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Social and Psychological Adjustment Problems Among Primary School Children
Professor David Schwartz
University of Southern California
Childhood Adjustment Problems
I.
Purpose of talk
A.
To present and overview of problems related to children’s psychological and behavioral
functioning in school.
B.
Will focus particularly on psychological problems such a depression and anxiety, that are
often the focus of psychiatrists and clinical psychologists.
C.
But, because my focus is typically on children in schools, I’ll also spend some time talking
about other basic problems related to children’s social functioning with peers, and academic
adjustment.
D.
Because I am a Western trained psychologist, my talk will be guided largely from Western
settings, and from my own clinical experience with Western children.
E.
But, insofar as possible, I’ll try to comment a bit on what is known about children in Asian
settings.
II.
Child Psychopathology - some general issues
A.
Before I begin talking about specific sorts of problems, I want to make a few comments that
will apply generally to the issue of children’s adjustment in the classroom.
B.
One important point to consider, is that children are developing organisms. They undergo
constant change and psychological reorganization. The issues that are important and salient
for a child at one stage of development will can be irrelevant at a later stage.
1.
EXAMPLE: peer relationships are a central issue to a 14-year old boy, and a disorders
that impact on social functioning can have really negative implications. However, this
might not be the case for a three-year-old.
C.
We also need to keep in mind what is normative at each stage of development.
1.
EX: We might expect a 2-year-old to wet the bed at night, but we are concerned when
an 8-year-old does it.
D.
It also may be a mistake to assume that disorders look the same at different stages of
development.
1.
EXAMPLE: As we will discuss later today, irritability may be a more significant
component of depression in childhood than adolescence.
E.
The organization of psychopathology
1.
Finally, we need to keep in mind that children rarely exhibit problems in only one
domain of functioning.
2.
A child who is experiencing serious psychological or behavior problems, is likely to
have adjustment problems across domains.
3.
For example, a child who suffers from depression will also be likely to have
difficulties in school, with peers, and problems getting along with mom and dad.
4.
This can make intervention with children very complex.
III.
Internalizing vs. Externalizing Disorders
A.
As we get into talking about specific sorts of problems, one general distinction we’ll need to
make is between internalizing sorts of problems, and externalizing problems.
B.
C.
D.
E.
F.
IV.
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Internalizing problems are a set of difficulties that tend to be associated with underlying states
of sadness or anxiety. These problems tend to be associated with social withdrawal, decreased
activity level, and inhibited or fearful behavior.
When we discuss internalizing disorders, we’ll really be focusing primarily on depression and
anxiety.
Externalizing problems are a set of difficulties that are related more to impulsiveness and
anger. These are problems that are related to aggressive, disruptive, or antisocial behavior.
Today, we’ll be focusing primarily on conduct disorder and hyperactivity.
In American, and other Western settings, teachers and parents seem to be most concerned with
externalizing problems. However, there is some evidence that in, Asian settings, internalizing
difficulties may be more of an issue.
Organizational issues
A.
I’m going to start off talking about internalizing problems.
B.
First, I’ll describe disorders that involve depression and anxiety.
C.
After I finish talking about the disorders and their symptoms, I’ll talk a little bit about
intervention and therapy.
D.
Then, I’ll go on to talk about the externalizing disorders.
Internalizing Problems
V.
Depression in childhood
A.
We’ll begin by talking about Major Depressive Disorder, which is a serious but relatively
common disorder.
B.
The central feature of this disorder is, of course, depressed, blue, or sad mood.
C.
Depressed children are also characterized by other negative emotional states, most notably
guilt and hostility.
D.
Irritability can be a very important component of depression particular during childhood and
adolescence. Some depressed children may, in fact, display more irritability than sadness.
E.
As we’ll discuss in a few moments, depressed children may sometimes become involved in
aggressive or disruptive behavior.
VI.
Anhedonia
A.
An important component of mood difficulties is a problem called "Anhedonia." This is
basically the loss of ability to experience pleasure
B.
The child losses interest in capacity to enjoy activities that were once pleasurable.
C.
The child may complain of feeling boredom, and will show a general decrease in social
interaction and play.
D.
Anhedonia seems to be a more significant component of depression for adolescents and adults
than younger children, but it is still a problem.
E.
When a child talks about losing interest in his/her favorite games and activities, than I start to
get worried that the depression is serious.
VII.
Motivation
A.
Common complaint associated with depression is lethargy or loss of energy.
B.
The child may seem listless, tired, or under motivated.
