichaels oppositional defiant disorder (ODD)
Case 12: Tyrone Wilson conduct disorder (CD)
Chapter 4: Introduction to Anxiety and Compulsive Disorders
Children who experience anxiety disorders can exhibit internalizing problems in a
number of different ways, including withdrawal from social contact, agitation, physical
tension and physical complaints, and a plethora of fears and worries causing
excessive distress. Unlike the externalizing behaviors, the anxiety disorders can be
more subtle and difficult to detect. Developmentally, very young children often can
present with a mixture of anxiety and depression, known as negative affectivity,
which presents as an undifferentiated form of shared characteristics of
anxious/depressed features (Achenbach & Rescorla, 2001). Case studies provide a
glimpse of the nature of anxiety and compulsive disorders from several
perspectives, including separation anxiety disorder (SAD; Winnie Kent, Case 13);
generalized anxiety disorder (GAD; Shirley Yong, Case 14); obsessive compulsive
disorder (OCD, Jordan Neeson, Case 15), and social anxiety disorder (Sandra
Silver Case 16). Discussions will include the DSM-5 rationale for moving the
category of OCD from the anxiety disorders to the section on “Obsessive
Compulsive and Related Disorders.”
Case 13: Winnie Kent separation anxiety disorder (SAD); selective mutism
Case 14: Shirley Yong generalized anxiety disorder (GAD)
Case 15: Jordan Neeson obsessive compulsive disorder (OCD)
Case 16: Sandra Silver social anxiety disorder
Chapter 5: Introduction to Problems of Mood: Depression and Bipolar
Disorders
Research in the area of mood problems in children and adolescence has increased
rapidly in the past twenty years, changing the way that these disorders are
conceptualized in children. Although it is widely recognized today that children and
adolescents can experience the entire array of depressive symptoms, from
depressed mood to depressive disorder, there is less agreement on how these
symptoms may appear developmentally in very young children, school-age children,
or adolescents. Nowhere is this controversy more prevalent than in the diagnosis
of pediatric bipolar disorder (PBD). In fact, in one study of psychiatric discharge
rates, prevalence rates of PBD escalated from 1992 to 2004 by 53.2% in children
and 58.5% in adolescents (Brotman et al., 2006). This chapter will include a
discussion of the rationale behind the DSM-5 decision to separate the categories of
bipolar disorders from depressive disorders and the new category of Disruptive
M ood Disregulation Disorder (DM DD), which has been recently added to the
depressive disorders of the DSM-5 to classify recurrent behavior patterns of temper
outbursts, depression, and anger. For comparative purposes, the case studies
present two very different perspectives on bipolar disorder, demonstrating how the
disorder can manifest in childhood (M atthew M organ, Case 19) relative to
adolescent onset (Jenny Stone, Case 20). The chapter also probes whether
M atthew should be diagnosed with disruptive mood dysregulation or pediatric
bipolar disorder. The case of David Steele (Case 18) provides an in-depth look at
suicidal ideation in an adolescent with comorbid substance use issues. At the
beginning of the chapter, the case of an 11-year-old girl (M aria Silva, Case 17) is
discussed. M aria was referred by her pediatrician due to her high scores on
pediatric scales indicating symptoms of depression and anxiety. Ultimately she is
diagnosed with a depressive disorder, in addition to disorders of generalized
anxiety and social anxiety disorder. The case illustrates, similar to the case of
Shirley Yong (Case 14; Chapter 4), the high rates of children, 10%–12% of the child
population in the United States, that present with anxiety and depressive disorders
(Beesdo, Knappe, & Pine, 2009; M erikangas, Nakamura, & Kessler, 2009), and the
high rates of children who present with comorbidity among the two disorders (Hong,
Lee, Tsai, & Tan, 2017).
Case 17: M aria Silva depressive disorder, generalized anxiety, and social
anxiety
Case 18: David Steele depression and suicidal ideation
Case 19: M atthew M organ pediatric bipolar disorder?
Case 20: Jenny Slone bipolar disorder, adolescent onset
Chapter 6: Introduction to Disorders of Emotion and Behavior
Dysregulation
Case studies presented in this section all share underlying facets of emotion
dysregulation (inability to regulate emotions in stressful situations), resulting in
behavior dysregulation (binge eating, excessive substance use, nonsuicidal selfinjury [NSSI]). The rationale for including these three behaviors in the same chapter
is that although no study could be found that links disordered eating to substance
use and NSSI, several studies have reported associations between substance use
disorders (SUDs) and disordered eating, while some studies have also linked
eating disorders to NSSI (Arbuthnott, Lewis, & Bailey, 2015; M uehlenkamp, Peat,
Claes, & Smits, 2012) or NSSI to substance use (Gratz & Tull, 2010). Although the
majority of youth will navigate this period of development without incurring long-term
negative consequences, for some, the road taken can lead to involvement in
greater risk-taking behaviors resulting in a trajectory that includes increased risk for
negative outcomes. Increased risk for body dissatisfaction has been associated
with early maturing girls (Swarr & Richards, 1996), while initial experimentation with
cigarettes, alcohol, and marijuana can take a turn for the worse under the tutelage
of deviant peer practices.
Disorders in this category have later onset, usually in late childhood or adolescence
and include disturbances in body dissatisfaction that may result in eating disorders
and substance use. Since this period of development is marked by significant
changes in biological, psychological, and social systems (Cicchetti & Rogosch,
2002), youth face a number of challenges that can result in shifts in mood, risktaking, and conflicts with authority figures (Arnett, 1999).
Alex Bishop (Case 21) is a youth who demonstrates many signs that should warn
his caregiver that he is at increased risk of substance use. His case is an important
lesson in the importance of recognizing the early warning signs and the need to
involve his caregiver in the intervention process. Alex’s case provides a good
example of multidimensional family therapy (M DFT) and how this intervention
program can be an effective method for working with troubled teens and their family.
Family conflict is also an area of concern for Sarah Burke (Case 22), an adolescent
who is openly defiant and aggressive with her mother. Sarah is experiencing social
and academic difficulties and secretly engages in binge and purge episodes when
her mother and sister are at work. Discussion will include difficulties of implementing
and sustaining treatment interventions for adolescents with eating disorders.
Although little is known about Tori Benson’s (Case 23) past, her current selfabusive behavior suggests that her physical scars mimic the emotional pain she
feels within.
Case 21: Alex Bishop substance use; multidimensional family therapy
Case 22: Sarah Burke eating disorder (bulimia nervosa)
Case 23: Tori Benson self-injurious behavior
Chapter 7: Introduction to Traumatic and Stress-Related Disorders
Stress can trigger an attempt to adjust to an isolated event or result in the ongoing
depletion of resources resulting from living in chronically stressful conditions. Over
time, stress can result in erosion of the immune system, placing individuals at risk
for negative consequences to physical and mental health and emotional well-being.
Children can experience trauma resulting from a significant traumatic event (natural
disaster, actual or threatened harm to self or others) or from repeated exposure to
sexual or physical abuse (type II trauma). Juan Hernendez (Case 24) feels a deep
sense of survivor guilt having lived through the fatal accident that claimed the life of
his best friend, while Ericka White (Case 26) and Jason Coleman (Case 25) have
past abusive experiences that have placed them on a developmental trajectory that
can have far-reaching negative outcomes for their future development. This chapter
will discuss the shift in classification of the stress disorders (posttraumatic stress
disorder, acute stress disorder), adjustment disorders, and reactive attachment
disorder to the newly formed category of Trauma and Stressor-Related Disorders
and proposed future criteria for nonsuicidal self-injury, as well as criteria for PTSD
established for children under 6 years of age.
Case 24: Juan Hernandez posttraumatic stress disorder (PTSD)
Case 25: Jason Coleman reactive attachment disorder (RAD)
Case 26: Ericka White not yet diagnosed
Overview of Case Presentations
The cases are a rich source of information on a number of developmental themes
and diagnostic considerations. Since children and youth can often present with a
number of comorbid disorders and features, an overview of the cases is presented
in Table P1 which can serve as a guide to the nature of the types of problems and
developmental considerations discussed in each of the 26 cases.
Table P1.
Appendices, Additional Information, and Resources
The Glossary contains definitions and examples for terms that have been
highlighted in bold throughout the casebook. The Glossary will provide a
handy reference guide when reviewing concepts and materials.
The Appendices contribute a wealth of additional information for advanced
areas of study.
Appendix A: Supplemental Case Information
This appendix will be especially helpful for readers interested in increasing their
understanding of the assessment process. Actual raw data are provided for four
cases (Colby Tyler, Scott M ichaels, Arthur Watson, and Shirley Yong), and readers
are encouraged to use this information in practicing skills in developing case
formulations and generating a written report. A sample psychological report and an
exercise in differential diagnoses are provided for the case of Colby Tyler.
Appendix B: Systems of Classification
Appendix B provides an in-depth discussion of the educational classification system
as it relates to four primary childhood disorders: specific learning disabilities,
intellectual disabilities (previously, mental retardation), ADHD, and emotional
disturbance. This information is a must for advising parents and for integrating
assessment results within a school-based setting. The section includes recent
updates of the Individuals with Disabilities Education Improvement Act (IDEA, 2004)
and the Americans with Disabilities Act Amendments Act of 2008 (ADAAA), which
impacts Section 504 of the Rehabilitation Act of 1973. This section will also address
the discrepancy criterion and response to intervention as they relate to criteria for
determining whether a child meets criteria for designation as learning disabled.
Appendix C: Guidelines to the Interpretation of Test Scores and
Assessment Information
In this section, readers will find a guide to interpreting standard scores and T
scores, as well as descriptions of the specific assessment instruments used in the
text.
REFERENCES
Achenbach, T. M ., & Rescorla, L. A. (2001). M anual for the ASEBA school-age
forms and profiles. Burlington, VT: University of Vermont, Research Center for
Children, Youth and Families.
American Psychiatric Association. (2013). Diagnostic and statistical manual of
mental disorders-5. Washington, DC: Author.
Arbuthnott, A. E., Lewis, S. P., & Bailey, H. N. (2015). Rumination and emotions in
nonsuicidal self‐injury and eating disorder behaviors: A preliminary test of the
emotional cascade model. Journal of Clinical Psychology, 71(1), 62–71.
Arnett, J. J. (1999). Adolescent storm and stress, reconsidered. American
Psychologist, 54(5), 317.
Beesdo, K., Knappe, S., & Pine, D. S. (2009). Anxiety and anxiety disorders in
children and adolescents: Developmental issues and implications for DSM -V.
Psychiatric Clinics of North America, 32:483–542.
Brotman, M . A., Schmajuk, M ., Rich, B. A., Dickstein, D., Guyer, A. E., & Costello, E.
(2006). Prevalence, clinical correlates and longitudinal course of severe mood
dysregulation in children. Biological Psychiatry, 60, 991–997.
Cicchetti, D., & Rogosch, F. A. (2002). A developmental psychopathology
perspective on adolescence. Journal of Consulting and Clinical Psychology,
70(1), 6–20.
Fishman, D. (2000). The case for pragmatic psychology. New York, NY: New York
University Press.
Gratz, K. L., & Tull, M . T. (2010). The relationship between emotion dysregulation
and deliberate self-harm among inpatients with substance use disorders.
Cognitive Therapy and Research, 34(6), 544–553.
Hong, R. Y., Lee, S. S., Tsai, F., & Tan, S. H. (2017). Developmental trajectories and
origins of a core cognitive vulnerability to internalizing symptoms in middle
childhood. Clinical Psychological Science, 5(2), 299–315.
M erikangas, K. R., Nakamura, E. F., & Kessler, R. C. (2009). Epidemiology of mental
disorders in children and adolescents. Dialogues in Clinical Neuroscience, 11(1),
7–20.
M uehlenkamp, J. J., Peat, C. M ., Claes, L., & Smits, D. (2012). Self‐injury and
disordered eating: Expressing emotion dysregulation through the body. Suicide
and Life-Threatening Behavior, 42(4), 416–425.
Swarr, A. E., & Richards, M . H. (1996). Longitudinal effects of adolescent girls’
pubertal development, perceptions of pubertal timing, and parental relations on
eating problems. Developmental Psychology, 32(4), 636–646.
ACKNOWLEDGMENTS
SAGE wishes to acknowledge the valuable contributions of the
following reviewers:
Deborah Harris O’Brien, Trinity Washington University
Pamela Schuetze, SUNY Buffalo State College
Elisa Geiss, California State University San M arcos
Sherry B. Eyer, Gallaudet University
ABOUT THE AUTHOR
Linda A. Wilmshurst, PhD, ABPP, received her BA and M A in
psychology from the University of Windsor and her PhD from the
University of Toronto. Linda, a Diplomate in Clinical Psychology
(ABPP) and a Registered Psychologist in Florida, has previously
held licenses in Ontario, Canada, Texas, and North Carolina. For 10
years, prior to coming to the Center for Psychology, in Florida, Dr.
Wilmshurst was a Professor in the Psychology Department at Elon
University, in Elon, NC, where she taught courses in child and adult
psychopathology. She was also involved in the supervision of
student internships and mentoring undergraduate research,
primarily in areas related to resiliency, self-perceptions, and wellbeing in college students with attention deficit/hyperactivity
disorder (ADHD). Dr. Wilmshurst has authored a number of
textbooks, including Clinical and Educational Child Psychology: An
Ecological-Transactional Approach to Understanding Child Problems
and Interventions (Wiley-Blackwell, 2013), Abnormal Child
Psychology: A Developmental Perspective (2nd ed.; Routledge,
2017), and Essentials of Child Psychopathology (2nd ed.; Wiley,
2014). In addition, Linda has co-authored three books with Alan W.
Brue: Essentials of Intellectual Disability, Assessment and
Identification (Wiley, 2016); A Parent’s Guide to Special Education
(AM ACOM , 2005); and The Complete Guide to Special Education
(Routledge Taylor Francis, 2018).
Linda has worked in the public school systems and mental health
facilities, internationally. Linda has published articles in scholarly
journals concerning programs for children and youth with severe
behavior problems and university students struggling with ADHD.
She currently works as a psychologist for the Center for
Psychology in Fort M yers, Florida.
1 INTRODUCTION : UNDERSTANDING THE
COMPLEXITIES OF CHILD AND
ADOLESCENT PSYCHOPATHOLOGY
A fundamental challenge inherent in the study of child and adolescent
psychopathology is distinguishing normal from atypical behavior. There are several
reasons why this decision-making process is so complex and why the task is so
difficult.
Determining “normal” from “abnormal” behavior requires an evaluation of the
frequency of the behavior (e.g., does the behavior occur on a daily, hourly basis?),
the duration (is this a recent or ongoing problem), and whether the behavior is
pervasive across all situations (or situation specific). With these factors in mind, we
can now begin to probe whether the behavior is atypical within a developmental
context. Ten of the most important questions that will need to be addressed are the
following:
1. Is the behavior atypical, given the child’s developmental stage? An
understanding of normal developmental milestones provides the foundation for
decisions regarding whether a behavior is atypical. For example, Grace is
concerned because her 2-year-old is aggressive. Yesterday, he shoved
another child off the swing because he wanted the swing. We know that
aggression typically peaks around 2 years of age and then progressively
declines, as children develop increased skills in self-control and emotion
management. Furthermore, instrumental aggression (pushing the child to
obtain an object, e.g., the swing) is a typical form of early aggression, which is
less serious than hostile aggression, which is an intent to injure someone. As
a result, we would be able to tell Grace with some measure of confidence that
the aggressive behavior is not atypical and will likely decline from this point
onward.
2. Is the behavior typical at one stage and not at another? Some behaviors are
more typical or atypical at various developmental stages. For example, toddlers
often engage in oppositional behaviors (the “terrible twos”) as they flex their
newfound sense of independence. However, when introduced to the cases of
Jeremy Jones who is 6 years old (Chapter 1; Case 2) and Scott M ichaels who
is 9 years old (Chapter 3; Case 11), we see “oppositional behavior” that is
atypical for both of these boys, given their ages. Both boys are defiant and
refuse to comply with the most reasonable of requests. Unchecked, these
behaviors can continue to escalate in severity, perhaps even developing into
conduct disorder (CD), a more serious variant of the disruptive behavior
disorders, which we see in the case of Jason Coleman (Chapter 7; Case 24).
3. Is it possible for the same disorders to have different symptom presentations at
different developmental stages? M atthew M organ (Chapter 5; Case 18) and
Jenny Sloan (Chapter 5; Case 19) are case studies of bipolar disorder (BPD);
however, while M atthew potentially has child-onset BPD, Jenny has
adolescent-onset BPD. M atthew’s symptoms evidence high levels of
aggression and rapid mood swings, typical of child-onset BPD, while Jenny’s
symptoms are closer to the adult version of the disorder, manifested in
pressured speech, grandiosity, the need for little sleep, and eventually crashing
into a depression and suicide attempt.
4. Do symptoms of disorders appear the same in children and adults? M any times,
symptom presentations in children are different from adult versions of the
disorders. The question is an important one because on the surface, the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American
Psychiatric Association [APA], 2013) actually lists even fewer disorders that
specifically refer to children (disorders with onset in infancy, childhood, and
adolescence) than the previous version of the DSM (DSM-IV, TR; APA, 2000).
This continues to be an area of concern, since symptoms for the majority of
disorders (including anxiety and depression) have historically been based on
field trials with adults. The DSM has attempted to address this concern by
adding increased descriptions of child and adolescent criteria to the disorders,
as well as associated developmental features. For example, the
“depressed/sad” features of adult depression may appear as “irritable mood” in
a child. Child and adolescent symptoms for posttraumatic stress disorder
(PTSD) differ from adults and across different developmental levels. While
younger children like Ericka White (Chapter 7; Case 26) will often reenact
traumatic experiences through repetitive play, adolescents like Jason Coleman
(Chapter 7; Case 25) and Juan Hernendez (Chapter 7; Case 24) may respond
by engaging in high-risk behaviors (e.g., theft, fast driving, moving in with a
girlfriend and leaving home, etc.). In preschool children, these symptoms can
reveal even more deviations from how symptoms present in older children and
adults, as was evident in Ericka’s clinical history. Compared to adults, children
experience far higher rates of comorbidity (more than one disorder occurring at
the same time). As a result, it is important to recognize that there are different
patterns of comorbidity and that some disorders have a greater tendency to
occur together than others, such as anxiety and depression (Chapter 4; Case
14, and Chapter 5; Case 17). The next three questions (5, 6, and 7) address
issues of comorbidity.
5. What are internalizing behaviors, and do they have a tendency to be comorbid?
Internalizing behaviors, or overcontrolled behaviors, refer to syndromes that
signify “problems within the self, such as anxiety, depression, and somatic
complaints that are without known medical cause and result in withdrawal from
social contact” (Achenbach & Rescorla, 2001, p. 93). Comorbidity among
internalizing disorders is frequent, since they share many common symptoms.
Prior to adolescence, anxiety and depression may often appear somewhat
undifferentiated as negative affectivity (Achenbach & Rescorla, 2001;
Kronenberger & M eyer, 2001). Shirley Yong (Chapter 4) and M aria Silva
(Chapter 5) are cases that demonstrate what researchers (Clark & Watson,
1991; Ollendick, Seligman, Goza, Byrd, & Singh, 2003) proposed as part of the
Tripartite Model, involving negative affectivity (NA), low positive affect (PA), and
physiological hyperarousal (PH). This model suggested that while the negative
emotional state of NA is shared in responses of anxiety and depression,
responses of PH are primarily associated with anxiety, whereas responses of
low PA, such as anhedonia, tend to be associated with depression.
6. What are externalizing behaviors and are they comorbid as well? Externalizing
behaviors, or undercontrolled behaviors, are referred to in the DSM -5 as the
disruptive behavior disorders: oppositional defiant disorder (ODD) and CD.
The hyperactive/impulsive and combined types of attention deficit/
hyperactivity disorder (ADHD) often are comorbid with ODD and CD. Scott
M ichaels (Chapter 3) and Jeremy Jones (Chapter 1) are case studies that
exemplify comorbid ODD and ADHD (hyperactive-impulsive type).
7. Can internalizing and externalizing disorders ever exist in the same child?
Children can have a number of different disorders at the same time (e.g.,
specific learning disorder, ODD, and ADHD). Having a multitude of comorbid
disorders can result in symptoms of depression, due to the cumulative effect of
these disorders on adjustment. The case of Jason Coleman (Chapter 7)
provides an illustration of how many of the internalizing and externalizing
disorders can occur together in the same child.Developmental trajectories are
the outcome of interactions between child characteristics (intelligence, social
competence, heritability, temperament, etc.) and environmental
characteristics (family, school, teachers, peers, neighborhood, etc.). An
investigation of situational or contextual variables can uncover the underlying
dynamics that precipitate and maintain problem behaviors. Question 8 is related
to environmental influences.
8. What are some of the influences in the environment that can contribute to
problem behaviors? Problems may be more evident in one environment (home)
than another (school) or pervasive across situations. The case study of
Jeremy Jones (Chapter 1) reveals how a “well-meaning” mom and grandma
exacerbate his behavior problems through reinforcement (at times thinking his
behaviors are “cute,” and at other times giving in to his demands out of
exhaustion). Jeremy is more controlled at school, due to the structure in the
classroom. The case of Colby Tyler (Chapter 2) illustrates how conflict in the
home can tip the scales. Even though he is trying to keep his world together,
academically and emotionally, with his parents going through a difficult divorce,
Colby’s resources have been stretched to the limit.Some factors can place
children at increased risk for negative outcomes, while other factors can
provide a protective buffer against harm. Risks and protective factors are
addressed in Question 9.
9. What are some important risk and protective factors? There has been
increased effort to uncover protective factors that can contribute to resilience
despite hardship. Knowledge of risk factors can alert practitioners to warning
signs, while knowledge of protective factors can provide the foundation for the
development of preventive measures. A number of risk and protective factors
will be discussed at the end of this chapter.It is important to know that there are
several possible pathways (developmental trajectories) that may produce the
same outcome—equifinality—and that children who experience similar risks
may have very different outcomes—multifinality (Cicchetti & Rogosch, 1996).
The final question addresses these issues.
10. What are equifinality and multifinality? In the case studies to follow, you will
meet Neesha Wilson (Chapter 1) and her brother Tyrone Wilson (Chapter 3):
two African American siblings who have very different outcomes, despite living
in the same home and being exposed to some of the same risk factors.
Neesha is 10 years of age and Tyrone is 15 years. However, while Neesha’s
story is one of resilience, her brother follows the path of least resistance,
developing a substance use problem and joining a street gang to support his
habit. Neesha and Tyrone illustrate the concept of multifinality. Although they
were exposed to similar circumstances growing up, Neesha is successful
despite the odds. When you read these two cases, ask yourself what factors
could have contributed to the very different outcomes for these two siblings.
While adults often self-refer, children are most likely to be referred based on adult
concerns. However, behaviors that may be concerning to parents (nightmares,
aggression, overactivity) are often frequently reported in “normal” children. In
addition, there may be wide variations in parent responsiveness to a child’s given
problems, based on extraneous circumstances at the time, such as tolerance level,
and stressors, such as financial difficulties or family conflict.
With an understanding of the complexities inherent in child and adolescent
psychopathology, we can now turn our focus to a number of theoretical
perspectives that have been developed to explain how problem behaviors develop
and provide direction for treatment and intervention.
CASE FORMULATION
Kronenberger and M eyer (2001) present a framework for diagnosis, assessment,
and treatment based on three essential questions that must be answered by the
child clinician. The authors suggest that regardless of the presenting problem or the
theoretical background of the therapist, the child clinician is usually faced with
providing answers to three primary questions:
1. What are the primary characteristics of the child’s problem?
2. How does the clinician conduct an in-depth evaluation of the problem?
3. How does the clinician decide which interventions are important?
The authors suggest that each of the questions addresses a specific issue or
aspect of child psychopathology. Clinicians respond to the first question when they
classify a child’s problem relative to a diagnostic category or provide a provisional
diagnosis or a case formulation based on the presenting symptoms and
characteristics. The second question involves the in-depth evaluation. Here, the
assessment process requires knowledge of appropriate interview and observational
techniques, as well as broad assessment strategies (e.g., cognitive, behavioral, and
emotional functioning) and syndrome-specific tests (e.g., instruments to detect
anxiety, depression, etc.). These assessment instruments can assist in confirming
or ruling out potential diagnoses. The final question requires knowledge of
developmentally appropriate evidence-based treatment methods that can be
applied to modify the problem (Kronenberger & M eyer, 2001, pp. 1–2).
Although the questions can be answered by the majority of theoretical viewpoints,
Held (1996) emphasizes the need for therapists to spend more time reconsidering
the nature and composition of the theoretical system that guides their decisionmaking process, in what she calls the three predetermined components of therapy:
1. What constitutes problems or impediments to solutions?
2. What causes those problems or impediments to occur?
3. What methods can help clients to solve their problems, overcome their
impediments, and obtain their goals? (p. 37)
Weerasekera (1996) defines case formulation as a process conducted to provide a
“hypothesis of how an individual comes to present with a certain disorder or
circumstance at a particular point in time” (p. 5). Case formulations have been
explored from a number of theoretical approaches, including psychodynamic (Eells,
1997; M cWilliams, 1999; Shirk & Russell, 1996), behavioral (Cipani & Golden, 2007;
M ash & Terdal, 1997), cognitive behavioral (Bruch & Bond, 1999; Esbjørn et al.,
2015), and family systems perspectives (Berman, 1997). Within the realm of child
psychopathology, research linking child outcomes to parenting styles (Baumrind,
1991) and attachment patterns (Ainsworth, Blehar, Waters, & Wall, 1978) suggests
that these areas could also provide rich materials for weaving into the fabric of case
formulations. Case formulation can provide a framework for assessing and
organizing information in a way that informs treatment planning, by going beyond
symptom presentation to deriving hypotheses regarding how the behavior
developed and why it is being maintained. Although the concept of case formulation
has its origins in the psychodynamic approach, the approach is readily adaptable to
a variety of theoretical perspectives and is gaining increased recognition across a
wide variety of theoretical models regarding adult as well as child populations
(Hersen & Porzelius, 2002; Shirk & Russell, 1996).
The case formulation approach is particularly well suited to clinical/developmental
child concerns because the approach
1. supports an understanding of underlying processes (cognitive, behavioral, and
emotional);
2. readily allows for consideration of the impact of personal and environmental
factors on past and present functioning at several levels: individual, immediate,
social and economic, and culture;
3. provides an opportunity to address how risks and protective factors can
impede or assist treatment;
4. provides a unique opportunity to place therapeutic interventions within an
ecologically valid context;
5. can accommodate behavioral (Weisz, Weiss, Han, Granger, & M orton, 1995)
and cognitive behavioral training programs that have been demonstrated to
reduce anxiety (Esbjørn et al., 2015; Kendall et al., 1992), depression (Stark,
Swearer, Kurkowski, Sommer, & Bowen, 1996), disruptive behavior disorders
(Cipani & Golden, 2007; Spaccarelli, Cotler, & Penman, 1992), and, combined
with pharmacology, symptoms of ADHD (Barkley, 1997);
6. is best utilized when a therapist is not confined to a single model or approach
and is best viewed as “part of a holistic approach, encompassing the biological,
psychological, social, and cultural” perspectives (Sim, Gwee & Bateman, 2005,
p. 291).
THREE STAGES IN CASE FORMULATION: A
CONCEPTUAL MODEL
As a construct, case formulation seeks to address the essential questions posed
by Kronenberger and M eyer (2001) and Held (1996). When a diagnosis is made, a
wealth of clinical knowledge about the disorder is readily available. The case
formulation is a hypothesis about potential underlying influences that precipitate
(cause) and maintain the behavior, including child factors (biological, genetic, and
neurobiological) and environmental factors (family, school, peers, community). To
this end, the case formulation provides a better understanding of
Problem identification (what is the problem?)
Precipitating and maintaining factors (why does the problem exist? why is the
problem persisting?)
Intervention (how can the problem be alleviated?)
The case formulation presents a three-stage model that provides an organizational
framework for discussing diagnosis, assessment, and treatment/intervention. The
three stages of the case formulation include
Stage 1: Problem identification (clarification and classification)
Stage 2: Problem interpretation/understanding (precipitating and maintaining
factors)
Stage 3: Treatment formulation (intervention strategies).
Stage 1: Problem identification: Knowledge of normative expectations, awareness
of the etiology of disorders, and familiarity with empirical research all add to our
understanding of specific disorders. At this stage, a wide variety of assessment
methods allows us to access information from multiple sources (parents, teachers,
child). In some multiple-problem cases, there may be a need to prioritize among
problem areas based on urgency and/or severity of problems. Sometimes, what
was originally thought to be “the main problem” is actually secondary to a different
concern. In these cases, hypotheses are reformulated.
Stage 2: Problem interpretation/understanding: Developmental and family history
can provide important information regarding potential genetic (family pathology,
biological implications) or event-based causes (family or school history, traumatic
events, etc.). Knowledge of risks and protective factors can also assist in better
understanding conditions that might exacerbate or moderate the problem. At this
stage, theoretical assumptions can influence how the problem is conceptualized;
however, the ability to integrate information from diverse theoretical perspectives
can increase our understanding of the dynamics involved.
Stage 3: Treatment formulation: Knowledge of evidence-based treatments that best
apply to the unique aspects of the case will increase opportunities for success.
M onitoring and evaluating treatment effectiveness are also important in order to
validate the effectiveness of the treatment or intervention (Box 1.1).
Box 1.1 Thinking Out Loud
Sections titled “Thinking Out Loud” will provide opportunities to consolidate
information, identify areas for further exploration, and assist in working through the
process of case formulation.
Although case formulation involves three stages, it is a dynamic and ongoing
process that has a built-in capacity for flexible thinking and revision at all stages. In
this way, case formulation can become case reformulation, allowing for ongoing
refinement and evaluation of problem areas and treatment plans.
CASE FORMULATION FROM FIVE DIFFERENT
PERSPECTIVES
The following section is devoted to case formulations developed from five different
theoretical frameworks: biological, behavioral, cognitive (social cognitive),
psychodynamic/attachment, and parenting style/family systems.
Case Formulation Based on the Biological Perspective
The biological perspective looks to genetics, physiological factors, and brain
anatomy (function and biochemical activity) to assist in understanding the etiology
of human behavior and possible treatment alternatives. Developmentally, rapid
growth in brain development in the first 2 years of life results in pruning of less
useful connections while increasing the efficiency of neural transmissions due to a
process of myelination which improves conductivity. Neurotransmitters, chemicals
released into the synapse between neurons, can have a profound influence on
moods and behaviors, such as depressive moods that can result from low levels of
serotonin or norepinephrine, or increases in anxiety resulting from malfunction of
gamma-aminobutyric acid (GABA) which is not performing adequately to inhibit
anxious responses. In addition, secretion of hormones into the bloodstream, such
as the release of cortisol in response to stressful circumstances, can cause the
hypothalamus–pituitary–adrenal system (HPA) to go on high alert by activation of
the sympathetic nervous system in individuals with PTSD or those vulnerable to
other anxiety-provoking situations. In addition to these responses, certain parts of
the brain have also been implicated in the etiology of specific disorders, such as
low levels of activity in the frontal cortex of individuals with ADHD or irregular
patterns of amygdale functioning in individuals with autism spectrum disorders (Box
1.2).
Box 1.2 Thinking Out Loud
When considering the biological perspective, it is important to consider the principle
of epigenesis, a concept that had its origins in biology but has been adapted by
psychology to explain how interactions between organisms and their environment
can transform both entities in the process. There are two variations on the theme of
epigenesis: deterministic epigenesis and probabilistic epigenesis. Deterministic
epigenesis was a concept that was originally supported by such theorists as Freud
and Erikson who believed strongly that developmental stages were predetermined
and that there was a direct link between biology (genes) and structure (behavior)
such that biology was destiny. However, more contemporary theorists, such as
Gottleib (2007), support a probabilistic epigenesis approach which speaks to the
theory that “there are bidirectional influences” (p. 1), such that biology is not destiny
because one can reduce the impact of a genetic inheritance (e.g., heart problems)
by intervening in the process (e.g., taking medications to reduce cholesterol and
changing exercise and diet). Within the probabilistic epigenetic framework, biology is
not necessarily destiny (Greenberg & Partridge, 2003).
The influence of genetics in placing individuals at risk for specific disorders, such as
depression, anxiety, and schizophrenia, has been well documented in research,
while specific types of child temperament have also been implicated in regulating
individual responses to positive or negative environmental stimuli (Fox, Snidman,
Haas, Degnan, & Kagan, 2015; Kagan, 1992). Temperament involves individual
differences in reactivity evident in responses related to motor, affective, autonomic,
and endocrine functions and self-regulation resulting from processes and behaviors
that serve to moderate reactivity, such as approach, withdrawal, attention, attack,
inhibition, and self-soothing (Kagan, 2003, p. 8).
Therapeutic implications: M any biologically based treatments rely on medical
management to regulate chemical imbalances due to faulty neurotransmitter
production. M edications for depression often seek to correct for low levels of
serotonin either by blocking the reuptake of serotonin (selective serotonin reuptake
inhibitor, SSRI medications) or by blocking the reuptake of serotonin and
norepinephrine (serotonin-norepinephrine reuptake inhibitor, SNRI medications)
(Box 1.3).
Box 1.3 Thinking Out Loud
Biological correlates of isolation: Results of a neuroimaging study have found that
the anterior cingulate cortex (ACC), which is activated during physical pain, is also
activated in response to distress caused by social exclusion and rejection
(Eisenberger, Lieberman, & Williams, 2003). The researchers suggest that these
neural connections may be part of the social attachment survival system to
promote the goal of social connectedness. In addition, studies of attachment
patterns have implicated neural pathways in the cognitive-affective processes that
generalize internal working models (IWMs) from interactions with caregivers to
other social situations. White et al. (2012) suggest that in situations of social
interactions or stimuli, there are differences in the activation of reward and
approach-related circuitry (e.g., left frontal activity) in the brains of those with secure
attachment patterns relative to those with insecure attachment patterns. White et
al. (2012) theorize that “Securely attached individuals learn to anticipate (and elicit)
support from others owing to similar past experiences with caregivers. Conversely,
insecurely attached children, whose parents are thought to be on average less
sensitive and responsive to bids for comfort,… may develop corresponding beliefs
of others as less supportive during distress and themselves as, essentially
unwantable” (p. 691).
Case Formulation Based on the Behavioral Perspective
According to M ash and Terdal (1997), the behavioral systems assessment (BSA) is
a “functional/utilitarian approach” to the assessment of children and families that
closely adhere to the broader meaning of diagnosis as “an analytic informationgathering process directed at understanding the nature of a problem, and its
possible causes, treatment options and outcomes” (pp. 11–12). In direct contrast to
psychodynamic theories, “BSA is more often concerned with behaviors, cognitions
and affects as direct samples of the domains of interest” rather than attempting to
speculate about “some underlying or remote causes” (pp. 11–12; emphasis added).
There has been increased focus on the use of BSA practices and strategies in the
decision-making process (Cipani & Schock, 2007; La Greca & Lemanek, 1996). For
example, functional behavioral assessments (FBAs) are routinely conducted in the
schools (Plotts & Lasser, 2013) with the goal of developing behavioral
intervention plans (BIPs) that often focus on increasing “on-task behaviors” (as in
the case of children with ADHD) or increasing “compliance” (as in cases of children
with ODD). It has been debated by some that FBA is a better approach to
intervention planning than classification of disorders by either the dimensional or
categorical systems (Cone, 1997; Haynes & O’Brien, 1990). An example of the FBA
approach can be found in this chapter, in the case of Jeremy Jones, where issues
of noncompliance are addressed in a program designed to increase compliance.
Proponents of BSA/FBA argue that the problem-solving strategy inherent in this
approach provides a flexible system of hypothesis testing that includes diagnosis,
prognosis, treatment design, and treatment efficacy/evaluation (Cipani & Golden,
2007; M ash & Terdal, 1997). The continuity between conducting the BSA/FBA and
developing the BIP are emphasized by proponents of the system (M ash & Terdal,
1997; Wielkiewicz, 1995). The behavioral framework consists, at its basis, of a fourstage process to identify the problem, analyze the problem, implement a plan, and
evaluate the plan.
From the behavioral perspective, behavior is learned in one of three primary ways:
classical conditioning, operant conditioning, or modeling (observational learning).
Classical conditioning occurs when a normally neutral stimulus takes on a positive
or negative connotation due to association with another stimulus which has the
power to trigger a reflexive response. Classical conditioning is not voluntary and
occurs often beyond our control. Phobias are a very good example of irrational
fears that have been classically conditioned. For example, fear of flying can result
from an experience of flying under turbulent conditions. In this case, the airplane is
initially a neutral stimulus (NS) which evokes a neutral response (NR); e.g., I see the
plane as a means of transportation. However, on one particularly turbulent flight, I
am extremely fearful that the plane is going to crash, and when I finally land, I get off
the plane, vowing never to fly again. Now, the plane has been changed from a
neutral stimulus to one that I am afraid of. In this situation, the plane has been
associated with “bad plane” because it caused me to be very “fearful.” In the
moment of flight, bad plane (US: unconditioned/automatic stimulus) was linked to
bad flight (UR: unconditioned/automatic response). Now the next time I look at a
plane, I don’t think of it a means of transportation, as I initially did, I now think of
crashing and dying. So the plane has now become a conditioned stimulus (CS)
which elicits the conditioned response (CR) of fear (see Figure 1.1). In this case, it is
also likely that if offered a ride in a hot-air balloon, I would also turn that down, since
my fear would generalize to all airborne systems of transportation. This conditioning
paradigm is actually used to explain and decondition phobias in an exposure
therapy called systematic desensitization where a fear hierarchy is developed and
relaxation techniques are paired at each step in the hierarchy until the phobia is
extinguished (see Figure 1.2).
Description
Figure 1.1 Classical Conditioning of Fear of Flying
Description
Figure 1.2 Example of Exposure Therapy (Systematic Desensitization) to
Decondition Fear of Flying
Rather than a reflex response, operant conditioning serves to increase our
tendencies to produce or inhibit behaviors based on our experiences with rewards
and punishments. If I produce a behavior and it is reinforced (rewarded), then my
chances of repeating that response increase, accordingly. If I produce a response
and I am punished, then the chances of me repeating that response decrease,
accordingly. In operant conditioning, reinforcement can occur in two ways: (1) I can
be rewarded positively by the addition of some positive consequence, for example,
money or candy, or (2) I can be rewarded by the removal of something negative—
for instance, if I do a good job on my school work, I do not have to serve a
detention after school to finish my school work (this is referred to as negative
reinforcement because it involves the removal of a negative consequence).
Punishment, which always serves to reduce a response, can also be applied in
two ways: (1) I can apply a direct adverse consequence for bad behavior (hitting,
shocking, slapping) or (2) I can be punished by the withdrawal of something I value,
such as removal of privileges. Examples of reinforcement and punishment are
illustrated in Figure 1.3 (Box 1.4).
Description
Figure 1.3 Increasing and Decreasing Behaviors With Reinforcement and
Punishment
Box 1.4 Thinking Out Loud
According to Cipani and Golden (2007), “In a functional behavioral treatment, the
function of the presenting problem needs to be disabled, while an alternate function
(that is more acceptable) needs to be enabled. To determine how such
consequences should be altered, a behavioral case formulation, relying heavily on
ascertaining the social and environmental function of the presenting problems, is
needed” (p. 539). In their case presentation, Cipani and Golden discuss a case of
avoidant behaviors (academic tasks) manifesting in aggressive responses. The
case concerns a severely disruptive boy, in the third grade, who was placed on
home instruction due to violent outbursts in the classroom. The child had a history
of abuse resulting in lack of attachment, poor emotion regulation, and an inability to
perform academically. In this case, it was crucial to reduce the academic load
(difficulty level) and reward success with stars that were later traded for time
volunteering in the first grade class (a teacher with whom he had a very good
rapport), which served as a positive reinforcement. This combination proved
successful, and after 3 months, the child was attending school on a regular half-day
basis.
Understanding how reinforcement and punishment can be effective consequences
on behavioral outcomes can provide powerful tools to institute behavioral change.
For example, schedules of reinforcement and objective observation techniques can
be very helpful in developing BIPs that can be monitored and modified if needed
(Box 1.5).
Box 1.5 Thinking Out Loud
Although M ash and Terdal (1997) argue against narrowly contrasting BSA with more
traditional assessment approaches, they do suggest some fundamental conceptual
differences between the two approaches. The BSA approach tends to focus on
state (situation-specific patterns of behavior) versus trait (underlying personality
dynamic) characteristics and ideographic versus nomothetic comparisons and
places emphasis on stability and discontinuity over time versus consistency and
stability of underlying causes.
Finally, modeling behavior refers to learning a behavior from observing the
behavior in others. Bandura’s classic experiment of the “bobo doll” is an example of
this type of learning. Children who watched an adult hit a doll were more likely to
imitate the same behaviors when they were placed in a room alone with the doll,
demonstrating the power of observational learning.
Therapeutic implications: Although many practitioners use cognitive behavioral
therapy (CBT; combined therapy based on both cognitive and behavioral
perspectives), there are situations that are very conducive to the use of a primarily
behavioral focus. For example, school psychologists will often conduct an FBA to
determine the antecedents and consequences of specific behaviors (ABC’s). Case
formulations derived using the FBA approach provide information concerning the
precipitating and maintaining factors inherent in a given behavioral pattern with the
goal of developing an appropriate BIP to reduce negative and enhance positive
behaviors (Plotts & Lasser, 2013). Children who experience various anxieties, fears,
and phobias can benefit from the use of exposure techniques such as systematic
desensitization and exposure and response prevention based on behavioral
methods that gradually expose the child to the fearful situation/object while the child
executes relaxation responses (e.g., deep breathing, mediation) that counteract
fearful responses.
In conducting a functional behavior assessment, Sattler (2014) emphasizes the
need to determine what is maintaining the behavior (predisposes the individual to
repeat the same behavior) by examining events in the environment that occur prior
to the behavior (antecedent events) and those that occur as a result of the
behavior (consequences). There are a wide variety of possible antecedent events,
such as social acts (a student may feel rejected by others) or activities (teacher
has instructed the student to read a passage out loud in front of the class) that can
serve as a trigger to a given behavior (child acts out and is removed from class).
The key is to identify the functions of behavior, e.g., “what works for an individual in
a given context” (p. 415). Sattler (2014) provides a seven-step guideline for
conducting an FBA, including the following: define the problem behavior; perform the
assessment; evaluate the assessment results; develop hypotheses; formulate a
behavioral intervention; implement the intervention; and evaluate the effectiveness
(pp. 416–417). The crucial step in this framework is the fourth step, “formulating a
hypothesis to account for the problem behavior” (p. 419). Sattler suggests an
extensive 16-point plan to assist practitioners in achieving their goal, including
noting the type of behavior; where the problem occurs; when the problem occurs;
characteristics of the antecedent events/conditions and setting; consequences;
relevant student background factors; relevant environmental background factors;
functions and goals (escape, attention, control, self-regulation); student’s reactions;
others’ reactions; level of teacher/parent understanding of the nature of the problem
behavior; student’s attitude about the learning environment; student’s attitude about
his/her parents; student’s cognitive and motivational resources for coping; and
student, family, school, and community strengths and resources (pp. 419–420).
Case Formulation Based on the Cognitive Perspective
Negative appraisals can be part of the maladaptive thought processes inherent in a
bias to interpret situations and behaviors in a negative way (Beck, 1997, 2002).
These negative attitudes produce errors in thinking, such as minimizing the positive
and accentuating the negative, which can be automatic and reflexive. For Beck, the
cognitive triad refers to thought processes involving feelings of helplessness,
hopelessness, and worthlessness. One potential outcome of this type of thinking
bias is the development of learned helplessness, a behavior pattern based on
tendencies to give up in the face of adversity (Seligman, 1975). Cognitive theorists
today believe that learned helplessness is caused by a range of negative
attributions that can be global or specific, blame internal or external causes, and are
seen as stable or unstable (Abramson et al., 2002). Attributions that are global
(“Nobody loves me”), internal (“Nobody loves me because I am worthless”), and
stable (“No one will ever love me”) are the most likely combination to result in
learned helplessness. Beck suggests that maladaptive and negative thought
patterns often begin in childhood based on responses to negative treatment and
evaluations within the context of their family. For example, research has
demonstrated that compared to mothers who are not depressed, depressed
mothers tend to be more inconsistent in their parenting, engage in less activity with
their children, and exhibit more frustration (irritable, control, and impatience) in
dealing with child problems (M alphurs, Field, Larraine, Pickens, & Pelaez-Nogueras,
1996; Box 1.6).
Box 1.6 Thinking Out Loud
Beauchaine, Strassberg, Kees, and Drabick (2002) questioned whether parents
using ineffective and harsh methods of discipline fail to generate alternative
solutions due to (1) an availability deficit (limited repertoire) or (2) an accessibility
deficit (processing deficit during times of stress). In order to enhance treatment
efficacy, the authors stress the need to address both negative attributions and
affect regulation in parent training programs. They suggest that negative parent
attributions may undermine successful use of the skills taught.
By the end of the preschool period, children have developed consistent
expectations about their social worlds and act accordingly (M ain, 1995; M ain &
Hesse, 1990). Studies have demonstrated that children’s faulty reasoning about
their social relationships can influence inappropriate behavior (Hartup & Laursen,
1993) and can be reinforced by adult responses to child behavior patterns.
Research suggests that adults respond with less-than-positive reactions to children
who present as “difficult” to manage (Bugental, Blue, & Lewis, 1990), and that these
adult responses can set the stage for a further extension of the child’s belief
system. Beauchaine et al. (2002) found that parents of children with poor
relationship skills were especially deficient in providing solutions to issues of
noncompliance, especially when required to do so under pressured conditions. The
authors recommend the need for treatment plans to target the underlying
processes of negative attribution bias and affect regulation, which they suggest are
the pivotal factors that drive coercive parenting patterns.
Therapeutic implications: Therapists who use cognitive techniques target
maladaptive thinking patterns in order to increase an individual’s ability to recognize
and “reframe” or “restructure” negative thoughts into more positive and healthy
alternatives. Some common maladaptive patterns are overgeneralization,
minimization (of positives), or magnification (of negatives) and all-or-nothing thinking.
For example, if Sally cancels our movie date, I might think to myself: “This always
happens to me”; No one wants to be with me,” or on a more positive note, I might
think “I guess something came up and Sally had to cancel.” Cognitive programs often
include homework assignments that target day-to-day experiences of negative
thought–inducing situations and exercises on how to restructure negative thoughts
into more positive interpretations. Social skills programs that target problems in
social information processing are also helpful in direct instruction of social
information processing techniques such as encoding social cues, clarifying social
goals, appropriate response selection, and monitoring of the consequences of
social actions and reactions (Dodge, 2000).
Cognitive Behavioral Therapy
Although it is possible to provide therapeutic interventions based on cognitive or
behavioral perspectives, practitioners often combine methods in an approach that
focuses on the behaviors and thoughts that drive the behaviors, simultaneously.
CBT seeks to facilitate positive integration of thoughts and behaviors. In their
recent meta-analyses, Weisz, Doss, and Hawley (2005, 2006) found that the most
common treatment approaches included some form of behavior or learning
approach, and that among these, CBT was the most frequent treatment for
depression. In an earlier study, Weisz et al. (1995) found that an 8-session schoolbased group CBT program was effective in reducing symptoms of depression,
relative to a wait list control group. The program focused on activity scheduling and
increasing the likelihood of positive reinforcement. A comprehensive CBT program
developed by Stark et al. (1996) emphasized ways to promote positive mood and
decrease negative thought patterns using individual and group formats. Individual
sessions provided an opportunity for children to discuss topics that may be too
embarrassing to bring up in the group, while group sessions allowed for practice in
developing social skills within a safe social context.
M ore recently, Esbjørn et al. (2015) evaluated the use of case formulation for CBT
in children (7–12 years of age) with anxiety disorders, under conditions of having
parents either as “cofacilitators” or “coclients.” Comparing the success rates to
children’s success rates reported for those who received therapy by manualized
treatment programs, they found that the case formulation approach to be as
successful. They found no difference in whether parents were enrolled as
cofacilitators or coclients.
Social Learning Theory
Social learning theory is another theoretical framework that combines cognitive
learning theory (learning is influenced by psychological factors) and behavioral
learning theory (learning is based on responses to environmental stimuli). Bandura,
who was most interested in observational learning or modeling integrated these two
theories, suggested four pivotal requirements for learning in the social learning
model: observation (environmental), retention (cognitive), reproduction (cognitive),
and motivation (both) (Box 1.7).
Box 1.7 Thinking Out Loud
Coercion theory came out of the larger behavioral perspective of social learning
theory which at its core has the belief that social relationships are maintained
through rewards and positive reinforcement. However, in nonrewarding or aversive
social situations, the outcome can be negative, resulting in conflict. While reciprocity
and positive social exchange are the outcomes of positive reinforcement, negative
exchanges can give way to coercive and aversive reactions that attempt to
exercise control over the behavior of the other. Patterson (1982) felt that parents
were often responsible for unknowingly reinforcing coercive behavior patterns in
their children through acts such as repetitive yelling and nagging when a child
continues to be noncompliant, until the parent reaches the point of exhaustion, at
which point the parent gives in to the child and the child’s aversive responses are
reinforced through negative reinforcement. Children soon learn that if they
misbehave long enough, they will eventually be able to control their parents and get
their way.
Dumas, LaFreniere, and Serketich (1995) observed interactive control exchanges in
dyads involving mothers and children (2.5–6.5 years) who were socially competent,
aggressive, or anxious. The exchanges between competent children and their
mothers were positive and reciprocal with firm limit setting regarding coercive
attempts. Although aggressive children and their mothers engaged in relatively
positive exchanges, there were frequent attempts by the children to gain coercive
control and poor ability of the mothers (inconsistent and indiscriminant attempts) to
effectively manage more extreme forms of coercive behaviors. Exchanges between
anxious children and their mothers were predominantly aversive, with mothers using
coercive methods, and being unresponsive, and children responding by being
resistant and coercive. The study demonstrated that behavior patterns were
influenced by both members of the dyads.
Case Formulation Based on Psychodynamic and
Attachment Perspectives
From a psychodynamic perspective, individuals must come to terms with three
components of their personality: the id (primitive impulses of the libido); the
superego (conscience); and the ego, which evolves over time (reality principle).
Freud believed that individuals were only aware of a very small portion of their
motives and beliefs because the vast majority was hidden from awareness in the
subconscious recesses of their minds. Unconscious conflicts would result in
individuals developing fixations or regressions to earlier psychosexual stages (oral,
anal, phallic, latency, genital) based on earlier unresolved issues, while the ego was
often protected through the use of defense mechanisms, such as denial,
regression, and repression. Erikson expanded Freud’s theory to include
psychosocial stages defined by tasks that were to be mastered by certain
developmental levels across the life span. The development of individual identity
requires that the individual separate from and develop a sense of self unique to the
caregiver. M ahler, Pine, and Bergman (1975) describe this process of separate
individuation as a crucial developmental milestone in the first three years of life,
culminating in the rapprochement phase, in which the toddler resolves the dilemma
of independence without vulnerability by developing a sense of object constancy
(the caregiver is a secure source of comfort).
Erikson’s first stage (trust versus mistrust) and M ahler’s sense of object
constancy provide pivotal points in development of secure attachment relationships
which was later expanded by Bowlby and Ainsworth in their theories revolving
around issues of attachment. Ainsworth et al. (1978) conducted a series of
experiments involving separation and reunion between mothers and infants, called
the Strange Situation experiments. As a result of these studies, two broad
categories of responses defined the areas of secure versus insecure attachment.
In the secure attachment situation, although infants protested their mother’s
leaving, they were able to be soothed by the mother upon her return. Infants who
were insecurely attached responded to mother’s leaving and reunion in two
different ways. Infants who were “anxiously attached” or “anxious/resistant types”
were distressed upon mom’s leaving but were unable to be soothed upon her
return, often responding with continued distress evident in arching their backs or
crying and squirming. Others, labeled “avoidant attachment,” responded to mom’s
leaving and return by ignoring both events. Later, M ain and Weston (1981) added a
fourth category “disorganized/disoriented attachment,” which they discovered in
their work with abused children. These children displayed atypical patterns of
inconsistent and contradictory (approach and avoidance) behaviors and volatile
emotions. Studies of the outcomes of attachment styles have reasoned that these
early patterns may result in embedded templates for future relationships (internal
working model, IWM), since studies have found that children who are securely
attached are more independent and better problem-solvers than their insecure
peers (Sroufe, 2002) who are at risk for self-representations that see the self as
“unlovable and unworthy” (Cicchetti & Toth, 1998).
Bowlby’s interest in the evolutionary importance of infant–caretaker relationships
initially envisioned “survival” as the goal to maintaining proximity to the caregiver.
He later combined psychoanalytic and ethological insights into a theory of
socioemotional development which envisioned early experiences with attachment
figures becoming later canalized as emotional responses to others through
reference to resulting cognitive representations (internal working model, IWM ) of
attachment relationships acquired during this early period (Cox, 2013).
However, in the early 1970s, debate began regarding whether insecure attachment
was the result of impaired attachment due to insensitive early caregiving or the
result of differences in child temperament. Kagan and Snidman (2004) found that
motor activity at 4 months of age (low or high reactive) predicted social
engagement that remained stable at 2 years of age. Children who were highly
reactive to stimuli were socially inhibited, while those that demonstrated low
levels of reactivity were socially engaged. However, even in these longitudinal
studies, the extremes of behavior noted at an early age modified over time,
suggesting the importance of environment as a moderating condition.
Greenberg (1999) has embedded attachment theory in an ecological developmental
framework to explain psychopathology resulting from the interplay of factors evident
in the child, parent, and environmental context. Drawing on principles of equifinality
(different pathways may lead to the same disorder) and multifinality (similar
disorders may produce multiple outcomes), Greenberg builds his model drawing on
four underlying processes found in theoretical models of attachment: IWM ,
neurophysiology of emotion regulation, observed behaviors, and functional
motivational processes. The degree of security/insecurity inherent in primary
attachment relationships provides IWM or templates for all future relationships
(Ainsworth et al., 1978; Belsky, 1988; Bowlby, 1982). While secure attachments can
be a protective factor, insecure attachments may place the child at increased risk for
developing problems.
According to Greenberg, neurological findings (neurophysiology of emotion
regulation) suggest that humans require positive experiences of resolving fearful
situations to allow for a buildup of brain structures that help to regulate responses
to anxiety and fear-producing situations (Siegel, 1999). In dysfunctional attachment
relationships, caregivers are not a source of assistance in the regulation of emotion
and can become a source of threat. Deficits in the acquisition of mechanisms to
regulate emotions result in an inability to self-soothe when upset, thereby reducing
the ability to cope in stressful situations. As far as observed behaviors are
concerned, Greenberg suggests that avoidance behaviors may serve an
instrumental role in the attachment process by acting to control and regulate
caregiver proximity and attentiveness. Ultimately, maladaptive attachment patterns
can help explain the functional motivational processes that can negatively influence
social orientation and subsequent prosocial competencies, including poor social
adaptation and withdrawal from social contact. Secure attachments can lead to
better understanding rather than avoidance of negative emotions (Laible &
Thompson, 1998).
M ore recently, studies have investigated whether differences in attachment
strategies may represent differences in how the brain processes sensory
information (Strathearn, 2006). Longitudinal studies have demonstrated that adult
attachment patterns, such as those measured by the Adult Attachment Interview
(AAI: George, Kaplan, & M ain, 1996), can reliably predict maternal caregiving
patterns, which in turn can predict subsequent social/emotional development
(Sroufe, Egeland, Carlson, & Collin, 2005) and attachment (Shah, Fonagy, &
Strathearn, 2010; van IJzendoorn, 1995) in the offspring (Box 1.8).
Box 1.8 Thinking Out Loud
The AAI classifies attachment into categories of secure attachment and insecure
attachment. Insecure attachment is further classified as either dismissing or
preoccupied. Studies have linked the dismissing type of attachment with difficulties
in adolescence in areas of seeking support (overly self-reliant), tendencies to
withdraw, lack of trust in others, and weaker social skills (Allen et al., 2002; Larose
& Bernier, 2001), while adolescents with the preoccupied type of attachment
evidence externalizing traits associated with delinquent activities such as the use of
violence and aggression toward the self or others (Bakermans-Kranenburg & van
IJzendoorn, 2009).
Strathearn (2011) provides an overview of maternal caregiving behavior that draws
on neurobiological sources to help explain maternal neglect. He specifically
addresses how “the oxytocinergic and dopaminergic systems” interact to inform the
mother how to interpret cues from the infant and how to subsequently respond to
those cues. It is his suggestion that oxytocin may be responsive for activating the
dopaminergic reward pathways in response to social cues. Strathearn supports his
theory with research evidence that mothers who have insecure/dismissing
attachment patterns (which have been associated with emotional neglect) evidence
“reduced activation of the mesocorticolimbic dopamine reward system in response
to infant face cues, as well as decreased peripheral oxytocin response to mother–
infant contact” (p. 1054). Furthermore, Strathearn (2011) hypothesizes from an
epigenetic perspective that “attachment” patterns may be transmitted
intergenerationally, mediated by maternal responses to infant cues that are
determined at a neuroendocrine level. The fact that levels of oxytocin and
dopamine can be inherited also sets the stage for future patterns of similar types of
insecure attachment and future responses to situations that are stressful or those
that rely on social engagement. According to Strathearn (2011), “from the emerging
field of epigenetics, we are beginning to understand how the caregiving
environment may influence the development of biological systems and behavioral
phenotypes, via stable changes in the regulation of gene expression” (p. 1057).
Therapeutic implications: Therapeutic attempts to improve the attachment
relationship have remained largely rooted in a psychodynamic approach and have
focused primarily on infant–parent psychotherapy (see Lieberman & Zeanah, 1999,
for review). M any of the programs are lengthy due to the emphasis on building a
therapeutic working alliance with the therapist and the need for extensive ongoing
assessments of child–parent or child–caregiver (foster care) interactions and family
circumstances. Observations and discussions of joint play provide opportunities for
insight-oriented dialogue designed to assist parents in acquiring more appropriate
perceptions of their child and developing interactional patterns that have greater
empathic attunement with the child’s needs. Based on the belief that obstacles to
attachment can occur on several levels (infant, parent, environment), therapeutic
goals in these programs are to determine the nature of the obstacles blocking
attachment (individual differences) and to design treatment to address these
specific areas (Zeanah et al., 1997).
The Seattle Program, developed by Speltz and colleagues (Greenberg & Speltz,
1988; Speltz, 1990), is a parent training program to assist families of children with
insecure attachment that melds attachment theory with a cognitive behavioral
approach. The program focuses on communication breakdown in the parent–child
dyad and emphasizes the need for better “negotiation skills.” The four-phase
intervention program includes components of parent education, reframing of the
child’s behaviors within a developmental framework, limit setting and problem
prioritizing, and communication/negotiation skills.
Although the realm of the unconscious renders many of the psychodynamic
therapies without empirical support, the application of psychodynamic principles to
play therapy has revealed success of a program, psychodynamic developmental
theory of children (PDTC), for children with behavioral issues (Fonagy & Target,
1996). The program has been successful in increasing skills in areas of selfregulation of impulses, capacity to play effectively, and awareness of others (Box
1.9).
Box 1.9 Thinking Out Loud
The foundations of psychodynamic theory are rooted in uncovering the internal and
often unconscious processes that drive an individual’s behaviors and the IWM
responsible for a weakened sense of ego development. As such, the
psychodynamic approach is not an easy fit with empirical research. While M esser
(2000) has called for the development of databases for case-based research to
remedy this problem, Fonagy, Target, Cottrell, Phillips, and Kurtz (2002) have
provided empirical support for the PDTC approach, which has an 85% success rate
for internalizing disorders.
Thinking outside the box: Strathearn (2011) compared secure and insecure mothers’
responses to facial pictures of their infant and reunion with their infant after
separation and found that mothers with an insecure/dismissing pattern of
attachment may have impaired peripheral and central oxytocin production, which
may help to account for the reduced activation of reward processing regions in the
brain when presented with facial cues or opportunities for reunion with the infant.
Based on results from rigorous experimental studies of the use of intranasal
oxytocin in enhancing social responsiveness in areas such as social memory eye
gaze and sense of trust, Strathearn is in the process of conducting randomized
trials to investigate the potential benefits of intranasal oxytocin in enhancing
maternal brain and behavioral responses in mothers with dismissing forms of
attachment.
Case Formulation Based on Parenting Style and Family
Systems Perspectives
Baumrind (1991) investigated parenting styles or the prevailing attitude and climate
evident in the amount of structure and warmth parents provided in the process of
parenting and the outcomes that the different styles had on children’s development.
Baumrind (1966) suggested three primary parenting styles that captured clusters
of parenting behaviors and childrearing goals: authoritative parenting, authoritarian
parenting, and permissive (indulgent) parenting. Later, M accoby and M artin (1983)
added a fourth style, neglectful parenting. These parenting styles are characterized
by emphasis on various combinations of warmth, demandingness or control, and
autonomy granting, although the majority of research has focused on two of the
dimensions: warmth and demandingness or control. The combinations evident in
each of the styles are as follows: authoritative (high warmth, high control);
authoritarian (low warmth, high control); permissive (high warmth, low control); and
neglectful (low warmth, low control). The four different parenting styles are
graphically illustrated in Figure 1.4.
Description
Figure 1.4 Schematic of the Four Types of Parenting Styles With Respect to
Variables of Warmth and Control
M ost recently, Baumrind, Larzelere, and Owens (2010) emphasized the distinction
between the different types of demandingness or control exercised by parents
using authoritative versus authoritarian parenting styles. Although both parenting
styles are “demanding, forceful, and power-assertive,” the two styles differ in how
they exert “power.” “Although both authoritative and authoritarian parents use
confrontive discipline, which is firm, direct, forceful, and consistent, authoritarian
parents differ from authoritative parents in that they also use coercive discipline,
which is peremptory, domineering, arbitrary, and concerned with retaining hierarchical
family relationships” (p. 158).
While authoritarian parents are concerned with maintaining status as power,
authoritative parents exercise control that is “reasoned, negotiable, outcomeoriented, and concerned with regulating behaviors.” In their study of the longitudinal
effects of parenting practices, Baumrind et al. (2010) isolated five different types of
coercive practices, including (1) unqualified power assertion, (2) arbitrary discipline,
(3) psychological control, (4) severe physical punishment, and (5) hostile verbal
criticism. The study compared the emotional health (low level of behavioral
problems) and competency (social and academic achievement) of adolescents
whose parents employed different types of parenting styles during the preschool
period. Results revealed that adolescents reared by authoritarian power-assertive
practices evidenced low communal competence, high internalizing problems, and
low self-esteem, compared to adolescents reared by authoritative and directive
parents who were prosocial and well adjusted.
In most situations, the authoritative parenting approach (high structure and high
warmth) is the desired practice and yields the best child outcomes. The
authoritarian parenting style, although high on structure, is very low on warmth, and
children raised in this type of household may become aggressive and
uncooperative. Parents who are uninvolved provide little structure or warmth, and
children are prone to develop a number of negative traits, including truancy.
Permissive parenting provides warmth but minimal structure. Based on an avoidant
attachment pattern and authoritarian parenting practices, parent–child dyads can be
thrust into a hostile/helpless pattern, with one member of the dyad being the hostile
aggressor and the other member becoming the passive, helpless, and
overwhelmed recipient (Lyons-Ruth, Bronfman, & Atwood, 1999; Box 1.10).
Box 1.10 Thinking Out Loud
Is the authoritative parenting style the best style for all children, regardless of
environment or culture? Research suggests that the authoritarian parenting style
may actually be more suited to raising children who live in neighborhoods that are at
increased risk for youth engaging in violent behaviors (Bradley, 1998). Studies have
also demonstrated that regardless of culture, stress may be the key variable in
moderating parenting style, with increased stress associated with increases in
adopting an authoritarian parenting style (Sue & Hynie, 2011).
Parenting style can also interact with other environmental conditions such as
socioeconomic status (SES), with lower SES predictive of increased risk for
negative child outcomes in areas of academics, behavior, and social difficulties
(Dodge, Pettit, & Bates, 1994). However, studies that have included data on
maternal education suggest that higher maternal education is associated with better
child outcomes regardless of SES (Callahan & Eyberg, 2010; Box 1.11).
Box 1.11 Thinking Out Loud
THE EYE OF THE TIGER: WHAT IS TIGER
PARENTING?
The term “tiger parenting” made its way to North America when Amy Chua (2011),
a Yale law professor, published Battle Hymn of the Tiger Mother. The term “tiger
mother” originated in China and is well known in Asia. Chua chronicles how her
Chinese heritage prepared her to raise her daughters with strict policies that were
driven by the goal to succeed academically (be a straight A student). The girls were
not allowed to watch TV, play games on the computer, or participate in sleepovers.
As a result, Chua reasons they were highly successful academically and
accomplished musicians. Although there are similarities between tiger parenting and
authoritarian parenting, in the focus on adherence to strict rules and routines, tiger
parenting also includes the positive element of “support” (Kim, 2013).
In addition to parenting style, family systems theory has also influenced how we
conceptualize the family unit as the focus of assessment and intervention. The
family unit is composed of many subsystems: parent–child, marriage partners,
siblings, extended family, and so on. Within families, behaviors are often directed
toward maintaining or changing boundaries, alignment, and power. Often, a family’s
degree of dysfunction can be defined by boundaries that are poorly or
inconsistently defined or those that are too extreme (too loose or too rigid).
Salvador M inuchin (1985), a proponent of structural family therapy, described
several family patterns that can contribute to dysfunction. In enmeshed families,
boundaries between family members are often vague, resulting in family members
being overly involved in each other’s lives. According to M inuchin, enmeshed
families (lacking in boundaries) may see a child’s need to individuate as a threat to
the family unit. Triangular relationships are alignments between family members
that serve to shift the balance of power and can include the parent–child coalition,
triangulation (e.g., mother and sibling, versus father), and detouring (maintaining the
child as the focus of the problem to avoid acknowledging other family problems,
such as marital conflict).
Research with a focus on the family systems model has been instrumental in
developing treatment programs for children (Fosco & Grych, 2013) and adolescents
(Grych, Raynor, & Fosco, 2004). Research has focused on such issues in children
as the influence of family on emotion regulation and the role of parent conflict on
children’s conflict appraisal (DeBoard-Lucas, Fosco, Raynor, & Grych, 2010; Fosco
& Grych, 2013). Studies with adolescents have covered topics such as the impact
of intraparental conflict on adolescents, family cohesion, and subjective well-being
(Fosco, Caruthers, & Dishion, 2012; Grych et al., 2004).
Treatment implications: Therapists can work with parents to better understand their
parenting style and to understand the benefits of adopting a consistent parenting
approach that more closely resembles the authoritative parenting style. Within the
family systems approach, the family therapist would create an alliance by joining the
family and observing family interactional patterns from the inside out. Once the
problem has been formulated, the therapist works with the family to restructure the
family interactions toward positive growth and change, such as repositioning the
balance of power and improving problem-solving and communication.
Several treatment programs have been developed that use family systems theory
and principles in conjunction with other therapeutic models and techniques. The
following is a discussion of just two of the main bodies of research in this area.
Parent–Child Interaction Therapy (PCIT) is a parent management training (PM T)
program that was developed for use with individual families to assist in addressing
behavioral problems (oppositional defiant and other behavior disorders) in children
2–7 years of age (Eyberg, Nelson, & Boggs, 2008). The program focuses on two
significant components: child-directed interaction (CDI) with a goal of enhancing the
parent–child relationship and a parent-directed interaction (PDI) component that
focuses on increasing child management strategies. PCIT is an evidence-based
treatment model that integrates aspects of play therapy and behavior therapy, as
well as social learning and family systems theories (Neary & Eyberg, 2002). The
program typically involves 12–20 weeks of commitment. The program has been
demonstrated to be effective in the treatment of a variety of behavioral problems
and there is increasing evidence that the program is as effective when delivered in
a group or individual format (Niec, Barnett, Prewett, & Chatham, 2016).
The Oregon Model of family behavioral therapy had its beginnings four decades
ago (Patterson, Chamberlain, & Reid, 1982) and over the course of time has seen
the development of a number of intervention strategies that have been effective in
alleviating behavior problems in children and adolescents. Currently, there are three
models that have been developed to target needs in specific areas, including the
Family Check-Up (FCU) model; Parent Management Training—Oregon (PMTO)
model; and Treatment Foster Care—Oregon (TFCO) model (Dishion, Forgatch,
Chamberlain, & Pelham, 2016). The Oregon group was one of four research
initiatives using family behavior management strategies that spearheaded parent
training programs based on core principles that emphasized the role of parents as
training agents; observers and recorders of data; and managers of contingency
programs. The research filled an important niche regarding how to assist parents in
managing child behaviors in a way that would halt the development of problem
behaviors into more serious forms of delinquency and antisocial behaviors.
Observations that child outcomes were worse for children whose parenting
practices were at either end of the discipline spectrum (overly lax or overly harsh)
led Patterson (1982) to develop the coercion model based on coercion theory.
Later research demonstrated that coercive cycles emerge slowly from repetitive
patterns and cumulative interactions between infants who are very demanding and
mothers who are unresponsive and detached. Over time, these demanding infant
and disruptive toddler behaviors predict disruptive behaviors in childhood (Keenan
& Shaw, 1995).
The Parent M anagement Training Oregon (PM TO) model contains the underlying
interventions and techniques that are used in all of the Oregon models, with a goal
to reduce coercive parenting practices and to replace these with positive parenting,
through the use of positive reinforcement, setting appropriate limits/discipline,
monitoring/supervision, interpersonal problem-solving, and emotion identification
and regulation (Dishion et al., 2016). Significant benefits of the PM TO have been
documented empirically for youth in areas such as reduced noncompliance, reduced
incidences of aggression on the playground and police arrests, and for parents in
areas of decreased incidences of coercive parenting and increased use of positive
parenting techniques (Forgatch & Patterson, 2010).
The Family Check-Up (FCU) model was designed as an initial stage (intake) to
assist families in distress and provide families with feedback concerning the family
assessment conducted at that time. Involvement in FCU has been related to
increased parental motivation and engagement in the parent training program and
reduced coercive conflict as well as antisocial behavior (Stormshak et al., 2011; Van
Ryzin & Dishion, 2012).
The Treatment Foster Care-Oregon (TFCO) model was developed as an
alternative to group homes or residential placements which have not been
successful for a number of reasons (Wilmshurst, 2002), including possible
iatrogenic effects (when treatments harm) of aggregating youth with similar
problems increasing the opportunities for deviancy training (Poulin, Dishion, &
Burraston, 2001). The program was developed for youth who can no longer be
managed at home and involves the placement of these youth in special foster care
homes under the supervision of foster parents who have been specifically trained in
behavioral methods and the consistent application of supervision, modeling, and
discipline. The youth are placed in the setting for 6–9 months until ready to be
reunited with their family or other longer-term placement. Foster parents are
provided with daily and ongoing support. Therapists also work closely with family
members to provide parenting skills to enhance opportunities for success upon
reunification.
INTEGRATING THEORETICAL PERSPECTIVES: A
TRANSACTIONAL ECOLOGICAL
BIOPSYCHOSOCIAL FRAMEWORK
Bronfenbrenner and the Contexts of Influence
Bronfenbrenner’s (1979, 1989, 2005) ecological systems theory was developed to
explain the importance of contextual influences on human development and
provides an excellent framework for the integration of numerous theoretical
perspectives. Bronfenbrenner depicts the child at the center of a series of
concentric circles, each circle representing a level of influence. Interactions
between the child and the environment are ongoing and transactional, such that
changes at one level can influence changes at other levels. The direction of
influence is bidirectional in that a child’s behavior can influence a parent and a
parent’s behavior can influence the child. For example, in the interaction between
the child and its parent, responses have a reciprocal influence and both can be
altered in the process. Bronfenbrenner and M orris (1998) have suggested that the
model might more appropriately be referred to as a bioecological model to
emphasize biological characteristics in the dynamic and ongoing interplay between
the child’s characteristics (biological and genetic) and the environmental
characteristics (proximal and distal factors) (Box 1.12).
Box 1.12 Thinking Out Loud
In discussing the dynamic interchange between the child’s characteristics and
environmental characteristics, it is important to revisit theories of epigenesis and
the recent contributions to our knowledge from the field of neuroscience. Within the
probabilistic epigenesis framework, individuals with the same genotype can have
different neural and behavioral outcomes based on the dissimilarity or uniqueness
of their relevant life experiences (Gottleib, 2007).
The ecological transactional model (Bronfenbrenner, 1979; Cicchetti & Lynch,
1993) can provide an overarching framework for discussing ecological contexts
“consisting of a number of nested levels with varying degrees of proximity to the
individual” (Lynch & Cicchetti, 1998, p. 235). Initially, Bronfenbrenner proposed three
levels of environmental influence: the microsystem, the exosystem, and the
macrosystem. The microsystem represents the immediate environment and
includes influences of family (caregivers and siblings), teachers, peers,
neighborhood, and school settings. Next is the exosystem, which incorporates
influences from more distal factors, such as parents’ employment and social
economic status. The macrosystem is the outer rim that represents influences
resulting from cultural beliefs and societal laws. Bronfenbrenner refers to the
communication among factors within the microsystem as the mesosystem, which
can be a very potent influence in the child’s ongoing success. Ultimately, a fourth
dimension was added, called the chronosystem, which refers to the cumulative
effect of one’s experiences over the course of a lifetime and includes environmental
events and important life transitions (such as graduation, change of schools,
divorce, birth of a sibling, etc.). Bronfenbrenner’s (2005) ecological system evolved
into what he referred to as the Process–Person–Context–Time (PPCT) model
comprised of four interrelated components, including developmental process
(dynamic interactions/relationship between the individual and the context); person
(the individual’s biological, cognitive, emotional, and behavioral characteristics);
context of human development (the system of nested influences); and time
(temporal aspects that moderate change over the course of
development/chronosystem, such as ontogenetic time, family time, and historical
time). Bronfenbrenner’s ecological systems theory is presented graphically in Figure
1.5 (Box 1.13).
Description
Figure 1.5 Bronfenbrenner’s Bioecological Systems Theory
Box 1.13 Thinking Out Loud
Mesosystem effects: If parents and teachers communicate regularly and share the
same goals for the child, the potential for academic success will increase
significantly. Conversely, poor communication between home and school has been
associated with increased risk for academic difficulties. Similarly, if both parents
share the same goals in their communications with the child, the child will benefit
from the consistency in the message. Bronfenbrenner referred to the system of
communication between influences in the child’s microsystem as mesosystem
effects.
A Transactional Ecological Biopsychosocial
Framework: Risks and Protective Factors
Bronfenbrenner’s model also provides an excellent framework for a discussion of
risks and protective factors that can influence development on a number of different
levels.
Individual Person
Bronfenbrenner (2005) considered the person to be at the core of the series of
concentric circles. Each individual brings unique contributions to the developmental
process in terms of their biological, cognitive, emotional, and behavioral
characteristics. Research has demonstrated that from a very early age, as young
as 4 months of age, temperament (reactivity and self-regulation) can predict social
engagement at 2 years of age. Infants who demonstrated high-reactive traits were
more likely to evidence shy, timid, and fearful responses to unfamiliar events in their
second year (Kagan, 2003, 2004). Evidence of such inborn wiring has led Kagan to
believe that different temperamental types are inherited by a distinct neurochemistry
that affects the excitability of the amygdale and brain activation, with low-reactive
children showing more activation on the left compared to right frontal activation,
whereas the reverse was true for high-reactive children who later demonstrated
behavioral inhibition (BI). Kagan also suggests that the inability to moderate
stress may signal impairment in the GABA (gamma-amniobutyric acid) system
which inhibits neural activation in stressful situations and allows individuals to
regroup. The hypothesis about GABA malfunction is interesting since impairment in
GABA is implicated in many anxiety disorders, and although BI is a temperamental
factor, it shares many similarities with social anxiety disorder (SAD) (e.g., wariness,
avoidance, and fear). Caouette and Guyer (2014) hypothesize that during
childhood, atypical functioning in a number of areas of the brain (i.e., amygdala,
basal ganglia, and prefrontal cortex) influences the tendency to develop a cautious
approach to unfamiliar situations for individuals with inhibited temperaments. They
reason that when children with BI enter adolescence, they are at increased risk for
developing SAD resulting from a conflict between “increased desire for social
reward and extreme fear of humiliation or embarrassment…a vulnerability
moderated in part by a history of inhibited temperament” (p. 67).
While Kagan believes that BI is directly related to temperament, Cassidy (1994)
suggests that emotion regulation strategies (i.e., responses to events and
circumstances meant to regulate emotions, through suppression or heightened
expression of emotions) are related to an individual’s attachment style. Subsequent
longitudinal studies (Schmidt, Nachtigall, Wuethrich-M artone, & Strauss, 2002;
Seiffge-Krenke, 2006) conducted regarding insecure attachment patterns (e.g.,
avoidant/dismissing patterns or ambivalent/preoccupied patterns) have found that
individuals with the dismissing pattern tend to consistently use strategies to
minimize emotional connectiveness while increasing aggressive responses,
compared to those with preoccupied patterns who tend to be more emotionally
dependent and use more negative, ineffective emotional coping strategies.
Within the area of attachment, Strathearn (2011) has suggested that the
transmission of attachment patterns across generations may be mediated by the
mother’s neuroendocrine responses to infant cues, which may in turn set the stage
for infant development of similar patterns either genetically or through a social
learning process which continues to influence the intergenerational transfer within
an epigenetic framework. Strathearn (2011) discusses the strong link between
social and parenting behaviors and biological mechanisms such as the
oxytocinergic and dopaminergic neuroendocrine systems which is supported by
evidence that women who report childhood emotional neglect show significantly
reduced levels of oxycontin in their system. Support for the role of oxytocin in social
information processing was recently demonstrated in a study of individuals with
Asperger’s syndrome (AS). Individuals with AS process information about faces in
the same region of the brain that others process information about objects. Domes,
Kumbier, Heinrichs, and Herpertz (2014) found that a dose of oxytocin applied
through a nasal spray enhanced facial emotion recognition and amygdala reactivity
in adults with AS. Strathearn (2011) is currently investigating whether a similar
procedure used on mothers who have low oxytocin levels might increase their
positive social responsiveness to their infant’s cues.
Other characteristics that can increase the risk for negative outcomes include male
gender (Rutter, 1979), physical handicaps (Werner & Smith, 1992), and having a
difficult temperament (Bates, Pettit, Dodge, & Ridge, 1998). Protective factors at
this level include good intelligence; a positive self-concept; effective emotional and
self-regulation; an outgoing style of social engagement; and easy temperament
(Kitano, & Lewis, 2005; M asten & Coatsworth, 1998; Passer & Smith, 2004).
Microsystem
The microsystem encompasses the most proximal influences, including the child,
family, school, peers, and neighborhood. It is at this level of influence that we see
how the process of development unfolds, for better or worse. In an environment of
positive and supportive influences, the child learns to trust, develop a secure
attachment to the caregiver, and construct an internal working model (IWM ) that will
serve as a blueprint for social relations with other individuals inside the family
(siblings, extended family) and outside the family context (teachers, peers,
coaches, and mentors). However, inadequate, inconsistent, or inappropriate
parenting styles, poor monitoring of child behavior, peer rejection, or other adverse
experiences can have a profound effect on development.
While children who experience risks in their immediate environment (microsystem)
are prone to developing externalizing problems, disturbances at the exosystem
level—for example, family hardship—can increase the risk for internalizing problems
(Atzaba-Poria, Pike, & Deater-Deckard, 2004). We also know that the number of
risks experienced can add significantly to the overall risk. For example, the
combined effect of social maladjustment and poor academic achievement can result
in a multiplier effect that can have a fourfold increase in the risk for long-term
adjustment problems relative to the presence of only one risk factor (Burchinal,
Vernon-Feagans, & Cox, 2008; Sameroff & Fiese, 2000). Egeland and Sroufe (1981)
found that within the immediate environment (microsystem), having an anxious and
insecure attachment pattern can place a child at risk for maltreatment (anxious
attachment), while an avoidant attachment pattern can increase the risk of physical
abuse or having a parent that is emotionally unavailable.
The interaction between biological and environmental factors has also been
suggested as a possible mechanism for exacerbating the outcomes of having a
temperament high in BI evident in extreme tendencies to avoid social situations.
Williams et al. (2009) investigated the role of BI and parenting styles on
externalizing and internalizing behaviors in children 4, 7, and 15 years of age. The
researchers found that at 4 years of age, children with BI had the most internalizing
problems if they were also exposed to a permissive parenting style, while being
exposed to an authoritative parenting style reduced internalizing problems over time
(Box 1.14).
Box 1.14 Thinking Out Loud
Remember from a biopsychological and probabilistic epigenesis perspective, it has
been proposed that attachment can also be influenced intergenerationally and that
“attachment” or “lack of attachment” messages may be sent to infants by mothers
based on neuroendocrine responses (oxytocinergic and dopaminergic
neuroendocrine systems) to infant cues that shape caregiving behavior. This
dynamic, in addition to any genetic variation, may also influence the infant’s
neuroendocrine development and set the stage for infant behavioral response
patterns (Strathearn, 2011).
Risk and protective factors can be conceptualized along a continuum where a factor
can be considered a risk if it is at one end of the spectrum and a protective factor at
the opposite end (M asten & Powell, 2003). For example, while having a positive
self-concept can serve as a protective factor and buffer a child from harm, having a
poor self-concept can increase the risk for negative outcomes.
Family dynamics and family context can influence development on a number of
levels, including a child’s ability to regulate emotions. Fosco and Grych (2013) found
that while maternal warmth and sensitivity and having a positive family climate were
predictors of the development of positive skills in areas of emotion regulation,
interparental conflict was associated with weaker development of emotion
regulation in children. Grych et al. (2004) found that for adolescents, a close
relationship with their fathers acted as a protective factor and was related to
reduced symptoms of maladjustment. DeBoard-Lucas et al. (2010) investigated the
relationship between interparental conflict and child self-blame in 150 8–12-yearolds and found that a mother’s coercive or controlling and emotionally unsupportive
parenting significantly increased the association between conflict and child selfblame, while emotionally supportive parenting practices and secure attachment with
fathers reduced tendencies for child self-blame regarding interparental conflict.
DeBoard-Lucas et al. (2010) concluded that “supportive responsive parenting can
buffer the effects of interparental conflict on children by reducing self-blaming
attributions for parental discord” (p. 163) (Box 1.15).
Box 1.15 Thinking Out Loud
While social difficulties can increase the risk for negative outcomes, such as school
dropout and delinquency (Blum et al., 2000), gender can make a difference in the
nature of these risks. Girls who feel isolated and are without friends are twice as
likely to engage in suicidal ideation as girls who belong to a social circle. While girls
are protected from suicide by a supportive and cohesive network, for males, sharing
activities with friends was a protective factor (Bearman & M oody, 2004).
Parenting style has also been implicated in influencing child behaviors for better or
worse. Baumrind’s (1991) work on parenting styles has inspired several studies that
have provided support for the notion that authoritative parenting (emphasizing high
degree of warmth and democracy/negotiation, with a focus on encouraging
autonomy by combining high warmth with high control) has been associated with
positive child outcomes in areas of self-esteem and academic achievement. In their
study of over 350 mothers of fourth graders, Fletcher, Walls, Cook, M adison, and
Bridges (2008) found that authoritative and authoritarian mothers were less likely to
yield to coercive tactics than indifferent or indulgent mothers. In addition, within
authoritarian families, tendencies to yield to coercive patterns of behavior resulted
in increased problems in areas of internalizing and externalizing, as well as social
skills. Within indulgent parenting styles, greater use of punitive discipline was
associated with more externalizing problems, while within the authoritarian group
more internalizing problems were evident.
Adverse child experiences (ACEs) can include exposure to such negative
circumstances as neglect, abuse, domestic violence, and maternal depression and
can place children at increased risk for developing a number of negative outcomes.
Clarkson Freeman (2014) examined the prevalence of ACEs and the
emotional/behavioral outcomes among children (birth to 6 years) in a large national
sample using data from the National Survey of Child and Adolescent Well-Being
(NSCAW, 2014). Results revealed that 70% of the sample had experienced at least
three ACEs and that exposure to three or more ACEs increased the risk of
internalizing problems more than four times, while increased risk for externalizing
problems was almost four times greater. As a result, Clarkson Freeman advocates
for increased screening and early intervention.
Using data from the Adverse Childhood Experiences Study (ACE, 1998), a
retrospective investigation of adult reports of early adverse experiences, Anda et
al. (2006) report on a number of changes in stress-responsive neurobiological
systems as well as brain structure and function resulting from exposure to ACEs.
