Transcript Externalizing disorders

Abnormal Psychology
Fifth Edition
Oltmanns and Emery
PowerPoint Presentations Prepared by:
Cynthia K. Shinabarger Reed
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Chapter Sixteen
Psychological Disorders of
Childhood
This multimedia product and its contents are protected under copyright law. The following are prohibited by law:
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Chapter Outline
• Externalizing Disorders
• Internalizing and Other
Disorders
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Overview
• Viewing abnormal behavior within the context of
normal development is important to understanding
all abnormal behavior.
• However, a developmental psychopathology
approach is absolutely essential to disorders of
childhood, because children change rapidly during
the first 20 years of life.
• Psychologists become concerned only when a
child’s behavior deviates substantially from
developmental norms, behavior that is typical for
children of a given age.
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Overview
• Psychological problems that commonly begin
during childhood are listed in the DSM-IV-TR
category Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence.
• Other than mental retardation and pervasive
developmental disorders, the most important
disorders in this category are the various
externalizing disorders.
• Externalizing disorders create difficulties for the
child’s external world.
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Overview
• Externalizing disorders are
characterized by children’s failure to
control their behavior according to the
expectations of parents, peers, teachers,
and/or legal authorities—for example,
as a result of hyperactive behavior or
conduct problems.
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Overview
• Internalizing disorders are psychological
problems that primarily affect the child’s
internal world—for example, excessive anxiety
or sadness.
• DSM-IV-TR does not list internalizing
disorders as separate psychological disorders
of childhood; rather, the manual notes that
children may qualify for many “adult”
diagnoses, such as anxiety or mood disorders.
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Externalizing Disorders
Symptoms of Externalizing Disorders
• Many externalizing symptoms involve violations
of age-appropriate social rules, including
disobeying parents or teachers, violating social or
peer group norms (e.g., annoying others), and
perhaps violating the law.
• Some misconduct is normal, perhaps even healthy,
for children.
• However, the rule violations in externalizing
disorders are not trivial and are far from “cute.”
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Externalizing Disorders
Symptoms of Externalizing Disorders
(continued)
• Externalizing behavior is a far greater
concern when it is frequent, intense, lasting,
and pervasive.
• That is, externalizing behavior is more
problematic when it is part of a syndrome,
or cluster of problems, than when it is a
symptom that occurs in isolation.
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Externalizing Disorders
Symptoms of Externalizing Disorders
(continued)
• Children’s age is important to consider in
relation to the timing as well as the nature
of rule violations.
• All children break rules, but children with
externalizing problems violate rules at a
younger age than is developmentally
normal.
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Externalizing Disorders
Symptoms of Externalizing Disorders (continued)
• Psychologists distinguish between externalizing
behavior that is adolescent-limited—that ends
along with the teen years—and life-coursepersistent antisocial behavior that continues into
adult life.
• In fact, externalizing problems that begin before
adolescence are more likely to persist over the
individual’s life course than are problems that
begin during adolescence.
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Externalizing Disorders
Symptoms of Externalizing Disorders (continued)
• Children with externalizing problems often are
negative, angry, and aggressive.
• Impulsive children act before they think.
• They struggle with executive functioning, the
internal direction of behavior.
• Hyperactivity involves squirming, fidgeting, and
restless behavior.
• Hyperactive children are in constant motion, and
they often have trouble sitting still, even during
leisure activities like watching television.
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Externalizing Disorders
Symptoms of Externalizing Disorders (continued)
• Attention deficits are characterized by
distractibility, frequent shifts from one
uncompleted activity to another, careless mistakes,
poor organization or effort, and general
“spaciness” (for example, not listening well).
• As with impulsivity, inattention is not intentional
or oppositional; rather, it reflects an inability to
maintain a focus despite an apparent desire to do
so.
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Externalizing Disorders
Diagnosis of Externalizing Disorders
• The DSM-IV-TR divides externalizing
disorders into three major types.
• Attention-deficit/hyperactivity disorder
(ADHD) is the problem that you may have
heard called “hyperactivity” or perhaps
“ADD.”
• Oppositional defiant disorder (ODD) includes
a wide range of problem behavior generally
found among school-aged children.