C.
It is sometimes important to intervene early, because issues related to low energy may become
more serious over time.
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VIII.
Vegetative
A.
From a treatment perspectives, very problematic class of symptoms that often require
intervention with medication.
B.
Symptoms involve disruptions in functioning around organism’s basic survival needs in
regard to sleeping and eating.
1.
Loss of appetite or, less common, excessive appetite.
2.
Sleep difficulties
IX.
Schemata
A.
Children who are depressed, also tend to be characterized by particular forms of selfevaluation.
B.
They often have low self-esteem, and are overly focused on themes of failure and defeat.
C.
Also, hopelessness and helplessness. Beliefs that one can’t avoid negative outcomes
X.
Cognition
A.
Their thought thinking tends to be ruminative. That is, they get stuck on certain kinds of
thoughts and can’t seem to move on to think about other ideas.
B.
Excessive cognitive activity revolving self, ideation about suicide is common
C.
Intrusive thoughts that tend to revolve around themes of self-degradation.
XI.
Concentration problems
A.
If a child is spending most of his or her cognitive energy on rumination, we could imagine that
it might have an negative impact on other aspects of cognitive function.
B.
Not surprisingly, depressed children then to have difficulties with focus and concentration.
C.
They may be forgetful and have difficulty staying on task.
XII.
Other difficulties
A.
Earlier, I made the observation that children rarely experience difficulties in one domain, and
that adjustment problems in a particular area can be expected to detract from functioning in
multiple domains. That is clearly the case with depression.
B.
In fact, depressed children have problems in a number of areas.
C.
Of particular relevance for our audience today, depressed children often experience
difficulties in academic functioning.
D.
Because these children have low levels of energy, and problems with concentration and focus,
they don’t tend to do well in school.
XIII.
Aggression and Depression
A.
When I first got into this area, I was surprised to find that depressed children often tend to
have problems with aggression and other forms of disruptive behavior.
B.
This seems counter intuitive - we tend to think of depression as problem that is associated
with low energy and decreases in social interaction.
C.
But, in fact, depressed children often have problems with irritability, anger, and
impulsiveness.
D.
For these reasons, they may also exhibit off-task or hyperactive behavior in the classroom.
E.
In this case, it might be best to think of aggression as a indicator of other underlying
problems. In fact, children who have any kind of adjustment problem are likely to have
difficulties with aggression.
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XIV. Social Withdrawal
A.
Depressed children may also be suffer from a more withdrawn sort of behavior pattern.
B.
Recall, that there energy levels are often very low.
C.
If they are not interacting with peers in an aggressive manner, they tend to be quite
withdrawn, avoiding peers and remaining isolated.
XV.
Peer Rejection
A.
Due, perhaps to their behavioral difficulties, depressed children don’t tend to be well liked by
their peers.
B.
In fact, they are often rejected, bullied, and ostracized.
C.
The problem becomes circular. Their depressive symptomology cause them to get rejected by
peers, and the rejection increases the severity of the depression.
D.
Clearly, intervening with children in the school setting will require some recognition of the
social difficulties that they are likely to encounter.
XVI. Problems at home
A.
Depressed children may also have problems getting along with their parents and siblings.
B.
They’re likely to noncompliant with parents and generally difficult to be around.
C.
They won’t be much fun for their siblings.
D.
So, they can have considerable difficulty in their social interactions at home.
XVII. Developmental Issues
A.
I mentioned earlier that there may be developmental changes in the symptom patterns
associated with different disorders, and that is clearly the case with depression.
B.
For younger children, it is associated closely with irritability, aggression, and problems with
family members.
C.
For older children, concentration problems become more of an issues, and social difficulties
with peers are more pronounced.
D.
Vegatative symptoms, such as loss of appetite and sleep problems are more of an issues for
older children
E.
Depression is probably an extremely rare disorder before the age of 5. It is more common in
early and middle childhood, and shows a substantial increase in prevalence after children
reach puberty.
F.
Before puberty, depression has a fairly equal gender distribution. However, after puberty, the
gender distribution changes rather dramatically. By early adolescence, depression occurs
much more often for girls than boys.
XVIII. Prevalence, gender distribution
A.
Depression has a high rate of spontaneous remission. That is, many children who have
depression will get better over time without any intervention from adults.
B.
About 1/3 of those individuals who become depressed, will spontaneously remit over time.
C.
However, episodes of depression can last for relatively long periods of time and the average
length of untreated episodes is eight to 10 months.