Results support other investigations of impaired memory of childhood experiences.
The researchers found that as the ACE score increased, impairment in memory
increased, suggesting dysfunction in the hippocampus, as well as impairments in
other neurological areas, including “the amygdale, medial prefrontal cortex, and other
limbic structures associated with anxiety and mood dysregulation following early
abuse” (p. 181).
Exposure to violence (ETV) is highest among ethnic minorities, lower SES youth,
and those living in inner cities (Buka, Stichick, Birdthistle, and Earls (2001) and has
been associated with increased risk for engaging in violent behaviors (Richters,
1993). As many as 27% of African American youth who have experienced repeated
ETV have symptoms of PTSD (Fitzpatrick & Boldizar, 1993). However, risk factors
seem to be highest for street children (children socialized into their street role at an
early age) compared to nonstreet children (parents take a more supportive role and
monitor their activities) who are better equipped to survive in a conventional world
(Jarrett, 1998). Case studies in Chapter 7 will discuss some of the outcomes of
different ACEs (Box 1.16).
Box 1.16 Thinking Out Loud
M axfield and Widom (1996) found that 49% of children who were victims of abuse
or neglect were arrested for any nontraffic offense, compared to controls (38%) or
committing a violent crime (18% versus 14%). Almost half of the victims of abuse
and neglect were arrested for nontraffic offenses by the time they were 32 years of
age.
Protective factors in the family that can assist in buffering a child in adverse
circumstances include secure attachment; at least one parent or caregiver who is
nurturing and emotionally supportive, who provides firm limits and boundaries;
authoritative parenting style; parental monitoring; and structured family routines
(Alvord & Grados, 2005; Bee & Boyd, 1999; Kerr & Stattin, 2000; Luthar, 2006;
M asten, Cutulti, Herbers, & Reed, 2009; Rak & Patterson, 1996).
Other protective factors at this level that can influence positive development
include role models outside the family that act as potential buffers; friendships with
prosocial peers; a positive school environment; and involvement in afterschool and
extracurricular activities (Alvord & Grados, 2005; M asten, 2007; Rak & Patterson,
1996; Box 1.17).
Box 1.17 Adv erse Child Experiences and the Brain
Alvord and M cEwen (2013) discuss why early adverse experiences can alter brain
activity due to what they refer to as “biological embedding” resulting from gene–
environment interplay that in a sense programs the individual to respond to
stressors both internal and external in a certain way. However, they also suggest
that it is possible that “adaptive calibration” (e.g., extreme conditions early in life can
alter neural and physiological patterns) may have a protective effect in preparing an
individual to function better in the expected extreme environment (e.g., an individual
living in high-risk and chaotic conditions may become more vigilant and anxious and
better able to adapt to a high-risk situation than an individual living in a secure
environment who is thrown into adverse conditions).
Exosystem
The exosystem involves the influences of the community and social institutions
(such as government and health care) and prevailing economic conditions (such as
employment conditions, inflation rates, and poverty). According to a recent report by
the Children’s Defense Fund (CDF, 2014), 21.1% of children were living in poverty
(defined as a family of four earning less than $2,019 a month, $466 a week, or $66 a
day), while 11.4% were living in extreme poverty (living below half the poverty
level). Black and Hispanic children are among those living in the highest rates of
poverty, with approximately two in five Black children and three in ten Hispanic
children living in poverty in 2014, compared to one in eight white children (Box 1.18).
Box 1.18 Thinking Out Loud
Children living in poverty are at increased risk for abuse or neglect (22 times more
likely), poor health (5 times more likely), and have absences from school in excess
of 1½ times compared to those not living in poverty (M axfield & Widom, 1996).
Protective factors that have been found to exist at this level include availability of
economic support for families and good public health care (Alvord & Grados, 2005;
Wright & M asten, 2005).
Macrosystem
The macrosystem is the level of influence that relates to cultural factors or changes
in policy that may impact large institutions, such as schools and businesses, on a
grand scale. Research concerning the effect of culture on parenting practices has
received increased emphasis in the past decade. A large body of research has
been accumulated on outcomes associated with the parenting styles, as originally
proposed by Baumrind (1966). The authoritative parenting style was initially thought
to be the best style of parenting for all parents. M ore recently, inclusion of cultural
influences in dynamics of parenting has suggested that, although this form of
parenting can serve as a protective factor for a wide variety of children, its influence
is most strongly felt in European American families from middle-class backgrounds.
Within this population, positive outcomes have been noted in a number of areas,
including self-esteem, social skills, and academic achievement. An authoritative
parenting style that includes parental monitoring and supervision can enhance an
adolescent’s exposure to positive activities and reduce an individual’s chances of
engaging in delinquent or high-risk behaviors (Wargo, 2007). A warm but firm
approach to parenting allows teens to be independent within the boundaries of
developmentally appropriate parental limits. On the other hand, use of the
authoritarian parenting style has been associated with increased behavior problems
and reduced academic success (Thompson, Hollis, & Richards, 2003).
Although the authoritative parenting style appears to be the gold standard among
white families, the authoritarian style of parenting appears to be more common
among ethnic minority families than among white families. Researchers suggest that
these differences in styles may be related to the influence of culture on parental
belief systems and subsequent parenting practices. Although authoritative parenting
is less common in ethnic minority families, this parenting style has been linked to
adolescent competence across a wide range of families (Steinberg & Silk, 2002),
with adolescents in minority families benefiting as much from authoritative parenting
as their nonminority peers.
However, within the context of the influences associated with the macrosystem,
Chaudhuri, Easterbrooks, and Davis (2009) suggest that “conceptualization of
parenting in minority groups provides a broad definition of what cultural context can
be a representation of ethnicity, income, immigration experience, and culture” (p.
294). Since different cultural groups support different goals for socialization, it is not
surprising to find that childrearing practices vary among these diverse groups
(Chao, 2000; Hughes, 2001; Polaha, Larzelere, Shapiro, & Pettit, 2004).
In their study of African American mothers, Cain and Combs-Orme (2005) found that
67% of their mothers (regardless of marital status and family structure) used very
strict methods of discipline in authoritarian parenting styles (high control, low
warmth) that featured such discipline practices as hitting, intimidation, and
belittlement (p. 36). There is some support for the use of strict methods of
discipline, especially in environments where parents are using these methods in an
attempt to deter the development of high-risk behaviors in dangerous
neighborhoods (Bradley, 1998). In another study, focusing on African American
adolescent girls living in impoverished communities, Pittman and Chase-Lansdale
(2001) found that adolescent girls experienced the most negative outcomes if their
mothers were disengaged (low on supervision, monitoring, and parental warmth).
However, focusing on a population of predominantly working and middle-class
African Americans, Bluestone and Tamis-LeM onda (1999) found that the majority of
mothers in that study used an authoritative parenting style, which suggests that
different situations and economic conditions are also important considerations when
discussing parenting style and ethnicity.
Given the premise that ethnic minorities’ parenting practices may differ from those in
families that do not experience some of the hardships associated with minority
status, such as poor financial resources, lower educational attainment, and feelings
of marginalization due to minority and or ethnic status, Domenech Rodriguez,
Donovick, and Crowley (2009) found the more traditional parenting styles (e.g.,
authoritative) were not as relevant to ethnic minority families. Some of the
differences that researchers have found in studies investigating ethnic minority
parents are the use of culturally specific methods of parental discipline and control,
lower levels of parental sensitivity, and higher levels of protectiveness (Chao, 1994;
Domenech Rodriguez et al., 2009; M esman, van Ijzendoorn, & BakermansKranenburg, 2012).
Domenech Rodriguiez et al. (2009) studied a sample of first-generation, lowincome, Latino parents (88% M exican origin) and their children (4–9 years of age).
The researchers found that the four traditional parenting styles used in most studies
were not a good fit with Latino families and that expectations for parenting styles
differed depending on whether the parent was the mother or father. Using the three
dimensions of warmth (support), demandingness (expectations and behavioral
control), and autonomy granting (independence, individuation), Domenech and
colleagues found that Latino parents in their sample were high on warmth and
demandingness, but lower on autonomy granting. Furthermore, there were gender
differences in parenting practices with parents granting less autonomy to girls than
boys and higher demandingness toward daughters than sons. The majority of
parents in this sample (61%) met criteria for “protective parents” (high on warmth
and demandingness, low on autonomy granting) (Box 1.19).
Box 1.19 Thinking Out Loud
Domenech Rodriquiez et al. (2009) suggest that different gender effects in their
study might be explained by parents’ perceptions of girls maturing earlier than boys
and having higher expectations for them as a result. They wondered if the
expectations might change as the boys aged.
Although hierarchical parenting (denoting clear guidelines of parental authority) has
been associated with externalizing behaviors in European American and families of
mixed ethnic origin, for Hispanic-American families, inconsistent parenting has been
associated with increases in problem behavior in boys (Lindahl & M alik, 1999).
Holtrop, M cNeil Smith, and Scott (2015) suggest that in Latino families hierarchical
parenting is expected because it embodies the cultural value of respeto or respect
which might suggest that the authoritarian parenting style would be more compatible
with this value. This has not been supported by the research, however, since
application of the authoritarian style in the name of respeto has produced negative
outcomes of increased externalizing and internalizing behaviors (Calzada, Huang,
Anicama, Fernandez, & Brotman, 2012). Based on the inconsistencies in results
with Latino families, Holtrop et al. (2015) suggest that our current knowledge of the
relationship between parenting styles and child outcomes in Latino families remains
unclear. They also suggest that findings may also emphasize the need to identify
culturally relevant practices when designing and implementing parenting
interventions, especially the concept of familism (i.e., emphasis on the family unit).
In a longitudinal study of 444 Chinese American families, Kim, Wang, OrozcoLapray, Shen, and M urtuza (2013) identified four parenting profiles: supportive, tiger
parenting, easygoing, and harsh parenting. Rather than evaluate parenting style
along the typical two dimensions (control and warmth), Kim et al. (2013) used a
multifaceted approach, which considered both positive (parental monitoring and
democratic parenting) and negative (psychological control and punitive control)
aspects of parent control and two forms of parent emotional responsiveness
(warmth and hostility). In this model, warmth and hostility are not considered as
extremes of the same concept, but two different dimensions. Within this context,
tiger parenting was associated with high warmth and high hostility, compared with
easygoing parenting (low warmth, low hostility), supportive parenting (high warmth,
low hostility), or harsh parenting (low warmth, high hostility). As for forms of parental
control, researchers compared confrontative control with coercive control (which
could be either punitive or psychological). Finally, they added the dimension of
“shaming” which they found to be highly important in the Chinese culture. Results of
their study revealed that although “supportive parenting, which is most beneficial for
adolescent adjustment, includes higher extent of shaming than easygoing parenting,
although not as high as the level of shaming in tiger or harsh parenting” (p. 15).
Results indicated that the supportive parenting profile was the most common
parenting style, followed by easygoing, tiger parenting, and harsh parenting (in that
order). Supportive parenting, the most common form of parenting, had the best
developmental outcomes, followed by easygoing parenting, tiger parenting, and
harsh parenting. Contrary to popular belief, Kim et al. (2013) found that tiger
parenting was not the most typical parenting profile among Chinese American
families, nor did it produce the best outcomes for adjustment in Chinese American
adolescents. Compared to adolescents reared under a supportive parenting style,
adolescents whose parents had a tiger parenting profile reported less of a sense of
family obligation and obtained lower educational outcomes, including GPA. The
concept of the tiger mother will be revisited in Chapter 4, the case study of Shirley
Yong (Case 14; Box 1.20).
Box 1.20 Outcomes of Tiger Parenting
In the study by Kim et al. (2013), adolescents who were raised by tiger parenting
reported more academic pressure, greater sense of alienation (lack of
belongingness), and more depressive symptoms.
According to Baumrind (2012) research on culture and parenting styles has
identified “culturally syntonic practices that would be described as confrontational
but not coercive,” including the following: the “training practices of Chinese American
parents”; “the emphasis on prompt compliance by African American parents”; the
emphasis on “respect by Latin American parents”; and the emphasis on “deference
by conservative European American parents” (p. 186). Although these processes of
“directive parenting” may look authoritarian on the surface (forceful and
confrontational), they are not because they are not coercive and are responsive
and child oriented. As such, Baumrind suggests that the “directive style” may be the
universal parenting style that will be associated with increased levels of
competence linking a family’s situational and cultural factors with parent authority
and child autonomy. The emphasis in future research should be, according to
Baumrind, on identifying the “indigenous family patterns specific to a variety of
cultural contexts” (p. 186).
Durlak (1998) conducted a meta-analysis of over 1,000 prevention outcome studies
and reported the findings regarding the following breakdown of risks and protective
factors within the context of Bronfenbrenner’s ecological model. In a more recent
review, Eriksson, Cater, Andershed, & Andershed (2010) conducted an extensive
review of the reviews on literature (30 different meta-analyses) regarding protective
factors that can buffer children and adolescents from externalizing and internalizing
problems. The risk and protective factors from both studies are summarized in Table
1.1.
Table 1.1
RESILIENCE
A discussion of risks and protective factors naturally leads to a discussion of the
concept of resilience. Resilience has been defined as “the capacity for adapting
successfully in the context of adversity, typically inferred from evidence of
successful adaptation following significant challenges or system disturbances”
(M asten & M onn, 2015, p. 6). As a result, studies of resilience have studied
children in high-risk conditions (adversity) who manage to adapt successfully and
have tried to uncover what protective factors can support this trajectory of positive
growth.
Although the topic of resilience has attracted research attention for quite some time,
the concept remains elusive in some respects because of diverse approaches to
defining, operationalizing, and measuring it. As a result, it has been difficult to collate
data across different studies (M asten & Gerwitz, 2006). Researchers studying risk
factors that can contribute to adversity have measured diverse sources of potential
stressors, including aspects such as low SES, low birth weight, number of adverse
life events, and parent divorce. Yet despite the diversity of measures used, results
point to a number of common outcomes (Luthar, Cicchetti, & Becker, 2000).
M asten (2001) summarizes results of studies on resilience that have focused on
two different methodologies: variable-focused studies and person-focused studies
(comparing groups of children living in the same adverse conditions who are
resilient versus those who are not resilient). Some of the outcome measures used
for variable-focused studies have included academic achievement and measures of
prosocial behavior (peer acceptance) and psychopathology (deviant behavior,
internalizing behaviors). Information from these studies has isolated a number of
protective factors that have been associated with resilience. While effective
parenting practices (e.g., authoritative parenting, monitoring, support) have been
associated with the best social and behavioral outcomes, intellectual functioning
has been associated with both academic success and behavioral control. However,
since intelligence includes a wide variety of skills and skill subsets (such as
executive functions) that may also influence self-regulatory process, M asten (2001)
suggests the need to further investigate the underlying processes.
In her review of results from person-focused studies (resilient group versus
nonresilient group), M asten (2001) states that at an early age, individuals in the
resilient groups shared better parenting skills and had an easy temperament. As
they progressed in school, they demonstrated more academic success and had
better self-perceptions and better social adjustment than their nonresilient peers
(Box 1.21).
Box 1.21 Protectiv e Factors and Resilience
Some common elements in resilience research have isolated several factors that
seem to contribute to the development of resilience despite living in adverse
conditions, including positive, supportive caregivers; positive views of self;
motivation to succeed; and cognitive and self-regulatory skills (M asten, 2001).
Resilience and Neurobiology
Alvord and M cEwen (2013) discuss resilience within a neurobiological framework
and within this context define resilience as the “ability of an organism to withstand
environmental challenges to normal function, and as such, successful allostatic
responses can directly contribute to resilience by providing stability in a changing
environment” (p. 338). They describe allostasis as the mediators that the brain
activates in order to regain homeostasis when stressors are detected. Although the
process when working should result in a smooth transition to a steady state, being
bombarded by a constant influx of stress can cause a system to allostatic overload
resulting in overuse of the system and dysregulation (wearing down the system)
(Box 1.22).
Box 1.22 Resilience and the Brain
In addition to the important role of hormones in communicating between body and
brain, Alvord and M cEwen (2013) identify key areas of the brain associated with
regulation of the stress response: hippocampus (central role in learning, memory,
and mood); prefrontal cortex (PFC; regulation of executive function, inhibitory
control, and cognitive flexibility); and the amygdale (AM Y; regulation of emotions,
aggression, and affect related to learning and memory, as in fear conditioning).
Alvord and M cEwen (2013) discuss how the interaction between genetics and early
environmental experiences plays an important role in setting the stage for how an
individual will respond to stressors later in life, based on previous areas of the brain
activated in areas of emotionality and cognition, especially the PFC, AM Y, and
hippocampus.
Resilience and Maternal Depression
Numerous studies have reported negative outcomes for children and youth who are
raised by depressed mothers. Risks that have been reported include social
withdrawal (Yan & Dix, 2014); the acquisition of inappropriate social skills (Carter,
Garrity-Rokous, Chazan-Cohen, Little, & Briggs-Gowan, 2001); increased risk for
psychopathology (Gotlib, Joormann, & Foland-Ross, 2014); and evidence of
dysfunctional physiological systems associated with the ability to manage stress
and engage in social relationships such as cortisol response (Waters et al., 2013)
and oxytocin production (Apter-Levy, Feldman, Vakart, Ebstein, & Feldman, 2013).
For example, Lupien, King, M eaney, and M cEwen (2000) demonstrated that
children’s levels of cortisol are correlated with their mother’s SES and depressive
symptoms.
Individual characteristics that have emerged as protective factors which can buffer a
child from the impact of having a depressed mother are having an easy
temperament (as opposed to difficult temperament) and having a higher IQ
(Compas, Langrock, Keller, M erchant, & Copeland, 2002; Dix & Yan, 2013). At the
family or environmental level, depressed mothers who demonstrate warmth, caring
and support, and a minimum of negativity reduce the impact of their child’s risk for
adverse outcomes (Wang & Dix 2013).
Alvord and M cEwen (2013) discuss evidence of hyper/hypocortisol reactivity in
children of depressed mothers, using a model of allostatic load. Apter-Levi et al.
(2016) also use the same model to address malfunctions in the children’s HPA
system, in their study of chronically depressed mothers and their children.
Collecting data over a period of six years, Apter-Levi et al. (2016) found that hyper
or hypo levels of cortisol and HPA malfunctions were related to the mother’s lack of
sensitive caregiving which did not provide opportunities for children to develop a
sense of security or appropriate social responsiveness. In addition, these
malfunctions were also directly related to negative parenting practices (anger,
negative affect, hostility, anxiety, depressed mood) and unpredictable mood swings
(parent vacillating between displaying incidents of negative mood or anger and
incidents of withdrawal). Due to these negative practices and unpredictable mood
swings, children would be forced to be in a state of constant vigilance in order to
adapt to erratic changes in the mother’s mood and behavior. As a result, Apter-Levi
et al. (2016) suggest, “It is thus possible that children with a biological propensity for
social withdrawal and behavior inhibition who are reared by more negative mothers
are less able to develop flexible HPA system functioning which may lead to a
socially-withdrawn style that places these children at a greater risk for later
psychopathology” (p. 54).
Yan (2016) investigated the role of three agentic processes (autonomy/selfassertion, effortful control, and motivation mastery) on children’s resilience
(academic, social behavioral) in a longitudinal study (infancy to first grade) in a large
national sample of children of depressed mothers. Results revealed that effortful
control was the single most reliable predictor of resilience across all areas
assessed (social, emotional, behavioral, and academic). Yan suggests that high
levels of effortful control allow individuals to regulate their emotions (emotionfocused coping, especially in stressful interactions with the mother) and regulate
and plan behaviors allowing them to engage in socially appropriate ways. Children
high on self-assertion were resilient in three areas: social competence, internalizing
behaviors, and externalizing behaviors. Yan believes that children high on
autonomy are more self-assertive and interact with their mother in ways that
promote negotiation and self-assertive communications. M otivation mastery related
to only one area of resilience which was academic competence.
Yan (2016) investigated patterns and interrelationships between the three agentic
processes and resilience and suggests the following important factors that
contribute to resilience in children with depressed mothers: high intelligence, child
temperament, maternal sensitivity, and quality of child care. High intelligence in early
childhood was predictive of greater self-assertion, effortful control, and mastery
motivation throughout the study, which in turn predicted resilience in all areas
measured (academic, social, behavioral). Children with less difficult temperaments
were also higher on effortful control and self-assertion which were predictive of
resilience in all areas of competence. Sensitive parenting was also significantly
related to self-assertion, effortful control, and mastery motivation, which in turn
predicted resilience. Finally, the opportunity to attend high-quality childcare facilities
was related to effortful control which was a strong predictor of resilience. This is an
important finding for treatment interventions and prevention, because it suggests
that extra-familial environments may assist in developing child qualities, such as
effortful control, which can foster resilience at a time when the mother is
experiencing challenges due to chronic depression.
Resilience: Intervention and Prevention
Research regarding promoting resilience in children has focused on two important
factors: individual characteristics and influences from family and parenting practices.
At the level of individual characteristics, several important factors have been
identified. The study by Yan (2016) provides important information regarding
potential avenues for promoting resilience in children who are faced with living in
adverse conditions. Interventions that are focused on enhancing the key processes
that are linked to resilience, such as effortful control and self-assertion, could lead
to increased positive, active engagement, and adaptive functioning. In addition,
these qualities can be targeted both in enhancing parenting practices and extra
familial contexts (good day care and school programs). Prilleltensky, Nelson, and
Peirson (2001) suggest that children’s sense of “personal control, empowerment,
and self-determination” are important aspects to target in programs aimed at
increasing psychological well-being and positive mental health. The researchers
suggest that these qualities can be enhanced by providing opportunities for children
in three important areas: (1) material resources (nutrition, housing, stimulation) and
psychological resources (secure attachments, empathy, and exercising problemsolving abilities) necessary to satisfy basic needs; (2) chances to engage in
meaningful decision-making to enhance self-determination; and (3) targeting growth
in areas of increased competence and self-efficacy.
The “FRIENDS for life” program (Barrett, 2004a, 2004b) was initially developed as a
group treatment program for children with anxiety disorders and was later adapted
into a school-based universal prevention program. The goal of the program is to
build emotional resilience in children by teaching them skills to cope effectively with
feelings of anxiety and depression. The program is based on cognitive behavioral
methods and has been used extensively throughout the world. Studies have been
conducted in Australia (Iizuka, Barrett, Gillies, Cook, & M iller, 2014; Stallard,
Simpson, Anderson, Hibbert, & Osborn, 2007), the Netherlands (Kösters et al.,
2012), the United States (Briesch, Sanetti, & Briesch, 2010), Ireland (O’Brien et al.,
2007), South Africa (M ostert, 2007), and the United Kingdom (Rodgers & Dunsmuir,
2015).
The “FRIENDS” acronym stands for Feelings; Remember to relax; I can do it;
Explore solutions and coping step plans; Now reward yourself; Don’t forget to
practice; and Stay calm for life. The program has 10 weekly sessions and 2 booster
sessions which are conducted 1 and 2 months after the program is completed.
There are also two parent sessions during the 10-week program. Coping
techniques used include psychoeducation, relaxation exercises, exposure, social
support training, problem-solving skills training, and cognitive restructuring
exercises.
Studies have demonstrated that the FRIENDS program can be successful in
enhancing self-concept (Stallard et al., 2005, 2007), coping skills (Stopa, Barrett, &
Golingi, 2010), social skills (Liddle & M acmillan, 2010), reduction in symptoms of
anxiety and depression (Stallard et al., 2005), and improvements in BI and socialemotional strength (Pahl & Barrett, 2010).
Having a positive, supportive caregiver can enhance opportunities for resilience in
the face of adversity. Studies that have focused on improved caregiving have used
several parent training programs to assist parents in developing better skills in
areas of emotional communication and appropriate uses of positive reinforcements.
According to Bai and Repetti (2015), engaging in warm, responsive, and supportive
family interactions may cultivate resilience in children through exposure to positive
emotional and physiological stress response systems.
Parent–Child Interaction Therapy (PCIT) is a widely used, evidence-based
treatment for parents of children who have disruptive behavior disorders
(Funderburk & Eyberg, 2011). PCIT involves 15 weekly sessions and is divided into
two phases. The first phase, CDI, focuses on improving the quality of the parent–
child relationships by strengthening the parent’s ability to actively attend to and
reinforce positive child behaviors, while ignoring negative behaviors. The acronym
PRIDE is used to relate to skills in five different areas: Praise, Reflection, Imitation,
Description, and Enthusiasm. Parents practise these skills while learning to follow
their child’s lead in dyadic play sessions. In the second phase, PDI, parents take
over the lead in play and real-life situations which focus on the importance of their
child obeying their instructions and requests. Compliance is rewarded with praise,
while the consequence for noncompliance is time out. Sessions involve direct
coaching of parent–child interactions. Skills are introduced in a parent-only session
and then skills are practiced in the parent–child dyad the following session.
Coaching takes place using a wireless earphone and one-way mirror.
The Triple P Positive Parenting Program is another widely used and empirically
supported parent training program that can be administered on a variety of
prevention levels from Level 1, universal prevention (media-based information for
parents) to Level 5, intensive individually tailored family programs for children with
major behavioral issues within the context of family dysfunction. This behavioral
family intervention program is based on principles of social learning (Patterson,
1982) and has been adapted to serve five different developmental stages (infants,
toddlers, preschoolers, school-aged children, adolescents). Parents at Level 4
(parents of children with more severe behavior problems who want intensive parent
training) have the opportunity to take part in one of four different types of programs:
Standard Triple P (individual parents may be involved in face-to-face or phone
consultations, home visits, or be self-directed); Group Triple P (groups of 10–12
parents); Group Teen Triple P; or Self-directed Triple P (parenting workbooks are
provided for a 10-week self-help program). Core parenting skills taught in the
programs include observation skills, managing misbehavior, preventing problems in
high-risk situations, self-regulation skills, and mood management and coping skills
(Sanders, M arkie-Dadds, & Turner, 2003).
Thomas and Zimmer-Gembeck (2007) conducted a meta-analysis of 24 studies
from the United States and Australia to evaluate and compare the outcomes of
PCIT and Triple P Positive Parenting Programs. The studies consistently found
positive outcomes for both programs, although the outcomes varied depending on
the length of intervention, components use, and the sources of outcome data. Both
programs were successful in reducing child behavior problems and parenting
problems. Parent reports found large effect sizes for PCIT and majority of Triple P
Positive Parenting Programs. An abbreviated version of the PCIT had moderate
effect sizes in one study, while Level 1 intervention for the Triple P (M edia Triple P)
had small effects.
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Descriptions of Images and Figures
Back to Figure
The figure is an illustration of how a neutral stimulus (NS) can transform into a
conditioned stimulus (CS). The NS in this instance, an airplane, evokes a neutral
response (i.e., the plane seen as a means of transportation). However, when an
unconditioned stimulus (US) is thrown into the mix, such as the possibility of a
turbulent flight, it becomes associated with a conditioned response (CR), which
uusually is fear of crashing and the experience comes to be classed as that of a
bad plane.
Back to Figure
The figure portrays an example of exposure therapy used to decondition fear of
flying. It is a systematic desentization stepwise that aids an individual in
overcoming his fear. The first step is to develop a fear hierarchy and the next is to
pair each step with a relaxation technique and to proceed as necessary until
stimulus is no longer evokes a sense of fear. The fear hierarchy is built by first
looking at a picture of a plane, then moving to books on planes with pictures, then
to a positive film on planes, then to actually going to an airport and watching planes
take off, to the decision of purchasing of tickets for a short flight, and finally to taking
a short flight. Each of these steps is accompanied with relaxation techniques like
deep breathing, meditation, and muscle relaxation until the fear is completely
extinguished.
Back to Figure
The figure clearly depicts the increasing and decreasing behaviors associated with
operant conditioning. Here reinforcement and punishment are used as conditioning
techniques to test behavior. There are two sides to behavior, negative and positive.
When behavior is tested, it can be either punished or rewarded. Here, a decreased
behavior can be punished in the form of spanking, detention, loss of phone time, or
loss of video game time. The way to increase behavior can be done in two ways:
through positive reinforcement or through negative reinforcement. A positive
reinforcement entails candy, money, or toys. Whereas a negative behavior includes
removal of a negative reward.
Back to Figure
The figure is a schematic demonstation of the four types of parenting styles. These
are depicted taking into account variables of warmth and control. The four parenting
styles include authoritative, authoritarian, permissive, and neglectful. The
authoritative style is portrayed as high warmth and high control; the authoritatian
style as low warmth and high control; the permissive style as high warmth and low
control; and finally, the neglectful style as low warmth and low control.
Back to Figure
The figure graphically portrays Bronfenbrenner’s biological systems theory. This
system is comprised of four aspects: process, person, context, and time. The
process is development and includes aspects like dynamic interactions or
relationships between an individual and their context. The person aspect revolves
around an individual’s biological, cognitive, emotional, and behavioral charateristics.
The context aspect delves into a human developmental system of nested
influences. And finally the time aspect centers around temporal aspects that
moderate change over the course of development or chronosystem.
CASE 1 TERRY HOGAN : THE
AVOIDANCE TRAP: DEVELOPING A
CASE FORMULATION
The Av oidance Trap
Terry’s fourth-grade teacher is concerned due to her progressively
declining grades. Terry was in a bike accident in the third grade and
was thrown from the bicycle, causing a separation of the cartilage
from the rib cage. This very painful condition resulted in Terry
missing several weeks of school and ultimately repeating the third
grade. Terry was assessed 4 months ago and the psychological
assessment revealed intellectual functioning to be in the average
range (range 87–100), with academic functioning at a mid–Grade 3
level in all areas (standard score range 85–87). Terry did not qualify
for special education assistance since the school district used the
discrepancy criterion of 2.5 standard deviations difference between
intellectual level and academic standard scores, which would
require academic standard scores to be well below current levels.
However, academic concerns have continued to escalate, and
Terry is becoming more and more vocal about disliking school.
There are frequent complaints of stomachaches, and there is often
a refusal to eat lunch. In the past 5 months, Terry has been absent
for 17 days and tardy on 16 occasions. The school is requesting
further assessment to clarify the nature of the problems. During the
follow-up assessment, Terry completed a number of self-report
scales (depression, anxiety, personality), and scores indicate
clinically significant elevations for all internalizing scales, including
depression, anxiety, and somatization.
After reading the case of Terry Hogan, ask yourself the following
question: Does Terry suffer from a significant mental illness?
According to a recent study based on data from the 2016 National
Survey of Children’s Health, approximately 16.5% of children
between the ages of 6 and 17 have a treatable mental disorder
(Whitney & Peterson, 2019), so the chances are approximately 1 in
6 that Terry does. However, unlike children who have disruptive
behavior disorders, Terry’s symptoms are not readily apparent,
which leads to the other part of the statistic in the study by
Whitney and Peterson (2019), which is that nearly half of the
children who suffer from a mental disorder do not receive treatment
from a mental health professional. How can the clinician determine
the nature and severity of Terry’s problems? What are the
essential questions that need to be addressed?
Since a clinician’s theoretical perspective can influence decisions, it
is very important that clinicians are aware of their own theoretical
biases in forming their opinions. Looking at a case through a set of
theoretically colored lenses can affect all aspects of information
processing, from hypothesis testing to treatment. The influence of
theory on practice will become increasingly clear as case
formulations are constructed from various theoretical viewpoints
and applied to the case of Terry Hogan. The following exercise will
provide a step-by-step look at how a case formulation would be
developed and applied to this case.
Stage 1: Problem Identification: A Question of “What.” At this stage,
the clinician must ask the question, “What is Terry’s problem?”
However, this is often more complicated than it looks. For example,
although Terry’s poor academic progress was the initial concern, a
very different set of problems eventually unfold that provided
increased insight into the high rates of absenteeism and an
increasingly negative attitude toward school.
Stage 2: Problem Interpretation/Understanding: A Question of
“Why.” At this stage of the process, the clinician draws on
information from Terry’s developmental and family history to provide
a snapshot of Terry’s history that can provide vital information
regarding potential genetic factors that may suggest a vulnerability
to some manifestations of behaviors (family pathology) or
circumstances (family or school history), which might add to
understanding how the problem evolved and what is maintaining
the problematic behavior. At this point, it is also important to
address any risks or protective factors that might help explain
conditions that could exacerbate or moderate the problem. An
understanding of the different theoretical perspectives can add to
the depth and breadth of the analysis and hypothesis, and the
ability to integrate information from these sources can contribute to
our overall understanding and success in developing interventions
based on the underlying dynamics involved.
Stage 3: Treatment Formulation: A Question of “How.” Ultimately,
our understanding of Terry’s problem will help to inform treatment
efforts regarding how to best address the problem based on our
knowledge of evidence-based treatments that are most successful
in dealing with problems of this nature. It will also be very important
to integrate plans for monitoring and evaluating the effectiveness of
the treatment plan in order to make any necessary changes.
CASE FORMULATION: APPLICATIONS TO
THE CASE OF TERRY HOGAN
With the first goal of case formulation in mind, return to the initial
description of Terry Hogan and reread the scenario with the
following questions in mind:
1. What are Terry’s main problems?
2. What is Terry’s primary problem? Why has the problem
developed (precipitating factors) and what is causing the
problem to persist (maintaining factors)?
3. What other information is needed to respond to the above
questions? Is Terry a boy or girl? Read the scenario again to
see if you can find the answer. Risk factors for males and
females can be different, so Terry’s gender may also be a
factor in determining targets for intervention (Box C1.1).
Box C1.1 Thinking Out Loud
Although Terry is struggling academically, the initial assessment
suggested that lack of academic progress was not due to lack of
ability (intelligence was in the average range) but some other factor
that was contributing to her lack of performance (production). Terry
said that she disliked school. Could lack of performance be
attributed to lack of motivation, interest, and effort?
Based on the information to date, pinpointing the problem is not an
easy task. In order to understand the problem, it is necessary to
delve into the information and focus on behavior patterns that are
most likely to yield relevant insights into Terry’s difficulties. Based
on the latest assessment results, the psychologist records the
following impressions:
During the follow-up assessment session, Terry seemed even
more agitated than she had been previously. She appeared pale
and had dark circles under her eyes. When asked about school,
she said that things were worse than before (referring to 4 months
ago). Her younger sister, Lilly, is now in the same grade and even
though they are in different classrooms, her younger sister is a
constant reminder of her failure. Terry said the family was living with
her grandparents until last week. She said her grandfather gets “too
angry” at her and yells a lot. Just before they moved out, her
grandfather had taken the belt out to hit her and she ran out the
front door and down the street. She said she did not care if she
was hit by a car, it was better than being hit by him. When asked
about her absenteeism, Terry said that she felt sick a lot. She also
mentioned that her back hurt because she had been sleeping on a
sofa bed that has a bar across the middle that digs into her back at
night and wakes her up, so she cannot sleep very well.
Her mother is a waitress who works long hours some nights. Since
they are no longer living with her grandparents, Terry and her sister
now go to the restaurant to eat their dinner and then walk home
with their mother when she is finished with work. She said that the
restaurant can be noisy, so it is hard to do her homework. Terry’s
father is a truck driver and is often away. When asked about
friends, Terry said she used to have some friends, but when she
repeated the third grade, they would not play with her anymore
because she was only a third grader. Terry’s favorite pastime is
watching TV. She said that she liked to watch Disney movies
because “they always have a happy ending, not like most things.”
REASON FOR REFERRAL
Although the original reason for referral was academic concerns, it
is becoming increasingly apparent that academic problems are
more a symptom than a cause of Terry’s difficulties. Further
investigation is necessary in order to probe different hypotheses
and provide an opportunity to develop case formulations from
different theoretical perspectives. Information on family history,
which would usually be obtained at the beginning of the case, is
still lacking, since Terry’s mother has not yet met with the school
psychologist.
ASSESSMENT RESULTS
Terry’s responses to the Revised Children’s M anifest Anxiety
Scale (RCM AS-2) indicated significant levels of social anxiety
(feelings of isolation from peers and feelings of inadequacy
compared to other girls her age). On the Child Depression Index
(CDI-2), scores for total depression, negative mood,
ineffectiveness, and anhedonia were all in the clinically significant
range. There were indications of suicidal ideation, although Terry
stated that she “would not do it.” Although responses to the
Personality Inventory for Youth (PIY) revealed a valid profile
(nondefensive), there were also indications of a potentially
exaggerated response profile. Responses indicated little pleasure
derived from academics and school-based activities, high scores
for distractibility and concentration problems, and tendencies to be
irritable and impatient. Terry admitted to having problems with
compliance issues and following the rules. She endorsed many
somatic complaints often associated with anxiety and depression
(frequent headaches, stomachaches, dizziness, fatigue), placing
her score on the somatic scale in the clinically significant range.
Terry’s profile suggested that when psychologically distressed, she
tended to show physical responses, such as feeling ill, loss of
appetite, and sleep disturbance. Responses to the family
dysfunction scale revealed that she was unlikely to view her home
as a source of satisfaction and instead saw home as conflicted and
fragmented. Responses suggested a troubled relationship with her
parents, who she describes as argumentative, frequently absent,
and in disagreement with each other. Responses indicated that
one or both of her parents might drink to excess or demonstrate
other signs of less than stable emotional adjustment.
Terry’s teacher completed the Behavioral Assessment System for
Children (BASC-2), a rating scale of behavioral and emotional
problems in children. Unfortunately, the parent version of the scale
had not been returned to the school, despite several calls. Similar
to Terry’s responses, her teacher also confirmed clinically
significant concerns on all internalizing scales, including total
internalizing problems, depression, anxiety, somatization, learning
problems, and withdrawal (tendency to evade others and avoid
social contact).
Based on the assessment results, the psychologist had a growing
concern that Terry was experiencing many symptoms of
depression, anxiety, and somatization. However, why these
problems were occurring and seemingly escalating could only be
speculated until there was contact with Terry’s family. The school
psychologist made several attempts to contact M rs. Hogan.
Several weeks later, M rs. Hogan agreed to meet with the school
psychologist to discuss the assessment results. She provided a
brief family history and answered most of the questions asked,
although she was guarded in her responses. She explained that
they had been living with her father for the past little while to ease
financial burdens. She said he could be stubborn at times and
blamed it on the Irish heritage. Her great-great-grandparents had
emigrated from Northern Ireland at the time of the potato famine
(mid-1800s) and worked as cheap labor in the United States, as did
many who settled in America. She said that she had kept the name
Hogan, not taking her husband’s name, because the name means
“warrior” and she was a fighter. After these comments, she added,
“I don’t know why Terry does not live up to her name. She’s a
whiner and complainer; she’s no warrior.”
Shortly into the interview, M rs. Hogan announced that the family
was relocating to Tennessee at the end of the week to live with
her sister’s family, which would place them closer to her husband’s
new truck route. When the assessment results were discussed,
M rs. Hogan became very defensive and stated that Terry was
pretty good at pulling the wool over people’s eyes, implying that
Terry had the psychologist “fooled.” She said that living with Terry
had been difficult since the day she was born. Terry was an irritable
baby who never slept well and was always a fussy eater. She was
a clingy baby who cried every time her mother left her, so it was
hard to find sitters who would look after her. She said that Terry
was a selfish child who only thought about herself. She wished that
Terry could be more like her sister, Lilly, who was easy to get along
with and had many friends. On the other hand, Terry was moody,
irritable, and difficult to please; she often walked around with a “chip
on her shoulder.” M rs. Hogan said that unfortunately, Terry took
after her father, who was the same way, especially when he was
drinking. When asked about family history for depression, M rs.
Hogan said she suspected that her husband might be “down in the
dumps” sometimes, especially when he would start drinking.
However, with the truck driving job, drinking was no longer an
option. M rs. Hogan admitted to having financial problems and
blamed Terry’s willful and disobedient attitude for getting them
“booted out” of Terry’s grandfather’s place. She explained that her
father (Terry’s grandfather) had always had problems controlling his
temper and that Terry would “mouth off” and cause him to lose his
temper. She described Terry as a complainer who often said that
she was not feeling well to get out of doing chores or helping
around the house. As a result, her sister often had to carry twice
the load.
The psychologist emphasized her concerns about Terry’s
emotional well-being and her symptoms of depression and
recommended that M rs. Hogan find a counselor for Terry when
they arrived in Tennessee. However, M rs. Hogan felt that would
just encourage Terry to feel sorry for herself and make it worse.
The psychologist requested permission to send the reports to
Terry’s new school, and M rs. Hogan reluctantly agreed (Box C1.2).
Box C1.2 Thinking Out Loud
Applying theory to case formulations: The psychologist has now
amassed information from several sources and can begin building
hypotheses regarding Terry’s internalizing problems (depression,
anxiety, and somatization). The following case formulations will
provide an increased understanding of how the problem can be
conceptualized from a variety of theoretical perspectives.
CASE FORMULATION: FIVE DIFFERENT
PERSPECTIVES
The following section is devoted to case formulations developed
from five different theoretical frameworks: biological, behavioral,
cognitive (social cognitive), psychodynamic/attachment, and
parenting/family systems.
Case Formulation Based on the Biological
Perspective
Terry’s family history may be positive for depression (father) and if
so, then she would have an increased risk (20%–45%) for
developing depressive symptoms (Rutter, Silberg, O’Connor, &
Simonoff, 1999). Imbalanced levels of serotonin, norepinephrine,
and possibly dopamine and acetylcholine have been associated
with depression in adults (Thase, Jindal, & Howland, 2002).
Abnormalities in the gene responsible for transporting the
neurotransmitter serotonin (5-HTT gene) have been linked to
increased risk for depressive disorder (Caspi et al., 2003;
Hecimovic & Gilliam, 2006). Caspi et al. (2003) found that children
who inherited the short allele of the serotonin transporter (5-HTT)
were more likely to respond to stressful events with symptoms of
depression and suicidal ideation than peers who did not inherit the
short allele.
Cortisol is a hormone that is released by the hypothalamic–
pituitary–adrenal system (HPA) in times of stress. High cortisol
levels can result in heightened sensitivity to threat that have been
linked to increased risk for depression (Pliszka, 2002).
Studies of the neurophysiology of emotion regulation are based on
the need for positive resolution of fearful experiences to allow for
the development of self-soothing behaviors in response to fear and
anxiety (Siegel, 1999). Results of a recent neuroimaging study
have found that the anterior cingulate cortex (ACC), which is
activated during physical pain, is also activated in response to
distress caused by social exclusion and rejection (Eisenberger,
Lieberman, & Williams, 2003). The researchers suggest that these
neural connections may be part of the social attachment survival
system to promote the goal of social connectedness. These
results help explain Terry’s feelings of physical pain in response to
her emotional loss and rejection.
Although the impact of genetic and environmental effects
(genotype–environment interaction: GEI) on childhood anxiety
and depression has been well established (Franić, M iddeldorp,
Dolan, Ligthart, & Boomsma, 2010), until recently, less emphasis
had been placed on examining how these factors combine to
influence outcomes. Silberg, Rotter, Neale, and Eaves (2001) found
that adolescents who had genetic ties to anxiety and depression
and experienced negative life events or adverse life experiences
(ACEs) had an increased risk for anxiety and depression compared
to adolescent females with genetic vulnerability who did not
experience negative life events. Results even more relevant to
Terry’s case were findings from a study by Feinberg, Button,
Neiderhiser, Reiss, and Hetherington (2007) who found that as
parent negativity increased, so did the risk for depression. The
finding was consistent with results obtained by Hicks, DiRago,
Iacono, and M cGue (2009) demonstrating that as negative
environmental factors increased (mother, father, and child
relationship issues; problems with achievement, stressful life
events, and negative peer affiliations), symptoms of anxiety and
depression also increased.
Therapeutic implications: Although medical management is common
in the treatment of depression in adults, approximately 30%–40%
of children with depression do not respond to medical treatment
(Emslie et al., 1997). Fluoxetine (Prozac) is the only medication
that has been approved by the FDA for use with children 8 years of
age and older. Results of a 6-year-long investigation with
adolescents found that combined treatment using antidepressants
and cognitive behavioral therapy (CBT) was superior to CBT alone
(Apter, Kronenberg, & Brent, 2005). However, in 2006, the FDA
issued a black box warning (the highest level of caution) for
antidepression medications potentially increasing depression and
suicidal behaviors in youth and young adults up to 25 years of age
(Box C1.3).
Box C1.3 Thinking Out Loud
Does the benefit outweigh the risk? Based on results of their
exhaustive review of clinical pediatric trials between 1988 and 2006,
Bridge et al. (2007) conclude that not taking prescription medication
for depression places children at greater risk than taking the
medications.
Case Formulation Based on the Behavioral
Perspective
From a behavioral perspective, principles of operant conditioning
can be very helpful in understanding how Terry’s symptoms of
depression, often manifested in claims of “not feeling well,” have
become ingrained in a repetitive pattern of avoidance behaviors.
When Terry initially stated that she was “not feeling well,” it is likely
that responses included increased attention from those around her
(positive reinforcement) and an opportunity to escape from doing
chores (negative reinforcement). Either way, feeling sick was
reinforced with a positive outcome, thereby increasing the
likelihood for the behavior to be repeated in the future. Positive
reinforcement involves the addition of a reward (e.g., when you feel
sick, I will comfort you and nourish you), while negative
reinforcement involves the removal of a negative situation.
Negative reinforcement, not to be confused with punishment, is
rewarding because it involves the removal of a negative situation
(e.g., if you are sick, you do not have to do chores or go to
school). Negative reinforcement has sometimes been called
escape because it allows one to escape a negative consequence.
In the Introduction, coercion theory (Patterson, Capaldi, & Bank,
1991) was discussed as it relates to social learning theory (a spinoff from the behavioral perspective). Coercion theory can help
explain how Terry and her mother have established a negative
cycle of interaction patterns. Parents who eventually yield to a
child’s escalating and demanding behaviors serve to positively
reinforce the child’s misbehavior. In this case, Terry’s feeling sick
has resulted in numerous absences from school, which allows her
to escape from a situation she wants to avoid (negative
reinforcement). In addition, as far as the communication pattern is
concerned, when Terry is allowed to play the “sick role,” the
behavior is reinforcing for Terry (escapes going to school) and her
mother (Terry stops whining and complaining). Therefore, the
parent learns that giving in will stop the demands and whining
(negative reinforcement), while the child learns that increased
demands result in parent compliance (positive reinforcement).
Since positive and negative reinforcement serve to strengthen
behaviors, parent and child become locked in to an escalating and
never-ending battle.
Therapeutic implications: Based on behavioral analysis, the payoff
for Terry feeling ill has been an ability to escape negative
situations, such as doing chores around the house or having to
attend school, where she is failing academically and socially. In
developing a behavioral program, goals would be to increase her
sense of academic and social competency at school in an attempt
to reduce her need to escape from a negative situation. At home,
reintroduction of chores should be done in a way that requires a
sense of responsibility but is also inherently rewarding, for
example, preparing dessert for the family. Terry and her sister
should have a chore list that is negotiated between them in the
presence of their parents, with a list of rewards (e.g., allowance,
privileges) that can be earned and traded at the end of each week
as compensation for completion of required tasks.
Through the use of behavioral tools such as knowledge of
schedules of reinforcement and objective observation techniques,
behavior intervention plans can be developed, monitored, and
modified to assist with behavioral change. Rewarding obedience
with attention and praise; issuing demands that are clear and age
appropriate; and providing consistent follow-through would
strengthen Terry’s compliant behaviors while increasing her selfconfidence and breaking the cycle of avoidance behaviors. Building
on earlier successes has proven to be a source of motivation in
increasing compliance with more difficult tasks later on (Ducharme
& Popynick, 1993).
The Parent Management Training – Oregon Model (PM TO)
discussed in Chapter 1 is well suited in Terry’s case and could
provide the necessary training to assist her mother in reducing
coercive parenting practices and increasing positive parenting by
focusing on the use of positive reinforcement, appropriate limit
setting, monitoring/supervision, interpersonal problem-solving, and
emotion identification and regulation (Dishion, Forgatch,
Chamberlain, & Pelham, 2016).
Case Formulation Based on the Cognitive
Perspective
Terry’s cognitive framework for social interaction places her at risk
for social rejection (Dodge, Bates, & Pettit, 1990). If Terry is overly
sensitive to rejection, then she is likely to misinterpret ambivalent
social situations as hostile and rejecting or what has come to be
known as the hostile attribution bias. Recently, Beauchaine,
Strassberg, Kees, and Drabick (2002) found that parents of children
with poor relationship skills were especially deficient in providing
solutions to issues of noncompliance, especially when required to
do so under pressured conditions. The authors recommend the
need for treatment plans to target the underlying processes of
negative attribution bias and affect regulation, which they suggest
are the pivotal factors that drive coercive parenting patterns. M rs.
Hogan’s communication pattern with Terry demonstrates high
expressed emotion (EE), a negative, critical, and disapproving
interactive style. Such communication styles have been found to
increase the risk for psychopathology in vulnerable family members
(Nomura et al., 2005).
Therapeutic implications: CBT seeks to facilitate positive integration
of thoughts and behaviors. For Terry, CBT would focus on how
Terry’s faulty belief system contributes to feelings of negative selfworth and avoidant behaviors. Social cognitive treatment might
involve role-play in areas of social cue awareness and the
underlying processes that contribute to the development of
prosocial behavior, such as secure attachment, social perspective
taking, empathy, and self-control. Parent training using CBT
methods would focus on negative attributions, emotion regulation,
and, ultimately, on increasing effective strategies for more positive
communication. One possible program to enhance communication
between Terry and her mother is the Seattle Program, which was
developed by Speltz and colleagues (Greenberg & Speltz, 1988;
Speltz, 1990). This parent training program uses cognitive
behavioral methods to assist families of children with insecure
attachment which is discussed next. The program focuses on
communication breakdown in the parent–child dyad and
emphasizes the need for better “negotiation skills.” The four-phase
intervention program includes components of parent education,
reframing of the child’s behaviors within a developmental
framework, limit setting and problem prioritizing, and
communication/negotiation skills.
Case Formulation Based on Psychodynamic
and Attachment Perspectives
On a psychodynamic level, Terry’s internalizing problems would be
represented as the internal manifestations of unconscious conflicts
stemming from an imbalance in the underlying personality structure.
In Terry’s case, her mother’s rejection could represent a symbolic
loss resulting in feelings of depression and feelings of guilt and
self-blame for driving her mother away. Freud would interpret the
loss within the context of unmet needs (lack of parental nourishing)
during the oral stage. This pervasive sense of loss can result in
feelings of emptiness and withdrawal from social contact, which can
increase symptoms of depression. Individuals may remain overly
dependent on others, feel unworthy of love, and have low selfesteem (Busch, Rudden, & Shapiro, 2004). In addition, Terry’s
somatic complaints may be interpreted as tendencies to translate
psychic pain into physical pain.
Ego psychologists might suggest that Terry’s insecurities result
from a lack of resolution of the rapprochement phase in the
separation individuation process. In this phase, the toddler is faced
with awareness of separation, separation anxiety, and conflicting
desires to stay close to the mother. Normally, the process of
gaining greater independence and self-identity is facilitated by the
parent, who performs the dual role of remaining emotionally
available while gently encouraging the push toward greater
independence (Settlage, 1977). However, as Terry’s mother was
not emotionally available for her, theory would predict that conflicts
between autonomy and dependence would be repeated
throughout development, especially in vulnerable times (Kramer &
Akhtar, 1989). Successful resolution of the conflict at this stage is
achieved through the development of an internal representation or
model of the parent–child relationship that can sustain separation
due to the securely developed ego. To ego theorists, the focus is
on consolidation of the ego, while for attachment theorists, the
focus is on the relationship (Fonagy, 1999).
From an attachment perspective, the degree of security/insecurity
inherent in primary attachment relationships provides internal
working models (IWMs) or templates for all future relationships
(Ainsworth, Blehar, Waters, & Wall, 1978; Belsky, 1988; Bowlby,
1982). While secure attachments can be a protective factor,
insecure attachments may place the child at increased risk for
developing problems. Terry’s avoidant behaviors may be the result
of IWM based on an early anxious attachment evident in an
avoidant attachment pattern. It is likely that Terry’s mother was, at
times, withdrawn and emotionally unavailable, and at other times
harsh, emotionally charged, and highly punitive (negative and highly
critical). Within this context, Terry’s avoidance behaviors may serve
to manipulate and regulate caregiver proximity and attentiveness.
Through the use of avoidant techniques, Terry can shield her
sensitivity to her mother’s harsh and rejecting responses. It has
been suggested that these maladaptive behaviors may fit with the
overall schema of family dysfunction (M arvin & Stewart, 1990).
Terry’s IWM is likely to evolve around avoidance and withdrawal to
shield her from fears of rejection. Within this framework, parent–
child dyads can be thrust into a hostile/helpless pattern, with one
member of the dyad being the hostile aggressor and the other
member becoming the passive, helpless, and overwhelmed
recipient (Lyons-Ruth, Bronfman, & Atwood, 1999).
Insecure attachments can develop for a variety of reasons,
including child characteristics (e.g., difficult temperament) and
characteristics in the immediate environment, such as parenting
style (Belsky, 1999). In Terry’s case, there is strong evidence to
suggest that both factors are highly interrelated. Greenberg, Speltz,
DeKlyen, and Endriga (1993) incorporate four factors in their risk
model for behavioral disorders, all of which are evident in the case
study of Terry: insecure attachment, atypical child characteristics,
ineffective parenting, and family environment. Although quality of
attachment can be seen as a risk or protective factor in its own
right, living in an environment that contains multiple risk factors (low
socioeconomic status, family stress, parent maladjustment, etc.)
also increases the likelihood of developing an insecure attachment
(Belsky, 1997).
Socially, maladaptive attachment patterns can also undermine
social orientation and subsequent prosocial competencies. Terry’s
lack of social reciprocity and withdrawal from social contact
preclude strong social motivation at this point in her life. For Terry,
the social world is a hostile territory that she would rather escape
from than attempt to cope with. On the other hand, there is
evidence that children with early secure attachments are more
socially oriented and compliant and have better developed abilities
to regulate their emotions (Ainsworth et al., 1978; Greenberg,
1999).
Therapeutic implications: Depending on the therapist’s
psychodynamic orientation, the therapeutic process might focus on
the individual child (working through internal conflicts in play
therapy), the parent (helping a parent resolve his or her own
childhood conflicts and traumas), or the parent–child dyad (conjoint
play therapy). In Terry’s case, all three approaches would be
appropriate—initially engaging Terry and her mother in individual
therapy sessions and ultimately bringing them together in conjoint
play therapy sessions. Psychodynamic developmental therapy for
children (PDTC) is a relatively recent advancement in
psychodynamic therapy developed by Fonagy and Target (1996).
Although the approach is psychodynamic in origin, principles of
social information processing (social cognition) are used to assist
children in linking thoughts to feelings and behaviors (reflective
processes). A PDTC therapist might provide corrective experiences
through play therapy and the use of metaphor to assist Terry in
replacing self-damaging feelings with increased positive views (Box
C1.4).
Box C1.4 Thinking Out Loud
Secure attachments can lead to better understanding rather than
avoidance of negative emotions (Laible & Thompson, 1998). Terry
demonstrates very few coping skills to effectively deal with
negative emotions or negative information. Thompson (1999)
suggests that “lessons learned” in attachment relationships may be
instrumental in defining expectations in such areas as how others
react when the child is experiencing difficulties coping with stress,
anxiety, or fears.
Case Formulation Based on Parenting Style
and Family Systems Perspectives
The authoritarian parenting style is a controlling and harsh style of
interacting that is lacking in warmth and often predictive of avoidant
attachment patterns (Rubin, Hymel, M ills, & Rose-Krasnor, 1991).
Baumrind (1991) found four different parenting styles, based on
the amount of structure and warmth parents provided. The
authoritative parenting approach (high structure and high warmth)
has been associated with the best child outcomes. Children raised
in a household that uses authoritarian parenting practices may
demonstrate aggressive and uncooperative characteristics, while
those whose parents are uninvolved or permissive may respond
with more negative traits due to the lack of structure. Based on an
avoidant attachment pattern and authoritarian parenting practices,
Terry may have developed her tendency to feel overwhelmed by
any emotional demands placed on her, or feel unable to cope with
challenges in her environment, and respond by withdrawing and
avoiding uncomfortable situations.
Family systems theory represents a variety of approaches that are
unique to the traditional psychological focus on individual
differences. Family systems theory, instead, looks at the family unit
at the primary source for assessment and intervention. Within
Terry’s family constellation, we see that Terry’s mother has aligned
with Lilly (the good daughter) and has used this system of
triangulation to shift the balance of power toward her and against
Terry. The family also tends to have a combination of very loose
boundaries (mother shares too many intimate details with Terry)
but rigid boundaries regarding how much Terry can share with the
family. Terry has also been flagged as the “problem child,” a
stereotype that allows Terry’s mother to detour her focus (Terry is
the problem, rather than to acknowledge other problematic issues
in the family, such as marital conflict, father absenteeism, and
financial concerns).
Treatment implications: Beauchaine et al. (2002) found that parents
who used ineffective and harsh methods of discipline associated
with the authoritarian parenting style often had children who
demonstrated poor relationship skills and did not have a good
ability to generate alternative solutions to problems. Parents and
children were especially deficient in providing solutions to issues of
noncompliance, especially when required to resolve these issues
under pressured conditions. Beauchaine et al. (2002) suggest the
need for treatment plans to target the underlying processes of
negative attribution bias and poor affect regulation, pivotal factors
that drive coercive parenting patterns.
Within the family systems approach, the therapist would attempt to
observe family interactional patterns as they emerge in the family
situation. The goal would be to restructure the family interactions
toward more positive growth and change. In Terry’s case, the
therapist would likely focus on repositioning the balance of power
and on improved problem-solving and communication between
family members. As far as communication style, the main style of
communication in this household best fits a description of high EE,
a communication style that is hostile, critical, and prone to
emotional overinvolvement (EOI). Families with communication
styles high in EE attributes tend to be more rigid, have more
intense and negative verbal exchanges that are often conflicted
and oppositional in tone, and have been associated with relapse of
psychiatric symptoms in individuals who are vulnerable to stress.
As such, communication styles that are high in EE attributes are
often considered within a diathesis-stress model as an
environmental stressor that can exacerbate or precipitate mental
distress in individuals with a given genetic vulnerability (Hahlweg et
al., 1989; Hooley & Hiller, 2000; Wuerker, Haas, & Bellack, 2001).
INTEGRATING THEORETICAL
PERSPECTIVES: A TRANSACTIONAL
ECOLOGICAL BIOPSYCHOSOCIAL
FRAMEWORK
The Case of Terry Hogan: A Brief Summation
Our case formulations for Terry Hogan have provided increased
awareness of how different theoretical perspectives can contribute
to an overall understanding of the nature and seriousness of her
depressive symptoms. For Terry, risk factors evident on several
levels of Bronfenbrenner’s model (Bronfenbrenner & M orris, 1998)
have added to the severity of her problems. At the individual level,
Terry’s difficult temperament was a poor fit for her mother’s
impatient, inherently negative, and hostile approach to parenting
(authoritarian parenting style). At a biological level, it is possible
that Terry inherited a genetic vulnerability to depression. Terry’s
poor relationship with her mother and isolation from her peers have
added to her feelings of being ineffectual, culminating in a sense of
learned helplessness. Her tendencies to use withdrawal and
avoidance, likely patterned after an avoidant attachment
relationship, have successfully allowed her to escape from
situations of discomfort (school and chores) by claiming to be
feeling ill, which has resulted in these patterns being negatively
reinforced, thereby increasing and strengthening this avoidant
behavior pattern. Risks in the immediate environment, microsystem
(home and school), exosystem (financial stress), and the overall
cumulative effect of her experiences, chronosystem, suggest that
Terry is in serious need of intervention. Her mother has focused on
Terry as the “problem child,” allowing her to ignore major problems
in the marital relationship. In addition to these underlying dynamics,
Terry is at increased risk for major depression and possibly a
suicide attempt because of the presence of a multitude of risk
factors. It is unknown whether her recent move to Tennessee will
provide a more stable environment with increased support from her
aunt’s family or begin a spiral that leads to increased symptoms of
depression and increased risk for suicide.
Post-Case Questions
At the end of every case, you will find a series of post-case
questions that are intended to assist you in consolidating the
information from the case with information provided in the
Introduction to Chapter 1, Appendices, and any outside readings
that may be suggested.
1. Terry’s family seems to have a history of depression. From a
biological perspective, what are the potential dynamics that
might be involved in inheriting the risk for depressive
symptoms? What are some of the positive and negative
issues and implications regarding medical management of
depression symptoms for Terry, based on the research
findings regarding children her age and given the family
dynamics?
2. Terry’s lack of compliance may be explained from a behavioral
perspective by using the ABC paradigm (antecedent, behavior,
consequence). How would coercion theory explain the
dynamic of escalating aversive responses between Terry and
her mother? Develop a behavioral intervention plan to assist
Terry and her mother with her noncompliant behaviors.
3. Terry and her mother often engage in communication that is
high in “expressed emotion.” From a cognitive perspective, this
communication style has been associated with a number of
negative outcomes. Explain how this dynamic works and apply
this to exchanges between Terry and her mother. What
suggestions would you have for improving the interactions?
4. Explain how Terry’s attachment history and attachment pattern
can be used to better understand the underlying dynamics in
this case. Be sure to include information on attachment from
the Introduction to Chapter 1, regarding the ecological
developmental framework (Greenberg, 1999) and Strathearn’s
(2011) work on neurobiological factors influencing maternal
responsiveness.
5. The authoritarian parenting style can often result in an avoidant
attachment pattern. Explain how this applies to Terry’s case.
Beauchaine et al. (2002) suggest the need for treatment plans
to target the underlying processes of negative attribution bias
and poor affect regulation that may develop from harsh
parenting styles. How would you address these issues
therapeutically in Terry’s case and what do you see as your
biggest challenges to being successful?
6. Using Brofenbrenner’s ecological transactional model as a
framework, discuss the risks and protective factors that exist
for Terry given the dynamics in her case.
7. Suggested individual or group presentation activity: The
principal has called a parent–school meeting to discuss
concerns about Terry’s progress and her future. Assign roles
to individuals who will role-play important individuals in Terry’s
life and how they would interact in this situation. Develop
important questions for each of the players who can add
information to the case. Some of the casting members might
be Terry, Terry’s mother, Terry’s father, Terry’s grandfather,
Terry’s teacher, the psychologist, and any other individual that
you feel might contribute to an understanding of the case and
assist with developing an overall case formulation and
treatment plan.
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CASE 2 JEREMY JONES : MOMMY AND ME
AND GRANDMA MAKES THREE:
DEVELOPING AN INTERVENTION PLAN
Jeremy is a 6-year-old Caucasian boy who came to the clinic accompanied by his
mother, Debbie, and his maternal grandmother, Blanche. Jeremy was referred for
assessment by his pediatrician. Despite trials of numerous medications and doses,
Jeremy has continued to demonstrate problem behaviors that are hyperactive,
impulsive, and noncompliant. Jeremy currently takes Adderall twice daily (morning
and noon) and risperidone (Risperdal) three times daily (morning, noon, and
evening). Jeremy has been taking Adderall for 2 years and risperidone for the past
year. Although Jeremy appears to be a very bright boy, he is currently repeating the
kindergarten program, since he was considered “too immature” to progress to
Grade 1.
DEVELOPMENTAL HISTORY/FAMILY BACKGROUND
Jeremy’s mother provided the following background information. Jeremy weighed 7
pounds 6 ounces at birth. Although the pregnancy, labor, and delivery were all
normal, Jeremy was severely jaundiced at birth. As a result, he remained
hospitalized for 5 days while he was placed under special lights called bili lights to
alleviate the jaundice. Neonatal jaundice was the result of G6PD deficiency (an
inherited human enzyme deficiency), a condition that causes an allergic reaction to
fava beans, which can induce a severe anemic response. A similar response could
develop if Jeremy developed viral hepatitis or pneumonia. He is monitored by his
pediatrician, and all medication trials have been closely supervised. Jeremy has had
no adverse reactions to the Adderall or the risperidone.
Jeremy’s milestones were advanced: walking at 8 months and speaking in simple
phrases at 7 months. However, Jeremy continues to exhibit articulation problems,
which his mother attributes to constant bouts of recurring ear infections. M other and
grandmother reported that by 2½ years of age, Jeremy was using words such as
humiliation and victimization in his conversation and would have long conversations
about experiments he was conducting in his “laboratory.” Currently, Jeremy is
receiving assistance for articulation from the speech pathologist at the school.
Shortly after his second birthday, Jeremy began to say “No” to everything, and
power struggles have been ongoing ever since. According to grandmother, “Jeremy
is as stubborn as a mule!” However, as much as Jeremy will say “No” or “I amn’t
gonna’ do it,” he will not take no for an answer. Jeremy coined the word amn’t as a
short version of “am not” when he was about 2 years of age, and his mother and
grandmother continue to find it very amusing and repeatedly taunt him with it, saying
they “amn’t gonna’ do it either.” Apparently, Jeremy will argue about anything and
everything and will “throw a fit” if he does not get his way. Although he likes to be
challenged by doing difficult tasks (multipiece puzzles), he is very quickly frustrated
and easily upset when he cannot solve something. His mother believes Jeremy’s
stubbornness and strong desire to be first have caused problems at school, since
Jeremy will push others out of the way in order to be first, and many of the other
children avoid him. Reportedly, Jeremy loves to go to school, but adjusting to formal
school routines and expectations has been difficult for him. His impulsive and willful
behaviors get him into trouble, and his tendencies to carry boisterous and loud
activities from the schoolyard into the classroom are disruptive. Jeremy was
retained in kindergarten due to issues of immaturity, problems relating to peers, and
lack of productivity regarding academic schoolwork. His teacher was unable to
estimate Jeremy’s current levels of functioning due to issues of noncompliance and
failure to complete assigned work.
Jeremy was described as a very active and curious toddler. He was generally a
good sleeper (the mother said that he just wore himself out) and had a good
appetite. When asked about any health issues, the mother stated that Jeremy has
been in good health. He has not had an ear infection in the past 2 years. He is
vulnerable to skin rashes and seasonal allergies. They believe that Jeremy
inherited both of these conditions from his grandmother, who has significant bouts
of psoriasis and allergies to pollens and grasses. During the interviews, Grandma’s
psoriasis was very noticeable, as patches covered her exposed arms.
According to his mother, Jeremy has always had his “good days and bad days.” He
can be fun and playful, but then again, he can be very difficult and demanding. There
were some difficulties with potty training and once again, his caregivers suggested
this might be due to Jeremy’s stubborn nature. Grandmother was quite proud of the
fact that her potty training methods made the difference in Jeremy finally becoming
trained. Grandmother said that eventually he was trained by 3 years of age;
however, she attributes successful training to monetary rewards. At one point,
grandmother was rewarding successful potty episodes at $5.00 each.
There is a history of mental instability in the maternal family. Jeremy’s mother and
grandmother are currently on medication for depression (Prozac), and Jeremy’s
mother, Debbie, said that she has suffered from episodes of depression “on and off”
for years. She did not do well in school and also wonders whether she has a
learning disability or attentional problems. M other is 25 years of age, is
unemployed, and is currently taking one course at the local college. Grandmother is
55 years of age and is on a small disability pension. Grandmother reports that she
is a highly anxious individual, as well as depressed, and “worries” about most
things. Blanche said that most people in the family have “some mental problem or
another” and added that her sister (Jeremy’s great aunt) will not leave the house
(agoraphobic) and has panic attacks. Apparently, the maternal grandfather is an
alcoholic and is also subject to violent outbursts and depression (bipolar); his
inability to tolerate medication made him “impossible to live with.” Shortly after
Jeremy’s birth, Blanche moved in with her daughter and Jeremy to help with child‐
rearing, since Debbie suffered an episode of postpartum depression lasting about 3
months. During this period, Debbie spent much of her time in bed sleeping, while
Blanche cared for Jeremy. She said that she was “very anxious,” since she had not
cared for a baby in 20 years and was fearful that she might do something wrong.
Debbie reported that Jeremy’s birth father told her he was “clinically classified as
insane” and that he often engaged in reckless, dangerous behaviors and had been
in trouble with the law. Jeremy has had no contact with his birth father or grandfather
since his birth. Debbie had little information about Jeremy’s birth father, other than
his problems with the law and thought that his family had always lived in the
southern United States. Debbie admitted that she only knew Jeremy’s father for a
few months before she got pregnant and that he left shortly after she told him she
was having his child. Blanche stated that she was unsure of where her family
originated from but the last three generations all had lived in New York State.
Debbie was in a car wreck 9 months ago, when her car was sideswiped by a truck.
Although she was not hospitalized, she did sustain major bruising and continues to
receive chiropractic treatment twice a week. Apparently, a teacher at Jeremy’s
school showed Jeremy a picture of the car, which had appeared in the newspaper,
and Jeremy was so upset that he did not want to separate from his mother to go to
school for the next 6 weeks. This has been a very difficult time for the family
because of the stress of the accident and Jeremy’s behaviors. School attendance
has been sporadic, since some days, Blanche does not have the energy to “drag”
Jeremy to school while Debbie is recuperating from her injuries.
REASON FOR REFERRAL
When asked the primary reason for having Jeremy assessed, the caregivers’
immediate response was that the pediatrician had recommended it. When pressed
further, both stated that they were very interested in knowing what Jeremy’s IQ
was. There was no mention of possibly finding a solution to managing his behavior
problems.
ASSESSMENT RESULTS
Descriptions of the test instruments used in this assessment and guidelines for
interpretation of standard scores and T scores are available in Appendix C.
Jeremy literally exploded into the clinician’s office, abruptly letting go of his mother’s
hand and immediately trying to pry open the test kit on the table. The psychologist
was able to halt further efforts to dismantle the test kit with a firm, “Not yet, Jeremy,”
while providing drawing paper and markers for his immediate attention. Despite his
whirlwind arrival, his mother confirmed that Jeremy had taken his medication prior to
coming. M other left immediately after introducing Jeremy to the psychologist, and
Jeremy evidenced no noticeable reaction to being left with a stranger or to his
mother’s departure. Although the psychologist attempted to engage Jeremy in
conversation, his poor articulation skills made conversation difficult.
Jeremy was far more interested in getting to the test materials, which were
undoubtedly the “good stuff” of the assessment for him. Test behaviors and learning
style revealed a youngster who was highly active and very fidgety and restless
throughout the assessment sessions. Although he was responsive, he did have
some difficulty staying on task when required and in complying with specific
requests. Jeremy had trouble remaining seated and took turns sitting, standing,
kneeling, rocking, and walking around the room. Attention span and compliance with
task demands varied considerably across tasks. Tasks requiring manipulation of
materials and hands-on activity were met with far more enthusiasm and focus than
verbal tasks. He responded poorly, if at all, to questions that required oral
responses and provided minimal visual input. During the vocabulary test, rather than
providing oral answers in response to word definitions, Jeremy delighted in giving
clues to the psychologist in visual form in a game-playing type of format. When
asked to spell the word cat on the test protocol, Jeremy jumped out of his chair and
drew a large picture of a cat on the blackboard. When asked to describe what a
“clock” was, Jeremy made an arrow on the blackboard in the room pointing to the
clock above it. When asked for a definition for the word hat, Jeremy again ran to the
blackboard and added a hat to his drawing of the cat.
On tasks that were maximally engaging (blocks, puzzles, working with pictures), it
was often necessary to curb Jeremy’s enthusiasm. On these tasks, Jeremy often
attempted to grab test materials before they were introduced and ignored
instructions to wait until materials were presented. Jeremy was very intent on
pursuing his own agenda, and there were frequent compliance issues. Redirection
to task was frequently required throughout the assessment. There were two 35minute assessment sessions, 1 week apart. At the completion of the first session,
Jeremy heard the elevator and immediately ran out of the room and down the hall
toward the top of a long staircase. The psychologist was concerned about safety
since Jeremy could easily have fallen down the stairs. M other and grandmother
took the opportunity to scold Jeremy for his behavior and, as punishment, canceled
plans to stop at a restaurant on the way home.
When engaged in a task he enjoyed doing, Jeremy was able to attend to the
stimulus materials adequately and problem‐solve without impulsive responding. He
did evidence frustration on occasion, when he was unable to obtain an adequate
solution, and appeared fatigued after working unsuccessfully on a block design for
1½ minutes. However, he was able to regroup and was more successful on the
next two designs attempted. His speech evidenced many sound substitution errors
(“wabbit” for “rabbit” and “ewebwoddy” for “everybody”) and cluttering of words
resulting in indistinct utterances. However, Jeremy readily repeated phrases when
asked for clarification.
Responses to the Wechsler Intelligence Test for Children (WISC-V) revealed that
Jeremy’s Verbal Comprehension Index (VCI) was within the average to high
average range at approximately the 66th percentile (VCI range 99–112). Jeremy’s
scores for Visual Spatial Index (VSI) and Fluid Reasoning Index (FRI) were both
within the Very High Range (VSI range 121–137; FRI range 118–135). His overall
score for nonverbal learning (Nonverbal Learning Index, NVI, range 123–135) was
significantly higher than his VCI. Given the significant discrepancy between scores
in the verbal and visual areas, the full-scale IQ was not calculated, since it would
merely represent the numerical average of three very discrepant scores (Kaufman
& Lichtenberger, 2000). Caution should be used in interpretation of the VCI score
as a valid indicator of Jeremy’s verbal skills, since his motivation and cooperation
were questionable during the administration of the verbal items. Given Jeremy’s
attention span and interest level, it was not possible to administer tasks for the
Working M emory Index (WM I), including digit recall and number–letter sequence.
He did, however, complete the coding and symbol search tasks of the Processing
Speed Index (PSI) well above average (scale score of 16 for the coding test and
scale score of 13 for symbol search). Scores for visual reasoning were more
consistent and revealed very strong performance overall. Relative strengths were
noted in figure weights, visual puzzles, matrix reasoning, and block designs, all of
which were at the 98th percentile. Academically, Jeremy’s responses to the
Wechsler Individual Achievement Test (WIAT-III) revealed inconclusive information,
since Jeremy completed only those questions he wanted to try. When asked to
draw a boy, Jeremy stated that he would draw a man instead. The drawing was
very immature in areas of line juncture and body proportion. Jeremy participated in
providing responses to the Joseph Pre-School and Primary Self-Concept Screening
Test. Jeremy’s responses indicated that his global self-esteem was within the high
positive range.
During the clinical intake interview, Jeremy’s mother completed several checklists
derived from criteria outlined in the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5; APA, 2013). M other endorsed the following items from the
attention deficit/hyperactivity disorder (ADHD) scale as occurring often or always:
fidgets with hands or feet (squirmy); has problems awaiting his turn; problems playing
quietly; problems sustaining attention in tasks; does not listen; problems organizing
tasks; problems remaining seated; easily distracted; forgetful; loses necessary items;
runs about and climbs incessantly; often on the go, driven; blurts out answers before
questions are asked; and avoids tasks that require sustained mental effort. On
informal scales for problem behaviors, Jeremy’s mother noted that he was very
often “noncompliant” and “defiant” and that he could, at times, be very difficult to
deal with. Particular behaviors that occurred frequently included the following: loss of
temper; blames others for his mistakes; argues with adults; touchy, easily annoyed;
and actively defies or refuses to comply with adult requests.
In addition to informal diagnostic scales, Jeremy’s mother also completed the
Conners Parent Rating Scale (Conners 3) and the Child Behavior Checklist
(CBCL). According to ratings on the Conners and CBCL, Jeremy demonstrated
clinically significant symptoms of ADHD, predominantly the impulsive/hyperactive
presentation. In addition, oppositional defiant behaviors and perfectionistic
tendencies were also in the clinical range. There were indications that Jeremy
complains of physical symptoms more than the average child and that he can be
prone to anxiety. Symptoms of distractibility and tendencies to perseverate on
ideas were evident on the CBCL. As part of the intake information, the mother also
completed the Parenting Stress Index (PSI; Abidin, 1995) where she rated Jeremy
at or above the 99th percentile for distractibility/hyperactivity, inability to adjust to
changes in environment, and demandingness. Elevations on these scales are
typical for parents of children with ADHD, with demandingness often at the peak
scale (Abidin, 1995). With respect to family stresses, the mother endorsed only
concerns about her health as a significant stressor. The grandmother declined to
complete any forms, saying that “Debbie is the mother.”
Jeremy’s teacher completed the Conners 3 Teacher Rating Scale and the Teacher
Report Form (TRF: Achenbach). Although the teacher ratings were less elevated
than Jeremy’s mother’s ratings in all areas, his teacher also noted some concerns
regarding perfectionistic tendencies. According to the TRF, hyperactive-impulsive
behaviors were at the 95th percentile, indicating significant difficulties in this area. In
addition, thought problems were also noted.
Based on assessment results, intake information, and clinical observations, the
psychologist produced the following preliminary summary and diagnostic impression.
Summary of Jeremy’s Formal Assessment
Jeremy is a 6-year-old boy who is currently repeating kindergarten at J. J. B.
Elementary School. Jeremy is a bright and engaging child; however, he is
experiencing difficulties at home and at school as a result of hyperactive and
impulsive behaviors and tendencies to be noncompliant in situations when he is not
in control and when he is expected to follow directions that may or may not be to
his liking.
Although Jeremy scored in the superior range on tasks of visual reasoning, his
scores on verbal reasoning tasks were less impressive due to several factors,
including Jeremy’s lack of interest and motivation to respond to verbal tasks. It is
suspected that his weaker performance on verbal tasks reflects his lack of task
engagement rather than his learning potential. Despite his excellent reasoning
ability, Jeremy maycontinue to experience difficulties due to poor ability to regulate
activity levels relative to task demands; Jeremy was either understimulated (task
was not interesting to him) or overstimulated (task was very exciting). In the former
case, Jeremy revealed poor attention span and distractibility, whereas in the latter
case, he showed poor restraint and impulsivity. Problems with compliance were
also noted throughout, suggesting that Jeremy has developed a strong repertoire
of manipulative strategies that may be more resistant to correction than if he were
not so high functioning. Another way in which his superior intelligence may be a risk
factor is that Jeremy’s lack of success academically may be even more frustrating
for him. The significant discrepancy between VCI and NVI may also indicate a
specific learning disability, which might complicate academic progress. Certainly at
this point, Jeremy’s academic skill levels are virtually nonexistent. Whether
academic difficulties result from a specific learning disability or an inability to apply
himself to the task at hand remains to be seen.
The mother and grandmother jointly completed the Home Situations Questionnaire
(Barkley, 1997) to provide increased understanding of the nature of Jeremy’s
noncompliant behaviors and how they were being managed within the home. The
Home Situations Questionnaire classifies compliance problems in three areas within
the home: instructions, commands, and rules. Results revealed four primary
problematic situations: when adults are talking on the telephone, when adults are
watching television, when Jeremy is asked to do chores (cleaning the room), and
when Jeremy is asked to do homework. Problem areas were discussed at length,
and the caregivers engaged in role-play to demonstrate how each would interact
with Jeremy under problem conditions. Based on the dialogue and role-play, two
areas of compliance difficulty were targeted for further investigation. The caregivers
selected problems with chores (specifically, when Jeremy is asked to clean up his
room or pick up his toys) and talking on the telephone (Jeremy’s intrusiveness
when mother or grandmother is occupied) as the two problem areas of most
concern.
1. Compliance with requests to clean his room: M om and grandmother agreed
that when asked to clean his room, Jeremy typically engages in argumentative
behaviors (why he should not have to do it), delay tactics (says he will do it
later), manipulations (asks for help), or refusals (says he cannot or will not do
it). There was also agreement about the methods used by each parent, saying
that each had figured out the “good cop, bad cop” routine was not working, nor
was the mother’s response to count to three. Jeremy had pretty well figured
out that most times there was not going to be anything happening after the
three count, so this was not very effective. M om’s response to Jeremy not
cleaning his room usually involved yelling and screaming. She proudly
described a recent situation in which Jeremy yelled back at her “as loud as
possible,” but the mother retaliated even more loudly, just to show him that she
could outscream him. He tried but he could not do it; as a result, his mother
said he had learned the lesson that she screams the loudest. While the mother
screams, the grandmother basically gives in and cleans the room for him to
avoid any further problems. A functional behavioral assessment and behavioral
intervention plan to increase compliant behaviors will be discussed as a
treatment alternative later in the chapter.
2. Interruptions while trying to talk on the telephone: Specifically, “Jeremy will
stand in your face and talk at you, so you can’t hear the person on the
telephone; he won’t wait until the call is finished.” The mother’s typical
response is to take the phone outside (if the weather is nice) or to yell at
Jeremy. The grandmother reports getting very upset with him and hanging up
the phone as a result.
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
Developing a Case Formulation From Several
Perspectives
Biological Perspective
Jeremy has a long history of family psychopathology (Cicchetti & Toth, 1998),
including attention problems (mother and possibly father); mood disorders (mother,
maternal grandmother, possibly maternal grandfather); anxiety disorders
(grandmother, potentially maternal aunt); substance abuse (maternal grandfather);
and antisocial personality disorder (father). Studies reveal that 50% of parents with
ADHD have a child who is also ADHD (Biederman et al., 1995). Genetic
transmission for depression is estimated to be between 20% and 45% (Rutter,
Silberg, O’Connor, & Simonoff, 1999), with almost half developing bipolar disorder;
odds for bipolar increase if there is a family history for the disorder (Geller et al.,
2002). General anxiety disorder, panic attacks, or obsessive thoughts and
behaviors result from malfunctions of GABA (gamma-aminobutyric acid), which
normally inhibits arousal, resulting in heightened levels of stimulation (Lloyd,
Fletcher, & M inuchin, 1992). Heritability of GABA malfunction can be as high as
30%–40% (Eley, 1999). If antisocial personality disorder is present in the immediate
family, there is an increased risk for aggressive and disruptive behavior disorders
(DSM-5; APA, 2013). Studies have found that individuals with disorders of impulse
control, such as antisocial personality disorder, react to stressful circumstances in a
dysregulated and destructive manner, often directing their destructive actions
toward violation of the rights of others. In these cases, individuals who inherit the
short allele (5-HTT) of the serotonin neurotransmitter react with heightened
activation of the amygdale and cortical systems (Barr et al., 2003; Hariri et al.,
2002). During these stressful episodes, aggressive behaviors (destructive impulses
toward others) become more probable (Stanley, M olcho, & Stanley, 2000). LyonsRuth et al. (2007) found that the short form of the 5-HTT was linked to an increased
risk for antisocial symptoms; individuals who had inherited the short form of the
serotonin transporter allele were twice as likely to express impulse disorder
symptoms, whereas those who inherited two of the short alleles were at four times
the risk of developing impulse disorders.
Child temperament can be another biological marker influencing a child’s response
to his or her environment. Rydell, Berlin, and Bohlin (2001) studied children who
were high on emotionality (intensity of emotional arousal) and low on social
adaptation (respond to emotionally charged situations in either a flight [withdrawal
and avoidance] or fight [anger and aggression] pattern). They found that children
with this combination were poorly equipped to manage their emotional responses to
environmental demands. Although previous research has demonstrated that
maladaptive responses occur under highly negative conditions (e.g., internalizing
children would withdraw and avoid social contact, while externalizing children would
aggress and break rules), Rydell et al. (2001) found that children with externalizing
problems escalated out of control in highly positively charged situations as well
(e.g., the child cannot manage negative or positive emotions).
Although above-average intelligence is usually thought of as a protective factor
(Luthar & Zigler, 1992), in Jeremy’s case, superior intelligence may place him at
greater risk for maladaptive behaviors, if he uses his intellectual capacity to “outwit
and outsmart” his caregivers by developing manipulative strategies and engaging
them in power struggles.
Environmental factors can interact with biological traits and vulnerabilities in a way
that exacerbates existing conditions. Barkley (1997) suggests a four-factor model to
explain factors that can maintain and increase noncompliant behavior. According to
this model, predisposing characteristics are
1. The temperament of the child (temperamental, high emotional reactivity,
impulsive, active, inattentive)
2. The temperament of the parents (immature, temperamental, impulsive)
3. Child management patterns (inconsistent, harsh, indiscriminate, and coercive
parenting, poor monitoring of child activities)
4. Distressed family environment (financial, health, and personal stressors)
The model is well suited as a framework for developing case formulations that can
integrate information across theoretical models.