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Externalizing Disorders
Diagnosis of Externalizing Disorders (continued)
• Conduct disorder (CD) is a lot like what you may
think of as juvenile delinquency, because CD
involves rule violations that also are violations of
the law.
• Hyperactivity was distinguished from ordinary
misbehavior about 100 years ago by British
physician George Still, who speculated that the
overactivity of some children he treated might be
due to biological “defects.”
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Externalizing Disorders
Diagnosis of Externalizing Disorders (continued)
• Since then, professionals have debated whether
the misbehavior of school-aged children should be
divided into two types.
• Children with what we now call ADHD are
assumed to have a biological problem best treated
with medication.
• Children with what we now call ODD are seen as
having a psychological problem requiring
psychological treatment.
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Externalizing Disorders
Diagnosis of Externalizing Disorders (continued)
• Interest in what DSM-IV-TR calls conduct
disorder also is about 100 years old but has a very
different origin.
• At the end of the nineteenth century, juvenile
crime was distinguished from adult criminal
behavior for the first time in American law.
• The law adopted a compassionate view of juvenile
delinquency, seeing the problem as a product of a
troubled upbringing.
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Externalizing Disorders
Diagnosis of Externalizing Disorders
(continued)
• As a result, the state adopted a parental role
in trying to help wayward youth, not just
punish them.
• Thus, the criminal behavior of juveniles
came to be seen as a psychological problem,
not just a legal one.
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Externalizing Disorders
Diagnosis of Externalizing Disorders
(continued)
• Attention-deficit/hyperactivity disorder
(ADHD) is characterized by hyperactivity,
attention deficit, and impulsivity.
• The symptoms of hyperactivity and
attention deficit each have been viewed as
being the core characteristics of ADHD.
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Externalizing Disorders
Diagnosis of Externalizing Disorders
(continued)
• Oppositional defiant disorder (ODD) is
defined by a pattern of negative, hostile, and
defiant behavior.
• The rule violations in ODD typically
involve minor transgressions, such as
refusing to obey adult requests, arguing, and
acting angry.
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DSM-IV-TR Diagnostic Criteria
for Oppositional Defiant Disorder
A. A pattern of negativistic, hostile, and defiant behavior lasting at
least 6 months, during which four (or more) of the following are
present:
1. Often loses temper.
2. Often argues with adults.
3. Often actively defies or refuses to comply with adults’ requests or rules.
4. Often deliberately annoys people.
5. Often blames others for his or her mistakes or misbehavior.
6. Is often touchy or easily annoyed by others.
7. Is often angry and resentful.
8. Is often spiteful and vindictive.
B. The disturbance in behavior causes clinically significant
impairment in social, academic, or occupational functioning.
Note: Consider a criterion only if the behavior occurs more frequently than
is typically observed in individuals of comparable age and
developmental level.
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Externalizing Disorders
Diagnosis of Externalizing Disorders (continued)
• Professionals have long debated whether
ADHD and ODD are the same or separate
disorders.
• The current consensus is that the two
disorders are separate but frequently
comorbid.
• Not only are ADHD and ODD highly
comorbid, but about 25 percent of children
with each problem also have a learning
disorder.
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Externalizing Disorders
Diagnosis of Externalizing Disorders
(continued)
• To a lesser extent, ADHD also is comorbid
with internalizing disorders such as
depression and anxiety.
• Comorbid internalizing disorders are
particularly common among girls with
ADHD.
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Externalizing Disorders
Diagnosis of Externalizing Disorders (continued)
• The subtyping of ADHD into the predominantly
inattentive, predominantly hyperactive-impulsive,
or combined types is another sometimes
controversial distinction.
• The predominantly inattentive subtype generally is
accepted as an important diagnosis.
• Some children have difficulty with inattention and
information processing, but they exhibit little or
no hyperactivity.
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Externalizing Disorders
Diagnosis of Externalizing Disorders (continued)
• There is less support for the predominantly
hyperactive-impulsive subtype.
• Preschool children generally are classified in
the predominantly hyperactive-impulsive
group, while school-aged children fall into the
combined type.
• This implies that the two subtypes actually
involve the same problems but are
developmentally related.