D.
Many children suffer multiple episodes of depression. There may be periods of remission
followed by further episodes. Recurrent episodes occur in about 75 % of the cases.
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XIX. Dysthymia
A.
I’ve been talking about MDD, which is the most serious of the depressive disorders.
B.
Another type depressive disorder that is described in American diagnostic systems is
dysthymia.
C.
This is a chronic disorder, that lasts at least six months, but can often last much longer.
D.
Generally, it has a similar symptom profile to major depression, but the symptoms are often
much less severe.
E.
These are children who suffer from chronic feelings of sadness and irritability. But, because
there symptoms are not always extreme enough to interfere with their daily functioning, they
may never receive attention from educators or clinicians.
F.
It is probably a problem that is more common in adolescence than childhood.
G.
Dysthymia is a risk factor for major depression. During period of stress, Dysthymic
adolescents and children may experience major depression.
XX.
Eitiology
A.
I’m not going to go into details about the research on where childhood depression comes
from, but I’d like to highlight a few areas that are potentially important.
B.
A lot of research in this area has focused on the children’s learning history. That is, what
kinds of information has the child learned about himself/herself and the world?
C.
Children who have had experiences with rejection, stressful circumstances, and or
maltreatment by significant caregivers, maybe particularly vulnerable.
D.
Whenever I work with depressed children, I always spend a lot of time trying to understand
their history of exposure to rejection and stress.
XXI. Therapy
A.
So, what kinds of therapy approaches work well with these childhood depression?
B.
With younger children, it is often helpful to take a very behavioral approach. The focus is
really on providing the children with positive reinforcement and help the child to develop a
more positive view of the self.
C.
For older children, and adolescents, cognitive behavioral approaches may be effective.
D.
With these approaches, the therapists works with the youngster to help him/her recognize the
biases in the way he/she sees the world.
E.
The idea is to correct beliefs systems that lead to, and maintain, depression.
XXII. Some practical issues
A.
Intervention involving formal therapy is one issue, but another question is what can be done in
the school, and how can teacher help?
B.
First, it is important to be aware that children who suffer from depressive disorders are likely
to have difficulty with schoolwork.
1.
They may need extra attention, and extra time.
2.
They probably will not respond well to criticism, but will need support.
C.
You might also need to be aware that these children are likely to experience difficulties in
peer relationships, and it may be necessary for teachers to intervene.
D.
Generally, depressed children are in need of support and positive reinforcement.
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Anxiety
I.
Introduction
A.
I’ll move on now to focus on anxiety disorders in childhood.
B.
We’ll be focusing here on a set of disorders that primarily involved unrealistic
fears or anxieties. We will be talking about anxiety, that is so disabling, that it
interferes with a child’s daily functioning.
C.
However, with children, it is especially important to keep in mind the normative
nature of fears and anxieties.
D.
It is natural for children to experience certain fears.
1.
Very young children, such a preschoolers, tend to be fearful of the dark,
loud noises, and animals. They sometimes suffer from anxieties regarding
separation from parents.
2.
By school age, children begin to experience more pronounced anxieties
about being alone, and being separated from mom and dad. You’ll also
see some fears regarding supernatural or mythical beings, and strangers.
3.
By the later years of primary school, many children begin to develop
significant anxieties regarding academic performance and acceptance in
school. They begin to worry more about how other children are
evaluating them. Other fears may focus on dangers in the environment
such as thunder and lightning. It is at this stage that children begin to
understand the concept of death, and develop fears related to personal
injury.
4.
In adolescence, we see some similar fears and anxieties, although much of
the focus moves to the peer group. Many adolescents harbor fears and
anxieties regarding social interactions with peers.
E.
Again, we have to remember that such fears are normative. But, when the
become extreme or unrealistic, or developmentally inappropriate, then we need to
think about disorder.
Phobias
I.
Introduction
A.
I’d like to start out talking about a very common class of anxiety disorders, that
many adults and children suffer from.
B.
These are persistent and intense fears and avoidance of a particular object or
situation.
C.
The important thing to remember here is that a phobia is an unrealistic fear, and is
it generally fairly disruptive to an individual.
D.
Adolescents who are phobic are often aware, on some level, that there fears are
unrealistic. With younger children, this is not always the case.
II.
Specific Phobias
A.
Most phobias are reactions to very specific fear producing stimuli.
B.
Some, phobias, like the fear of heights and fear of snakes, are quite common,
whereas others that are quite rare
C.