Disruptive behaviors can be enduring, with patterns of persistent oppositional and
aggressive behaviors beginning in the preschool years and persisting across
development (Owens & Shaw, 2003). Jeremy has several risk factors for the
development of disruptive behavior patterns. Historically, Jeremy’s temperament
has been problematic in areas of adaptation to change and emotional reactivity,
resulting in difficulties with emotion regulation (Bridges & Grolnick, 1995; Rothbart &
Sheese, 2007). When we place this temperament pattern within the context of the
underlying dynamics inherent in this mother–grandmother‐parented family that often
seems to shift roles as to who is the parent and who is the child, the problems
increase in intensity. Other environmental risk factors for disruptive behavior
disorders include insecure attachment (Rutter, 1995; Sroufe, 1997), cycles of
maternal depression and rejection (postpartum depression), child aggression and
impulsivity (Owens & Shaw, 2003), poor school adjustment, and lack of positive
peer relationships (Blum et al., 2000). M aternal depression with features of
irritability, criticism, and lack of positive affect can also increase the risk of disruptive
behaviors in children (Aguilar, Sroufe, Egeland, & Carlson, 2000).
Parenting, Attachment, and Family Systems Perspective
Insecure attachment may pave the way for Jeremy to develop separation anxiety in
response to his mother’s recent car accident, resulting in excessive need for
proximity and heightened fears of possible loss. When placed in fearful situations,
being soothed by the parent can assist the infant in building brain structures that
can help regulate responses to fearful situations in the future. However, in
dysfunctional attachment relationships, caregivers do not provide assistance in the
regulation of emotions, such as fear, and actually can become a fear-provoking
agent. In these circumstances, infants do not learn how to self-soothe in stressproducing situations. Lyons-Ruth et al. (2007) found that early childcare problems
resulted in negative outcomes several years later. As a result, Lyons-Ruth (2008)
suggests that “disruptions in early mother–infant communication are clearly
important to long-term prediction of some forms of psychopathology” (p. 209). Since
early attachment patterns provide the schema for later relationships, Lyons-Ruth
goes on to suggest that contradictory cues may disable an individual’s ability to
develop an appropriate working model for relationships. Pertinent to Jeremy’s case,
research has also found transgenerational effects that explain how the controlling
pattern of hostile, punitive, or rejecting behaviors of mothers with insecurely
attached boys with oppositional defiant disorder mimic their own backgrounds of
insecure attachment patterns (DeKlyen, Speltz, & Greenberg, 1996; Roelofs,
M eesters, Ter Huurne, Bamelis, & M uris, 2006). Disruptive behaviors may play an
instrumental role in the attachment process by acting to control and regulate
caregiver proximity and attentiveness. Through the use of negative attentionseeking behaviors, such as noncompliance, the child can “lock in” attachment
figures based on the use of negative attachment behaviors. It has been suggested
that these maladaptive behaviors may fit with the overall schema of family
dysfunction (M arvin & Stewart, 1990; Zvara et al., 2014).
Family systems theory would recognize several problems inherent in this family triad
that has few limits and very loosely defined boundaries. M other, grandmother, and
Jeremy seem to be enmeshed in each other’s lives (M inuchin, 1985) and, as a
result, Jeremy is often privy to information that is well beyond his years. It is also
likely that triangulation can occur, with the balance of power and status shifting
among the family members, depending on which two members are aligned together.
Today, many grandparents fill the role of surrogate parent for their grandchildren
(Edwards, 2003). Within the past 20 years, the number of grandparents who
assume an active role in caring for their grandchildren has increased dramatically
(Cox, 2000; Goodman & Silverstein, 2005). Currently, approximately 4.5 million
children are living in grandparent-headed households (American Association of
Retired Persons, 2007), with the average age of grandparents in this situation
between 55 and 64 (Smith & Dannison, 2002).
Within this situation, family members are often placed in a nonnormative relational
context that can place grandparents in a conflicted relationship (Cox, 2000), and
many grandparents have revealed feelings of being “torn” between tending to their
grandchildren’s needs and the needs of their own adult children (M usil, Schrader, &
M utikani, 2000). According to Cox (2000), this ambiguous role often leaves
grandparents confused regarding how to define their position in the family, while at
the same time feeling “responsible for shaping and giving meaning to this new
identity, defining it according to their own personalities, resources, and values” (p.
6). In their research, Williamson, Softas-Nall, and M iller (2003) identified a number of
positive feelings that grandparents associated with their surrogate role, including the
emotional feeling of grandmothering and being able to contribute; however, a
number of negative experiences were also revealed, including depression, financial
worries, abuse and neglect of grandchildren, and problems with disciplining the
children.
Erbert and Alemán (2008) investigated the dialectical tensions inherent in the
grandparenting experience and identified three contradictory processes that
occurred in their sample: connection versus separation (a feeling of greater
connectedness with their family is offset by the loss of their own retirement
activities and fears about their inabilities to care for grandchildren), stability versus
change (becoming reinvolved in the raising of children at a time when the
intergenerational gap has widened, e.g., an inability to relate to their social world in
the face of fears of increasing gang violence), and protection versus expression
(fears of being unable to protect the children from threats that are so different from
when they raised their children, e.g., gangs, kidnapping, molestation).
Grandparents raising children are twice as likely to be diagnosed with depression
than their peers who are not in a caregiver role (Fuller-Thompson, M inkler, & Driver,
2000) and experience lower levels of psychological well-being (Baker & Silverstein,
2008). Grandparent-headed households reveal a significantly higher rate for poverty
level than parent-headed households, while children in these families are twice as
likely to receive public assistance (Fuller-Thompson et al., 2000).
Social Cognitive Perspective
Parents of aggressive children may be unsuccessful in deescalating conflict due to
a negative attribution bias regarding their aggressive children, blaming the defiant
behavior on the child’s personality trait (e.g., stubbornness), which is beyond the
parent’s control (Beauchaine, Strassberg, Kees, & Drabick, 2002; Dix & Lochman,
1990; Strassberg, 1995; Wang, Deater-Deckard, & Bell, 2013). Especially in
ambivalent situations, or when compliance is not immediate, some parents may
anticipate more defiance and resistance and act accordingly (Bargh, Lombardi, &
Higgins, 1988; Wang et al., 2013). The coercion model describes the processes
involved in the parent–child exchange that serve to precipitate and maintain
aggressive and defiant behaviors (Campbell, Pierce, M oore, M arakovitz, & Newby,
1996; Dishion, Forgatch, Chamberlain, & Pelham, 2016; Patterson, Capaldi, & Bank,
1991; Snyder, Schrepferman, & St. Peter, 1997). Within this paradigm, parents’
negative schema drive coercive parenting practices that escalate and maintain
aggressive child responses, in a pattern of increasing arousal that becomes
negatively reinforced (Snyder, Edwards, M cGraw, Kilgore, & Holton, 1994).
Observational studies of parent–child attempts at conflict resolution have
determined that while mothers of nonaggressive boys are successful in decreasing
conflict, mothers of aggressive boys tend to escalate conflict (Snyder et al., 1994).
Parents of aggressive children generate fewer cognitive strategies for
noncompliance (Azar, Robinson, Hekimian, & Twentyman, 1984; Dishion et al.,
2016). Parent strategies are weakest when required to perform under pressured
conditions and tend to dissipate over the course of several trials (Beauchaine et al.,
2002). The authors recommend the need for treatment plans to target the
underlying processes of negative attribution bias and affect regulation, which they
suggest are the pivotal factors that drive coercive parenting patterns.
Behavioral Perspective
M ash and Terdal (1997) suggest that behavioral assessments provide a form of
data collection that naturally lends itself to an increased understanding of the nature
of a problem, the precipitating causes, treatment options, and potential outcomes.
By maintaining a focus on the “observable,” the behavioral approach to case
formulation distinguishes itself from other theoretical approaches that target
underlying process.
Based on results of the Home Situations Questionnaire, behavioral analysis
revealed two situations that were especially problematic for Jeremy and his
parents:
1. Problems with chores (noncompliance when asked to clean up his room)
2. Interruptions while trying to talk on the telephone (Jeremy’s demands for
attention when parents are otherwise engaged, e.g., talking on the telephone)
In the next section (treatment alternatives), a functional behavioral assessment is
conducted and, based on the prevailing assessment information, a behavior
intervention plan is developed for implementation in the home. The exercise
demonstrates how behavioral assessment can be applied to this and future case
studies.
Treatment Alternatives and Developing an Intervention
Plan
Cognitive Behavioral Treatment
The cognitive behavioral approach seeks to understand the link between thinking
and behaving. Therefore, the cognitive behavioral therapist would focus on how
Jeremy’s faulty belief system might contribute to aggressive behavior. Social
cognitive treatment might involve role-play in such areas as social perspective
taking, empathy, and self-control. Parent training using cognitive behavioral methods
would focus on negative attributions, emotion regulation, and, ultimately, increasing
effective strategies for behavior management.
In their investigation of maternal responses to child noncompliance, Beauchaine et
al. (2002) investigated whether parents using ineffective and harsh methods of
discipline fail to generate alternative solutions due to an availability deficit (limited
repertoire) or an accessibility deficit (processing deficit during times of stress). The
authors contend that research support for the accessibility bias has important
implications for parent training programs devoted to teaching parents alternate
methods of child management, since parent attributions may undermine successful
use of the skills taught. The authors emphasize the need to address negative
attributions and adding an affect regulation component to parent training programs in
order to enhance treatment effectiveness.
Jeremy’s Functional Behavioral Assessment and the Behavioral
Intervention Plan
Functional Behavioral Assessment
The behavioral framework consists of a four-stage process designed to
identify the problem,
analyze the problem,
implement a plan, and
evaluate the plan.
Jeremy’s noncompliant behavior can be identified as a behavioral deficit (low levels
of obedience) or a behavioral excess (high levels of noncompliance). Placing
Jeremy’s behaviors within a functional behavior assessment paradigm (see Table
C2.1), the goal is to identify the problem as it relates to precipitating conditions,
consequences, and results.
Table C2.1
One of his parents’ presenting complaints is Jeremy’s lack of compliance when
asked to clean his room. In this case, the precipitating conditions would represent
the requests initiated by the parents that would begin the behavioral sequence of
events. When faced with these requests, Jeremy demonstrates the following
repertoire of behaviors (argues, delays, manipulates, refuses). When faced with
these behaviors, parents respond with a number of reactions or consequences
ranging from doing the task themselves (in whole or part) to escalating battles that
may end in either abandoning the request or in harsh punishment. See an outline of
the Behavioral Intervention Plan in Table C2.1.
Behavioral Intervention Plan
In developing a behavioral plan, it is preferable to concentrate on increasing a deficit
behavior rather than on reducing an excessive behavior. In this case, it is preferable
to increase obedient behavior rather than to attempt to reduce noncompliant
behavior, since increasing a positive behavior can be inherently rewarding in itself.
At this time, the positive reinforcement that Jeremy is receiving due to his
noncompliance far outweighs the occasional and inconsistent punishment he may
receive. The behavior plan would be to shift the positive reinforcement to
obedience rather than reduce noncompliance.
Principles of operant conditioning predict that there are two options available for
increasing or maintaining obedient behavior: positive reinforcement or negative
reinforcement. Reinforcements are acts that have a positive outcome and, as
such, will be rewarding, thereby increasing the likelihood that a behavior will be
repeated. Positive reinforcement involves the addition of a reward (e.g., clean your
room and you will get a sticker book). Positive reinforcement, however, is not
always what it appears to be, and in Jeremy’s case, his parents unknowingly
reinforce many of his negative behaviors in various ways: humor (suggesting
acceptance), boasting (suggesting pride), and providing increased attention. In this
case, Jeremy is rewarded by negative attention, which to Jeremy might be better
than no attention at all. Negative reinforcement, not to be confused with punishment,
is also rewarding because it involves the removal of a negative situation (e.g., if
you clean your room, you will not have to take out the trash). Negative
reinforcement has sometimes been called escape because it allows one to escape
a negative consequence. Jeremy’s argumentativeness and noncompliance are
often negatively reinforcing because they allow him to escape having to do a task.
Principles of learning also provide a set of assumptions for reducing or eliminating
behavior: punishment that involves adding a negative consequence or penalty,
removing a positive reward. Complete withholding of any reinforcement will
eventually result in elimination of the behavior, or what the behaviorists refer to as
extinction.
Although coercion theory from a cognitive framework attends to the underlying
processes of negative attribution and emotion regulation, a behaviorist might use
the theory to describe the antecedents and consequences of noncompliance.
Parents who eventually yield to a child’s escalating and demanding behaviors serve
to positively reinforce the child’s misbehavior (child eventually gets what child wants)
and at the same time give negative reinforcement for their own compliance
(cessation of whining and complaining). Therefore, the parent learns that giving in
will stop the demands, while the child learns that increased demands result in
parent compliance. Since positive and negative reinforcements serve to strengthen
behaviors, parent and child become locked in to an escalating and never-ending
battle.
The importance of developing early treatment interventions to reduce noncompliant
behaviors is evident in the repeated associations of defiant behavior and later
maladjustment in adolescence and adulthood. In their meta-analysis of
psychosocial treatments for children and youth with oppositional defiant disorder
and conduct disorder, Brestan and Eyberg (1998) revealed behavioral parent
training programs to be a successful method for reducing deviant behavior in young
children.
Home-based, parent-delivered interventions often are the result of programs
directed toward parent management training (PM T), and research has
demonstrated that between one-third and two-thirds of children show clinically
significant improvement (Barkley, 1997, 2006; Kazdin, 1996, 2013). The rationale for
PM T is based on the premise that coercive parent–child interchanges and
environmental contingencies are predisposing factors in the development and
maintenance of oppositional, defiant, and noncompliant behaviors. Given the
dynamics involved in this family and the issues of compliance, the goal was to
develop a home-based behavioral intervention plan. Barkley (2006) suggests a
number of components that are helpful in organizing a behavior intervention plan,
including assessment and establishment of a baseline, operationalizing treatment
goals, psychoeducation for parents concerning issues of behavior management,
monitoring, contingency management, generalization to other settings, maintenance
and relapse prevention, and follow-up.
A behavioral intervention program was developed for Jeremy for use in the home,
based on behaviors targeted by mother and grandmother on the Home Situations
Questionnaire. A written copy of “Jeremy’s Star Chart Program” was provided,
outlining agreed-upon consequences for rule infractions, such as loss of stars, as
well as other possible strategies (time-out, logical consequences, loss of privilege).
A general description of possible rewards was discussed; however, it was urged
that Jeremy also be involved in selecting some of the rewards to increase incentive
and participation in the program. Goals of the behavior program were to assist with
increasing compliant behaviors and applying a consistent approach to
consequencing Jeremy for noncompliance. The program involved posting of house
rules on the fridge and dealing with rule infractions through the use of (1) time-out,
(2) logical consequences, and (3) a Response Cost Coupon Program. The
Response Cost Coupon Program, called Jeremy’s Star Chart, was illustrated in a
booklet with rules outlined for loss of stars, regaining of lost stars, and adding up of
star gains to trade for rewards on the Star Chart menu. The program was monitored
by weekly telephone contact. An example of the Star Chart is shown in Table C2.2.
Table C2.2
Another powerful source of learning is observation. Bandura’s (1977) understanding
of the social aspects of learning has been instrumental in increasing our awareness
of the possible implications of observing the behavior of others. Children’s
observation and subsequent modeling of adult behavior can have positive (nurturing
and empathic caring behaviors) or negative (aggressive responses, e.g., witness of
domestic violence) consequences. These responses can be immediately
observable or can be evident in a delayed response.
Research has repeatedly demonstrated that the nature of parent–child interactions
is a strong predictor of childhood noncompliant, defiant, and aggressive behavior
patterns. Poor management practices due to ineffective, inconsistent, and
indiscriminate parental controls often result in overly harsh but inconsistent
discipline and inadequate monitoring of activities. As a result, child noncompliance
becomes an effective means of avoidance or escape from doing undesirable tasks
such as picking up toys or cleaning a bedroom. M other and grandmother are often
at odds over setting limits and often present Jeremy with contradictory messages.
Grandmother is particularly reinforcing of Jeremy’s manipulations and often gives in,
allowing his successful escape or avoidance of unpleasant tasks. Jeremy’s mother
often responds with escalating and coercive responses (screaming as loud as
possible), likely due to their occasional success (“he couldn’t scream as loud, even
though he tried, so I won that time”). In this context, Jeremy has learned how to
successfully avoid unpleasant tasks on the one hand and learned to model
negative behaviors on the other.
Post-Case Questions
1. Jeremy presents with symptoms of ADHD and ODD. Using the DSM-5 (APA,
2013) as a guide describes how Jeremy’s symptoms match criteria as outlined
in the DSM-5. Based on what you have found, would Jeremy meet criteria for
either disorder, and if so, which disorder(s) and why?
2. Jeremy’s parents indicated two areas on the Home Situations Questionnaire
that were in need of behavior management. One problem, compliance with
chores, was selected to demonstrate how a functional behavioral assessment
and a behavior intervention plan were developed to assist in increasing
compliant behaviors. What was the second problem that his parents identified?
Conduct a functional behavioral assessment and develop a behavioral
intervention plan to assist his parents with the second problem.
3. According to Bronfenbrenner (1989), the mesosystem predicts the degree to
which a system remains healthy, functional, and in balance. Given the
information you know about Jeremy’s family and the school system, describe
what you believe the current status to be and how you would attempt to
maximize the mesosystem between these two environmental contexts.
4. Using coercion theory as the overarching dimension, describe power struggles
in the family from the viewpoint of cognitive, behavioral, and family systems
theories.
5. From an attachment theory perspective, using information from the case study,
the Introduction, and any related outside sources, describe the potential
transgenerational effects that are underlying problems with the parent–child
interaction. How does having the grandmother living in the home contribute or
moderate the effects of attachment issues?
6. Child temperament can be another biological marker influencing a child’s
response to his or her environment. Using information from the case study, the
Introduction, and any related outside sources, discuss the role of temperament
in influencing Jeremy’s response to situations and other individuals. Explain
how this can be better understood within the context of epigenesis.
7. Suggested individual or group presentation activity: The teacher has asked
Jeremy’s mother and grandmother to attend a meeting at the school to address
Jeremy’s increasing noncompliance and difficulties with emotion regulation,
especially during less-structured activities. Jeremy’s mother has requested that
the psychologist come to the meeting to share the results of the assessment
and assist with planning a behavior program for Jeremy. At a minimum, the
meeting will include the teacher, Jeremy’s mother and grandmother, and the
psychologist. Prepare a script for role-playing each of the player’s parts in the
meeting and how they could potentially contribute information to assist with
developing a case formulation, functional assessment, and behavioral
intervention plan. Who else would you want to invite to the meeting and why?
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CASE 3 NEESHA WILSON :
PHOENIX RISING: RISKS,
PROTECTIVE FACTORS AND
PSYCHOLOGICAL WELL-BEING
Neesha Wilson, a 10-year-old African American girl, was referred
for assessment to the school psychologist as a result of a child
study team meeting held at the school in M ay. Presenting
problems included poor school progress and escalating behavioral
concerns. It was the school’s impression that Neesha might qualify
for special education assistance as a child with an emotional
disorder. Currently, Neesha has an older brother, Tyrone, who is
attending an alternate school program for children and youth with
severe emotional disturbance.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
The school social worker completed Neesha’s initial workup just
prior to the end of the academic term; intake information is
summarized as follows:
Neesha lives with her 15-year-old brother, Tyrone, and her mother
in a two-bedroom apartment. The social worker described the
apartment as tiny but very well kept. Neesha has her own
bedroom, and Tyrone sleeps on the couch, which folds out into a
bed. The social worker noted that it was difficult to book an
appointment with M rs. Wilson, who was reportedly working two
jobs: cleaning offices and working as a hairstylist. M rs. Wilson
graduated from hairstylist classes last year. Although her career as
a hairstylist has a lot of potential, she is only beginning to develop
clientele. She also works part time cleaning offices. Despite the
lack of financial resources, the children were clean, well dressed,
and did not miss any meals. The children were on the free lunch
program at the schools. According to M rs. Wilson, Neesha’s early
history was unremarkable and motor and language milestones
developed on schedule.
An immediate concern of the social workers centered on who cared
for the children when their mother, Tanya, had to work evenings
cleaning offices. Tanya stated that it was not a problem for her
because she would either send the children to her sister’s
apartment a few blocks away or have a cousin who lived in the
building check in on the kids. Also, Tyrone was 15, so he was
capable of watching his sister, although she preferred to have an
adult nearby, given Tyrone’s behavior problems.
Neesha’s mother described her as an easy baby and said that she
never really had any problems with her. She added that it was
Tyrone who was giving her all the problems, not Neesha. The
family had struggled since her husband, Walt, left the family about 3
years ago, when Neesha was in the first grade. In the past 2
years, Walt has had virtually no contact with the children. He
moved in with his girlfriend and their 1-year-old baby and recently
moved to another state. Neesha was very upset with the marriage
breakdown and misses her father very much. Neesha visited with
her dad and his new family, initially, but was very disappointed that
the visits were neither consistent nor more frequent. Neesha did
not like Walt’s girlfriend and felt that her father was more interested
in the new baby than her. According to Tanya, Neesha often talks
about wanting to visit her father and continues to set herself up for
disappointment. Tanya blames Walt’s lack of involvement with the
children for Tyrone’s problems, which became more severe after
Walt left.
When Walt moved out, Tanya could no longer afford to live in the
apartment they were living in. Tanya described the previous 2
years as very difficult for her and the kids. As Tanya spoke, the
social worker noted in the file that the mother’s affect was very flat.
She also seemed preoccupied with her financial situation and said
that at times she just was not sure how she would make the rent.
They have struggled to survive financially, and Tanya often gets
depressed and—if she is not working the evening—either goes to
bed early or cries herself to sleep. On these occasions, Neesha is
very quiet and tries to comfort her mother. Tanya said that when
she woke up the other morning, Neesha had placed a handmade
card on her pillow. The card was decorated with hearts and bows
and huge letters: “I love you, M om. Neesha.” Tanya said she did
not understand why Neesha was doing so poorly in school
because she seemed to love to “play school” on the weekends
and in the evening. When asked whether Neesha has
demonstrated any behavior problems at home, Tanya said she is
more like a little mother than a kid and has no behavior problems at
all. Her brother is the problem; Neesha is more like a little adult.
She described Neesha as a sweet and loving child who always
tries to please.
The social worker expressed her concern to Tanya about her own
symptoms of depression and fatigue and wondered if Tanya might
see her physician for a referral to talk to a counselor. The social
worker stated that she was concerned because Tanya seemed
overwhelmed by all the financial stresses the family faced that
seemed to be taking their toll on her emotionally. However, Tanya
was quick to say that the extended family was very supportive and
that her two sisters were always there for her to talk to when she
needed it. She also said that her church was a continued source of
comfort and support for herself and the children. In addition to
information obtained from the clinical interview, the social worker
also had Tanya complete the Behavioral Assessment System for
Children (BASC-2).
In August, at the beginning of the new term, the school
psychologist completed a review of Neesha’s cumulative school
record and obtained teacher ratings (BASC-2) from her previous
years’ teachers, which were on file in the guidance office. Neesha’s
school record contained the following additional information.
Neesha began her formal schooling at Franklin Elementary School
but transferred schools midway through the Grade 1 program. She
completed Grade 1 and Grade 2 at Vista Springs Elementary. She
has been attending Heartfield Elementary since her enrollment in
the Grade 3 program. Neesha is currently repeating the fourth
grade. Neesha’s records reveal that her Grade 3 teacher was
concerned because Neesha was repeatedly falling asleep in class.
Because Neesha seemed overly fatigued, her mother took her to
the family physician to check out any possible physical causes;
however, no medical reason was evident to explain her fatigue.
Last year, Neesha was absent 15 days. On the days she attended
school, Neesha was late more than one-third of the time (51 days).
The school counselor had written a summary report based on her
observations of Neesha in the classroom, toward the end of the
Grade 4 program, when the paperwork was being collected for her
assessment in the fall. The notes indicated that Neesha was off
task (daydreaming, looking out the window, staring out into space)
for the majority of time that she was observed. The observation
supported teacher comments that Neesha often failed to complete
her seatwork and handed in assignments unfinished. During
another observation session, the counselor recorded that during a
25-minute seatwork session, Neesha completed only 2 out of 8
comprehension questions for a story read aloud in class. Her
teacher also reported that, at times, Neesha’s lack of attention to
task could also result in class-disturbing behaviors such as
humming, playing with articles on her desk, and socializing.
As part of the referral process, in addition to notes on classroom
observations, the teacher also was asked to record what
interventions were attempted and to comment on the success of
these attempts. Interventions included sending a daily agenda
regarding Neesha’s behavior for home signature, providing extra
time for task completion, and seating her closer to the teacher’s
desk. However, the daily agenda often was returned unsigned,
since her mother was sleeping, and providing extra time did not
increase her productivity. In all, the interventions generally were not
successful. Ultimately, the decision was made to have Neesha
repeat the Grade 4 program, since she had not completed any
assigned tasks during her Grade 4 year, and to place her on high
priority for a comprehensive assessment early in the fall term.
The school psychologist saw Neesha for an initial assessment
session, early in the fall term. Neesha was very well groomed, with
matching accessories and her hair stylishly braided in a way that
must have taken hours to complete. When asked about her hair,
Neesha was very proud to say that her mother had done it for her,
and that her mother was a very good hairdresser. Neesha was
very polite and cooperative. Neesha’s responses and demeanor
suggested a precocious maturity for her 10 years. The
psychologist felt that Neesha tried her best on all tasks presented
but questioned the validity of overall intellectual scores.
REASON FOR REFERRAL
The school requested assessment due to Neesha’s escalating
academic difficulties and increased behavioral problems (irritability,
moodiness, and beginning to strike out at other children). There
were concerns that Neesha might warrant placement in a program
for children with emotional problems.
ASSESSMENT RESULTS
Information concerning specific assessment instruments and the
interpretation of standard scores and T scores can be found in
Appendix C.
Responses to the Wechsler Intelligence Scale for Children (WISCV) revealed Neesha’s overall intellectual score of 92, which was
within the average range (IQ range 87–98). However, there were
several indicators to suggest that this score was likely an
underestimate of her “true potential.” Neesha’s mature
conversational tone, insight, and academic levels obtained on
standardized testing suggested intellectual functioning more
appropriately suited to the upper average to high average range.
Based on her overall obtained score, Neesha performed in the
average range of ability at the 30th percentile when compared with
children her age. There was minimal difference in her scores for the
Verbal Comprehension Index (VCI, standard score of 90), the
Visual Spatial Index (VSI, standard score of 95), and the Fluid
Reasoning Index (FRI, standard score of 93). Based on these
scores, it would be anticipated that Neesha should be performing
approximately at grade level academically. An analysis of the
individual pattern of test results indicated that Neesha had relative
strengths in the areas of the Working M emory Index (WM I = 100),
which involves the manipulation of mental information and shortterm working memory, and Processing Speed Index (PSI = 103),
which measures speed of copying and scanning information. An
analysis of the individual pattern of subtest scores indicated that
Neesha had relative strengths in the area of visual analysis and
reasoning (picture concepts) and recall for letter and number
sequences. Weaknesses were noted in vocabulary development,
social judgment, and part-to-whole visual organization (block
design).
Academically, according to the Woodcock Johnson Test of
Achievement, Neesha’s current functioning levels were far in
excess of her current grade placement and also exceeded
predicted levels according to the WISC-V (which was considered
as an underestimate of her intellectual potential). Overall, Neesha
was performing at a Grade 7.2 level in Broad Reading (age score of
12.7), Grade 5.8 level in Broad M ath (age score 11.4), and Grade
7.9 level in Broad Written Expression (age score 13.2). Overall,
Neesha was achieving in the high average range when scores
were compared with those of other children her age who would be
enrolled in a regular Grade 5 program. When compared with other
children enrolled in a regular Grade 4 program (which Neesha was
currently repeating), her scores represented functioning in the
superior range.
Neesha was cooperative during the clinical interview and provided
thoughtful and conscientious responses to the interviewer’s
questions. When asked what types of things or situations made
her feel happy, sad, angry, or frightened, Neesha provided the
following information. Neesha stated that “compliments, surprises,
and visits with her Dad” were all things that could make her “happy.”
She said she felt “sad” when kids threaten her or people say bad
things about her or her family. She also stated that she gets very
sad when her mother cries because she does not know how to
make it better.
Neesha looked sad as she spoke about her mother, and her voice
trailed off as she swallowed hard. Neesha admitted to feeling angry
and upset when her older brother (15 years of age) hits her, and
she is “frightened” when she visits her aunt’s neighborhood,
because the kids are loud and scary. In response to what worries
her presently, Neesha said that she is worried that she will not be
able to advance to the fifth grade this year. She said that she
asked her mother to talk to the principal because she is working
very hard and wants to go to Grade 5. She said she did not want to
be in Grade 4 again, and she is very afraid that the kids will start
being mean again and call her names like they did last year. She
said she did not want to get into trouble this year like she did last
year.
When asked why she was falling asleep in class, Neesha said that
in the past she had lots of problems falling asleep but added that
was 2 years ago and things were different then. She said that at
that time she would come home from school very tired and fall
asleep after dinner. Then she would wake up at night and not be
able to go to sleep again. She said that she has stopped taking
naps in the afternoon and now she does not wake up at night
anymore. Neesha volunteered that she also worried a lot about
things and that sometimes when she worries she has a hard time
falling asleep. Not so much now, but it was bad then because she
missed her dad and wanted him to come home. She said that last
year she got in trouble for being late so many times, but it was hard
to wake up. Neesha said that she was tired and had trouble getting
herself ready for school. Her mom was sleeping late because she
was working more nights cleaning the offices. Neesha said it was a
very hard year. She was tired and cranky and just could not seem
to concentrate on her work. She said she would read a page and
then not remember what she read. Neesha said she got so far
behind that she just gave up. She was also having problems with
the other girls in the class, who were starting to tease her about
sleeping in class and not doing her work. She said they called her
names like “Sleepy” and “Dummy.” She said that at first it made her
very sad and then it made her very mad. That is when she started
to hit them to make them stop. When I asked what made the
difference this year, Neesha said, for one, she now has an alarm
clock. She sets the clock and lets her mom sleep in. The school
bus picks the kids up on the corner, so she just goes and waits
with the other kids who live in the apartment building. When asked
about schoolwork, Neesha stated that she was very proud of her
reading ability and said that she is now concentrating on finishing
her work and that keeps her going.
Neesha completed several self-report inventories. Overall
response to the Revised Children’s M anifest Anxiety Scale
(RCM AS-2) revealed total anxiety to be within normal limits.
However, there was a significant elevation on the Physiological
Indicator scale, and Neesha endorsed several items indicating a
generalized heightened state of arousal often associated with
stressful conditions, such as trouble getting her breath, feeling sick
to her stomach, and hands feeling sweaty. She also admitted to
worrying a lot of the time and having problems falling asleep. An
elevated validity scale (the Lie scale on the RCM AS) was
suggestive of Neesha’s tendency to try to project a good image
and suggesting that perhaps her anxiety was more of an issue than
Neesha was letting on.
Neesha’s responses to the Children’s Depression Inventory (CDI2) revealed overall depression level to be within the norm when
compared to girls of a similar age. However, the elevation on the
Negative M ood scale was significant, indicating problems with
sleeping, fatigue, and worry about aches and pains. Neesha also
completed the Personality Inventory for Youth (PIY), a 270-item
questionnaire that assesses emotional and behavioral adjustment
and family characteristics and interactions, as well as school
adjustment. The instrument also includes validity scales that
identify a respondent’s level of consistency and defensiveness.
Neesha’s scores on the validity scales suggested that her profile
was an honest attempt to reflect her current emotional and
behavioral concerns. Scores indicated normal concerns typical of
girls her age in most areas. However, consistent with the RCM AS,
Neesha endorsed a significant number of items indicating somatic
concerns (T = 73). Scores in this range suggest a large and varied
number of somatic symptoms and health concerns, such as fatigue,
headache, stomachache, back pain, dizzy spells, trouble breathing,
and the like. Results of this kind are often seen in children who
worry about and are preoccupied with illness and may become
emotionally upset when they are sick. Often these symptoms
represent the physical aspects of anxiety and tension. Neesha’s
particular pattern of endorsement suggests that symptoms are
likely connected to feelings of psychological distress within the
home.
Projective assessment was also conducted using the Robert’s
Apperception Test, a series of pictures that are used as prompts
for children’s stories. The characters in Neesha’s stories revealed
difficulties in the following areas: conflicts with siblings, fear of being
punished for doing something wrong, fear of being ill, and concerns
regarding school performance. Family matters included a mother
having a new baby and a young girl being a bridesmaid for her
parents’ wedding. Neesha’s drawings for the House–Tree–Person
indicated a positive openness to communication and were
generally free of suggested pathology.
Two of Neesha’s teachers from the fourth grade last year, her
current teacher, and her mother completed the BASC-2. It should
be noted that although the BASC-2 suggests that rating be
conducted by individuals who have known the child for at least 6
months, the desire to have a current behavioral rating for
comparison violated this suggestion since her current teacher has
known Neesha only since the beginning of August (less than 2
months). Therefore, results should be interpreted with caution. The
BASC-2 is a comprehensive measurement of common behavioral
and emotional problems in children. Ratings of children are
interpreted to indicate behavioral concerns that are normal, at risk,
or clinical. Behaviors falling within the at-risk range represent an
emerging problem area that needs attention but does not warrant a
formal diagnosis, while behaviors within the clinical range are
problems that warrant attention and intervention.
Ratings are based on the observations of informants in different
situations, and it is not unusual for children to behave differently in
various situations. Therefore, inconsistencies between informants
are not unusual. According to Neesha’s teachers last year, there
was agreement in several areas on the BASC-2 ratings. The two
teachers rated her behaviors as clinically significant in the following
areas: Aggression (physical and verbal), Conduct Problems (rulebreaking behaviors), and overall Externalizing Problems. They also
agreed that the following behaviors were at risk: Attention
Problems, Leadership, Social Skills, and Study Skills. At-risk or
clinically significant elevations were also noted for Composite
Adaptive Skills (Adaptability, Social Skills, Leadership, Study Skills).
Neesha’s current teacher and Neesha’s mother have indicated all
behaviors currently to be within the normal range.
In the final assessment session, Neesha appeared very positive
about her school successes this year and said that she was
working very hard to go to the next grade level. When asked if she
would like to meet with the school psychologist once in a while,
just to talk about her worries, Neesha said that she would like that
very much. As she left the office, she turned and thanked the
psychologist for working with her and added, “You know,
sometimes, it’s hard being a kid.” When Neesha’s mother came to
talk to the school psychologist about the test results, the
psychologist mirrored the social worker’s earlier concerns about
the mother being depressed and preoccupied. Affect was very flat
despite the excellent news she was receiving regarding her
daughter’s academic skills and behavioral turnaround. Her mother
reported that what Neesha had accomplished, she had done on
her own. She stated that Neesha had received no help from her.
The mother appeared preoccupied with the interview making her
late for work and asked if she could please leave quickly.
Postscript
Three weeks later, at 10:00 a.m., the school principal received a
call from Neesha’s mother, who asked that her daughter not be
sent home from school because she was going to kill herself. As
she spoke on the telephone, she explained that she was holding a
loaded gun to her head and that she had to do it because she was
not going to make this month’s rent. She could not take it any
longer, but she did not want Neesha to come home and find her
dead.
While the guidance counselor continued to keep the mother talking,
the school principal contacted the police, who apprehended mom
while she was talking on her cell phone from her car in the
driveway of the apartment building. The loaded gun was on her lap.
M other was Baker Acted (taken into custody due to fears
regarding danger to self) and taken to the local psychiatric facility.
Currently, the mother is on medication for depression.
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
Considering Neesha’s case within the framework of developmental
contexts and environmental influences, there are several risk
factors that are affecting her development that are not within
Neesha’s immediate control, including poverty, her mother’s mental
illness (depression), and living with a sibling who has severe
emotional disturbance.
Case Formulation
Unlike the other two cases presented in this introductory section,
developing a case formulation for Neesha requires thinking outside
the box. Neesha does not present with enough symptoms of
depression or anxiety to meet criteria for any specific anxiety or
depressive disorder. However, she does meet diagnostic criteria
for an adjustment disorder with mixed anxiety and depressed
mood. Adjustment disorders are evident as emotional or behavioral
symptoms that develop in response to an identifiable stressor and
occur within 3 months of the onset of the stressor. Although this
stress-related disorder is considered to be a “temporary” condition
that “lasts no longer than 6 months after the stressor or its
consequences have ceased” (APA, 2013, p. 287), in Neesha’s
case, she is experiencing ongoing stress related to environmental
influences that continue to be present. The DSM does specify that
“if the stressor or its consequences persist, the adjustment
disorder may continue to be present and become the persistent
form.”
Risks, Protective Factors, and Resilience
Several researchers have focused on the role of protective factors
in buffering some children living in high-risk environments.
Emphasis has shifted from focusing on risks to determining
environmental resources and adaptive strengths in children who do
not show early signs of deviance (Richters & Weintraub, 1990).
Rutter (1987) noted several years ago that instead of searching for
broadly defined protective factors, emphasis needs to be placed on
better understanding “why and how some individuals manage to
maintain high self-esteem and self-efficacy in spite of facing the
same adversities that lead other people to give up and lose hope”
(p. 317). Furthermore, Rutter (1990) suggests that we go beyond
listing risk factors to looking at the underlying processes or
mechanisms that are instrumental in producing the buffering effect.
Rutter defines these processes as reducing risk impact, reducing
negative chain reactions, increasing factors that promote selfesteem, and opening opportunities. The role of timing (life events)
in changing the trajectory away from vulnerability is also discussed.
In their discussion of risk and resilience, Werner and Smith (2001)
concluded that certain environmental factors, such as positive
emotional support from caregivers and mentors, could provide
protection from negative outcomes, despite living in adverse
conditions, while M asten (2001) found the following to be
protective factors in resilience: positive, supportive caregivers;
positive views of self; motivation to succeed; and cognitive and
self-regulatory skills. Although resilience was once thought of as a
trait, currently, resilience is thought of as “a process or
phenomenon reflecting positive child adjustment despite conditions
of risk” (Luthar & Zelazo, 2003, p. 510). M asten and M onn (2015)
suggest that “resilience involves successful adaptation following
significant challenges or system disturbances” (p. 6).
Durlak (1998) reviewed 1,200 outcome studies concerning
prevention programs for children and identified several common risk
and protective factors across seven major outcome areas:
behavior problems, school failure, poor physical health, physical
injury, pregnancy, drug use, and AIDS. Analysis of risk and
protective factors linked each factor with the appropriate
developmental context, including individual, immediate (family,
school, peers), and community. Durlak found multiple factors playing
a protective role for more than one outcome. For example,
attending a “high-quality school” protected against behavior
problems, school failure, early pregnancy, drug use, and AIDS and
having “positive peer models” also protected across the same five
areas. Having a good parent–child relationship and good personal
and social skills protected across all seven major outcomes. Highrisk factors included living in an impoverished neighborhood, low
family socioeconomic status (SES), parental psychopathology,
marital discord, and punitive parenting. Stress was considered to be
a risk factor that crossed all levels of development, while social
support was a protective factor that crossed all developmental
levels.
When discussing risk and protective factors, the risks of being in an
ethnic minority have rarely been addressed. Gibbs and Huang
(2001) emphasize that when ethnic identity is combined with
membership in a minority race, children are faced with a dual
challenge. The authors also note that ethnic minority status has
often been associated with restricted range of opportunities, and
children growing up in minority families may be exposed to
circumstances and experiences very different from the majority of
the community. In addition, there is often an interaction among
factors of ethnicity, race, and social class (SES), with higher status
typically perceived for white, Anglo-Saxon, middle-class families
and lower status associated with non-white, ethnic minority, and
lower class families (Hacker, 1992). In their study of child poverty
rates, Lichtner, Quian, and Crowley (2005) found that while 9% of
white children were living below the poverty line, one-third of all
Black children and 27% of Hispanic children were living at this level.
According to the 2014 census, approximately 38% of African
American youth under 18 years of age live below the poverty line,
compared with 30% Hispanic, 9.6% Asian, and 10.7% whites
(DeNavas-Walt & Proctor, 2014). Within this context, the role of the
family has assumed a position of strength and resilience. One
central value that is cultivated by African American families is the
importance of being “independent” and the value of independence.
In this manner, the family unit is sustained by members who are
self-reliant. Other strong family values often include obedience,
respect for elders, and emphasis on obtaining a good education.
However, culture clash may be evident in the way in which family
members or children whose sense of time is fluid and eventoriented interact with largely white establishments where time is
determined by the clock, calendar, or school agenda (Lynch &
Hanson, 1998).
A growing body of research has revealed that maternal depression
and depressive symptoms place children and adolescents at
increased risk for negative social and emotional outcomes
(Goodman & Gotlib, 2002). Recent studies have found that by
adolescence, children and youth exposed to maternal depression
demonstrate higher levels of internalizing and externalizing
problems relative to peers whose mothers are not depressed
(Foster, Garber, & Durlak, 2008; Nelson, Hammen, Brennan, &
Ullman, 2003). Campbell, M organ-Lopez, Cox, and M cLoyd (2009)
found that adolescents whose mothers reported chronic depressed
symptoms across their childhood evidenced more symptoms of
depression, dysphoria, and loneliness compared to peers whose
mothers were without a history of depression. It has also been
found that children living in stressful conditions surrounding
maternal depression (parent–child conflict, less parental monitoring
and supervision) are likely to engage in more risk-taking and
externalizing behaviors (Wiesner & Kim, 2006). Research has also
demonstrated that boys and girls may respond differently to
maternal distress, with boys being more inclined to react with
externalizing problems, while with increasing age, girls are more
likely to develop internalizing problems (Angold, Erklani, Silberg,
Eaves, & Costello, 2002). In addition to trajectories that might be
predicted by gender, the principles of equifinality and multifinality
provide different mechanisms to assist our understanding of the
nature of different outcomes (Cicchetti & Rogosch, 1996). The
principle of equifinality is used to explain how similar symptoms
(depression) can result from different sources (e.g., two children
may both suffer from depression; however, one child may be
reacting to a parental divorce and another child may be depressed
because of peer rejection). The second principle of multifinality is
important in understanding how individuals who experience similar
circumstances may be on different paths that will predict very
different outcomes. For example, although Neesha shows many
signs of distress due to her stressful living conditions, she also
demonstrates qualities that suggest resilience in the face of
adversity. However, her brother Tyrone, whom we will meet in
greater depth in the case study of Tyrone Wilson, has moved
further and further along a path of self-destructive behaviors,
leading to his recent entry into the juvenile justice system.
Therefore, despite living in the same stressful conditions, their
outcomes are very different. In their study of resilient and
nonresilient youth, Buckner, M ezzacappa, and Beardslee (2003)
found that compared to their nonresilient peers, resilient youth
demonstrated greater self-regulatory skills and self-esteem, as well
as more active parental monitoring. Children who grow up in lessthan-ideal conditions may accept these conditions as part of the
“normalcy” of their life and learn to cope with what they have.
Others may develop a sense of positive self-esteem and
independence that may serve to buffer them from more negative
outcomes (Cicchetti & Rogosch, 1997). Yet others, like Tyrone, will
follow a path of aggression and retaliation and join others who are
on a similar self-destructive trajectory.
Post-Case Questions
1. In discussing the plight of resilient children, Luthar (1993)
contrasts earlier concepts of the invulnerable child with present
concepts of the resilient child. Luthar observed that children
who survived difficult circumstances without developing
maladaptive outcomes often presented with more subtle
internalizing problems. In Luthar’s study, 85% of the resilient
children had clinically significant symptoms of anxiety and
depression. Similarly, longitudinal data from studies by Werner
and Smith (1992) also noted that resilient children in adulthood
were plagued with somatic complaints (headaches, backaches)
and feelings of dissatisfaction. In the Introduction to this
chapter, the topic of resilience and neurobiology was
discussed. According to Karatoreos and M cEwen (2013),
initially an individual can withstand environmental challenges
(stressful circumstances) by successful allostatic responses
that can contribute to resilience; however, over the course of
time, continued stressful circumstances can cause a system to
go into “allostatic overload” resulting in overuse of the system
and dysregulation (wearing down the system). Discuss
Neesha’s current clinical profile in light of the information
provided by these studies on resilience.
2. In a study of developmental response patterns to maternal
depression, Solantaus-Simula (2002) found four response
patterns: active empathy, emotional overinvolvement,
indifference, and avoidance. Of the four types, children in the
emotional overinvolvement and avoidance groups
demonstrated the most internalizing and externalizing
symptoms, independent of mother’s level of depression.
Furthermore, children in the active empathy group fared best.
They did not feel guilty about their parent’s depression and
were able to discriminate their experiences from those of the
depressed parent, supporting Beardslee’s (1989) theory of the
protective function of self-understanding. The most common
response to maternal depression in the active group was to
make some effort to cheer up the parent. Discuss these
findings in relation to Neesha’s case.
3. The way in which a child responds to distress can be strongly
influenced by the cultural context in which the circumstance is
embedded. Discuss this comment with respect to Neesha’s
case.
4. Studies on resilience and maternal depression discussed in
the Introduction to this chapter report a number of negative
outcomes that can occur for children and youth who are raised
by depressed mothers. Some of the reported risks include
social withdrawal, inappropriate social skills, increased risk for
psychopathology, and dysfunctional physiological systems
associated with managing stress and regulating social
engagement (e.g., cortisol responses and oxytocin
production). Karatoreos and M cEwen (2013) discuss how
hyper or hypo cortisol reactivity in children of depressed
mothers can influence a child’s tendency to withdraw socially
or demonstrate behavioral inhibition. Describe how Neesha’s
mother’s parenting behaviors may have influenced the
development of these behaviors in Neesha.
5. Research regarding promoting resilience in children has
focused on two important factors: individual characteristics and
influences from family and parenting practices. Discuss
possible interventions that would enhance Neesha’s
opportunities for developing and sustaining resilience.
6. Suggested individual or group presentation activity: The
guidance counselor has asked Neesha’s mother to attend a
meeting at the school to address Neesha’s academic skills
and social engagement. The school psychologist and social
worker will be invited to attend the meeting, as well as
Neesha’s teacher. Prepare a script for role-playing each of the
player’s parts in the meeting and how they could potentially
contribute information to assist with developing a case
formulation and intervention plan. Who else would you want to
invite to the meeting and why?
7. After reading the case of Neesha’s brother, Tyrone Wilson,
discuss the concepts of multifinality and equifinality as they are
related to the two case studies.
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risk children from birth to adulthood. Ithaca, NY: Cornell
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1220–1235.
2 INTRODUCTION TO
NEURODEVELOPMENTAL
DISORDERS
Disorders that are classified under the category of
Neurodevelopmental Disorders include those conditions with early
onset (likely prior to formal school entry) that are characterized by
“developmental deficits that produce impairments of personal,
social, academic, or occupational functioning” (DSM -5; APA, 2013,
p. 31). The recent revision process of the DSM included lengthy
discussions regarding how to best to recategorize childhood
disorders which were previously housed in the category of
“Disorders Usually First Diagnosed in Infancy, Childhood, or
Adolescence.” Although the category of Neurodevelopmental
Disorders was an obvious choice for a classification category, there
was considerable debate as to the validity of including or excluding
specific disorders from this category. A meta-analysis was
conducted and several possible candidates were considered for
inclusion under this umbrella, including conduct disorder (CD),
separation anxiety disorder, attention deficit/hyperactivity disorder
(ADHD), mental retardation (intellectual disability), pervasive
developmental disorders (PDDs) (autism spectrum disorder [ASD]),
motor disorders, communication disorders, and learning disorders
(Andrews, Pine, Hobbs, Anderson, & Sutherland, 2009). However,
while some disorders were a more natural fit, meeting the majority
of validating criteria (such as intellectual disability and ASD), other
disorder subtypes, such as the externalizing features of CD and
the hyperactive-impulsive or combined subtypes of ADHD,
seemed to share features not common to other disorders. Based
on shared features, such as, etiology, symptom similarity, early
onset, and course persistence, Andrews et al. (2009) suggested
five potential disorders for inclusion under the category of
Neurodevelopmental Disorders, including intellectual disability,
ASDs, motor disorders, communication disorders, and learning
disorders.
On final publication, the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5, APA, 2013) included six disorders under the
category of Neurodevelopmental Disorders: intellectual disability,
communication disorders, ASD, ADHD, specific learning disorder,
and motor disorders.
The rationale for including the above six disorders within this
category include the following:
1. The disorders are often comorbid (children with ASD also often
evidence intellectual disabilities; children with ADHD often
experience specific learning disorders);
2. The disorders represent a wide range of neurodevelopmental
functioning and impairments from global delays to specific
deficits in executive functions.
This chapter contains seven cases which provide a broad look at
the types of disorders that area clustered within the category of
Neurodevelopmental Disorders: Colby Tyler (Case 4), a gifted
teenager who also has been diagnosed with ADHD; Thomas
M cLearn (Case 5), a young boy with a specific reading disorder
(dyslexia); Sandy Smith (Case 6), a young girl who has a very
unique type of learning disorder, a nonverbal learning disability;
Dylan Bach (Case 7), a child with higher functioning autism who is
exceptionally gifted in specific areas; Bradley Hunter (Case 10), a
case that presents a more traditional picture of a child with more
severe autistic features; and Brian Williams (Case 9), a child who
has an intellectual disability, but a very specific variant, known as
Williams syndrome. Since children with William’s syndrome are
often hypersocial, comparing Brian’s profile to Dylan’s can make for
a very interesting discussion, as would reviewing both these cases
in the light of comments made earlier about Sandy Smith (Case 6;
nonverbal learning disability). Arthur Watson (Case 8) is an
example of a case that is frequently seen in clinical settings; a child
who can be a puzzle to those who attempt to address whether
lack of performance is a matter of “won’t or can’t.”
DISORDERS OF ATTENTION AND
LEARNING
Attention deficit/ hyperactivity disorder (ADHD): Individuals who
meet criteria for ADHD display a persistent pattern of inattention,
overactivity, or impulsivity. Based on the symptom configuration,
specifiers for ADHD will indicate whether the disorder represents a
predominantly inattentive, hyperactive/impulsive, or combined
presentation. Diagnostic criteria for ADHD in the DSM -5 remain
consistent with previous criteria (DSM -IV-TR; APA, 2000), with the
following exceptions: the symptoms now must be evident prior to
12 years (rather than 7 as noted previously); only five symptoms,
instead of six, are required for inattention or hyperactive/impulsive
presentations if individuals are 17 years of age or older, and the
symptom descriptions include more examples of how the disorder
may appear in adults and inclusion of indicators for the degree of
severity (mild, moderate, or severe). The most recent prevalent
rates suggest that the disorder is present in about 5% of children
and 2.5% of adults, and the disorder commonly is comorbid with a
specific learning disorder (APA, 2013).
Specific learning disorder: Specific learning disorders (formerly
learning disorders) are biological in origin and influence an
individual’s ability to effectively process visual or verbal information
necessary for the acquisition of academic skills in areas of reading
(accuracy, fluency, comprehension) or written expression (spelling,
grammar, organization) and/or mathematics (number sense, math
facts, calculation, or reasoning) (APA, 2013, p. 67). Although the
DSM no longer requires a significant discrepancy between
intellectual functioning and academic performance (previously a
significant discrepancy between intellectual functioning and
achievement was suggested to be two standard deviations), the
DSM -5 requires that academic skills be significantly below age
expectations (as measured by a standardized assessment), are
persistent (originating in the school years), and “are not better
accounted for by intellectual disabilities,” in addition to other
neurological problems or lack of instruction (p. 67). Severity can
range from mild to severe.
INTELLECTUAL AND DEVELOPMENTAL
DISABILITIES
Intellectual disability: The criteria for intellectual disability (formerly
mental retardation) also known as intellectual developmental
disorder remain consistent with previous diagnostic requirements of
significant deficits in intellectual (IQ 65–75; 70 ± 5) and adaptive
functioning. However, there is a significant change in how the
ranges are now conceptualized. Specifiers for mild, moderate,
severe, and profound levels of intellectual disability are no longer
related to levels of intellectual functioning, but they are now linked
to levels of adaptive functioning and the supports required across
three domains of adaptive functioning, including conceptual
(academics, problem solving), social (social judgment,
communication, relationships), and practical (life skills) domains.
The rationale for this change was the lower validity of IQ measures
in the low ranges. In addition, the change is more in keeping with
the concept of intensity of support services (ISS) recognized by
the American Association of Intellectual Developmental Disabilities
(AAIDD).
Global developmental delay: The DSM -5 has added this category
for children under 5 years of age who may demonstrate lags in
achieving milestones; however, given their age or conditions (e.g.,
physical impairments, problem behaviors), valid measures of
functioning may not be obtainable. This category is considered to
be temporary and is to be removed following a formal assessment.
Autism spectrum disorder (ASD): Disorders that are included in this
category were previously known as the pervasive developmental
disorder (PDD) which contained five different but symptom-related
disorders: autism, Asperger’s disorder, Rhett’s disorder, childhood
disintegrative disorder, and PDD not otherwise specified
(PDDNOS). Disorders within ASD meet criteria for two broad
symptom categories, indicating persistent
1.Deficits in social communication and social interaction in
three areas (social–emotional reciprocity, nonverbal
communication, developing/maintaining relationships);
2.Restricted, repetitive patterns of behaviors, interests, and/or
activities in two out of four possible areas (motor movements,
rituals, fixated interests, hyper/hypo response to sensory
information).
Specifiers can be used to indicate whether ASD is accompanied
with or without intellectual or language impairment or the severity
levels/supports required for problems in areas of social
communication or restricted, repetitive behaviors (APA, 50–51).
According to the DSM -5, the diagnosis of ASD should replace
previous diagnoses for autistic disorder, Asperger’s disorder, or
PDDNOS. The prevalence rates suggest that ASD can be evident
in up to 1% of the population, and the DSM -5 states that it is
unclear whether escalating rates reflect inclusion of “subthreshold
cases, increased awareness, differences in study methodology, or
true increases in the frequency of ASD” (APA, 2013, p. 55).
REFERENCES
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders-IV-TR. Arlington, VA: Author.
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders-5. Arlington, VA: Author.
Andrews, G., Pine, D. S., Hobbs, M . J., Anderson, T. M ., &
Sunderland, M . (2009). Neurodevelopmental disorders. Cluster 2
of the proposed metastructure for DSM V and ICD-11.
Psychological M ediciane, 39, 2013–2023.
PART A PROBLEMS OF ATTENTION
AND SPECIFIC LEARNING
DISORDERS
Case 4: Colby Tyler: Attention Problems or Distracted by Life?
Case 5: Thomas M cLearn: Read M e a Story
Case 6: Sandy Smith: M arching to the Beat of a Different Drum
CASE 4 COLBY TYLER :
ATTENTION PROBLEMS OR
DISTRACTED BY LIFE?ADHD;
GIFTED; DIVORCE
Colby, a 14-year-old Caucasian teenager in the ninth grade, came
to the clinic accompanied by his mother, Tina. The appointment had
finally been booked after Tina found Colby’s midterm report card
crumpled in the garbage can.
Not only was he failing one course, but also he was performing
miserably across all subjects. When confronted, Colby lashed out
at her, saying it was her fault, and ran out of the house. Tina
admitted to running down the street after him, yelling like a
“maniac.” It was at this point that she realized that things had
gotten out of control and that she needed help with Colby. His
academic performance and temper outbursts were getting worse
and worse. Tina explained that she also felt less able to cope with
circumstances lately, due to her recent separation from her
husband, Josh. Colby and his 7-year-old sister, Susy, continued to
visit with their father every Wednesday and every second
weekend.
Colby’s parents both have university degrees. Tina works as an
advertising account executive and Josh is an entrepreneur.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
Despite a normal and full-term pregnancy, Tina stated that the labor
was lengthy (12 hours) and ended with a forceps delivery. Tina
reported that she was under a lot of stress during her pregnancy
due to marital conflicts and admitted to smoking and having an
occasional drink during the pregnancy. Colby weighed 6 pounds 2
ounces, and although somewhat underweight, he seemed to be in
good health at birth. The first 3 months were very difficult for Tina
and Colby due to Colby’s sensitive digestive system. After eating,
Colby would often have bouts of projectile vomiting, diarrhea, and
colicky behavior. Although Tina tried to nurse Colby, he was
constantly hungry (feeding every 2 hours), and after 6 weeks, the
doctor felt that Colby and mom would both be better off if he went
on formula. Eventually, Colby settled into a better routine, although
digestive problems and poor sleep patterns continue to be areas of
difficulty for him, especially when under stress. On occasion, Colby
will complain of stomachaches and ask to stay home from school.
He also has difficulty both falling asleep and staying asleep. On
many nights, Colby is still awake when Tina goes to bed, which is
around midnight.
Developmental milestones were achieved within normative
expectations, with the exception that Colby started to read
spontaneously at 2 years of age. His first sight word was “Sears”;
he pointed to the catalog after seeing a commercial on TV. After
that, he started recognizing labels and logos on billboards and on
the television. He was able to read printed words on paper by
about 2½ years of age. Language skills also developed rapidly, and
Colby’s conversational skills were very well advanced by the time
he entered nursery school.
Although Colby’s health has been generally good, he had a severe
outbreak of hives at 5 years of age (source never detected) and
was placed on an elimination diet for 1 month during which time his
food was restricted to rice and lamb broth. Colby has never been
hospitalized, although he does have a tendency to be accident
prone and has experienced cuts, scrapes, and bruises from falls
and bike accidents. Colby’s hearing and vision have both been
assessed. Hearing is within normal limits, and glasses have been
prescribed for distance vision.
When asked about family history, Tina noted that Colby’s maternal
grandmother has always been an anxious woman who has many
fears and who has been on medication for depression. Colby’s
maternal grandfather was of Polish descent and was a heavy
drinker and often became aggressive and physically abusive to his
wife and eldest son. Colby’s maternal grandfather also had
Parkinson’s disease and eventually died after a lengthy battle with
Alzheimer’s. Tina feels that her mother also likely suffers from
posttraumatic stress disorder, due to the violence in the home.
Although Tina’s parents lived some distance away, Colby has
maintained contact with his grandmother through her biyearly visits.
Tina is herself an anxious woman who was a witness to domestic
violence. Colby’s paternal grandmother and grandfather are
deceased and, according to Tina, there was no known pathology.
His paternal grandmother was born in Ireland while his paternal
grandfather was of English descent. There is a paternal uncle who
has problems with alcohol and is also believed to have some
psychotic features (hallucinations and delusions). He is unable to
support himself, is currently on social assistance, and is basically
estranged from Tina’s husband.
Tina described her marriage of 15 years as very turbulent. There
was a previous marital separation due to Josh’s infidelities, about 8
years earlier; however, Tina discovered that she was pregnant with
Susy and they reconciled the marriage. Tina was never able to
reestablish a sense of trust in Josh, and their relationship
continued to slide. During the past year, the children had been
exposed to many arguments and verbal accusations that centered
on Josh’s denial of any infidelities. Although Tina and her husband
Josh had been living in the same house for the past year, they
slept in separate rooms. Six months ago the house finally sold, and
they moved into separate quarters. Tina has been seeing a
counselor for the past year.
REASON FOR REFERRAL
Colby presented as an articulate and well-mannered adolescent.
According to Colby, his mother really got very upset and angry
when she found his report card. He was not eager to share it with
her because she got very angry at him after the parent–teacher
conference in January. He described the parent–teacher
conference as embarrassing and frustrating. First of all, both his
mom and dad were present and were throwing cold stares at each
other across the room. All his teachers were in the room at the
same time, and he felt like he was on trial. Only one teacher, his
English teacher, M r. Brighton, had anything good to say about him.
The other teachers made him angry by saying that he was not
trying, was not motivated, and did not care about his schoolwork.
M rs. Fischer said that most times Colby was not prepared for class
and did not even bring his text with him. All accused him of wasting
his potential. After all, Colby had been identified as a “gifted”
student as part of the Grade 4 screening for the Gifted Program.
Colby’s IQ was 147. However, in spite of all this intelligence, Colby
had never really been a shining academic. In elementary school,
Colby managed to get by with the little amount of effort he put in.
However, Colby began to really slide academically when he
entered Grade 9. Currently, Colby’s grades are well below what
would be expected, and he may not pass Chemistry at all.
Colby is up most nights until very late, and he cannot get up in the
morning. He has been late many times, and the school counselor
has called Tina often to complain about Colby’s tardiness.
Historically, Colby has always had problems sleeping. As a
consequence, getting ready for school in the mornings had been
problematic, with one exception. One day a week, when Colby
attended the Gifted Program, he would have no difficulty getting up
or being on time. The Gifted Program was Colby’s favorite day of
the week, and Colby was noticeably distressed upon learning that
the gifted program would not extend into the secondary school
level.
The level of Colby’s intelligence was evident in his articulate
conversational style and the depth of his knowledge in areas of
interest, like computers. He was an engaging youth who was very
captivating. However, as the conversation turned toward
academics, Colby’s entire demeanor changed, and he became very
quiet. Tina addressed the issue of homework, which was a
constant source of frustration for both of them. Colby seemed to
have tremendous difficulty staying on task; everything was a
potential distraction. Little things, like the telephone ringing or a
noise outside, would be enough to break Colby’s concentration,
and once off-task, it was very difficult to get him back on track.
However, when Colby was playing computer games, he was
riveted to the screen, and it would become very difficult to
disengage Colby from the task. Tina could not understand how
Colby could be so intensely focused when interested in something
and so distractible when interest level was low. Like Colby’s
teachers, Tina thought it was a question of motivation. Tina
described how Colby would begin each academic year all
motivated and excited about school: new binders, pencils, and so
on. Within a matter of weeks, however, old patterns would return
and Colby would begin sleeping in, assignments would remain
incomplete, and pencils would be lost or misplaced. According to
Tina, Colby was the master of good intentions. Although Colby
would often start projects with great enthusiasm, he had
considerable difficulty sustaining this effort over the long haul. The
Gifted Program was the only place where Colby really seemed to
do well.
When asked what was so special about the Gifted Program, Colby
said the teacher was fantastic, most of the kids were great, and
they did a lot of computer work and mind-bending logic games. Tina
interjected that she had talked at length with the teacher of the
Gifted Program, who described Colby as a great kid and a
wonderfully creative and divergent thinker. The teacher of the
Gifted Program thought that one of Colby’s difficulties might be that
he had so many ideas that it was very hard for him to put things
down on paper. He had, as she described it, “an explosive mind for
brainstorming.” Colby said that outside of the Gifted Program, it was
difficult to concentrate and focus. When asked what helped to clear
his head and give him a better ability to stick with something, he
immediately said, “walking or riding my bike in the park.” Colby
explained that sometimes he had the clearest thoughts just walking
by himself on the golf course. He wished he could bring that kind of
focus into the classroom.
When asked about temper outbursts, Tina said that at times Colby
seems incredibly patient, and she saw this behavior at its best
when he was tutoring younger children in a reading program and
giving golf lessons. However, at other times, Colby could be highly
reactive and respond with a short fuse. At these times, Colby
would be more prone to take things personally, be less responsive
to logical reasoning, and be in a highly aroused state. When in this
aroused stated, it is not possible to reason logically with Colby until
he settles down, which can take a while.
According to Colby’s mother, behavioral outbursts had increased
since the marital breakup. Tina stated that Colby has never
adapted well to change and that the emotional split and physical
move have likely added to the intensity of Colby’s reactions.
Having to shift between two households was not easy for Colby,
especially in light of his problems with losing things and misplacing
his notes. Colby now seemed even more disorganized than
before. Tina also wondered whether Colby at some level somehow
blames himself for the split.
When asked about the separation, Colby said very little. He said
that his little sister was upset because he got to choose where he
wanted to live and she did not. He said she does not understand.
It’s awful to have to choose. Colby said his dad asked him why he
chose to be with his mom and he said “because she is closer to
school.” Colby said that his dad called him “shallow.” According to
Tina, Colby has a tense relationship with his father because Josh
tries to compete with Colby instead of supporting him. Tina said
she is afraid that unless there are some answers to what is going
on with Colby at this stage, Colby may end up having real
problems. As it is, he can get very angry and flare up in a second,
and this is really beginning to worry her. In response to that
comment, Colby just looked at his mother and said, “I have been
living in a house that is like the movie The War of the Roses. . . and
you wonder why I get angry.”
ASSESSMENT RESULTS
Guidelines for the interpretation of standard scores and T scores
are available in Appendix C, as are descriptions of the assessment
instruments used in the current assessment, as well as other
resources. Colby’s case serves as the prototypical case for this
book, and with this goal in mind, actual test scores for each
assessment measure and anecdotal examiner comments are
available in Appendix A, along with scores for the assessments of
three other children (Scott M ichaels, Shirley Yong, and Arthur
Watson). In addition, there is an in-depth discussion in Appendix A
concerning how the clinician arrived at the case formulation for
Colby based on differential diagnosis: evidence in support of a
diagnosis of attention deficit/hyperactivity disorder (ADHD) primarily
inattentive presentation and the rationale for ruling out other
comorbid or competing diagnoses. There is also a written report
wherein the clinical psychologist reports and shares her clinical and
diagnostic impressions of Colby based on the assessment results.
Since there is significant supplemental information for this particular
case in Appendix A, the summary of assessment results in this
chapter will be relatively brief.
Responses to the Wechsler Intelligence Scale for Children (WISCV) confirmed overall intellectual functioning to be within the
Extremely High Range (General Ability Index 142; range 138–149),
with all Index Scores in the Extremely High Range with the
exception of Processing Speed (PSI 103; range 94–112) which was
in the Average Range. Colby’s overall IQ score places him within
the top 1% of the population (99.9th percentile). However, his
scores were not evenly distributed among the different aspects of
the IQ profile. Colby’s score of 130 on the Working M emory Index
(WM I; range 120–135) was an area of relative weakness,
compared to his Index Scores for Verbal Comprehension (VCI 142;
range 131–146), Visual Spatial analysis (VSI 135; range 124–140),
and Fluid Reasoning (FRI 137; range 127–142). As was noted
above, his Perceptual Reasoning Index (PRI) scores was severely
impaired, relative to all his intellectual scores. Slow speed of
psychomotor responses noted on paper-and-pencil tasks was
accompanied by fatigue, awkward writing style, and ease of
distraction. Despite adequate core academic skills (reading,
spelling, math calculations), Colby had significant problems
organizing his ideas when asked to write a short paragraph. Colby
had difficulty getting started on the task, changed his topic many
times, and, after approximately 10 minutes, ultimately produced a
very short but well-written passage of two lines.
Colby’s mother completed the Conners Parent Rating Scale and
the Achenbach Child Behavior Checklist (CBCL). Significant
elevations were noted on scales of Somatic Complaints, AnxiousDepressed M ood, and Attention Problems. Teacher responses on
the Teacher Report Form (TRF) also noted significant Somatic
Complaints, and significant problems with Inattention and low
frustration tolerance (Emotional Lability) were noted on the
teacher’s Conners Scale. Colby’s self-ratings on the Youth SelfReport (YSF), Conners-Wells Adolescent Self-Report Scale
(CASS:L), and Beck Youth Inventories (BYI-2) revealed significant
elevations for Internalizing, Inattentive Behaviors, and Low SelfConcept, and significant elevation of Depressed and Anxious
M oods. Further assessment with the Children’s Depression
Inventory (CDI-2) ruled out significant depression or suicidal
ideation.
ISSUES, TRENDS, AND ALTERNATIVE
TREATMENT METHODS
ADHD is a commonly diagnosed neurodevelopmental disorder with
a lifetime prevalence rate of between 5.9% and 8.7% (M erikangas
et al., 2010; Willicut, 2012), with between 3% and 5% of school-age
children meeting criteria for the disorder (APA, 2013; Barkley, 1998).
Although once thought of as a childhood disorder, it is now
estimated that between one-third and two-thirds of children with
ADHD will continue to exhibit symptoms of the disorder throughout
their lifetime (Wender, Wolf, & Wasserstein, 2001). Prevalence
rates in adulthood are estimated to be around 2.5% (APA, 2013).
Although hyperactivity and impulsivity decline with age, inattention
and distractibility are likely to persist (Larsson, Lichtenstein, &
Larsson, 2006), at a time when the environmental demands
(increased workload and expectations) become more challenging
and complex (multiple teachers), and require more self-discipline
and organization (Barkley, 1998).
Adolescents with ADHD are at increased risk for academic
problems, difficult interpersonal relationships, low self-esteem, and
car accidents and have a higher incidence of psychiatric disorders,
substance use disorders, and antisocial behavior (GrenwaldM ayes, 2002; Thompson, M olina, Pelham, & Gnagy, 2007).
M annuzza and Klein (2000) found that children who demonstrate
deficits in social skills and self-esteem continue to experience
difficulties in these areas throughout adolescence and adulthood.
Although there has been significant research and theoretical
emphasis devoted to the primarily hyperactive/impulsive
presentation of ADHD (Barkley, 1997), less is known about the
predominantly inattentive presentation of ADHD, which has only
been recognized as a separate type of disorder since the DSM-III
(APA, 1980). However, focus on the inattentive type led Lahey et
al. (1988) and Lahey and Willicut (2010) to suggest the likelihood of
a variation on the inattentive type called sluggish cognitive tempo
(SCT) based on the presence of a three-symptom cluster:
(sluggishness, drowsiness, and daydreaming). Although there is
some research support for the inclusion of SCT as a variant of the
inattentive presentation (Garner, M arceaux, M rug, Patterson, &
Hodgens, 2010 found over half their subjects with ADHDInattentive (ADHD-IN) met criteria for SCT), there is continued
controversy regarding the merits of adding an additional category
and unresolved questions regarding the nature of the differences or
similarities between SCT and ADHD-IN. In order to resolve some
of these issues and concerns, Barkley (2013) conducted a study of
1,800 children (6–17 years of age) to examine the presence of
symptoms of SCT and ADHD-IN with respect to executive
functions, level of impairment, and comorbidity. Parents completed
rating scales for symptoms of ADHD (18 symptoms from DSM -IV);
SCT (14 symptoms of SCT); a 70-item scale regarding deficits in
executive functioning; and a functional impairments scale. Results
revealed that symptoms of SCT were a separate cluster from
symptoms of ADHD, although they shared more features of
ADHD-IN than ADHD-impulsive type (ADHD-HI). Over half of
those who met criteria for SCT (59%) also met criteria for ADHD,
primarily the ADHD-IN type. When SCT overlapped with ADHD,
there was a higher rate of comorbidity for most disorders than was
evident for either disorder, in isolation. Overall, results suggested
that SCT is not primarily a disorder of executive function like ADHD
but carries its own risks for psychosocial impairment (sports, social,
leisure, community domains) compared to ADHD. Barkley
concludes that therapeutic interventions for SCT would likely be
unique in some ways to current treatments for ADHD.
Currently, ADHD is recognized as a neurodevelopmental disorder
with three possible variations: predominantly inattentive (ADHDIN), hyperactive-impulsive (ADHD-HI), or ADHD-Combined
presentations. The DSM -5 (APA, 2013) has included increased
descriptions of how symptoms may manifest in adulthood (e.g.,
work is inaccurate; has poor time management; fails to meet
deadlines; problems reviewing lengthy papers; misplaces/loses
important items, such as keys, mobile telephones, etc.). The number
of symptoms required for a diagnosis in late adolescence (17 years
or older) and adulthood has been reduced to five symptoms (six
are required for children) from a list of nine possible symptoms in
each of the inattentive or hyperactive/impulsive symptom
categories (APA, 2013, pp. 59–60).
Medication As a Treatment
From a neurobiological perspective, ADHD has been associated
with low levels of the catecholamines (dopamine, norepinephrine,
epinephrine) which are neurotransmitters that impact attention and
motor activity. Dopamine is especially important since pathways
usually rich in dopamine, such as the prefrontal cortex, are
underactive in the brains of individuals with ADHD (Barkley, 1998).
The most widely researched treatment for ADHD is the use of
stimulant medication. The most commonly prescribed medications
for ADHD are methylphenidate (Ritalin), dextroamphetamine
(Dexedrine), and pemoline (Cylert), which act to increase the
number of catecholamines in the brain (Berridge & Devilbiss, 2011;
Berridge et al., 2006). Each of these medications has been
demonstrated to be effective in reducing the symptoms of ADHD in
numerous clinically controlled trials (Greenhill, 1998; Spencer et al.,
1995). M ore recently, a nonstimulant medication, atomoxetine
(Strattera), a selective norepinephrine reuptake inhibitor, has met
with FDA approval for ADHD (Garnock-Jones & Keating, 2009) and
is recommended to treat ADHD with comorbid anxiety, since
stimulant medication can often exacerbate anxious responses in
individuals.
ADHD is often associated with impaired academic performance and
problems in social functioning, and individuals with ADHD are also
at increased risk for comorbid externalizing and internalizing
disorders (Jensen et al., 2001).
Although some parents are concerned that giving their child
medication for ADHD can result in a gateway phenomenon, leading
to abuse of other types of substances later on, most research
supports the opposite conclusion. Adults with ADHD who were not
treated are more likely to abuse substances later in life compared
to those whose ADHD was managed medically in their youth
(Biederman, Wilens, M ick, Spencer, & Faraone, 1999). Wilens
(2001) found youth with ADHD who took medication had lower
rates of substance use (marijuana, cocaine, alcohol) compared with
controls. However, M olina and Pelham (2003) conducted an 8-year
follow-up of children and youth with ADHD and found higher levels
of substance use across all substances (alcohol, tobacco, illicit
drugs) compared to peers without ADHD. Surprisingly, the greatest
substance use was related to the severity of attention problems,
not impulsivity-hyperactivity, as had been noted previously
(Barkley, DuPaul, & M cM urray, 1990). However, in their longitudinal
study of drug use outcomes for youth, August et al. (2006) found
that youth with ADHD who also demonstrated externalizing
problems had significantly worse drug outcomes (frequency of use
and substance disorders) than those with ADHD-only or
community controls, suggesting that ADHD without externalizing
problems is not an increased risk for drug problems.
There is no optimal treatment method for ADHD, but up to 80% of
children with ADHD take some form of medication (Frame, 2003).
Although medication has been proven effective in reducing
symptoms of inattention, impulsivity, and hyperactivity, effects have
not consistently been demonstrated to carry over to other areas
such as social relationships or academic achievement (Pelham,
Wheeler, & Chronis, 1998). There has been significant controversy
regarding the overuse of stimulant medication for children with
ADHD (Diller, 1996). Although research has supported the use of
methylphenidate (Ritalin) as a performance enhancer for children
and adults with ADHD, it has been estimated that the use of
stimulant medication has increased as much as 300% since 1990
(Hancock, 1996; Robison, Sclar, Skaer, & Galin, 1999). Although a
recent study conducted in Tennessee found that prevalence rates
for primarily inattentive (4.7%), primarily hyperactive (3.4%), and
combined subtypes (4.4%) of ADHD to be below 5% (Wolraich,
Hannah, Pinnock, Baumgaerrel, & Brown, 1996). According to
Leutwyler (1996), as many as 10%–12% of all boys in the United
States are currently taking Ritalin for ADHD.
Other studies demonstrate combining medical management with
behavioral treatment and can enhance outcomes (Frame, 2003;
Kendall & Shelton, 2003; Rey & Sawyer, 2004). However, other
researchers have suggested that there is no definitive proof that a
combined approach is more effective than medical management
alone (Jensen et al., 2001; Wimett & Laustsen, 2003). Results do
suggest, however, that medical management with stimulant
medication is successful for short-term treatment of ADHD
symptoms (Jensen et al., 2001), while studies of the success of
longer-term medical management using stimulant medication have
found an overall reduction in symptom presentation (Charach,
Ickowicz, & Schachar, 2004), reduced risk for comorbid disorders
(Biederman, M onuteaux, Spencer, Wilens, & Faraone, 2009),
improved occupational outcomes (Halmoy, Fasmer, Gillberg, &
Haavik, 2009), and improved academic performance (Powers,
M arks, M iller, Newcorn, & Halperin, 2008).
In part, the tendencies to overprescribe medication may result from
the fact that the core symptoms of inattention, restlessness, and
impulsivity found in ADHD also occur in other disorders, such as
anxiety, learning disorders, childhood depression, bipolar disorder,
and posttraumatic stress disorder. There is also evidence that only
one-third to one-half of children diagnosed with ADHD by their
pediatrician have had any type of psychological or educational
assessment to support the diagnosis (Leutwyler, 1996). M ore
recently, Reich, Huang, and Todd (2006) studied treatment patterns
for a large sample (1,555) of twins diagnosed with ADHD and found
that 60% of boys and 45% of girls who met full diagnosis for ADHD
were on stimulant medication, while 35% of the sample was
receiving stimulant medication but did not meet DSM criteria for
ADHD.
Multimodal and Alternative Treatment
Methods
Some children may be unable to tolerate the side effects of
medications for ADHD, or some parents may opt for alternative
methods to treat the disorder. For these reasons, and the wide
range of possible negative outcomes for children and youth with
ADHD, the management of ADHD will often require a multimodal
approach, combining psychosocial approaches in lieu of or conjoint
with medical interventions. Other forms of treatment that have been
used to treat children and youth with ADHD include behavior
modification and contingency management in the classroom,
cognitive behavior modification (CBM ), parent training, and a
variety of coaching techniques (Goldstein, 2005; Hallowell, 1995;
Pelham et al., 1998).
There are many examples in the research literature of attempts to
justify the use of CBM for children with ADHD, in programs
designed to increase verbal self-instruction, problem-solving
strategies, cognitive modeling, and self-monitoring. The underlying
premise in these approaches is that training in problem-solving will
assist children with ADHD to manage behavioral self-control better
(Hinshaw & Erhardt, 1991). However, while initial results of CBM
were encouraging, more recent evidence suggests that CBM in
isolation does not enhance outcomes for children with ADHD
(Pelham et al., 1998).
In collaboration with the National Institute of M ental Health (NIM H),
the M TA (multimodal treatment study of ADHD) investigated
treatment alternatives for ADHD in six independent research
centers. The investigators compared medical management alone
(M EDM GT), behavioral modification (BEH), combined treatment
(COM B), and a community comparison (CC). The BEH and CC
groups did not receive medication. At the completion of the study,
only the M EDM GT and COM B groups demonstrated symptom
reductions (Swanson et al., 2001). However, follow-up at 14
months revealed that the effect size was reduced by 50%, while
follow-up at 24 months revealed further deterioration. Within-group
analysis revealed the greatest deterioration was for those who
took medication as part of the study but discontinued after the
study was completed, while the greatest long-term reduction in
symptoms was for those children who were not medicated during
the study, but who began taking medication once the study was
completed (M TA Cooperative Group, 2004). One important side
effect for the group who took medication the longest (throughout
the study and remained on medication throughout the follow-up
periods) was after the first 2 years; they demonstrated a 20%
reduction in stimulant-related height gain (approximately 2 cm)
compared to peers who never took the medication. Although a
rebound was expected in the third year, it never occurred, although
no further reduction was evident; researchers continue to monitor
the effects over 10-year and 12-year periods for height and weight
concerns and other long-term functional and symptomatic
outcomes (Swanson et al., 2008).
Psychiatrist Ned Hallowell (1995) introduced the concept of
“coaching” as a therapeutic measure for assisting adults with ADHD
to manage life’s challenges and expressed his frustration at being
unable to provide such support on a daily basis. In practice, the
technique, which seems to make clinical sense, has gained
momentum; however, there has been very little effort to empirically
measure the effectiveness of this intervention (Goldstein, 2005).
Although Jaksa and Ratey (1999) attempt to define coaching as a
set of goal-driven and practical strategies that are developed by a
coach and client to facilitate meeting the challenges of everyday
life, they do not address how the strategies are developed, which
strategies are most successful, and how success should be
objectively measured and monitored. M ore recently, the Edge
Foundation funded a national study, involving eight universities and
two community colleges. The goal of the study was to document
the effectiveness of coaching for college students with ADHD, and
the study examined the effects of coaching on 127 students
randomly assigned to treatment or control conditions. In this study,
executive functioning and related skills were measured using the
Learning and Study Strategies Inventory (LASSI; Weinstein &
Palmer, 2002). Results revealed a significant difference in total gain
on the LASSI for those enrolled in the coaching group relative to
controls on all three cluster scores, including self-regulation, skill,
and will. Follow-up focus groups revealed increased positive
feelings of well-being, empowerment, and reduced feelings of
stress in those who participated in the coaching groups (Field,
Parker, Sawilowsky, & Rolands, 2010). Similarily, Kubik (2010) found
that ADHD coaching for adults with ADHD showed a positive effect
on pre- to postcoaching scores for cognitive, behavioral, and
emotional outcomes.
When Colby mentioned that he could think more clearly after riding
his bike or walking in the park or on the golf course, he had
intuitively discovered a method of increasing his focus and
attention in a way that has only recently been investigated
empirically. Taylor and Kuo (2009) studied the attention and
concentration abilities of 17 children diagnosed with ADHD (7–12
years of age) after taking a 20-minute walk in three different
environments: downtown, in a neighborhood, or in the park.
Children in the study concentrated significantly better after the walk
in the park, relative to walks in the other two environments. The
researchers suggest that “doses of nature” might be a “new tool in
the tool kit for managing ADHD symptoms” (p. 402).
Post-Case Questions
1. According to Russell Barkley (1997), sustained attention
comes in two different forms: contingency-shaped attention and
goal-directed persistence.Factors that can be instrumental in
increasing or decreasing contingent attention include task
novelty, intrinsic interest, reinforcing properties inherent in the
task, fatigue state of the participant, and presence or absence
of adult supervision. According to Barkley, this form of
sustained attention is often not problematic for ADHD children.
However, goal-directed persistence requires sustained
persistence of attention and effort in the absence of highly
reinforcing task properties, which is extremely problematic for
children with ADHD.
Based on Barkley’s descriptions of the two forms of
sustained attention, prepare a response for Colby’s
mother that would address her questions regarding why
Colby can stay focused for long periods of time playing
video games but is extremely distracted while attempting
his homework assignments.
Given your understanding of sustained attention, how
might Colby’s “gifted” intelligence serve to further
exacerbate his problems?
2. Based on the information presented in the case study, would
Colby’s symptoms match criteria in the DSM for ADHD? If so,
which type of ADHD does Colby exhibit?
3. Develop a case formulation for Colby from two different
perspectives (e.g., cognitive behavioral, family systems,
biological, etc.). How would these different models influence
the nature and development of an intervention program for
Colby?
4. Colby was identified as “gifted” when he was in the fourth
grade. Do you believe that Colby’s gifted label was ultimately a
positive factor or a negative factor in his development?
Explain.
5. Recently, there has been increasing research in the area of
resilience. For example, Wilmshurst, Peele, and Wilmshurst
(2011) found that college students with ADHD might be a
particularly resilient group. Individual characteristics that have
emerged as protective factors which can buffer a child from the
impact of having a depressed mother are having an easy
temperament (as opposed to difficult temperament) and having
a higher IQ. Some common elements in resilience research
include positive, supportive caregivers; positive self-views;
motivation to succeed; and cognitive and self-regulatory skills.
Given these findings and the discussion of resilience in the
Introduction to Chapter 1, discuss the strengths and limitations
that Colby faces that will challenge his ability to be resilient.
How might his chances for increasing resilience be increased?
6. Suggested individual or group presentation activity:
As part of your intervention plan, you have asked that Tina
and Josh attend a session together in the clinic to
address how to best manage Colby’s attention problems
and his issues with emotion regulation. You want Colby to
be part of the session, as well. How would you prepare
Colby for the session, and what questions would you
want answered by Tina and Josh? Who else might you
want to invite to the meeting at the clinic? Prepare a script
for role-playing each of the player’s parts in the session
and how they could potentially contribute information to
assist with developing an intervention plan that would best
meet Colby’s needs.
Tina has asked that you attend a meeting at the school to
provide feedback regarding your assessment and to
assist in the development of a 504 plan for Colby. Who do
you think should be involved in the meeting? Prepare a
script for role-playing each of the player’s parts in the
school meeting and how they could potentially contribute
information to assist with developing a 504 plan that would
best meet Colby’s needs.
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324.
CASE 5 THOMAS MCLEARN :
READ ME A STORY DYSLEXIA
Thomas was referred to the clinic by his parents to evaluate his
learning potential and academic profile and to investigate any
possible areas of social/emotional concern. His parents were
puzzled. Thomas, a bright, chatty, and active child, was falling
behind in the second grade. What made this situation even more
difficult to comprehend was that Thomas had already repeated the
first grade to allow for consolidation of foundation skills. Parents
were convinced that if they held Thomas back a year, his increased
maturity would guarantee his academic success. Although he
seemed to enter second grade much better prepared than he
would have a year ago, his first progress report indicated that he
was well below his peers in the language arts areas.
Thomas presented as a typical 8-year-old Caucasian boy from a
middle-class family. He was immediately drawn to the picture of the
solar system on the psychologist’s office wall and engaged in a
lively conversation about the planets and the fact that M ars has at
least three moons that we know of. Thomas chatted at length
about his love of the television science program Bill Nye the
Science Guy and how he loved the show on gravity, called
“Attraction Action.”