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Externalizing Disorders
Diagnosis of Externalizing Disorders (continued)
• Conduct disorder (CD) is defined primarily by a
persistent and repetitive pattern of serious rule
violations, most of which are illegal as well as
antisocial—for example, assault or robbery.
• DSM-IV-TR distinguishes the age of onset in
defining conduct disorders—a distinction between
adolescent-limited versus life-course patterns of
antisocial behavior.
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Externalizing Disorders
Diagnosis of Externalizing Disorders (continued)
• Most of the symptoms of conduct disorder involve
index offenses—crimes against people or property
that are illegal at any age.
• A few diagnostic criteria are comparable to status
offenses—acts that are illegal only because of the
youth’s status as a minor.
• However, juvenile delinquency is a legal
classification, not a mental health term.
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Externalizing Disorders
Frequency of Externalizing Disorders
• The National Academy of Sciences concluded that
at least 12 percent of the 63 million children living
in the United States suffer from a mental disorder,
and the majority of these are externalizing
disorders.
• Between 3 and 5 percent of children in the United
States are estimated to have ADHD at any point in
time.
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Externalizing Disorders
Frequency of Externalizing Disorders (continued)
• Anywhere from 5 to 15 percent of youth in the
United States may have ODD and/or CD.
• After the first few years of life, from two to ten
times as many boys as girls have an externalizing
disorder.
• Except for the normative increase during
adolescence, the prevalence of externalizing
behavior generally declines with age, although it
declines at much earlier ages for girls than for
boys.
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Externalizing Disorders
Frequency of Externalizing Disorders (continued)
• Externalizing disorders are associated with various
indicators of family adversity, a fact highlighted
by British psychiatrist Michael Rutter.
• Rutter’s Family Adversity Index includes six
family predictors of behavior problems among
children:
(1) low income,
(2) overcrowding in the home,
(3) maternal depression,
(4) paternal antisocial behavior,
(5) conflict between the parents, and
(6) removal of the child from the home.
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Externalizing Disorders
Frequency of Externalizing Disorders (continued)
• Other epidemiological findings underscore
the relationship between children’s
externalizing problems and social
disadvantage.
• For example, psychological disorders are
found in more than 20 percent of children
living in inner city neighborhoods and are
associated with divorce and single
parenting.
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Externalizing Disorders
Causes of Externalizing Disorders
• Research on infants and toddlers indicates that a
difficult temperament is a risk factor for later
externalizing disorders.
• Neuropsychological research suggests other
biological contributions to externalizing disorders,
particularly to ADHD.
• Brain damage can produce overactivity and
inattention, but hard signs of brain damage, such
as an abnormal CT scan, are found in less than 5
percent of cases of ADHD.
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Externalizing Disorders
Causes of Externalizing Disorders
(continued)
• Neurological soft signs, such as delays in
fine motor coordination (as may be evident
in poor penmanship), also are more frequent
among children with ADHD.
• However, many children with ADHD do not
show soft signs, while many normal
children do.
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Externalizing Disorders
Causes of Externalizing Disorders (continued)
• Minor anomalies in physical appearance, delays
in reaching developmental milestones, and a
history of mothers’ pregnancy and birth
complications also appear more commonly
among children with ADHD than normal
children.
• Still, researchers have yet to discover a specific
marker of biological vulnerability.
• One candidate is impairment in the prefrontal
cortical-striatal network, an area of the brain that
may control executive functions including
attention, inhibition, and emotion regulation.
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Externalizing Disorders
Causes of Externalizing Disorders
(continued)
• Several studies show that genetic factors
strongly contribute to ADHD.
• Strong evidence on genetic contributions
does not mean that ADHD is an “either you
have it or you don’t” disorder, that is, a
problem qualitatively different from normal.
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Externalizing Disorders
Causes of Externalizing Disorders
(continued)
• Genes contribute less to ODD and
especially CD than to ADHD.
• Genetic influence is stronger for early than
late onset antisocial behavior.
• Part of what is inherited may be a tendency
to react more negatively to adverse
environments.
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Externalizing Disorders
Causes of Externalizing Disorders (continued)
• Specific problems in parenting also contribute to
children’s externalizing problems.