The most common phobias for children apply to animals, particularly snakes,
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D.
E.
F.
mice, spiders, cats, and dogs.
1.
Animal phobias tend to develop very early in childhood.
Situation phobias are also relatively common, such a fear of heights, or enclosed
places.
Children may also develop phobias focused on loud noises, or environmental
events, like thunder and lightning.
Childhood is, in fact, a developmental period during which phobias are likely to
develop. As we’ve discussed, children normatively have certain fears and
anxieties, which can be exaggerated through formation of a phobia.
III.
Social Phobias
A.
Most diagnostic schemes also has a separate category for social phobias.
B.
Social phobias are persistent unrealistic fears, and avoidance, of social situations.
C.
They can be very generalized, such as the case for individuals who are fearful and
avoidant of any sort of social interaction.
D.
Often, they’re more specific. Some children are fearful only when meeting
strangers, eating or using the bathroom in public, or speaking in front of crowds.
E.
The common theme here is that social phobia is associated with a fear of
evaluation by others. The social phobic child is usually very self-focused and has
concerns regarding evaluation.
F.
Social phobia does occur across cultures, but may be more common in societies
that place a higher value on social interaction.
G.
For example, Asian countries tend to be characterized by a cultural emphasis on
social interaction, whereas US culture focused more on independence.
H.
Social phobias may also involve different sorts of features in other culture. There
is some evidence that, in Asian cultures, social phobia tend to involve a fear that
one will offend others, whereas in Western cultures the fear is that others will
negatively evaluate you.
I.
If this disorder is a phobia, why does it get its own category? The other
phobias are all grouped in the simple phobia category, but social phobia is on
its own? Why is social phobia so important?
IV.
Incidence, gender distribution.
A.
Social phobias are about as common specific phobias.
B.
They tends to first develop in adolescence, which is not surprising given the
emphasis on social interaction during this period of development.
Etiological perspectives on Phobias
I.
Behavioral Models
A.
A lot of theorizing about he development of phobias focused on the idea that
phobias are classically conditioned. That is, the child learns to associated anxiety
with a particular stimuli, because he or she was exposed to that stimuli in the
presence of something else that was fear producing.
B.
So, if something negative happens to me when I am near a dog, the negative
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C.
D.
E.
F.
G.
stimulus could become classically conditioned to dogs.
From a behavioral perspective, phobias can be classically conditioned and
negatively reinforced.
There is some research that does support this perspective. Phobias clearly can
develop through classical conditioning mechanism. In fact, you can
experimentally induce a phobia by pairing some object with a negative stimulus.
But, not all phobias seem to develop in this way. Children can develop phobias
without ever having a negative experience that is paired with the object or
situation.
Moreover, there are lots of situations in which a negative experience is paired
with a stimulus, and individuals do not develop a phobia.
So, this perspective clearly doesn’t explain all phobias.
II.
Preparedness
A.
Phobias may develop as an exaggeration of evolutionary processes.
B.
For this reason, phobias tend to be more common for particular stimuili
III.
Behavioral Treatments
A.
Have been very effective in the treatment of phobias. Among the most effective
therapies we have.
B.
Usually involved some sort of gradual exposure to the threatening stimulus.
C.
In systematic desensitization, you expose the individual to progressively more
extreme levels of the stimulus, accompanied by relaxation
1.
e.g., fear of romantic interactions, go from just saying hello to a woman, to
asking her on a date.
D.
Another approach is a bit more extreme. You expose an individual to extreme
amounts of the stimulus for a period of time, and then the stimulus begins to loose
its aversive qualities. This is called flooding.
1.
e.g., my cure from needle phobia.
IV.
Dealing with Phobias in the classroom
A.
I always encourage parents and teachers to be respectful of a phobias, when
children present with them.
B.
It is sometimes helpful to provide children with information about a fearful
stimuli:
1.
example: books about lightning.
C.
However, if one takes a punishing or stern approach, it can actually exacerbate the
problem.
Separation Anxiety Disorder
V.
Introduction
A.
I talked a bit about school phobia, and I want to move on now to talk about
separation anxiety disorder - which is one of the factors that may underlie a
child’s fears regarding school.
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B.
C.
Does seem to be a fairly well validated category and in my clinical experience,
does occur with some degree of regularity.
Can be extremely disruptive disorder which will often bring families to the clinic.
VI.
Description of disorder
A.
Fears revolving around separation from loved ones, significant care givers.
B.