Thomas has an older sister, Elaine, who is currently at the top of
her class, in the fifth grade.
Although Elaine is very protective of Thomas, he is finding it
increasingly difficult to accept her successes, given his academic
failures. His parents are now feeling uncomfortable praising her
accomplishments in front of Thomas and are becoming increasingly
concerned because their once confident son who can be a leader
on the athletic field was becoming increasingly turned off by school
and frustrated by homework assignments that he could not
complete on his own.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
Nancy M cLearn was very prompt in completing and returning the
intake surveys and called the clinic to inquire whether there was
any additional information that she might provide. The birth history
was relatively uneventful, except for the fact that the delivery was
very long and labor was intense. Eventually, they had to use
forceps to complete the delivery. Thomas achieved all
developmental milestones as expected and walked just a few days
after his first birthday. Once he began talking, he was very chatty
and loved to talk to his sister who treated him as if he were a real
live doll. Because they lived in a rural area, there were few other
children around and Thomas and Elaine became very close
“buddies” early on. Nancy did not send Thomas to preschool, since
she was a stay-at-home mom and loved the time together, as she
was homeschooling Elaine, at the time. Eventually, the family
moved closer to town, across from the community park, and at that
point, Thomas and Elaine seemed to find their own set of friends.
The family took advantage of the community athletic complex which
had a very strong program for children in the summer and during the
school year. Thomas loved sports and was a natural at T-Ball.
Soon he was playing soccer, softball, and joining his friends
skateboarding at the park. He was a natural athlete and the young
boys on his team looked up to him as their leader.
In the fall, Thomas and Elaine were enrolled at Garden City
Elementary School which was a short walk from their home.
Thomas entered the first grade, while his sister began the third
grade. Nancy also found a part-time job working for a real estate
company, while her husband Arnold continued to gain promotion
after promotion in the sales department of a major corporation, 20
minutes from their new home. Everything seemed to be going
according to plan, until Thomas got his first midterm report. Despite
his natural curiosity and love of science, his teacher was
concerned because he was not progressing as she expected in
the language arts program. Despite his love of science books, he
was having problems learning the weekly word lists. His teacher
also described him as having problems remaining focused on the
task at hand and taking forever to get to work. Thomas clearly
preferred socializing to working on academic tasks. Strengths were
noted in his gross motor skills (well coordinated), his ability to
produce very detailed drawings for projects, and his facility with
numbers. Nancy and Arnold met with Thomas’ teacher to find out
how they could support her efforts and enhance Thomas’ success
in the language arts program. The teacher recommended that
Nancy continue to read to Thomas every night (Thomas loved this,
especially science books) and help him review his word lists, daily.
Despite these efforts, Thomas was clearly not ready to progress to
the second grade at the end of the school year, and the
consensus was to repeat the first grade to allow for consolidation
of key academic skills.
Although his parents were reluctant to have Thomas repeat the
grade, they rationalized that since he had an early birthdate
anyway, this additional year would allow for Thomas to catch up
and the increased maturity would benefit his skill acquisition and his
ability to remain focused in class. M idway through the second year
in the Grade 1 program, it looked as if the decision was a good
one. Thomas was feeling more confident academically, although
they did catch him telling his teammates that he was in the second
grade, because he was embarrassed to let them know he had to
repeat the first grade. The following year, it seemed that Thomas
has started out on a better level; however, the midterm report was
very discouraging. Thomas was not progressing at the same rate
as his peers, and despite his ability to tell beautiful stories, orally,
he was becoming increasingly embarrassed during oral reading and
was not very successful on his spelling tests. In order to avoid his
embarrassment, Thomas would have his mother read the
passages to him at home every night and then memorize them so
he could “appear” to be reading them during oral reading the next
day. This worked for a while, until the teacher introduced a new set
of reading materials to the class, and when it was Thomas turn to
read, it was as if the words were in a foreign language; he could
not recognize any of the words he have previously “read.”
His teacher expressed a number of additional concerns about
Thomas’ classroom performance, including ease of distractibility,
poor ability to concentrate, daydreaming, losing or misplacing items
necessary for tasks, making careless mistakes, being very
disorganized, and forgetfulness. The teacher recommended smaller
group instruction led by some of the older children (the reading
buddies program) and suggested parents talk to the school
psychologist about potential attention problems. Nancy and Arnold
agreed to have the school psychologist observe Thomas in the
classroom and then meet with them to discuss her impressions.
The school psychologist observed Thomas for one morning, during
a class lesson, followed by a 15-minute period of independent seat
work. During this period of time, Thomas was noted to be engaged
in on-task behaviors for approximately 15% of the time and in offtask behaviors for the vast majority of the observation period. The
school psychologist asked the parents to complete the Conners
Rating Scales and also obtained permission to have his teacher
complete the scales, as well. Thomas’ parents and teacher both
rated Thomas in the clinical range for inattentive problems (failing to
finish tasks, problems in sustaining attention), the ADHD Index, the
DSM Inattentive, and Total Scales. Based on the findings, the
family agreed to seek further counsel regarding potential treatment
for ADHD from the family pediatrician. Thomas was diagnosed with
ADHD, primarily inattentive type, and was placed on a trial of
Ritalin.
Although Thomas seemed to improve his on-task performance
initially and seemed to be better able to focus on Ritalin, the quality
of his work continued to reflect his continued struggle with reading
and written expression. Despite considerable efforts at home,
Thomas was not able to bring these skills to new tasks with new
reading or writing assignments.
REASON FOR REFERRAL
Nancy and Arnold were becoming increasingly concerned about
Thomas’ psychological well-being. He could often be heard calling
himself “stupid” when he was trying to complete his homework and
was becoming more temperamental, breaking into tears or throwing
his books on the floor in fits of frustration. He would be entering the
third grade in the fall and was still struggling to learn even the most
basic reading vocabulary. His strong analytical skills were often
evident in class discussions, especially on science topics, yet
written work would be far inferior to what he could express verbally.
Often his poor spelling would result in Thomas using only words
that he had memorized by sight, resulting in a very basic response
to most writing assignments. Nancy and Arnold decided to bring
Thomas to the clinic for a complete assessment over the summer
so that they could be better prepared to help Thomas tackle the
Grade 3 program.
During the intake interview, the M cLearns answered many
questions about their family history, Thomas’ developmental
milestones, and his school history. There were a number of
relatives on both sides of the family who did not go far in school,
not because they were not intelligent (most were highly successful
entrepreneurs) but because formal schooling was not a good fit for
them. Nancy excelled academically, and if her financial resources
were better, she would have loved to go on to University and
study architecture. Arnold was a different story. He admitted that he
did not like school because he found it “boring.” He would much
rather “experience” life than read about it. In fact, he really disliked
reading, and throughout English classes, he would always seek out
the “movie version” rather than have to labor through the written
word. He stated that his high energy profile is an excellent fit with
sales, and he could never be a “book worm.” He also wondered if
maybe Thomas was just more like him than Nancy.
ASSESSMENT RESULTS
Guidelines to the interpretation of standard scores and T scores,
as well as information regarding specific assessment instruments
used in the case can be found in Appendix C.
When Thomas entered the assessment room, he seemed innately
curious about what was going to take place and asked some very
good questions about the nature of the assessment process. He
also asked if he had to do “school type work.” When the response
was, “a bit,” he immediately confessed that he was not good at
reading or spelling and said that if the work was too hard he would
not be able to read it. He asked if we were going to do any “fun
stuff.” The interviewer continued to try and establish rapport, since
it was clear that Thomas was getting apprehensive about having to
read or spell. When ask what he liked to do best, he responded
that he loved to build things, do science experiments, and draw
robots. Thomas was given a sheet of paper and asked to draw one
of his favorite robots. There was no delay in responding, and
Thomas immediately set pencil to paper producing a very
sophisticated picture of a robot with transformer-like capabilities. He
went on to add detailed drawings of different features that could be
activated to transform into different functions. He was very
animated and engaged as he described the features in the robot he
had created.
Thomas’ overall IQ score on the WISC-V of 110 places him in the
high average range overall. Usually students who score within this
level do not encounter problems academically; however, his
intellectual scores did not produce an even profile. Thomas scored
at the 16 percentile (Standard Score of 85) for the Verbal
Comprehension Index (VCI); however, this was significantly below
his scores on the Fluid Reasoning Index (FRI) of 120 (91st
percentile). Working memory was higher than might be anticipated
given his attention problems (Standard Score of 105), but still well
below his FRI score. Processing speed was within the average
range (50th percentile). Given these scores, the immediate
impression is that Thomas has a significant strength in areas of
visual perceptual reasoning and a relative weakness in the area of
verbal comprehension.
Academically, Thomas managed to struggle through the academic
tests and was much more confident in his approach to the
mathematical portions of the test than when asked to read, spell, or
write. On the Weschler Individual Achievement Tests (WIAT-III),
Thomas scored in the high average range for mathematics
(Standard Score 115) and in the borderline range for reading
(Standard Score of 72) and written expression (Standard Score 70).
Clearly, Thomas’ ability in the language arts areas was significantly
below his intellectual level, especially his superior skills in fluid
reasoning.
Further assessment was conducted using the Woodcock Johnson
Cognitive Assessment and revealed additional support for a
diagnosis of a specific learning disorder (SLD). There was
significant variation between skill levels for perceptually based
versus auditory-based functioning. Significant strengths ranged
from standard scores of 120 (visual spatial thinking), short-term
memory of 115, and processing speed of 115, compared to
significant weaknesses in standard scores ranging from 80 for longterm memory, 75 for cognitive fluency and auditory processing, and
70 for phoneme awareness. Results suggest that Thomas is
experiencing problems primarily with auditory processing which
likely translates into difficulties making fine discriminations between
letter sounds. Students with this type of difficulty may mishear
sounds like (b, p, t, v). There are also difficulties with fluency which
would make oral reading more difficult and require additional time to
respond to questions. Reading would likely be slow, labored, and,
due to problems with longer term memory, be difficult to retrieve out
of long-term storage because information is poorly organized and
labeled. When asked a question, there would be anticipated delays
due to retrieval problems. These processing problems are severe
and when standard scores in these weak areas (70–80) are
compared to his IQ (110), there is a discrepancy of over one and a
half standard deviations (30–40 points) between these two areas
of functioning.
Thomas’ parents and teacher completed the Achenbach System of
Empirically Based Assessment (ASEBA) Scales with parents
noting clinical elevations on scales for anxious/depressed
behaviors and attention problems, while his teacher noted
elevations on the attention problems scale. On the Beck Youth
Inventories, Thomas’ score for self-concept was at the 40th
percentile.
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
An SLD or specific learning disability is evident when an individual
encounters significant problems in the acquisition of specific
academic skills during the school-age period and is noted in skills
that are significantly below age expectations (APA, 2013). There
has been considerable controversy regarding how SLD is defined
and identified, and differences exist in recommendations proposed
by the DSM -5, IDEA (2004), and organizations such as the
Learning Disabilities Association of America (LDA) and the National
Joint Committee on Learning Disabilities (NJCLD). Please see
Appendix B for a detailed discussion on issues in the definition and
classification of SLD.
The DSM -5 recognizes learning disorders in three broad areas,
including impairments in reading, written expression, and
mathematics (dyscalculia). In order to meet criteria for an SLD, the
impairments must indicate skill levels that are significantly below
age expectations (as measured by standardized assessments),
manifest when demands for the skill exceed limitations, and are not
better accounted for by intellectual disabilities, organic causes
(hearing, vision), other neurodevelopmental disorders, or adversity
(lack of teaching/learning opportunity) (APA, 2013, p. 67). The most
recent criteria do not emphasize the discrepancy between IQ and
achievement that was part of the previous description of the
disorder, stating simply that the disorder appears in those who
otherwise demonstrate normal levels of intellectual functioning,
which the DSM defines as “generally estimated by an IQ score of
greater than about 70,” and that the SLD is “unexpected academic
achievement,” which is not part of a more global learning problem
such is evident in intellectual disability or global developmental
delay (APA, 2013, p. 69).
Several different types of SLD have been identified in the research,
including dyslexia (reading disability with spelling problems),
dysgraphia (disability in written expression), dyscalculia (disability in
mathematics), nonverbal learning disability (disability in visuospatial
areas), and dyspraxia (developmental coordination disorder, DCD).
M ost researchers consider dyslexia to be the most common type
of SLD, accounting for up to 80% of all cases, with prevalence
rates ranging between 5% and 17% depending on the nature of the
population sampled (Ferrer et al., 2010). However, others contend
that as many as 92% of those with SLD cite written expression as
the major problem (M ayes & Calhoun, 2007). Younger children with
reading disabilities may go undiagnosed, especially if good memory
skills allow the “appearance” of reading. However, by the third
grade, children who are poor readers are often painfully aware of
their reading problems and may try to avoid reading in public to
escape embarrassment. Individuals with a reading disability
evidence problems in accuracy of decoding, especially in the
primary grades; however, with increasing age, fluency problems
(reading that is slow and labored) pose increased barriers to
academic success, especially during “high stakes standardized
tests” such as the SAT and GM AT (Ferrer et al., 2010; Shawitz &
Shaywitz, 2008). The DSM-5 (APA, 2013) specifically provides
criteria for using the terms dyslexia and dyscalculia to refer to
patterns of learning difficulties characterized by the following
problems: dyslexia—accurate and fluent word recognition, poor
decoding, and poor spelling; and dyscalculia—processing numerical
information, learning arithmetic facts, and performing accurate or
fluent calculations. The DSM -5 also notes the importance of noting
any additional problems that may be evident in areas of reading
comprehension (for dyslexia) and math reasoning (for dyscalculia).
Heritability is associated with etiology for at least half of all cases
(Olson & Byrne, 2005), with between 23% and 65% of individuals
with dyslexia having a parent with the disorder and 40% having a
sibling with the disorder (Pennington & Gilgern, 1996). The
association between ADHD and dyslexia runs high between 38%
and 45% of those with ADHD or SLD being diagnosed with both
disorders.
Weaknesses in working memory, executive function, and receptive
and expressive language have all been associated with dyslexia
(Johnson, Humphrey, M ellard, Woods, & Swanson, 2010).
Neurological studies using functional magnetic resonance imaging
(fM RI) have charted the path of reading in poor readers compared
to normal readers and have found that while those with dyslexia
access both the left and right anterior systems, good readers focus
primarily on the left hemispheres for phoneme recognition (anterior
system), sound symbol association (posterior system), and
storage of sight vocabulary (posterior system). Developmentally,
normal reading progresses from the right to left hemisphere and
from the posterior to frontal regions (Shawitz & Shaywitz, 2008).
Far less information is known about disorders of written expression
(dysgraphia) even though dysgraphia often accompanies dyslexia
(Hooper, Swartz, Wakely, de Kruif, & M ontgomery, 2002).
Dysgraphia can manifest in a number of different ways, including
errors of grammar, punctuation, organizational presentation, and
initiating written assignments.
Intervention: Although Response to Intervention (RTI) is an
approach that is frequently used to identify early reading problems
and provide supportive remedial interventions, results of at least
one metacognitive study suggest that for those with SLD who
have IQ scores in the higher ranges, this method may not be ideal.
Tran and colleagues (2011) found that children with significant
reading problems who had IQ scores in the higher ranges were
less responsive and that reading problems were resistant to this
form of intervention. On a more positive note, Shawitz and
Shaywitz (2008) found that individual tutoring and direct instruction
(50 minutes daily) on phonemes and sound symbol association
resulted in the development of reading patterns detected by fM RI
that resembled those of normal readers.
Programs that target problems in written expression have met with
success through the use of direct instruction in techniques of
planning and the use of prompts and guided feedback (Vaughn,
Gersten, & Chard, 2000). For students with severe writing
problems, dictating passages orally may be the only way that they
can be successful in maximizing their potential (Graham, Harris, &
Larsen, 2001).
Post-Case Questions
1. Using information from the case study and the supplemental
information in Appendix B, state how Thomas’ SLD might be
identified and described by proponents of the different
classification systems: DSM -5, IDEA (2004), Joint National
Joint Committee on Learning Disabilities (NJCLD).
2. Develop a case formulation for Thomas from two theoretical
perspectives. How would these formulations affect different
treatment outcomes?
3. At one point, Thomas’ parents had a significant disagreement
about whether or not Thomas should continue to be involved
in extracurricular activities such as being a member of the
soccer team, given his poor academic performance. If you
were the school psychologist, how would you advise his
parents regarding this issue? What are the benefits and what
are the disadvantages for Thomas of being involved in
extracurricular activities?
4. There has been a major controversy regarding whether
identification of SLD should involve the discrepancy criteria
(see Appendix B). Having read the different arguments, what
identification procedure would you support and why? Please
use citations to support your arguments.
5. There are several theories on student “retention and
promotion.” Visit the NASP website and read the article that is
posted regarding “Grade Retention and Promotion: Information
for Parents.” After reading the article, what advice would you
have given Thomas’ parents if they consulted with you
regarding having Thomas repeat the first grade.
6. Thomas’ mother has invited you to attend a meeting at the
school to provide feedback regarding your assessment. In the
meeting, it will be decided whether or not Thomas meets
criteria for Special Education and Related Services. If it is
determined that he is eligible for services, what Goals and
Objectives would you want to see as part of his IEP?
7. Would you recommend he receive “related services” and if so,
what should the nature of those services be?
8. Prepare a script for role-playing each of the player’s parts in
the school meeting. Who do you think should be attending the
meeting? How could each participant potentially contribute
information to assist with developing an intervention plan that
would best meet Thomas’ needs?
REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders (5th ed.). Arlington, VA: Author.
Ferrer, E., Bennett, A., Shaywitz, J. M ., Holahan, J. M ., M archione,
K., & Shaywitz, S. E. (2010). Uncoupling of reading and IQ over
time: Empirical evidence for a definition of dyslexia.
Psychological Science, 21(93), 93–101.
Graham, S., Harris, K. R., & Larsen, L. (2001). Prevention and
intervention of writing difficulties for students with learning
disabilities. Learning Disabilities Research and Practice, 16, 74–
84.
Hooper, S. R., Swartz, C. W., Wakely, M . B., de Kruif, R. E., &
M ontgomery, J. W. (2002). Executive functions in elementary
school children with and without problems in written expression.
Journal of Learning Disabilities, 35(1), 57–68.
IDEA. (2004). Individuals with Disabilities Education Act (IDEA).
Retrieved from https://sites.ed.gov/idea/
Johnson, E. E., Humphrey, M ., M ellard, D. F., Woods, K., &
Swanson, H. L. (2010). Cognitive processing deficits and
students with specific learning disabilities: A selective metaanalysis of the literature. Learning Disability Quarterly, 33, 3–18.
M ayes, S. D., & Calhoun, S. L. (2007). Challenging the
assumptions about the frequency and coexistence of learning
disability types. School Psychology International, 28(4), 437–448.
Olson, R., & Byrne, B. (2005). Genetic and environmental
influences on reading and language ability and disability. In H.
Catts & A. Kamhi (Eds.), The connections between language
and reading disability (pp. 173–200). Hillsdale, NJ: Erlbaum.
Pennington, G., & Gilgern, J. (1996). How is dyslexia transmitted?
Baltimore, M D: York.
Shawitz, S. E., & Shaywitz, B. A. (2008). Paying attention to
reading: The neurobiology of reading and dyslexia. Development
and Psychopathology, 20, 1329–1349.
Tran, L., Sanchez, T., Arellano, B., & Swanson, H. L. (2011). A
meta-Analysis of the RTI literature for children at risk for reading
disabilities. Journal of Learning Disabilities, 44(3), 283–295.
Vaughn, S., Gersten, R., & Chard, D. J. (2000). The underlying
message in LD intervention research: Findings from research
syntheses. Exceptional Children, 6, 99–114.
CASE 6 SANDY SMITH :
MARCHING TO THE BEAT OF A
DIFFERENT DRUM NONVERBAL
LEARNING DISABILITY
When Eileen opened the clinic door, it was as if she were facing
her worst fears head on. Sandy’s pleas and verbal exchanges
could be heard by the office staff all the way from the elevator at
the other end of the building. Although Sandy was physically petite
for her 8 years, her stiff posture almost anchored her mother’s arm
to the ground. Eileen was embarrassed by Sandy’s behavior, but
Sandy’s reaction only served to confirm her resolve to finally seek
professional help. As Eileen approached the receptionist’s desk,
Sandy bumped into the desk and slid onto the couch awkwardly
beside her mother, with her legs entwined around each other like a
pretzel. In the waiting room, Eileen tried to collect her thoughts
about her daughter’s development in anticipation of the many
interview questions that might be asked.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
Eileen had hoped for a daughter her entire pregnancy, even though
Tom’s family lineage had produced predominantly males. Against
the odds, Eileen’s hopes were answered and miraculously Sandy
was born 8 years ago. The pregnancy and delivery were
uneventful. Sandy was a beautiful baby, and Tom was proud to be
the father of a baby girl. Sandy was also adored by her two older
brothers, Jason, 6 years, and Sean, 4 years. Everything seemed to
be going well. There were some minor stresses initially when
Eileen had to give up attempts to nurse Sandy. Eileen had no
problem nursing her other two infants, but due to Sandy’s erratic
sleep habits and irritability, her doctor recommended switching to
the bottle. This switch proved difficult; Sandy’s poor coordination
meant that propping the bottle would not work, since she often lost
the bottle if her mother was not holding it. Sandy was a very active
baby and she seemed to require little sleep. Eileen reasoned that
perhaps the fact that the baby needed less sleep was a sign of
curiosity and intelligence. Eileen placed a brightly colored mobile
over the bed and added the crib activity center that her infant sons
had enjoyed so much. However, Sandy had no interest in the
mobile or in exploring the activity center. Sandy actually became
very agitated with the crib additions, and Eileen responded by
removing everything from the crib, which seemed to calm Sandy
down. Through trial and error, Eileen eventually found that the
sound of a wind-up merry-go-round on the dresser could be helpful
in soothing Sandy. To this day, Sandy listens to music to help calm
her down when she is anxious.
Despite her difficulties adjusting to any changes in her environment
or schedule, Sandy did demonstrate one extremely advanced area
of development. She was a very early talker and had amassed an
amazing vocabulary by the time she was 2. At 2½ years of age,
Sandy was sounding more like a miniature adult than a child and
would repeat her grandmother’s phrases “verbatim.” Sandy would
surprise onlookers in the grocery store with her pseudo-adult
comments on the quality of the fruits and vegetables. By 3 years of
age, Sandy could repeat stories from taped texts, word for word,
and Sandy often recited these stories riding in the car, during
dinner, or when playing by herself.
Sandy’s strong verbal skills were in sharp contrast to her slowerdeveloping motor skills. Sandy was a highly verbal but very
awkward toddler. Initially, Eileen worried about her muscle
coordination, since Sandy was slow to sit and would fall over if not
securely propped with a pillow. When Sandy began to walk, she
looked as though she was drunk, swaying to the left and with an
off-balance gait. Sandy’s legs were black and blue from falling down
and bumping into things. At first, Eileen thought that Sandy was so
preoccupied with talking that she was not looking where she was
going. She eventually had Sandy’s vision checked, but results
came back negative. Sandy’s poor coordination also seemed to
influence her choices of play activities. Unlike the boys, Sandy had
little interest in Legos, blocks, or puzzles. Sandy was definitely
much more interested in chatting than doing. Eileen tried to enroll
Sandy in a preschool gymnastics program to improve her
coordination. However, this strategy backfired, since Sandy was
extremely frustrated and unable to reproduce many of the tumbling
movements; she could not touch her toes to her head and
repeatedly fell off the balance beam. The other children were soon
making fun of Sandy, imitating her awkward movements, and Eileen
removed her from the program. Eileen was becoming concerned
about Sandy’s fears of going anywhere new and her increasingly
clingy behavior. Sandy was soon going to be kindergarten age, and
Eileen worried about the transition. She enrolled Sandy in a
morning preschool program 2 days a week. Each day was torture,
getting Sandy into the car and over to the day care center. Sandy
did not want to go and would scream, hide, and run away (often
running into something) in a frenzied panic. Eileen was determined
to persist, however, knowing that it would only be worse if she
were to give in.
Sandy’s preschool experience was not very successful. As long as
she could sit and read by herself or play on the flannel board,
spelling words with preformed letters, Sandy was quite content.
However, other children did not seem to want to play with Sandy,
and during free playtime, Sandy was often left alone. On the few
occasions that Sandy tried to enter a group activity, her awkward
sense of timing and poor social skills usually resulted in a negative
experience, and Sandy would withdraw once again. She did not
seem to profit from experiences, either. The following day, Sandy
would approach the same child in the same way, setting herself up
for another rejection and subsequent retreat. When Sandy was
enrolled in the kindergarten program, her social struggles continued
on a regular basis.
Social skills were very immature and Sandy did not seem to take
nonverbal communication (facial expressions, conversational tone)
into consideration at any time. Her sense of social/personal space
was also poor, and Sandy would often stand too close and
encroach on other children’s sense of comfort zone. Eventually,
Sandy preferred to shadow the teacher instead of interacting with
the other children. She gained her rewards when she could read
aloud to the class and write words on the board in big letters.
However, a lot of kindergarten activities were very difficult for
Sandy: cutting and pasting, tracing, drawing, painting, and the big
shoe with the lace to be tied and untied. Sandy often cried at
home, asking if she could please stay home from school.
Sandy continued to experience problems with coordination. At 8
years of age, Sandy had yet to learn how to ride a two-wheeler.
She never made the transition from training wheels, and even with
the training wheels on, Sandy continued to lose her balance and fall
over. Had it not been for the bicycle helmet, Eileen was sure that
Sandy might have also had a head injury to deal with. Luckily, to
Eileen’s knowledge, Sandy never injured her head in any of the
falls, although she did sustain many bruises on her arms and legs.
Recently, Sandy’s teacher had contacted Eileen concerning
Sandy’s reluctance to participate in the gym class and the many
excuses that she gave to avoid engaging in the ongoing activities.
Sandy had begged her mother to write a note to the teacher to get
her out of gym class, but Eileen refused. Sandy’s lack of
coordination and clumsiness also seemed to permeate her total
appearance. Despite her mother’s extensive efforts at home to
coordinate and organize Sandy’s outfits for the next day, Sandy
always looked somewhat disheveled and thrown together: buttons
would not match the right button holes; shoelaces were dangling
from her feet. Eileen eventually refurbished Sandy’s wardrobe,
removing button-up shirts and replacing lace-up shoes with Velcro-
strap shoes. Sandy’s lack of organization and messiness was
pervasive. If Sandy wanted to remove an object from her dresser
drawer, half the drawer often spilled over onto the floor. It was the
same with her desk at school, which was jammed with papers
crumpled and rolled into little balls.
Although Sandy’s messiness and disorganization were annoying,
they were not the reasons that brought Eileen to the clinic. Eileen
was frustrated and confused. Sandy was a real puzzle to her and
Eileen was now very motivated to find out what could possibly
explain how her daughter’s abilities could be so extreme:
seemingly so very bright in some areas, yet totally lost in others.
Sandy had an excellent vocabulary and wonderful memory for
words. As a result, she could read beautifully and spell most words
she had seen, without error. However, despite Sandy’s excellent
vocabulary, spelling, and reading skills, she was having increasing
problems with reading comprehension. Sandy could recall a
passage verbatim, but she seemed to have real problems
answering any questions that required an inference going beyond
information presented in the passage. Eileen recalled last night’s
homework assignment involving a reading passage that described
a family eating breakfast together. Sandy had to answer a number
of comprehension questions about the story. Sandy had no idea
how to answer one question, which asked, “What time of day is it?”
Even with Eileen’s help and questions directed at passage clues,
Sandy was unable to answer the question, saying: “I read it over
and over. It doesn’t tell you the time of day!” Eileen wondered if
Sandy’s problems telling time could somehow be related to her
difficulties with comprehension. Sandy was still unable to tell time
on an analog clock. Even if she could tell you the time on a digital
clock, she seemed oblivious to how time related to activities.
Eileen recalled an incident where Sandy wanted to have some ice
cream for breakfast. When Eileen told Sandy, “You don’t have ice
cream for breakfast,” Sandy’s response was, “Fine. Then I’ll have
dinner, now!” Initially, she thought Sandy was joking, but she was
completely serious. There were other situations as well, where
Sandy’s odd thinking caught Eileen completely off guard. Sandy
seemed to take things very literally, all the time. Sandy could be
very gullible, and Eileen had to monitor her brothers carefully so
they would stop playing tricks on Sandy. Eileen remembered one
time that Sean told Sandy if she ate her ice cream cone from the
bottom of the cone, she would get more ice cream. Eileen came in
to find Sandy trying to eat the ice cream cone upside down with it
melting all over the place. Eileen recalled another incident when
they were watching a TV movie about an odd character and Tom
mentioned that, “He certainly marches to the beat of a different
drum.” Sandy looked up and said, “Where’s the parade?” Tom tried
to explain the expression, but Sandy just did not get it and
continued to ask about the drummer in the parade. She was very
upset that she missed the parade. She eventually went to bed that
evening upset, talking about the parade and how drummers march.
At school, Sandy’s literal interpretations often were not appreciated
by her teacher, who thought that Sandy was just being smart.
M athematics was another area of real difficulty for Sandy. It was as
if mathematics involved a foreign language. Homework was an
endless struggle involving hours and hours of explanations and
discussions. Sandy did not seem to be able to perform the same
task twice in a row without having it all explained over and over
again. The next day, it was as if she had never heard the
explanation. Academic problems were compounded by Sandy’s
poor handwriting. Numbers as well as letters were often scrawled
across the page without attention to writing between the lines,
spacing, or direction. Often, her writing was impossible to decipher.
As a result of her problems with math, comprehension, and writing,
Sandy was falling farther and farther behind. At a recent school
conference, Eileen was informed that the school was
recommending that Sandy repeat the third grade.
Socially, Sandy seemed to have few friends at school. At the
parent–teacher conference, Eileen asked Sandy’s teacher what
was keeping Sandy from forming more friendships with the other
children. According to Sandy’s teacher, it was Sandy’s poor sense
of timing that often turned the other kids off. Sandy often made
comments at inappropriate times or out of context, and the other
girls seemed to respond by ignoring and excluding her. Sandy also
talked nonstop and did not give the other girls a chance to get a
word in. Eileen was very disappointed last week by the poor
showing of classmates at Sandy’s birthday party. After Sandy
struggled for hours making invitations to her birthday party (cutting,
coloring, and pasting were never Sandy’s strengths), only one child
showed up. Ann, a 5-year-old who lives next door, was the only
one who attended the party. Although initially upset, Sandy soon
became absorbed in playing a new audiotape she received as a gift
and totally ignored Ann for the rest of the party. When Ann finally
left, Sandy seemed to have no idea as to where she went or why
she might have left.
REASON FOR REFERRAL
Eileen had talked to Sandy’s pediatrician, hoping to gain insight into
Sandy’s “odd” ways of thinking and marginal school progress.
Eileen had always thought that Sandy would outgrow her awkward
ways, but she was now beginning to fear that her daughter’s
difficulties were more permanent. Her concerns were also
escalating because of the lack of social contacts in her daughter’s
life and how this might impact negatively on her social development
later on. Finally, Eileen decided that “knowing” was better than “not
knowing,” and she brought Sandy to the clinic with the hope that
she could find some answers to her questions.
ASSESSMENT RESULTS
Information regarding specific assessment instruments and
guidance in the interpretation of standard scores and T scores can
be found in Appendix C.
The psychologist administered the Wechsler Intelligence Scale for
Children (WISC-V) and noted the following test behaviors. Sandy
was very verbal throughout the assessment, and comments often
resulted in digressions away from the target task. Sandy often had
to be redirected to the task at hand. When verbal responses were
required, such as on the Vocabulary and the Similarities subtests,
Sandy tended to overelaborate, giving verbose responses far in
excess of what was required. When nonverbal tasks were
presented, Sandy used self-talk to work her way through the task.
Sandy frequently requested feedback regarding her performance
and seemed to become somewhat agitated when informed by the
examiner that he was unable to tell her how she was doing. Sandy
seemed to be somewhat comforted, however, when the examiner
expressed comments of encouragement and praised her effort in
general.
Visual tasks were very difficult for Sandy. She was able to
reproduce the initial block designs by placing the blocks on top of
the designs in the model booklet, itself. However, as the designs
increased in complexity and external cues were reduced, Sandy
became visibly upset. She wanted to know where the lines went in
the sixth design: “There are supposed to be lines to tell you where
the blocks go!” She also reproduced two of the designs correctly,
but in a rotated manner, not recognizing the need to match the
orientation as well as the colors of the blocks. Although able to
complete the initial items on the Picture Concepts task, when a
third row of pictures was added, which increased the complexity
and demands for abstract reasoning, Sandy began to respond in a
random manner. Sandy was extremely frustrated by the M atrix
Reasoning task, which requires the child to select the correct
solution to complete a pattern from five possible alternatives.
Responses to the WISC-V revealed a significant discrepancy
between her Verbal Comprehension Index (VCI = 112; range 103–
119), which was in the high average range, and her scores on the
more visually oriented tasks, such as those clustered in the Fluid
Reasoning Index (FRI = 83; range 80–98), and Visual-Spatial Index
(VSI = 82; range 79–95) which were in the low average range.
Less than 1% of the population would have had a discrepancy of
this extent between these components. Scores for the Working
M emory Index (WM I = 94; range 87–102) and the Processing
Speed Index (PSI = 88; range 80–98) were in the upper low
average to average range. On the VCI, Sandy revealed a
significant strength in Vocabulary (SS = 14), while scores on the
Perceptual Reasoning Index (PRI) were very weak overall: Block
Design (SS = 7), Picture Concepts (SS = 7), and M atrix Reasoning
(SS = 6). Sandy’s full scale IQ was 89 (range 83–101), which
placed her functioning in the upper limits of the low average range.
Academically, Sandy’s scores for language arts subjects on the
Wechsler Individual Achievement Test (WIAT-III) revealed average
to low average scores for Reading Comprehension and Fluency
(SS = 102; 55th percentile) and Written Expression (SS = 86; 18th
percentile). Scores for Numerical Operations (SS = 75; 5th
percentile) and M ath Problem Solving (SS = 73; 4th percentile)
were significantly below what would be anticipated given her
overall intellectual ability and represent a discrepancy of more than
one standard deviation (e.g., greater than 15 points) between her
full scale IQ of 89 and her overall score for M athematics (SS = 74;
4th percentile). M ath was at an early Grade 2 level with difficulties
noted in computation, word problems, and math reasoning. Sandy
demonstrated some letter and number reversals on the spelling
test. Handwriting was very poor.
Sandy’s response to the Bender Gestalt test revealed a visual
motor perception score to be equivalent to a child of 5 years 5
months, two standard deviations below her expected age level.
Sandy’s drawings were extremely immature, despite taking
excessive time to complete the task (in excess of 15 minutes).
Although Sandy counted and recounted dots, and often traced
designs with her finger before execution, the resulting
reproductions were poor due to problems with rotations, design
integration, substitution of circles for dots, and tendencies to run
designs into each other. When asked to “draw a person,” Sandy
seemed to take forever to produce the finished product, and after
many erasures, the resulting image was very immature. Somewhat
embarrassed by the lack of results, and partially as an evasive
tactic, Sandy eventually produced a stick figure. She compensated
for her poor motor skills, however, by creating an elaborate story
about what the stick figure was doing and how he came from the
“land of stick people.” Parent responses to the Achenbach, Child
Behavior Checklist (CBCL) revealed significant elevations on
scales for Withdrawn/Depressed Symptoms, Social Problems,
Thought Problems, and Attention Problems, while Conners Scale
responses noted elevations for Cognitive Problems/Inattention,
Anxious/Shy, and DSM Inattentive scale. Teacher responses to
the Achenbach, Teacher Report Form (TRF) revealed significant
concerns in areas of Social Problems, Thought Problems, and
Attention, while responses to the Conners Scale revealed
significant elevations on scales measuring Oppositional Behaviors,
Cognitive Problems/Inattention, and Social Problems.
Sandy’s responses to the Revised Child M anifest Anxiety Scales
(RCM AS-2) revealed significant elevations in areas of
Worry/Oversensitivity and Attention/Social Concerns. There were
no significant elevations on the Child Depression Index (CDI-2).
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
Children who experience specific learning disorders (SLDs) differ
from children with general learning problems or intellectual
disabilities (IDs) in that those with ID will demonstrate generalized
problems across a wide variety of adaptive areas commensurate
with impaired intellectual functioning (e.g., cognitive ability, functional
academics, life skills, communication, etc.), while those with SLD
will experience difficulties in a specific domain (such as reading,
written expression, or mathematics) despite having average
intelligence. It has been estimated that between 5% and 15% of
school-aged children will be diagnosed with SLD (DSM -5, APA,
2013). The most prevalent type of SLD (80%) is dyslexia, a
reading disability that often includes poor spelling with deficits in
areas of oral reading, reading fluency, and faulty reading
comprehension. Disorders of written expression are often detected
in errors of punctuation, grammar, organization, spelling, and poor
handwriting. M athematics disorders are relatively rare and seen in
approximately 1% of the population. M any children who experience
SLD in reading and/or written expression will be significantly
stronger on tasks of visual/PRI than those that measure verbal
reasoning index (VCI).
The criteria for identifying children with SLD differ depending on the
classification system used. While the DSM -5 (APA, 2013) refers to
learning disorders (reading disorder, mathematics disorder,
disorders of written expression) and provides criteria for diagnosis,
the educational system (IDEA, 2004) refers to SLD and provides
guidelines for determining whether children meet criteria for special
education services based on the extent and nature of their learning
disability. An in-depth discussion of the criteria used by the different
systems of classification and additional insight into current issues in
the identification process can be found in Appendix B. Children who
suffer from reading and spelling disorders (dyslexia) experience
problems decoding words due to basic phonological processing
deficits; however, they are usually able to perform adequately in
math. However, children with nonverbal learning disability (NLD)
experience just the opposite pattern: they are able to fluently
decode words but encounter significant problems with mathematics
(Rourke & Conway, 1997; Rourke, Hayman-Abello, & Collins,
2003). Although not all children with NLD will experience math
problems (Pennington, 1991; Semrud-Clikeman & Hynd, 1990),
based on extensive research, Rourke (2000) found that 72% of
children with NLD also experience deficits in math reasoning, and in
some cases, math skills may be limited to achievement levels
equivalent to the fifth grade (Rourke, 1995). Rourke and Tsatsanis
(2000) compare individuals with dyslexia to individuals with NLD,
stating that while children with dyslexia demonstrate deficits in
“psycholinguistic skills,” due to a “basic phonological processing
disorder (BPPD),” they demonstrate strengths in areas of “visualspatial organizational, tactile-perceptual, psychomotor, and
nonverbal problem-solving areas.” However, children who have
NLD have the opposite profile: “deficits in visual-spatial
organizational, tactile-perceptual, psychomotor, and nonverbal
problem-solving and concept formation skills” and strengths in
areas of “psycholinguistic skills such as rote verbal learning, regular
phoneme-grapheme matching, amount of verbal output, and verbal
classification” (p. 241).
The syndrome of NLD, which has also been referred to as
nonverbal learning disorder, or developmental right hemisphere
syndrome (DRHS), has been described in a number of sources
over the past 10–15 years (Gross-Tsur, Shalev, M anor, & Amir,
1995; Harnadek & Rourke, 1994; Palombo, 2006; Rourke, 1989;
Rourke & Tsatsanis, 2000; Strang & Casey, 1994). Individuals with
this syndrome experience problems in information processing and
motor impairments in three broad areas: motor skills (coordination),
analysis and synthesis of visual information (visuospatial
integration), and social/pragmatic awareness and development.
The core symptom presentation includes social problems due to
interpersonal skill deficits, motor slowness, weak visual-perceptual
organization, difficulties with nonverbal problem-solving, and
especially weak arithmetic ability. Soft neurological signs can also
be evident on the left side of the body (Gross-Tsur et al., 1995;
Rourke & Tsatsanis, 2000). Often symptoms of ADHD are
comorbid with the disorder.
The role of visual-spatial deficits in NLD has been investigated in
its influence on weaker mathematical performance as well as its
contribution to potential difficulties in the area of social information
processing. Results of an investigation by Garcia-Sanchez,
Estevez-Gonzalez, Suarez-Romero, and Junque (1997) suggest
that visuospatial deficits associated with right hemisphere
dysfunction are more pronounced in those youth who had
attention-deficit disorder without hyperactivity, compared to youth
with ADHD hyperactive-impulsive type. However, SemrudClikeman, Walkowiak, Wilkinson, and M inne (2010) compared
groups of children with ADHD, Asperger’s syndrome (AS), and
NLD with respect to understanding emotional and nonverbal cues
using direct and indirect measures. Results indicated that the NLD
and AS groups demonstrated significantly more difficulty
understanding and interpreting emotional and nonverbal cues,
compared to children with ADHD or those with no disorder. Their
sample of children with AS or NLD also were rated as
demonstrating higher rates of symptoms related to sadness and
social withdrawal compared to the other groups. Although attention
skills were related to social perception, problems with attention did
not predict difficulties in social perception compared with symptoms
of AS. M ore recent studies have increased our understanding of
the role of visuospatial processing problems in children with NLD to
the extent that Cornoldi, Venneri, M arconato, M olin, and M ontinari
(2003) suggest calling the disorder a visuospatial learning disability.
Recently, M ammarella, Lucangeli, and Cornoldi (2010) examined
the role of visuospatial working memory (VSWM) in weak
mathematical performance of individuals with NLD. They compared
performance on tasks of VSWM and mathematical skills in children
with NLD and peers without NLD. Results revealed that children
with NLD scored significantly weaker on both tasks of arithmetic
and VSWM , suggesting that VSWM deficits in individuals with NLD
may be instrumental in influencing math performance. These results
support earlier findings by Venneri, Cornoldi, and Garuti (2003) that
difficulties with math calculations may be due to deficits in VSWM .
Researchers have also probed the role of weak visual-spatial
ability in the social arena for individuals with NLD. In one study,
Liddell and Rasmussen (2005) found that despite average ability to
recall verbal information, children with NLD demonstrated significant
deficits in the recall of visual information. Of special note was the
very poor performance of these children on a task of immediate
recall for faces, even though their scores improved on the delayed
facial recall task. The researchers suggest that right hemisphere
processing deficits (right temporal lobe) may contribute to the
problem, while the need for additional time to consolidate
information may explain the better performance on the delayed
task. Rourke et al. (2002) have also addressed deficits in the right
cerebral hemisphere of individuals with NLD, suggesting potential
damage to white matter (myelinated fibers) evident in mild
abnormalities to the right hemisphere in brain scans of those with
NLD (Rourke, 1995). Recently, Galway and M etsala (2011)
examined if visual-spatial problems were implicated in difficulties
that children with NLD have in perception and interpretation of
nonverbal social information. Following from previous research on
social information processing (Crick & Dodge, 1996; Dodge, 2006;
Dodge, Bates, & Pettit, 1990) and hostile attribution bias, as was
anticipated, Galway and M etsala (2011) found that relative to peers
without NLD, children with NLD encoded fewer social cues and
were weaker at interpreting emotions based on those cues.
However, probing into social information processing through
perspective taking tasks, the researchers also found that when
asked to comment on the child’s (story character) intention in
behaving in the manner related in the scenario, children with NLD
were significantly more likely to attribute a story character’s actions
as being mean, compared to the norm. Galway and M etsala (2011)
state that this finding is supported by previous work by Crick and
Dodge (1994) and highlights the importance of integrating
information regarding the child’s past experiences into the
interpretation of responses to social situations, since children with
NLD may be interpreting situations based on faulty judgments from
past experiences. As a result, the researchers recommend
interventions for children with NLD based on direct instruction in
social skills learning experiences to assist children in developing
more neutral or benign interpretations of the social responses of
others, in order to increase recognition of more favorable
responses that could be initiated by them in return.
In a recent investigation of the clinical characteristics associated
with NLD or DRHS, Gross-Tsur et al. (1995) found the following
characteristics that were shared by children in their sample: 65%
demonstrated left-sided soft neurological signs; the mean Verbal IQ
was approximately 20 scale score points higher than the mean
Performance IQ of 85; the lowest Verbal scale score was
Arithmetic, followed by Comprehension; the lowest Performance
scale score was for Coding; 94% had at least one SLD, and 67%
had dyscalculia (math disability). In this particular sample, 90%
demonstrated graphomotor impairment evidenced by weak
performance on Coding and the Bender Visual M otor Gestalt Test,
and 80% were referred for slow cognitive and motor performance.
Descriptions of slow cognitive and motor output were noted in an
inability to complete schoolwork, sluggish response to activity, and
slowness to initiate and complete routine tasks. All children
demonstrated poor social skills, often evident in inadequate or
inappropriate facial expressions, eye contact, weak pragmatic
language, and poor comprehension of social rules. Children with
NLD display considerable difficulties in nonverbal problem-solving.
According to Harnadek and Rourke (1994), deficits in concept
formation and hypothesis testing result in poor ability to profit from
environmental reinforcers that normally shape our behavior. These
children do not readily establish a cause-and-effect relationship,
which brings structure and contextual meaning to our experiences.
They fare poorly in complex or novel situations and can appear
scripted and inappropriate in their responses.
Rourke et al. (2002) compared the syndrome of NLD to other
pediatric neurological disorders and ranked the disorders from high
to low on the basis of symptom overlap. They found the closest
sharing of similar features was for AS (impairment in motor skills,
social pragmatics, pragmatic communication, and visuospatial
deficits). Individuals with Williams syndrome shared similar features
of deficits in visuospatial processing and the pragmatics of
communication, although obvious differences were also evident in
overall cognitive ability and hypersociability for individuals with
Williams syndrome.
Interventions and Treatment
Empirically supported interventions for NLD continue to remain a
high-need area for research. Despite the lack of empirically
supported programs for NLD, a number of recommendations have
been suggested as clinically effective in remediating
neuropsychological deficits (visual-perceptual organization,
psychomotor, and concept formation skills) responsible for
problems in areas of social skills, mathematical abilities, and
responses to novel problem-solving situations (Rourke, 1993).
Treatment suggestions involve direct instruction and guided
practice. The following list summarizes some of the suggested
directions for treatment (Foss, 1991; Galway & M etsala, 2011;
Rourke, 1995):
Teach the child in a predictable, step-by-step, rote manner.
Ensure that language concepts are clarified.
Enhance verbal reasoning.
Encourage the application of problem-solving strategies and
their transfer to new situations.
Teach a problem-solving format, or template, that the child can
use to structure the situation (e.g., STOP: Stop and see what
is happening; Think about what I am going to do now; Observe
how others are responding to me; Practice and improve).
Enhance social cognition through the use of direct instruction
to teach appropriate verbal social responses and how to read
verbal cues.
Provide many opportunities for practicing these new skills and
applying them to new situations until the responses become
more fluid and automatic.
Teach the child to link visual information (facial expression,
body posture) with auditory information—not only what is said,
but how (tone, inflection) it is said.
Teach visual-organizational skills.
Teach comprehension directly.
Enhance self-esteem and feelings of self-efficacy.
As is evident in these guidelines, direct instruction is crucial to
assisting children with NLD to make connections that they may
miss due to subtleties in the language, interpreting information
literally, or not attending to nonverbal communication (facial
expressions and body language). Since children and youth with
NLD often take things literally, one of the major difficulties with
problem-solving is generalizing from one situation to another or
interpreting statements in a more generic manner (M arti, 2004). As
a result, directions need to be as specific as possible, for example,
the statement “I want you to clean up your room” could lead to an
array of probable uncertainties (Does cleaning mean washing my
room? How do I do that? What part of the room do I clean? How
long do I have to do that for? When do I know I am done? and so
on) that could be circumvented through proper elaboration.
Despite increasing awareness of NLD, Thompson (1997) suggests
that many school districts have not recognized NLD because the
syndrome does not conform to the more traditional concept of a
language-based learning disability. In these cases, students may
not receive appropriate CAM S (compensations, accommodations,
modifications, and strategies). Furthermore, if students with NLD fall
into the minority of those with the disability that do not have
significant problems in math, they will likely not qualify for special
education assistance, despite encountering many problems in the
regular classroom (Semrud-Clikeman & Glass, 2008). The dangers
and risks of not detecting or providing early intervention can be
found in retrospective studies of adults with NLD. These
retrospective studies (Ellison & Semrud-Clikeman, 2007; Rourke,
Young, & Leenaars, 1989; Rourke, Young, Strang, & Russell, 1986)
suggest that undetected children with NLD demonstrate a greater
degree of developing internalizing disorders, such as depression;
are at greater risk for suicidal behaviors; and report a greater
incidence of loneliness and social isolation as adults. Palombo
(2006) suggests a wide variety of therapeutic approaches that
might be applied to strengthen functioning in two important areas:
enhanced self-efficacy and increased awareness of the nature of
their problems and how to navigate stressful and challenging
situations, academically and socially.
In a case study investigation, Brodeur (2006) demonstrated that
direct instruction techniques were highly beneficial for a 15-year-old
female with NLD who participated in a class to increase awareness
of social pragmatics. After attending the classes, the student
demonstrated significant gains on all measures of adaptive, social,
and leadership skills (self-ratings, teacher ratings, and parent
ratings). Recommendations for future research included a focus on
forming and maintaining friendships for older students and
instruction focusing on maintaining eye contact and turn taking for
younger children with NLD.
Post-Case Questions
1. Children who demonstrate a NLD may pose a particular
problem for diagnosis and intervention since their symptoms
do not conform to the traditional concept of a language-based
learning disability.
Discuss some of the difficulties of diagnosis of NLD with
respect to how learning disabilities are defined by (a) the
DSM -5 (APA, 2013), (b) Education (IDEA, 2004), and (c)
National Joint Committee on Learning Disabilities (NJCLD;
see Appendix B).
2. Discuss the similarities and differences between an NLD and a
variant of higher functioning autism spectrum disorder (Dylan’s
case) or Williams syndrome (Williams’ case).
3. Discuss case formulations from the following theoretical
frameworks: biomedical, psychodynamic, behavioral, cognitive,
family systems, and attachment/parenting style. How would
these different theoretical frameworks influence the
development of intervention strategies?
4. Social skills are often an area of weakness for children with
NLD. Using a social information processing model, develop a
case formulation for Sandy’s social skills deficits and explain
how you would target specific areas for treatment.
5. Compare and contrast differences between strengths and
weaknesses in the two cases of SLDs that have been
discussed so far, e.g., Thomas (who has dyslexia) and Sandy
(who has a NLD). In your discussion, be sure to include
information on the different parts of the brain that are
influenced by each of these disorders, especially left versus
right hemisphere dysfunction.
6. Suggested individual or group presentation activity: You have
been invited to provide feedback to the school regarding
Sandy’s assessment, at a meeting where they will decide
whether Sandy meets criteria for Special Education and
Related Services. If it is determined that she is eligible for
services, what Goals and Objectives would you want to see
as part of her IEP? Would you recommend she receives
related services, and if so, what would the nature of those
services be?
7. Prepare a script for role-playing each of the player’s parts in
the school meeting mentioned above. Who do you think
should be attending the meeting? How could each participant
potentially contribute information to assist with developing an
intervention plan that would best meet Sandy’s needs?
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PART B AUTISM SPECTRUM
DISORDERS (ASD) AND
INTELLECTUAL DISABILITIES
Case 7: Dylan Bach: The World According to Dylan
Case 8: Arthur Watson: Won’t or Can’t: A Case of M istaken
Identity
Case 9: Brian Williams: M y Name Is Williams, Too
Case 10: Bradley Hunter: Not Yet Diagnosed
CASE 7 DYLAN BACH : THE
WORLD ACCORDING TO DYLAN
MILD VARIANT OF ASD
Dylan’s behavior was discussed at a school intervention meeting
shortly after Dylan enrolled in the kindergarten program at Cyprus
Springs Elementary School. His teacher was concerned because
Dylan displayed very “odd” behaviors and despite being very
verbal seemed to be in “his own world.” Dylan’s speech was
indistinct, and although he seemed to chatter a lot, it was very
difficult to comprehend what he was saying. Often he would talk to
himself, in a singsong refrain, reciting entire monologues. Dylan
was a spontaneous reader, and he would take great pleasure in
reading everything from book titles to footnotes. He could also
spell his name. However, Dylan preferred solitary activities and it
was very difficult to engage Dylan in the normal classroom routines
and group activities. Dylan could be very resistant. Not only did the
teachers have problems engaging Dylan in regular classroom
activities, it was equally difficult trying to disengage Dylan from an
activity that he was involved in. When asked to participate in
activities not to his liking, Dylan had thrown a number of temper
tantrums. On these occasions, he would scream a very loud and
persistent “No!!!!”
Dylan was awkward and poorly coordinated and often seemed to
walk into things. Dylan seemed to be in constant motion and was
very fidgety. During quiet times, like story or circle time, Dylan’s
constant motion (rocking, squirming, fidgeting) was often disturbing
to the other children. This, coupled with Dylan’s poor coordination,
would often result in his falling into other children or tripping over
things in the classroom.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
The school social worker met with Dylan’s mother, Celeste Bach,
to discuss the school’s concerns and to obtain a social history.
Celeste and her husband Arnold were both 23 years old when
Dylan was born. They had been married for 2 years. The Bachs
owned an art studio and made their living through the sale of their
own creative art pieces. Celeste was an oil painter and Arnold was
a sculptor. They supplemented their income from the sale of their
artwork by giving art lessons and selling art supplies. Celeste
described a difficult and unpleasant pregnancy. She was nauseated
through most of the pregnancy and also developed toxemia
midway through the pregnancy. Dylan was born 2 weeks ahead of
schedule after a very long labor (40 hours) and weighed almost 9
pounds (8 lbs. 10 oz.). The delivery was uneventful.
Celeste described Dylan as cheerful, affectionate, and sociable
during his first year. He had a good appetite but was difficult to put
on a schedule. He experienced many colicky bouts, and sleep was
often disrupted. When he woke, it was difficult to get him back to
sleep. M ilestones were achieved within the norm, and Dylan was
walking and saying his first words by 1 year of age. M rs. Bach
admitted to difficulties with toilet training, and at almost 5 years of
age, Dylan continued to exhibit occasional bed-wetting incidents.
Accidental soiling stopped about a year ago. Health was described
as good, with the exception of vulnerability to ear infections and
food allergies (dairy products). Dylan is rarely ill; however, when he
does get ill, he tends to develop a fever and requires monitoring.
Family history notes a paternal uncle with cerebral palsy and
mental retardation. There is a history of bipolar disorder with
obsessive compulsive disorder in the family (maternal
grandmother), as well as anxiety (paternal aunt). Celeste stated
that Dylan’s pediatrician felt that Dylan might be autistic; however,
no further assessment was conducted. She added that Dylan can
be stubborn at home, but that he will comply when necessary.
Dylan gets along well with their adult neighbors, who have all been
very impressed with Dylan’s reading and writing abilities. Celeste
added that they currently live in an area that has no children
Dylan’s age and that he has had very little practice socializing with
peers.
Toward the end of the kindergarten program (Dylan was 5 years 6
months of age), a brief assessment was conducted by the school
psychologist to obtain information regarding Dylan’s cognitive
functioning. The Differential Ability Scales (DAS) were administered
and revealed a Verbal Cluster standard score of 56 and a
Nonverbal Cluster score of 86. The school psychologist noted that
rapport was very difficult to establish and cautioned interpretation of
the assessment results due to Dylan’s immaturity, lack of
compliance, low frustration tolerance, and insistence on doing
things his own way.
The school convened a staffing meeting to determine eligibility for
special education programming and decided on the following course
of action. Due to difficulties establishing whether the results of the
assessment were valid, based on Dylan’s test behavior, Dylan was
given a temporary designation as Developmentally Delayed, which
would lapse on his sixth birthday, the age established by the Local
Educational Authority (LEA) for discontinuation of services under
the category of Developmental Delay. (See Appendix B for an
explanation of the classification of developmental delay under
IDEA, 2004; and the DSM -5 Category of Global Developmental
Delay.) The decision allowed for an additional 6-month period in
which a more valid and in-depth evaluation of Dylan’s ability levels
could be conducted. Dylan would be provided with services from
occupational therapy, speech and language therapy, and the
special programs teacher, while awaiting his reevaluation.
Unfortunately, Dylan’s parents moved over the summer holidays,
and Dylan began attending Lawton Elementary School for the next
academic year. M eetings were convened prior to the start of
school to determine how to best accommodate Dylan’s special
needs within the new school environment. At this time, the
decision was made to have Dylan attend the kindergarten program
for a half-day and receive specialized services in a class for
children with varying exceptionalities (VE Program) for the
remainder of the day. Speech therapy was provided on a daily
basis by the school speech pathologist, and occupational therapy
was programmed for on a once-weekly visit. Dylan had always
experienced problems with adjusting to new routines, and it was
not surprising that the move to a new school was very difficult for
Dylan. The first struggle began when he did not want to get on the
bus and threw himself on the ground kicking and screaming.
However, his parents were persistent and eventually his resistance
mellowed. After about 3 weeks, Dylan began to settle into his new
routines. Recently, he has begun to reexperience difficulties, and
resistance to riding on the school bus has resurfaced. Just prior to
his formal reassessment, Dylan was observed throwing himself to
the ground and refusing to get on the school bus. School officials
were currently investigating potential reasons for the resurgence of
Dylan’s refusals to board the school bus.
REASON FOR REFERRAL
A referral for reevaluation was initiated by Dylan’s new school to
remove his temporary designation as developmentally delayed. A
full assessment was requested to update intellectual estimates of
Dylan’s abilities and to determine how to best meet Dylan’s
academic, social, and emotional needs within the current school
system.
ASSESSMENT
Knowing the difficulties that the previous school psychologist had
encountered in attempting to conduct a comprehensive
assessment, the school psychologist took several precautions to
obtain a valid assessment of Dylan’s functioning on several levels.
Several observations of Dylan’s behaviors were obtained by
classroom observations of Dylan’s behaviors in different classroom
environments, and more formal psychometric tasks were
administered in environments that were within Dylan’s comfort
zone and within his tolerance for removal from normal classroom
routines.
Classroom Observations
The school psychologist began a series of observations of Dylan
in the two classroom settings. Observation of Dylan in the
kindergarten program revealed a number of interesting behaviors.
On one occasion, Dylan was observed while his teacher read a
story to the class. The children were sitting on the floor, gathered
around the teacher’s chair. Although Dylan seemed attentive
initially, he soon began a series of excessive movements
(fidgeting, rocking, sprawling on the floor, hanging upside down)
that were distracting to the other children. He spontaneously got up
and walked to the back of the classroom in search of paper and
crayons. For the next 15 minutes, the teacher would make
comments to redirect Dylan back to the circle and Dylan would
comply momentarily and then get up and return to the back of the
classroom. At one point he was very insistent on leaving the circle,
saying, “I want to do my work!” The teacher responded by saying,
“You will sit and listen to the story!” Dylan responded, “I won’t sit
and listen to the story!” At this point, the teacher reminded him of
good and bad choices and the consequence of losing a star for bad
choices. If he did not do as he was told, he would lose a “star.”
(The star chart was a classroom behavior merit program. Children
earned stars for good behavior and lost stars for poor behavior.
Stars could be traded in for activities and small prizes at the end of
the day.) Dylan immediately complied and remained on the floor.
However, his constant motion eventually resulted in his kicking
another child (by accident), resulting in the child breaking into tears.
Dylan seemed oblivious to his role in the event and clearly did not
understand the teacher’s request to apologize to the other child for
the infraction. Within the kindergarten program, the teacher’s goals
and expectations for Dylan were the same as for all children in her
classroom. Within this environment, Dylan struggled with the lack of
flexibility and did not understand the need to be involved in
activities that held little interest for him.
For Dylan, the VE Program had several advantages: fewer children,
older children (7–9 years of age), and a teacher trained in special
education. In this environment, Dylan seemed to enjoy the freedom
of being allowed to work on a task at his own pace. Dylan worked
very quickly and seemed to thoroughly enjoy coloring in pictures,
drawing animated cartoons, and writing captions beside the
drawings. He was highly productive and was not distracted by the
grouped activities that were going on around him. Since the children
were of varying levels of ability (slow learners, learning disabled),
the children were often grouped for instructional purposes. Due to
Dylan’s uniqueness, his teacher provided instruction on a 1:1 basis
and then provided opportunities for independent learning (computer
access) or individual seatwork. While he worked, Dylan was
observed to be singing to himself, mimicking lyrics from various
audio computer programs (e.g., “Rock and Roll,” “ABC’s”). Dylan
often repeated refrains over and over in a singsong fashion while
he worked. Although reluctant to disengage from a task when
requested to do so, he did comply and brought his work to the
teacher for her remarks. He followed routines relatively well and
enjoyed his times when called on to read to the teacher, which he
did flawlessly. He was rewarded for following routines and
completing seatwork with individual computer time. During individual
computer time, Dylan quickly became totally absorbed in the
computer programs, repeating the monologue as if he were
narrating the program himself.
Comments on classroom observations: The school psychologist
noted that many behaviors demonstrated by Dylan fit descriptions
in the literature on autism spectrum disorders (ASDs), especially
the higher functioning variation of this disorder, including
idiosyncratic areas of interest, odd and peculiar behaviors, intense
interest in specific areas, poor coordination, and lack of social
reciprocity. Having the opportunity to watch Dylan’s behavior in the
two different classroom settings provided considerable insight.
While Dylan constantly resisted attempts to engage him in grouporiented activities in the regular kindergarten program, he welcomed
an opportunity provided by the special education setting to work
within the confines of his own little world, without attempts to draw
him into any group activities.
Individual Assessment Sessions
In addition to observational assessments, Dylan was seen for
three individual assessment sessions. The psychologist decided to
conduct Dylan’s assessment in a small resource room off the VE
classroom. Dylan was familiar with the room because he received
his language and occupational therapy in the same room; also, he
could readily see his teacher through the glass windows. By this
time, Dylan was also familiar with the school psychologist and
willingly accompanied her into the room. Since Dylan seemed to
enjoy artwork, as an introductory task, Dylan was asked to draw a
person. Dylan responded by saying that he would draw a pig, which
he did. The pig had a big sign on its neck: “Babe.” Apparently,
Dylan had been watching the movie Babe (a story about a pig)
over and over and was very interested in pigs at this time. He did
comply with a request to copy Bender Designs and completed the
Bender design drawings in a short period of time. Dylan used a
whole-hand pencil grip for all drawing and printing.
Throughout the assessment sessions, Dylan’s enthusiasm waxed
and waned, and his compliance shifted relative to his interest in the
task at hand. Dylan was very excited about doing the Picture
Concepts subtest of the WISC-V (a supplementary test that was
included due to the suspected level of interest that the task would
have for Dylan). He loved to find out “What goes together?” and
repeated the phrase “What goes together!” over and over again.
He wanted to draw an arrow connecting the pictures that went
together in the stimulus book, and the examiner had to confiscate
writing materials to ensure this did not happen. Dylan’s enthusiasm
for visual materials far outweighed his interest in responding to
verbal questions, and assessment results reflect this disparity.
Despite a predominance of fidgety and tense behaviors, Dylan
became very focused, deliberate, and methodical working with
block designs. He carefully moved each block with precision,
checking and rechecking with the stimulus card to ensure accuracy.
Dylan also made humorous comments, and when the 11th block
design was revealed, he said, “Scary!” and laughed. Then he
added, “You will have to help me on this one.” Throughout the
assessment, when one subtest was completed, Dylan repeatedly
asked if he could play “What goes together” game again.
Eventually, the examiner had to remove the stimulus book from the
room, since Dylan kept trying to find it, to play the find the “What
goes together” pictures game.
Williams (1995) discusses the impact of sensory overload on
children with Asperger’s disorder (a type of pervasive
developmental disorder (PDD) that was recognized by the DSM-IVTR (APA, 2000), prior to the DSM -5 (APA, 2013) which excluded
Asperger’s disorders as a specific diagnosis, and clustering it
among the other ASDs). According to Williams, these children can
be overwhelmed by very little change and sensory overload can
throw these children off balance. During the course of this first
session, Dylan fell off his chair three times. A combination of poor
coordination and becoming overly stimulated served to throw him
off balance, literally and figuratively.
Currently, the DSM -5 includes the symptom of “hyper/hyporeactivity to sensory input” as one of the possible symptoms of
restricted/repetitive response patterns evident in ASD.
When the examiner arrived in the classroom for the second
session, Dylan jumped up from his seat (almost falling into the
desk) and greeted her with an enthusiastic and announced, “You’re
back! You’re back!” He spontaneously took her hand and led her to
the assessment room. The Woodcock Johnson Test of
Achievement was introduced and Dylan completed the Letter Word
Identification subtest with ease. The Passage Comprehension
subtest was next, and it was anticipated that this would be another
area of high interest for Dylan. However, what transpired was not
expected. The Passage Comprehension subtest requires that the
students read a passage and then orally fill in the blank to
complete the sentence in the stimulus book. For example, a
statement that “Children often like to play on swings in the park” is
followed by a statement to test comprehension, such as: “Children
like to play on ____ in the park.” When this task was introduced,
Dylan was insistent on filling in the blanks by writing the answer in
the stimulus book. Although the school psychologist made several
attempts to explain why Dylan could not write in the book, it was
not possible to console him. He became visibly upset and started
to shake, was on the verge of tears, and repeatedly stated, “You
must fill in the blank with the missing word!… You must fill in the
blank with the missing word!” Dylan was extremely distraught. At
this point, the examiner removed the book from the room and
brought in sheets of paper and crayons, allowing Dylan to draw and
color his favorite cartoons. Drawing seemed to be an activity that
served to soothe Dylan in times of stress; this discovery could
play an important role in the development of a treatment plan.
After Dylan calmed down, the examiner accompanied Dylan to the
kindergarten room, where he was supposed to go after lunch.
However, when they arrived, the other students had already left for
physical education (PE) and the examiner began to walk Dylan
over to the playground to join his class. Given Dylan’s poor
coordination and reluctance to engage in group activities, it is not
surprising that PE is his least favorite subject. He became very
upset about going to PE and began clinging to the examiner’s arm,
refusing to let go. The examiner talked to him about all the good
choices he had made that day and added that he might earn a star
for joining his class, because this was a very good choice indeed.
Reluctantly, he separated and joined his class in session. The
psychologist then talked to his teacher to ensure that he did
receive a star for compliance to provide support for his difficult
choice.
In order to complete the academic assessment the following day,
the examiner photocopied the Passage Comprehension and
Applied Problems subtests of the Woodcock Johnson. The plan
was to provide Dylan with worksheets that would allow him to fill in
the blanks on the actual pages rather than respond orally. Although
this technique was not part of the standardized procedure, the
psychologist wanted to avoid unduly upsetting Dylan, who was
“locked into” a “filling in the blanks” mode of operation. The
psychologist considered the deviation in protocol a minimal
concession, and it avoided the risk of another emotional upset for
Dylan. In addition, the task actually became more difficult, since
Dylan now had to spell the words to complete the sentences,
rather than just provide the answers orally. When presented with
the sheets, Dylan proceeded to fill in a large number of blanks
correctly and also spelled the words appropriately. He was
rewarded by being allowed to color in the pictures and then draw
another series of cartoon animals. As he was drawing, Dylan
recited, verbatim, an entire dialogue from a computer program that
he had previously heard: “This CD program is a Random House
Production. As a special bonus feature, be sure to try our newsletter
and programs for kids. . . . Each issue is packed with behind-thescenes action and fun-filled games for kids. Your first issue is
free. . . . To obtain your free issue send the enclosed postcard to
Random House Productions, P.O. Box 1478, Chicago, Illinois, Postal
Code 68374. So don’t miss an issue. Send your postcard in today!”
Dylan’s drawings were quite remarkable and very well done. He
titled his drawing of animated characters as the “Walkabe Rabbit
Collection.” Dylan also drew another picture, this time of the
Windows 2000 logo, complete with copyright. Ultimately, Dylan
completed the academic assessment, although it required
considerable redirection to task. Dylan fell out of his chair again
during this assessment session.
Dylan was able to engage with the examiner socially, albeit within a
restricted range. Although eye contact was established, at times he
would actually open his eyes wide with a penetrating stare, but at
other times visual distance and lack of eye contact was far more
comforting. Dylan displayed a sense of humor and could be very
engaging; however, laughter would often escalate quickly out of
control. Dylan preferred to engage the examiner on his own terms
and could become totally absorbed in paper-and-pencil tasks or
verbal monologues that effectively excluded social contact. Dylan
was able to request help when needed for a cognitive problemsolving task (puzzles, blocks); however, he experienced difficulty
eliciting assistance when emotionally upset, due to a very high
level of anxiety and distress. On these occasions, Dylan seemed
to respond either by clinging or by attempting to escape (tantrums).
ASSESSMENT RESULTS
Information regarding specific assessment instruments and
guidance in the interpretation of standard scores and T scores can
be found in Appendix C.
Dylan’s responses to the Wechsler Intelligence Scale for Children
—Fifth Edition (WISC-V) revealed a Verbal Comprehension Index
(VCI = 92; range 86–99) in the average range. Scores for the
Visual Spatial Index (VSI = 117; range 108–123) and the Fluid
Reasoning Index (FRI = 115; range 106–122) which rely on visual
tasks and visual information processing were in the high average
range. Both scores were considered to be an underestimate of
global cognitive reasoning, yet likely an adequate picture of day-today functioning. Verbal tasks were responded to poorly, and
despite an excellent base vocabulary, Dylan’s responses to verbal
tasks were lower than anticipated, but in the predicted direction for
higher functioning ASD (HFASD). A relative strength was noted in
Vocabulary (12), while weaknesses were noted in Comprehension
(4) and Similarities (5). On tasks measuring VSI, a significant
strength was evident on Block Design (16), while on the VSI and
Picture Concepts (14) was also an area of strength. Dylan’s WISCV profile of superior visual to verbal ability was not in the predicted
direction (Klin, Sparrow, Volkmar, Cicchetti, & Rourke, 1995);
however, Dylan was also more compliant on visual tasks, which
may have served to alter overall scores. Despite this fact, subtest
scatter actually did conform to suggested patterns in the literature
on Asperger’s disorder: Vocabulary much higher than
Comprehension (Klin, Volkmar, Sparrow, Cicchetti, & Rourke, 1995).
Dylan received an error score of 9 for his reproductions of Bender
Designs, which was within the expected range for his age. His
substitution of lines for dots in designs 2, 3, and 5 is often
associated with brain dysfunction.
Standard scores for academic performance on the Woodcock
Johnson Achievement Test revealed a score for Broad Reading
equivalent to a standard score of 150, which is in the highly gifted
range. The Broad Reading score is a composite based on
performance from three reading tasks: Letter Word Identification
(SS = 135), Reading Fluency (SS = 119), and Passage
Comprehension (SS = 128). Scores for written expression revealed
Spelling (SS = 148) and Writing Samples (SS = 140) to also be
within the gifted range. Scores for M ath Calculation (SS = 94) and
Applied Problems (SS = 84) were Dylan’s weakest areas of
performance.
Dylan’s mother completed the Vineland Adaptive Behavior Scale,
the Gilliam Autism Rating Scale (GARS), and the Asperger
Syndrome Diagnostic Scale (ASDS). M rs. Bach’s ratings placed
Dylan within the normal range of behaviors on the GARS (SS = 87),
which would suggest below average indicators for autism. Ratings
on the ASDS indicated an overall Asperger’s Syndrome Quotient of
105, suggesting that Dylan met criteria for a likely diagnosis of
Asperger’s disorder. A significant elevation was noted for the
Social Behavior scale on the ASDS. According to Dylan’s mother,
overall adaptive behavior on the Vineland was within the expected
range for his age level.
Dylan’s teachers also completed the GARS and the ASDS. Since
Dylan was observed to behave very differently in the two
classroom settings, it was not surprising that the kindergarten
teacher and the special programs teacher (VE teacher) rated
Dylan’s behaviors quite differently. On the GARS, the kindergarten
teacher rated Dylan as having an average probability of autism (SS
= 91), with only Communication slightly elevated. The VE teacher
rated Dylan much higher on the Autism scale (SS = 126),
suggesting a “high” probability of autism with significant elevations
on the Communication scale (scale score = 14) and Social
Interaction scale (SS = 19). Teachers reported better agreement on
the ASDS, with his kindergarten teacher suggesting a likely (SS =
97) probability of Asperger’s syndrome and his VE teacher ratings
indicating a very likely (SS = 111) probability of Asperger’s
syndrome. According to the ASDS, the kindergarten teacher noted
significant escalation on the Cognitive scale (SS = 13), while the
VE teacher noted significant elevations on the Social (SS = 13) and
Sensorimotor scales (SS = 13).
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
Prior to the fourth edition of the DSM-IV (APA, 1994), Asperger’s
disorder was not a recognized Axis I disorder. The DSM-IV listed
Asperger’s disorder as one of the five disorders under the
category of Pervasive Developmental Disorders (PDDs), which
were characterized by severe and lifelong impairments in a number
of areas. Currently, the DSM -5 (APA, 2013) has replaced the
category of PDD with a new category of autism spectrum
disorder (ASD) to include disorders which share two common
features: pervasive and consistent deficits in social communication
and interaction (evident in three areas) and restricted, repetitive
patterns of behavior, interests, or activities (in two areas). The
DSM -5 states that children previously diagnosed with Asperger’s
disorder, autistic disorder, or PDD should now be reclassified as
meeting criteria for ASD. Based on the symptom criteria, Dylan
meets criteria for ASD based on social communication and
interaction deficits in the three areas of social-emotional reciprocity,
verbal and nonverbal communication, and social relatedness; and
restrictive, repetitive behavior patterns, evident in insistence on
sameness (inflexibility), restricted/fixated interests, and hyperactive
response to sensory input. In Dylan’s case, the specifier “without
accompanying intellectual impairment” would be identified due to his
elevated scores evident in the intelligence testing.
Some children with ASD can become preoccupied with numbers or
letters and demonstrate an ability to decode almost anything
(hyperlexic) at a very early age. Some higher functioning children
are able to form attachments to family members; however, their
ability to relate to others is often not evident outside the family
circle, and the skills do not transfer to peers. Attempts to carry on a
meaningful reciprocal conversation with children who have HFASD
are often derailed by their tendencies to produce pedantic
monologues on topics of interest to them and their lack of
understanding of the give and take necessary in areas of social
pragmatics (Attwood, 1998).
The ability to form and maintain social relationships and friendships
is often at the core of normal emotional development and can
provide children with feelings of belongingness, emotional security,
and self-worth (Rubin et al., 2004). In normally developing
adolescents, friendships provide the basis for gaining increased
social cognitive awareness through disclosures evident in intimate
relationships, such as sharing information with close friends (Allen,
Porter, M cFarland, M arsh, & M cElhaney, 2005). Although it was
once thought that children with HFASD preferred to be alone, more
recent investigations have found that although adolescents with
the disorder demonstrate less participation in social activities
(Orsmond, Krauss, & Seltzer, 2004), lack of social relationships
may not be related to lack of desire, but to difficulties they
encounter with social understanding due to such deficits as theory
of mind (Kaland et al., 2002). As a result, higher functioning
adolescents with ASD disorder can become very lonely and
isolated at a time when they want to join peer groups (Klin &
Volkmar, 1997; Whitehouse, Durkin, Jaquet, & Ziatas, 2009) and
may be at increased risk for depression and anxiety disorders,
relative to the population at large (Sofronoff, Attwood, & Hinton,
2005). Whitehouse et al. (2009) investigated the relationship
between depression and quality of friendship in youth with HFASD
and found that relative to their peers, youth with HFASD
demonstrated less intrinsic motivation to engage in friendships and
experienced poorer quality of friendships and elevated levels of
loneliness and depression. The researchers suggest that
intervention to improve social competence in adolescents with
HFASD (possibly through the use of story modeling techniques;
Carrington, Papinczak, & Templeton, 2003) might have significant
implications for enhanced mental health.
Higher Functioning ASD
HFASD is an informal subcategory of ASD and applies to
approximately 25% of children with ASD who score above the
mentally retarded range (who have an IQ greater than 70).
Individuals with HFASD may be far more likely to attempt
conversations with others than those with lower functioning ASD
(LFASD); these conversations are usually one-sided in nature.
Ghaziuddin (2008) suggests that in social interactions, individuals
with HFASD may tend to be more aloof and passive or may appear
more active, but odd.
Individuals with HFASD score higher on IQ tests than those with
LFASD, either due to strengths in areas of perceptual reasoning or
better verbal skills (Ehlers et al., 1997). Sahyoun, Soulieres,
Belliveau, M ottron, and M ody (2009) found that while some
individuals with HFASD used visuospatial processing during a
pictorial reasoning task, others with HFASD used linguistic
mediation to solve the same tasks.
HFASD and Nonverbal Learning Disabilities
The distinction between children with HFASD and children with
nonverbal learning disability (NLD) (see Case of Sandy for a
comparison) can be a difficult differential diagnosis since both share
similar features of a social disability due to poor understanding of
the pragmatics of social communication, inability to read social
cues, and poor understanding of nonverbal social indicators. Klin,
Sparrow, Volkmar, Cicchetti, and Rourke (1995) suggest that it is
most likely that these disorders represent different perspectives on
a heterogeneous set of disorders that share some overlapping
features.
Rourke et al. (2002) found that youth with HFASD and youth with
NLD shared strengths in processing left hemisphere functions (e.g.,
verbal ability) and deficits in right hemisphere processing
(weaknesses in social interaction, complex reasoning, and
nonverbal communication). Although they note that little research
has been published regarding interventions for HFASD, Klin et al.
(1995) suggest that interventions developed to address NLDs
might also be helpful for this population.
Communication and Social Pragmatic
Speech
Woodbury-Smith, Klin, and Volkmar (2002) suggest it is important to
recognize that individuals with HFASD process deficits in social
information and communication that are demonstrated in a different
way from those with LFASD. Although both disorders share
impairments in social relationships, the social disability is unique to
each disorder with their own unique patterns of behaviors and
communication deficits. Individuals with HFASD do have
communication abnormalities (pragmatic communication
impairments) that “interfere with the ability to initiate and sustain a
conversation,” even though deficits are “fundamentally different
from the type of language and communication impairments
described in autism in which the language is delayed, echolalic,
idiosyncratic, and repetitive” (p. 238). A new addition to the DSM -5
(2012) is the category of social (pragmatic) communication
disorder (SCD) which is clustered among the section on Language
Disorders in the chapter on neurodevelopmental disorders.
Children with SCD have difficulties in verbal and nonverbal skills
related to social communication in areas such as responding to
others appropriately; staying on topic; talking about emotions or
feelings; engaging in two-way communication (reciprocity); taking
turns when talking or playing; using gestures; interpretation of
nonverbal information (body language, facial expressions);
understanding the subtle nuances of language (e.g., jokes, idioms);
and regulating speech to fit the context (location, e.g., classroom,
playground; recipient, e.g., teacher, friend). The DSM -5 (APA, 2013)
states that a differential diagnosis between ASD and SCD is made
based on the degree to which an individual also demonstrates the
additional criterion for ASD of engaging in restricted and/or
repetitive behaviors. Individuals with SCD are most likely to receive
therapy from speech-language pathologists.
Treatment/Intervention
Far more research evidence is available for the treatment of
individuals with more severe forms of autism than for those with
HFASD. Given the wide variations in intellectual functioning
between these two populations, severity of problems exhibited,
and the range of areas targeted for improvement, it becomes
difficult to generalize results from these studies of LFASD to a
population of HFASD.
Since the typical age for diagnosis of HFASD can be delayed
compared to the identification of LFASD (Howlin & Asgharian,
1999), early treatment and intervention can be challenging.
Approaches most often used for children with LFASD include
applied behavioral analysis and approaches that draw on a variety
of behavioral, developmental, and social pragmatic resources
(Tsatsanis, Foley, & Donehower, 2004). For the most part,
treatment has focused on increasing social and emotional
awareness and improving social exchange. Techniques that have
been developed to assist social competence include direct
instruction in role-playing, social skills groups, practicing of skills
with peers, and the use of social stories.
Social stories can provide a framework for teaching lessons about
appropriate social behavior, the sequencing of social events, and
the interpretation of social cues. Scripts can provide a template for
social exchange and increase the child’s understanding of what is
likely to happen and how to respond. Since the story can include
different characters, the child with HFASD can also learn how to
take the perspective of another person, a skill that is often difficult
for individuals with HFASD (Attwood, 2000). Sansosti and PowellSmith (2006) introduced children with HFASD to emotions within
themselves and others through the use of social stories. Despite a
small sample and lack of long-term effects, the procedure is a
promising avenue for further investigation, especially if stories are
infused with highly visual supports (Kana, Keller, Cherkassky,
M inshew, & Just, 2006).
Results from neurological research have revealed that when
children with ASD are presented with tasks that involve decoding
facial expressions and vocal tone, their brains are activated in
areas used to identify objects in normal populations (Schultz et al.,
2000). Lindner and Rosen (2006) suggest that children with HFASD
focus too heavily on the verbal message and ignore relevant
signals in facial cues and tone. LaCava, Golan, Baron-Cohen, and
M yles (2007) used a computer-generated program to teach
children with HFASD to recognize emotional expressions and
complex emotional voice patterns.
M arriage, Gordon, and Brand (1995) developed a social skills
intervention program for children with HFASD, targeting skill
deficiencies peculiar to that population. The program of eight
weekly 2-hour sessions was followed by six weekly 1-hour
reinforcement sessions. M ultimodal techniques (role-play,
videotaping, games, show and tell) were practiced during the
sessions, and homework was assigned to provide carryover into
the home. To assist skill generalization, sessions were varied
across a number of different settings within the clinic. Parents met
for an informal discussion group while the children attended the
sessions. Although results did not reveal significant positive
outcomes, the authors suggest that lack of positive outcomes may
have been an artifact of the measurement process, since anecdotal
comments and observation pointed to overall social gains. The
authors’ recommended future studies include increased
generalization of the program within an actual school setting.
M ore recently, Lopata et al. (2010) conducted a rigorous research
program to evaluate a manualized social treatment for HFASDs
which involved randomized clinical trials (RCTs). Based on findings
from previous research regarding treatment to improve social
functioning in individuals with HFASD (Klin, Sparrow, M arans,
Carter, & Volkmar, 2000; Klin & Volkmar, 2000; Rao, Beidel, &
M urray, 2008; White, Keonig, & Scahill, 2007), the program targeted
the following areas: development of social skills, interest
expansion, facial emotion recognition, and interpretation of
nonliteral language. After screening and meeting criteria (diagnosis
of HFASD, intellectual functioning, etc.), 18 subjects participated in
the first six-week program consisting of 4 treatment cycles per day,
while the remaining 18 functioned as the wait list control prior to
their involvement in the second run of the program. Each day,
children met in groups of 6 (divided into three age groups: ages 7–
8, 9–10, and 11–12 years) and were instructed by three staff who
spent 20 minutes involved in intensive instruction followed by a 50minute session involving therapeutic activity as recommended by
previous research (Klin & Volkmar, 2000; White et al., 2007) in
areas of repeated practice, modeling, and role-playing, providing
high rates of feedback on performance and using behavioral
techniques. Parents attended weekly 90-minute sessions to
expand their knowledge of HFASD and appropriate parenting
practices. Significant treatment effects were found for direct child
measures assessing social skills knowledge and understanding
idioms on post treatment measures.
On a more practical note, Williams (1995) suggests several
guidelines for teachers of students with HFASD. A number of
school-based programming suggestions are provided that target
seven defining characteristics of HFASD: insistence on sameness,
impairment in social interaction, restricted range of interests, poor
concentration, poor motor coordination, academic difficulties, and
emotional vulnerability. Describing children with HFASD as “easily
stressed and emotionally vulnerable” (p. 9), Williams states that
although there are no precise recipes for success due to the
diverse nature of the disorder, broad strategies can be adapted to
meet the needs of the individual child. For example, insistence on
sameness can be counteracted by giving the student sufficient
warning or pretraining regarding pending changes, incorporating
consistent routines, minimizing transitions, and providing a safe and
predictable environment. Issues of emotional vulnerability can be
addressed by skill-building exercises to reduce stressful
responding. The introduction of step-by-step problem-solving
exercises can be very helpful in providing a structured plan to adopt
in times of stress.
Post-Case Questions
1. Initially, Dylan was diagnosed with developmental delay
because testing was inconclusive due to his noncompliance
during the testing session. Discuss how “developmental delay”
is recognized by the DSM -5 and IDEA, 2004. What are the
similarities and what are the differences? The category is
controversial because some favor delaying a diagnosis to
avoid a misdiagnosis, while others feel that the delay only
delays the inevitable any may result in fewer immediate
services. What side of this debate would you support and why
(provide support for your comments from the research and
documents)?
2. In terms of differential diagnosis, how do Dylan’s behaviors fit
with a profile of HFASD relative to that of LFASD or nonverbal
learning disability? Use illustrations from Sandy’s case (Case
of Sandy Smith) and Dylan’s case presentation to compare
and contrast the most salient features.
3. Provide some possible explanations for the wide
discrepancies in ratings between the three raters (two
teachers and parent). Discuss these potential differences
relative to various levels of influence, or developmental
contexts, suggested by Bronfenbrenner’s model. Design an
intervention program drawing on the strengths of both
classroom programs.
4. With the newly introduced category of social (pragmatic)
communication disorder (SCD) and changes in the DSM -5
that now allow comorbid diagnoses of attention
deficit/hyperactivity disorder (ADHD) and ASD, develop a
differential diagnosis for Dylan that considers ruling out or ruling
in ASD, SCD, and ADHD. Support your comments with
citations from the case and the DSM -5.
5. The “theory of mind” refers to the ability to understand and
attribute mental states (beliefs, attitudes, interests, prior
knowledge) to oneself (self-perception) and to other
individuals (perception of others). Fundamental to this theory is
the ability to understand that others may have different beliefs,
attitudes, and knowledge, based on their own unique
experiences. An example of an experiment involving theory of
mind is as follows. John watches as the teacher places chalk
in a crayon box. The teacher tells John that she wants to store
the chalk in the crayon box because the chalk box is broken.
Stuart is out of the classroom when this happens and enters
shortly after the teacher is finished. The teacher asks John:
“What do you think, Stuart will say is in the crayon box?” If
John is capable of understanding theory of mind he will
respond “crayons,” if not, he will respond “chalk.” Find a
research article on autism and theory of mind. Construct a
theory of mind experiment for Dylan, and predict (based on the
article and your reading of this case study) what Dylan’s
responses would be. Support your comments with symptoms
from his diagnosis and the research.Suggested individual or
group presentation activity:
6. You have been invited to provide feedback to the school
regarding Dylan’s assessment at a meeting where they will
decide whether Dylan continues to meet criteria for Special
Education and Related Services. If it is determined that he is
eligible for services, what Goals and Objectives would you
want to see as part of her IEP? Would you recommend he
receives related services, and if so, what would the nature of
those services be?
7. Prepare a script for role-playing each of the player’s parts in
the school meeting, mentioned above. Who do you think
should be attending the meeting? How could each participant
potentially contribute information to assist with developing an
intervention plan that would best meet Dylan’s needs?
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CASE 8 ARTHUR WATSON : WON’T
OR CAN’T: A CASE OF MISTAKEN
IDENTITYINTELLECTUAL
DISABILITY; PARENT DENIAL;
ACADEMIC AND BEHAVIOR
PROBLEMS
Arthur, who was 15 years and 5 months of age, came to the
interview accompanied by his mother and father. M r. and M rs.
Watson were requesting a psychological assessment of their son
Arthur to determine whether Arthur might have a learning disability.
The parents were concerned that weak academic progress and
lack of behavior controls might be the result of frustration resulting
from learning problems.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
Arthur was delivered by cesarean section, 2 weeks post due date,
weighing 8 pounds 3 ounces. The pregnancy was reportedly
normal with the exception of fluid retention, which was monitored
over the course of five ultrasound assessments as well as pelvic
X-rays. Arthur was jaundiced at birth; however, this was treated
and he was released from the hospital within the normal time frame.
Developmental motor milestones were delayed: sitting at 8–9
months, walking at 16 months. Language skills were also reported
as delayed, and although he did say his first word at about 1 year,
he reportedly did not speak much in his initial years. Descriptions of
infant behaviors revealed that Arthur was neither temperamental
nor overly active or colicky. Arthur experienced febrile convulsions,
and he had a history of earaches, ear infections, and impacted ears
due to wax buildup. There were difficulties with bed-wetting until
Arthur was 11 years of age.
Family history reveals that Arthur is the oldest child in a family of
three, having a younger sister (11 years) and brother (8 years).
Arthur’s siblings appear to be well adjusted both emotionally and
academically. There is no known history of psychopathology in the
families of either parent. Arthur’s parents, Celia and Paul Watson,
met at university and have been in a stable marital relationship for
almost 20 years. Celia works as a counselor in a women’s shelter,
and Paul works as a financial consultant for the government.
Previous Assessment Results/School
History
Arthur has had an extensive history of previous assessments, and
his initial investigation was conducted by a developmental
pediatrician when he was 3 years 8 months of age. At that time,
Arthur presented with articulation problems and developmental
delays. An EEG was conducted and results were normal. The
recommendation was for enrollment in a nursery school program,
and Arthur began attending a M ontessori program the next year.
However, progress continued to be difficult and problems with
aggression, overactivity, and difficulty following directions made the
transition to kindergarten problematic. Arthur’s behaviors continued
to be a concern with a high level of overactivity, aggressive
responding, and poor ability to follow directions. Arthur was
reassessed by the developmental pediatrician at 5½ years of age.
On this occasion, Arthur presented with “silly” behaviors and
appeared distractible and agitated, although he was able to score in
the lower average range on a picture vocabulary test. The
recommendation was for a classroom with reduced pupil–teacher
ratio and a trial of stimulant medication. However, the placement
broke down and Arthur’s parents were asked to remove Arthur
from the kindergarten program midway through the academic year.
Apparently, Arthur’s behavior could not be maintained within the
kindergarten program and administrative staff felt that Arthur
required more supervision than could be provided in the regular
program.
M r. and M rs. Watson were becoming increasingly frustrated with
the public education system and took Arthur to a private
psychologist for an assessment when he was 5 years 9 months
old. Results of the Wechsler Preschool and Primary Intelligence
Test (WPPSI-R) revealed verbal functioning to be within the lower
limits of the lower average range, while performance skills were
within the borderline range. Results from the picture vocabulary test
were identical to those obtained 6 months earlier by the
developmental pediatrician, indicating receptive vocabulary to be
within the lower average range. The recommendations were in
support of a trial medication period, future assessment of central
auditory processing, and the need for a structured behavioral
management program. History repeated itself, however, and
Arthur’s continued behavioral outbursts resulted in his eventual
removal from the regular class program in the public school. As a
result, the school board recommendation was for future placement
in a behavioral program. Parents appealed the decision, stating that
Arthur had attention deficit/hyperactivity disorder (ADHD) and that
his needs would be better served in a program that addressed his
learning needs. However, Arthur’s parents were unable to produce
a clear diagnostic statement to confirm that Arthur had ADHD, and
Arthur had not responded favorably to stimulant medication.
Ultimately, the school board decision to place Arthur in a special
program was upheld; however, the designation of exceptionality
was changed from “Emotionally and Behaviorally Disordered”
(EBD) to “Learning Disabled” (LD).
Over the course of the next 4 years, Arthur attended programs in
several schools with limited success. At 7 years of age, he
enrolled in a day treatment program affiliated with a local children’s
mental health center. While at the center, assessment of
intellectual level was attempted; it was only partially completed,
however, due to lack of compliance on Arthur’s part. Although
results of that intellectual assessment were inconclusive, it was
reported that subtest scores ranged from average (general
information, block design) to very delayed (oral math, visual
sequencing). Arthur scored at the 8th percentile on a
readministration of the picture vocabulary test, which was well
below previous scores. It was suggested that Arthur’s outbursts
might be attempts to avoid academic difficulties and were likely
developmental in nature. The following year, Arthur was discharged
from day treatment and placed in a primary learning disability
program in a community school. However, Arthur’s transition to the
program was not successful and parents ultimately removed Arthur
from school; he was homeschooled the following year.
Parents enrolled Arthur in a local private school when he was 9
years of age; progress was minimal and the school was forced to
shut down due to financial reasons. For the next 2 years, Arthur
returned to the public school system and was placed in a Junior
Special Learning Class. Despite continued problems with attention
and concentration, Arthur demonstrated improved work habits, and
aggressive acting out was replaced with a newly developed sense
of humor. Arthur seemed to relate to his teacher in a very positive
manner. However, the following year, when Arthur was moved to a
Senior Special Learning Class, previous difficulties with aggression
resurfaced and Arthur was removed once again and
homeschooled. Parents hired a tutor to assist Arthur during this
period, and assessments conducted by the tutor revealed core
academics to be at the 1st percentile (kindergarten/Grade 1 level).
Reassessment on the picture vocabulary test revealed receptive
language to be below the 1st percentile, and at 14 years of age,
Arthur had a vocabulary that was approximately equivalent to a
child half his age (7 years 9 months).
Arthur was now becoming a teenager, and aggressive outbursts
were becoming more threatening to his parents and younger
siblings. Out of desperation, parents sent Arthur to a private
boarding school in upstate New York. They were hopeful that the
school would be able to provide the structure and behavior
management that Arthur required and that he would return from the
school with many positive changes. A review of reports suggests,
however, that the facility was more of a prep school than one
geared to special needs and was highly inappropriate for Arthur.
Parents have had little understanding of what transpired over the
year, since Arthur has refused to share any information about his
school experience with his parents. When Arthur returned home
after 1 year in the program, he was more angry and resentful than
ever. Behaviors continued to escalate, and Arthur was beginning to
use threatening gestures toward his parents and physically and
verbally abusive behaviors toward his siblings (kicking, swearing,
hitting, pushing).
As a result of a recent violent outburst (Arthur chased his sister
around the house with an electrical cord, saying he was going to
get her), parents sought temporary placement for Arthur in a
residential facility for youth with emotional and behavioral problems.
At the time of the current interview, Arthur was being slowly
integrated back into his home on weekends.
REASON FOR REFERRAL
Arthur’s parents were desperate for any information that would help
them with Arthur. They were requesting a formal assessment to
clarify the nature of cognitive functioning, academic levels, and any
other information that might assist in better understanding Arthur’s
social/emotional and behavioral difficulties. According to M r. and
M rs. Watson, despite a number of previous attempts to assess
Arthur’s functioning, to their knowledge, Arthur had not had a
complete formal psychological assessment in the past.
During the interview, Arthur appeared highly agitated. He shifted his
position in the chair continuously, slouching down with his long legs
dangling across the floor. At approximately 5 feet 10 inches tall,
Arthur towered over his parents when he stood up. Throughout the
interview, Arthur would make grimacing faces, mimic his parents’
comments, interrupt often, and correct his parents, especially his
mother, in a loud and mocking voice. When asked about the private
school he had attended in New York, Arthur said that he hated the
school and he hated the kids at the school. In response to specific
questions, Arthur was difficult to understand, partially due to poor
articulation and sound substitutions (“s” for “t”), but mostly because
he tended to be very tangential in his responses. Cluttered
speech, a tendency to trail off at the ends of sentences, and a
propensity to make “silly voices” also rendered communication
difficult to understand.
When asked if he knew why he was at the clinic, Arthur said that
he was “too violent” sometimes and added that lately he was
“more bad than good.” He did seem remorseful, however, and said
that he wanted to be better. When asked if he might agree to take
medication to help control his behavior and do better at school,
Arthur responded that he was prepared to try, if it would work. He
added that things were very difficult now, and he was getting into
trouble a lot because of his temper. He said that he was also
having trouble sleeping and falling asleep. In response to a
question about what concerned him most, Arthur said that
sometimes he did stuff that he wished he had not but then it was
too late. He spontaneously added that he did not have any friends
and that he hated his “zits” and wanted them to go away so he
could get a girlfriend. He worried that he would not be able to get
rich and find a wife when he got older.
Arthur was seen for three assessment sessions. Behavior varied
across sessions, with Arthur becoming more vocal and
volunteering more personal information as time progressed.
However, Arthur was quite agitated when he arrived for the third
session and muttered an obscenity as his father dropped him off at
the office. When asked if he wanted to talk, he said that he just
wanted to do his work with the psychologist for the day, but then
spontaneously began to discuss what had occurred. Arthur was of
the impression that he would not be able to go back to school
because it cost too much money and that he would have to stay
home and do jobs all day. When he was reassured that parents
and psychologist were working together to find out which school he
would be happiest at, he seemed to be very relieved and was
eager to get back to the assessment. A fourth assessment
session was scheduled; however, further assessment was
preempted when Arthur’s behavior again escalated at home,
resulting in admission to the crisis unit at the regional children’s
hospital. On that occasion, Arthur had threatened harm to his
parents, sister, and eventually himself and was admitted to the
hospital for 1 month to allow for medication trials, observation, and
behavioral stabilization.
While in the hospital, Arthur responded well to a combination of
sertraline and thioridazine, his behavior stabilized, and he was
discharged back to his home at the end of the month. A discharge
planning meeting was held prior to Arthur’s release from the
hospital, and parents again voiced their frustrations with the
“system,” complaining that they had been given very little direction
regarding future placements for Arthur. Parents returned to the clinic
to complete Arthur’s assessment and for assistance regarding
future planning.
ASSESSMENT RESULTS
Arthur’s scores for all the assessment instruments that he
completed and the scales completed by his parents are available in
Appendix A. The following is a summary of those findings.
Information regarding specific assessment instruments and
guidelines for the interpretation of standard scores and T scores
are available in Appendix C.
The Wechsler Intelligence Scale for Children (WISC-V) was
administered over three sessions to allow for sufficient rapport
building and to accommodate Arthur’s tangential response style.
Spontaneous digressions were frequent throughout the
assessment session. Arthur’s effort was considered optimum, and
although anxiety and low frustration tolerance were evident, results
were considered to be a valid index of functioning levels. Although
Arthur’s overall scores on the visually oriented tasks, Visual Spatial
Reasoning (VSI = 69; range 65–76) and Fluid Reasoning Index
(FRI = 65; range 59–72), were superior to his score of 55 for the
Verbal Comprehension Index (VCI; range 51–62), the discrepancy
was not significant. Therefore, Arthur’s full scale IQ of 57 (range
53–64) is considered to be a good index of composite intellectual
functioning. Scores for the Processing Speed Index (PSI) of 54
(range 49–61) and Working M emory Index (WM I) of 55 (range 51–
62) were similar to scores for VCI. Overall intelligence was below
the 1st percentile. Arthur is cognitively challenged and his abilities
range within the range of mild intellectual disability (M ID).
Developmentally, cognitive skills are similar to a child several years
his junior, at approximately 8–8½ years of age. Results suggest a
global and pervasive cognitive deficit rather than any specific
learning disorder. Arthur is a concrete thinker, and transferring
information between different environments is challenging for him.
Verbal expression is weak and vocabulary knowledge limited.
Arthur often uses words inappropriately, familiar with the word but
not completely grasping the meaning. His comprehension improves
if visual aids (pictures) are added.
Academically, according to the Weschler Individual Achievement
Test (WIAT-III), Arthur’s academic performance was commensurate
with his intellectual functioning, and Arthur scored consistently at
the Grade 1 level across the core academic areas. He
demonstrated a relative weakness in numerical operations and a
relative strength in spelling.
Parents completed the Adaptive Behavior Scale (ABS-S:2) and
Vineland Adaptive Inventory. According to the ABS-S:2, Arthur was
rated at age level in all areas of Personal and Personal-Social
Responsibility. Similarly, parents also rated Trustworthiness and
Social Engagement within the norm. Language Development,
Hyperactive Behaviors, and Disturbing Interpersonal Behaviors
were rated as minor problems. Ratings on the Vineland Interview
were consistent with the ABS-S:2 and placed Daily Living Skills and
Socialization within the normal range for his age and
Communication Skills at a low average level. Caution was advised
in interpreting overall adaptive functioning using the scores from the
parental assessments, which evaluated his behavior in an
environment of high familiarity (home, high predictability, highly
structured), and offered situations with few external distracters. It
was suggested that adaptive functioning would deteriorate
considerably when he was in situations that were novel and
unexpected, offered many distracters, were unstructured, and
offered a wide variety of academic and social pressures.
According to parent ratings on the Conners Scales and Achenbach
(CBCL), Arthur demonstrated significant problems in areas of
Conduct (T = 96), Learning (T = 71), Impulsivity (T = 68), and
Anxiety (T = 68).
Further assessment: Psychiatric consult: A psychiatric referral was
initiated to assist in the monitoring of Arthur’s medication following
his release from the hospital. Resulting from the psychiatric consult,
the possibility of Tourette’s disorder was also raised due to
evidence of some complex motor and vocal tics with associated
mimicry. During his interview with the psychiatrist, Arthur admitted
that although he sometimes would engage in swearing, facial
grimaces, silly voices, and mimicry on his own accord, at other
times, he had difficulty controlling these behaviors. As a result, the
psychiatrist suggested that Tourette’s disorder might also be a
possibility.
Although recent evidence of depression with aggressive behavior
patterns had responded to a combination of sertraline and
thioridazine, the psychiatrist recommended that the family slowly
wean Arthur off the thioridazine, which was causing excessive
sedation. The psychiatrist indicated that future pharmacological
treatment might include an SSRI (sertraline or Prozac) in
combination with stimulant medication. Other areas to be
addressed would include possible risperidone for the motor tic
disorder and/or lithium to reduce aggressive behavior.
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
The concept of intellectual disability (ID) (formerly known as mental
retardation) has evolved over the course of history. Seguin, the
founding father of the American Association on M ental Retardation
(AAM R), established the association in 1876 to advocate for the
rights of individuals who had mental deficiencies resulting from
arrested development. By the late 1950s, there was growing
discontent with the practice of determining an ID on the sole basis
of intelligence testing (IQ below 85; one standard deviation below
the mean), and criteria were expanded to include the need to
establish accompanying deficits in adaptive functioning, in addition
to onset in childhood (initially before age 16). Twenty years later,
criteria were further narrowed to include an IQ level which was two
standard deviations below the mean (IQ 70), and in 1992, the
AAM R increased the age of onset to include onset prior to age 18
(AAM R, 1992), which was also the age of onset in the DSM-IV-TR
(APA, 2000).
In January 2007, the AAM R changed its name to the American
Association on Intellectual and Developmental Disabilities (AAIDD)
to address concerns with the use of the label mental retardation for
individuals with ID (AAM R, 2006). The switch from mental
retardation to intellectual and developmental disability was instituted
to better conform to terminology used in Canada and Europe and
to focus on the mission of AAIDD, which is to assist and advocate
for those with developmental disabilities, such as autism, which
often coexist with IDs. The newly revised DSM -5 (APA, 2013) has
also changed the name of the disorder to one of intellectual
disability (intellectual developmental disorder). The DSM -5 criteria
for ID remain unchanged from the previous version of the DSM ,
with onset during the developmental period and including significant
deficits in intellectual (IQ score of 65–75) and adaptive
functioning. However, the DSM -5 no longer classifies the severity
of ID by range of intellectual functioning (mild, moderate, severe,
profound), as was the previous methodology; instead, specifiers of
mild, moderate, severe, or profound can be used to identify levels
of support needed for adaptive functioning in three domains:
conceptual (academic functioning), social, and pragmatic (life skills).
At least one of the three domains must be sufficiently impaired
(requiring support to adequate functioning) to meet criteria for
diagnosis of ID.
There are currently three different systems that can be used to
classify IDs in North America: the DSM -5 (APA, 2013), AAIDD
(2009), and the educational system (IDEA, 2004; Yell, Shriner, &
Katsiyannis, 2006). A more detailed discussion of the similarities
and differences between these systems regarding the classification
of IDs is available in Appendix B. In addition to revealing
impairment in intellectual functioning, deficits in adaptive functioning
have also been a critical component of a determination of IDs for
the above systems, although the systems vary in how they define
adaptive behaviors.
Regarding the case of Arthur, in addition to deficits in mental
capacity and adaptive behavior problems, there was also concern
that Arthur might demonstrate symptoms of Tourette’s disorder.
According to the DSM -5 (APA, 2013), Tourette’s disorder is a tic
disorder classified under neurodevelopmental disorders that is
characterized by uncontrollable tics (rapid, nonrhythmic movements
or vocalizations) that are evident in multiple motors and at least
one vocal tic. The course of the disorder is unpredictable, with
many youth outgrowing the disorder in adulthood.
Behavioral Interventions and Treatments
Treatments and interventions for children and adolescents with
mental impairments often focus on two broad areas:
1. intellectual adaptive deficits and
2. associated behavioral–emotional problems (Kronenberger &
M eyer, 2001).
Evidence-based treatment for associated behavioral difficulties will
be discussed first, followed by a discussion of the efficacy of
educational treatments.
The Behavior Management of Behavioral and Emotional
Problems
Determining the prevalence rate for comorbidity of mental disorders
and ID in children and adolescents is a difficult task due to the wide
variability in samples used and research methods employed.
Koskentausta, Iivanainen, and Almqvist (2002) reported rates
ranged from 10% to 60% depending on the nature of the population
sampled (clinical versus nonclinical), level of intellectual impairment,
and inclusion criteria (nature of assessments and types of
assessment instruments used). In their review of the research on
ID and comorbid disorders, Einfeld, Ellis, and Emerson (2011)
limited their findings to 9 studies out of a possible 85, based on
rigorous inclusion criteria and report that “overall, 30%–50% of
children and adolescents with ID were identified as having a mental
disorder” (p. 138).
In order to assess the prevalence, comorbidity, and impact of DSM
disorders in 7–20-year-olds with ID, Dekker and Koot (2003) had
parents’ complete modules of the Diagnostic Interview Schedule
for Children (DISC) for anxiety, mood, and disruptive disorders for
474 children who were randomly selected from Dutch schools for
the intellectually disabled. Based on parent responses to the DISC,
Dekker and Koot (2003) reported the following prevalence rates for
disorders: anxiety 21.9%; mood disorder 4.4%, and disruptive
behavior disorder 25.1%. Overall, approximately, 37% of children
with ID met criteria for a comorbid disorder, with those who
received ratings for multiple disorders rated as more severely
impaired in everyday functioning. Less than half the children with
reported disorders (27%) were receiving mental health care.
“Comorbidity between major groupings of disorders was most
common between disruptive disorder and mood disorder, followed
by disruptive disorder with anxiety disorder” (p. 921).
Negative outcomes for youth with impaired cognitive functioning
and challenging behaviors include physical risk to the youth or
peers and increased risk of isolation, abuse, and other forms of
inappropriate interactions with peers (Emerson, 2001), which
increases the long-term risk of developing serious psychological
difficulties (Deater-Deckard, 2001; LaFontana & Cillessen, 2002).
Furthermore, in their study of child and adolescent impressions of
those with challenging behaviors, Byrne and Hennessy (2009)
found that similar to their average-functioning peers, children and
adolescents with IDs are less willing to engage in shared activities
with peers who display challenging behaviors.
In addition to comorbid disorders, individuals with IDs also present
with social skill deficits that can influence coping ability and result in
tendencies to withdraw, stigmatization, and increased rates of
psychopathology (M atson, Anderson, & Bamburg, 2000). The
majority of children and adolescents with IDs have social skill
deficits. Bielecki and Swender (2004) state that “research
demonstrates that there is an established relationship between
social skills and maladaptive behaviors, but because the data are
correlational, it is unclear if social skill deficits result in problem
behaviors or if the presence of maladaptive behaviors results in
social impairments” (p. 695). However, Bielecki and Swender (2004)
emphasize that although there are limitations in assessing social
skills in the population of children and adolescents with IDs due to
limited verbal responses, researchers need to rely on methods of
observation of social skills and parental reports for assessing
social skills through “behavioral observations, role-playing, and
checklists.” They state that “more knowledge could then be gained
regarding the relationship between specific social skills variables”
by integrating information from other assessment measures used
(e.g., cognitive assessments, assessments of affect and mood) in
order to inform clinical treatment planning (p. 705).
The topic of emotion regulation in children and adolescents with
ID has been significantly underresearched (see M cclure, Halpern,
Wolper, & Donahue, 2009 for a review), despite the fact that the
concept of emotion regulation is integral to our understanding of
developmental processes such as the role of language and peer
interaction on the development of skills in the area of selfregulation. Developmentally, children usually develop skills in
emotion regulation, noted in self-soothing behaviors, somewhere
between 3 and 6 years of age based on modeling behaviors
observed in caregiver responses to them when in emotional
distress. Later on, children learn how to manage emotional
responses in social situations in order to maintain positive social
relationships with others. However, individuals with ID likely
experience more difficulty with emotion regulation due to limitations
in areas of language development and social skills. Since lack of
emotion regulation can interfere with performance in a wide variety
of situations, it is important to seek out interventions that can
assist individuals to perform when they are in a state of negative
emotional arousal. Two interventions that have focused on
reducing negative emotional arousal in individuals with ID include
the Stop-Think Relax self-control strategy (Chapman, Shedlack, &
France, 2006) and the use of mindfulness-based approaches
(Singh et al., 2007, 2013). The Stop-Think Relax program
(Chapman et al., 2006) is a simple three-step approach to selfregulation which is reinforced by visual cues. Although the program
has been primarily used with adults, it could readily be adapted for
adolescents. M indfulness-based training was effectively used to
assist young adults with IDs (average age of 23 years) to control
physical and verbal aggression (Singh et al., 2013). M indfulness
training has also been successful in assisting parents of children
with developmental disabilities (aged 4–6) in areas of satisfaction
with parenting, increased social interaction with their child, and
lowering parent stress (Singh et al., 2007). Children benefitted from
“mindful parenting” with increased positive behaviors and
decreases in negative altercations with siblings.
Treatment programs developed to assist with behavioral and
emotional problems in populations with IDs have largely used
methods of functional analysis based on applied behavior analysis
(ABA). ABA has been defined as “the extension of experimental
methods to applied settings” (Kazdin, 1994, p. 25). Behavior
management programs can be simplistic (using praise to increase
or ignoring to decrease behaviors) or very complex (contingencybased programs). Behavior management techniques are based on
sound empirical support that has been documented in countless
studies and journals devoted specifically to behavioral research:
Behavior Modification, Journal of Applied Behavior Analysis,
Behavior Therapy, and others. However, successful behavior
management programs require more than a knowledge of the
mechanisms of behavioral change. They also require an
understanding of how the child’s different situational contexts
contribute to the problem behaviors.
Behavioral treatment programs can be developed to either
increase deficit behaviors or decrease behavioral excess. Although
it is always preferable to increase deficit behaviors, such as
targeting increased compliance through the use of positive
reinforcement or negative reinforcement, there are times when it is
necessary to focus on reducing a behavioral excess (e.g., highly
aggressive behavior) through the use of punishment or extinction.
Behavioral principles of schedules of reinforcement, shaping
behavior and behavior chaining, secondary rewards, and token
economies have all been demonstrated as effective methods for
managing behavioral change.
Behavioral programs can benefit from the use of an empirical
approach to select target behaviors (Weist, Ollendick, & Finney,
1991) to create a reinforcer hierarchy; the selection of reinforcers
for specific populations (such as adolescent populations); and
techniques to promote generalization of outcomes across
situations. In their review of treatment programs for aggressive
behaviors in individuals with ID, Brosnan and Healy (2011)
emphasize the need to establish the function of aggression in a
behavioral context in order to develop effective strategies for
remediation. To this end, Brosnan and Healy (2011) underline the
importance of conducting a functional behavioral assessment
(FBA) prior to developing a treatment plan. The authors mention
three of the most successful intervention approaches including
antecedent manipulations and changes in instructional context
(activity schedules, prompts, video priming); reinforcement-based
strategies (picture exchange communication system [PECS],
functional communication training [FCT], differential reinforcement
procedures); and consequential control (extinction, overcorrection,
response cost, time out).
One of the oldest behavioral intervention programs, the token
economy, uses contingency management systems or token
economies to improve behavior in children and adolescents.
Lieberman (2000) states that the token economy allowed for the
full range of services to be “modified by systematic and preplanned
use of antecedents (e.g., prompts) and consequences (e.g.,
reinforcers) …” to shape behavior based on the same “laws of
learning” that influenced normal behavior.” The term “token
economy” originated from the use of tokens (earned for good
behavior) that could be exchanged for rewards selected by the
patient (candy, privileges, etc.) (p. 1398). Although token
economies were in high demand in the 1970s and 1980s, they fell
out of favor when the movement to deinstitutionalization relocated
individuals with ID back into the community. However, the efficacy
of using contingency management systems or token economies to
improve behavior in children and adolescents has been
demonstrated across many settings (Wielkiewicz, 1995). M ore
recently, Reitman, M urphy, Hupp, and O’Callaghan (2003)
compared group and individualized contingency management
programs for children and found that the contingency management
program assisted in reducing unwanted behaviors compared to the
wait list control, and that furthermore, whole group contingency was
generally as effective as the individually administered contingency
program in motivating children to increased desired behaviors by
earning tokens or coupons that could be traded for concrete
reinforcers. Contingency programs to increase deficit behaviors can
be used in the regular classroom (Brantley & Webster, 1993),
special classroom (Kratochwill, Elliott, & Rotto, 1990), and home.
Contingency programs can also be developed to reduce excess
behaviors. Programs that target reducing behaviors function on a
response cost basis, where children lose tokens, coupons, and
the like when they demonstrate the undesirable behavior.
Positive behavior support (PBS) is a theoretical framework for
understanding problem behaviors that was primarily derived from
ABA. The PBS approach emerged in the mid-1980s amid
increasing concerns regarding the use of aversive techniques to
control behavior (Will, 1999) with the goal of extending programs
from the laboratory and clinics into the broader community at large
(Horner et al., 1990).
Undesirable behavior can be reduced by behavioral modification
through teaching children to behave in new ways or promoting
behavioral change through the use of positive or negative
reinforcements (Kappel, Dufresne, & M ayer, 2012). In contrast to
punishment (use of aversive consequences) or response cost
programs which were used to reduce negative behaviors, the
concept of PBS, which promoted interventions to increase positive
behaviors, began to increasingly appear in educational settings for
individuals with IDs due to increased focus on inclusion (Carr et al.,
2002). School-wide PBS programs focus on prevention, skills
building, and environmental modification and can involve three
levels of interventions, namely, primary, secondary, and tertiary.
Behavior programs for training in adaptive skills and social
behaviors have also demonstrated successful positive change
(Embregts, 2000). Teachers can use reinforcers to increase
desirable behavior through extrinsic rewards such as stickers and
tokens which can be exchanged to acquire privileges (free time) or
desired objects (toys, candy) or social reinforcers such as
attention, praise, and affection (Liberman, 2000).
Currently, PBS interventions encompass social, behavioral,
educational, and biomedical science drawing on evidence-based
practices conducted in naturalistic settings (Clarke & Dunlap, 2008;
Gable, Hendrickson, & Van Acker, 2001; Scott et al., 2005) to
improve quality of life and reduce problem behaviors (Carr et al.,
2002). PBS has attempted to integrate the ABA framework of
instrumental/operant learning (evident in principles of reinforcement,
contingency management, stimulus control, shaping, fading,
prompting, functional equivalence, generalization, and maintenance)
with information available from other disciplines (Cooper, Heron, &
Heward, 2007). As a result, PBS creates a cross-discipline view of
behavior that encompasses pharmacological, genetic,
neurodevelopmental, and psychological approaches that can assist
in the development of a more comprehensive view of the range of
factors that can influence the development of challenging behaviors
and the interventions that can help alleviate them (Carr & OwenDeSchryver, 2007; Eisenberg et al., 2005).
PBS has moved away from the tendency to emphasize immediate
environmental contingencies in favor of a broader look at systemslevel factors that may be influencing behaviors and potential
outcomes (e.g., the classroom, the family). There has also been
increased focus on strategies for prevention, intervention, and the
importance of developing positive replacement behaviors to
accompany the reduction of problem behaviors (Dunlap, Carr,
Horner, Zarcone, & Schwartz, 2008). In a recent meta-analysis of
interventions for challenging behaviors, Harvey, Boer, M eyer, and
Evans (2009) found that behavioral interventions, especially when
developed through functional behavioral analysis, significantly
reduced challenging behaviors and that teaching replacement skills
for problem behaviors was highly effective.
Parent management training and behavioral family interventions
(BFIs) are programs that train parents to respond to the child’s
inappropriate behavior in ways that increase positive and decrease
opportunities for disruptive behavior. Parent training programs and
BFI have been demonstrated to be an effective component for
treatment of children with intellectual and other disabilities (Handen,
1998). The literature strongly supports the engagement of the
family in treatment programs for children and adolescents with ID to
ensure generalization to other contexts (M atson, M ahan, &
LoVullo, 2009) and to address any stressful outcomes that parents
and children may face, since stress is one variable that has
frequently surfaced as a risk factor for parents of children with ID
(Peer & Hillman, 2014). Singh et al. (2013) found that parents who
were engaged in a mindfulness parenting program had significantly
more success in reducing aggressive behavior and increasing their
children’s social skills, while also experiencing increased
satisfaction with their parenting and a reduction in parenting stress.
In addition, there is also an emphasis on maintaining flexibility in
using different protocols (Willner, 2005) and involving the child or
adolescent’s family (Gavidia-Payne & Hudson, 2002).
Parent training programs have focused on increased understanding
of their child’s behavior and the application of specific behavioral
techniques to assist in reducing inappropriate behaviors and
enhancing parent–child interactions. Studies involving parent
training have reported significant reductions in undesirable
behaviors, such as the disruptive behavior disorders (conduct
problems, oppositional defiant disorder) and hyperactivity, and
increases in desirable behaviors, such as obedience/compliance
(Bagner & Eyberg, 2007; Roberts, M azzucchelli, Studman, &
Sanders, 2006). Some of the factors that have been related to the
effectiveness of parent training programs include decrease in
negative parenting style (M cIntyre, 2008), increase in constructive
parent–child interactions (Bagner & Eyberg, 2007), and reduced
stress and tendencies to be overreactive in mothers (Roberts et
al., 2006). Parent training programs have been proven effective and
have the flexibility to be administered in a number of different ways,
whether administered in groups or individually. Hudson et al. (2003)
used a BFI program called Signposts for individuals 4–19 years of
age and report that the program was successful in reducing
behavior problems and parental stress, while increasing feelings of
efficacy in parenting practices, regardless of whether administered
via group, telephone, or self-directed modes.
Educational Programs: Academic Achievement and
Intellectual Adaptive Deficits
Fundamental to IDEA (IDEA, 2004) is the assurance that all
children with disabilities in the United States receive a free and
appropriate public education (FAPE) in the least restrictive
environment. The IDEA also outlines procedures that should be
followed by special education personnel, including obtaining
informed written consent of the parents prior to assessment and
the need to develop an individualized education program (IEP) for
each disabled child. The IEP serves as the child’s educational plan
and outlines needs for meeting the child’s educational goals
through assessment, intervention, and monitoring of progress
during annual reviews (see Appendix B for a more detailed
discussion of IDEA, 2004). Controversy concerning the validity of
special education placements evolves around two important
questions:
1. Does placement in special education programs benefit
students with special needs?
2. Should placements be categorical (separate placements for
different disabilities) or noncategorical; for example, can all
children with special needs benefit from the same resources?
With regard to issues of placement, IDEA (2004) focuses on
providing education for children with disabilities in the least
restrictive environment such that special education programs are
complemented by mainstreaming (the integration of disabled
children into the regular class program) for as much time as
possible. Students who qualify for special education also are
provided with related services (speech language, occupational
therapy, etc.) if these are needed. M ost recently, the Regular
Education Initiative has taken the position that full inclusion, rather
than mainstreaming, would be the best solution and that the needs
of children with disabilities would be best served by full-time
placement in the regular or general education program. Proponents
of mainstreaming and inclusion frequently cite results from the
Carlberg and Kavale (1980) meta-analysis comparing general with
special education. Results of this analysis suggested that students
with M ild Intellectual Disability (M ID) generally obtained better
outcomes in regular programs. It has further been argued that
placing students with M ID in contained special classrooms can
actually place them at a disadvantage, isolating them from
normative role models (Ysseldyke, Thurlow, Christenson, &
M uyskens, 1991).
M ore recently, Hocutt (1996) reviewed more than 100 studies
conducted over the last 25 years and suggests that claims of the
efficacy of special education placement versus regular placement
are difficult to substantiate, since much of the research is flawed
methodologically and/or outdated with respect to today’s
classification systems. On a more positive note, Hocutt (1996)
suggests that it is the intervention program (intensive individualized
instruction and monitoring of progress) rather than the placement
that predicts success for students with M ID. The question remains,
however, whether adequate monitoring and intervention are more
likely to occur in a class with smaller enrollment.
Sabornie, Cullinan, Osborne, and Brock (2005) conducted a metaanalysis of 58 studies to determine whether separation of students
into high-incidence categories, specific learning disabilities, M ID, or
emotional/behavioral disabilities (E/BDs) was meaningful based on
research examining three dependent variables that are necessary
for eligibility for special education placements, including intelligence
(IQ), academic achievement, and behavior. Results of their study
support the retention of different disability categories, especially for
students with M ID, based on significant differences between
students with M ID and the other two groups in areas of IQ;
academic achievement; and the need for specific emphasis on
functional and life skills, personal care skills, communication ability,
social skills, and transition-oriented planning in their educational
programming (p. 55).
In addition, there is some evidence that students with M ID who are
mainstreamed may be stigmatized, avoided, and marginalized in
that setting (Dovidio, M ajor, & Crocker, 2000), while students in
segregated settings may be protected from being stigmatized
(Todd, 2000). However, the potential negative impact of living within
such a protective environment might be that they have more limited
awareness of their potential, since their only comparables are other
students with IDs (Finlay & Lyons, 2000; Todd, 2000). In summary,
comparing oneself to similar peers may be protective of self-
esteem, while comparing oneself to nondisabled peers may lower
one’s self-esteem (Crabtree & Rutland, 2001).
Cooney, Jahoda, Gumley, and Knott (2006) studied 28 students
attending mainstream schools and 32 students who attended a
segregated school (mean age 15.6 years; mean IQ = 62). While
both groups of students reported similar levels of stigmatization
beyond school (in the community), the students who were
mainstreamed also reported stigmatization at school by their
nondisabled peers and perceived problems with support from
teachers and staff who they felt were not sympathetic to their
learning needs. There was no difference between the two groups
with respect to future goals and the likelihood of meeting these
goals. M ortweet (1997) studied the effect of class-wide peer
tutoring of M ID students within the regular program; results
revealed positive gains academically and socially, although social
interaction did not generalize to other settings outside the
programmed instruction.
Kuntz and Carter (2019) reviewed 40 studies that examined
interventions for middle and high school students with ID who were
enrolled in a range of core academic and elective classes. The
interventions were classified into five primary categories:
systematic instruction, peer support arrangements, selfmanagement strategies, peer-mediated communication
interventions, and educational placement changes (p. 114). Their
report revealed interventions involving peer support arrangements;
systematic instruction; vocational interventions; and selfdetermination interventions all have support as evidence-based
practices for students with ID. However, Kuntz and Carter (2019)
emphasize that many “academic and behavioral interventions
evaluated in special education classes have yet to be adapted for
use in general education classes,” and furthermore, the five
categories of interventions they reviewed should be “drawn upon
by IEP teams as they consider how best to enhance the learning
and social outcomes of students with ID in inclusive classrooms”
(p. 114).
M any students find the transitions to middle school and high
school from elementary school to be major challenges, as the
curriculum becomes more complex, class sizes increase, students
are responsible to multiple teachers, and expectations increase
dramatically (Carter, 2018). For students with IDs, this challenge
can be a very difficult one, unless structure and support are
provided to assist them through the transitions and develop
increasing skills in areas of self-management and independence.
Although there has been attention paid to the possible positive and
negative social implications of integration within the regular class
program, there has been less attention paid to the longer-term and
vocational implications of educational preparation for youth with
M ID. The National Longitudinal Transition Study-2 (Wagner,
Newman, Cameto, Garza, & Levine, 2005) revealed that students
with M ID demonstrate persistent underemployment, with only 52%
of postgraduates with M ID engaged in postgraduate activities,
such as employment, training, or further schooling (Wagner,
Newman, Cameto, Levine, & Garza, 2006). Hartman (2009) outlines
a step-by-step approach to creating a community-based treatment
program for students with IDs, which is focused on the integration
of resources in schools, business partnerships, and training in selfdetermination and advocacy issues.
According to Butterworth, Hiersteiner, Engler, Bershadsky, and
Bradley (2015), approximately only 10% of individuals with ID are
gainfully employed in the community. Based on these low
employment rates and previous findings that individuals with ID
who have higher levels of self-determination experience more
positive employment outcomes (Shogren & Shaw, 2016; Shogren,
Wehmeyer, Palmer, Rifenbark, & Little, 2015), Shogren, Wehmeyer,
and Burke (2017) examined interventions to teach skills associated
with self-determination to be used in planning and setting goals for
students to assist in making this important transition from
secondary education to employment for individuals with IDs.
Shogren et al. (2017) evaluated the effectiveness of two selfdetermination training programs: Self-Determined Learning M odel of
Instruction (SDLM I), alone, and the SDLM I program in combination
with Whose Future Is It? The focus of the programs was on
developing skills associated with self-determination, including skills
such as decision-making, problem-solving, planning, selfmanagement, self-advocacy, and goal setting to enhance future
transition to postsecondary school employment (i.e., choice
making, decision-making, problem-solving, planning, goal setting
and attainment, self-management, self-advocacy, self-awareness,
and self-knowledge) to enable students to set and attain transition
goals related to integrated employment. Results revealed that
teachers rated students in both programs as making significant
positive changes in self-determination.
Post-Case Questions
1. Would Arthur’s profile warrant a diagnosis of ID? Discuss this
question from the perspective of each of the following
classification systems: DSM -5 (APA, 2000), AAIDD (American
Association on Intellectual and Developmental Disability), and
the educational system (IDEA, 2004). Information available in
the case study and Appendix B will provide the framework for
answering this question.
2. Lalli, Kates, and Casey (1999) investigated the rates of
problem behavior relative to academic demands in two boys
with M ID. Results revealed that aggression was highest during
spelling instruction and that problem behavior was driven by
negative reinforcement. Changes in instructional format
produced a reduction in negative behaviors.
Explain how these findings might be relevant to Arthur’s
case. How might an FBA of Arthur’s behaviors have
helped with programming? Based on information in the
case presentation, develop a likely FBA for Arthur’s
disruptive classroom behaviors outlining possible
behaviors (suggest possible examples of disruptive
behaviors), precipitating conditions (situations that trigger
the behavior), consequences of behavior
(situations/events that follow the behavior), and functions
of behavior (underlying processes/motivations that sustain
the behavior).
Show how you would conduct a similar assessment to
determine the extent to which behaviors were also
occurring in other contexts: playground, after-school
program, home.
3. The psychiatrist felt that Arthur may also have Tourette’s
syndrome. How common is it for individuals with IDs to have
Tourette’s syndrome and how might this impact his overall
functioning, socially, behaviorally, and academically? Would
Arthur also meet criteria for ADHD, given the information
providing in the case and in the extended results section in
Appendix A?
4. Given the research on benefits versus negative outcomes of
children with M ID receiving instruction in special education
versus regular education classes, what would you recommend
for Arthur based on his profile and past history? Support your
comments with citations from the case and the research.
5. Patricia M acGill Smith (2010) published an article that is
particularly relevant to Arthur’s case because it explores the
many feelings that parents experience when they have been
told that their child has a disability. The article which was
originally published on the NICHY website can still be found at
the following link: https://www.parentcenterhub.org/wpcontent/uploads/repo_items/notalone.pdfIn the article, Smith
describes feelings of shock, denial, fear, grief, guilt, confusion,
powerlessness, disappointment, and rejection (of either the
diagnosis or the child). Read the article and map the feelings
on to the responses of Arthur’s parents to a history of
information received from assessments and failed
interventions. Reflect on whether the system did not provide
enough support and, if so, how the parents could have been
better informed and their expectations managed throughout.
What would you do to assist these parents and Arthur at this
time?Suggested individual or group presentation activity:
6. You have been invited to provide feedback to the school
district regarding Arthur’s assessment at an administrative
meeting called to decide placement options for Arthur within
the public school system. Given his test results, you suggest
he have a specialized placement where he can receive
sufficient attention to his learning and behavioral and emotional
needs. In addition to an IEP, you are also recommending a
FBA be conducted by school personnel so that they can
develop a behavioral intervention plan for use in the school.
What Goals and Objectives would you want to see as part of
his IEP? Would you recommend other related services, and if
so, what would the nature of those services be?
7. Prepare a script for role-playing each of the player’s parts in
the school meeting, mentioned above. Who do you think
should be attending the meeting? How could each participant
potentially contribute information to assist with developing an
intervention plan that would best meet Arthur’s needs?
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CASE 9 BRIAN WILLIAMS : MY
NAME IS WILLIAMS, TOO:
WILLIAMS SYNDROME
Brian came to the clinic accompanied by his grandmother. At 9
years 7 months of age, Brian was a walking paradox. On the one
hand, he was a highly sociable youngster and showed a maturity in
caring and empathy for others. His welcoming and friendly
demeanor should have set the stage for a host of social
relationships. However, he experienced extreme problems with
social functioning. Despite a keen love of people and a strong
desire to have friends, Brian could also appear anxious, experience
numerous peer difficulties, and then withdraw socially. Brian’s
original assessment results from testing conducted when he was 4
years old and again when he was 6½ have revealed wide
variations in patterns of strengths and weaknesses for intellectual
and adaptive functioning. An update was requested to evaluate
interim gains and to reexamine his profile of strengths and
weaknesses, especially in the social arena, and to provide
intervention strategies to assist with social functioning.
Academically, Brian continues to struggle, especially with very
basic math concepts, while language-based functions are an area
of relative strength. A reevaluation was requested to better identify
the nature of his difficulties to assist with recommendations for
interventions in the future.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
Brian’s paternal grandmother accompanied him to the clinic and
provided the information for the family background and
developmental history for this African American family. Brian’s
mother gave birth to Brian when she was only 17 years. The
delivery was by cesarean section due to fetal distress. Brian was
beyond a full-term baby and considered as “prolonged gestation,”
born at approximately 42 weeks, and weighing 7 pounds 11
ounces. The Apgar score was 9 for entries recorded at 1 and 5
minutes. Brian’s biological father was 20 years old at the time of his
birth. Brian currently lives with his father and paternal grandparents
and has visitation with his mother two or three times monthly.
Currently, his father works as a machine operator and his mother is
a cashier.
M otor milestones were delayed, and he was able to roll over at 6
months, sit at 12 months, and walk at approximately 18 months. In
addition, fine motor skills have always been problematic, and he
has experienced problems with writing, buttoning his clothes, and
tying his shoes. Although speech was initially delayed, not saying
his first word until his first birthday, once he began to combine
words and produce two-word utterances, his language skills
seemed to improve dramatically. Currently, language is an area of
strength for Brian, while fine motor skills continue to be an area of
significant weakness. Visual spatial skills are also area of
weakness, with little interest or aptitude in putting together puzzles
or working with legos.
When discussing his general health and outlook, his grandmother
said that Brian started out as a very fussy and colicky baby who
had a lot of problems swallowing and keeping his food down and
falling asleep and staying asleep. However, when he outgrew that
stage, he developed into a very agreeable and happy youngster. In
fact, he was so overly social that she was afraid he would go away
with anyone. He seemed to be totally focused on people, their
faces, and their voices, from the time he could walk, and teaching
him about “stranger danger” continues to be a worry. However,
even though he is drawn to people, he is also anxious enough that
she believes he would not really go away with anyone. He has
many fears and often can be clingy. He can also worry about the
strangest things. Grandmother recalled that after hearing a story
about sink holes on the news, Brian was worried that he would be
swallowed up if a sink hole happened in his yard or the school
yard. Once he starts worrying about something, she said, it takes
considerable patience to have him stop dwelling on it. There are
times, she admitted, when he can be oppositional at home, but his
teachers really do not see that behavior at school. For the most
part, his teachers describe him as a pleasant child who tries to be
accommodating. However, grandmother and teachers have been
puzzled about why there is such a disconnect between his social
desires and the outcomes of his relationships, and to this point, no
one seems to be able to shed any light on the subject.
His health has been good; however, he was diagnosed with a
heart murmur last fall, which is being monitored. In view of this, the
pediatrician has recommended that he lose weight, although his
grandmother does not think he needs to. He was prescribed
glasses this spring for strabismus, and unlike most kids who balk at
wearing glasses, he was delighted because the preacher wears
glasses.
When asked about his personality and strengths he might have, his
grandmother responded with a huge smile and said, “That boy is
gonna be a preacher some day!” She said church is one of his
favorite activities and he loves to sing the hymns, which he has
committed to memory. He is also able to recite the sermon when
they get home and often she finds Brian standing in front of the
mirror preaching the sermon that they have just heard and using
the exact emphasis on the words, sounding just like the preacher.
The choir master has said that Brian has “absolute pitch,” a rare gift,
especially in one so young, without any formal training. She was
very proud of Brian’s performance in church last Sunday when he
sang a duet in front of the congregation that was flawless, and he
had absolutely no sense of stage fright. Grandmother also
mentioned that despite his gift and love for music, he has very
sensitive hearing and will sometimes overreact to sounds
(especially high-frequency sounds) by covering up his ears. Brian
did have a middle-ear infection (otitis media) a few years ago, but it
has not happened since. She had mentioned this overreactivity to
sound on the last visit to the pediatrician, who has scheduled an
appointment with a hearing specialist. Grandmother wondered why
Brian has such a short attention span for school subjects (he is
very distractible at school) but he can listen to music for a long time
and does not miss a musical note.
She said that she has tried to get him to slow down on the
sermons, but he seems to be obsessed and often just goes on
whether she likes it or not. Although he has tried to bring this
behavior into the classroom, it was quickly discouraged as
disruptive, and he has complied with his teachers’ requests.
Brian has been assessed twice in the past, and results have been
inconclusive, with little explanation of why his profile is so extreme
or to help explain his problems in the social area. The following is a
summary of those findings.
Brian was seen at the child development center prior to his
entrance into the kindergarten program, just before his fifth birthday.
At that time, scores on the Differential Abilities Scale (DAS)
revealed the following standard scores: Verbal Cluster of 70 (range
70–87) and Nonverbal Cluster of 67 (range 61–72). General
Conceptual Ability was a standard score of 65. The Spatial Cluster
was not reported. Scores on the Bracken Basic Concept Scale
(BBCS-R) revealed significant delays in conceptual development,
with an overall standard score of 63 (1st percentile), equivalent to
an age score of 2 years 6 months at a chronological age of 4 years
10 months. The evaluator noted, however, that there was
significant variability in his conceptual skills, with significant
weaknesses noted for conceptual skills in areas of
Direction/Position and significant strengths noted in concepts
related to Self/Social Awareness. Grandmother completed the
Vineland Adaptive Behavior Scales, which resulted in an overall
Adaptive Behavior Concept of 69 (3 years 4 months). Strengths
were noted in areas of Socialization (SS = 76; 3 years 0 months),
Communication (SS = 76; 3 years 3 months), and Daily Living (SS
= 86; 4 years 1 month). A significant weakness was evident in
M otor Skill Development (SS = 61; 3 years 1 month).
Brian was seen in the child development clinic, again when he was
6 years 6 months of age. At that time, the Standford Binet 5 was
administered. His overall full scale IQ score was 67 (range 60–75),
with a standard score for Verbal Reasoning of 72 and Nonverbal
Reasoning of 66. Overall Visual Spatial Reasoning was a significant
weakness (SS = 59), while Working M emory for auditory
information was a relative strength (SS = 12). Academically,
according to the Woodcock Johnson Test of Achievement (WJIII),
he was functioning at the following levels: Broad Reading (SS =
86), Broad M ath (SS = 69), and Broad Written Expression (SS=
85). As a result of his assessment, it was recommended that
physical therapy be added to his services for “awkward gait” and
fine motor problems. Brian was already receiving occupational
therapy.
REASON FOR REFERRAL
When asked what one thing she would like to find out about Brian
from the current assessment, his grandmother said, “To finish the
puzzle.” She explained that although he had been assessed twice
before, no one could provide any “name” for his condition or explain
why he behaves the way he does and how to help him. She said
that he is becoming increasingly frustrated socially, and she is
afraid that he will begin to withdraw into his fantasy world about
being a preacher. She just wanted him to have fun with friends and
wanted to know how to help.
ASSESSMENT RESULTS
When Brian entered the room, he presented as a child who looked
much younger than his 9½ years. He had a short stature, and his
facial features were distinct with pronounced eyes, puffiness
around the eyes, a short nose with a broad tip, and large ear lobes.
His cheeks were full and filled with a wide smile. Yet his features
seemed almost top heavy, with a broad forehead and a jaw that
was very narrow and slight. Although Brian was very interested in
meeting the psychologist, he was somewhat apprehensive and
anxious, so his grandmother sat with them for the first 5 minutes
and then Brian was fine. Although he was cooperative initially, he
was very easily distracted and had a hard time remaining seated.
He preferred to stand during parts of the assessment and often
shifted his weight from side to side. When asked about his likes
and dislikes, Brian said music and “preaching” were his favorite
things. As for dislikes, Brian said that he hated broccoli, because it
tasted like “sand and rocks,” and he also did not like surprises
because they were scary. When asked what else was “scary,”
Brian said loud noises, especially fire alarms, and that it was scary
when another teacher was in his class because his teacher was
sick.
Responses to the Differential Abilities Scale (DAS:2) revealed an
overall General Conceptual Ability Level (GCA) of 70 (range 66–
77), placing his functioning at the 2nd percentile. However, as had
been found on previous assessments, there was a significant
discrepancy between ability levels in different areas. While he
scored within the low average range for Verbal Reasoning (SS =
84), he scored within the extremely low range for Spatial
Reasoning (SS = 64). Nonverbal Reasoning was approximately
midway between these two ranges (SS = 72). Brian encountered
extreme difficulty with both spatial tasks: recall of designs and
pattern construction. He encountered significant problems with
design recall because of his very poor fine motor skills and his
inability to recall how the design parts fit together or their
orientation in space. He could reproduce some parts, but there was
no relationship between them. Brian did not seem to be frustrated
by the pattern construction task; he just placed his blocks down on
the desk and would then look at the psychologist to indicate that
he was done. He did not seem to understand that the blocks had
to be turned to match the direction of the picture or that there was
a pattern that was to be constructed. This behavior pattern was in
sharp contrast to his skills on the verbal reasoning tasks, where he
was able to provide very good definitions for words and made
good attempts at the verbal similarities; however, this latter task
was more difficult for him due to the abstract nature of the task.
Academically, scores on the Wechsler Individual Achievement Test
(WIAT-III) revealed the following standard scores and grade-level
equivalents: Oral Reading Fluency (SS = 76; grade equivalent of
2.2), Reading Comprehension (SS = 60; grade equivalent of 1.7),
M ath Problem Solving (SS = 54; grade equivalent of K.8),
Numerical Operations (SS= 60, grade equivalent of 1.0), and
Spelling (SS = 63; grade equivalent of 1.5). Given these results,
Brian is achieving above the level expected, given his GCA (70) in
Oral Reading Fluency; however, all other scores are below the
expected level. M ath Problem Solving was significantly (16 points)
below his anticipated level of functioning.
Brian’s teacher and grandmother completed the Adaptive Behavior
Assessment System (ABAS III), and the discrepancy between
scores obtained on this adaptive measure for the various areas
was even more extreme than had been obtained in early
administrations. Despite having an ability level for cognitive
functioning that places his reasoning ability around the 2nd
percentile (GCA 70), ratings for Total Social Adaptation were well in
excess of this level and in the average range, as rated by his
teacher (SS = 95) and grandmother (SS = 107). Also, in terms of
the Practical Adaptive score (measuring community use,
home/school living, health and safety, and self-care), Brian scored
in the average range (SS = 101) according to his grandmother and
just below the average range (SS = 89) according to his teacher.
However, in the area of Total Concepts (including communication,
functional academics, and self-direction), Brian was well below the
range expected, given his GCA. On this area, his grandmother
rated him in the extremely low range with a standard score of 55
and his teacher rated him with a standard score of 61. As can be
seen, although his Overall General Adaptive Composite for
grandmother’s rating (SS = 80) and teacher’s rating (SS = 84) is a
score that reflects overall functioning in lower average range, it is
based on a profile of abilities that are widely spaced apart.
Finally, the Conners parent and teacher rating scales were
completed by Brian’s grandmother and teacher. Although his
teacher rated him as clinically significant in the area of inattention
and in the at-risk range for hyperactivity, his grandmother did not
rate his behaviors on this scale as significant and did not feel there
were significant concerns regarding the possibility of Brian having
symptoms of attention deficit/hyperactivity disorder (ADHD).
Grandmother and teacher completed the Devereux Scales of
M ental Disorders (DSM D), which revealed significant attention
problems, only on the teacher rating scales. However, grandmother
and teacher ratings did agree on the existence of significant
symptoms of anxiety, especially endorsing fearfulness in many
areas, and endorsed several items relating to social intrusiveness
(annoys others, talks too much, interacts with strangers
inappropriately, etc.).
Summary of the Psychologist’s
Findings/Impressions
Brian is a 9½-year-old boy who demonstrates a wide discrepancy
between and within his intellectual and adaptive functioning skills.
Intellectually, although his overall functioning is low (2nd percentile),
this represents a composite score of three very different ability
levels: a significant strength in Verbal Reasoning (low average); a
significant weakness in Spatial Analysis (extremely low); and a
Nonverbal Reasoning Ability (low) that is midway between these
two levels. From an adaptive perspective, while he has obvious
strengths in social adaptation and a desire to make friends, he is
currently not successful in maintaining any long-term friendships.
He has some obvious and possible “savant skills” in the areas of
musical ability (pitch, tone, and recall for lyrics and melodies) and
can sustain attention for musical activities over a long period of
time. On the other hand, academically, his attention span is short
and he is highly distractible and fidgety when required to focus on
academics in the classroom (or in the assessment situation).
During the assessment session, he was very restless and moved
about constantly. He has acquired a good ability to decode and
read; however, this is likely due to his good memory for phonetic
information. His reading comprehension and written expression lag
behind, likely due to cognitive deficits in dealing with more abstract
applications of language functions. M athematical skills that can
benefit from visual spatial abilities are an obvious area of
weakness for Brian.
Brian’s physical features, including his short stature, distinctive
facial features (broad forehead; wide eyes with puffiness around
the eyes; a short nose with a broad tip; full lips; wide smile; full
cheeks; and small, receding chin), his intellectual and adaptive
profile, his musical ability, and his intense interest and desire for
social connectivity, all suggest the possibility of a diagnosis of
Williams syndrome (WS). Individuals with WS often present as a
paradox because they are drawn to social contact, and on the
surface, due to strengths in verbal skills, it seems that they should
be among the most popular children. However, deficits in
processing cognitive information may result in their inability to
interpret the subtle nuances of social situations or to understand
the more complex social dynamics evident in visual spatial
processing (e.g., appreciating social space), and they are likely to
be rejected by peers as a result. Because of their empathy and
sensitivity, however, this may result in their becoming more
apprehensive and anxious in social situations, and they may
withdraw from social contact. Since they are drawn to social
contact, though, they may place themselves in this situation in a
repetitive basis, which may result in increased anxiety and
depression in adulthood. Since the majority of individuals with WS
have cardiovascular problems, and especially in light of a heart
murmur being recently diagnosed, it is recommended that Brian
receive a complete cardiology workup. Also, since individuals with
Williams share many symptoms of ADHD, and given his behavior in
the classroom and assessment setting, further consultation with
the family physician is recommended. Brain also has many fears
and anxieties that can be overwhelming for him at times, especially
loud unexpected noises, like fire alarms. He also has a tendency to
dwell on things that cause him to be fearful, and it takes much
convincing to calm him down.
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
In the introduction to their book about WS, Semel and Rosner
(2003) pose the question, “How is it possible to conceptualize a
group of children who test as though retarded, speak as though
gifted, behave sometimes as though emotionally disturbed, and
function like the learning disabled?” (p. 1). In essence, this
summarizes some of the puzzling aspects of individuals with WS, a
genetic neurodevelopmental disorder occurring in approximately 1
in 7,500 births (Stromme, Bjornstad, & Ramstad, 2002) to 1 in
10,000 births (Huang, Sadler, O’Riordan, & Robin, 2002). However,
according to Huang et al. (2002), there is a significant delay in the
diagnosis of WS by pediatricians, since physical manifestations of
the disorder may be very subtle at an early age, making diagnosis
difficult in infants and young children. The authors survey 46
parents of children eventually diagnosed with WS and found that on
average children were not diagnosed until approximately 3½ years
of age, despite concerns noted in the first year. Involvement of a
geneticist was associated with significantly earlier diagnosis. The
authors also speculated that the pediatricians may not have been
aware that irritability and gastrointestinal problems/vomiting were
common symptoms of WS in the first year.
While the disorder is most commonly referred to as WS in the
United States, in Europe, the disorder is often referred to as
Williams-Beuren syndrome (M orris, 2006a). There is a deletion on
chromosome 7 (part of the chromosome is missing), and although it
occurs as a random genetic mutation, individuals with WS have a
50% chance of passing the gene on to their children (Bellugi et al.,
2007). The deletion involves the elastin gene (ELN), which is a
major component of connective tissues, such as the ligaments,
lungs, heart valves, and arteries, allowing them to expand and
contract (Gosline et al., 2002). Approximately 80% of those with
WS will have some cardiovascular anomaly, while 95% will have
developmental delay (M orris, 2006b). Individuals with WS often
exhibit early cardiovascular problems that may result in premature
death (average life span of 50 years). Some of the more common
cardiovascular difficulties include narrowing of the arteries,
hypertension, and strokes (Kaplan, 2006). In one study of
individuals with WS, 75% were diagnosed with a heart murmur at
some point in their lives (Jones & Smith, 1975).
Problems with ears and hearing include middle-ear infections (otitis
media experienced by 60% of children with WS) and ear pain or
hyperacusis (Kaplan, 2002), often associated with heightened
sensitivities to certain sounds, often high-frequency sounds
(Dykens, 2003; Einfeld, Tonge, & Florio, 1997; Van Borsel, Curfs, &
Fryns, 1997). By late childhood, some children with WS will develop
sensorineural hearing loss for high-frequency sounds in one ear
(Johnson, Comeau, & Clarke, 2001). There are also vision
problems associated with WS, such as hyperopia, which occurs in
68% of those with WS (Winter, Pankau, Amm, Gosch, & Wessel,
1996), and strabismus, which is likely in between 27% and 78% of
the population (Kaplan, 2002). Infants with WS are often described
as fussy and colicky, although the majority outgrow this in the first
year and become much more content and happy as toddlers
(Levine & Wharton, 2000). However, many children with WS have
difficulty falling asleep and maintaining sleep (Einfeld et al., 1997),
and they are more likely to experience “restless leg syndrome,”
periodic limb movements during sleep, than peers without the
disorder (Arens et al., 1998).
While many with WS will exhibit developmental delays, there is a
wide range of IQ scores possible within the WS population, from
low average intelligence to severe intellectual disabilities. M ean IQ
scores have been reported in the 55–60 range (M ervis, M orris,
Bertrand, & Robinson, 1999; Udwin, Davies, & Howlin, 1996). There
are excellent strengths in verbal short-term memory (Udwin & Yule,
1991), and linguistic skills are far superior to those with Down
syndrome (Bellugi, Lichtenberger, Jones, Lai, & St. George, 2000);
however, Singer Harris, Bellugi, Bates, Jones, and Rossen (1997)
found that the superiority of skills in those with WS did not surface
until after the initial accumulation of approximately 50 words. As
children and adults, despite overall limitations, intellectually, they
demonstrate remarkable skills in expressive vocabulary, syntax,
and semantics (Bellugi, Wang, & Jernigan, 1994; Udwin & Yule,
1990).
However, in individuals with WS, there are significant deficits in the
visuospatial area, including tasks of visual motor integration evident
in difficulty with fine motor tasks such as handwriting and copying
(M ervis, Robinson, & Pani, 1999). According to Rourke et al.
(2002), individuals with WS evidence processing deficits similar to
those of individuals with nonverbal learning disabilities (NLDs). This
is especially true for strengths in verbal skills (yet obvious
weaknesses in the subtle nuances of social pragmatics) and
deficits in visual spatial and visual motor integration. Often there is
evidence of remarkable musical ability both in the ability to produce
absolute and relative pitch (Lenhoff, 2006) and in memory for tone
and lyrics, which may be related to their strong phonological
memory skills (Peretz & Coltheart, 2003).
In their study of social competence in individuals with WS, Rosner,
Hodapp, Fidler, Sagun, and Dykens (2004) found that compared to
peers diagnosed with Down syndrome or Prader–Willi syndrome, in
a situation of free choice activities, those with WS tended to
gravitate toward activities that included musical instruments, while
they tended to avoid activities like puzzles that required visual
spatial skills. Occupational problems that have been associated
with adolescents and adults with WS include job interference due
to distractibility, social disinhibition and overfriendliness, and anxiety
(Davies, Howlin, & Udwin, 1997). In addition, deficits in visual motor
skills required in many chores, such as bed making, and entry-level
jobs, such as assembly line work, have also been identified as
barriers to success (Dykens, Hodapp, & Finucane, 2000).
Individuals with WS are characteristically overly friendly and often
can be socially inappropriate and somewhat intrusive due to their
trait of “social disinhibition” (Wang, 2006). Bellugi et al. (2007)
describe those with WS as demonstrating a “hypersociability,
including overfriendliness and heightened approachability toward
others, combined with anxiety relating to new situations and
objects and a difficulty forming and maintaining friendships with
peers” (p. 99). The researchers suggest that although they do not
see social situations as threatening, per se, their overly anxious
nature may undermine their ability to successfully connect their
social perceptions with their social expression, resulting in an
inability to successfully engage in social encounters. Also, they
seem to lack social pragmatics, such as the recognition of social
group membership, which can place them at a serious
disadvantage and even risk, since they enthusiastically will
approach strangers and family members in the same manner. They
are also prone to repetitive greetings, unaware of social
conventions, and may engage in incessant greeting behavior or
use forms of address that are overly familiar when greeting virtual
strangers (Semel & Rosner, 2003).
Although children with WS can be anxious by nature, they do not
respond to threatening faces like other children do, as a result of
unusually low activation levels in the amygdala, which is
responsible for regulating the fear response (M eyer-Lindenberg et
al., 2005). Fifty percent of individuals with WS are diagnosed with
ADHD and generalized anxiety, while about 50% have specific
phobias, especially fear of loud noises (Doyle, Bellugi, Korenberg,
& Graham, 2004; Klein-Tasman & M ervis, 2003).
Semel and Rosner (2003) identify six types of behavior problems
that commonly occur in individuals with WS, including “fears and
anxieties, distractibility and attentional problems, impulsivity, poor
adaptability, low frustration tolerance, and atypical activity” (p. 295),
evident in such behavior patterns as restlessness, fidgeting, and
stereotyped movements (squirmy or engaging in repetitive motor
routines), wandering, overactivity, and hyperactivity. Individuals with
WS also experience problems in regulating their emotions, which
can result in heightened responses and inflated emotional
reactions to unexpected sights, sounds, or tactile stimulation.
Semel and Rosner (2003) suggest that inherent to their behavior
problems are tendencies toward high reactivity in the presence of
low self-regulation.
Intervention Programs
M edical management is an important component of planning and
programming for children with WS. Kaplan (2006) suggests that
“optimal medical, educational, and community support can help the
child with WS lead a fulfilling life” (p. 83). Physicians can consult the
guidelines for managing WS produced by the American Academy of
Pediatrics (2001), while parents can also consult specialists in
multidisciplinary clinics that have been established throughout the
United States for the treatment of WS. The multidisciplinary team
servicing the WS clinic would have personnel with expertise in
areas such as cardiology, genetics, developmental pediatrics,
behavioral pediatrics, psychiatry, pediatric psychology, and
neurology, as well as access to physical, occupational, and speech
therapies. According to Kaplan (2006), children should be
reevaluated in the clinic every 3 years.
Special education and related services would be an important
aspect of the child’s programming on a day-to-day basis. Because
most of the children will require assistance with academics, special
education programming would be required, especially in areas that
are more dependent on visual spatial analysis such as
mathematics and for assistance in understanding subject material
that requires higher-order processing, such as reading
comprehension, solving word problems, and written expression.
Related services: Physical and occupational therapy should be
provided, if needed, for possible areas of support such as awkward
gait, handwriting, and fine motor skills.
Social skills training programs may be helpful to increase the ability
to integrate social perceptions and social expression and to
provide an opportunity to practice skills in an environment that
minimizes anxiety.
A successful cognitive behavioral intervention for reducing anxiety
in children is the Coping Cat Program (Kendall, 1994). The program
is suited to children 7–16 years of age and has been used to treat
several forms of anxiety, including separation anxiety disorder,
generalized anxiety disorder, and social anxiety disorder. The
program can be administered individually or in group settings
(Flannery-Schroeder & Kendall, 2000) and focuses on the
development of coping skills (first eight to nine lessons) and then
on practicing those skills in either imagined or in vivo (actual)
conditions (last eight to nine sessions). An acronym developed for
the program acts as a memory aid for highlighting the four key
steps in the process:
Feel frightened (recognition of physical symptoms that
accompany anxiety)?
Expect the worse (recognition of negative self-talk)?
Attitude/actions that can help (replace negative self-talk with
positive coping comments).
Results and rewards (self-monitoring, evaluation, and selfreward).
For adolescents and young adults with WS, concerns about
completing chores and doing many entry-level jobs such as
assembly line work that rely on visual spatial skills can be assisted
with the ongoing support of job coaches (Dykens et al., 2000).
Semel and Rosner (2003) suggest a number of interventions that
can assist the behavioral problems of those with WS. They
suggest that techniques that draw on strengths of individuals with
WS (e.g., verbal mediation, stress reduction, environmental control)
would all potentially benefit those with WS. The following is a
summary of some of the techniques that have been addressed by
Semel and Rosner.
Fears and anxieties: In addition to methods already suggested
(e.g., Kendall’s Coping Cat Program), Semel and Rosner (2003)
suggest teaching verbal mediation strategies and providing
reassurance, role-play, explanations, and self-instruction (selfstatements to calm in times of stress) can all assist in reducing
fears and anxieties. In addition, providing a structured and
predictable environment and minimizing alterations to schedules
can also assist in reducing anxiety. Teaching relaxation techniques
for use in the presence of behavioral methods such as systematic
desensitization and imagined or in vivo practice to overcome
feared situations in a step-by-step manner can also be beneficial.
Learning and distractibility: Using direct instruction to focus on the
task at hand and ensuring that instructions are repeated to check
for errors can assist with day-to-day performance in a number of
areas, academically and socially.
Classroom seating: Seating close to the board and where the child
can have eye contact with the teacher will assist focused
performance and reduce distractibility. Seating away from major
traffic routes in the classroom can also improve chances of
success.
Medication: To date, few studies have investigated
psychopharmacology alternatives for individuals with WS for such
problems as anxiety, depression, and ADHD. Kaplan (2002)
suggests the following regime for individuals with WS who have
ADHD and/or sleep problems: “M ethylphenidate appears to be
effective for ADHD at a dosage of 0.5 mg/kg or 10 mg twice daily
and Clonazepam significantly improves sleep and behavior” (p.
279).
Post-Case Questions
1. Individuals with WS often meet criteria for intellectual disability.
Given Brian’s assessment results and symptoms as
presented in the case study, would Brian meet criteria for an
intellectual disability according to the DSM -5 (APA, 2013)?
Would he qualify under IDEA (2004) for special education and
related services? Support your answer with specific references
to the criteria (Appendix B may be helpful) and Brian’s
assessment results.
2. There are several similarities and differences between
individuals with WS and individuals with NLDs. Compare
information from Brian’s case with that of Sandy Smith. What
are the similarities and what are the differences in these two
cases?
3. Children with WS are often seen as the opposite of those with
autism spectrum disorders. What are the similarities and
differences between the case studies of Brian and Dylan
Bach?
4. As Brian’s therapist, how would you help him deal with his fear
of loud noises? Develop a program that can be used in the
home and in the school.
5. Using Brian’s strengths, develop a program to help him feel
more successful socially.
6. Suggested individual or group presentation activities:
You have been invited to provide feedback to the school
regarding Brian’s assessment at a meeting where they will
decide whether Brian should receive Special Education
and Related Services. If it is determined that he is eligible
for services, what Goals and Objectives would you want
to see as part of his individualized education program?
Would you recommend he receives related services, and
if so, what would the nature of those services be?
Prepare a script for role-playing each of the player’s parts
in the school meeting, mentioned above. Who do you
think should be attending the meeting? How could each
participant potentially contribute information to assist with
developing an intervention plan that would best meet
Brian’s needs?
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CASE 10 BRADLEY HUNTER : NOT
YET DIAGNOSED
NEURODEVELOPMENTAL
SYMPTOMS
Bradley is an African American male who is 5 years 5 months of
age and enrolled in the kindergarten program at John Williams
Elementary School. He is currently receiving services from the
special education resource teacher under the category of
Developmental Delay. He also receives speech and language
therapy, as well as occupational therapy as related services.
Reevaluation was requested to determine the extent of his delays
currently and the nature of his learning problems.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
Bradley is at risk for neurodevelopmental difficulties due to a
history of prematurity and its complications. Bradley’s mother
provided the following information regarding his developmental
history. M other was 22 years when she was pregnant with Bradley
and reported that she did not smoke or drink during the pregnancy.
She was, however, involved in a car accident when she was 25
weeks pregnant and was admitted to emergency due to vaginal
bleeding. Throughout the remainder of the pregnancy, there were
several incidents of vaginal discharge. Bradley weighed 3 pounds
at birth and was born at 28 weeks gestation. Apgar was 6 at 1
minute and 7 at 5 minutes. Bradley was placed on a ventilator for
2½ weeks after birth because he suffered from respiratory distress
syndrome.
A tracheotomy was performed due to upper airway obstruction, as
Bradley was not getting enough oxygen. He remained in the
hospital until he was discharged, 120 days after his birth. While
hospitalized, he developed pneumonia several times. Two years
ago, he returned to the hospital, where he had a laryngoscopy and
adenoidectomy in preparation for having the tracheotomy tube
removed 2 months later.
Bradley’s motor and speech and language milestones have all
been delayed, and Bradley did not begin walking until he was 19
months of age. When he was 26 months old, he was seen at the
Infant Care Clinic for physical therapy and speech and language
assessments. At that time, his expressive and receptive language
score was 18 months, while global language was 16 months.
Physical therapy evaluation at that time revealed that motor skills
ranged from 14 months for stationary skills to 17 months for
locomotion to 19 months for object manipulation.
Due to the severity of his problems and pervasive delays, Bradley
was seen in the Child Developmental Clinic when he was 34
months of age. At that time, the Bayley Infant Scales (Bayley-2)
were administered and Bradley scored an age equivalent of 22
months, with a M ental Development Index (M DI) of 54. M other
was interviewed and the Vineland Adaptive Behavior Scales were
administered. Bradley scored in the following ranges:
Communication SS = 64 (16 months), Daily Living SS = 67 (19
months), Socialization Skills SS = 83 (24 months), M otor Skills SS
= 70 (23 months), and the Adaptive Behavior Composite SS = 65
(21 months). At 34 months of age, Bradley was in the process of
being toilet trained; however, nocturnal enuresis was occurring on a
nightly basis. The examiner noted that although Bradley was
almost 3 years old, his mother reported that he was not yet able to
drink from a cup or use a fork. He was, however, able to use a
spoon and drink from a sippy cup. During the interview with the
psychologist at the clinic, Bradley’s mother described him as being
a highly active youngster who was impulsive and easily distracted.
She also noted that he can be very stubborn and aggressive,
especially with his brother, whom he often fights with. He is difficult
to manage and is prone to throw temper tantrums when he cannot
have his way.
M other is now 27 and father is 30, and they both have some
community college education. M other said that neither she nor
Bradley’s father had any learning problems in school. Bradley has
an older brother who is 8 years old who has significant
developmental delays and receives special education services.
M other and father are no longer living together, and Bradley lives
with his mother, the maternal grandmother, an uncle, and his older
brother. Bradley has not had any contact with his biological father
since his birth. Several paternal cousins have behavior problems
and attention deficit/hyperactivity disorder. A paternal aunt has an
intellectual disability.
REASON FOR REFERRAL
It has been approximately 2 years since Bradley has had an
assessment of intellectual and adaptive functioning. Having the
benefit of having scores from his previous assessments will be
helpful in understanding how Bradley’s skills have developed since
that time. There was a question as to whether Bradley might have
symptoms of a neurodevelopmental disorder, such as autism
spectrum disorder (ASD), so a comprehensive assessment was
conducted to provide as much information as possible to assist
with future planning.
ASSESSMENT RESULTS
Bradley was initially observed in the regular kindergarten classroom
for a 30-minute observation period. At the time, the class was
engaged in determining the sequential pattern of a series of
interlocking colored blocks (independent seatwork), followed by a
small group interactive activity about community helpers.
During the first part of this observation period, Bradley dropped a
block and he bent down to pick it up until the teacher came over to
see why he was not working. He then told the teacher that he
could not work because the block fell on the floor. The teacher
instructed him to pick up the block and continue with the
sequencing task. This delay set him behind his classmates in
completing the task. While he worked, he talked out loud to himself
in order to guide his selections (e.g., “blue, blue, black…”) but then
shortened the scheme (“blue/black … blue/black”), which resulted
in completing the task incorrectly. He seemed excited about
completing the task (“I did it!”) and was not discouraged when the
teacher noted that it was incorrect, and he set out to fix it.
Bradley seemed to be very aware of the class routines and
followed the other children as they participated in snack time and
tidying up. Although he did not interact with the other children, he
did seem to be observing them and then would follow along and
imitate what they were doing. After snack time, Bradley went to the
play mat and was joined by a couple of other children. He then
made some strange guttural noises and faces, which the other two
boys repeated, until the teacher told the boys to stop imitating him.
The final activity was matching community uniforms to
community/employment roles. Bradley was the only one in the
group to recognize the word “astronaut” and was very pleased to
be able to dress the cut-out appropriately in the correct uniform.
Although Bradley demonstrated an ability to follow predictable
routines, he also revealed an inability to adapt if something
unpredictable happened, such as dropping the block. Adaptive
behavior deficits seemed to be most pronounced in areas of social
and pragmatic concerns.
The psychologist administered the Differential Ability Scales (DAS2) and Bradley obtained the following standard scores, placing his
ability in the low average range: Nonverbal Reasoning Ability, SS =
87; Verbal Ability, SS = 85; and Spatial Ability, SS = 83. Overall,
General Conceptual Ability was a standard score of 81 at the 10th
percentile. Academically, his scores on the Young Children’s
Achievement Test (YCAT) revealed standard scores above his
ability level in all areas except Spoken Language (SS = 79). Other
academic scores included General Information, SS = 90; Reading,
SS = 100; M athematics, SS = 91; and Writing, SS = 109. Compared
to his previous assessment results, Bradley had made excellent
gains in his ability and academic skills.
Bradley’s mother and teacher completed the rating scales for the
Adaptive Behavior Assessment System (ABAS III). There was a
significant difference between scores obtained on the mother’s
ratings when compared to the teacher’s ratings. Scaled scores can
range between 1 (very inferior) and 19 (very superior). While his
mother rated him extremely low (all scores were scaled scores of 1
or 2), the teacher’s ratings were significantly higher. However, both
mother and teacher rated Bradley a scale score of 1 for
communication. According to his teacher, his functional academics
were within the average range (scale score of 11), which is
consistent with Bradley’s scores on the YCAT. However, even
though his teacher rated him significantly higher than his mother, his
adaptive scores were much lower than would be predicted, given
his scores on the DAS-2. According to the teacher, his adaptive
scores for Social were SS = 70 and Practical SS = 75, with an
Overall General Adaptive Composite of SS = 70. According to his
mother, these scores were significantly lower: Social, SS = 54,
Practical, SS = 40, and Overall General Adaptive Composite, SS =
41.
The parent and teacher completed an informal screening
questionnaire concerning symptoms often associated with ASD.
The following list of descriptions was endorsed as occurring
sometimes or frequently, both at home and school:
Social interaction:
Requires specific instructions to begin task
Lacks subtlety in expression of emotion
Has difficulty cooperating in a group
Has difficulty playing with other children
Does certain things repetitively or ritualistically
Has difficulty understanding when being teased
Fails to predict consequences in social events
Communication:
Repeats or echoes words or phrases
Speaks with flat affect
Fails to initiate conversations
Answers questions inappropriately
Uses pronouns inappropriately
Stereotypical behavior:
Flaps hands or fingers
Eats specific foods, a fussy eater
Rocks back and forth while seated or standing
Flaps hand or fingers in front of his face
Demonstrates eccentric forms of behaviors
Has abnormal focus, preoccupied with specific objects
Requires extensive direction from others
Is clumsy or uncoordinated
Cognitive patterns:
Talks about single subjects excessively
Displays superior knowledge or skill in a specific area
Has difficulty understanding jokes, humor, sarcasm
Shows excellent memory
Pragmatic skills:
Has difficulty understanding slang
Has difficulty understanding when being teased
Has difficulty understanding when ridiculed or made fun of
Has difficulty understanding what causes others to dislike him
Fails to predict probable consequences to social events
M other and teacher agreed that Bradley has a love of reciting the
alphabet and that he has the same two books that he wants to
read on a daily basis. At home, when Bradley wants something, he
repeats it over and over again, if the answer is no.
M other and teacher also completed the Devereux Scales of
M ental Disorders. Results revealed a number of areas of concern.
There is a consistent agreement between raters regarding
externalizing problems, especially in areas of conduct problems.
Although attentional problems are very evident at school, in the
home situation, these are less pronounced. Teacher and parent
agreed that the following attention problems occur at school and in
the home, at least occasionally, in the form of the following
behaviors: he fidgets or acts restless, becomes easily distracted,
and fails to pay attention. During classroom activities, Bradley is
easily distracted or preoccupied, has trouble concentrating, and
fails to follow through on assignments.
Other areas that have some overlap between the home and
school environments include behaviors that are atypical (e.g.,
autism). According to parent and teacher ratings, there was a
consensus that Bradley frequently or very frequently makes odd
movements, facial grimaces, and noises that can be disruptive in
the classroom.
Post-Case Questions
1. Based on the referral information and the assessment results,
what are your impressions of Bradley? Does he meet criteria
for any of the diagnoses in the category of
Neurodevelopmental Disorders? If so, which diagnoses?
2. If you were assessing Bradley, what other information might be
valuable in developing a case formulation? What other
assessments could you conduct, or what other interview
information might be relevant?
3. How would you account for the significant difference between
the mother’s ratings for Bradley and the teacher’s ratings on
the Adaptive Behavior Assessment System?
4. Suggested individual or group presentation activities:
The principal has called a parent/school meeting to
discuss concerns about Bradley’s progress and his future.
Assign roles to individuals who will role-play important
individuals in Bradley’s life and how they would interact in
this situation. Develop important questions for each of the
players who can add information to the case. Some of the
casting members might be Bradley’s mother, maternal
grandmother, teacher, the psychologist, and any other
individual that you feel might contribute to an
understanding of the case and assist with developing an
overall case formulation and treatment plan.
You have been invited to provide feedback to the school
regarding Bradley’s assessment at a meeting where they
will decide whether he meets criteria for Special Education
and Related Services. If it is determined that he is eligible
for services, what Goals and Objectives would you want
to see as part of his individualized education program?
Would you recommend he receives related services, and
if so, what would the nature of those services be?
3 INTRODUCTION TO DISRUPTIVE
BEHAVIOR DISORDERS
In the previous version of the DSM -IV-TR (APA, 2000),
oppositional defiant disorder (ODD) and conduct disorder (CD)
were classified under the category of “Attention-Deficit and
Disruptive Behavior Disorders,” which was a subcategory of
disorders under the main classification of “Disorders Usually First
Diagnosed in Infancy, Childhood, or Adolescence.” Currently, ODD
and CD are found under the category of “Disruptive, ImpulsiveControl, and Conduct Disorders” (DSM -5; APA, 2013). Other
disorders in this category include intermittent explosive disorder,
antisocial personality disorder (cross-referenced and also
appearing under the category of Personality Disorders), pyromania,
and kleptomania. Disorders in this category share “problems in selfcontrol of emotions and behaviors.” The DSM -5 (APA, 2013)
states that although other disorders may also demonstrate
problems in areas of emotion regulation, the disorders in this
category are unique in the manifestation of “behaviors that violate
the rights of others (e.g., aggression, destruction of property)
and/or that bring the individual into significant conflict with societal
norms or authority figures” (p. 461). Conceptually, the DSM -5
further subdivides problems of self-control into two major areas:
emotional control and behavioral control. At one extreme, disorders
of conduct evidence a significant lack of behavioral controls in a
number of areas which often can result from a lack of emotional
control (anger), while disorders of impulse control primarily are
associated with a lack of emotional control and emotional
responses that are well in excess of what would be attributed to
the event or exchange that provoked the response. ODD is seen
midway between these two extremes with equal tendencies to
exhibit problems in areas of emotional control (irritability) and
behavioral control (defiance).