Includes fear and distress about separation from care givers as well as excessive
fear and concerns about well being of care givers.
C.
Can be manifested in nightmares, preoccupations, or intrusive thoughts about
harm befalling care givers and may be associated with behaviors designed to
insure safety of loved ones. Example of boy who stayed awake to lock doors to
insure safety of parents.
D.
May be associated with school refusal.
E.
Can feature somatic complaints, both as an instrumental strategy for avoiding
separation and as an physiological reaction to the anxiety.
VII.
School and Social Phobia
A.
Sometimes, school refusal or school phobia may develop as part of the separation
anxiety.
B.
With school refusal, a child has anxiety about going to school in the morning.
C.
This can be related to a fear that something bad might happen to mom or Dad
during the day.
D.
However, it can also be related related directly to things that happen at school,
like academics or peer relations.
E.
I’ve seen this once or twice, usually as a function of issues such as bullying.
F.
It is important to emphasize that this is not simply an issue of truancy. Some
children experience anxiety regarding school that is so overwhelming, that they
avoid going to school. This is not an issue related to defiance of authority or
avoiding school work, it is a legitimate anxiety disorder.
VIII.
Developmental Issues
A.
Must once again keep in mind developmental context - appropriate for children to
have some fears regarding separation although morbid fears associated with SAD
are not typical.
B.
Can develop after chronic subclinical levels of separation anxiety, but can also be
a more sudden onset.
C.
I am unaware of much research on etiology but some history of traumatic
separation or “false alarms” regarding separation might be hypothesized.
D.
Bosnia example. Children separated from parents during ethnic cleansing.
E.
There is also some suggestion in the literature that mothers may somehow
communicate their own anxiety regarding separation to children.
IX.
Treatments
A.
There are actually effective treatments for school refusal, but it isn’t particularly
pleasant for the child.
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B.
C.
D.
1.
flooding.
For separation anxiety, can help to do family therapy, and resolves children’s
difficulties.
Also, behavioral techniques can prove effective.
Important to get a professional involved!
Generalized Anxiety Disorders
X.
Introduction
A.
I’ve been talking about anxieties and fears in very specific situations, like school
or separation from others.
B.
However, about half the children who are treated for anxiety disorders have fears
that are much more pervasive.
C.
Children also experience a disorder called Generalized Anxiety Disorder or
Overanxious Disorder of Childhood.
D.
GAD is a disorder that involves pervasive anxiety. Its central characteristic is
constant worry.
E.
Children with this disorder worry endlessly over numerous minor events.
F.
They often seem overwhelmed by fears and negative thoughts.
G.
They are often irritable and tense, and they fatigue easily as a result of there
constant state of hyperarousal.
H.
They tend to report a lot of somatic problem like minor aches and pains. In
Western settings, children with GAD often first come to our attention when the
present with medical problem.s
I.
Often they have difficulty concentrating,
J.
They may also have difficulty falling asleep at night.
XI.
Treatment of GAD
A.
GAD can be a hard disorder to treat. Why do you think that is the case?
B.
Because it so pervasive, and the fears and anxieties associated with GAD focus on
so many different domains of an child’s life, behavioral techniques are usually not
very effective.
C.
Procedures like flooding and systematic desensitization don’t tend to work well,
because those techniques require the fear to be centered on specific stimuli.
D.
The most effective treatments may involve cognitive behavioral techniques that
focus the cognitions that may underlie chronic worry.
E.
It would be important to involved a qualified mental health professional in the
treatment of this problem.
OCD
Obsessive Compulsive Disorder
XII.
OCD
A.
Let’s move on to talk about another serious, but much rarer anxiety disorder,
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B.
C.
D.
E.
F.
XIII.
Obsessive Compulsive Disorder.
This is a very serious disorder that, in its most extreme forms, can require
hospitalization.
The core features of OCD are obsessions and compulsions- and I’ll describe what
obsessions and compulsions in a few moments.
In OCD, the child experiences persistent obsessions that provoke anxiety, and
engages in compulsive behaviors to relieve the anxiety.
Often, the compulsions and the obsessions will have no apparent connection to
each other.
The compulsive behaviors often have a seriously disruptive impact on the
individual.
Obsessions
A.
What does the term “Obsession” mean to you? What is an “obsession”?
B.
Obsessions are unwanted thoughts, feelings, or images that an individual can’t get
out of his or her mind.
C.
Obsessions are usually quite irrational, and are sometimes almost
D.
Common obsessions include:
1.
Fear of contamination by disease or dirt.
2.
Disgust of body waste or secretions.
3.
Fears regarding impulsive violent or sexual behavior
4.
Concern that particular tasks of aspects of a job have not been done
correctly
XIV. Compulsions
A.
What about a “compulsion”? What does the word “compulsion” mean to you
all?
B.
Compulsions are repetitive and ritualistic behaviors that temporarily neutralize the
obsession or relieve the anxiety associated with the obsession.
C.
The most common compulsions involve:
1.
Washing: Either cleaning of hands or objects.
2.
Checking: Checking doors or windows to see that they’re closed, checking
light to see that they are off, checking the order of objects, or repeatedly
counting objects.
D.
As I said before, the compulsion does not have to be related to the obsession. So,
an obsession of sexual activity could be associated with a compulsion about
cleaning.
E.
In some cases, compulsions don’t involved any actual activity, but instead a
particular thought or special type of fantasy.
F.
Another important point to make, is that compulsion in OCD differ from
compulsions in other disorders, such as alcoholism, gambling, or overeating, in
that there is not pleasure associated with them.
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XV.
Prevalence
A.
OCD is a relatively rare disorder, occurring for about 2 to 3 percent of the
population.
B.
It also occurs for about 1 percent of children and maybe 2 to 3 percent of
adolescents.
C.
After puberty, it occurs about more frequently for females than males . For
children, the gender distribution is not as pronounced.
D.
It is important to emphasize, however, that many children experience obsessions
or compulsions at one time or another. Like most aspects of anxiety, obsessions
and compulsions do occur normatively, but not in a disabling fashion.
XVI. Therapies
A.
Techniques such as flooding and systematic desensitization don’t always work
with OCD.
B.
There are some more complex techniques, that I don’t have time to describe
(response blocking!).
C.
Also, some medications have proved to be quite useful.
PTSD
XVII. Introduction
A.
The final anxiety disorder we’ll talk about today, is PTSD.
B.
PTSD is an anxiety disorder that represent and extreme response to a traumatic
stressor.
C.
I’ll define what I mean by traumatic stressor in a moment or two.
XVIII. History of PTSD
A.
PTSD is a concept that has really evolved over time. What sort of historical
events increase interest in this disorder? Usually, following a major war there
is an increased interest in the impact of trauma.
B.
After WW I and II, psychologists were talking about syndromes such as “battle
fatigue” or “shell shock”. These syndromes were probably the precursors of
what we now call PTSD.
C.
In the last two decades, the concept of PTSD has really become more
systematized.
D.
However, for a long time, it was actually thought that children could not
experience PTSD. Trauma was not believed to lead to the development of a
PTSD-like syndrome for children.
E.
Lenore Terr’s descriptive work had a big impact on alerting the field to the
difficulties that children face.
F.
Also recent research on children living in war zones, or in violent communities,
has been very informative.
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XIX. Traumatic Stressor
A.
What do I mean by a trauma? What exactly does the term trauma mean to
you all?
B.
In my view, a traumatic event has three components:
1.
Outside the range of normal human experience
2.
It involves significant threat to life or well being. I usually tend to restrict
the use of the term trauma to situations in which a person is at significant
risk for death. For children, the loss of a parent or the threat of hard to a
parent or caregiver can often be thought of as a stressor as well.
3.
It must be an experience which produce horror or an intense feeling of
terror.
C.
It is important here to recognize that the term trauma refers to a very specific sort
of event. We’re not talking about events that might be extremely stressful but
don’t involve loss of life or the experience of horror.
D.
We often here people apply the term trauma to any painful stressor, such as the
loss of a job, or the ending of a relationship, or an academic failure. Certainly,
these are stressful experiences. But, they are not trauma.
XX.
PTSD
A.
A subset of individuals develop the disorder called PTSD, following exposure to
such events.
B.
The core features of PTSD involve a cycle of re-experiencing the traumatic event,
avoidance of stimuli associated with the event accompanied by symptoms of
increased arousal.
C.
What might be some symptoms of re-experiencing?
1.
nightmares
2.
intrusive thoughts - thoughts that continually intrude the individual’s
consciousness
3.
strong affective reactions to reminders of the event
4.
in extreme cases: hallucinations and flashbacks.
5.
Flashbacks are incidents in which the individually vividly recalls the
trauma, sometimes feeling as if her or she was back in the situation.
6.
With children, repetitive themes in play.
7.
In most cases of PTSD, there are significant difficulties with nightmares
and intrusive thoughts. Flashbacks and hallucination are rarer.