Developmentally, ODD has earlier onset than CD and may appear
as early as the preschool years, with the average onset around 4
and 8 years of age. Although there was once considerable debate
as to whether ODD and CD were unique disorders or represent a
continuum of the same disorder, with ODD being the milder version
of CD, research supports the retention of two separate disorders,
since the age of onset for ODD is considerably earlier than CD,
and the fact that the majority of children with ODD never go on to
develop CD. Although ODD and CD can often be comorbid
disorders and can share some of the same risk factors, the majority
of children with ODD do not develop CD (Rowe, M aughan, Pickles,
Costello, & Angold, 2002). However, Rowe, Costello, Angold,
Copeland, and M aughan (2010) also noted that despite the
similarities, there are also key differences in the outcomes of ODD
and CD. In their study, using the Great Smoky M ountains Study
longitudinal dataset, they found that having CD largely predicted
largely behavioral outcomes, whereas ODD was more closely
associated with risk for emotional disorders in early adult life.
In their study of the lifetime prevalence of ODD, of over 3,000
adults, from the National Comorbidity Survey, Nock, Kazdin, Hiripi,
and Kessler (2007) found that the lifetime prevalence rate for ODD
was 10.2% (males = 11.2%; females = 9.2%) with over 90%
(92.4%) having a comorbid disorder (mood disorder [45.8%],
anxiety disorder [62.3%], impulse-control disorder [68.2%], and
substance use disorder [47.2%]). In that sample, less than half also
met criteria for CD (42.3%) while only a quarter met criteria for
ADHD (25.0%). Nock and colleagues suggest that the high
comorbidity rates found in their study are likely due to the fact that
they were studying “lifetime” prevalence where the majority of
studies have not measured lifetime prevalence. They also found
that the most likely comorbid diagnoses were other diagnoses with
early onset, such as phobias, separation anxiety disorder, and
ADHD. The average duration of ODD was 6 years, remitting at 18
years of age with earlier onset associated with increased risk of
developing other disorders, later in life.
Although it was once thought that ODD was specific to childhood,
more recent research has suggested that the disorder may have
more longevity than previously thought with evidence of symptoms
persisting into young adulthood, evident as late as 25 years of age
(Biederman et al., 2008; Harpold et al., 2007; Nock et al., 2007).
Comorbidity rates for ODD and ADHD have been reported to be
as high as 65% in some studies (Biederman et al., 1996; Petty et
al., 2009) with 30% of those with this combination persisting into
adulthood (Harpold et al., 2007).
In addition to evidence of a pervasive pattern of “angry/irritable
mood, argumentative/defiant, or vindictiveness” lasting for at least 6
months, the DSM -5 (APA, 2013) criteria for ODD require four
additional symptoms evident in one of the three symptom clusters:
angry/irritable mood (temper, touchy, angry/resentful);
argumentative/defiant behavior (arguments with authority figures,
compliance refusals, annoys, blames); and vindictiveness (spiteful,
vindictive at least twice in last 6 months). The DSM -5 suggests
that depending on the extent to which symptoms are clustered
around “angry/irritable mood” or “defiant and vindictive” traits might
predict whether a child is at risk for developing internalizing
disorders (the former cluster) or CD (the latter presentation). The
DSM -5 provides guidelines for decision-making regarding the
frequency of behaviors relative to normal development for children
younger than 5 years of age (most days in past 6 months) or older
than 5 years of age (weekly occurrence, past 6 months). In
addition, specifiers are available to indicate the severity of the
disorder from mild (one setting), moderate (two settings), or severe
indicators (three or more settings).
CD is also recognized as a persistent pattern of behavior, but one
that focuses on the violation of the rights of others or societal
norms. Three symptoms are required from a list of 15 possible
symptoms clustered into four themes: aggression to people or
animals (bullies, physical fights, weapon use, physical cruelty to
humans, physical cruelty to animals, theft while confronting, forced
sexual activity); destruction of property (fire setting, vandalism),
deceitfulness or theft (break and enter, lies or cons,
shoplifting/forgery); and serious violations of rules (out all night prior
to 13 years, run away, truant prior to 13 years) (APA, 2013, pp.
469–470).
Specifiers are available for CD to provide additional information in
three different areas (onset, limitation in prosocial emotions, and
severity):
Onset: One of the three onset categories can be specified
(childhood-onset, one symptom prior to 10 years; adolescentonset, no symptoms prior to 10 years; unspecified-onset,
unknown).
Limited prosocial emotions: This specifier was added to reflect
recent research in the area of callous and unemotional
characteristics (CU) that are evident in some youth with CD.
Studies have demonstrated that individuals with CU traits do
not recognize emotions in others; exhibit less physiological
response to emotional cues; and are more likely to
demonstrate proactive aggressive patterns and have a family
history of antisocial personality disorder (Hubbard, Smithmyer,
& Ramsden, 2002). This specifier is used if youth demonstrate
persistent characteristics in two of the following areas for the
past 12 months:
Lack of remorse/guilt
Callous/lack of empathy
Lack of concern about performance
Shallow/lack of affect (DSM -5; APA, 2013, pp. 470–471).
Severity: M ild, moderate, and severe specifiers are used to
denote the degree to which symptoms are present.
Children who demonstrate earlier onset have the poorer prognosis;
they are more likely to be male and tend to display more
aggression and have an increased risk for developing CD. M any
individuals with CD also exhibit comorbid disorders of impulse
control, ADHD, and ODD. Other disorders that may be comorbid
with a diagnosis of CD include specific learning disorder, anxiety
disorders, depression and bipolar disorders, and substance use
disorders (APA, 2013).
REFERENCES
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders-IV-TR. Arlington, VA: Author.
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders-5. Arlington, VA: Author.
Biederman, J., Faraone, S. V., M ilberger, S., Carcia Jetton, J., Chen,
J., & M ick, E. (1996). Is childhood oppositional defiant disorder a
precursor to adolescent conduct disorder? Findings from a fouryear follow-up study of children with ADHD. Journal of the
American Academy of Child and Adolescent Psychiatry, 35,
1193–1204.
Biederman, J., Perry, C. R., Dolan, C., Hughes, S., M ick, E., &
M ontuteauz, M . C. (2008). The long-term longitudinal course of
oppositional defiant disorder and conduct disorder in ADHD
boys: Findings from a controlled 10-year prospective longitudinal
follow-up study. Psychological M edicine, 38, 1027–1036.
Harpold, T., Biederman, J., Gignac, M ., Hamamerness, P., Surman,
C., & Potter, A. (2007). Is oppositional defiant disorder a
meaningful diagnosis in adults? Results from a large sample of
adults with ADHD. Journal of Nervous and M ental Disease, 195,
601–605.
Hubbard, J. A., Smithmyer, C. M ., & Ransden, S. R. (2002).
Observational, physiological and self-report measures of
children’s anger: Relations to reactive versus proactive
aggression. Child Development, 73, 1101–1118.
Nock, M . K., Kazdin, A. E., Hiripi, E., & Kessler, R. C. (2007).
Lifetime prevalence, correlates, and persistence of oppositional
defiant disorder: Results from the National Comorbidity Survey
Replication. Journal of Child Psychology and Psychiatry, 48(7),
703–713.
Petty, C. R., M onteaux, M ., M ick, E., Hughes, S., Small, J., &
Faraone, S. V. (2009). Parsing the familiality of oppositional
defiant disorder from that of conduct disorder: A familial risk
analysis. Journal of Psychiatric Research, 43, 345–352.
Rowe, R., Costello, E. J., Angold, A., Copeland, W. E., & M aughan,
B. (2010). Developmental pathways in oppositional defiant
disorder and conduct disorder. Journal of Abnormal Psychology,
119(4), 726–738.
Rowe, R., M aughan, B., Pickles, A., Costello, E. J., & Angold, A.
(2002). The relationship between DSM ‐IV oppositional defiant
disorder and conduct disorder: Findings from the Great Smoky
M ountains Study. Journal of Child Psychology and Psychiatry,
43(3), 365–373.
CASE 11 SCOTT MICHAELS : BOYS
WILL BE BOYS? OPPOSITIONAL
DEFIANT DISORDER; ADHD
Scott came to the intake interview accompanied by his mother,
Ruth. Scott is 9 years old and is currently in Grade 4 at Second
Street School, which he has attended since his earliest enrollment
in kindergarten. According to Ruth, the presenting concerns are
twofold: academic problems at school and behavior problems at
home.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
Ruth described the birth history as uneventful. Scott was born 2
days early and weighed 8 pounds 4 ounces. Developmental
milestones were mildly delayed, and Scott walked at 15 months.
Scott was slow to speak and did not use simple phrases at 3
years. Speech problems continued, and Scott received assistance
for problems with articulation and speech production in
prekindergarten and kindergarten.
Scott was described as an active infant who was not content to
take long naps. Sleeping was not a problem, however, since he
seemed to need his rest after all the activity. There was a problem
with bed-wetting until Scott was 6 years old. The problem was
resolved when they stopped allowing Scott to have apple juice
before bedtime. As a toddler, Scott seemed to be more demanding
than all of Ruth’s other children put together. Scott was not content
to stay in the playpen like his other siblings. He would often
scream and have tantrums until Ruth took him out of the playpen.
However, when he was out of the playpen, he seemed to be into
everything. Scott was very easily frustrated and difficult to calm
down, especially if he could not have his way. At first, Ruth said
she could distract him by offering something else, but that usually
did not last very long. Ruth added that for Scott the “terrible twos”
never went away, but just got worse with each passing year.
Ruth recalled one incident that occurred shortly after Scott’s sixth
birthday. On this occasion, Ruth had asked Scott to help her pick
up some toys that his brother Brian (age 4) and sister Tia (age 2)
had scattered. All of a sudden, Scott started grabbing toys out of
their hands and throwing them at Tia and Brian. Then he went over
to his toy box and dumped the entire toy box all over the floor. The
event made such a lasting impression on Ruth that since that time
she has not asked Scott to help her with cleaning up.
Scott’s academic difficulties became evident early in his schooling,
and Ruth was contacted by the teacher diagnostician, who
recommended that Scott have his vision and hearing tested to rule
out any physical reasons for Scott’s learning problems. Although
Scott’s vision was normal, testing of central auditory processing
(CAP) revealed a selective attention deficit in the left ear, problems
tuning in to auditory information, and likely difficulties with visual
tracking. Recommendations from the CAP assessment were to
present information to the dominant right ear, cue prior to
presenting information, and provide assistance in copying
information from the board. Ruth stated that she had asked her
family physician for a referral to have Scott tested for learning
problems; however, when she took Scott to the appointment
(about a year ago), she was told that testing was not necessary
because Scott did not have any “developmental” problems. Ruth
could not elaborate further on the nature of the therapist’s
expertise.
Ruth outlined the following family history during the course of the
intake interview. There is a history of depression (maternal
grandmother) and alcohol abuse (maternal grandfather) in Ruth’s
family. Ruth’s father was incarcerated several times for assault
resulting from fights in local bars. Ruth’s only brother, Jacob, was
bright but did poorly in school. Jacob seemed to fall in with the
wrong crowd and dropped out in Grade 9. He spent some time in
juvenile detention for breaking and entering, but eventually got back
on track when he joined the armed forces, where he received
training as a mechanic.
Ruth’s husband Eric knows very little about his own family history,
since he was adopted as an infant. Eric’s adoptive parents were
killed in a car accident shortly after Ruth and Eric were married. Eric
has no known siblings. Ruth liked school and graduated from high
school prior to getting married to Eric. Eric did not do well in school,
and he did not complete high school. He currently works at a local
box-making factory. Ruth worked as a grocery clerk at the local
supermarket after graduation, until the birth of her daughter when
she was 20. Ruth has not returned to work since that time. Ruth
admitted that they have had financial problems recently, since the
money from her husband’s inheritance has been exhausted.
Although she was never diagnosed with depression, Ruth does
admit to feeling overwhelmed and exhausted much of the time,
especially since the birth of Tia. Ruth is considering returning to
work now that Tia is in school, but she is afraid of what the
consequences will be for Scott’s behavior. Ruth recalled recently
going to a shower for a neighborhood friend and returning home to
find the kitchen an absolute mess. Apparently, Scott had
deliberately messed up the kitchen in her absence because he
was upset that she was not there to make his lunch. When asked
why he had messed up the kitchen, Scott said that it was his
mother’s fault. If she had been home, it would not have happened.
When asked how he would feel about his mom returning to work,
Scott said that it would be unfair, and that moms should be home
for their kids.
Ruth described Scott’s relationship with his siblings in the following
way. Scott gets along with his youngest sister, Tia (5 years), the
best, while his relationship with his older sister, Christine (11
years), is the most problematic. She added that Scott often
responds to Christine in the same way he responds to his mother.
When asked to clarify what she meant, Ruth replied that whenever
Christine wants Scott to help her with dinner or the dishes, he
starts a huge argument. It always ends the same way, with Scott
saying that “it’s unfair” and that he has to do all the work, or it’s not
his turn. Finally, Christine ends up just doing it herself, rather than
argue with Scott. His relationship with his younger brother Brian (7
years) is less predictable. When Scott wants to play with Brian and
Brian goes along with him, they have a great time. However, when
Brian does not want to follow Scott’s lead, Scott loses his temper
very quickly.
REASON FOR REFERRAL
When asked what brought her and Scott to the clinic at this time,
Ruth stated that Scott had become progressively more difficult to
manage. He walks around with a “chip on his shoulder” and
responds to even the smallest requests with an inflated emotional
response. The outbursts have increased in frequency and intensity.
Ruth admitted that she is beginning to “lose it” more frequently,
herself. According to Scott, his mother is always picking on him and
asking him to do things, like chores, that his brother and sisters
should be doing. He added that he only gets mad when his mother
is “not fair.” Scott’s school reports have noted increasing difficulties,
especially in reading comprehension. Scott struggles with retaining
the sequential order of information and has problems recalling
information he has read. He is slow to copy information from the
board and his notes are not only messy but also often incomplete.
Scott is receiving approximately 30 minutes of resource help daily
to focus on reading, spelling, and written work. His teacher is very
supportive of an assessment for Scott to provide specific
information to assist with programming. The teacher noted that
although behavioral problems are not significant at school, Scott
does have some difficulty accepting criticism and waiting his turn.
The teacher has also noted, on more than one occasion, that Scott
will complain that the teacher has not been fair. Homework
assignments are often incomplete or not returned, despite attempts
to set up a homeschool communication system. Socially, he is not
well liked by peers, because he tends to want to be in control and
often interrupts or intrudes on others. Problems waiting his turn are
also evident on the playground, and Scott has to constantly be
reminded to give others a chance to talk.
Scott was asked to comment on his feelings about school. Scott
said that the kids were all right, but that some of the teachers were
not so great. When asked what he liked best about school, Scott
rolled his eyes back and said “Recess.” Scott became defensive
when questioned about academics and said that he could do better
if the teacher did not pick on him. He also said that the teacher is
always busy with other students and does not have the time to
answer his questions. He says he has to sit and wait until the
teacher finally gets around to his question and that is why he does
not get his work done. According to Scott, the resource room
teacher is also too busy with other kids to help him. Scott added
that if the teacher would explain schoolwork better, he would be
able to understand it better. He described his teacher as unfair in
the amount of work she expected students to do. Outside of
school, Scott said he really likes playing hockey and that he
probably would drive race cars, like NASCAR, when he was older.
He said he would not go to school if he did not have to.
Ruth began to describe the current home situation by saying that
Scott is a good-natured boy when things are going his way.
However, he can be very difficult to manage when asked to comply
with any requests that interfere with his own agenda. Ruth has tried
various incentive programs (such as using the purchase of a new
bike as a reward for completing his homework for a week);
however, after receiving his incentive, Scott loses all motivation
and things go right back to where they began. She described it as a
tug of war to get him to do anything. Attempts to set up a
communication system with the school have been undermined by
Scott’s forgetfulness to bring messages home. At times, when
asked to do something, Scott will be very touchy, talk back to her,
and begin yelling and complaining that it is unfair and comparing
himself to his sister who he says has no responsibilities around the
house. At the worst of times, tantrums will escalate into a shouting
match that involves throwing things and yelling. During these times,
Ruth admits to “losing it” and producing numerous threats and
ultimatums. M ore often than not, these scenarios end with Ruth
completing the tasks herself, just to stop the battle. At the best of
times, Scott will not be confrontational, though he will still avoid
doing tasks by either passively ignoring the requests or trying to
buy time, saying he will do it later (when a TV program is finished,
or when he finishes what he is working on, etc.). Ruth stated that
sometimes it just seems easier to do it herself than to nag and
hound Scott. Scott seems to be in constant motion, and he has a
hard time even sitting down for dinner. He becomes very restless
and squirmy when he is asked to remain seated, and often his leg
is in motion while he is sitting down.
Scott’s relationship with his older sister is very poor, since Scott is
often jealous and resentful of any attention that she receives.
Yesterday, when Christine asked him to turn down the volume on
the television because she was on the telephone, Scott
deliberately turned the volume up to the absolutely loudest notch.
Ruth seemed notably depressed in her admission that it is getting
to the point that everyone at home is afraid to ask Scott to do
anything for fear of retaliation.
When asked about her husband Eric’s role in the management of
Scott’s behaviors, Ruth stated that her husband often works the
4:00–11:00 p.m. shift and is not home when Scott has his
behavioral outbursts. Although Eric tries to be supportive of her, he
has said that he thinks Ruth is making too much out of Scott’s
behavior. He says that he was like Scott when he was a kid. After
all, he says, “Boys will be boys.” When Eric and Scott do things
together, like fishing, there are rarely any outbursts.
Ruth is very hopeful that the assessment will not only provide help
for her to manage Scott’s behavior at home but perhaps also help
convince her husband that Scott is in need of some kind of
management program. Right now, Eric is of the opinion that Scott
will just grow out of it.
At the completion of the intake interview, Ruth admitted in
confidence to the psychologist that she was feeling increasingly
overwhelmed, distraught, and alone. Her husband seemed to be
withdrawing from the family and was coming home from work later
and later, often stopping in at the local sports bar before returning
home. There were many arguments about money and Ruth’s
desire to return to work, since her husband was not in favor of her
working. Ruth was feeling less and less capable of managing
Scott’s escalating problems. At Ruth’s request, a referral was
provided to a therapist for her to obtain supportive therapy.
ASSESSMENT RESULTS
The actual raw scores for Scott’s assessment are available in
Appendix A. The following is a summary of those findings.
Guidelines to the interpretation of standard scores and T scores,
as well as information regarding specific assessment instruments
used in this text and other assessment resources can be found in
Appendix C.
Examiner comments noted frequent requests for repetition
throughout the assessment, word-finding problems, and tendencies
toward word substitutions (e.g., using “found” instead of “lost”).
Overall intellectual functioning on the Weschler Intelligence Scale
for Children (WISC-V) was within the low average to average
range (IQ = 88; range 83–93), with no significant discrepancy
between scores among the various Indexes. The Working M emory
Index (WM I) was an area of relative weakness (WM I = 80; range
74–89), and Scott experienced significant difficulties understanding
the instructions to sequencing tasks, especially for picture span
which asked that he remember the pictures “in order” of
presentation. On the Verbal Comprehension Index, Scott’s
responses to the comprehension subtest revealed that as the
questions became more complex, Scott asked for several
repetitions of the questions and asked for further explanations,
which are not permitted, according to the manual.
Academically, according to the Wechsler Individual Achievement
Test (WIAT-III), Scott was functioning commensurate with his
intellectual level in most areas assessed (standard scores ranged
from highs of 100 for math computation and 95 in Reading Fluency
to lows of 80 for reading comprehension). Although the two lowest
scores were below his full scale IQ of 88, the discrepancy of 9
points (88–79) was not significant. (In Scott’s school district, a
discrepancy between IQ and achievement must be in excess of
one and a half standard deviations, which requires a discrepancy of
at least 22 points. For further information on applications of the
discrepancy criteria, please see Appendix B: Specific Learning
Disorders and the Discrepancy M odel.) Analysis of cognitive
processing revealed that academic difficulties are largely due to
problems in cognitive fluency (SS = 67). Scott required more than
the anticipated time to label common objects and to perform tasks
that required him to recall names for “as many” (friends, foods, etc.)
that he could name in 1 minute. In this task, after naming two or
three objects, or names, Scott would either go blank or repeat
names he had already given.
Response to parent ratings scales (ASEBA) revealed borderline
clinical elevations on Withdrawn/Depressed and Total Internalizing
Behaviors and significant clinical elevations on Attention Problems,
Aggressive Behavior, Total Externalizing, and Total Problems.
Teacher ratings noted clinical elevations for Social Problems and
Attention Problems. While his mother’s comments pertained to
aggressive behaviors in the home (e.g., argues, brags, is mean, is
stubborn, disobeys, etc.), his teacher noted many problems in the
classroom (e.g., acts young, fails to finish, poor schoolwork, does
not listen, etc.) and with classmates (does not get along, is not well
liked, prefers younger kids). On the Conners scales, Scott’s mother
rated Scott’s Hyperactivity/Impulsivity (DSM scales) as in the
borderline clinical range. Oppositional behaviors and the emotional
lability scale of the Global Index were both within the clinically
significant range. Scott’s teacher rated him as borderline clinical for
Social Problems and in the clinically significant range for Cognitive
Problems/Inattention, Inattentive scale (DSM), HyperactiveImpulsive scale (DSM), and the DSM Total scale.
Scott endorsed items at the borderline clinical level on the Beck
Youth Inventory (BYI-2) for Disruptive Behaviors (SS = 68; 94th
percentile) and in the highly significant clinical range for the Anger
Inventory (SS = 86; 99th percentile).
CURRENT ISSUES, TRENDS, AND
TREATMENT ALTERNATIVES
Oppositional defiant disorder (ODD) and attention
deficit/hyperactivity disorder (ADHD) are two of the most common
childhood disorders with each of the disorders having a prevalence
rate of approximately 10% of children referred for mental health
support (Nock, Kazdin, Hiripi, & Kessler, 2007). The transition from
normal behavior demonstrated in what has been called the “terrible
twos” to ODD behavior is evident in the frequency and intensity of
noncompliant behaviors that continue to persist well beyond the
toddler period (Gabel, 1997). Comorbidity rates for ADHD and ODD
are very high with one-third to one-half of children diagnosed with
one disorder also receiving a diagnosis for the other disorder (Nock
et al., 2007; Waschbusch, 2002). Although the impact of having
either ADHD or ODD alone can cause significant disruption at
home, school, and in social interactions, the risk for poor outcomes
is multiplied for individuals who have both disorders (Waschbusch,
2002). Burns and Walsh (2002) investigated the co-occurrence of
these two disorders with respect to the type of ADHD exhibited
and found that it was the hyperactive/impulsive component of
ADHD that was associated with the development of ODD
behavior. According to Boden, Fergusson, and Horwood (2010),
children who demonstrated early symptoms of ADHD were at
increased risk for developing argumentative/defiant behaviors.
They suggest that the reason that ADHD and anger/irritability tend
to overlap is because these characteristics tend to be evident in
family histories of individuals with ADHD and ODD.
One of the difficulties with isolating risk factors specific to ODD is
that many studies have examined “behavior disorders” or
“disruptive behavior disorders,” which combine populations of
children and youth with ODD and conduct disorder (CD). As a
result, far less is known about the specific risks for children with
ODD or long-term prognosis for children who demonstrate both
ODD and ADHD, despite very high rates of comorbidity of these
two disorders (Biederman et al., 1996; Kadesjo & Gillberg, 2001;
Petty et al., 2009). A more recent investigation has suggested that
comorbid ADHD and ODD may represent a distinct familial subtype
and, furthermore, that antisocial, mood, anxiety, and addictive
disorders found in relatives were related to risk for CD and not
ODD when the two groups are separated out. Based on these
findings, Petty et al. (2009) suggest further support for considering
ODD and CD as separate and distinct entities (Biederman et al.,
1996; Greene et al., 2002), which they hope will deter “lumping” CD
and ODD together in future clinical studies.
Biederman et al. (2008) investigated the long-term outcomes for
children who are diagnosed with comorbid ODD and ADHD. Their
results suggest that youth with comorbid ADHD and ODD
demonstrated higher scores on the CBCL “Aggressive Behavior”
scale compared to those with ADHD alone. Youth with ODD at 10year follow-up were at increased risk for major depressive disorder
(M DD) compared to controls. Longitudinally, the majority of youth
with comorbid ODD and ADHD demonstrate a decline in ODD
symptoms with age (Biederman et al., 2008; Whittinger, Langley,
Fowler, Thomas, & Thapar, 2007). Although some youth with ODD
will later progress to CD (Rowe, M aughan, Pickles, Costello, &
Angold, 2002; Whittinger et al., 2007), results suggest that the
majority of subjects with ADHD and comorbid ODD will not develop
CD (Biederman et al., 1996, 2008).
Results of a recent longitudinal investigation suggest that by 25
years of age, ODD was persistent in 16.6% of the ODD group
(Biederman et al., 2008), although Harpold et al. (2007) found that
of referred adults with ADHD who had ODD in childhood, 30%
continued to demonstrate symptoms of ODD into adulthood. Risk
factors that have been associated with ODD include attachment
problems noted in insecure attachment (DeKlyen, 1996) and
anxious avoidant attachment patterns (Erickson, Sroufe, & Egeland,
1985); difficult temperament (Rey, 1993); and parenting style and
level of parental involvement (Frick et al., 1993).
One of the difficulties in locating evidence-based treatments
specifically for ODD is that despite evidence of the existence of
ODD and CD as two distinct disorders (Biederman et al., 2008;
Frick et al., 1993), treatments are often discussed relative to the
broader category of “Disruptive Behavior Disorders,” which include
both ODD and CD. As noted previously, although research has
generally grouped ODD with CD and other disorders characterized
by disruptive behavior, ODD is a disorder of emotional
dysregulation (Cavanagh, Quinn, Duncan, Graham, & Balbuena,
2017), which is reflected in affective symptoms of irritability and
anger (APA, 2013) and often shares significant comorbidity with
mood and anxiety disorders (Boylan, Vaillancourt, Boyle, &
Szatmari, 2007; Nock et al., 2007). As will be discussed in Case
#19, the case of M atthew M organ, it has been speculated by
Lochman et al. (2015) that increasing rates of bipolar disorder
diagnosis in children could reflect diagnostic confusion regarding
the presence of bipolar disorder among children in view of the more
severe symptoms of emotional dysregulation which may exist in
some children who should more appropriately be diagnosed as
having ODD. As a result, the DSM-5 (APA, 2013) has added a new
and highly controversial diagnostic category, disruptive mood
dysregulation disorder (DMDD), for children who demonstrate
severe recurrent temper outbursts (three or more times per week),
with persistently irritable/angry mood nearly every day between
outbursts, which occur across settings (at least two out of three
settings). However, the diagnosis cannot coexist with ODD.
Recently, in their study of a sample from the general population,
M ayes, Waxmonsky, Calhoun, and Bixler (2016) noted the
controversial nature of the diagnosis of DM DD, given that DM DD
could not be differentiated from ODD based on symptomatology. In
their study, 92% of children with DM DD symptoms also met criteria
for ODD, and 66% of children with ODD presented with symptoms
of DM DD, suggesting that although it is unlikely for individuals to
have DM DD symptoms without ODD, ODD can occur without
DM DD symptoms. The fact the DSM-5 does not allow for a mixed
diagnosis makes the diagnosis of DM DD very controversial.
M ore recent trends have seen ODD conceptualized more as a
disorder of emotion regulation, rather than a disruptive behavior
disorder. Within this context, emotion dysregulation is seen as
affective lability evidenced in a lack of temper control and emotional
overreaction (Reimherr et al., 2005). Cavanagh et al. (2017) note
that conceptualizing ODD as a disorder of emotion regulation is
consistent with findings that deficient regulation of emotions is the
pervasive factor across many childhood disorders, such as ADHD
and ODD (Ambrosini, Bennett, & Elia, 2013; Stringaris, Cohen,
Pine, & Leibenluft, 2009).
In their evaluation of affective and behavioral components of ODD,
Stringaris and Goodman (2009) suggest three possible factors
inherent in ODD: irritable (i.e., temper outbursts, easily annoyed,
angry/resentful), headstrong (i.e., argued with grown-ups, rule
violations, purposefully annoyed others, blamed others), and hurtful
(i.e., been spiteful/vindictive). Developmentally, Stringaris and
Goodman (2009) found the following developmental outcomes: at
16 years of age, irritable was associated with depression while
headstrong was associated with problems of conduct and callous
attitude. Hurtful was not associated with any outcomes at this age.
Nock et al. (2007) studied the lifetime prevalence rates for ODD in
a large adult population and found that 92.4% of individuals who
met criteria for ODD also met criteria for another disorder, including
mood disorders (45.8%), anxiety disorders (62.3%), impulse control
disorders (68.2%), substance use disorders (47.2%), CD (42.3%),
or ADHD (25.0%).
Steiner and Remsing (2007) discuss practice parameters in the
treatment of children with ODD and state that based on the
complex etiology of the disorder, involving biological/genetic,
psychological, and environmental/social factors, multimodal
treatment is recommended, involving “individual and family
psychotherapeutic approaches, medication, and sociotherapy” (p.
126).
Steiner and Remsing (2007) recommend a number of important
factors to include when building a treatment plan for children with
ODD, based on a thorough case formulation, including the
following:
1. Delineate whether this is truly ODD or a simple adjustment
reaction;
2. Determine whether this is still ODD or if symptoms have
progressed to CD;
3. Target domains that are currently dysfunctional;
4. Incorporate appropriate parent management training (PM T)
(contingency management methods) to assist them in better
coping with disruptive behavior.
As part of the PMT program, Steiner and Remsing (2007) suggest
the following key aspects to focus on (p. 139):
1. Reduce positive reinforcement of disruptive behavior.
2. Increase reinforcement of prosocial and compliant behavior.
Positive reinforcement varies widely, but parental attention is
predominant. Punishment usually consists of a form of time
out, loss of tokens, and/or loss of privileges.
3. Apply consequences and/or punishment for disruptive
behavior.
4. M ake parental response predictable, contingent, and
immediate (p. 139).
The interventions mentioned above have been proven effective in
both community and clinical samples (Connor, 2002) and are based
on the coercion model, with its roots in social learning theory and
addresses how negative communication between the parent and
child is reinforced by a parent giving in to the child’s demands.
M ore recently, studies have examined the use of PM T in comorbid
populations to determine the extent to which these strategies
would be successful for children with ODD who also had a
comorbid disorder and have found that PM T resulted in significantly
reducing problem behaviors in children with ODD and comorbid
ADHD (Hartman, Stage, & Webster-Stratton, 2003; Kazdin &
Whitley, 2006), while Costin and Chambers (2007) found that PM T
was successful regardless of the comorbidity with ODD across
three different groupings of primary school children (ODD alone;
ODD/ADHD; ODD/ADHD/Affective Problems). Furthermore, the
Costin and Chambers (2007) study demonstrated that an 8session PM T program could be delivered in a public health setting
and that results remained stable on 5-month follow-up.
Other programs that have been found to be effective in the
treatment of problems associated with ODD include the following:
Problem-Solving Skills Training (PSST;
Kazdin, 1996)
A typical problem-solving intervention to teach children how to
approach a problem in a logical and predictable fashion, using a sixstep procedure, includes the following:
1. Define the problem
2. Identify the goal
3. Generate options
4. Evaluate options
5. Choose the best option
6. Evaluate the outcome
Children are taught how to apply this approach to social problems
in a number of ways, including role-playing, social reinforcement,
and therapeutic games. The Problem-Solving Skills Training (PSST)
procedure is administered individually over 20 sessions, each
lasting approximately 45 minutes.
Coping Power (Larson & Lochman, 2002)
This anger control program has evolved from an original 12-session
school-based program called Anger Coping (Lochman, Lampron,
Gemmer, & Harris, 1989) to a 33-session program called Coping
Power (Lochman & Wells, 1996), with sessions for a parent group
recently added. Children develop skills in anger management
through in vivo practice sessions (weekly groups of six children)
using problem-solving techniques to address specific goals and
objectives in social situations. Children are also taught to be aware
of feelings and physiological states associated with anger arousal.
In their research review, Brestan and Eyberg (1998) found that the
majority of interventions involved direct contact with the child
and/or the child’s parent (usually mother) and usually were based
on cognitive behavioral techniques. In their summation, the authors
conclude that age may be the overarching variable that determines
the effectiveness of the outcome of treatment: parent training
programs would be more effective for younger children, while
cognitive behavioral methods may be more applicable for older,
school-aged populations. There is evidence to suggest, however,
that for some groups (Kazdin, 1996), combining PSST and parent
training may be more effective than either treatment alone.
Collaborative Problem Solving (Greene, 2001;
Greene and colleagues, 2003, 2004)
Since many children with ODD also experience ADHD, Greene
(2001) and colleagues (Greene, Ablon, & Goring, 2003; Greene,
Ablon, Goring, Fazio, & M orse, 2004) have developed a program
that focuses on deficits in cognitive skills involved in “executive
functions” such as working memory, self-regulation (emotion
regulation, frustration tolerance, and regulation of arousal to engage
in goal-directed activity), shifting of cognitive set (flexibility and
transfer of rules and expectations from one situation to another),
and problem-solving (organization of information and generating a
plan of action). The program, Collaborative Problem Solving (CPS;
Greene, 2001; Greene et al., 2004), focuses on parent education
(underlying parent/child dynamics) and interventions aimed at
deficits in executive functions.
M any children diagnosed with mood disorders (Geller & Luby,
1997) and anxiety disorders (Greene et al., 2002) also have
comorbid ODD. In one study, 70% of youth with M DD, 85% of
those with bipolar disorder, and 45% of those with an anxiety
disorder had comorbid ODD (Greene et al., 2002). In addition,
language processing problems are also prevalent, with over 20% of
youth diagnosed with ODD also demonstrating processing
problems that can compromise problem-solving in academic as well
as social situations. Previous research by Dodge and colleagues
(Dodge, Price, Bachorowski, & Newman, 1990) demonstrated that
some children act aggressively when they misread social cues
based on cognitive distortions such as the hostile attribution bias
(e.g., child interprets an ambivalent facial expression or provocation
as hostile and responds aggressively as a result). In order to
address these processing issues, Green and colleagues
incorporate tasks of social cognitive processing in their program to
assist children in developing increased ability to analyze social
situations, develop alternative responses, and monitor outcomes.
The program also focuses on parent–child compatibility by helping
parents understand the processing difficulties, the need for
providing consistent patterns of discipline, and the need for
increased monitoring and feedback. The program has been very
successful.
ACADEMIC INTERVENTIONS
An empirical review of specific programming remediation for
difficulties in reading and written expression reveals the following
information. The importance of developing good reading skills at an
early age is of paramount importance, not only to a child’s sense of
self-esteem and academic accomplishment but also due to the
escalating impact that reading has on the child’s subsequent
acquisition of vocabulary and information acquired through reading.
M any years ago, Stanovich (1986, 2000) coined the phrase
“Matthew Effects” to refer to the ever-widening gap that develops
between good and poor readers as those who struggle with
reading increasingly avoid tasks involving reading, while those who
are good readers gravitate toward seeking out additional
opportunities to read. As a result, good readers continue to
develop skills in reading fluency and comprehension evident in
increased acquisition of vocabulary knowledge and general
information obtained through the written word, while poor readers
demonstrate poor reading fluency and comprehension, as well as
significantly weaker vocabulary development and a dearth of
acquired information.
To this end, Quirk and Schwanenflugel (2004) discuss the
importance of increasing the motivation to read in children who are
poor readers. According to Quirk and Schwanenflugel (2004), the
three most important aspects of motivation for reading that should
be integrated in remedial reading programs include
improving reading self-efficacy;
making internal and controllable outcome attributions for
successes and failures associated with reading; and
establishing personally relevant value in becoming a better
reader (p. 1).
The importance of developing phonological awareness for reading
acquisition and spelling has been demonstrated by several
researchers (see Kuhn & Stahl, 2003, for a review). Strategies that
focus on improving phonics, such as the Fernald Keller approach,
often rely on multisensory and multimodal strategies that can be
helpful in assisting children like Scott in developing greater phonetic
awareness. Given Scott’s learning profile, the following specific
strategies may be helpful. A repeated readings approach (Kuhn &
Stahl, 2003) may be helpful in targeting difficulties in decoding (sight
word vocabulary, fluency) and comprehension and to enhance
Scott’s attention to task as well as independent work habits.
Cognitive approaches to spelling, such as the 12 plus 1 strategies
for remediation of misspellings (M ontgomery, 1990), would also be
very helpful in emphasizing the phonetic as well as rule-based
aspects of spelling.
PHAST (Phonological and Strategy Training) is a program
developed by Lovett and colleagues that incorporates many
different strategies for children to use in order to develop
independent reading skills (Lovett, Lacerenza, & Borden, 2000b;
Lovett, Lacerenza, Borden, Frijters, Steinbach, & De Palma, 2000a).
Initially, children learn how to apply strategies to assist in increased
phonological awareness and skill development in sound letter
association which will eventually result in developing a repertoire of
“metacognitive strategy–based methods.” Children are taught four
different word identification strategies (WIST), including “word
identification by analogy; seeking part of a word you know;
attempting various vowel pronunciation; and “peeling off” prefixes
and suffixes” (p. 463).
To assist with compliance issues regarding homework submission
and reducing home conflict regarding homework completion, a
homework management program would be helpful to increase
productivity (percentage of homework completed) and accuracy
(percentage completed correctly) of homework, using a
combination of home-note, self-monitoring, and group contingency
approaches based on the Good Behavior Game or Good Behavior
Plus Merit approach (see Tingstrom, Sterling-Turner, & Wilczynski,
2006, for a review). The programs have been instituted to assist in
reducing inappropriate behaviors and increase productivity and
have been used in classroom settings, but can easily be adapted
for individual use. Research has demonstrated the success of the
program in not only increasing academic performance but also
reducing negative and noncompliant behaviors. By adding a merit
component, teams or individuals can regain lost points for previous
misdemeanors. Tokens or credits can be exchanged for previously
negotiated prizes based on the number of credits earned.
Post-Case Questions
1. Using situational and contextual factors, explain why Scott’s
behaviors were described as more oppositional at home than
at school. Is this a common finding?
2. Barkley (1997a) has developed a theoretical model for ADHD
that places “behavioral inhibition” as the focal point of the
model. According to this model, the ability to delay or inhibit a
given response allows for the necessary time required for
executive information processing to occur. Included within
these executive processes are abilities to manipulate
information mentally (working memory), self-regulation
(emotional control, motivation/drive), self-reflection (inner
speech, problem-solving), and reconstitution (analysis and
synthesis). Furthermore, the ability to maintain the delay is
also required to block possible interference factors (see
Barkley, 1997b for a complete description of this model of
hyperactivity and impulsivity). How might the concept of
“behavioral inhibition” be used to help explain Scott’s
behaviors?
3. At a minimum, Scott demonstrates at least two comorbid
disorders. What are the two disorders? How often do they
occur together in clinical populations? Using Barkley’s model of
behavioral inhibition, explain the underlying dynamics in these
two comorbid disorders.
4. The role of parenting practices in the maintenance and
management of disruptive behavior disorders has been welldocumented (Barkley, 1997a; Chamberlain & Reid, 1991, 1998;
Patterson, Reid, & Dishion, 1992). Various theoretical
perspectives have focused on different aspects of parent–child
interactions in maintaining maladaptive behaviors—for example,
the coercion model and coercion theory (Patterson et al.,
1992; Steiner & Remsing, 2007). Refer to the section on
coercion theory in Chapter 1: Introduction to refresh your
memory about the importance of coercion theory. Develop
case formulations to explain how Scott’s interactions with his
family members serve to sustain his disruptive behavior from
the following perspectives: behavioral, cognitive, family
systems, and parenting style/attachment. What therapeutic
approach would you recommend for Scott and his parents?
5. Although most children who have ODD do not progress to CD,
some are more at risk than others. Taking into consideration
what research suggests are risk factors for ODD developing
into CD and looking at Scott’s individual assessment results
(Appendix A), do you think that Scott is at risk for developing
CD? If so, why? If not, why not? Also, the DSM -5 suggests
that the extent to which symptoms cluster around two
predominant themes (angry/irritable versus
argumentative/defiant) may predict whether a child is at greater
risk for internalizing versus externalizing disorders. Based on
Scott’s symptom profile, do you think he is more at risk for
internalizing or externalizing problems in the future? Why?
6. Using information from the case study itself and the
supplementary assessment data found in Appendix A and the
Glossary, identify as many symptoms as you can find of ODD
and ADHD that meet the DSM criteria. Remember to specify
the predominant type of ADHD that Scott’s symptoms match.
7. Scott’s parents do not agree about the extent and nature of his
behavioral problems. As his therapist, how would you
approach this situation, and what suggestions do you have for
bringing his parents in closer alignment regarding his
difficulties?
8. Suggested individual or group presentation activity:
The principal has called a parent/school meeting to
discuss concerns about Scott’s progress and attitude at
school. Assign roles to individuals who will role-play
important individuals in Scott’s life and how they would
interact in this situation. Develop important questions for
each of the players who can add information to the case.
Some of the casting members might be Scott, his mother
and father, his teacher, the school psychologist, and any
other individual that you feel might contribute to an
understanding of the case and assist with developing an
overall case formulation and treatment plan.
You have been asked to attend a meeting at the school to
share your assessment results with the student support
team. What would be the main emphasis in your
presentation; who would you want to be present at the
meeting; and what would your recommendations be for
accommodations/or modifications to his program based on
the test results?
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CASE 12 TYRONE WILSON : THE
GANG’S ALL HERE NEESHA’S
BROTHER; MULTIFINALITY;
LEARNING AND BEHAVIOR
PROBLEMS; GANG ACTIVITY;
FORENSIC ASSESSMENTS; FETAL
ALCOHOL SPECTRUM
Tyrone Wilson, 15 years of age, is an African American youth who
is the older brother of Neesha Wilson (see Case of Neesha
Wilson). Although the two siblings were brought up under
somewhat similar circumstances, there was a significant difference
in the outcomes for the two children. While Neesha’s story is one
of resilience, Tyrone suffered through significant challenges that
have escalated out of control since his father left the family 3 years
ago.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
Tyrone lives with his 10-year-old sister, Neesha, and their mother
in a two-bedroom apartment. The apartment is small but very well
kept. Tyrone sleeps on the couch, which folds out into a bed.
Tyrone’s mother is currently working two jobs: cleaning offices and
working as a hairstylist. M rs. Wilson graduated from hairstylist
classes last year. Although her career as a hairstylist has a lot of
potential, she is only beginning to develop clientele. She also
works part time cleaning offices. Despite the lack of financial
resources, the children are clean and adequately fed. M other
admits to drinking more than she should have when she was
pregnant with Tyrone. She said,
You know you read about it a lot now, but when I was
growing up, I mean I was 19 when I got pregnant with
Tyrone, I just became legal drinking age, and it was time to
party. I was done with high school and I was taking some
community college courses and working part time at the
deli. Their dad was a mechanic and he worked hard and
long hours. When we were done with working, like we just
were ready to let loose.
When asked how much she drank during her pregnancy, M rs.
Wilson said there was not a night that she did not drink probably
one or two beers, plus a couple of glasses of wine. She stated that
she did not do any drugs whatsoever during her pregnancy. When
she conceived Neesha, she was more mature and had heard more
about drinking and pregnancy, so she did not drink while pregnant
with Neesha. Tanya stated that although there are some nights
that she is not home because she may be working, she is not too
concerned about the children since she has family nearby. She can
send the children to her sister’s place a few blocks away, or if they
do not want to go, they can stay home, since she also has a
cousin who lives in the apartment complex, who can drop by if the
children need something. Also, Tyrone is old enough to babysit his
sister; however, given his behavior problems, she prefers to have
an adult nearby.
When asked about Tyrone’s developmental milestones, Tanya said
that he seemed to start out on the wrong foot. She said that she
and her husband were not great parents because they were so
young and immature and Tyrone was a difficult child to manage.
Tanya said that Tyrone was an agitated infant and did not eat or
sleep well. He was a late talker but was walking by 14 months. He
was a difficult child to potty train since it seemed to take forever for
him to make the connection. He was also an impulsive child, and
still is, which can get him into trouble, since he often acts without
thinking. He also does not seem to learn from past mistakes and
will do the same thing over again, even if he was punished for it
previously.
He managed to have some academic success when enrolled in
special education, but he continually would get into trouble for
disobeying the rules. His mother feels that part of his disability is
that he cannot understand rules, but the school did not agree.
Tanya felt that punishments at school for rule violations (in-school
suspensions, after-school detentions, being kept in at recess, etc.)
resulted in Tyrone becoming more resentful and anxious about
school. Social skills were also poor, and Tyrone experienced
problems being accepted by the other children and was often
isolated as a result. She said that she began to feel guilty because
Tyrone was having so many problems, so after trying a few
different schools, she decided to try homeschooling, which would
also allow her to stay home with Neesha, who was then 4 years of
age, and she would not have to pay for day care. But eventually,
Neesha was ready for school and Tanya felt it was unfair to
Neesha to hold her back from a normal school experience, so they
enrolled Tyrone back into the school system. At this time, Tyrone
was almost 11 years of age and the school recommended an
updated assessment, since Tyrone had not had an evaluation
since he was 6 years of age. Results of the assessment at that
time revealed intellectual functioning in the below average range
(full scale IQ was 84, range 80–89), with scores for the Fluid
Reasoning and Visual Spatial Reasoning in the average range (FRI
= 93, range 87–100; VSI = 95, range 88–102) and much higher than
Verbal Comprehension (VCI = 80, range 74–89). The Similarities
subtest, which measures abstract reasoning, was very challenging
for Tyrone. A severe problem was noted in speed of processing,
likely due to poor eye–hand coordination and deficits in short-term
visual memory. Academically, Tyrone was functioning at
approximately a mid–Grade 4 level in reading and written
expression (approximately 1½ years below the expected level) and
almost 2½ years below the expected level in mathematics.
Problem-solving was especially weak, and Tyrone did not know
which numbers were relevant to the questions and which numbers
were not needed to solve the problem. Based on his assessment
results, it was recommended that Tyrone receive special education
assistance to assist in meeting his educational goals.
Initially, Tyrone seemed to improve his academic skills with the
resource room help. However, after his father left, Tyrone became
very unsettled and started to experience more problems socially
and academically. He was suspended for fighting, and when the
suspension was lifted, he immediately got into another fight and
was placed in an alternative school program for students with
severe behavioral problems.
At home, Tyrone was getting more and more difficult to control.
When his mother worked nights, he would stay out until 3:00 or
4:00 a.m. and leave his sister Neesha alone. On these occasions,
he would threaten to make Neesha’s life miserable if she told her
mom that he was not home. On the nights that Tanya was not
working, she would often go to bed early. She said that she was
fatigued and just needed to sleep a lot. This also gave Tyrone
more freedom to come and go at all hours of the night. One night,
when Tyrone eventually arrived home, he was very badly beaten.
He would not tell his mother, but this was the night he was “beaten
down” as part of his initiation into the gang. That was the night that
he was “jumped in,” the rite of passage for new male gang member
who gains entry into the gang by being beaten up by the brothers.
It was not so bad, Tyrone thought, since afterward, all the gang
members hugged him. This was his new family. For Tyrone, joining
the gang would give him protection on the streets and the respect
he was looking for. However, it also opened the door to drugs and
crime. Tyrone started hanging out on the streets and getting
involved in petty theft (stealing bikes for parts), and by 14, he was
regularly smoking marijuana and drinking beer on a daily basis.
REASON FOR REFERRAL
Currently, Tyrone is in detention following his recent arrest for
robbery and assault with a weapon. He and two of his gang
members were arrested as they confronted and threatened two
youth with knives, as they were waiting for a bus. Tyrone was
especially belligerent and aggressive during the incident, wielding
his knife in the air and shouting lyrics from “gangsta” rap music.
The detention center is a short-term, secure facility, sometimes
called a youth jail, where a youth may be held “during the
processing and disposition of the youth’s legal case for the
purposes of evaluation or placement if a secure environment is
deemed necessary” (AACAP, 2004, p. 2). The judge had ordered
an assessment to determine the nature of Tyrone’s difficulties and
to assist in determining an appropriate placement (e.g., juvenile
correctional facility, community-based or other residential treatment
program, etc.).
ASSESSMENT RESULTS
Forensic Assessments Versus More
Traditional Psychological Assessments
Forensic assessments differ from the more conventional
psychological assessments that have been discussed in this
casebook in several ways. Traditional psychological assessments
are conducted for a variety of reasons (e.g., to evaluate
educational or occupational aptitudes or to investigate mental
health concerns) and may include assessments of intelligence
(learning capacity), achievement (academic performance), cognitive
or neuropsychological functioning (information processing, brainbased functioning, executive functions), personality assessment
(traits and personal style), and emotional or behavioral status
(mood disorders, anxiety, etc.). However, forensic assessments
are more likely to be conducted to address questions of
competency on two levels:
1. Is the individual competent to stand trial (is the individual
competent at the time of the trial)?
2. Was the individual competent at the time of the crime (which
addresses issues of criminal responsibility)?
In the former situation, three areas of competency are considered
to determine whether the individual is mentally competent to stand
trial: does the defendant understand the charges; does the
defendant understand the seriousness of the potential outcomes of
the trial; and is the defendant capable of assisting in his or her own
defense? Regarding whether the individual was competent at the
time of the crime, experts would be called in to provide opinions as
to whether the defendant was suffering from diminished capacity
because of a mental or emotional disorder that interfered with the
ability to distinguish right from wrong.
Forensic assessments may also investigate whether an individual
is malingering, or pretending to be more incapacitated (competency
or mental illness), in order to obtain a lesser penalty. Other
questions that forensic assessments may address include
determining the risk of recidivism (repeat offending) or providing
information about the psychological factors that may be contributing
to the maladaptive and criminal behavior.
In addition to differences in the types of assessment instruments
that may be used and the general goals of the assessment,
forensic assessment also differs in the nature of the psychologist
(mental health practitioner)/client relationship. While most children
and adolescents are referred for assessment by concerned
parents and teachers, forensic assessments are conducted to
answer forensic questions and, as a result, clients are often
mandated to participate in the process by the authorities.
Therefore, rather than developing a therapeutic relationship, the
psychologist is required to remain neutral.
The American Psychiatric Association (APA, 2013) has issued a
“cautionary statement for the forensic use of the DSM -5,” stating
that when the DSM -5 “categories, criteria, and textual descriptions”
are used for forensic purposes, “there is a risk that diagnostic
information will be misused or misinterpreted.” Furthermore, APA
clarifies that the clinical diagnosis of a mental disorder, such as
intellectual disability, does not suggest that an individual with that
diagnosis meets “legal criteria” such as legal standards for
“competence, criminal responsibility, or disability” (p. 25).
Assessment Findings
Information regarding specific assessment instruments and
guidance in the interpretation of standard scores and T scores can
be found in Appendix C.
The forensic psychologist reviewed Tyrone’s file and noted his
developmental history, especially the information regarding his
mother’s drinking habits during the pregnancy. The psychologist
also reviewed the intellectual assessment information noting
intellectual delays in language functions, relative to average scores
for visual reasoning. The need for special education assistance
was also noted, especially for significant difficulties with
mathematics. There were indications that behavior problems have
been ongoing, with poor ability to profit from prior experiences and
weak social skills, making him vulnerable to gang recruitment and
involvement in crime and drug usage.
In order to answer a number of forensic questions, the
psychologist administered a battery of tests, including the
Structured Assessment of Violence Risk in Youth (SAVRY), the
Jesness Inventory Revised (JI-R), the Vineland Adaptive Behavior
Scales, and the Behavior Rating Inventory of Executive Function
(BRIEF). A summary of historical risk factors from the SAVRY
included history of nonviolent offending and poor school
achievement. Social contextual risk factors were significant with
many items endorsed, including peer delinquency, peer rejection,
stress and poor coping, poor parental management, lack of
personal/social support, and community disorganization. Individual
risk factors on this instrument were highly significant, as Tyrone
matched many of the high-risk items, including negative attitudes,
risk-taking/impulsivity, substance use difficulties, anger
management problems, low empathy/remorse, attention deficit
hyperactivity difficulties, and poor compliance/commitment to
school. Unfortunately, significant problems indicated by personal
risk factors were not offset by any protective factors that could
buffer the harmful effects posed by the risk factors.
On the JI-R, the DSM subscales of Conduct Disorder and
Oppositional Defiant Disorder were both clinically significant. In
addition, Tyrone had high clinical loadings on the Personality scales
for social maladjustment, immaturity, alienation, asocial index,
manifest aggression, and withdrawal. He also endorsed significant
items on scales measuring depression, social anxiety, and denial.
On the subtype scales, Tyrone’s responses placed him in the
clinical range for the following subscales:
aggressive/undersocialized and conformist/immature. The Vineland
Adaptive Behavior Scales were completed by Tyrone’s mother, and
according to her responses, Tyrone obtained the following standard
scores: Communication Skills, 80; Daily Living Skills, 80; and
Socialization Skills, 75. Therefore, adaptive behavior was below the
norm for all areas assessed, especially poor in the area of social
competence.
On the BRIEF, the subscales of the M etacognitive Index (M I) were
significant for deficits in areas of working memory, self-monitoring,
and organization/planning ability. On the Behavioral Regulation
Index (BRI), significant problems were evident in his ability to inhibit
responses, in his ability to shift attention between tasks, and in the
area of emotional control.
The psychologist noted that although Tyrone did not have any of
the physical features often associated with fetal alcohol syndrome
(FAS), such as dysmorphic facial features or microcephaly, he did
exhibit a number of abnormalities often associated with fetal alcohol
effects (FAEs), including small stature, delays in motor and speech
performance, poor coordination, and impulsive/hyperactive
behaviors. Also, his poor social skills and inability to consider the
consequences of his behaviors are characteristics that often can
make youth with FAE vulnerable to gang recruitment and having
eventual problems with the law.
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
Fetal Alcohol Spectrum Disorders (FASDs)
Streissguth et al. (2004) report that incidence rates of 3 per 1,000
births would suggest a prevalence rate of 12,000 children with FAS
born annually in the United States. However, as Riley, Infante, and
Warren (2011) emphasize, although the prevalence rate of FAS
may be 2–7 per 1,000, this rate is significantly higher when
diagnoses for fetal alcohol spectrum disorders (FASDs) are
included, increasing the estimated prevalence rate to as high as
2%–5% of all younger school children in the United States and
Western Europe.
Riley et al. (2011) describe the many labels that have been used
over the years to define and describe what has more recently
been termed FASD, from the more rigid definitions of FAS for those
with the more traditional and recognizable symptoms of FAS noting
“physical parameters including facial anomalies and growth
retardation, with evidence of developmental delay or mental
deficiency” (p. 73), to the less well-differentiated term “FAE” to
apply to those who demonstrate more subtle difficulties in areas of
cognitive and adaptive functioning without the more obvious
physical characteristics. Other terms that have been used in the
past, but are no longer regularly used, include “alcohol-related birth
defects” (ARBDs) and “alcohol-related neurodevelopmental
disorder” (ARND) (Riley et al., 2011).
There are several issues that have been raised concerning how to
best define and diagnose FASD and other variations that exist
among those with FASD. Currently, the term FASD is used to refer
to “the spectrum of structural anomalies and behavioral and
neurocognitive disabilities” evident in individuals who have been
exposed to alcohol prenatally (Hoyme et al., 2005, p. 39).
Individuals with FAS present with cardinal diagnostic features in
various degrees of severity: facial anomalies, central nervous
system damage/dysfunction, and exposure to alcohol in utero
(Hoyme et al., 2005). Although individuals who have the more
severe and physically recognizable form of FAS may be more
readily diagnosed, many cases that demonstrate the more subtle
form of FAE often are undetected and undiagnosed. In their study
of the adverse effects of individuals diagnosed with FAS or FES,
Streissguth et al. (2004) found that the lifetime prevalence rates for
the percentage of individuals who experienced negative outcomes
in five critical areas were as follows: Disrupted School Experience
(DSE) (61%); Trouble with the Law (TWL) (60%); Confinement
(CNF) (in detention, jail, prison, or a psychiatric or alcohol/drug
inpatient setting: 50%), Inappropriate Sexual Behaviors (ISBs) on
repeated occasions (49%); and Alcohol/Drug Problems (ADPs)
(35%) (p. 228). However, one of the crucial factors in their analysis
was the finding that those who had a diagnosis of FAS or FAE at
an earlier age and who had a stable life environment had a 2–4
times better chance of avoiding these negative outcomes.
However, Streissguth et al. (2004) also found that patients with
FAE had higher rates on all five adverse outcomes compared to
those with FAS. The fact that those with more subtle forms of
FASD such as FAE are at even higher risk for going undetected
(Astley & Clarren, 2000) suggests that they are at greater risk for
negative outcomes such as those mentioned above, which was
demonstrated in the study by Streissguth et al. (2004).
In their analysis of individuals with FASD, Spohr and Steinhausen
(2008) found that 60% of children with FASD also meet criteria for
attention deficit/hyperactivity disorder with symptoms of
hyperactive, erratic, and uncontrolled behaviors as well as
concentration difficulties.
Children and youth with ARBD and ARND have normal faces,
growth, and development, but those with ARBD have specific
structural malformations, while those with ARND demonstrate
characteristics and behavioral patterns typically associated with
fetal alcohol exposure (Hoyme et al., 2005). One of the
characteristic problems faced by children and youth with ARND is
marked impairment in executive functioning (EF) associated with
poor judgment and failure to consider the consequences of their
behaviors. EF is used to describe cognitive abilities that are
required to adequately perform complex tasks, including cognitive
flexibility, planning, organization, sequencing, response inhibition,
and self-regulatory behaviors (Eslinger, 1996). Connor, Sampson,
Bookstein, Barr, and Streissguth (2000) studied EF in individuals
diagnosed with FAS or FAE and controls. Results revealed that the
mean IQ scores were higher for those with FAE (SS mean = 90)
than those with FAS (SS mean = 79) and that subjects with FAS
and FAE performed poorer on tasks of executive functions than
would have been predicted by IQ alone. The researchers noted
deficits in EF related to “shifting or changing strategies, especially
when there is uncertainty about which rules to employ” and
problems in interpersonal relationships due to an inability to detect
subtle cues resulting in feeling isolated or from being “prone to
inappropriate behaviors that could get them into trouble both
socially and legally” (Connor et al., 2000, p. 351). Hoyme et al.
(2005) list a number of characteristics commonly found in the
behavioral profile of children with FASD, including
problems with communication and speech (talking too fast
or interrupting others), difficulties in personal manner
(clumsiness, disorganization, and losing or misplacing
things), emotional lability (rapid mood swings,
overreacting), motor dysfunction (difficulty playing sports),
poor academic performance (poor attention span and
completing tasks), deficient social interactions (lack of
awareness of the consequences of behavior and poor
judgment), and unusual physiologic responses
(hyperactivity and sleep disturbances). (p. 45)
In their study of 415 patients with FAS and FAE, Streissguth et al.
(2004) found that 42% reported placement in special education,
66% had received resource room assistance, and 65% had
received remedial help for reading and arithmetic. Adaptive scores
from the Vineland Adaptive Behavior Scales and performance on
arithmetic were two of the greatest areas of deficit for both groups.
Adverse life outcomes were evaluated for five different areas: ISB,
DSE, TWL, CNF, and ADP. Of the study sample, 53% of
adolescents had been suspended from school, 29% had been
expelled, and 25% had dropped out. The most common areas of
school difficulty included problems with attention, incomplete work,
problems getting along with peers, and being disruptive in class.
Sixty percent of adolescents and adults reported TWL, with crimes
against persons (45%), shoplifting/theft (36%), and assault (17%),
the three most common areas of criminal activity. Sixty-seven
percent of adolescents had been charged, arrested, or convicted,
while 35% were actually incarcerated for a crime. Twenty-nine
percent of adolescents admitted to ADP. The authors found that
one of the strongest correlates for adverse outcomes was age of
diagnosis, with the odds increasing from two to four times the risk,
if age of diagnosis was after 12 years of age. A significant finding
from the study was that patients with FAE had higher rates of
adverse outcomes in all five areas than those with FAS and double
the odds of TWL and ADP than those with FAS. Streissguth et al.
(2004) suggest that those with FAE, who do not have the physical
features associated with FAS, nevertheless, are significantly
impaired in academic and adaptive behavior.
Gang Involvement
In their analysis of gang membership in the United States for
children between the ages of 5 and 17, Pyrooz and Sweeten
(2015) found significantly higher rates of gang membership than had
been previously estimated. Pyrooz and Sweeten (2015) found that
the prevalence of youth gang membership was approximately 2.0%
overall, with the highest rate of 5% recorded for youth at 14 years
of age, with the majority of participation occurring after age 10 years
of age. Given the vulnerability of younger aged youth, Pyrooz and
Sweeten (2015) suggest that the middle school years, particularly
before the age of 12 years, would be an appropriate time for
individuals to institute interventions aimed at prevention of gang
membership. To this end, the researchers suggest the importance
of targeting risk factors for gang membership that have been
revealed in the research to date, including negative life events,
antisocial tendencies, prodelinquent attitudes, low parental
supervision, and association with delinquent peers. Early
intervention is crucial, given the evidence that preventing someone
from joining a gang is far more effective than attempting to
persuade an active gang member to leave (Thornberry, Krohn,
Lizotte, Tobin, & Smith, 2003).
As noted above, Pyrooz and Sweeten (2015) revealed a number
of risk factors associated with gang membership, including low
parental supervision and association with delinquent peers. M ost
disadvantaged youth are often the most unsupervised who live in
crowded housing conditions where private space is limited (Vigil,
2007). Pyrooz and Sweeten (2015) found that although the risk for
joining a gang peaked at 13–14 years of age and then declined as
youth approach adulthood, their research also supported their
earlier reports (Pyrooz, Decker, & Webb, 2014) that for some youth
the gang influence continues to feel its negative impact into
adulthood, even after leaving a gang. Some of the negative
outcomes of gang association have been noted in the following:
substance use/abuse, juvenile delinquency, carrying weapons,
involvement in illicit drug activities, arrest, and violence, all of which
contributed to hardships in areas of family well-being, educational
advancement, and economic opportunities (Decker & Pyrooz,
2010; Egley, Logan, & M cDaniel, 2012; Watkins, Huebner, &
Decker, 2008).
In addition to the risk factors noted above, researchers have also
probed the theoretical foundations inherent in gang membership in
order to better understand what would motivate an individual to join
a gang in order to address potential preventative measures that
can be exercised to deter the process of gang enrollment. To this
end, Pryooz, Fox and Decker (2010) examined the theoretical
correlates of gang membership in order to determine the
interrelationship between economic disadvantage and ethnic
heterogeneity on gang membership.
Pryooz, Fox and Decker (2010) found that ethnic heterogeneity
and economic disadvantage, which they described as the “two
cornerstones of social disorganization theory,” accounted for the
highest levels of gang membership across the United States. To
this end, they emphasize the importance of considering the role
that race and ethnicity play in any theoretical underpinnings of gang
formation and gang membership and as such the need to factor in
these variables separately (e.g., percent Black, Hispanic) rather
than grouping these variables as one factor.
One of the most interesting theories of gang formation has been
suggested by Vigil and colleagues in the application of theories of
multiple marginality to gang formation in the city of Los Angeles.
According to Vigil (2002), social exclusion is one of the prime
motivators of gang formation based on feelings of marginalization
and racial conflict inherent in the process of gang formation and
gang membership. Conchas and Vigil (2013) discuss the role of the
street gang as a source of identity formation in low-income
neighborhoods for primarily male adolescent youth. In their article,
Conchas and Vigil (2013) address how “human developmental
influences promote gang formation as well as inform possible wellbalanced antigang strategies” (p. 36). Conceptually, using multiple
marginality as the organizational framework, Conchas and Vigil
(2010) suggest that the process of gang affiliation is influenced by
and in turn influences perceptions on a number of different levels
including economic, sociocultural, and psychological. Conchas and
Vigil (2013) suggest that youth growing up in the streets form
“newly established social bonds,” which “are reinforced,” a sense of
protection is gained, and new behavior patterns and values are
learned (p. 37). As a result, growing up in an impoverished area
within the context of a gang “family” influences subsequent
development in many ways, including social (acceptance,
protection, sense of belonging); emotional (sense of security,
identity formation); cognitive (rules of group engagement, dress,
conduct); and physical (need to show “toughness,” development)
(Conchas & Vigil, 2013). Based on their analysis of gang formation,
Conchas and Vigil (2013) recommend a number of preventative
measures which are summarized in the Section
Treatment/Prevention.
Race is a strong predictor of poverty and the problematic behaviors
that may result, such as delinquency, violence, and substance use
(M cLoyd, 1998). However, individual differences exist in that not all
African American male youth experience the problematic behaviors
associated with poverty and race. Taylor et al. (2003) examined
characteristics of African American adolescent males who were
involved in gangs (GI) participating in criminal behaviors (drug use,
violence) relative to African American adolescent males who were
involved in community groups (CG). Researchers found very
different attitudes and attributes among the two groups. Youth in
CG were more likely to describe their parents as supportive, as
having rules, and as settling disagreements peacefully. As for
drugs, while the CG sample reported having as many friends who
got high as did not, the GI youth were significantly more likely to
associate with friends who get high. Attitudes toward school were
also highly discrepant, with the GI sample attending school to
socialize or to meet parent demands, while those from the CG
sample attended school to get a better job or go to college. With
respect to role models, youth in the GI group were more likely to
have a “rapper” as a role model, and those in the CG sample were
more likely to seek advice from a role model. According to Vigil
(2002), minority youth are subjected to multiple marginality, “living
and working in marginal situations and conditions,” where there is a
breakdown of social control, and are socialized by the street and
assume the street or “gang” identity (p. 8), as the gang replaces
the family and becomes the family.
Treatment/Prevention
FASD: Of course, the best prevention for FASD is to increase
awareness of the dangers of females drinking during pregnancy. As
there has been no safe amount of alcohol determined, abstinence
is the best method. Prevention programs can be launched on
several levels, including primary/universal prevention (targeting all
pregnant females), secondary/selective prevention (targeting
pregnant women who are at risk for drinking), and tertiary/indicated
prevention (targeting women who drink who become pregnant).
There is an increased risk for individuals with FASD to become
involved in the juvenile justice system (Streissguth et al., 2004;
Streissguth & Kantor, 1997) due to problems in the areas of
intellectual disabilities, learning disabilities, hyperactivity, attention
deficits, and poor social skills, which can increase their chances of
breaking the law. In their fact sheet on FASD and the juvenile
justice system, the Substance Abuse and M ental Health Services
Administration (SAM HSA, 2007) suggests that youth with FASD
can be impulsive and not consider the consequences of their
actions. Furthermore, their poor sense of personal boundaries,
susceptibility to peer pressure, and tendency to be easily led can
all contribute to their vulnerability for criminal and gang-related
behaviors. SAM HSA (2007) emphasizes many ways that youth
with FASD pose a “challenge” to the judicial system, including their
inability to understand the process and communication problems.
As a result, it is recommended that youth should be screened for
FASD at all entry points into the juvenile justice system to ensure
that if the condition exists, it can be detected. The resource also
encourages attorneys to become aware of FASD and the
consequences that this can have in order to appropriately
advocate for their client in areas of
Competency (understand the charges and participate in their
defense)
Diminished capacity (ability to distinguish right from wrong)
Decisions to decline/remand/waive (juvenile rather than adult
facility)
Sentencing (FASD as a mitigating factor)
Treatment (appropriate court-ordered interventions)
The SAM HSA (2007) report also cautions that incarceration may
increase the risk of reoffending due to the iatrogenic effects of
deviancy training from other youth in detention. It is also
recommended that probation or aftercare include a supervised and
structured living situation, where life skills can be monitored and
supported.
Given their cognitive limitations, it is unlikely that insight-oriented
therapy would be beneficial; however, training in ways to improve
executive functions can assist in developing better skills to enable
individuals to be more successful in their relationships with others
and in following through on task demands. Involvement in CG can
also foster increased socialization with more normative peers and
counteract gang involvement.
Gang involvement: M ost gang members showcase their
involvement by a form of dress, behaviors, hand signals, and
tattoos (Gaustad, 2000). Potential gang members are typically
recruited when they reach the teen years, when developmentally,
adolescents are seeking a sense of belonging to a group and
identity formation. The gang can provide both (Reiboldt, 2001).
While Latino members join gangs for a sense of “macho,” African
American youth join gangs to be “cool” (Hunt & Laider, 2001). In
their study of gang member characteristics, Esbensen, Winfree, He,
and Taylor (2001) found these youth to be more impetuous and
violent, engage in more high-risk behaviors, and report less
feelings of guilt.
There are a number of prevention programs that have been
launched to reduce the successful recruitment of new gang
members. Vigil (2002) suggests that unless the policymakers
understand why gangs formed from a cultural and economic
perspective, then intervention and prevention will not be possible.
Furthermore, he states that a proactive approach is necessary and
must begin in early childhood, in low-income areas, with secondary
prevention programs aimed at those children most at risk.
Interventions must also focus on the critical preteen years (9–12),
when youth are at the optimum age for gang recruitment. Finally,
tertiary intervention should focus on those youth who have already
joined a gang to recruit them back into society, not through punitive
means (incarceration) but by offering mentoring, tutoring, and
counseling for them, as well as their families. Based on their
analysis of the role of multiple marginality and social exclusion in
the process of gang formation and affiliation, Conchas and Vigil
(2013) suggest the importance of timing and skill acquisition in
positive areas, in order to assist youth to reinforce a sense of
conventional life. To this end, the authors stress that interventions
must be initiated at youth in the “crucial preteen years, from about
age 9–13” with a focus on “training, work, jobs can engage youths
in productive, conventional activities and ground them in the skills,
knowledge, and attitudes that will stay with them for life and give
them a stake in society” (p. 41). The authors also emphasize the
need to strengthen families (family counseling, parenting classes),
school engagement (remedial programs, individual student
attention), and positive relations with law enforcement (community
outreach programs).
The Gang Resistance Education and Training (G.R.E.A.T.) program
(Esbensen, Osgood, Taylor, Peterson, & Freng, 2001) is a gang
and delinquency prevention program delivered by law enforcement
officers within a school setting. Although initial program reviews
revealed a number of positive outcomes (students in the program
experienced lower levels of victimization and risk-seeking
tendencies, more negative views about gangs, and more positive
views of law enforcement), there were no significant differences
evident between students in the control group and experimental
group in overall levels of delinquency, violence, or gang
membership (Esbensen, Freng, Taylor, Peterson, & Osgood, 2002;
Esbensen, Osgood, et al., 2001). Based in part on these findings of
little program effect, the G.R.E.A.T. program underwent a rigorous
programmatic review that resulted in substantial program
modifications, particularly in the core curriculum. The revised
curriculum was piloted in 2001, with full-scale implementation
occurring in 2003. Presently, the G.R.E.A.T. II program is taught to
middle school students by law enforcement officers, primarily
school resource officers (SRO).
The revised program includes 13 skill building lessons that focus on
addressing known risk factors for gang involvement, including
avoiding involvement in negative associations (gang membership,
violence, criminal activity) and increasing positive associations with
law enforcement. The program teaches specific skills to reduce the
possibility of gang involvement, including communication (refusal
skills), conflict resolution, and anger management techniques. The
program was also expanded to include outreach to families and the
community, including partnerships between law enforcement and
agencies such as the Boys and Girls club, with optional
components available in elementary schools and summer
programs.
A more recent evaluation of outcomes for the G.R.E.A.T. II program
is far more encouraging. In a longitudinal study of approximately
3,800 students involving 31 public middle schools in the United
States, short-term effects revealed the program was effective in
increasing a number of the targeted skills, reducing gang
involvement and improving youth–police relations (Esbensen et al.,
2011; Esbensen, Peterson, Taylor, & Osgood, 2012).
Post-Case Questions
1. The concepts of equifinality (several possible pathways can
lead to the same outcome) and multifinality (being raised in
similar circumstances can result in different outcomes) have
been suggested to assist our understanding of the nature of
different developmental trajectories (Cicchetti & Rogosh,
1996). Although Neesha and Tyrone were siblings who were
raised in the same household, Neesha’s story is one of
resilience, while Tyrone’s path has led to gang membership
and the juvenile justice system. What are some of the factors
that have contributed to the negative outcomes that Tyrone
has experienced?
2. There are many issues and different definitions for the FASD.
Which type of FASD is most likely to apply to Tyrone, and
what characteristics are most common in this form of FASD?
3. What are some reasons that gang membership was so
attractive to Tyrone, and how is this complicated by FASD?
4. Name several ways in which a forensic assessment differs
from a more conventional psychological assessment.
5. Why are so many individuals with FASD involved with the
juvenile justice system and what are the challenges that the
juvenile justice system must face in dealing with these cases?
6. In the Introduction to Chapter 1, several reasons were
discussed for why children and youth raised by depressed
mothers have reported a number of negative outcomes,
including social withdrawal; the acquisition of inappropriate
social skills; increased risk for psychopathology; and evidence
of dysfunctional physiological systems associated with the
ability to manage stress and engage in social relationships
such as cortisol response. Individual characteristics that have
emerged as protective factors which can buffer a child from the
impact of having a depressed mother are having an easy
temperament (as opposed to difficult temperament) and having
a higher IQ. Given Tyrone’s history and
biological/psychological profile, what are the risks and
protective factors for him regarding the potential for positive or
negative outcomes?
7. Suggested individual or group presentation activity: You have
been invited to provide feedback to the court regarding
Tyrone’s assessment. What would be the focus of your
presentation, and what would your recommendations be? How
would you prepare for your presentation (who would you
interview and what additional data would you want to collect),
and who would you want to be in attendance at that session,
for potential questioning? How could each participant
potentially contribute information to assist with developing an
intervention plan that would best meet Tyrone’s needs?
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4 INTRODUCTION TO ANXIETY AND
COMPULSIVE DISORDERS
Compared to the behavioral disorders which are externalizing
disorders that are often highly visible, disruptive, and disturbing to
others, the anxiety disorders can often go undiagnosed because
they are behaviors that are more subtle and internalized within the
self. Other disorders that share similar overcontrolled features
include depression and somatic complaints, which can often be
comorbid with anxiety disorders.
Over time, the DSM has changed the way that anxiety disorders in
children have been conceptualized. While the DSM -III (APA, 1980)
recognized three anxiety disorders of childhood (separation anxiety
disorder [SAD], avoidance disorder, and overanxious disorder), the
DSM -IV-TR (APA, 2000) included only SAD in the category of
“Disorders Usually First Diagnosed in Infancy, Childhood or
Adolescence,” although the symptom criteria for all other anxiety
disorders were expanded to include descriptions of child-oriented
symptoms in the text revision. In keeping with the move toward a
more developmentally oriented perspective, the DSM -5 (APA,
2013) lists all anxiety disorders in the section on “Anxiety
Disorders.”
Although the actual symptom criteria for the anxiety disorders
remain consistent with the previous version of the DSM (APA,
2000), in addition to medically or substance-induced disorders, the
chapter on anxiety disorders is arranged developmentally (based
on age of typical onset) and now includes discussions of SAD,
selective mutism, specific phobia, social anxiety disorder (social
phobia), panic disorder, panic attack specifier, agoraphobia, and
generalized anxiety disorder (GAD). Selective mutism is new to
this category and was previously included as one of the “Other
Disorders of Infancy, Childhood or Adolescence” along with SAD,
reactive attachment disorder, and stereotypic movement disorder.
M issing from the category of Anxiety Disorders are the stress
disorders (posttraumatic stress disorder [PTSD]; acute stress
disorder), which are now found in the section on “Trauma and
Stressor-Related Disorders,” and obsessive compulsive disorder
(OCD), which has been relocated to a new section “Obsessive
Compulsive and Related Disorders.” In this chapter, we will discuss
cases that include symptoms of SAD, selective mutism, GAD,
OCD, and social anxiety. Cases related to trauma (reactive
attachment disorder, nonsuicidal self-injury) and stress-related
disorders (PTSD) will be presented in Chapter 7.
ANXIETY AND ANXIETY-RELATED
DISORDERS
Anxiety disorders share common traits of excessive fear and worry
that go beyond what is developmentally appropriate and persist
longer than what would be expected given a normal adjustment
period (lasting longer than 6 months). Although the anxiety
disorders share reactions of excessive fear and avoidance, the
nature of the situation or event which induces the response will
determine the type of anxiety disorder that is present. For example,
persistent fear of harm to a caregiver would suggest symptoms of
SAD, while a sense of free-floating anxiety and worry across a
variety of situations/events may signal GAD. Individuals with
specific phobias have an excessive fear and avoidance of an
anxiety-provoking situation/event or object (e.g., fear of heights,
animals, etc.), while those with social anxiety disorder are fearful of
being humiliated or embarrassed while in the company of others
unfamiliar to them. The DSM emphasizes that panic attacks can
accompany a variety of different mental disorders; however, the
attack itself is not a mental disorder, whereas panic disorder is
diagnosed when individuals fear having panic attacks to the extent
that it interferes with normal functioning. Agoraphobia is diagnosed
if an individual avoids two or more situations because of excessive
fear of having a panic attack, including public transportation, open
spaces, enclosed spaces, crowds, or being outside the home.
The following summaries provide an outline of DSM criteria for
anxiety disorders discussed in this chapter.
Separation anxiety disorder (SAD): Individuals with SAD have an
excessive fear of being separated from their caregiver, lasting for at
least 4 weeks, evident in at least three symptoms, including
persistent and recurrent distress/worry, resulting from
separation or the expectation of separation from the caregiver;
fears of harm to the caregiver;
fear of an event that will result in separation (accident, illness);
refusal/reluctance to leave home/caregiver;
refusal to sleep away from home;
nightmares about separation;
anticipation or fear of separation resulting in physical
complaints/symptoms.
The distress is not accounted for by refusal to change or
adherence to rituals as noted in autism spectrum disorder (APA,
2013, p. 191).
Selective mutism: Children diagnosed with selective mutism
refuse to speak in certain social situations (e.g., school) despite
being able to speak in other situations (e.g., home). Their
reluctance to speak in these specific situations is not related to
any sense of discomfort in speaking, lack of language fluency, or
any communication disorder. The condition must persist for at least
1 month, excluding the first month of school (APA, 2013, p. 195).
Generalized anxiety disorder (GAD): Individuals diagnosed with
GAD will present with symptoms of excessive and pervasive
anxiety and worry regarding events or activities related to day-today functioning and performance (school or work), lasting for at
least 6 months. While adults with GAD must present with three of
more symptoms from a list of six possible symptoms, only one
symptom is required for a diagnosis in children: restlessness, ease
of fatigue, problems concentrating, irritability, muscle tension, and
sleep disturbance (APA, 2013). The nature of worries tends to vary
developmentally with children and adolescents exhibiting concerns
related to performance at school or in sports, while adult worries
tend to focus on family well-being or health-related concerns.
Social anxiety disorder: Social anxiety disorder occurs when an
individual has a marked fear or anxiety associated with social
situations where the individual is exposed to possible evaluation or
judgment by others and fears embarrassment or humiliation as a
result. The social activities may include such situations as having a
conversation with someone, meeting unfamiliar people, or
eating/drinking or performing in the presence of others. For children,
the fear or anxiety must occur in the presence of peers, not just
adults. Often the situations are avoided because they are so
anxiety provoking.
OBSESSIVE COMPULSIVE AND
RELATED DISORDERS
Although the diagnostic criteria for OCD have not changed from the
previous edition of the DSM (APA, 2000), the disorder has been
relocated to a newly created chapter, “Obsessive Compulsive and
Related Disorders,” which includes disorders such as OCD, body
dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling
disorder), and excoriation (skin-picking) disorder. Disorders in this
chapter share features of preoccupations and repetitive behaviors
that are excessive and beyond what would be expected given an
individual’s developmental level or insight.
Obsessive compulsive disorder (OCD): Individuals with OCD
experience intrusive obsessions (recurrent and persistent thoughts,
urges, images) that they attempt to neutralize or suppress through
some action (e.g., compulsion) or compulsions (repetitive behaviors
or mental acts) performed in order to reduce anxiety associated
with a situation or event, or they experience both obsessions and
compulsions. These obsessions or compulsions are pervasive,
consuming more than 1 hour daily. Individuals with OCD can
demonstrate various levels of awareness, from good/fair insight to
poor insight, or with absent insight and delusional beliefs (APA,
2013, p. 238). Common forms of OCD include contamination
(cleaning or hand washing compulsions), symmetry (ordering,
arranging), and safety (checking).
Trichotillomania (hair-pulling disorder): Trichotillomania is a
repetitive behavior that involves hair pulling often resulting in hair
loss in a specific area (eyelids, scalp, eyebrows, etc.). The act of
hair pulling causes significant distress (embarrassment, feeling of
loss of control), as does repeated attempts to not engage in the
activity. Females are significantly more likely to engage in
trichotillomania than males (ratio of 10:1), although among children
there is minimal gender differences (APA, 2013).
REFERENCES
American Psychiatric Association. (1980). Diagnostic and statistical
manual of mental disorders-III. Arlington, VA: Author.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders-IV-TR. Arlington, VA: Author.
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders-5. Arlington, VA: Author.
CASE 13 WINNIE KENT : SILENCE
IS NOT GOLDEN SEPARATION
ANXIETY DISORDER; SELECTIVE
MUTISM
Winnie, a 5½-year-old girl, was referred for assessment by her
pediatrician. Winnie was accompanied by her mother, Isabel.
Despite being a seemingly normal and talkative youngster at home,
Winnie had always been rather shy and reticent in larger group
settings. Although her mother had anticipated some early
reservations on Winnie’s part regarding her initial school placement,
Isabel was totally unequipped to deal with the current situation,
which had developed over the past 6 months of enrollment in the
kindergarten program.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
Isabel Kent and her husband Frank were both in their early forties.
They met and married while attending graduate school. Frank is an
engineer, and Isabel is currently a stay-at-home mom. Prior to
Winnie’s birth, Isabel was a research assistant for a pharmaceutical
company. Isabel stated that there was no serious mental illness on
either side of the family, although she described herself as “high
strung” and a bit of a loner. She felt that her husband was a
workaholic, since he spent the majority of his time either working or
thinking about working. She described their marriage “as successful
as most enduring marriages.”
Isabel stated that although Winnie is an only child, it was not by
choice. The pregnancy was planned and it was decided that when
the baby was born, Isabel would quit her job and devote her time
to child rearing. Although the plan was to have two or three
children, Isabel suffered a miscarriage when Winnie was about 14
months old and then a second miscarriage about 5 months later.
Isabel described herself as depressed during this period with
frequent bouts of crying and fatigue. Her physician suggested a trial
of Prozac; however, Isabel developed headaches and
nervousness/agitation as side effects. A trial of Paxil produced
fewer side effects and eventually, with the help of Paxil, Isabel was
coping much better. Because of the risk of complications in
pregnancy, given Isabel’s age, and fear of the depression returning
if she had another miscarriage, the Kents decided to abandon any
further attempts to conceive a child.
Winnie weighed 5 pounds 6 ounces at birth, and although
pregnancy and delivery were normal, complications developed later
on. Immediately after the birth, an attempt to intubate a blocked
nasal passage resulted in swelling. Winnie was fed intravenously
and required an artificial airway until the swelling subsided and
surgery could finally be performed to remove the membrane that
was blocking the nasal passage. During this time, Winnie
experienced what her mother described as “blue spells,” a term she
used to describe the color of Winnie’s face and body resulting from
lack of oxygen. Isabel said that this was a very emotionally draining
time for her. Isabel was very fearful and anxious concerning
Winnie’s health, even though the medical staff assured her that
Winnie would be fine. Winnie remained in the neonatal intensive
care unit for 3 weeks before Isabel could take her home from the
hospital.
As an infant, Winnie had bouts of being fretful and colicky, and she
had some difficulties keeping her food down. M rs. Kent recalled
that at least twice a week, if not more, Winnie would lose almost
half her intake in rather severe episodes of projectile vomiting. M rs.
Kent was concerned and asked the pediatrician about it, but his
response was that it was likely due to a sensitive and immature
digestive system. He suggested they change the baby formula;
that helped somewhat, but the matter never really resolved itself
until Winnie was totally on solid food. M rs. Kent stated that even
today, Winnie is a picky eater, and if she is upset, she tends to eat
very little because her stomach is easily upset.