D.
As you can imagine, re-experiencing can prove to be quite stressful to an
individual. So, a set of symptoms develops which involves avoidance of stimuli
associated with the trauma.
1.
Child tries avoid thinking about the trauma, and avoid situations or objects
that involve reminders of the trauma.
2.
Numbing, detachment from others, avoidance of emotions. Often, there is
so much affect associated with the trauma that the child will avoid an
experience of emotion.
E.
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The other core set of symptoms involves arousal, in a physiological sense. With
PTSD, you often seen hypervigilance, difficulty concentrating, exaggerated startle
response.
XXI. Therapy
A.
The sense you get with children who have PTSD is that there are stuck in a
painful pattern.
B.
They need to understand the trauma, and come to terms with it so they spend a lot
of time re-experiencing.
C.
Yet, the re-experiencing is overwhelming and painful, so they engage in
avoidance behaviors.
D.
In therapy, you need to help the child process the trauma, and understand it, so
that they can break this cycle.
E.
With older adolescents, there are some good cognitive approaches.
F.
With young children, play therapy and behavioral approaches might prove useful.
Externalizing
I.
Introduction
A.
Let’s move on now from out focus on internalizing disorder, to the other side of
the coin, externalizing disorders.
B.
Most child clinicians get interested in this field out of a desire to help children. I
think when we first get started in training, we imagine ourselves helping children
with problems such as anxiety and depression.
C.
In truth, however, it is the externalizing disorders that tend to take most of our
time, at least in Western settings.
D.
These are the disorders that most frequently concern parents and school systems.
In my experience, far more parents come to the clinic complaining of disruptive
behavior disorders than any other class of disorders.
E.
Partially, this may be because children lack the ability to communicate internal
states such as sadness, but aggressive or disruptive behavior is easily observed.
F.
Moreover, I think that there is a fundamental difference in what brings children
and adults to psychiatric settings. Adults seek help because they are in pain.
Children are brought for help because they are engaging in behaviors that are
distressful to others. The distinction here is between the distressed and the
distressing.
G.
So, the sorts of problems you see children for a more of the disruptive acting-out
kind than the neurotic mood disorders.
II.
ADHD
A.
Let’s start off by talking about a disorder that is the focus of many unfortunate
myths: ADHD.
B.
Attention Deficit Hyperactivity Disorder is a behavior disorder of childhood that
involves two general classes of symptoms:
1.
Hyperactivity/impulsiveness: These symptoms involve difficulties
2.
3.
4.
V.
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inhibiting impulses, and high rates of inappropriate overly-active behavior.
a.
Children with these symptoms have difficulty sitting still and
staying focused on activities, particularly activities that are not of
interest.
b.
They talk excessively, run around aimlessly, and display
disorganized and restless behavior.
c.
If there in the classroom, they may blurt out answers, or interrupt
others who are trying to talk.
d.
They have difficulty resisting impulses to behave in ways that
bring momentary reinforcement.
e.
Not surprisingly, this class of symptoms get children into frequent
trouble at school and has a serious negative impact on academic
performance.
Inattention: The second class of symptoms, inattention, really refers to
difficulties regulating attention and directing attention.
a.
Children may have difficulty sustaining attention on particular
stimuli, such as a school work or a television show.
b.
They can be easily distracted and have difficulty in activities that
require sustained focus.
c.
Often, they’re poorly organized, forgetful, and prone toward losing
things.
The American diagnostic systems allows for three subtypes of ADHD:
a.
ADHD with attention problems only.
b.
ADHD with attention problems and hyperactivity
c.
ADHD with hyperactivity only
Subtypes are controversial
a.
Most of the available research suggest that ADHD with only
attention problems only is rare, and perhaps non-existent. I know
the notion of disorders of attention has been in the Western media
a good deal lately, but it doesn’t seem to hold up empirically.
b.
Seems to be more of an issue of impulsiveness and behavioral
control.
Adult ADD
A.
One interesting question to ask is what happens to young children who have
ADHD when they become older.
B.
We certainly don’t see hyperactive behavior in adults the way we sometimes do
with children.
C.
Probably, some adults who had ADHD as children continue to have the
underlying difficulties, but learn strategies for coping.
D.
Other adults may go on to develop related problems with aggression and
impulsivity.
E.
Still, another group may succeed in out growing the problem through some sort of
developmental change.
F.
VI.
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But, this is all conjecture, we really don’t know much about long-term outcome of
ADHD.
Gender Distribution, course, prognosis
A.
About 3 boys to ever girl. But, this issue could stand some further investigation.
A.
B.
As I said before, does not appear to be stable over the lifetime. Some clinicians
have suggested that children “out-grow” the disorder or learn to cope with the
underlying traits over the course of time.
Does respond to treatment. Wide variety of psycho-pharmacological approaches
are utilized as well as rigorous behavioral management techniques.
CD and ODD
I.
Conduct Disorder
A.
Let’s move on to the other major category of disruptive behavior disorders in DSM IV,
Conduct Disorders.
B.
CD is basically the label used for children who engage in high rates of antisocial,
aggressive, or rule-breaking behavior.
C.
I think this is probably the disorder that most people mean when the refer to
delinquency.
D.
The behavior in this category can involve violation of the law, injury to others, and
almost always incorporate some sort of violation of norms.
E.
A classic sort of symptom of CD, is a lack of remorse or guilt. When you see a
youngster who engages in lots of aggressive, antisocial, or criminal behavior, and seems
to feel little guilt, your often looking at the early stages of a life long pattern.
II.
Oppositional Defiant Disorder
A.
ODD is a related disorder, although the focus here is less on child’s interactions with
peers and society as a whole, and more on basic difficulties in interaction with
significant adult authority figures, particularly parents.
B.
Basically, a category that captures angry, defiant children who are difficult for parents to
manage. What do you think of this category? Does it make sense to label
oppositionality as a disorder?
C.
This is not just a category for kids who don’t do what mom and dad says. The severity
of the oppositionality must be enough to warrant clinical attention.
III.
Comments
A.
But, as you can imagine, there is lots of comorbidity between ODD and CD and many
researchers believe that these are similar manifestations of the same underlying disorder.
B.
In fact, we know that most CD children display ODD at one time or another, and that
the family origins of CD and ODD are similar. Some researchers have argued that
ODD is simply a manifestation of CD at an earlier stage of development. These may
not really be distinct disorders.
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IV.
Comorbidity
A.
There is also lots of overlap between these disorders and other classes of childhood
problems, as I’ve touched on earlier today.
B.
Comorbidity between CD and ADHD is high. In fact, it has been argued that CD and
ADHD are not distinct disorders. I think the evidence on this issue is, however, a bit
stronger than the evidence regarding CD and ODD.
C.
CD is comorbid with other disorders as well: substance abuse, mood disorders, anxiety
disorders.
D.
In fact, the comorbidity is so high that one begins to wonder wether it is even
appropriate to think of this a distinct disorder instead of some sort of global
maladjustment. As I’ve argued, disorders aren’t very distinct in childhood and we rarely
see children who have only one kind of problem.
V.
Gender Distribution
A.
What do you think the gender distribution is like? CD and ODD are diagnosed far
more often for young boys than young girls. CD prevalence rates are about 9 % for
boys, 2 % for girls. The difference is large.
B.
Finding that has, in fact, been reported across socioeconomic group, and culture.
Emerges by early childhood and seems to be relatively stable species-wide propensity.
C.
But, there is some evidence now that aggression might take a different form for young
girls than young boys.
D.
Basic notion is that girls tend to used more passive forms of aggressive behavior -such
as exclusions, or spreading rumors. In the research literature, this is referred to as
“relational aggression” or “indirect aggression.”
E.
One positive aspect of this new formulation, it has forced the field to be more aware of
aggression amongst girls.
F.
May be differences in the West and East, however. Our research suggests that girls
rarely engage in even this form of aggression in China.
VI.
Prognosis
A.
The prognosis for CD is mixed.
B.
Some children displays these problems and then go on to have a fairly good adjustment.
C.
Other kids have more significant problems and develop long-term chronic
psychopathology.
D.
Childhood aggression does seem to be a powerful predictor of later problems. It may
not be the case that being aggressive causes later problems, but we do know that
aggressive kids are at high risk for all kinds of problems.
E.
One interesting finding is that there may be two different sorts of prognoses of
aggressive children.
F.
One group of children, who are often called “early starters” or “life course persistent”
develop aggressive or conduct disordered behavior rather early in life and continue to
display problems of this nature throughout their lives. For these children, biological
factors, such a biological proclivity toward impulsive behavior are thought be more
involved.
G.
The other group, know as “later starters” or “adolescence limited” seem to experience a
few years of antisocial type of behavior, developing around the time of puberty, but go
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on to make a full recovery.