M otor milestones were slightly advanced developmentally, and
Winnie was sitting independently at 4 months, standing at 7–8
months, and walking at 10 months of age. Language development
lagged behind motor skills. Winnie did not say her first word until
about 15 months, and simple sentences were not produced until
about 2½ years of age. Winnie had some articulation problems and
substituted a few sounds, the most prominent of which were “w” for
“r” (wabbit for rabbit) and “l” for “y” (lellow for yellow). The
articulation errors stopped about a year ago. Currently, Isabel
believes that Winnie’s speech is normal for her age, based on
conversations between Winnie and her best friend Kate’s daughter,
M olly, who is almost the same age as Winnie. At home, she
described Winnie as very chatty and quite the conversationalist,
with speech far more adult-like than childlike.
Isabel described herself as somewhat aloof and not one to initiate
a lot of social contact. She was fortunate that Kate lived across the
street, since Winnie and M olly were about the same age and
played very well together. Kate was more outgoing than Isabel and
was often responsible for organizing activities for the foursome,
such as outings to the park or attending movies or concerts. Isabel
and her husband Frank rarely went out in the evenings, due to
Frank’s long work hours, but when they did, Winnie would just go
over and spend the night at Kate’s house with M olly. Similarly,
M olly would spend the night with them whenever Kate and Brian
went out for an evening. People often mistook Winnie and M olly
for twins, since they were about the same age and looked
somewhat alike. Unfortunately, about 9 months ago, Brian was
suddenly transferred and the family moved out of state. Isabel said
that until the separation, she never really realized how much time
the four of them had spent together. Isabel said that she really
misses Kate’s company and she is sure that Winnie must really
miss M olly, too, although she does not talk about M olly very much.
Isabel wondered if she were grieving in silence or just did not feel
as strongly as an adult might.
About 2 months after Kate and M olly left, Isabel decided to enroll in
a Tuesday morning art class at the local gallery and enroll Winnie in
a once-weekly preschool program for that morning. Isabel thought
that this would be good for both herself and Winnie. However,
when she tried to drop Winnie off at the preschool center, Winnie
had a severe temper tantrum, attached herself to her mother’s leg,
and began sobbing uncontrollably. Isabel was in shock since she
had never seen such behavior from Winnie before. Isabel stayed
with Winnie for the next half hour hoping that Winnie would calm
down. Eventually, sobs dissipated into heaving sighs and Isabel
decided to make another attempt to leave. On cue, Winnie’s sobs
began again, this time even more violently and accompanied by
screaming and begging her mother not to go. The preschool staff
encouraged Isabel not to give in to Winnie at this point, since it
would only make matters worse. Isabel left, without looking back,
afraid if she saw Winnie, she would not be able to carry on. When
Isabel returned 3 hours later, Winnie looked as though she was
totally drained. She was engaged in subdued solitary play in the
corner, rocking her doll. Her eyes were red and swollen from crying.
The preschool staff said that she continued with her sobbing for
quite some time after Isabel had left. That night, Winnie was like
Velcro and refused to sleep alone. The whole ordeal was far more
than Isabel had bargained for. The next night, had it not been for
Frank’s insistence that Winnie sleep in her own bed, the nightly
ritual probably would have continued. As it was, Winnie started
calling out at night, and often Isabel would have to go into Winnie’s
bedroom to comfort her. Isabel ended up sleeping in Winnie’s room
the next night because Winnie had a nightmare that her mom had
gone away. Isabel started leaving the light on in Winnie’s bedroom
so she would not be afraid of the dark.
The following Tuesday, Winnie started crying when Isabel began to
prepare to leave. Winnie started to complain that her stomach was
hurting and held on tightly to her stomach saying, “It hurts, it hurts.”
Although Isabel could not be definite, she was pretty sure that
Winnie was saying she was sick and wanted to stay home. Rather
than give in, she picked Winnie up and carried her to the car, with
Winnie sobbing and complaining about her aching stomach. The
tears, the sobbing, the protests, and the aches and pains
continued every Tuesday for the next 3 months. Eventually, Winnie
would comply, but began to sit beside the preschool window
waiting and watching for signs of her mother’s return. When they
were home, Winnie was constantly in need of reassurance that her
mother was all right and that everything was okay.
Despite the difficulties, Isabel persisted in taking Winnie to
preschool because kindergarten would be starting shortly, and
Isabel knew Winnie had to become more prepared. Winnie was
having considerable difficulty adjusting to preschool, which was
only one day a week. How would she cope with kindergarten on a
daily basis? She also needed more practice socially. She seemed
so withdrawn at the preschool and didn’t seem to interact with the
other children. Her teachers said that she was very cooperative,
but she did not seem comfortable talking to anyone.
Isabel was thrilled when a new family moved in a few doors down
the road because they had a daughter Winnie’s age. Isabel really
pushed herself to be more social and extended an invitation to the
new mother and daughter to come over for afternoon tea. Winnie
seemed to get along well with her new friend and soon they were
playing together, much like she and M olly had. After a few months,
Winnie was invited to a sleepover at Becky’s. Although the girls
had planned the event for some time, Winnie began to get anxious
just before it was time to leave. She asked an endless series of
questions about what her mother would be doing in her absence.
Isabel continued to reassure her that she was just going to take a
bath and watch television. Winnie immediately became concerned
that her mother might slip in the bathtub and if nobody else was
home, she could drown. Isabel continued to attempt to calm
Winnie’s fears. Finally, Becky and her mother came to pick up
Winnie for the sleepover. Winnie’s goodbye hug was more like a
desperate attempt to carry her mother along with her. Two hours
later, Winnie was standing at the door, sleeping bag in tow,
complaining that she had to come home because she did not feel
well.
Kindergarten finally started and after much struggle and distress,
Isabel finally got Winnie to walk to school with her friend Becky.
Winnie would walk beside Becky with her head bent down,
constantly looking sideways to see if her mother was still watching
from the outside steps. The school was only a block away, and
Winnie told herself that if she looked really hard, she could
probably see her house between the trees. At school, Winnie just
seemed to go through the motions until it was home time. On the
playground, she was always peering through the fence, trying to
see her house. Her teachers were very patient and encouraging,
and Winnie was cooperative, but she would not participate verbally
in any activities that were going on. For the first month, her
teachers thought it was just a case of reluctance to talk in the new
environment. After all, Winnie did appear to be very shy, and her
mother had cautioned the kindergarten teachers that Winnie was
slow to warm up. They anticipated that it might take a while for her
to feel comfortable talking to the teachers and the other children.
However, 4 months had gone by and Winnie had not said a word.
When asked a question, Winnie would nod her head in the
affirmative or shake her head to signal “no,” but no words
accompanied the gestures. Winnie would talk only to Becky at
school and then only in whispers, until they got far enough away
from the schoolyard that no one could hear. Then she would talk to
Becky as if they were at home.
REASON FOR REFERRAL
Isabel finally brought Winnie to the pediatrician for help, not
understanding why her daughter was giving the school situation the
silent treatment. The pediatrician suggested that Isabel take Winnie
to see a child psychologist, who could evaluate the causes of
Winnie’s silent behaviors and suggest ways to best deal with this
behavior in the school.
ASSESSMENT RESULTS
When Isabel contacted the psychologist at the clinic, prior to
seeing Winnie in the clinic, the psychologist requested permission
to observe Winnie in the classroom. Isabel was very much in
agreement. After observing Winnie for a morning and interviewing
her teachers, the psychologist sat beside Winnie and asked her to
draw a picture for her. Winnie drew a picture of a little girl skipping.
The psychologist found it interesting that the skipping rope
surrounded the little girl’s head, as if her head were in a space
capsule. The drawing was sophisticated enough, however, to
suggest that Winnie was likely, at least, of average intelligence.
The psychologist contacted Isabel and suggested she bring Winnie
to the clinic for a comprehensive assessment.
Isabel brought Winnie to the clinic the following week. Winnie
would not go into the assessment room unless her mother came
with her. Throughout the assessment, Winnie would not speak
directly to the psychologist or answer any questions verbally. On
occasion, Winnie would bend over toward her mother and whisper
something into her mother’s ear. But even on these occasions,
she would cup her hand around her mouth, blocking the
psychologist from any entry into her verbal world.
Winnie’s drawing of a person (Draw-A-Person) and Bender Visual
M otor Gestalt designs were all within the average range. Scores
on the Peabody Picture Vocabulary Test (PPVT-IV) also revealed
an understanding of vocabulary that was above the expected level
for her age (SS = 110). The psychologist asked Winnie’s teacher
and mother to complete the Behavioral Assessment System for
Children (BASC-2) Preschool Scales. Based on Winnie’s
responses to the school setting, M rs. Kent rated Winnie in the
clinical range for Adaptability; however, all other ratings were within
the norm. Winnie’s teacher rated clinical elevations for Anxiety,
Atypicality, Adaptability, and Social Skills.
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
Separation Anxiety Disorder (SAD)
Separation anxiety disorder (SAD) is the first anxiety disorder listed
in the DSM -5 (APA, 2013) which presents the anxiety disorders in
order of developmental onset. According to the DSM -5, SAD is
“the most prevalent anxiety disorder in children younger than 12
years” (p. 192). Anxiety disorders can result from a combination of
genetic factors (heredity, inhibited temperament) and environmental
factors, such as cumulative risks, exposure to traumatic
events/repeated exposure to negative outcomes, and
overprotective parenting practices (Ollendick, Vasey, & King, 2001;
Vasey & Dadds, 2001). Although most infants go through normal
anxieties related to separation from caregivers, which usually
decline after 2 years of age, for some children, separation anxiety
may intensify and persist well into early childhood (Kearney, Sims,
Pursell, & Tillotson, 2003). SAD is an intense emotional response
resulting from excessive worry surrounding the possibility of
separation from the caregiver. The DSM -5 (APA, 2013) lists a
number of possible symptoms of the disorder resulting from
excessive distress, fears of harm coming to the caregiver, and
fears of being alone (see Glossary for the complete list of criteria).
Because it is so painful for the child to separate from the caregiver,
young children will often refuse to participate in activities that
remove them from their caregiver. As a result, approximately 75%
of children with SAD will demonstrate school refusal when it is time
to begin school or refuse to return to school, following an absence
due to illness or a school move (Black & Uhde, 1995; Kearney &
Albano, 2004).
SAD is the most prevalent childhood anxiety disorder which
accounts for one half of the referrals for mental health treatment for
anxiety disorders (Cartwright-Hatton, M cNicol, & Doubleday, 2006).
Shear, Jin, Ruscio, Walters, and Kessler (2006) found a prevalence
rate of SAD in children to be approximately 4%, while one-third of
those cases (36%) will continue to demonstrate symptoms of SAD
in adulthood.
While some research has linked SAD to problematic or chaotic
home environments (Egger, Costello, & Angold, 2003; Kearney et
al., 2003), other findings have suggested that children are at
increased risk for SAD if their mothers were diagnosed with an
anxiety or major depressive disorder (Biederman et al., 2001).
Deiner and Kim (2004) found that mothers who reported feelings of
separation anxiety, themselves, were significantly more likely to
have children who evidenced social withdrawal and problems with
self-regulation. In their study, Dallaire and Weinraub (2005) reported
that children who were classified as insecurely attached at 15
months of age demonstrated significantly higher levels of
separation anxiety at 6 years of age compared to securely
attached peers.
A major developmental task for children in the preschool years is
the task of separation from caregivers, as many will initiate their
first contacts with preschools or prekindergarten/kindergarten
enrollments at that time. Although some children can manage this
transition with relative ease or display only minor and temporary
distress, research concerning parenting styles of parents of
anxious children (e.g., more controlling, less warm/more critical,
more overprotective) suggests that their less engaging style may
serve to exacerbate preexisting anxious behaviors in children,
especially when required to separate from the caregiver (Eisen,
Engler, & Geyer, 1998).
Selective Mutism
Among the anxiety disorders discussed in the DSM-5 (APA, 2013),
selective mutism is listed second in the anxiety disorder category
based on developmental age of onset, preceded by SAD. Although
selective mutism was initially thought to be a rare disorder (e.g.,
ranging between 0.03% and 1%), according to the DSM -5 (APA,
2013), some studies have found as many as 7 children in every
1,000 in kindergarten through second grade meet criteria for the
disorder (Bergman, Piacentini, & M cCracken, 2002). Based on
more recent research, prevalence rates have been estimated to
range from 0.7% to 2% of early elementary school students,
although researchers suggest that this may be an underestimate of
true rates due to the lack of knowledge of the disorder
(Cunninghan, M cHolm, & Boyle, 2006; Lescano, 2008; Schwartz,
Freedy, & Sheridan, 2006; Sharkey, M cNicholas, Barry, Begley, &
Ahern, 2007). Prevalence rates have been reported as
disproportionately higher among female populations (Cohan,
Chavira, & Stein, 2006; Cunninghan, M cHolm, Boyle, & Patel, 2004;
Lescano, 2008; M endlowitz & M onga, 2007; Sharkey et al., 2007).
There has been controversy about how the disorder should be
conceptualized relative to other childhood or anxiety-related
disorders. Although the DSM -IV-TR (APA, 2000) placed selective
mutism among one of the five disorders listed under the category
of “Other Disorders of Infancy, Childhood or Adolescence” (ASD;
reactive attachment disorder; stereotypic movement disorder; and
disorder of infancy, childhood, or adolescence NOS), the DSM -5
(APA, 2013) has located the disorder within the chapter on anxiety
disorders. Since a number of studies have found that children with
selective mutism also meet diagnostic criteria for social phobia
(social anxiety disorder), although earlier studies suggested that
selective mutism be considered as a subtype of social phobia
(Black & Uhde, 1995; Kristensen, 2000), more recently, Cunninghan
et al. (2006) provide evidence in favor of considering two subtypes
of selective mutism (generalized versus specific mutism), similar to
subtypes of social phobia, although their study suggests that both
types share significant socially phobic behaviors and deficits in
social skills.
Selective mutism is considered a disorder of “younger children” with
the average age of onset ranging from 2.7 to 4.1 years
(Cunninghan et al., 2004; Garcia, Freeman, Francis, M iller, &
Leonard, 2004). Although symptoms of the disorder are usually
present by the age of three, researchers emphasize that there may
be a lag between actual age of onset and when the disorder is
actually detected, since oftentimes the disorder does not manifest
until the child is school aged (approximately 5 years of age) and is
required to speak in the classroom, outside their usual comfort
zone (Cunninghan et al., 2006; Sharkey & M cNicholas, 2008).
Since onset of the disorder often coincides with initial school
entrance, an underlying feature of the disorder may be school
refusal. However, the DSM attempts to control for this issue by
criteria which state that the disorder must be present for at least
one month “not limited to the first month of school” (APA, 2013, p.
195). Issues regarding how the disorder should be conceptualized
have affected research, diagnosis, assessment, and treatment.
There has been significant debate regarding whether selective
mutism should best be conceptualized as an early precursor to
social phobia (Krysanski, 2003). However, while selective mutism
has onset most likely in the 4- to 7-year range, social phobia is
most likely to have onset in adolescence, which makes this line of
reasoning difficult to support for some researchers.
While early theorists suggested that selective mutism might be the
result of trauma or major life events, such as child abuse or death
of a family member (Dow, Sonies, Scheib, M oss, & Leonard, 1995),
more recent findings have refuted these claims (Gray, Jordan,
Ziegler, & Livingston, 2002) finding no history of trauma of major life
events in the history of children with selective mutism. Current
theories tend to support the notion that selective mutism seems to
develop from an interplay of genetic and environmental factors
(Cohan, Price, & Stein, 2006). Similar to families of children with
SAD, families of children with selective mutism have also been
described by characteristics that mirror specific anxiety symptoms
such as being more isolated and refraining from social contact (e.g.,
Remschmidt, Poller, Herpertz-Dahlmann, Hennighausen, &
Gutenbrunner, 2001). Parents have been described as
overprotective, and families of children with selective mutism have
been seen as socially less active and less involved in outside
activities, such as participating in recreational outlets (Vecchio &
Kearney, 2005).
Numerous studies have documented that anxiety disorders can
have a genetic basis. Research has found that parents of children
diagnosed with selective mutism are also more likely to exhibit
signs of moderate to severe anxiety (Kristensen & Torgerson,
2001; Schwartz et al., 2006). In one study, Schwartz et al. (2006)
reported that 33% of the participants in their study reported a family
history positive for a diagnosis of social anxiety disorder, while
12.1% of the families had family members who actually had
experienced selective mutism, as a child.
Presently, conceptualizations of selective mutism support strong
links of the disorder with other anxiety disorders, especially social
phobia (Cunninghan et al., 2006; M cHolm, Cunningham, & Vanier,
2005; Sharkey & M cNicholas, 2008). Social phobia often results in
the restriction of social interaction or communication with others
due to fears of being negatively scrutinized by others. Although
many children may be shy in social situations, or have specific
fears, phobias are irrational fears that result in behaviors motivated
to avoid the fearful situation or object (M cHolm, Cunninghan, &
Vanier, 2005) resulting in children with selective mutism developing
a fear of talking in public that is exacerbated to be anxiety.
However, unlike shyness, which is often overcome with increased
familiarity, “individuals with selective mutism do not fully overcome
their anxiety without formal intervention” (Composano, 2011, p. 48).
Aside from reluctance to engage in verbal communication, many
children with selective mutism also demonstrate other symptoms of
inhibition (M cHolm et al., 2005). Kristensen (2001) found that
children with selective mutism also shared symptoms of limited
smiling, avoidance of eye contact, blushing, fidgeting, and tantrum
behaviors.
There have been a number of suggestions regarding how to best
classify variants of the disorder. Although initially called elective
mutism (DSM-III; APA, 1980), current emphasis is on the
“selective” nature of those individuals that the child will speak to.
As noted earlier, Cunninghan et al. (2006) suggested classifying
groups with selective mutism along criteria used for social phobia:
generalized (for those whose symptoms are demonstrated across
a variety of situations) and specific (for those whose symptoms are
restricted to speaking in classrooms at school). Cunningham et al.
(2006) found that children with the generalized variant of selective
mutism experienced more symptoms of obsessive thinking,
somatic complaints, and depression and were less proficient
socially than controls, leading the authors to suggest that the
generalized variant was the more severe form of selective mutism,
although as previously mentioned, both groups shared similar
significant results when compared to controls.
Beidel and colleagues (Beidel, Turner, & M orris, 1999) outline
several areas of social anxiety in children that might be seen to
overlap with selective mutism, such as fears of reading aloud in
class, joining in on conversations, speaking to adults, and starting
conversations. Vecchio and Kearney (2005) found that all children
who were diagnosed with selective mutism in their study also
received a diagnosis of social anxiety disorder, while 53% received
an additional anxiety disorder diagnosis. Comparing parent and
teacher ratings for internalizing problems in the selective mutism
group and the anxiety disorders group, the researchers found
minimal between-group differences, suggesting a high degree
symptom similarity between these two groups. Cunninghan et al.
(2004) found that parent and teacher ratings for symptoms of
anxiety and obsessive compulsive disorder were significantly
higher for children diagnosed with selective mutism compared to
controls, while Bergman et al. (2002) also found that teachers rated
children with selective mutism significantly higher than controls on
scales measuring internalizing, withdrawn, and anxious/depressed
symptoms. The above findings demonstrate consistent support for
conceptualizing selective mutism as an anxiety-based disorder.
There is a wide range of variability in social skills development
among children with selective mutism (Amir, 2005). Amir (2005)
suggests that although most children with selective mutism will be
unable to communicate verbally with an adult, patterns of
interaction with peers define three different variants of selective
mutism: children who are able to interact easily with peers inside
and outside of the home; children who will interact with peers but
not communicate verbally; and children who isolate themselves
and withdraw in social settings.
TREATMENT FOR SEPARATION ANXIETY
DISORDER AND SELECTIVE MUTISM
Separation Anxiety Disorder (SAD)
Although anxiety disorders are often treated using cognitive
behavioral therapy (CBT), younger children are often less receptive
to CBT due to their restricted level of cognitive skills (Grave &
Blissett, 2004). Given the demonstrated influence of parenting style
on child behavior and possible genetic transmission of SAD, it is
not surprising to see research focusing on parent management
training as a possible treatment for SAD. One such parent training
program is Parent–Child Interaction Therapy (PCIT; Brinkmeyer &
Eyberg, 2003), an empirically supported treatment program based
on attachment and social learning theories that was originally
developed to reduce disruptive behaviors in children. PCIT has
been adapted to meet the needs of children with SAD and their
parents and evaluated in a number of current research studies
(Choate, Pincus, Eyberg, & Barlow, 2005; Hood & Eyberg, 2003 ;
Pincus, Eyberg, & Choate, 2005; Pincus, Santucci, Ehrenreich, &
Eyberg, 2008). The program has been tailored to suit children in the
4–8-year range (Pincus et al., 2005). The original program
consisted of two phases: Child-Directed Interaction (CDI) and
Parent-Directed Interaction (PDI). The CDI component of the
program targets changing the quality of the parent–child
relationship. The actual length of the program depends upon the
parent’s ability to master the skills; however, the original average
number of weekly one-hour sessions was 13 sessions. Focus
during these sessions is on positive interactive skills (increasing
warmth, responsiveness, attention, and praise for appropriate
behavior) and consistent ignoring of undesirable behaviors. The
overall goal is to improve the security of attachment between
parent and child, thereby reducing the fear of separation in the
future (Pincus et al., 2005). A later revision of the protocol reduced
the number of sessions to 9–10 with 3–4 sessions for CDI and 3
PDI sessions. A new phase (3 sessions) was added called
Bravery-Directed Interaction (BDI) to address specific anxiety
concerns and assist parents in helping children to approach
previously avoided situations (Pincus et al., 2008). The BDI
sessions included psychoeducation to teach parents about the
nature of anxiety (etiology, symptoms, feelings) and included
assistance in progressive introduction of the child to the feared
situation. Tools used to increase separation behavior are the
Bravery Ladder (progressive list of steps in the process of
separation) and Reward Store (list of rewards to be achieved for
each step completed). Children are engaged in choosing the steps
of exposure for weekly assignments to encourage autonomy.
In a recent study of CBT for youth (7–14 years of age) with a
principal diagnosis of SAD (47), generalized anxiety disorder (88),
or social phobia (63), Suveg et al. (2009) found comparable results
for individual child-focused CBT and child-focused family CBT in
decreasing symptoms and improving adaptive functioning.
Furthermore, a family-based education support and attention
approach (a 16-session treatment featuring education about youth
anxiety and providing attention and support, but not including any
training in how to manage anxious responses or exposure tasks)
also proved to be equally effective.
Selective Mutism
Researchers emphasize that the most effective treatment for
selective mutism is treatment that is implemented as soon as
symptoms are evident (e.g., Schwartz et al., 2006; Stone &
Kratochwill, 2002) in order to reduce the negative reinforcement
associated with avoidant behaviors. Although early treatment
focused primarily on psychodynamic approaches due to the initial
thoughts that selective mutism was the result of early trauma, more
recently, treatments of behavioral, cognitive behavioral, and familybased therapy have all provided approaches to the treatment of
selective mutism. From a psychodynamic perspective, play therapy
(Terr, 2008) and music therapy (Amir, 2005) have both provided
venues for children to explore their emotions in a “safe” and
“nonthreatening” environment.
In their review of treatments for selective mutism, Cohan et al.
(2006) found that the most frequent and successful treatments
involved behavioral interventions and/or cognitive behavioral
interventions. From a behavioral perspective, therapy is focused on
the goal of decreasing anxiety and increasing verbal
communications in difficult settings, such as a school environment
(Cohan et al., 2006). Some of the most common behavioral
methods used for selective mutism include shaping, self-modeling,
and contingency management (systematic desensitization) to
increase verbal communication and lower anxiety. Shaping involves
breaking down the target of verbal communication into very small
steps and gradually building to higher forms of verbal
communication; for example, the therapist begins with reinforcing
mouth movements and sounds resembling speech (M endlowitz &
M onga, 2007).
Graduated behavioral exposure treatments (systematic
desensitization) can also be very helpful in the treatment of
selective mutism (M cHolm et al., 2005; Stone, Kratochwill,
Sladeczek, & Serlin, 2002). Lescano (2008) suggests that
contingency management is often used in conjunction with
systematic desensitization allowing for the counselor to set goals
that increase in difficulty and provide the appropriate rewards for
each of the levels successfully mastered. Cognitive behavioral
methods emphasize changing an individuals anxious thoughts to
more neutral ways of thinking. Although the approach has been
successful with older children, the focus on learning techniques to
manage anxious thoughts (Chansky, 2004), there are limitations for
the use of CBT for very young children due to cognitive limitations,
although Fung (2002) recently adapted a CBT program for children
(Coping Bear Workbook; M endlowitz et al., 1999) into a web-based
Internet program for selective mutism and reports success in
alleviating symptoms of selective mutism in a 7-year-old child. In
addition, CBT can be successfully applied to parent and familybased treatment approaches (Chansky, 2004) to assist parents in
developing skills to assist children in recognizing their physiological
responses and how these relate to behaviors that are associated
with anxiety. CBT techniques can also assist with behavioral
interventions, especially if a child responds to the therapy session
with anxiety. Children who are taught relaxation techniques, such
as breathing techniques, muscle relaxation, or story telling (Sharkey
& M cNicholas, 2008) to assist with anxiety, may also benefit from
using these techniques to reduce anxiety during their therapy
sessions (Cohan et al., 2006). Practice in techniques and skills to
assist with anxiety management can often be integrated into parent
and family-based sessions to assist children in developing
methods to cope with anxiety (M endlowitz & M onga, 2007).
Given the environmental impact of the school setting on selective
mutism, the importance of including members of the child’s school
community in the treatment process must be emphasized.
Researchers have demonstrated that for children diagnosed with
selective mutism collaboration between parents, teachers, and
counselors can significantly impact treatment outcomes
(Kumpulainen, 2002; Lescano, 2008; M cHolm et al., 2005). Vecchio
and Kearney (2007) emphasize the importance of using a team
approach in the schools to counteract the “widespread” nature of
child’s reluctance to speak within the school setting.
Pharmaceutical interventions have demonstrated success with the
use of fluoxetine in the reduction of social fears in children with
social phobia suggesting that fluoxetine reduces arousal in social
settings (Beidel and Turner, 2005), and although not generally
recommended in isolation, medications can often be very helpful
accompanying other CBT or behavioral interventions (Kumpulainen,
2002). Since researchers have reported a significant association
between selective mutism and anxiety disorders in general and
social anxiety disorder (social phobia) in particular, it has been
suggest that selective serotonin reuptake inhibitors (SSRIs) or
monoamine oxidase inhibitors may be helpful in the treatment of
children with anxiety disorders in general and social anxiety
disorder (social phobia) in particular (Garcia et al., 2004; Kearney &
Vecchio, 2007; Vecchio & Kearney, 2005). However, the fact that
the medication does not increase social skills (Beidel and Turner,
2005) suggests that combinations of this medication with social
skills instruction might be helpful in treating children with selective
mutism.
Post-Case Questions
1. Does Winnie meet the DSM -5 criteria for SAD and selective
mutism? If so, what symptoms are evident? If not, why not?
The DSM -5 criteria are available in the Glossary.
2. There are several models that can be advanced to explain the
sequential development of internalizing disorders, such as
anxiety disorders, and the factors that might be responsible for
variable outcomes, including temperamental and environmental
factors. M anicavasagar, Silove, Rapee, Waters, and M omartin
(2001) found support for genetic influences in the transmission
of anxiety, in that 63% of children with a diagnosis of SAD also
have a parent with clinical levels of anxiety. Other researchers
have emphasized the role of environmental factors in SAD,
serving to enhance cognitive vulnerabilities (anxiety
sensitivity, intolerance of uncertainty, fear of negative
evaluation) in triggering anxious responses (Hong, 2013; Hong
& Cheung, 2015). Hong, Lee, Tsai, and Tan (2017) suggest
that this sense of cognitive vulnerability and the accompanying
pervasive sense of unpredictability and uncontrollability
regarding internal and external environments develop from the
child’s feelings of emotional distress resulting from their inability
to cope with adversity early in life. Consistent with a diathesisstress model, Shell, Gazelle, and Faldowski (2014) found that
that anxious solitude (individual vulnerability) and that major
school transitions, such as middle school transition
(environmental stress), together, increased the likelihood of
peer exclusion and victimization.From the perspective of the
diathesis-stress model, an inherited genetic vulnerability to
anxiety may remain dormant until environmental conditions are
adverse (peer rejection; family conflict; parent
psychopathology; school transition), causing the disorder to
become overt. In addition, temperamental factors such as
behavioral inhibition (BI) may also account for why one child
may be more vulnerable to stressful or unfamiliar surroundings
than another child. Children with BI have often been described
as hypervigilant of their environments and are particularly wary
of novel or unfamiliar social situations, tending to withdraw from
social interaction (Degnan, Almas, & Fox, 2010). Discuss how
Winnie’s separation anxiety and selective mutism might be
explained using the diathesis-stress model.
3. There are a number of possible theories that can be
suggested to account for the etiology or development and
onset of SAD. There is support to suggest that children with
SAD come from families that share a greater prevalence for
anxiety and mood disorders (M anicavasagar et al. (2001).
Attachment theory might predict that an anxiously attached
infant might be more prone to develop SAD than a securely
attached or resistant infant. Discuss the onset and
development of Winnie’s SAD as a psychologist from each of
the following perspectives: behavioral, cognitive, and
psychodynamic. Suggest possible treatment alternatives that
might be developed for each of these perspectives relative to
probable cause.
4. Discuss how selective mutism might be influenced by the
various contexts of development, using Bronfenbrenner’s
model: individual characteristics, immediate environment, social
and economic factors, and cultural factors.
5. Develop a case formulation for Winnie based on factors
discussed in Chapter 1, “Introduction: Understanding the
Complexities of Child and Adolescent Psychopathology,” from
the perspectives of the family systems and attachment
theories. What therapeutic interventions would you
recommend that are consistent with these frameworks.
6. Suggested individual or group presentation activity: The
principal has called a parent/school meeting to discuss
concerns about Winnie’s poor social interactions skills and her
lack of verbalization. Assign roles to individuals who will roleplay important supports in Winnie’s life and how they would
interact in this situation. Develop important questions for each
of the players who can add information to the case. Some of
the casting members might be Winnie’s parents, teacher,
psychologist who observed Winnie in the classroom, and any
other individual that you feel might contribute to an
understanding of the case and assist with developing an
overall case formulation and treatment plan.
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CASE 14 SHIRLEY YONG :
WORRIED TO
PERFECTIONGENERAL ANXIETY
DISORDER; DEPRESSION;
RELATIONAL AGGRESSION;
CULTURAL CONFLICT;
TRICHOTILLOMANIA
Shirley was referred to the clinic by her family physician, Dr. Long,
to evaluate her emotional status. For the past 6 months, Shirley
has been suffering from alopecia (hair loss), which has resulted in a
prominent bald spot on the side of her head. Shirley was wearing a
hat when she came to the interview accompanied by her mother,
Lilly. Shirley presented as a serious young girl who looked more
mature than her age of 11 years. Shirley was currently attending
Heartfield M iddle School in the regular Grade 6 program. Shirley
has one younger sibling, a brother, David, who is 4 years of age.
Lilly Yong is a nurse and her husband, David, is a computer
programmer. The Yongs came to the United States from China
when David was offered a position as a senior computer
programmer with an American-based firm. The move occurred
approximately 4 years prior to Shirley’s birth. Lilly began working
soon after their arrival in the United States. With a background in
nursing, Lilly was able to obtain a position very quickly, due to a
nursing shortage.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
Shirley weighed 7 pounds 5.5 ounces at birth. Shirley’s mother
described the pregnancy as difficult and the labor as lengthy (12
hours). Although the delivery was normal, there were minor
complications due to meconium aspiration, and Shirley stayed
overnight in the pediatric critical care unit. Lilly said that to her
knowledge, Shirley was relatively easy to manage as an infant and
for the most part slept well and had a good appetite. M rs. Yong
admitted, however, that Shirley’s early years were spent primarily
under the care of her mother, Shirley’s grandmother.
Shortly after Shirley was born, Lilly’s widowed mother came from
China to live with the Yong family. This situation provided Lilly with
a full-time caregiver for Shirley and, as a result, Lilly was able to
return to work at the hospital almost immediately. The situation was
also helpful for Lilly’s mother, who was grieving the loss of her
husband. When asked about other extended family, Lilly was not
eager to discuss the extended family, saying that she had lost
contact with most of her relatives. Lilly stated that to her
knowledge there were no known mental or physical difficulties for
any of the extended family members. With the exception of her
mother, all other extended family continued to reside in China.
Although Lilly could not recall much information about Shirley’s early
development, she did believe that developmental milestones were
generally achieved within the norm. There were some difficulties
with speech, however, and Shirley did not say her first word until 18
months of age. Lilly remembered this vividly, since a colleague at
work had an infant boy who was already saying words at 13
months, and Lilly felt that Shirley should have been talking by then
as well. She had read that, generally, girls begin to speak earlier
than boys and felt that the delay was unusual. The concern actually
resulted in a fight between Lilly and her own mother, since Lilly
began to blame her mother for Shirley’s speech delay. Lilly was
worried that Shirley’s language delay may have resulted from the
use of both Chinese and English in the home. Despite Lilly’s
protests, her mother continued to speak to Shirley exclusively in
Chinese, while Lilly communicated with Shirley only in English.
Although Shirley was described as a relatively timid and passive
toddler, Lilly admitted that there were times when Shirley could
become quite irritable or fussy. On these occasions, Shirley would
experience problems falling or staying asleep. Lilly recalled these
incidents because they were very annoying and disruptive to her
schedule. Being a nurse, Lilly needed her sleep to survive the
lengthy shifts at the hospital. When Shirley had those fretful and
irritable nights, it was impossible to get any sleep or to soothe
Shirley.
Shirley remained very close to her grandmother, who was her
primary caregiver, until the grandmother’s death 7 years ago.
Shirley’s grandmother passed away in her sleep of natural causes
when Shirley was 4 years of age. When asked how Shirley
responded to her grandmother’s death, Lilly said that the whole
family was very distraught. Not only had they suffered a great
personal loss, but now they had to face child care problems as
well. Shirley could not adjust to the new babysitters and would cry
endlessly when her mother left for work, only to refuse to being
comforted upon her return. Fretfulness, eating difficulties, and
sleeping problems were prominent during this period. After an
endless parade of babysitters, Lilly eventually had to quit work and
stay home to care for Shirley. Lilly readily admitted that this was not
an easy time for both of them. Shirley’s demands for consoling
were exhausting and frustrating, and Lilly longed for the days when
she could return to work at the hospital.
Lilly enrolled Shirley in a half-day M ontessori program and was
very adamant that Shirley do well in the program. However, she
was unhappy with the multi-aged grouping principle and did not like
the fact that Shirley’s classmates ranged from 2 to 6 years of age.
After one month, she removed Shirley from the program and placed
her in a “private learning center” which was designed to escalate
academic skills in children and prepare them for entrance into the
traditional school environment. When Shirley would come home
from the program, her mother would insist she do homework at the
kitchen table. Shirley was only allowed to watch television on
Saturdays. Lilly welcomed Shirley’s sixth birthday, since this
signaled mandatory schooling and some relief from parenting
demands. Shirley was able to find work as a nurse in a physician’s
office, which meant that she did not have to contend with shift work
in the evenings. For the next year, Lilly did not tolerate Shirley’s
complaints about her school, the teacher, and her classmates. Lilly
constantly reminded Shirley that when she was a child in China, no
one was allowed to complain, you just did your work, and did what
was expected of you. Lilly often felt a sense of relief after she
dropped Shirley off at school and went to work. However, after a
year of working, Lilly found out that she was pregnant, and 7
months later, Lilly was again homebound with her new son, David
Jr.
Shirley was now 7 years old and did not adjust well to having a
baby brother who was able to stay home with her mother while she
was forced to go to school. M ornings were often disruptive and
chaotic. Shirley would compete with David’s cries for food with her
own complaints of stomachaches or headaches and asking to stay
home from school. Lilly reminded Shirley constantly that
complaining was not allowed and that she needed to keep those
types of concerns to herself because she was not really sick. Lilly
refused to give in to Shirley’s demands and instead demanded that
she be more successful in school. Shortly after the birth of David
Jr., Lilly was diagnosed with postpartum depression, which
manifested in fatigue, loss of pleasure in activities, overwhelming
bouts of sadness, and self-blame. During this time, Lilly was
increasingly demanding of Shirley and when she came home from
school, after her homework time, she was expected to also help
out with the baby and to assist with household chores. Because
her mother was so demanding, Shirley tried to keep everything
spotless and would immediately pick up David’s toys, sometimes
almost before they hit the floor.
Lilly says that all the cleaning Shirley did as a child may have
backfired somewhat, because Shirley can now be “a real neat
freak” to the extent that others find it annoying. Shirley will often
become very upset at David Jr. for playing with toys in an area that
she has cleaned. She is always at him to clean up and put his toys
away before he has even had a chance to play with them. Shirley’s
own bedroom is arranged to perfection, with a place for everything
and everything in its place. Shirley has asked for a lock for her door
to make sure David Jr. does not go into her room or touch her
things.
REASON FOR REFERRAL
Shirley was reticent throughout the initial part of the interview and
did not volunteer any information spontaneously. Lilly said that she
was concerned most recently because Shirley was demonstrating
more tension and mood swings than she had seen before. The hair
loss was particularly upsetting for both mother and daughter, and
Lilly mentioned that it was embarrassing for her to be seen with a
daughter who was partially bald. She described her daughter as
being more moody and short-tempered in the past few months.
She also thought that her daughter was starting to be more
secretive and not sharing information about what she was doing at
school. Shirley would often come straight home after school and go
right up to her room, where she locked the door. A call from
Shirley’s teacher last week revealed that Shirley was not handing in
her assignments and that she was falling behind the class,
especially in her journal writing. Of course, Lilly was extremely
upset that Shirley was not being successful at school, after all the
effort she had put into getting Shirley ready for school and the high
expectations she had created.
When Lilly confronted Shirley about the missing assignments,
Shirley stomped into her room and slammed the door. Lilly said that
this was totally unacceptable behavior from her daughter. She also
complained that Shirley was spending more and more time in her
room and less time with the family. When asked what she was
doing in her room, Shirley would say that she was working on her
homework. Lilly said that she did not believe her because the
teacher said the assignments were not being completed.
When asked about stress in her life, Shirley looked at her mother
and then responded to the interviewer in a disgruntled manner.
Attempts to engage Shirley in a conversation about her school life
also met with minimal response. However, when asked how she
was feeling, physically, Shirley said that she was not feeling very
well and complained of headaches, stomachaches, and feeling very
tired. Lilly interjected that Shirley was very quick to complain and
that complaining was not allowed in her culture. M ore recently,
Shirley’s mother had found her getting up in the middle of the night
making herself a snack at midnight. Lilly said that this seemed to be
becoming a nightly ritual. (Although it was not addressed in the
interview due to Shirley’s guarded nature, Lilly had mentioned when
making the appointment that Shirley was putting on much weight
recently and had gained about 10 pounds in the past 2 months.)
Shirley was obviously upset by her mother’s comments and
responded defensively, saying, “Well, I was hungry because I didn’t
like the tofu stuff you made for dinner. It was awful … like eating
chalk.” When asked if she could change one thing in her life,
Shirley’s eyes filled with tears and she said, “Everything.”
With encouragement and patience, Shirley began to outline some
of her worries about herself and her school situation. Shirley said
that reading had become harder and harder because she could not
concentrate. She would read a page and then not remember what
she had read. She wanted to make her work very neat, and so she
would print out all her assignments. Often she would work long
hours making sure that the printing was perfect. M any times, she
would have erased so many words that she would have to start all
over again from the beginning on a fresh piece of paper. It took so
long to print her work that she had problems finishing the
assignments. Shirley said that she received only a “C” on the last
assignment she handed in because it was incomplete. Shirley said
she did not tell her mother about the paper because she was
embarrassed about her grade and felt guilty that her mother would
be ashamed of her.
When asked about social life at school, Shirley admitted that she
was miserable socially. Shirley said that she had no friends and the
girls at school teased her. They were calling her names and
laughing at her bald spot, saying that she was going to be a “bald
old fat man.” She had also found a note hidden in her desk from
someone, with a drawing of a fat, bald person with the label
“Shirley” written across the top. One girl had started a rumor that
Shirley was contagious and that if you touched her, your hair would
fall out too. Now no one would even stand beside her in line.
Shirley was so upset the other day that she just hid in the restroom
during recess so she would not have to go outside. When asked if
she knew why her hair had fallen out, Shirley denied that she had
anything to do with it. Her mother seemed incredulous that the
interviewer would ask Shirley if she had been pulling out her own
hair.
When asked if she was a worrier, Shirley looked concerned and
said that she could not stop worrying and added, “I worry about
doing poorly at school; I worry about being late for school; and I
worry about making mistakes in my work. I worry so much that I
keep waking up because I think I forgot to do something, or I am
afraid I might sleep in and be late for school. I can’t sleep so I
straighten and clean my room or go to the kitchen and eat
something. But then I can’t remember if I have cleaned the kitchen,
so I go back and check on it. Sometimes, I have to keep checking
because I don’t remember seeing it clean enough.” In response to
Shirley’s list of concerns, Lilly shook her head and said, “Kids
today, what can you do about them.” She then looked at Shirley
and in an attempt to minimize her difficulties stated that Shirley was
exaggerating her problems. In China, she said, we did what we
were told and worked hard at our schoolwork. That was our job.
We did not have time to complain about all these things. In our
culture, we value emotional restraint, not self-indulgence.
ASSESSMENT RESULTS
The actual raw scores for Shirley’s assessment can be found in
Appendix A. The following is a summary of those findings.
Information regarding specific assessment instruments and the
interpretation of standard scores and T scores is available in
Appendix C.
Shirley’s responses to the WISC-V were notable. The examiner
reported that Shirley lost bonus points due to slow task completion
resulting from tendencies to waste time lining up edges to meet
perfectly on the block designs. M ultiple responses to verbal items
were also observed, as if Shirley were unsure when to stop giving
information. Requests for feedback were also frequent.
Shirley’s full scale IQ was in the lower average range (IQ = 85;
range 81–91) with a significant strength in Verbal Comprehension
Index (VCI) with an index score of 100 (range 93–107), which was
in the average range. Generally, weaknesses were evident in
tasks measuring the Visual Spatial Index (VSI) with an index score
of 84 (range 79–93); Fluid Reasoning Index score of 86 (range 82–
95); Working M emory Index with a score of 83 (Range 77–92); and
Processing Speed Index (PSI), with an index score of 83 (range
76–94). Academically, Shirley was functioning at grade level in
language arts (Grade 5 level on both decoding and
comprehension), but she was approximately one year behind grade
placement in math computation. Shirley’s mother’s response to
Child Behavior Checklist (CBCL) noted significant elevations on all
Internalizing scales: Withdrawn/Depressed (T score = 68;
borderline clinical range) and Anxious/Depressed (T = 73) and
Somatic Complaints (T = 74) were all in the clinical range. In
addition, Thought Problems (T = 73) were in the clinical range due
to many obsessions and repetition of acts, while Attention
Problems (T = 70) were also in the clinical range, evident in
problems of concentration and frequent confusion. On the Conners
scales, M rs. Yong also endorsed clinical levels for Inattention,
Anxious-Shy, Perfectionism, Social Problems, and Psychosomatic
concerns. Shirley’s teacher responded to the TRF with clinical
elevations on scales for Anxious-Depressed M ood (T = 72) and
Thought Problems (T = 70) noted in obsessions and repetitive
behaviors. On the Conners scales, Shirley’s teacher indicated
significant concerns in areas of Inattention, Anxious-Shy,
Perfectionism, and Social Problems. According to the YSR, Shirley
self-reported significant concerns for all Internalizing scales:
Withdrawn/Depressed, Somatic Complaints, and
Anxious/Depressed symptoms, as well as Social Problems and
Thought Problems. Other problems noted by Shirley included many
fears, nightmares, nail biting, sleep problems, and concerns
regarding being overweight.
On the Beck Youth Inventories of Social and Emotional Impairment,
Shirley endorsed significantly low levels for Self-Concept (below
the 4th percentile) and significantly high levels of anxiety (98th
percentile) and Depression (95th percentile). Clinical levels of
depression were also noted on the Child Depression Inventory
(CDI; Kovacs, 1992), with significant concern in areas of
Ineffectiveness, Anhedonia, and Negative Self-Esteem. On the
CDI, Shirley admitted that she thinks about killing herself, but would
not do it. Shirley scored just below the threshold for high
hopelessness on the Hopelessness scale (Kazdin, Rodgers, &
Colbus, 1986).
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
Anxiety disorders represent one of the highest prevalence rates for
disorders. In their review of research, M ichael, Zetsche, and
M argraf (2007) found that the lifetime prevalence rates for an
anxiety disorder in Western countries was between 13.6% and
28.7% with the highest risk rates for developing an anxiety disorder
to be between 10 and 25 years of age. Other risk factors that
surfaced included “female gender, behavioral inhibition, and
negative life events” (p. 136).
According to the DSM -5 (APA, 2013), when considering a
diagnosis of general anxiety disorder (GAD) in children, “a thorough
evaluation for the presence of other childhood anxiety disorders
should be done to determine whether the worries may be better
explained by … separation anxiety disorder, social phobia, and
obsessive compulsive disorder” (p. 224), since these disorders
may present with symptoms that can “appear” to be symptoms of
GAD. There is also a likelihood that GAD symptoms of
“restlessness” and “concentration problems” may be mistaken as
symptoms of attention deficit/hyperactivity disorder. In addition to
the various forms of anxiety disorders, diagnosis in childhood is
further complicated by some disorders appearing early and others
manifesting at later developmental stages. One study reported an
increase in prevalence rate for anxiety disorders from 7% at 11
years of age to almost 20% in early adulthood (Kovacs & Devlin,
1998).
High rates of comorbidity are evident within the anxiety disorders,
with some studies suggesting that that three-quarters of people
with a lifetime anxiety disorder also met criteria for at least one
other mental disorder (Kessler et al., 1997). In addition to
comorbidity with other disorders, many individuals who have an
anxiety disorder also meet criteria for more than one anxiety
disorder. The most common combinations include GAD and panic
disorder and panic disorder and agoraphobia (M ichael et al., 2007).
Among other disorders, there is a strong association between the
anxiety and affective disorders (mood disorders or depressive
disorders). When individuals experience both anxiety and affective
disorders, there is a strong likelihood (66%) that the anxiety
disorder developed prior to the affective disorder (Kessler, 2001).
M any adults with anxiety and depressive disorders report that
these problems had their onset in childhood, indicating that anxiety
disorders can represent a stable construct across the life span
(Ollendick & King, 1994). For children and adolescents with GAD,
concerns and worries often focus on their performance
academically or athletically even if competence in these areas is
not under the evaluation and scrutiny of others (APA, 2013).
According to researchers (Van Ameringen, M anicini, & Farvolden,
2003), children with anxiety or depression are at increased risk for
having academic issues, relative to their peers, and exhibit more
difficulties with their peers and parents (Bergeron et al., 2007;
Greco & M orris, 2005).
In childhood, rates for comorbidity of anxiety and depression have
been reported to be as high as 60%–70% (Kovacs & Devlin, 1998),
which led to early theorists to speculating that in childhood
“negative affectivity (NA)” may be a more accurate reflection of
variations of the same syndrome (Laurent et al., 1999), rather than
two unique disorders. Although there is support for this line of
reasoning, based on high rates of comorbidity in childhood and the
fact that developmentally, the onset of anxiety is earlier than the
onset for depression (Kovacs & Devlin, 1998).
In the past decade, research has focused on investigating the role
of temperamental influences on increasing the risk for both
disorders in children (Compas, Connor-Smith, & Jaser, 2004).
Studies have demonstrated that children with high levels of NA are
at increased risk for the development of anxiety and depression
(Lonigan, Vasey, Phillips, & Hazen, 2004). With respect to anxiety,
it has been demonstrated that an attentional bias toward threat can
be an important factor in precipitating and maintaining anxiety
problems (Dandeneau, Baldwin, Baccus, Sakellaropoulo, &
Pruessner, 2007). M uris and Ollendick (2005) suggest that children
who have a high tendency to react emotionally (high reactivity) and
poor effortful control (EC) suffer from an inability to defer their
attention from the bias to threat, resulting in increased fear (NA)
and social withdrawal (internalizing problems). Other children who
are also highly reactive, emotionally, but who have poor behavioral
control may react aggressively (externalizing problems).
Furthermore, Lonigan and Vasey (2009) suggest that while high NA
is a necessary condition for anxiety, it is not a sufficient condition,
and that low EC is also a required ingredient. Studies have found
that these patterns (high NA, low EC) predicted internalizing
problems in children (M uris, M eesters, & Bliglevens, 2007), and
that fearfulness at age 10 predicted the development of
internalizing symptoms 2–3 years later.
In addition to the concept of “NA,” some researchers have shifted
the emphasis to the underlying process of “perseverative thinking”
that is embedded in anxious and depressive thoughts which may
contribute to an emotional response style that links these two
disorders (Bagby, Rector, Bacchiochi, & M cBride, 2004). This line
of reasoning suggests that brooding (rumination) and worry both
represent forms of perseverative thinking (Segerstrom, Tsao,
Alden, & Craske, 2000), with rumination tending to dwell on events
in the past and worry focusing on potential future events
(Papageorgiou and Wells, 2004). According to their findings on
anxiety and depression, Sorg, Vögele, Furka, and M eyer (2012)
suggest that perseverative thinking has an influence on both
negative and positive affectivity.
Longitudinal studies have demonstrated that children who
experience the combined effect of anxiety and depression have
more severe and persistent problems, as well as present with a
more serious history of risk factors (M offit et al., 2007). In addition
to temperamental factors, such as NA and EC, contextual
influences have also been related to the development of anxiety
and depression in children. Some of the pathways that have been
linked to anxiety and depression include family adversities and
maternal distress (Essex et al., 2006; Rutter, M offit, & Caspi, 2006),
which can be moderated by the availability or lack of social support
(Leech, Larkby, Day, & Day, 2006). In a recent study of the
potential pathways and predictors of anxiety and depression,
Karevold, Roysamb, Ystrom, and M athiesen (2009) identified two
main pathways: temperament (emotionality) and early family
adversity in support of the concept of “equifinality” (Cicchetti &
Toth, 1998), namely, that different pathways might lead to the same
outcome. Leve, Kim, and Pears (2005) found that the combination
of child shyness at 5 years of age and maternal distress predicted
an increased trajectory for internalizing problems for girls in early,
middle, and late childhood, through adolescence, while Essex,
Klein, Cho, and Kraemer (2003) found that exposure to maternal
depression, family conflict, or divorce from the preschool years
forward increased the risk for internalizing problems in girls.
Furthermore, Eaves, Silberg, and Erkani (2003) found that genes
specific to depression can lead to an increased sensitivity to the
impact of adverse life events, increasing the risk through genetic
vulnerability in children of distressed mothers. Other factors in the
family environment that have been associated with increased
anxiety in children include overprotective or overly controlling
parents, overinvolvement, encouragement of avoidant/anxious
responses, parental rejection, parental criticism, and lack of parental
warmth (Hudson & Rapee, 2002; M icco & Ehrenreich, 2008).
Perfectionism can be conceptualized as an individual’s tendency to
set goals or expectations that are overly rigid, excessively high,
and subject to self-criticism when the exceptionally high standards
are not met. According to Flett and Hewitt (2002), developmentally,
perfectionism is a phenomenon that has its onset in childhood and
adolescence. M iloseva and Vukosavljevic-Gvozden (2014) studied
the relationship between perfectionism, anxiety, and depression
among children 11–14 years of age. Their concept of perfectionism
was evaluated using a scale that tapped items in four core areas:
sensitivity to mistakes; contingent self-esteem; compulsiveness;
and need for admiration. Results revealed that tendencies toward
perfectionism were associated with increased likelihood of anxiety
and/or depressive disorders.
Pushed to the extreme, perfectionistic tendencies can place
individuals at increased risk for a number of mental health issues,
including depression (Enns & Cox, 2005; Rice & Aldea, 2006) and
worry (Chang et al., 2007; Santanello & Gardner, 2007).
Perfectionist tendencies may be evident in such areas as worry
about punctuality, overdoing or redoing tasks in order to improve
the quality of the product, and the need to seek constant
reassurance about their performance (APA, 2013).
Trichotillomania (TTM)
In addition to symptoms of anxiety and depression, Shirley also
suffers from symptoms of trichotillomania (TTM ), which manifests in
persistent and excessive pulling out of one’s own hair, resulting in
noticeable hair loss or alopecia. The most common areas affected
include the scalp, eyebrows, and eyelashes. Since the
dermatologist had already ruled out any medical cause for the hair
loss, it was believed that Shirley was responsible for pulling out her
own hair, although she and her mother adamantly denied this
possibility.
TTM was originally included in DSM -III-R in 1987 and at that time
was formally acknowledged as a psychiatric disorder and was
classified as an impulse control disorder (Stein et al., 2010). Within
the DSM -5 (APA, 2013), TTM can be found in the chapter on
“Obsessive Compulsive and Impulse-Related Disorders,” which
includes other impulse control disorders, such as excoriation (skin-
picking), pyromania, kleptomania, and pathologic gambling. The
impulse control disorders all share an increase in tension, prior to
the impulse, in this case hair pulling, and a sense of pleasure or
relief once the act (hair pulling) is completed. It has been
suggested that individuals with the disorder often deny their hairpulling behavior and try to conceal the results. Lochner et al. (2012)
found that although not all individuals with TTM experience a
preexisting urge to pull, almost all were in agreement that they
continued to engage in hair pulling, despite repeated attempts to
decrease or stop. Children may not meet criteria for the disorder
because they may not be aware of the tension/release cycle. Nail
biting is often also evident, as are symptoms of other disorders,
such as the mood and anxiety disorders (especially obsessive
compulsive disorder [OCD]) and eating disorders. Prior to the
publication of the DSM -5, it was suggested that TTM might be
more suited to inclusion among the anxiety disorders, especially
because of its association with obsessive compulsive features.
However, the relocation of OCD to this chapter, including TTM ,
accomplishes this goal. Onset is typically between 9 and 13 years,
and children typically pull their hair when alone and in a relaxed
situation: on the phone, watching television, reading, or falling
asleep (Tay, Levy, & M etry, 2004).
TTM may not be readily detected since hair pulling often takes
place outside the presence of others and can be substituted by
pulling hair from pets, dolls, or other hair-like fibrous materials, such
as sweaters (APA, 2013). TTM can be triggered by a number of
situations, including separation from an attachment figure, problems
with school performance, birth of a young sibling, or sibling rivalry
(Tay et al., 2004). Children with TTM also have more perfectionistic
tendencies and low feelings of self-worth (Soriano et al., 1996).
The disorder onset may be associated with the onset of puberty,
and symptoms in females may be exacerbated by hormonal
fluctuations (APA, 2013).
TTM is often associated with significant impairment and distress
that permeates social and emotional areas. The lack of control over
hair pulling and the changes in appearance that can result often
produce feelings of shame and embarrassment as well as
tendencies to avoid social contact. Results from some studies
suggest that hair pulling may serve a purpose in reducing negative
emotions, with some individuals reporting pleasurable feelings or
gratification during or after hair pulling, while others indicating
boredom, tension, or anxiety before pulling episodes, with a
significant reduction in negative emotions after hair pulling
(Diefenbach, Tolin, M eunier, & Worhunsky, 2008; Roberts,
O’Connor, & Bélanger, 2013). Cognitive behavioral models support
the notion that individuals engage in hair pulling because the
behavior is positively reinforced (production of pleasurable feelings)
or negatively reinforced (removal of aversive consequences such
as urges, tension, anxiety, or boredom) (Shusterman, Feld, Baer, &
Keuthen, 2009). From a classical conditioning model, over time,
situations and states (boredom, specific chair, certain activity) may
become associated with and ultimately trigger urges (Franklin &
Tolin, 2007).
Treatment for TTM has traditionally included behavioral
interventions such as habit reversal training; however, more
recently, researchers have enhanced treatment protocols by
combining traditional behavioral strategies with other cognitive
behavioral interventions, such as cognitive therapy, dialectical
behavioral therapy, and acceptance and commitment therapy
(Snorrason, Berlin, & Lee, 2015, p. 105), which will be reviewed
shortly in the section on Treatments of Anxiety Disorders.
Treatments of Anxiety Disorders in Children
Cognitive behavioral methods: In their review of empirically
supported treatments for children with phobic and anxiety disorders,
Ollendick and King (1998) found several treatments to be effective
in reducing fears and phobias. However, with respect to anxiety
disorders, the authors found only one treatment method, cognitive
behavioral procedures, with or without family inclusion, that met
criteria for the probably efficacious treatment category. Since that
time, several studies have been conducted to determine the best
CBT programs for anxiety disorders in children. Beidas, Benjamin,
Puleo, Edmunds, and Kendall (2010) discuss important ways to
adapt empirically supported programs (ESTs) such as the Coping
Cat Program in ways that promote “flexibility within fidelity” (Kendall
& Beidas, 2007; Kendall, Gosch, Furr, & Sood, 2008). The concept
of “flexibility within fidelity” argues for the merits of using an EST
such as a manualized treatment program (like the Coping Cat
Program) while using clinical judgment in the application of those
tools to the needs of the specific client. They provide a number of
suggestions for how to adapt the two manuals of the Coping Cat
(Instructor’s manual; Kendall & Hedtke, 2006a) and the Coping Cat
Workbook (Kendall & Hedtke, 2006b). The article discussed
recommendations for adapting the Coping Cat program to children
and adolescents of different ages and those with comorbid
disorders such as inattentive symptoms, social skills deficits, and
depressive symptoms (Beidas et al., 2010).
Kendall (1992) initially developed several treatment strategies,
based on CBT methods, called Coping Cat, for children and youth
with anxiety disorder, which has been demonstrated effective in
several studies. The program focuses on children 7–13 years of
age who have been diagnosed with generalized anxiety disorder,
social phobia, or separation anxiety disorder. The program currently
is supported by two manuals: a therapist manual which provides a
framework for treatment (Kendall & Hedtke, 2006a) and a workbook
for children/youth which contains activities that correspond to the
treatment plan (Kendall & Hedtke, 2006b). The 16 sessions are
presented in two phases: Phase 1—identification of cues of
anxiety and introduction to necessary coping skills, such as roleplay, modeling, in vivo exposure, and relaxation training (8
sessions); and Phase 2—application of the behavioral treatment
plans. The program centers on the development of a graded
hierarchy of fears to assist the child/youth to address fears in a
systematic manner. To aid in this process, the program uses the
mnemonic FEAR to outline the FEAR plan (Podell, M ychailyszyn,
Edmunds, Puleo, & Kendall, 2010):
F—Feeling frightened (recognition of physiological responses
to anxiety)
E—Expecting bad things to happen (identification of anxious
thoughts)
A—Attitudes and actions can help (coping skills: deep
breathing, relaxation, problem-solving)
R—Results and rewards (rating their coping skills in each
situation; rewards for effort).
In Australia, researchers investigated the combined effect of CBT
for children and a family component (FAM ). The FAM included a
parallel 12-week program for parents to learn skills in areas such as
supportive praise for courageous behavior and planned ignoring for
excessive anxious responses. Results revealed that the Australian
children treated with a 12-week CBT + FAM performed significantly
better than children treated by CBT alone (Bartlett, Dadds, &
Rapee, 1996). M ore recently, Wood, Piacentini, Southam-Gerow,
Chu, and Signam (2006) demonstrated that children who received
CBT treatment for anxiety disorders with their families (familyfocused CBT) had better outcomes than children who received
child-focused CBT, with minimal parent involvement.
M edical management of anxiety disorders: The selective serotonin
reuptake inhibitors (SSRIs) have been found to successfully
alleviate symptoms of OCD in adolescents and children (Riddle,
Subramaniam, & Walkup, 1998). Other treatments that are currently
under increased investigation include exposure with response
prevention and CBT. Exposure procedures such as desensitization
or flooding can bring the child into increased contact with the
anxiety-provoking stimulus either in reality (in vivo) or through
guided imagery or pictures. The child is taught a form of muscle
relaxation that is incompatible with heightened anxiety in an attempt
to link the object or situation that evokes anxiety with a lower level
of arousal (relaxed state).
Neziroglu, Yaryura-Tobias, Walz, and M cKay (2000) found that
combining an SSRI (fluvoxamine) with behavior therapy of
exposure and response prevention was superior to medication
alone and that children and adolescents in the study continued to
show improvement 2 years later, while the Pediatric OCD Team
Study (2004) found the combined treatment effect of CBT and the
serotonin reuptake inhibitor, sertraline, to be superior to either
treatment in isolation for children and youth with OCD. M arch and
M ulle (1998) have developed a cognitive behavioral treatment
manual for children and adolescents with OCD that provides a
session-by-session guide for clinicians through the four stages of
treatment: psychoeducational, cognitive training, mapping OCD,
and graded exposure and response prevention. Initial studies of
the effectiveness of the manualized program with adolescents are
encouraging (Thieneman, M artin, Creggar, Thompson, & DyerFriedman, 2001).
Treatment of Trichotillomania (TTM) in
Childhood
Treatment for TTM in children and youth can be challenging, since
they often deny that they are pulling out their own hair.
Nonpharmacologic treatments such as cognitive and cognitive
behavioral therapy should be considered initially, especially if the
psychosocial trigger(s) can be identified (e.g., sibling rivalry, birth of
a new sibling). Golomb and Vavrichek (2000) have developed a
workbook for children and adolescents (10–16 years of age) to
assist them in developing the means for “How to solve the
trichotillomania puzzle” by developing strategies to help manage
their behavior. Parents can adapt the workbook for use with
younger children. Other behavioral methods that can be used with
children include
habit reversal (methods to increase awareness, develop
competing replacement behaviors, practice stress/anxiety
reduction, and increase parental support and encouragement);
self-monitoring (charting behavior and responses); and
teaching replacement behaviors (this can be used alone to
develop socially appropriate behaviors that can be used as
alternatives to hair pulling; Ellis & Roberts, 2006).
Post-Case Questions
1. The co-occurrence of depression and anxiety in childhood is
not unusual.In younger children, this co-occurrence is
frequently associated with a depressive-anxious syndrome
(see CBCL: Achenbach). The features of this syndrome have
also been referred to as NA. Research has demonstrated that
while children in the sixth grade can demonstrate the separate
syndromes for all three presentations of these disorders
(anxiety, depression, and NA), children in the third grade are
better represented by the combined syndrome of NA alone
(Cole, Truglio, & Peeke, 1997). It has been suggested that
developmentally, NA represents a less differentiated form of a
syndrome primarily dominated by negative emotions.
Developmentally, differentiation into anxious responses
(physiological arousal) and depressed mood (deflated mood)
would occur at a later date.Furthermore, Bagby et al. (2004)
suggest that the underlying process of “perseverative thinking”
that is embedded in anxious and depressive thoughts may be
instrumental in influencing an emotional response style that
links these two disorders, e.g., perseverative thinking can be
represented as both brooding (rumination) which focuses on
past events and worry concerned about possible future
occurrences (Papageorgiou and Wells, 2004).Given the above
information, describe how Shirley’s anxious and depressed
symptoms can be conceptualized with respect to NA and
perseverative thinking.
2. According to the DSM -5 (APA, 2013), Shirley might meet
criteria for one of the anxiety disorders. Given the symptoms
noted in the case and your understanding of the different
anxiety disorders (see DSM -5 criteria in the Glossary), which
anxiety disorder does Shirley most likely exhibit? What are the
symptoms that meet the DSM -5 criteria?
3. Gibbs and Huang (2001) outline three broad ways in which
ethnicity can influence mental health in children and
adolescents. First, ethnicity can shape beliefs about what
constitutes mental illness at a general and specific level. Next,
cultures may also influence the manifestation of the symptoms
(internalizing, through physical somatic symptoms,
externalizing), as well as reactive patterns and defensive
styles. Ultimately, ethnicity can also be highly influential in
determining whether it is acceptable to seek assistance for
mental health issues outside of the family, and who should be
consulted for assistance (family elder, priest, minister, herbalist,
etc.). Some high-risk factors related to cultural context include
high risk for suicide in native populations and dropout rates for
ethnic minorities.Huang and Ying (2001) discuss a number of
potential stressors and conflicts that may face the bicultural
child who is attempting to incorporate values from both the
Chinese and the American cultures. While expression of
feelings is often encouraged in Western cultures, the Chinese
culture values emotional restraint, especially for negative
emotions. The authors also suggest that although many
children develop somatic complaints in response to stress, this
particular form of symptom expression is often accompanied by
sleep and appetite disturbances, followed by declines in
academic performance in children of traditional Chinese
American families. A major barrier to effective treatment for
these children is that mental health service is highly
underutilized by the Chinese American population. For those
few families who seek treatment, drop out after the initial
sessions is highly probable.Discuss the potential impact of
cultural contexts on Shirley’s emotional status.
4. In the Introduction to Chapter 1, Kim and colleagues discuss
four parenting profiles: supportive, tiger parenting, easygoing,
and harsh parenting. Rather than evaluate parenting style
along the typical two dimensions (control and warmth), Kim,
Wang, Orozco-Lapray, Shen, and M urtuza (2013) used a
multifaceted approach, which considered both positive
(parental monitoring and democratic parenting) and negative
(psychological control and punitive control) aspects of parent
control and two forms of parent emotional responsiveness
(warmth and hostility). Discuss whether Lilly employs a “tiger
parenting” approach. Within this context, compare tiger
parenting, easygoing parenting, and supportive parenting.
5. Children of depressed mothers are twice as likely to become
depressed themselves (Goodman & Tully, 2008). Possible
suggestions for this linkage include lack of adequate models
for emotion regulation; excessive use of controlling, irritable,
and impatient parenting (Cicchetti & Toth, 1998); and lack of
emotional availability (M alphurs et al., 1996). Girls seem to be
at much higher levels of risk for transmission of depression
than boys (Sheeber, Davis, & Hops, 2002). Based on this
information, discuss Shirley’s depressive features relative to
her mother’s symptoms of depression.
6. While boys are more likely to use bullying tactics, which rely
on physical aggression, girls have been found to engage in
forms of relational aggression, such as causing hurt to others
through the propagation of rumors, ridicule, exclusion from a
peer group, or withdrawal of friendship and support (Crick,
Casas, & Nelson, 2002; Crick & Grotpeter, 1995). Although
early research suggested that girls are more relationally
aggressive than males, more recently, findings have noted that
although males also engage in relational aggression, the social
and emotional impact of relational victimization is greater for
girls than for boys (Yoon, Barton, & Taiariol, 2004). The
outcomes of relational aggression are peer rejection and
feelings of loneliness and isolation (Crick et al., 2002; Crick &
Grotpeter, 1995).Explain how relational aggression had an
impact on Shirley’s socialization. What could be done at a
school level to counteract this behavior in peers?
7. In an Australian study, Bartlett et al. (1996) found that children
who were involved in the combined effect of CBT and a family
component (FAM ) performed significantly better than children
treated by CBT alone. M ore recently, Podell, M ychailyszyn,
Edmunds, Puleo, and Kendall (2010) suggested that both
individual and family versions of the Coping Cat program were
successful in alleviating anxiety in anxious youth. What
challenges do you see in involving Shirley’s family in the
therapeutic process?
8. Develop a therapeutic plan to assist Shirley in reducing
tendencies to hair pull.
9. Suggested individual or group presentation activity:You have
been invited to provide feedback to the school regarding
Shirley’s assessment at a meeting where they will decide
whether Shirley meets criteria for Special Education and
Related Services. If it is determined that she is eligible for
services, under what category would you expect that she
would meet criteria, and what Goals and Objectives would you
want to see as part of her IEP? Would you recommend she
receives related services, and if so, what would the nature of
those services be?Prepare a script for role-playing each of the
player’s parts in the school meeting, mentioned above. Who
do you think should be attending the meeting? How could
each participant potentially contribute information to assist with
developing an intervention plan that would best meet Shirley’s
needs?
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CASE 15 JORDAN NEESON : LET
ME COUNT THE WAYSOBSESSIVE
COMPULSIVE DISORDER
Jordan appeared agitated and upset as he walked into the clinic
accompanied by his mother, Sally Neeson. The last thing Jordan
wanted to do this morning was get dressed and go to a clinic. After
all, he was on his summer vacation. M rs. Neeson brought Jordan
to the clinic because the school had recommended he be retained
in the Grade 3 program due to academic difficulties and problems
with attention and concentration. Work was rarely handed in or
completed, and Jordan was beginning to really hate school.
DEVELOPMENTAL HISTORY/FAMILY
BACKGROUND
Sally Neeson completed the intake survey and was available for a
telephone intake conversation prior to bringing Jordan in for his
assessment session. In recalling Jordan’s birth history, Sally stated
that the pregnancy was very hard on her. She had considerable
nausea in the first 3 months and was very fatigued throughout the
majority of her pregnancy. The delivery was also difficult, and
Jordan had a lowered Apgar score because of birth complications.
During the delivery, there were knots in the umbilical cord that cut
off or reduced the oxygen supply. It seemed to take forever, but he
was finally breathing on his own. Jordan seemed to rebound, and
Sally was able to bring Jordan home with her when she left the
hospital. Sally reported that appetite and sleep habits were normal
for the first year.
At one point in the rather lengthy telephone conversation, Sally
seemed particularly agitated and wanted to know why the
interviewer was asking her personal questions about her marriage
and relatives. After all, she just wanted to have Jordan tested for
school; there was absolutely nothing wrong with his behavior and
he did not have any “mental” problems. Sally described Jordan as a
sensitive boy who was very aware of his academic difficulties. Sally
was definitive in stating that Jordan did not have any behavior
problems. Sally also was very sure that there was no mental illness
in either her family or her husband’s. However, Sally did recall an
aunt, Bertha, who would not leave her house. She remembered
family members talking about Bertha at family functions, because
she would never attend. They said she was afraid to go outside
and that she even had to have groceries delivered to her door.
Sally could not recall any more about Bertha, who died about 10
years ago. Sally described herself as a bit of a worrier and said that
her husband, Ralph, was pretty easygoing and just liked to watch
sports on TV when he finished work at the office. Ralph sold
insurance and Sally was a full-time homemaker. Jordan has a sister,
Susy, who is 2 years older than Jordan, but she is very mature for
her age. Sally said that Susy is 11 years old, going on 20, while
Jordan is 9 years old, going on 5. When asked how they get along,
Sally said that there are times when Susy, who really is a very
patient person, just loses it when Jordan goes into what she calls
his “weirdness.” Sally explained that Jordan can be very fussy
about particular things, such as having his food all separate on the
plate with nothing touching (peas separate from potatoes and
chicken). If the foods touch each other, then he does not want to
eat it. Susy also is very annoyed when she has to take Jordan to
school, since he takes forever to get ready in the morning, and
bathroom rituals, such as handwashing or teeth brushing, seem to
take a very long time. In the evening, Sally said that these
bathroom routines are a normal part of his getting ready for bed,
and she is fine with it because, unlike some kids, Jordan really likes
being clean, and she never has to remind him to wash up or brush
his teeth at bedtime.
Sally stated that Jordan’s milestones were achieved on time and
he walked at about 14 months and talked a bit later. Sally admitted
that she was not a very good historian about dates and times.
Jordan had some ear infections and had tubes inserted for drainage
when he was about 3 years old. Sally described Jordan as a bit of
a “mama’s boy.” She said that they were like “two peas in a pod,”
and when Jordan was a toddler, Sally took him everywhere with
her. Jordan never went to preschool and Sally chose to
homeschool him rather than send him to kindergarten. Jordan was
not eager to go to first grade. M ost mornings, his sister Susy had
to hold his hand all the way to school so that he would not try to
run the other way. Jordan was finally starting to settle into Grade 1
by December, when the family had an opportunity to purchase a
home in a better neighborhood across town. As a result, Jordan
had to change schools in January. Jordan started to resist going to
school all over again, and Susy was once again forced to drag him
with her. One good thing about the relocation was that the house
was within eyesight of the school. Jordan’s mother told him that if
he missed her, he could just look across the street and know that
she was thinking about him. This seemed to comfort Jordan
somewhat.
One day shortly after the move, Jordan’s mother had an
appendicitis attack and had to be rushed to the hospital.
Unfortunately, shortly after the ambulance arrived, Jordan’s class
was let outside for recess. Jordan was terrified when he saw the
ambulance in his driveway, and he ran across the street just as the
ambulance pulled away. Jordan ran down the street, yelling and
crying, until he was retrieved by the school principal. For the next 5
months, Jordan was very fearful of leaving the house. He was
afraid that something might happen to his mother if he left. Often he
would ask to stay home, saying that he was not feeling very well.
Sally said that she felt she was to blame because she had scared
him with her appendicitis attack. Often she felt sorry for him and
would let him stay home. By the end of first grade, Jordan’s
teachers were becoming concerned. He had missed quite a bit of
school (21 days) and did not have a firm grasp of the fundamentals.
His handwriting was very poor and most of his letters and numbers
were reversed or upside down.
The following year, Sally tried to keep Jordan’s absences in check
by making promises that they would do things together after class.
Jordan went to school, but his midyear report was very poor.
Jordan was falling further and further behind. Sally tried reading with
him at home, but Jordan seemed to have a very poor memory for
the words, and each day it was like he had not seen the word
before. Recently, the school recommended that Jordan repeat
Grade 3. Sally finally decided to have him assessed.
Sally noted that Jordan’s health had been good except for frequent
complaints of headaches and stomachaches. Vision and hearing
had been recently tested and were within the normal range.
Although the intake supervisor sent behavior rating scales to M rs.
Neeson (Behavior Assessment Scale for Children [BASC-2] and
the Conners Parent Rating Scale) to be completed prior to his first
assessment session, Sally forgot to complete them ahead of time
and brought them with her to the first assessment session. As a
result, it was not possible to score these results until after Jordan’s
first assessment session. In hindsight, having this information
beforehand would have provided significant insight into Jordan’s
emotional profile. On a positive note, Sally was able to locate
Jordan’s Grade 3 teacher, who volunteered to complete the
teacher forms during her summer break.
REASON FOR REFERRAL
Sally brought Jordan to the clinic because she wanted to know why
he was having academic problems and whether Jordan had this
“attention deficit” problem his teacher had mentioned. It was
important to M rs. Neeson that an assessment be completed
before the new school year because she was very concerned
about his success in the Grade 4 program and Jordan’s growing
reluctance to continue attending school.
ASSESSMENT RESULTS
Information regarding the specific assessment instruments used in
this assessment and guidance in the interpretation of standard
scores and T scores can be found in Appendix C.
The examiner found Jordan to be a very cautious participant in the
assessment process. Jordan took a long time to respond to openended questions, and it was often difficult to determine whether he
was formulating a response to a question, not comprehending the
question, or lost in his own thoughts. During the first assessment
session, Jordan participated in a semistructured clinical interview
and completed the WISC-V and Bender Gestalt.
Jordan obtained a full scale IQ within the average range (IQ = 91;
range 85–98), with minimal discrepancy between his Verbal
Comprehension Index, Visual Spatial Index, and Fluid Reasoning
Index. Jordan’s profile indicated a number of strengths and
weakness. Strengths were noted in vocabulary knowledge, picture
concepts, and matrix reasoning (SS in the 11–13 range), while
relative weaknesses were evident in comprehension (SS = 7),
block design (SS = 8), digit span (SS = 6), and coding (SS = 6). The
Working M emory Index (WM I) was at the 8th percentile (WM I =
79; range 73–88).
Jordan became very anxious when the stopwatch was introduced
for the timed tests (block design, visual puzzles, figure weights,
coding, and symbol search) and was visibly upset. He said he was
afraid that he would not be able to do his work on time. At this
point, the examiner explained that he would have plenty of time to
compete the tasks and encouraged Jordan to continue, which he
did. Throughout the assessment, Jordan was hesitant and
tentatively approached each task in an approach-retreat style.
Requests for question repetition were frequent, and Jordan also
evidenced word-finding problems throughout. On a supplementary
task of mental arithmetic, Jordan was observed tapping on his leg
with his index finger, three times, before he would verbalize a
response. When he saw that the examiner had noticed this, he
pulled himself farther under the desk to conceal his legs from view.
Other mannerisms were noted, such as touching his shoe before
lifting his pencil and touching his ear before writing. However,
Jordan was very subtle and secretive in performing these touching
and counting compulsions, and it is likely that these rituals had
escaped detection in most situations.
In addition to these behaviors, Jordan also demonstrated
perfectionist tendencies on many tasks. For example, he spent
considerable time and effort carefully aligning his blocks to ensure
that the edges were straight, a procedure that resulted in the loss
of any possible bonus points he may have earned on the task.
Similarly, repeated erasures to make the symbols “just so” resulted
in reducing his score on the coding subtest. At Jordan’s age level,
it is considered to be significant if the Bender Gestalt designs are
not completed within 7 minutes. Jordan required 20 minutes to
complete the task. Jordan requested a ruler prior to starting the
Bender Gestalt so that his lines could be straight and the paper
could be partitioned. However, he was told that this was a task to
see how well he could reproduce the designs himself, without a
ruler. At this point, Jordan folded the paper to make eight sections
and proceeded to draw each design in one of the folded squares.
Despite all the attempts to structure his responses, the designs
were very poorly executed, due to his weak visual motor
integration skills. He spent a great deal of time checking and
rechecking the number of dots on the cards, rather than actually
executing the designs. Jordan would count the dots and start to
draw and then recount to make sure that he had remembered the
number correctly. On one design, Jordan recounted the dots 15
times before he completed the drawing. His responses were
delayed even further by a ritualistic tendency to punctuate each
drawing by the touching and tapping compulsions noted previously.
Furthermore, although Jordan achieved above average scores on
the untimed tasks of picture concepts and matrix reasoning (WISCV), he required excessive time to complete these tasks (twice the
amount of time that normally would be required).
Jordan’s response to the Wechsler Individual Test of Achievement
(WIAT-III) was also enlightening. It took almost an hour and a half
to complete this instrument, which usually takes about 40 minutes.
Prior to starting tasks, Jordan had a series of questions he asked
to make sure that he understood what was required. On the
spelling dictation test, Jordan spent several minutes erasing and
rewriting words to improve the quality of his writing. Each
mathematical calculation had a pizza drawn beside it (he called
them “pizza faces”), with pepperoni slices indicating the number.
For example, in order to perform the calculation 5 + 6, Jordan drew
two pizzas: one with five slices of pepperoni and one with six
slices of pepperoni. He then added up the pepperoni slices to
obtain the final answer. Reading was also performed very
hesitantly, with much doubting as to the correct pronunciation.
Jordan continually requested feedback about his performance. Only
the Reading Fluency is timed on the WIAT-III, and his score for
reading fluency was significantly below his age level (standard
score of 72, at the 3rd percentile). On the remaining tasks, which
are not timed, Jordan demonstrated functioning about 2 years
behind his grade level in all areas. Jordan continued to
demonstrate the touching and tapping rituals noted during his
previous assessment session.
After Jordan’s first assessment session, it became evident from
clinical observations that Jordan was experiencing many symptoms
of obsessive compulsive disorder (OCD), and that these ritualistic
compulsions were likely causing significant problems at school and
at home. Subsequent assessment sessions and behavioral reports
would confirm the extent to which Jordan’s secret world would be
revealed.
M rs. Neeson completed three behavioral rating scales: the
Achenbach CBCL, BASC-2, and Conners scales. Clinical
elevations were noted on the Thought Problems and
Anxious/Depressed scales of the Child Behavior Checklist
(CBCL); the Atypicality scale (BASC-2); and the Perfectionistic
scale (Conners). Teacher reports noted elevations on the Attention
and Thought Problems scales (Achenbach TRF) and on Atypicality,
Adaptability, Learning Problems, Social Problems, and Attention
Problems (BASC-2; Conners).
Further clinical interviews with M rs. Neeson confirmed several
other OCD behaviors and possible family history for the disorder.
M rs. Neeson said that Jordan could be superstitious, much like her
mother, who seemed to have a superstitious saying for everything.
Her mother was also what she called a “clean freak” and “checking
perfectionist.” Often they would make several attempts to get out
of the driveway because her mother would constantly get out of
the car and return to the house to make sure that the stove and
coffee maker were turned off or the door was locked securely.
Although Sally did not consider these behaviors to be mental
health problems, she did say it was very annoying to try to do
anything with her mother. During the course of the conversation,
Sally began to discover several likenesses between Jordan and
his grandmother.
Sally was aware that Jordan did have some superstitions, like
counting or touching rituals; however, she did not know the extent
to which Jordan engaged in these behaviors. Sally became aware
of these rituals when she caught him on occasion and questioned
his repetitive behaviors. Jordan explained that it was about
“threes.” Apparently, he had some system worked out that if he
repeated an action three times or tapped three times, then it would
prevent something from happening. Sometimes, he had to do more
than one count of “threes,” for example, count to 3 two or three
times in a row before he was satisfied. Further conversation
revealed that Jordan also hoarded useless items under his bed
and had other peculiar habits involving arranging and placement of
certain items in very specific places. At the dinner table, the family
had just accepted the fact that Jordan’s fork and knife had to be
perfectly aligned on the stripe of the place mat before he would
begin eating. They were also accustomed to his odd mannerism of
eating his food starting at the outside of the plate and working
toward the center. Sally had just accepted these behaviors as
“Jordanisms” and reasoned to herself that he would eventually
outgrow the habits, or they would later develop into other orderly
and beneficial ways of organizing his world.
Although Jordan’s bathroom routines in the morning could be a
source of annoyance when trying to get Jordan to school, M rs.
Neeson never thought that these behaviors would signal any
cause for concern. Sally said that personal cleanliness was a
strength of Jordan’s, and she surely did not want to discourage his
excellent hygiene.
Jordan completed the BASC-2 but had considerable difficulty with
the yes/no response format. He had trouble making up his mind
and was very uncomfortable not being able to use “sort of” as a
response. On the Personality Inventory for Youth (PIY), the
Feelings of Alienation scale was somewhat elevated due to
Jordan’s endorsement of items referring to repetitive and
distressing thoughts and behaviors. Jordan did not endorse
significant symptoms on the Child Depression Inventory (CDI-2),
which was in the normal range for his age. Jordan did, however,
admit to having a significant number of symptoms that were
indicative of Worry/Attentional Concerns and Physiological
Indicators on the Revised Child M anifest Anxiety Scale (RCM AS2).
Based on clinical interviews, observations, and assessment
results, increasing confirmation and support were obtained to
suggest that Jordan suffered from an OCD. Jordan evidenced a
number of compulsions: repeating, touching, counting, arranging,
cleaning, and hoarding. Obsessive thoughts that seemed to drive
these compulsions included concerns regarding doubts, lack of
symmetry, contamination, and danger. Upon completion of the
Children’s Yale Brown Obsessive-Compulsive Scale (CY-BOCS),
the examiner felt that Jordan’s compulsions were time-consuming
(likely involving more than 1 hour a day) and were interfering
significantly with his schoolwork and social relationships.
Furthermore, Jordan seemed to have very little control over his
obsessions, nor was he able to resist performing the compulsive
acts.
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
Although initially thought to be uncommon among children, current
prevalence rates (between 0.5% and 3%) for OCD are similar for
children and adults (Heyman et al., 2003); however, OCD in
children often goes undiagnosed (Valleni-Basile et al., 1994). There
is a 3:2 male to female ratio for OCD with more boys being
diagnosed at younger ages. The mean age of onset is
approximately 10 years of age with the range from 7.5 to 12.5 years
(Geller & M arch, 2012, p. 100). Because the disorder involves
distressing and often unpleasant thoughts (obsessions) that drive
unwanted acts or behaviors (compulsions) that can often appear
embarrassing to children, OCD may be hidden by young children
and adolescents, who secretly suffer in silence. OCD is
characterized by obsessions (obsessive thoughts) “recurrent and
persistent thoughts, urges, or images that are experienced as
intrusive and unwanted” that cause individuals to feel anxious and
distressed, unless they engage in compulsions (compulsive
behaviors) “repetitive behaviors or mental acts that an individual
feels driven to perform in response to an obsession or according to
rules that must be applied rigidly” in order to reduce the anxious
state (DSM-5; APA, 2013). Although OCD was classified as an
anxiety disorder in the previous version of the DSM-IV-TR (APA,
2000), currently, the DSM-5 (APA, 2013) lists the disorder in a
category reserved specifically for Obsessive Compulsive and
Related Disorders, which also includes body dysmorphic disorder,
hoarding disorder, trichotillomania (hair-pulling) disorder, and
excoriation (skin-picking) disorder.
In 40%–75% of cases of OCD, individuals struggle with a disorder
that evidences a chronic course (M icali et al., 2010; Stewart et al.,
2004). There are also high rates of comorbidity in children with
OCD (Ivarsson, M elin, & Wallin, 2008) with depression anxiety,
attention deficit/hyperactivity disorder (ADHD), and tic disorder
often accompanying OCD in pediatric populations (Weidle,
Ivarsson, Thomsen, Lydersen, & Jozefiak, 2015). Geller et al.
(2001b) found that early onset of OCD predicted increased risk for
comorbidity with the following disorders: ADHD, specific phobias,
agoraphobia, tic disorders, and multiple anxiety disorders; while
mood disorders were a more likely occurrence at later ages.
Though OCD was once thought to have a primarily psychological
basis, many who suffer from it show evidence of a biological basis
for the disorder. Two areas of research have investigated biological
explanations for the disorder: one explanation involves relating
OCD behaviors to low levels of the neurotransmitter serotonin; the
other explanation looks to malfunctioning in a key area of the brain.
Support for the serotonin theory has come from clinical trials that
have established SSRIs such as fluoxetine (which serve to
increase serotonin levels) as a successful treatment approach for
OCD in adults and children/adolescents (Geller et al., 2001c; Riddle
et al., 1992; Rosenberg, Russell, & Fougere, 2005). Other biological
theorists suggest that regions of the brain that convert sensory
information into thoughts and actions (orbital region of the frontal
cortex and caudate nuclei) may be overactive in people with OCD.
Because the system malfunctions, impulses that should be filtered
pass on to the thalamus and the person becomes driven to
perform the acts (Peterson et al., 1998; Saxena & Rauch, 2000).
Although the DSM-IV-TR (APA, 2000) considered OCD as one of
the several anxiety disorders, results from several recent
investigations led researchers to question whether OCD should be
conceptualized apart from the other anxiety disorders, as a distinct
disorder based on unique physiological and neurological
dysfunctional patterns (Bartz & Hollander, 2006; M acM aster et al.,
2006). As it is, the DSM -5 (APA, 2013) has removed OCD from the
section on anxiety disorders and has created a new chapter in the
DSM , “Obsessive Compulsive and Related Disorders” that clusters
OCD with body dysmorphic disorder, hoarding disorder,
trichotillomania (hair pulling), and excoriation (skin picking).
Disorders in this chapter all share features of obsessive thoughts
or compulsive behaviors related to cycles of tension production
and tension release.
Implications of the basal ganglia in OCD have also been suggested
due to the high rates of comorbidity between OCD and Tourette’s
syndrome (King, Leonard, & M arch, 1998). Recently, research has
amassed increasing support for some children who develop acute
OCD symptoms resulting after a strep infection. These children
who demonstrate OCD symptoms from PANDAS (Pediatric
Autoimmune Neuropsychiatric Disorders Associated with
Streptococcal Infections) an autoimmune response to
streptococcal infection (strep throat) may require a very different
method of treatment. Giedd, Rapoport, Garvey, Perlmutter, and
Swedo (2000) compared the cerebral magnetic resonance images
(M RIs) of 34 children with OCD who had had a streptococcal
infection to 82 healthy comparisons and found a subgroup of
subjects with OCD and/or tics who had enlarged basal ganglia due
to a streptococcal infection. M urphy and Pichichero (2002)
monitored 12 cases of OCD with new-onset PANDAS and found
that antibiotic treatment was effective in alleviating symptoms of
OCD in all the children on first trial, and for the 7 children who
suffered a future relapse, once mediation was reintroduced
resulting in symptom remission. The PANDAS-related OCD
symptoms included handwashing behaviors and preoccupation with
germs and are thought to result from an inflammation of specific
regions of the brain.
According to Leonard, Swedo, and Rapoport (1991), some
indicators that OCD behaviors may be occurring in children and
adolescents include hoarding of useless objects, repeated touching
of objects, taking an inordinate amount of time to complete tasks,
and constant erasures or reworking of homework assignments.
The long-term consequences of OCD have long been established,
and the disorder is also often associated with other comorbid
disorders (Bolton, Luckie, & Steinberg, 1995). Research evidence
supports the importance of early intervention in childhood and
adolescence in reducing the long-term severity of OCD (Leonard et
al., 1993). Wewetzer et al. (2001) reassessed 55 patients originally
diagnosed with OCD (mean age of diagnosis 12.5 years; mean
follow-up interval 11.1 years) and found that on follow-up, 71% met
the criteria for a psychiatric disorder, while 36% still met clinical
criteria for OCD. Of those who were positive for a diagnosis of
OCD on follow-up, 70% had at least one comorbid clinical disorder
(most notably, anxiety and affective disorders). Factors associated
with more severe OCD symptoms in adulthood included in-patient
treatment, terminating treatment against advice, and evidence of
tics in childhood or adolescence.
Some of the most frequently occurring compulsions in child and
adolescent populations include handwashing, checking, counting,
ordering, touching, rearranging, and hoarding, while obsessions
may dwell on fears of family loss (fear of death of a parent),
contamination, excessive feelings of guilt, or sexual and/or somatic
associations (Geller, Biederman, Faraone, Agranat et al., 2001). In
some children, compulsions may occur without being associated to
a given obsession, such as blinking or breathing rituals (Geller &
M arch, 2012).
Quality of Life (QoL) is considered to be a measure of subjective
well-being on several dimensions of life (Weidle et al., 2015). M ore
recently, researchers have investigated the role of symptom
severity and QoL in a number of childhood disorders, including
children with ADHD (Danckaerts et al., 2010) and anxiety and
depression (Stevanovic, Jancic, & Lakic, 2011). In their study of
children and adolescents with OCD, Lack et al. (2009) found
significantly lower QoL scores in individuals with OCD, compared to
healthy controls. In addition, children with comorbidity (externalizing
and internalizing symptoms) in this population had the lowest
scores on QoL, compared with those who only had symptoms of
OCD. These findings have since been replicated by Weidle,
Jozefiak, Ivarsson, and Thomsen (2014). QoL instruments, such as
the KINDL-R, measure QoL in areas such as physical well-being,
emotional well-being, self-esteem, family, friends, and school.
Piacentini, Bergman, Keller, and M cCracken (2003) studied
functional impairment in 151 children and youth with OCD and
report that almost 50% indicated OCD-related problems were
evident in all three major domains: home, school, and social
relationships. At school, concentration and homework surfaced as
the two most critical areas of difficulty. Within the home, 60% of
families of children with OCD report detrimental effects of the OCD
behaviors on siblings and marital discord due to increased distress
and feelings of manipulation (children attempting to engage family
members in the OCD behavioral rituals; Cooper, 1996).
Perfectionistic tendencies have also been significantly associated
with OCD, and many cognitive theorists see perfectionism and
responsibility (self-blame) as two of the core features of cognitive
models of OCD (Obsessive Compulsive Cognitions Working
Group; OCCWG, 2001, 2005). In their study of perfectionism and
OCD, Wu and Cortesi (2009) found that perfectionism was most
strongly associated with checking rituals related to ordering,
arranging, symmetry, and grooming and more weakly associated
with contamination obsessions and washing compulsions, a finding
that supported results of an earlier study by Julien, O’Connor,
Aardema, and Todorov (2006). Wu and Cortesi (2009) suggest that
this finding provides an important contribution for targeting cognitive
restructuring in those with checking rituals.
Treatment for OCD
Historically, theoretical explanations for OCD have focused on the
maintenance of fear and anxiety due to negative reinforcement; for
example, performing the compulsion serves to reduce the anxiety
caused by the obsession (behavioral theories) and the faulty
appraisals (excessive self-doubt and self-blame and feeling overly
responsible for the obsessive thoughts), which tend to lock
individuals into the obsessive and compulsive rituals (cognitive
theoretical perspective). As a result, the majority of treatments
have focused on behavioral techniques, such as exposure and
response prevention (ERP) and cognitive behavioral therapy
(CBT) techniques for reframing maladaptive thinking (e.g., selfblame, self-doubt) into more positive thought patterns. From a
neurobiological perspective, unlike anxiety disorders that respond
to a wide range of medications (benzodiazepines and
norepinephrine reuptake inhibitors), antidepressant medication
(serotonin reuptake inhibitors: SRIs, such as fluoxetine) has been
the only category of medication that has been successful in
alleviating symptoms of OCD in adults and assisting some children
in reducing symptoms of OCD (Geller et al., 2001a, c) The most
recent revision of the Practice Parameters for the Assessment and
Treatment of Children and Adolescents with ObsessiveCompulsive Disorder (Geller & M arch, 2012) recommends that
assessments of children and adolescents involve routine
psychiatric screening for indications of obsessive and compulsive
behaviors; evaluation using DSM criteria; reviewing multiple
sources to determine possible comorbidity; and full medical,
developmental, family, and school history. In addition, treatment
approaches for the management of OCD were outlined as follows:
CBT as the first line of treatment, medication (SRIs, such as
clomipramine) as a first-line medical treatment in addition to CBT for
moderate to severe OCD, or if CBT alone is ineffective.
Barrett, Farrell, Pina, Peris, and Piacentini (2009) conducted a
meta-analysis of evidence-based treatments for children and youth
with OCD, based on 21 studies conducted since 1994 that adhered
to Type 1, 2, or 3 criteria as set out by Nathan and Gorman (2002).
The two treatments that maintained the highest quality of empirical
rigor (Type 1: randomized, controlled studies) were studies
conducted by Barrett, Healy-Farrell, and M arch (2004) and the
POTS Team (2004). Barrett et al. (2004) compared family-focused
individual therapy (ICBT) and family-focused group therapy (GCBT)
using a manualized family component “Freedom From Obsessions
and Compulsions Using Cognitive-Behavioral Strategies” (FOCUS:
Barrett, 2007), which was adapted from an earlier version of the
individual treatment program established by M arch and M ulle
(1998). The FOCUS program included sessions devoted to
education, cognitive training, ERP, and parent sessions. Follow-up
12 and 18 months after the completion of the program revealed that
70% of those in the ICBT program and 84% from the GCBT
program remained symptom free (Barrett, Farrell, Dadds, & Boulter,
2005). The POTS study (POTS Team, 2004) compared treatment
groups of youth with OCD (7–17 years of age) who were randomly
assigned to one of the four conditions: ICBT alone, sertraline (SRI
medication) alone, combined ICBT and sertraline, or placebo pill.
The CBT protocol was based on the program developed by M arch
and M ulle (1998) and included 14 sessions over a 12-week period.
Results revealed that all three treatments were superior to
placebo, but that combined CBT and sertraline was superior to
either treatment alone, although both of the CBT conditions (with
and without sertraline) were superior to the sertraline alone
condition, suggesting that CBT alone or in conjunction with SRI is
an effective treatment for OCD in children and youth. Another
study, conducted by Asbahr et al. (2005) and also using the GCBT
format prescribed by M arch and M ulle (1998), found that youth who
received CBT in the group condition demonstrated significantly
lower rates of symptoms compared to youth who were treated with
sertraline.
In another recent research program designed to compare the
effects of combined treatments, Neziroglu, Yaryura-Tobias, Walz,
and M cKay (2000) found that children who received a combination
of fluvoxamine and ERP demonstrated more immediate
improvement and continued improvement 2 years later than those
receiving either treatment in isolation. However, Sabine (2001)
argues that CBT may be at least as effective and a less stressful
alternative than ERP for children and adolescents with OCD.
Techniques commonly used in CBT programs include cognitive
restructuring, psychoeducation (to dispel irrational fears of
contamination, etc.), distraction, and relaxation.
Weidle et al. (2014) studied the impact of CBT treatment (14
weekly sessions of 45 minutes of individual CBT with ERP
intervention) on a sample of 135 children and adolescents ranging
in age from 7 to 17 (mean age 13 years). Parents participated in
additional 30-minute sessions added to the initial three sessions, 2
additional sessions and the final session. Child attendance during
the parent sessions was optional. The program adhered to
traditional ERP protocol with a focus on the construction of a fear
hierarchy and gradual exposure to threatening situations (based on
the established fear hierarchy) and included homework practice
assignments. The final sessions focused on generalizing what
skills were learned and relapse prevention. QoL was measured by
the KINDL-R, a 24-item (5 point) scale completed by parents and
children that measures QoL in six areas: physical well-being,
emotional well-being, self-esteem, family, friends, and school. Other
rating scales were used to measure OCD symptom severity and
symptoms of internalizing and externalizing disorders. Results
revealed that for children with OCD, QoL scores reported by
children and their caregivers showed marked improvement after
treatment in all areas, with the exception of the friends and school
subscale in the children’s report, suggesting that CBT with ERP
was highly effective in reducing symptoms of OCD and in improving
QoL in children and adolescents with OCD.
Post-Case Questions
1. It is possible to explain OCD from a number of theoretical
positions. Develop a case formulation to explain the
development of obsessions and compulsions based on the
following theoretical perspectives, in light of Jordan’s history:
biomedical, behavioral, cognitive, and family systems. Provide
the specific treatment implications for Jordan’s OCD based on
each of the case formulations derived.
2. Behavioral interventions for OCD often include exposure
techniques designed to elicit the anxiety (either gradually or
completely) by either direct exposure (in vivo) or in an
imagined state. Graduated levels of anxiety can be
predetermined by the construction of an anxiety hierarchy
(from least to most stressful situation). Anxiety can be reduced
by pairing increasing levels of anxiety-provoking situations with
a relaxation response (muscle relaxation exercises).Another
intervention for OCD involves exposure followed by response
prevention. In this technique, the child would be limited in
performing the compulsion (e.g., checking, counting) when he
or she has an obsessive thought. The child would agree to
limit the response and would be rewarded for following
through.Design a behavioral intervention plan for Jordan’s use
in the classroom, using ERP.
3. Discuss the relationship between separation anxiety and OCD
in Jordan’s developmental history.
4. Based on the DSM -5 (APA, 2013) criteria for OCD (see
Glossary), what symptoms of OCD does Jordan demonstrate,
and does he qualify for a diagnosis of OCD according to the
DSM?
5. In the Introductory chapter, the section on case formulation
based on a psychodynamic and attachment perspective
discusses Greenberg’s theory of the neurophysiology of
emotion regulation. According to Greenberg, humans require
positive experiences of resolving fearful situations to allow for
a buildup of brain structures that help to regulate responses to
anxiety and fear-producing situations. In dysfunctional
attachment relationships, caregivers are not a source of
assistance in the regulation of emotion, and children do not
develop the ability to self-soothe when upset. Explain whether
Greenberg’s theory applies to Jordan, and if so, how and why
this situation has developed.
6. Suggested individual or group presentation activity: You have
been invited to provide feedback to the school regarding
Jordan’s assessment at a meeting where they will decide
whether Jordan meets criteria for Special Education and
Related Services. If it is determined that he is eligible for
services under what exceptionality would you suggest he
meets criteria for services? What Goals and Objectives would
you want to see as part of his individualized education plan?
Would you recommend he receives related services, and if so,
what would the nature of those services be?
7. Prepare a script for role-playing each of the player’s parts in
the school meeting, mentioned above. Who do you think
should be attending the meeting? How could each participant
potentially contribute information to assist with developing an
intervention plan that would best meet Jordan’s needs?
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Asbahr, F. R., Castillo, A. R., Ito, L. M ., Latorre, M . R. D. O.,
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CASE 16 SANDRA SILVER : SHY OR SOCIAL
ANXIETY DISORDER (SOCIAL PHOBIA)
SOCIAL ANXIETY DISORDER
When they arrived at the clinic, it was clear that Sandra was not pleased to be here.
Sandra tried to distance herself from her mother and sat in a chair on the other side
of the waiting room. She slumped in the chair as if she wanted the chair to swallow
her up. Her mother, Georgia, on the other hand, was a very gregarious woman who
immediately tried to engage the woman sitting next to her in a conversation. After
what seemed to Sandra to be an eternity, the psychologist finally came into the
waiting room and asked them to accompany her to her office. Sandra’s mother had
finally decided to get some help for Sandra because she was very shy and fearful,
especially in social situations. Initially she thought that this was just part of being an
adolescent but now that she was in the 10th grade, she was still experiencing
problems socially, at a time when others her age were becoming even more social.
DEVELOPMENTAL HISTORY/FAMILY BACKGROUND
Sandra was visibly uncomfortable when she sat down on the couch in the
psychologist’s office. Her mother immediately sat beside her and started to provide
some history, almost before the introductions were finished. The psychologist was
immediately very aware of the contrast between these two individuals. Georgia
stated that there was no biological history available for Sandra who was adopted
from an orphanage in China at 2 years and 8 months of age. Georgia is a single
mother, who was never married. She retired from teaching 2 years ago when
Sandra graduated from middle school. Gloria was able to be close to her daughter
during her early schooling since she taught at the elementary school that Sandra
attended, and when Sandra transferred to middle school, Georgia was able to
obtain a job at the local middle school. Georgia was quite proud of the fact that
Sandra was able to have her mother teaching at the same school she attended
until she moved on to high school.
When it came time to start school, Sandra was fearful of being in a class with so
many children, but with her mother nearby, the situation was not as bad as it could
have been. However, by the third grade, her teacher noticed that Sandra had
problems focusing on her work and was very easily distracted by everything around
her. She had problems sitting still and was very inattentive, and as a result she
started to fall behind, academically. With increased pressures evident in the third
grade (when state testing would determine whether the student remained in the
third grade or passed on to the fourth grade), the teacher talked to Gloria about the
possibility of having her tested for attention deficit/hyperactivity disorder (ADHD).
Gloria did not want to have Sandra tested and instead took Sandra to her
pediatrician who asked Sandra’s mother and teacher to complete the Vanderbilt
Rating Scales (NICHQ). The teacher rated Sandra as demonstrating many
symptoms associated with ADHD predominantly inattentive type, such as fails to
give attention to details or makes careless errors; difficulty sustaining attention during
tasks; does not seem to listen when spoken to; does not follow through on
instructions; has difficulty organizing tasks and activities; and avoids or dislikes, or is
reluctant to engage in tasks that require sustained mental effort. Although Sandra’s
mother also rated the same symptoms, the teacher’s ratings were significantly
more elevated than Gloria’s ratings. The teacher also endorsed other symptoms
not related to ADHD, including: is fearful, anxious or worried; is self-conscious or
easily embarrassed; and is afraid to try new things for fear of making mistakes.
These symptoms were not endorsed by Sandra’s mother. Based on these ratings,
the pediatrician diagnosed Sandra with ADHD and prescribed Concerta
(methylphenidate), a central nervous system stimulant medication for ADHD.
Georgia stated that shortly after the medication was prescribed, Sandra started to
get better grades and her teacher noted that her attention and concentration had
improved significantly. However, her mother noticed that as she entered puberty,
she started to become more irritable, especially when she took her medication for
school (Gloria had her taking the medication on school days, only). Although never
a social child, toward the end of middle school and in the transition to high school,
Gloria stated that Sandra was becoming more reclusive. Although she had a few
close friends, these friends were not what Gloria would have liked to see as
Sandra’s “friends,” since they came from very dysfunctional home situations.
The psychologist asked Gloria to take a seat in the waiting room while she asked
Sandra some questions, privately. Both Gloria and Sandra agreed that this would be
appropriate at this time. When asked what her biggest problem was, Sandra said
she was very angry that her mother does not understand her. She said she is very
uncomfortable in social situations and that her mother makes this worse by
approaching strangers and talking to them or saying things to her in public that other
people might overhear. She said her mother is loud and talks about personal things
that are private to her, and she is devastated when her mother does this in public.
She felt her mother was very judgmental and critical of her. She said her mother has
made comments about her to other people that are embarrassing (saying she is 4
feet, 11½ inches tall; one foot is bigger than the other). She ended up saying that
her mother just does not get her. Sandra agreed to come for therapy sessions,
where the psychologist said she would help her to learn how to cope with her fears
and feelings of discomfort socially and also work to help her mother to understand
her better. Sandra said she was looking forward to coming to sessions with the
psychologist.
REASON FOR REFERRAL
Gloria brought Sandra to the clinic because she was concerned about her poor
social skills and her increased tendencies to avoid being out in public and
socializing with her peers. She was becoming increasingly self-conscious and
reclusive. She was fearful of going to places that were not familiar, and even when
going to familiar places, she would try to be as inconspicuous as possible and often
ask to leave soon after they got there. She wanted Sandra to be more outgoing like
she was.
ASSESSMENT RESULTS
Information regarding the specific assessment instruments used in this assessment
and guidance in the interpretation of standard scores and T scores can be found in
Appendix C.
During the intake, the psychologist had Gloria complete the Child Behavior
Checklist (CBCL) while Sandra completed a number of self-report scales (Child
Depression Inventory [CDI-2]; Revised Child M anifest Anxiety Scale [RCM AS-2];
and the Youth Self-Report [YSR]). Sandra and her mother were in agreement that
she demonstrated a number of Anxious/Depressed symptoms, although the degree
of elevation was significantly higher on Sandra’s rating (T score of 93) compared to
her mother’s rating (T score of 67). Sandra and her mother agreed that she
demonstrated symptoms, including: feeling she must be perfect; feeling worthless;
nervous; self-conscious; and worries; however, Sandra also noted that she cries a
lot; has many fears; is fearful of going to school; fears she will do something bad; is
feeling guilty; and has had thoughts of suicide. None of the other scales on Gloria’s
CBCL were elevated and all ratings were within the normal range (T score 40–60).
Sandra endorsed several scales in the elevated ranges with clinical ratings on
scales for Withdrawn/Depressed symptoms (T score 70), Social Problems (T score
77), Thought Problems (T score 77), and Attention Problems (T score 74).
Withdrawn/Depressed symptoms were evident in: enjoys little; rather be alone;
won’t talk; secretive; shy/timid; and withdrawn. Sandra indicated Social Problems in
behaviors such as: lonely; doesn’t get along with others; jealous; feels others are out
to get her; gets teased; and not liked by others.
On the RCM AS-2, Sandra’s overall score for Anxiety was a T score of 67 which is
in the At-risk Range, with elevations on individual scales for Physiological Anxiety
(T score of 63) and Social Concerns (T score of 67). Items endorsed on the Social
Concerns scale, included: others seem to do things easier than I can; I feel that
others do not like the way I do things; I feel alone even when there are people with
me; other people are happier than I; I feel someone will tell me I do things the wrong
way; and a lot of people are against me. On the CDI-2, her overall depression score
was a T score of 73, however, all individual scales were only marginally elevated,
with the exception of the scale for Interpersonal Problems which was a T score of
84. Items endorsed on this scale, included: I get into fights many times with other
people; I do not have any friends; and I do not want to be with people at all.
Based on the results of the interview and behavioral rating scales, the psychologist
diagnosed Sandra with social anxiety disorder (SAD) (social phobia) and developed
several goals for Sandra’s treatment plan, which included cognitive behavioral
therapy (CBT) to work on assisting Sandra to recognize how her negative thoughts
are contributing to her anxious feelings and work on trying to get her to reframe her
thinking into more positive terms (use of Situation, Feelings, and Thoughts
worksheets); psychoeducation for Sandra’s mother regarding the nature of SAD and
how she can assist Sandra to develop her coping skills; and have Gloria and
Sandra talk to the pediatrician regarding the potential to switch medications from
Concerta which may be contributing to feelings of anxiety to something like
Strattera (atomoxetine), a selective norepinephrine reuptake inhibitor which may
target both ADHD and anxiety.
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
The lifetime prevalence rate for anxiety disorders in children and adolescents is
estimated to be between 15% and 20% (Beesdo, Knappe, & Pine, 2009).
Generally, anxiety disorders are far more prevalent in females than males with rates
ranging from twice as many to three times as many females having an anxiety
disorder than males (Pine, Cohen, Gurley, Brook, & M a, 1998). Although this
pattern seems to be consistent across all age groups for most anxiety disorders
(Roza, Hofstra, van der Ende & Verhulst, 2003), certain anxiety disorders, like SAD,
are more prevalent in females during adolescence (Weems & Costa, 2005).
Experiencing social fears, such as excessive shyness, have been reported in up to
20% of the population, with approximately 13% meeting diagnostic criteria for SAD,
with typical onset in childhood or adolescence (Knappe, Sasagawa, & Creswell,
2015).
SAD is among the most common mental disorders in children and adolescents.
Studies suggest that 6% of children (Chavira, Stein, Bailey, & Stein, 2004) and
12.1% of adolescents meet criteria for a diagnosis of SAD (M erikangas et al., 2011).
However, despite high rates of prevalence of the disorder, Colognori et al. (2012)
found that few students are actually treated for the disorder. Colognori et al. (2012)
surveyed a sample of over 1,500 high school students and found that 17.2% of the
sample met criteria for SAD (clinical cutoff score on the M anifest Anxiety Scale);
however, only 14% of those who met criteria were receiving any sort of services for
the disorder. Of those receiving services, 68% saw a therapist outside of school,
22% saw a school counselor, and 6.5% were being treated medically.
According to the DSM (APA, 2013), 75% of individuals who have SAD have onset
of the disorder between 8 and 15 years of age, with the median age of onset being
13 years of age. Youth with SAD have been noted to have fewer friends, engage in
limited extracurricular activities, and often experience issues with school attendance
and underachievement (Khalid-Khan, Santibanez, M cM icken, & Rynn, 2007).
Temperamental traits such as fear of negative evaluation and behavioral inhibition
(which is predominantly an inherited trait) can predispose an individual to SAD. The
DSM (APA, 2013) notes that shyness should be distinguished from SAD when
social reticence impacts social, occupational, or other important areas of functioning,
According to the DSM -5, “only a minority (12%) of self-identified shy individuals in
the United States have symptoms that meet criteria of social anxiety disorder” (p.
206). During adolescence there is increased social pressure at a time when
important cognitive and social-emotional changes are taking place. The result is that
due to the marked increased in social pressures, youth encounter more powerful
emotional experiences and are often faced with tendencies to engage in risk-taking
behaviors (Casey et al., 2010). This is a vulnerable period of development which is
evident in peak prevalence rates for anxiety and depression, which can often cooccur resulting in a cumulative prevalence rate of approximately 15% at 16 years of
age (Costello, M ustillo, Erkanli, Keeler, & Angold, 2003). Caouette and Guyer
(2014) suggest that SAD is prevalent in adolescence because those who have an
inhibited temperament (mediated by arousal of the amygdale, basal ganglia, and
prefrontal cortex) are faced with pressure to engage in social activities during this
time period when they are motivated to develop a cautious approach that has been
rooted in childhood. The conflict now is evident between the pressure to engage in
activities and the extreme fear of humiliation and embarrassment that might result
from such social engagement.
It has also been suggested that adolescence also brings with it a pronounced
change in perspective and preoccupation with peers and romantic interests.
Compared to adults, adolescents are far more apprehensive regarding peer
feedback and react more negatively to peer exclusion (Reijntjes, Stegge, Terwogt,
Kamphuis, & Telch, 2006; Westenberg, Drewes, Goedhart, Siebelink, & Treffers,
2004). Although there is significant improvement in self-regulation in adolescence
compared to earlier stages of development, studies using functional magnetic
imaging resonance techniques have found that the integration of the prefrontal
cortex with other brain areas is not as effective as it is in the adult brain.
Adolescents still lag behind adults in the ability to inhibit responses, planning ability,
and future orientation (Steinberg et al., 2009). The immaturity of the prefrontal
network in conjunction with heightened neural activity and excitation during
adolescence results in adolescents responding to situations with inflated reactions,
whether this involves responding to a distressing (stressful) or pleasurable
experience. In addition, the sex hormones are also responsible for heightened
responsiveness in the prefrontal cortex and amygdale which are instrumental in our
recall for emotional events and our interpretation of nonverbal emotional
expressions (Steinberg et al., 2008). Increases in sensitivity and heightened
activation of the emotional centers and increases in hormone levels can result in
instabilities in adolescent moods. It has been determined that adolescents report
more dissatisfaction with their mood states, which has been attributed to an
increase in stressful life experiences during this period, such as problems at home
and school, relationship problems, and family conflict (Larson & Ham, 1993).
In addition, adolescents tend to be more self-consciousness and increasingly use
social comparison (social referencing) as a means of self-evaluation compared to
pre-adolescent children (Elkind, 1967, 1985). The preschool child views the world
through an egocentric perspective (egocentrism) because of an inability to take the
perspective of another. In adolescence, the ability to think about thinking
(metacognition) and consider abstract and hypothetical situations can result in a
self-conscious framework for analysis. Adolescents are also highly sensitive to
emotional information due to heightened brain activity in the subcortical regions
relative to immaturity in the prefrontal cortex. Within this context, adolescent
egocentrism can result from excessive self-reflection and a preoccupation that
they are the focus of everyone’s attention.
Two important concepts that are fundamental to adolescent egocentrism are the
concepts of the imaginary audience and personal fable (Elkind, 1967; Elkind &
Bowen, 1979). The imaginary audience reflects the adolescent’s concern that
everyone is looking at them which may cause them to retreat into their own private
world or perform for the audience (talking loudly, wearing dramatic clothing, etc.).
The personal fable typically reflects an exaggerated sense of uniqueness (“You
couldn’t possibly understand what I am going through!”), which may also place the
adolescent at risk for danger, since they do not generalize that mishaps of others
could ever happen to them (e.g., teen pregnancy, reckless driving) which increases
their feelings of invulnerability. In their study of over 100 middle school students,
Alberts, Elkind, and Ginsberg (2007) found that scores on an instrument measuring
personal fable increased with age, were higher in males than females, and were
positively related to risk-taking. Eventually, sharing experiences with peers often
enhances the understanding that others share similar feelings and concerns.
However, adolescents who are isolated from peers may continue to harbor fears of
being scrutinized and criticized by others, as well as increased feelings of being
misunderstood, which can increase the risk for developing SAD. Studies using
behavioral paradigms have found that over time, sharing experiences with peers
should contribute to adolescents developing a growing understanding of another’s
mental state; a tendency to “mentalize” in terms of visual perspective-taking,
feelings, and motivations (Dumontheil, Apperly, & Blakemore, 2010; Vetter, Leipold,
Kliegel, Phillips, & Altgassen, 2013); and a more differentiated sense of prosocial
behavior (Guroglu, van Den Bos, & Crone, 2014).
The DSM -5 (APA, 2013) considers SAD (social phobia) as an excessive anxiety
regarding a social situation or multiple social situations where the individual is fearful
of scrutiny by others. Examples of situations that might be associated with SAD
include social interactions (communicating with individuals; meeting new individuals),
being observed (e.g., eating), or performing in front of others (e.g., talking in front of
the class; giving a speech). For children, the anxiety must also be evident in peer
interactions, not just during interactions with adults. The anxiety results from the
fear that the individual will be judged by others in a negative way, leading to
humiliation, embarrassment, and rejection. Because of these intense feelings, social
situations are avoided if possible, and if situations cannot be avoided, they are
experienced with intense fear and anxiety which may result in a panic attack. The
DSM -5 uses the specifier “performance only” to refer to a form of SAD that is
restricted to situations where the individual is fearful of performing or speaking in
public. Velting and Albano (2001) found evidence of two adult subtypes of the
disorder: generalized social phobia (pervasive across most social situations) and
specific social phobia (evident in particular situations, e.g., public speaking).
Hofmann et al. (1999) found that almost half of the adolescents in their study had
the generalized subtype of the disorder which is the more severe form associated
with higher levels of psychopathology. Wittchen, Stein, and Kessler (1999) revealed
that compared to those with specific SAD, adolescents and young adults with the
generalized form of SAD developed the disorder at earlier ages and were more
likely to have a history of behavioral inhibition, as well as exposure to a greater
number of early childhood risk factors.
A typical profile of someone with SAD would often include having fewer friends,
avoidance of social situations, and experiencing difficulties participating in activities
that involve others, such as classroom discussions, answering or asking questions,
working in groups, and avoiding social situations and interactions, such as joining
clubs or groups (Connolly, Bernstein, & The Work Group on Quality Issues, 2007).
SAD has been associated with feelings of loneliness, depression (Beidel et al.,
2007), and impairment in functioning that can impact a number of areas, including
transitions, employment, suicidal ideation, and increased risk for substance use and
abuse (Kessler, 2003; Stein & Stein, 2008).
In an effort to provide specific treatment alternatives for youth with SAD,
researchers have explored the potential risk factors and underlying causes of SAD,
including variables of personality and temperament, such as behavioral inhibition
and negative affectivity/physiological hyperarousal (cognitive triad), and
environmental factors such as parenting style (Beesdo, Knappe, & Pine, 2009;
Knappe et al., 2009). De Voogd, Wiers, Prins, and Salemink (2014) investigated
SAD in adolescents and the role of negatively biased attention on the interpretation
and recall of information (M athews & M acLeod, 2005). Based on theories involving
the cognitive triad, De Voogd et al. (2014) suggest that individuals with SAD are
very self-conscious and anticipate and believe that they will not do well in social
interactions and social events which ultimately becomes a self-fulfilling prophecy
because they become so nervous and anxious in anticipation of the event that they
are unable to perform adequately. Studies have determined that cortisol release in
response to a stressful situation is related to selective attention toward social
threat (Dandeneau, Baldwin, Baccus, Sakellaropoulo, & Pruessner, 2007). As a
result of attentional bias, the tendency to preferentially focus attention on negative
information can be a predictor of potentially negative outcomes (White, Suway,
Pine, Bar-Haim, & Fox, 2011). Using a visual search technique (subjects had to find
a smiling face among a grid of faces with emotional expressions), De Voogd et al.
(2014) found that attention bias training was successful in reducing attentional bias
for negative information and decreasing symptoms of SAD.
Treatment for Social Anxiety Disorder
Studies have demonstrated that the majority of children and youth with anxiety
disorders benefit from cognitive behavioral therapy (CBT) (In-Albon & Schneider,
2007).Within the realm of specific and social phobias, several types of treatments
have been integrated into cognitive behavioral programs (CBT), including
psychoeducation to better understand the nature of negative thought patterns and
specific cognitive and behavioral methods to decrease anxiety and to reframe
negative thought patterns, such as participant modeling and reinforced practice. A
review conducted by Davis and Ollendick (2005) indicated that reinforced practice
and modeling showed the greatest degree of empirical support for their efficacy in
reducing fearful or phobic reactions to stimuli.
Reinforced practice is one of the several different forms of exposure therapy
traditionally used to treat fears and phobias. Exposure therapy is a form of CBT for
anxiety and fear-based disorders that involves repeated approaches toward a fearprovoking situation. Exposure can be graduated or intense (such as in flooding
therapy), brief versus extended, and imagined or in vivo/real life (Craske, Liao,
Brown, & Verliet, 2012).
Reinforced practice using these methods can positively reduce anxiety (Ollendick &
King, 1998), especially if used in conjunction with systematic desensitization
programs based on methods initially developed by Wolpe (1958). Systematic
desensitization involves initial training in methods of deep relaxation (deep
breathing or muscle relaxation exercises); developing a fear hierarchy (from the
least feared situation to the most feared situation); and gradually progressing up the
list pairing the feared situation with deep relaxation, until the situation no longer
evokes an anxious response. At each step in the hierarchy, the individual is
exposed to a higher level of approximation to their feared situation while pairing
each step with a relaxation response. Reinforcement of the child’s attempts and
contingent on the successes of the approach or avoidance typically takes the form
of verbal praise and is used to shape behavior in the required direction. As noted
earlier, negative attention can be a powerful motivating force for avoidance and
withdrawal behaviors in children with SAD. For children who have an attention
component to the maintenance of their social phobia, application of praise and
attention during approach behaviors can be very successful (Davis, Kurtz, Gardner,
& Carman, 2007). By the same token, withdrawal of attention or praise (while
remaining empathic and supportive) can be very helpful in reinforcing appropriate
behaviors during fearful responses. Research has demonstrated that the application
of reinforcements for approach and the withdrawal behaviors can be a significant
treatment intervention for shaping appropriate responses to fearful situations that
would have traditionally been maintained by attention, escape, and avoidance
behaviors (Davis et al., 2007; Zlomke & Davis, 2008). Another important technique
used in the treatment of phobias is participant modeling and observational learning
which are used to demonstrate positive responses to feared social situations. The
models can be live or seen on video-taped segments, although live models (known
as in vivo participation) have been shown to have more successful outcomes than
those viewed on tapes or imagining oneself in a fearful situation (covert or imaginal
participation).
Participant modeling provides a framework for breaking down difficult steps in the
fear hierarchy into tasks that are more manageable task, while supporting each step
with guidance and feedback (Zlomke & Davis, 2008).
The following programs have been developed, specifically, to treat children and
youth with SAD. The discussion will initially focus on two programs that are
traditionally used in community clinic settings and the discussion will eventually shift
to applications of intervention programs within the school environment. All the
programs discussed below include variations on four pivotal treatment elements:
psychoeducation; exposure techniques (construction of a fear hierarchy and use of
reinforced practice); participant modeling; and acquisition of anxiety coping
mechanisms/skills (problem-solving, relaxation).
Two programs that have been researched in clinical/community populations include
CBT (CBTG group [Albano, M arten, Hold, Heimberg & Barlow, 1995] and CBTI
individual [Clark, 2001] formats) and social effectiveness therapy (SET; Beidel,
Turner, & M orris, 2000).
Cognitive behavioral therapy: The majority of interventions used for children with
SAD were initially developed to treat anxiety in general (Herbert et al., 2009) and
were based on CBT techniques developed for adult populations (Zaider &
Heimberg, 2003). There are significantly fewer CBT programs developed to treat
anxiety in child and adolescent populations. One CBT program which has proven
successful in treating anxiety disorders in children and youth is the Coping Cat
Program (Kendall & Beidas, 2007), which was discussed in Case 14, Shirley Yong;
however, as noted previously, the Coping Cat Program was developed for
generalized anxiety disorder and not specifically for SAD. Although the majority of
studies conducted on CBT for SAD have been conducted using adult populations,
studies have demonstrated that CBTG can be an effective approach to treating
SAD in children and youth (Hayward et al., 2000; Spence, Donovan, & BrechmanToussaint, 2000). In their study of the use of individual and group CBT programs for
children.
Treatments using a more directed CBT program that targets negative attention bias
as the treatment focus have also demonstrated post treatment success in reducing
symptoms of SAD in adolescents De Voogd et al. (2014). In their investigation of
attention bias, Legerstee et al. (2010) found that positive outcomes did not
significantly differ between CBT delivered in group (41% of children were free from
symptoms of anxiety) or individual (48% of children were free from symptoms of
anxiety) formats.
Social effectiveness therapy for children (SET-C): SET-C is a program that consists
of 24 sessions which are presented over a 12-week period. Each week, one of the
sessions focuses on exposure, while the second session focuses on social skills
training. Initial results revealed significant gains in several areas, including increased
social skills, reduced social fear and anxiety, decreased associated
psychopathology, and increased social interaction Beidel et al. (2000). Follow-up
revealed that the majority of gains were maintained 5 years following treatment
(Beidel, Turner, & Young, 2006). The program involves four core components,
including Child and Parent Education, Social Skills Training, Peer Generalization
Experiences, and In Vivo Exposure. The program begins with a focus on
psychoeducation and then focuses on the last three components, simultaneously
(Beidel et al., 2006). All components were delivered in group format, with the
exception of the In Vivo Exposure which was presented in individual sessions
averaging 1 hour in length. The Peer Generalization sessions involved interaction
with children who did not have social phobia in a natural setting, to allow children
with SAD the opportunity to practice skills they had learned.
Increased emphasis has been placed on the advantages of providing services in
schools for children and adolescents with mental health issues, especially
internalizing disorders, such as anxiety disorders M asia-Warner, Nangle, and
Hansen (2006). School-based mental health interventions can become one of a
number of services that have been integrated into the school culture and in many
cases may be the venue that students prefer. A recent study by Husky, Sheridan,
M cGuire, and Olfson (2011) revealed that 80% of youth who were identified “at-risk”
for mental health problems would likely access treatment from school-based
services compared to only 42% who indicated that they would access communitybased treatment. Given these advantages, school-based services have been
increasingly recognized as a critical avenue for helping address the unmet mental
health needs of youth with anxiety disorders. However, Herzig-Anderson,
Colognori, Fox, Stewart, and Warner (2012) recommend that additional research be
conducted to determine the best methods for training school personnel to
implement evidence-based treatments.
Recognizing the need for an empirically supported program that could be provided
in the schools, M asia et al. (1999) developed a school-based program, Skills for
Social and Academic Success (SASS), based on techniques developed by Beidel,
Turner, and M orris (1998) in their program called SET-C. The program previously
described is somewhat unique in that it has an emphasis on peer-mediated
learning, which is especially conducive to use within a school setting. Adolescents
enrolled in the SASS program demonstrated significant reduction in social anxiety
compared to the wait list control group (Fisher, M asia-Warner, & Klein, 2004).
The SASS program typically runs over the course of 3 months and involves 12 (40
minute) weekly in-school group sessions. The groups are comprised of 3–6
students and are facilitated by one or two group leaders. Group sessions are
devoted to four main topics, including (1) psychoeducation, (2) realistic thinking, (3)
social skills training, and (4) exposure. The two final group sessions are concerned
with relapse prevention. In addition to the group sessions, there are two (20minute) individual sessions. In addition to the above, the program also involves four
weekend social events lasting approximately 1½ hours where children in the SASS
program can mingle with peers (called peer assistants) who do not have social
anxiety issues and participate with them practicing their social skills in activities
such as bowling or rollerblading. Parents are encouraged to attend two group
sessions (45 minutes) which focus on psychoeducation regarding social anxiety
issues and techniques that can be used to assist the child at home. Teachers can
also be invited to attend similar sessions for their information.
The following is a very brief description of what each of the five main topics focus
on and the overall goals of each of the session topics. The first sessions evolve
around Psychoeducation and Realistic Thinking where participants are given an
overview of what SAD is all about and the relationship between thoughts, feelings,
and behaviors. Emphasis is placed on increased awareness that thoughts drive
feelings, and it is the anticipation of negative outcomes that drives the anxiety. The
goal is for students to identify the negative thoughts and to practice developing the
necessary skills to replace these negative thoughts with more positive “realistic”
ways of thinking (M arisa Warner, Fisher, Shrout, Rathor, & Klein, 2007).
Social skills sessions focus on developing skills in four key areas: (1) Initiating
Conversations, (2) M aintaining Conversations and Establishing Friendships, (3)
Listening and Remembering, and (4) Assertiveness. Concepts are introduced and
students are given opportunities to practice each skill within the group session. The
first session involves topics to initiate conversations with others and the
importance of attending to nonverbal communication. Throughout the training
sessions, students are given feedback regarding their performance and also
provide feedback for their peers.
There are five Exposure sessions referred to as “Facing your Fears”. During these
sessions, participants are introduced to the role that avoidance plays in maintaining
anxiety and presented with information regarding an exposure technique to assist in
reducing the anxiety. Students are assisted in the development of a personal fear
hierarchy by rank ordering ten anxiety-provoking situations using a scale called the
subjective units of distress scale assigning ratings from 1 to 100 (1 = very calm to
100 = extreme distress) for each situation on the hierarchy ladder. Individual
sessions involve practicing these exposure trials and mastering their fear hierarchy.
The object is to reduce the fear by at least 50% after each exposure. A final group
session focuses on Relapse and Prevention.
Scaini, Belotti, Ogliari, and Battaglia (2016) investigated the impact of specific
variables on therapeutic outcome, including the magnitude and duration of CBT.
Results indicated that the higher number of CBT sessions and the inclusion of
social skills training exercises were variables that enhanced the positive outcomes
of CBT for children and adolescents with SADs.
Post-Case Questions
1. It is possible to explain SAD from a number of theoretical positions and case
formulations. Develop a case formulation to explain the development of SAD
from a cognitive and behavioral perspective.
2. Sandra’s therapist is using CBT charts as homework assignments to assist
Sandra in better identifying the negative feelings that are causing her anxious
responses to social situations, and to help her identify “realistic” thoughts that
could apply in this situation.An example of the CBT chart and Sandra’s
responses follows: Develop your goal and treatment plan for the session with
Sandra based on what she has given you as her homework assignment.
3. Individuals who experience various anxieties, fears, and phobias can benefit
from the use of exposure techniques such as systematic desensitization and
exposure and response prevention based on behavioral methods that
gradually expose the individual to the fearful situation/object while the individual
executes relaxation responses (e.g., deep breathing, mediation) that counteract
fearful responses. David is 15 years old and he is experiencing serious
problems resulting from a SAD. He is fearful of approaching other students at
school and his parents are very concerned because he is making excuses to
avoid social situations. Assist David to develop a fear hierarchy to increase his
ability to start conversations and engage with other students in his school.
4. In Chapter 1, the Introduction, case formulation from a biological perspective
discusses several implications for malfunction of GABA and cortisol production
in the etiology of anxiety disorders. Provide a case formulations for Sandra’s
SAD based on a biological perspective, including theories of behavioral
inhibition. In addition, provide a case formulation for Sandra from an attachment
perspective.
5. Sandra and her mother are two very different personality types. Develop a
case formulation from a parenting perspective that would discuss how
dynamics between these two distinct personality types might have a positive
and/or negative impact on Sandra’s disorder.
6. Based on information from theory and research regarding biological, social,
emotional, and cognitive development, explain why adolescence is a
particularly vulnerable time for the development of SAD.
7. Studies have noted that as high as 30%–40% of those with ADHD have a
comorbid anxiety disorder (Jarrett, 2013). However, stimulant medication, which
is the most common medication used for ADHD, has been found to be less
effective in children who also have an anxiety disorder (Blouin, M addeaux,
Firestone and Van Stralen, 2010), while not reducing and potentially increasing
the anxiety. Geller et al. (2007) found that atomoxetine (Strattera) did
effectively reduce both anxiety and ADHD symptoms in children with comorbid
ADHD and anxiety. Conduct a research investigation and provide a statement
supported by research regarding the impact of stimulant medication on
preexisting anxiety disorders in children with ADHD.
8. Suggested individual or group presentation activity: You have been invited to
provide feedback to the school regarding Sandra’s assessment. Prepare a
script for role-playing each of the player’s parts in the school meeting,
mentioned above. Who do you think should be attending the meeting? How
could each participant potentially contribute information to assist with
developing an intervention plan that would best meet Sandra’s needs?
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223.
5 INTRODUCTION TO PROBLEMS
OF MOOD: DEPRESSION AND
BIPOLAR DISORDERS
BIPOLAR DISORDERS
The DSM-5 (American Psychiatric Association [APA], 2013) has
made a major change regarding how bipolar disorders are to be
conceptualized relative to depressive disorders. With its focus on
presenting a continuum of mental illness based on developmental
onset and severity, the DSM-5 states that the rationale for the
placement of bipolar disorders as separate from depressive
disorders and between chapters on schizophrenia spectrum and
psychotic disorders and depressive disorders was based on the
need to recognize bipolar disorders “as a bridge between the two
diagnostic classes in terms of symptomatology, family history, and
genetics” (APA, 2013, p. 123). As such, the DSM-5 emphasizes
family history as “one of the strongest and most consistent risk
factors for bipolar disorders” with a “ten-fold increased risk” for the
disorder among adult relatives with bipolar I or bipolar II (APA,
2013, p. 130). Although, historically, bipolar I has been considered
to be the more serious variant of the disorder, the DSM questions
this assumption based on the increased recognition of the amount
of time that individuals with bipolar II are in a depressive state and
the high degree of impairments the disorder causes to their
functioning on the job or in social relationships resulting from
instability in mood.
Bipolar disorder has been considered by many to be a more
severe disorder than major depression based on reports of lifelong
recurrence and higher rates of comorbidity with other disorders,
such as anxiety and substance use disorders (Angst, 2007).
Bipolar disorder I is diagnosed when an individual meets criteria
for experiencing a manic episode which has been “preceded or
may be followed by a hypomanic episode or major depressive
episode” (p. 123), while Bipolar II is diagnosed if a hypomanic
episode follows or precedes a major depressive episode, and
there has never been a manic episode (pp. 132–133). In order to
improve the diagnostic reliability in the criteria, the DSM-5 has
expanded Criterion A for manic and hypomanic episodes so that in
addition to a distinct period of “abnormally and persistently
elevated, expansive or irritable mood,” the episode also includes
“persistently increased goal-directed activity or energy,” lasting for
at least 1 week (manic episode) or 4 consecutive days (hypomanic
episode) (APA, 2013, p. 124). Other criteria remain unchanged from
the previous DSM and include three or more symptoms (four if the
mood is only irritable), from Criterion B, including grandiosity
(inflated self-esteem); decreased sleep; pressured speech; flight of
ideas; distractibility; increased goal-directed activity; and excessive
engagement in high-risk activities. While mania is associated with
severe impairment, hypomania does not cause marked impairment.
Developmentally, bipolar disorder is difficult to diagnose in children
and adolescents since many of the above symptoms overlap with
symptoms for other disorders, such as attention
deficit/hyperactivity disorder (ADHD), including distractibility, racing
thoughts, pressured speech, and less need for sleep. Since
children and adolescents also often manifest symptoms of
depression as irritability, the DSM warns that a diagnosis of bipolar
should only be given in cases where there is an identifiable “timebased” episode of irritability marking the onset of Criterion B
symptoms. In addition, there are high rates of comorbidity with
anxiety disorders (75% of those with bipolar disorder also have
anxiety disorders), ADHD, and the disruptive behavior disorders
adding to the complexity of this diagnosis (APA, 2013, p. 132).
In addition to the increased emphasis on increased energy
(activity) as well as mood for Criterion A symptoms, the DSM has
also added a number of specifiers that can assist in clarifying the
nature of the bipolar disorder, such as those accompanied by
symptoms of anxious distress (restless, keyed up); rapid cycling
(4 mood episodes within 12 months); or melancholic features
(loss of pressure and emotional reactivity, guilt, weight loss,
depression).
Because symptoms of bipolar disorders can manifest in conditions
that do not meet all criteria for bipolar I, II, or cyclothymic
disorder, or mimic bipolar disorder, especially in children, the DSM
has a number of possible alternatives for diagnosis, including
disruptive mood dysregulation disorder (DM DD) (see
depressive disorders below for an explanation), and other specified
bipolar and related disorders, which includes depressive episodes
with short-duration hypomania included in Section III, “Conditions
for Further Study.” The DSM-5 suggests that future study be
conducted to determine whether this new category should be
established for individuals who experience at least one major
depressive disorder (M DD) and at least two episodes of
hypomania, lasting 2–3 days. These hypomanic episodes would
meet all criteria for a hypomanic episode, however would be
shorter than the required 4-day duration (p. 787).
DEPRESSIVE DISORDERS
The chapter on depressive disorders (previously called “mood
disorders”) has incorporated a number of changes in addition to
removing the bipolar disorders from the chapter and establishing a
unique section for these disorders separate from what would be
considered as “unipolar” versus bipolar disorders. Included within
this chapter are the original disorders from the previous edition,
including MDD, persistent depressive disorder (previously known
as dysthymia), and depressive disorders that are
medication/substance-induced and those related to medical
conditions. New to the chapter are premenstrual dysphoric
disorder, which has been moved from Appendix B (“Criteria Sets
and Axes Provided for Further Study” of the DSM-IV), and a new
category of depressive disorders, disruptive mood dysregulation
disorder (DMDD), which was created to address concerns of
overdiagnosis of bipolar disorder in children up to 18 years of age.
After a discussion of the criteria for a major depressive episode,
criteria for DM DD will be addressed.
MDD: Individuals are diagnosed with M DD if they experience a
major depressive episode which requires five or more symptoms
evident during the same 2-week period, with at least one symptom
meeting criteria for (1) depressed mood (which may appear as
irritability in children and adolescents) or (2) loss of interest or
pleasure. The other 7 symptoms of major depressive episode
include significant weight loss/gain (failure to meet expected weight
for children); nightly, insomnia, or hypersomnia; psychomotor
agitation or retardation; feelings of worthlessness, guilt; problems in
concentration/decision-making; and recurrent suicidal ideation
(APA, 2013, p. 161). Although the previous version of the DSM
excluded bereavement (of 2 months or less) from the criteria for
M DD, the DSM-5 omits this exclusion, due to the recognition that
bereavement can last up to 2 years, and the degree to which
bereavement can act as a significant psychosocial stressor.
Although depression can occur at any age, the prevalence rates
increase significantly in adolescence with the onset of puberty.
Persistent depressive disorder (previously known as dysthymia):
The category of persistent depressive disorder replaces the
disorder of dysthymia and chronic M DD in the DSM-IV. Criteria for
persistent depressive disorder differ from criteria for M DD in two
important ways, including the duration of the disorder and the
number of symptoms required. For a diagnosis of persistent
depressive disorder, depressed mood (irritability in children and
adolescence) must be evident for most days (with no lapse from
depressive symptoms for longer than 2 months) over the course of
2 years for adults (1 year for children and adolescents), with
evidence of an additional two symptoms from a list of six possible
symptoms, including problems of appetite (overeating or
undereating); insomnia or hypersomnia; fatigue; low self-esteem;
poor concentration/decision-making; and feelings of hopelessness.
The DSM-5 notes that if symptoms meet criteria for M DD over the
course of 2 years (either during or preceding persistent depressive
disorder), then a diagnosis of persistent depressive disorder, as
well as M DD should be applied. The DSM-5 also includes
specifiers for M DD and persistent depressive disorder, including
the addition of symptoms of anxious distress and melancholic
features.
DMDD: There has been increased concern regarding the suitability
of criteria for bipolar disorder for children and youth, especially in
view of the rapidly increasing rates of diagnosis of the disorder in
children. In their study of prevalence rates for bipolar disorder
among children, youth, and adults in 1996 compared with rates in
2004, Brotman et al. (2006) found alarmingly high increases in
prevalence rates between these two time periods for children
(53.2% increase) and teens (58.5% increase) relative to adults
(3.5% increase). Since symptoms of pediatric bipolar disorder often
are accompanied by patterns of volatile behaviors and low
frustration tolerance, also seen in disruptive behavior disorders,
such as oppositional defiant disorder (ODD) and attention
disorders, such as ADHD combined presentation, some
researchers have suggested that the use of “irritability” as a marker
for bipolar has been confused with bouts of “episodic irritability”
associated with depression and more “chronic” forms of irritability
associated with ODD, ADHD, and some variants of autism
spectrum disorders (Geller et al., 2000; Leibenluft, Charney,
Towbin, Bhangoo, & Pine, 2003). In order to address these
concerns and the resulting overdiagnosis of bipolar disorder in
children and youth, researchers have suggested the use of the
term severe mood dysregulation syndrome to identify children
who exhibit these severe forms of irritability. In the DSM-5, DM DD
was included in this chapter to address the above issues and
concerns and to assist in distinguishing children who demonstrate
severe and persistent irritability “relative to children who present
with classic (e.g., episodic) bipolar disorder” (APA, 2013, p. 157).
However, given the close association between symptoms of ODD
and DM DD, the diagnosis of DM DD remains controversial (see
case 11, Scott M ichaels, and case 19, M atthew M organ).
Criteria for DM DD require that the disorder be present for at least 1
year, occur in more than one setting, and include two major criteria,
involving Criterion A, severe temper outbursts (verbal or physical)
that are significantly beyond what would be expected
(intensity/duration) given the situation, and Criterion D, a
predominant mood of severe irritability and or anger that is evident
between tantrums. Tantrums must be inconsistent with
developmental level (Criterion B) and occur three or more times
weekly (Criterion C). The diagnosis is reserved for children and
youth between 6 and 18 years of age, with onset before 10 years
of age. It is important to consider children in this category, if and
only if the severe irritable or angry mood is present “most of the
day, nearly every day.” The diagnosis cannot accompany a
diagnosis of ODD, intermittent explosive disorder or bipolar
disorder, but can be comorbid with M DD, ADHD, conduct disorder,
and substance use disorders. Individuals who meet criteria for
ODD and DM DD are given a diagnosis of DM DD (APA, 2013, p.
156).
Differential Diagnosis
Because of the nature of DM DD, it is important to be able to
distinguish this disorder from others that will present with similar
features, including bipolar disorder, ODD, ADHD, M DD, the anxiety
disorders, and autism spectrum disorder.
In their study of bipolar disorder in preschoolers and young schoolage children, Wilens et al. (2003) described manic episodes as
those that demonstrated abnormally high levels of “giddy, goofy,
drunk-like” or severely irritable mood and temper outbursts (p. 497),
in the presence of at least three other symptoms, from the
following list: grandiosity, insomnia, pressured speech, flight of
ideas, distractibility, extreme goal-directed behavior, and excessive
pleasurable activities (e.g., masturbation) (p. 497). In making a
differential diagnosis between DM DD and bipolar disorder,
Youngstrom, Findling, Youngstrom, and Calabrese (2005)
emphasize that it is important to not define bipolar disorder by
symptoms such as “distractibility, impulsivity, concentration
problems, and motor agitation” that overlap with other disorders, but
to focus on those symptoms which can assist in making a
differential diagnosis associated with bipolar disorder, namely,
grandiosity, hypersexuality, pressured speech, and racing thoughts
characteristic of mania. Furthermore, bipolar disorder should be
considered as an episodic disorder, and as such, irritable mood
states should be identifiable as episodes distinct from day to day
functioning, and in the company of other bipolar symptoms (such as
grandiosity and elevated/expansive mood), as opposed to DM DD
where irritability/anger is persistent over many months (at least 1
year). When considering DM DD and ODD, Wozniak et al. (2005)
suggest that irritability associated with ODD can best be described
as the type of irritability associated with being easily annoyed,
which can result in loss of temper. Although children who meet
criteria for DM DD will also exhibit symptoms of ODD, only
approximately 15% of those with ODD would meet criteria for
DM DD (APA, 2013). However, a recent study by M ayes,
Waxmonsky, Calhoun, and Bixler (2016) found significant overlap in
symptoms between the two disorders, with 92% of children with
DM DD exhibiting symptoms of ODD and 66% of children with ODD
demonstrating symptoms of DM DD which lead researchers to
suggest the ICD-11 deviate from the DSM by considering DM DD
as a type of ODD (specifier) rather than a different disorder.
Irritability associated with M DD can best be associated with the
type of irritability that one relates to a mad/or cranky mood that
would be evident most of the day (Wozniak et al., 2005). These
descriptors can assist in distinguishing episodic or milder forms of
irritability from the severe form of pervasive irritability and angry
outbursts associated with DM DD.
REFERENCES
American Psychiatric Association. (2013). Diagnostic and statistical
manual of mental disorders-5. Washington, DC: Author.
Angst, J. (2007). The bipolar spectrum. British Journal of
Psychiatry, 190, 189–191.
Brotman, M . A., Schmajuk, M ., Rich, B. A., Dickstein, D., Guyer, A.
E., & Costello, E. J. (2006). Prevalence, clinical correlates and
longitudinal course of severe mood dysregulation in children.
Biological Psychiatry, 60, 991–997.
Geller, B., Zimerman, B., Williams, M ., Bolhofner, K., Craney, J. L., &
Delbello, M . P. (2000). Diagnostic characteristics of 93 cases of a
prepubertal and early adolescent bipolar disorder phenotype by
gender, puberty and comorbid attention deficit hyperactivity
disorder. Journal of Child and Adolescent Psychopharmacology,
10, 157–164.
Leibenluft, E., Charney, D. S., Towbin, K. E., Bhangoo, R. K., &
Pine, D. S. (2003). Defining clinical phenotypes of juvenile mania.
American Journal of Psychiatry, 160, 430–437.
M ayes, S. D., Waxmonsky, J. D., Calhoun, S. L., & Bixler, E. O.
(2016). Disruptive mood dysregulation disorder symptoms and
association with oppositional defiant and other disorders in a
general population child sample. Journal of Child and Adolescent
Psychopharmacology, 26(2), 101–106.
Wilens, T., Biederman, J., Forkner, P., Ditterline, J., M orris, M ., &
M oore, H. (2003). Patterns of comorbidity and dysfunction in
clinically referred preschool and school-age children with bipolar
disorder. Journal of Child and Adolescent Psychopharmacology,
13, 495–505.
Wozniak, J., Biederman, J., Kwon, A., M ick, E., Faraone, S., &
Orlovsky, K. (2005). How cardinal are cardinal symptoms in
pediatric bipolar disorder? An examination of clinical correlates.
Biological Psychiatry, 58, 583–588.
Youngstrom, E. A., Findling, R., Youngstrom, J. K., & Calabrese, J.
R. (2005). Toward an evidence-based assessment of pediatric
bipolar disorder. Journal of Clinical Child and Adolescent
Psychology, 34, 433–448.
CASE 17 MARIA SILVA : ANXIOUS AND SAD
OR DEPRESSION BEREAVEMENT
M aria is an 11-year-old girl who is currently enrolled in the 6th grade. Although
M aria does take medication for thyroid issues, which is monitored by her
pediatrician, her mother could not remember the name of the medication during the
intake. In addition, M aria takes iron and B12 supplements. M aria was referred for
assessment by her pediatrician who had M aria and her mother complete a number
of questionnaires, and their responses (a score of 9 on the Public Health
Questionnaire [PHQ] and a score of 14 on the generalized anxiety scale [GAD-7])
suggested a diagnosis of ICD-10, F39 unspecified mood (affective) disorder.
Presenting complaints included fatigue, loss of appetite, loss of interest in activities,
lack of motivation, and anxiety.
DEVELOPMENTAL HISTORY/FAMILY BACKGROUND
M aria’s mother (Heather) was not sure about her family background (her maiden
name was Adams) except that her parents had lived in New York (where she was
born) all their lives. On the other hand, M aria’s father (David) was very aware of his
family heritage and very proud that his grandparents immigrated to the United
States from Portugal and settled in Pennsylvania where both his parents continue
to reside. M aria’s mother stated that she met M aria’s father in Florida after they
both moved here from the North and were introduced by friends. Her husband
works as a project manager for a large corporation and she is employed in fashion
design for a Florida-based retailer.
M aria has one older brother, Steve who is 14 years of age, and a younger sister,
Anna who is 10. M aria’s mother mentioned that M aria gets along well with her
siblings and that neither of the other children exhibits any of the difficulties that
M aria presents, although M aria tends to act like a parent to her younger sister and
is very protective of her. M aria’s mother provided the following information regarding
her developmental history. M aria weighed 7 pounds 2 ounces at birth and the
pregnancy, labor, and delivery were all normal. Early years were normal with the
exception that compared to her siblings, M aria had more difficulty being calmed
when upset. She experienced night terrors at an early age and would scream in the
night and not recall any difficulties or problems when she would eventually wake up.
However, fear of the dark often resulted in M aria sleeping with her mother or having
her mother sleep in her bed to comfort her during the evening when she was feeling
unsettled. Her developmental milestones were ahead of schedule. M aria walked at
10 months and was using simple phrases to communicate at 7 months of age.
In the early school years, M aria experienced some difficulties with separation
anxiety and was anxious and fearful of attending school. Often her mother would
have to take her to the school and wait with her to ensure that she did not try to
run back to the car. Her mother said that her biggest fear then was similar to what it
is now, which is not doing well and disappointing others.
M aria was mostly reticent during the intake interview but did respond to specific
questions. When asked what was most difficult for her, she mentioned that she has
problems following along when the teacher is explaining something. She said it is
easy to get distracted and forget about what she was doing or thinking at the time.
Her mother noted that she had asked to be homeschooled, but given her
tendencies to withdraw, her mother did not support her request.
The family has noted significant problems in the past two years with the death of
close family members. Within the past 2 years, M aria has lost both grandparents
who died within a year of each other. In addition, her uncle passed away just last
month. M aria’s mother said that they were very close to the grandparents and that
Heather tended to work out of an office in their home so that she could provide
daily care for both her parents. M aria would visit often since their home was very
near her school. Heather noted that she had just sold her parents home a month
ago and that the need to be involved in the sale of the home and furnishings took
its toll on all of them. She said they are just now in the grieving process. Three
months ago, M aria and her father were in a severe car crash on the way to school
and both were taken by ambulance to the hospital. M aria suffered from trauma to
her neck and ribs and her father is still receiving treatment for his injuries sustained
in the crash.
When asked about any specific concerns that she was having at this time, M aria
stated “the fear of death and worry about people dying. I am afraid of losing special
people and wonder about the after-life.”
REASON FOR REFERRAL
M aria was referred for assessment by her pediatrician due to concerns in areas of
depression and anxiety. M aria’s mother noted that although there had been issues
in the past, M aria’s symptoms of depression and anxiety had worsened in the past
year and that she was having increasing difficulty concentrating on school work and
completing tasks that she used to be very capable of.
ASSESSMENT RESULTS
Information regarding specific assessment instruments and guidelines to the
interpretation of standard scores and T scores can be found in Appendix C.
M aria was cooperative throughout the assessment and results are considered to
be a valid index of current functioning levels. M aria’s overall score on the WISC-V
was a Full Scale Score of 112 (106–117), which is in the High Average Range, at
the 79th percentile. However, in M aria’s case, the General Ability Index (GAI) was
the better indicator of overall intelligence since it is less influenced by scores from
Working M emory and Processing Speed. Since Working M emory was one of
M aria’s weakest areas of performance, the GAI of 118 (112–123) in the High
Average Range at the 88th percentile was significantly higher than her Full Scale IQ
of 112 and is the best indicator of overall intelligence. Scores were consistently in
the High Average Range across all areas except Working M emory (standard score
of 100), which includes scores for auditory (digit recall) and visual (picture recall)
memory. However, when scores were tabulated for just the auditory working
memory index (AWM I), her standard score dropped to 89, which was significantly
below what would be anticipated given her GAI of 118. Since M aria had complained
of problems following along with instructions, it is likely that poor concentration for
auditory information may be related to symptoms associated with depression and
anxiety. However, her profile also suggests that she meets criteria for a diagnosis
of a specific learning disorder in the area of auditory working memory,
suggesting that she will require a distraction-free environment in order to perform to
the best of her ability when doing tasks that require mental problem-solving or
mental manipulation of information. In addition, her score in the area of M ath
Fluency was well below what would be anticipated given her GAI and current grade
placement, resulting in a diagnosis of a specific learning disorder in mathematics
(fluency). This would suggest that she would require more time to complete math
tests than would be normally anticipated.
In order to “rule out or rule in” attention problems being related to a disorder such as
attention deficit/hyperactivity disorder (ADHD), the Conners Continuous
Performance Test (CPT-3) was completed by M aria and the Conners ADHD Rating
Scales were completed by M aria, her mother, and teacher. Results of the CPT-3
revealed only one atypical T score which is associated with minimal likelihood of
ADHD, while the Conners Rating Scales revealed all areas to be within the normal
ranges (T scores 40–60) across all three raters, ruling out a potential diagnosis of
ADHD and inattentive presentation.
The Achenbach System of Empirically Based Assessment (ASEBA) was completed
by M aria (YSR), her mother (CBCL), and teacher (TRF). There was agreement
among all raters that M aria demonstrates symptoms of withdrawn/depressed (little
she enjoys; rather be alone; won’t talk; secretive; shy/timid; lacks energy; sad;
withdrawn) and anxious/depressed behavior (cries a lot; has many fears; fears doing
badly; feels she must be perfect; feels unloved; feels worthless; fearful; selfconscious; and tendencies to worry a lot). Both categories of responses were in the
*Elevated to ***Clinical Ranges. M aria and her mother also rated
somatic/complaints (nightmares; overtired; feeling dizzy; aches, headaches) and
thought problems (can’t get her mind off thoughts; repeats acts; stores things;
trouble sleeping) in the *Elevated to **At-Risk Range, while M aria endorsed social
problems (lonely; feels others are out to get her; accident prone, and prefers
younger) in the **At-Risk Range. (See Appendix C, Guidelines for the Interpretation
of T scores, to better understand the difference between Elevated, At Risk and
Clinical Ranges of behavior rating scales.)
M aria also completed self-rating scales for Depression (Child Depression Inventory
[CDI-2]) and Anxiety (Revised Chile Manifest Anxiety Scale [RCMAS]) and the
General Anxiety Scale (GAD-7). On the CDI-2, M aria’s scores on all scales were
above normal with the majority in the Very Elevated Range, including Total
Depression, Emotional Problems, Negative M ood/Physical Symptoms, Functional
Problems, and Interpersonal Problems. Her score on the Negative Self Esteem
scale was in the Elevated Range, while her score for Ineffectiveness was in the
High Average Range. The items that were indicative of Emotional Problems
included sad many times; don’t like myself; feel like crying everyday; feel cranky all
the time; trouble sleeping every night; tired all the time; loss of appetite; problems
falling asleep. Items associated with Interpersonal Problems included not sure if I
am important to my family; do not want to be with people at all; feel alone many
times; have some friends but wish I had more.
Revised Child Manifest Anxiety Scale (RCMAS) is a 37-item scale that evaluates
anxious symptoms in a number of different areas. M aria’s overall score for anxiety
was in the Clinical Range with a T score of 69. Symptoms of physiological anxiety
(trouble making up her mind; hard to get to sleep at night; often feel sick to her
stomach; hands feel sweaty); worry/oversensitivity (get nervous when things do
not go the right way for me; worry a lot of the time; worry about what my parents will
say to me); and social concerns/concentration problems (others seem to do
things easier than me; feel others do not like the way I do things; feel alone when
people are with me) were all elevated. The General Anxiety Disorder &-item Scale
(GAD-7) looks at the degree to which an individual has experienced difficulty in the
past two weeks, in meeting challenges in seven different areas. The levels of
difficulty are rated from 0 (Not at all) to 3 (Nearly every day). M aria’s score on the
GAD-7 was 17, which placed her in the level of Severe Anxiety. Situations which
were encountered nearly every day included worrying too much about different
things; trouble relaxing; being so restless that it is hard to sit still; and feeling afraid
as if something awful might happen.
In addition to the above specific learning disorders, M aria also scored very high on
measures of depression and anxiety, resulting in the following diagnoses. M aria is
diagnosed with symptoms of depression; M aria met criteria for other specified
depressive disorder with the rationale being insufficient information regarding
length of time symptoms have been present. Given her developmental history, her
mother did mention early signs of depressed symptoms, but it is not clear whether
these symptoms would have met criteria for a diagnosis. However, her extended
grief over the death of her grandparents has continued to be demonstrated in high
levels of symptoms of depression, especially physiological responses to
distressing situations and vegetative symptoms (disturbed sleep, loss of appetite,
fatigue, loss of interest or pleasure).
M aria’s tendency to dwell on negative thoughts also results in a pervasive
symptoms of worry and an inability to control the worry which meet criteria for
generalized anxiety disorder (GAD). Symptoms of depression and anxiety have
impacted her negative self-esteem, increasing her tendencies to worry about being
successful in school and her tendencies to withdraw from social contact.
ISSUES, TRENDS, AND TREATMENT
ALTERNATIVES
Comorbidity of Depression and Anxiety
Comorbidity refers to the presence of two coexisting separate disorders in the
same individual. Approximately, 10%–12% of children in the United States will meet
criteria for a diagnosis of disorders of depression and/or anxiety (Beesdo, Knappe,
& Pine, 2009; Garber & Weersing, 2010; M erikangas, Nakamura, & Kessler, 2009),
both of which have been associated with significant impairment in functioning
(Kendall et al., 2010). With respect to depressive disorders, Biederman, Faraone,
and M ick (1995) reported that in excess of 95% of children with a major depressive
disorder (M DD) also met criteria for another disorder, the most common of which
was an anxiety disorder. For youth who meet criteria for depressive disorder,
anxiety disorders are the most common comorbid condition, from 15% to 75% of
those with depression also meeting criteria for an anxiety disorder (Avenevoli,
Stolar, Li, Dierker, & M erikangas, 2001; Yorbik, Birmaher, Axelson, Williamson, &
Ryan, 2004) and 10%–15% of those with anxiety also meeting criteria for a
depressive disorder (Costello, M ustillo, Erkanli, Keeler, & Angold, 2003). However,
lower rates for anxiety may have resulted from earlier research findings focusing
more on anxiety, which has an earlier onset than depression, and may have missed
underlying depressive symptoms in this population (Van Voorhees, M elkonian,
M arko, Humensky, & Fogel, 2010).
Based on their extensive literature review, Cummings, Caporino, and Kendall (2014)
discuss a number of theoretical models that could be used to explain the
comorbidity between depression and anxiety including the tripartite model
originally proposed by Clark and Watson (1991), which suggests that although
anxiety is unique in a factor related to physiological hyperarousal (PH) and
depression is unique in the factor of low positive affectivity (PA), they both share a
common core feature of negative affectivity (NA), which is shared in responses of
anxiety and depression. However, more recent research with children suggests that
this may not be the case in younger children. Bushman and Crowley (2010)
investigated the role of low PA and NA in responses to anxiety and depression in
children in third to sixth grades and found that in younger children PA and NA were
less distinguishable; however, older children tended to see PA and NA as two
unique factors. See also positive affectivity, negative affectivity, and physiological
hyperarousal.
Another model discussed is based on the behavioral inhibition system (BAS) and
the behavioral activation system (BIS) proposed by Gray (1991). While the BIS is
related to anxiety and tendencies to withdraw (inhibited), the BAS is associated
with tendencies to act impulsively (undercontrolled). Studies have since linked BIS
sensitivity to anxiety (Campbell-Sills, Liverant, & Brown, 2004), while BAS
sensitivity has been linked to depression (Kasch, Rottenberg, Arnow, & Gottlib,
2002).
Taking into consideration the various models that have been proposed to account
for the link between depression and anxiety, Cummings et al. (2014) suggest three
pathways that can be used to explain the co-occurrence of depression and anxiety,
beyond genetic links, including Pathway 1, individuals that have a predisposition to
anxiety be it environmental, temperamental, or biological; Pathway 2, individuals that
share a predisposition to anxiety and depression; and Pathway 3, individuals who
have a predisposition to depression. Individuals who develop depression (distress)
via Pathway 1 do so as a result of anxiety impairment leading to enhanced
tendencies to perceive conditions based on negative affectivity. Individuals with
comorbid anxiety and depression explained by Pathway 2 often will demonstrate
GAD with a moderate level of depression with symptoms of both overlapping in
feelings of worry and anxious/distress. Finally, Pathway 3 describes individuals who
are primarily depressed but who also develop anxious symptoms due to fears in
areas vulnerable to being judged or evaluated by others (e.g., social anxiety
disorder, GAD).
With respect to the comorbidity of GAD and M DD, 62% of individuals diagnosed
with GAD will have comorbid M DD. The presence of both disorders is also
associated with higher rates of poorer treatment outcomes and treatment
resistance (van Balkom et al., 2008).
Depression and Bereavement
Since M aria and her family were responding to a situation of bereavement of the
loss of both grandparents and an uncle within the two years prior to intake, it is
important to discuss the role of grief in symptoms of depression. In the previous
version of the DSM (DSM-IV-TR, APA, 2000), the topic of bereavement was listed
at the end of the manual in a section titled “Other Conditions That M ay Be a Focus
of Clinical Attention.” In discussing criteria for mood disorders, the DSM-IV-TR (APA,
2000) stated that “even if depressive symptoms are of sufficient duration and
number to meet criteria for a M ajor Depressive Episode, they should be attributed
to Bereavement rather than to a M ajor Depressive Episode, unless they persist for
more than 2 months or include marked functional impairment, morbid preoccupation
with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor
retardation” (p. 326). Furthermore, in distinguishing bereavement from adjustment
disorder, the DSM -IV-TR stated that “Bereavement is generally diagnosed instead
of Adjustment Disorder when the reaction is an expectable response to the death
of a loved one. The diagnosis of Adjustment Disorder may be appropriate when the
reaction is in excess of, or more prolonged than, what would be expected” (p. 626).
According to DSM-5 (APA, 2013), there are two ways for clinicians to address the
topic of bereavement: individuals can be given the diagnostic label of F43.8 for
Other Specified Trauma and Stressor Related Disorder with the specifier of
persistent bereavement disorder, or individuals can elect the category of Persistent
Complex Bereavement Disorder with proposed category criteria, which appears at
the end of the DSM-V in a section titled “Conditions for Further Study.” In this
section, suggested criteria for future consideration of persistent complex
bereavement disorder are provided for symptoms that have persisted for 12
months after the death (6 months for children), including persistent longing for the
loved one; intense sorrow and emotional pain; preoccupation with the deceased;
and preoccupation with how the individual died (which may appear through themes
of play, in children). In addition, the individual must experience 6 additional
symptoms from categories of reactive distress to death (difficulty accepting the
death; disbelief/emotional numbness; bitterness/anger; avoidance of reminders)
and social/identity disruption (desire to die to be with the deceased; problems
trusting others; feeling detached from others; feeling life is empty; confusion about
one’s role in life; reluctance to pursue interests since the loss). According to the
DSM-5 (APA, 2013), the disorder is more common in females than males and
includes potential for “increased risk for social identity disorder and risk for
depression …in older children and adolescents” (p. 791). Furthermore, while
depressive disorders and persistent complex bereavement disorder “both share
depressed mood… the latter is characterized by a focus on loss” (p. 792).
However, as outlined in their review of the literature on bereavement in children and
youth, Kaplow, Layne, Pynoos, Cohen, and Lieberman (2012) emphasize that the
DSM-V criteria for these disorders of bereavement do not include sufficient
information on how these criteria might be expressed at different developmental
stages. Based on concepts of grief emanating from theories of “complicated grief,”
qualitative differences in degree of grief responses, and “prolonged grief,” which
stresses the length of time/duration of the grief responses, Kaplow and colleagues
stress that the DSM -V criteria for bereavement lack the necessary consideration of
essential developmental and environmental factors that might contribute to
increasing or decreasing these symptom presentations in children. For example, if a
caregiver cannot manage their own grief responses to the loss of a significant other
(be it spouse, parent, sibling, or child), that could have significant impact on how the
child is able to manage their mourning without caregiver support. For this reason,
Kaplow et al. (2012) suggest that under such circumstances, the diagnosis of an
adjustment disorder with persistent complex bereavement disorder might be the
most appropriate diagnosis for children and adolescents.
Kaplow et al. (2012) list a number of common reactions to bereavement evident in
children in the first two years after a death, including elevations in feelings of
depression/dissatisfaction, irritability, anxiety (generalized and separation), somatic
complaints, behavioral problems, and social withdrawal. Approximately, 5%–10% of
those who experience child bereavement will evidence clinically significant
psychiatric symptoms (Dowdney, 2000). However, an important step in being able
to differentiate between positive adjustment and maladjustment in bereaved
children and adolescents is an understanding of normal responses to grief at
different developmental levels. Green and Connolly (2009) present a list of trends in
how children conceptualize death at various developmental levels, themes that
might be evident in play, and manifestations in bereavement (p. 86). A summary of
that information is presented in Table 17.1.
Table 17.1
TREATMENT ALTERNATIVES: COMORBID ANXIETY
AND DEPRESSION
Psychotherapeutic Approaches
In their extensive review of the literature of studies involving comorbid depression
and GAD, Coplan, Aaronson, Panthangi, and Kim (2015) describe the results of the
studies that used a variety of therapeutic models. Studies that focused on
emotional dysregulation and the acceptance models emphasized the importance of
the concept of exposure on changing the underlying emotional experience, while
studies that supported the cognitive behavioral therapy (CBT) and intolerance
models primarily addressed faulty cognitions that supported the development of
worries. Proponents of the behavior activation model emphasized behavior over
cognitive restructuring (CR), while those supportive of the interpersonal therapy
model focused on relationship behaviors exclusive of the cognitive components
accompanying the actions. Based on their review, Coplan et al. (2015) suggest that
therapeutic programs that employed the behavioral activation model based on the
work of Lewinsohn, Steinmetz, Larson, and Franklin (1981) revealed the most
consistent positive outcomes. This approach which is summarized in the Glossary
is based on the theory that individuals who are depressed have restricted access
to positive events which further increases their negative mood state. In these
cases, emphasis on activities such as event scheduling can have a positive impact
on mood. However, they also suggest that the most notable similarities for all the
models they discussed in their review included the following components:
psychoeducation, homework, improving problem orientation by CR, progressive
muscle relaxation exercises, and exposure.
Chu, Colognori, Weissman, and Bannon (2009) adapted a behavioral activation
format for group administration, group behavioral activation therapy for 7th and 8th
grade students with anxiety and depression, and demonstrated the positive impact
of the program which could be implemented in a school setting. In a later version of
the program implementation, Chu et al. (2016) focused on antavoidance in vivo
exposure techniques and found that youth who participated in the program
administered in a school setting demonstrated higher rates of posttreatment
behavioral activation and fewer negative thoughts. Examining the effectiveness of
brief behavioral therapy, 8–12 weekly 45-minute sessions of behavioral therapy
administered in pediatric clinics by master’s-level clinicians, Weersing et al. (2017)
found that children and youth who participated in the program evidenced clinical
improvements on all measures of anxiety and depression, post treatment. One of
the main findings of this study was that contrary to many previous studies, the
positive effects were especially strong for children from Hispanic families, which the
researchers suggest may be very helpful in addressing any ethnic disparities noted
in previous research.
There are many CBT programs and manuals available for assisting children and
adolescents with anxiety and depressive disorders. CBT programs often include
various therapeutic techniques to assist in developing skills in areas related to
problem-solving, CR, exposure, pleasant activity scheduling, behavioral activation
(as noted above), and training in areas related to family communication skills,
assertiveness, and relaxation exercises (Garber & Weersing, 2010). Unlike the
primarily behavioral programs that focus exclusively on the generation of activity
and behavioral-based responses, CBT programs emphasize the need to integrate
thoughts, feelings, and behaviors to promote a more effective manner of coping
with distressing situations by perceiving and responding in a positive manner to
distressing events.
Psychopharmacological Treatment
In their review of the research regarding treatment for comorbid depression and
anxiety, M elton, Croarkin, Strawn, and M cclintock (2016) found that the majority of
studies presented findings on either anxiety or depression, but few addressed the
optimum treatment for individuals with comorbid depression and anxiety. However,
the authors suggest that selective serotonin reuptake inhibitors (SSRIs) such as
sertraline and fluvoxamine are effective in treating both pediatric depressive
disorders and anxiety disorders; however, they emphasize that research
demonstrates that the combination of an SSRI plus CBT is superior to
monotherapy.
Treatment Alternatives: Bereavement
Literature reviews of treatment for bereavement have been conducted using
primarily adult populations (Forte, Hill, Pazder, & Feudtner, 2004) or child and
adolescent populations (Currier, Holland, & Neimeyer, 2007; Rosner, Kruse, & Hagl,
2010). In their literature review of 74 studies on bereavement, Forte et al. (2004)
analyzed studies involving a number of different interventions including structured
therapeutic programs (cognitive behavioral, psychodynamic, psychoanalytical, or
interpersonal therapies), pharmacotherapy, and support groups. However, of the 74
studies reviewed, only 1 study included family counseling for children and only 5
studies included group counseling for children, as a form of intervention. Results of
the review were disappointing due to the lack of information on controlled clinical
trials. The researchers stated that no rigorous evidence-based recommendations
could be made regarding the programs reviewed with the exception for the positive
effects of the medical management of depression (pharmacological treatment).
Literature reviews involving child and adolescent populations have also been
disappointing. Currier, Holland, and Neimeyer (2007) reviewed the effectiveness of
bereavement interventions for children in 13 studies involving child and adolescent
populations (8 years of age to 13 years of age) using a number of different
interventions, with the vast majority using group therapy as the primary treatment
modality. Interventions were delivered in a number of different settings including
schools and other community-based organizations, participants’ homes, and once in
a weekend camp setting. All programs shared an emphasis on sharing
psychoeducational information and techniques to assist in developing better skills in
areas of coping with grief, understanding of death and grief, sharing information
about the loss, and grief-related feelings through verbal and graphic (e.g., drawing)
methods. Results of the review revealed that interventions with bereaved children
do not appear to produce a significant positive impact on child adjustment. Children
who participated in the programs did not benefit relative to those who did not
participate.
Rosner et al. (2010) reviewed 25 studies involving preventative or
psychotherapeutic interventions and found only small to moderate effects of
interventions with children who were displaying more symptoms and impairment
making better gains. Preventative interventions targeted individuals who were
asymptomatic (displaying normal responses to grief) or symptomatic and were
primarily based on theories emanating from attachment theory, psychodynamic, and
expressive art therapy and included counseling, music therapy, psychoeducation,
and techniques designed to normalize responses to bereavement through social
sharing. Psychotherapeutic interventions included targeted individuals who were
symptomatic and included psychoeducation and cognitive behavioral music therapy.
All interventions reviewed primarily involved group and/or individuals and family
members.
Overall reviews suggest that more rigorous research is needed to provide a better
sense of direction regarding the best treatment for children who are experiencing
difficulties due to excessive and prolonged grief and how to best intervene given
the child’s level of development and specific symptom presentation.
There have been several case presentations in the research as well as pilot
investigations in the area of grief/bereavement interventions. Some of the most
recent intervention programs include the following play/expressive techniques:
music-based bereavement therapy for child groups (Hilliard, 2001); music therapy
and songwriting in bereavement therapy for children and adolescents (Dalton &
Krout, 2005); Jungian family sand play for bereavement in children (Green &
Connolly, 2009); and use of play/expressive therapies for bereavement in individual,
family, and group treatment (Webb