• One of the most important is psychologist Gerald
Patterson’s concept of coercion, which occurs
when parents positively reinforce a child’s
misbehavior by giving in to the child’s demands.
• Coercion describes a system of interaction in
which parents and children reciprocally reinforce
child misbehavior and parent capitulation.
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Externalizing Disorders
Causes of Externalizing Disorders (continued)
• Sometimes children misbehave as a way of
getting attention rather than as a way of getting
what they want.
• Negative attention refers to the idea that
attempts at punishment sometimes accidentally
reinforce children’s misbehavior.
• Inconsistent discipline also is linked with
children’s externalizing problems.
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Externalizing Disorders
Causes of Externalizing Disorders
(continued)
• Peer groups also can encourage delinquent
and antisocial behavior, and among
adolescents, peer influences may be
stronger than parental ones.
• Neighborhood and society also contribute to
externalizing problems.
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Externalizing Disorders
Causes of Externalizing Disorders (continued)
• There are no theories of how social factors
play a unique role in the development of
ADHD.
• Mothers of children with ADHD are more
critical, demanding, and controlling compared
to the mothers of normal children.
• However, research shows that problems
primarily are a reaction to the children’s
troubles, not a cause of them.
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Externalizing Disorders
Causes of Externalizing Disorders (continued)
• Several investigators have found problems with
self-control among children with externalizing
disorders.
• Low self-esteem, feelings of low worth, also is
sometimes blamed as a cause of externalizing
problems, but research shows, perhaps
surprisingly, that children with ADHD
overestimate rather than undervalue their
competence.
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Externalizing Disorders
Causes of Externalizing Disorders
(continued)
• One area of research on self-control focuses
on delay of gratification—the adaptive
ability to defer smaller but immediate
rewards for larger, long-term benefits.
• In general, children with externalizing
problems are less able to delay gratification
and are more oriented to the present than
are other children.
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Externalizing Disorders
Causes of Externalizing Disorders (continued)
• Children with externalizing problems also may fail
to exert self-control because they misinterpret the
intentions of others, particularly in ambiguous
social situations.
• A related psychological issue concerns the
“conscience” of children with externalizing
problems.
• Some evidence indicates that aggressive children
follow the hedonic principles commonly used by
children at younger ages.
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Externalizing Disorders
Causes of Externalizing Disorders (continued)
• Externalizing disorders have many causes, not
one.
• Biological, psychological, and social factors
clearly interact in causing externalizing
disorders.
• The combination of a difficult temperament
and family adversity may result in ODD and
eventually conduct disorder, while a
temperamentally “easy” child might turn out
well-behaved despite growing up in difficult
family circumstances.
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Externalizing Disorders
Treatment of Externalizing Disorders
• Psychostimulants produce immediate and
noticeable improvements in the behavior of
about 75 percent of children with ADHD.
• Traditionally, medication was discontinued
in early adolescence, because it was
believed that the problem was “outgrown”
by that age.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• However, research shows that, while
hyperactivity usually improves during the teen
years, problems with inattention and
impulsivity often continue.
• Thus psychostimulants now are taken through
the teen years, and perhaps into adulthood, as
interest has grown in “adult ADHD,”
inattention, impulsivity, and to a lesser extent,
overactivity in adults.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• Numerous double-blind, placebo-controlled
studies show that psychostimulants indisputably
improve children’s attentiveness and decrease
their hyperactivity.
• More aggressive behavior therapies, including
summer treatment programs, may produce notable
benefits.
• Still, the evidence establishes psychostimulant
medication as the first-line treatment for ADHD.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• Although psychostimulants improve hyperactivity
and impulsivity, their effects on attention and
learning are less certain.
• The side effects of psychostimulants can be
troubling.
• Some side effects are minor, such as decreased
appetite, increased heart rate, and sleeping
difficulties.
• Other problems are more serious, such as an
increase in motor tics in a small percentage of cases.
• Evidence that psychostimulants can slow physical
growth is also an important concern.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• Psychostimulants are an inexpensive and effective
treatment for ADHD, especially in comparison
with the alternatives.
• Still, the benefits of medication are limited,
various side effects are a source of concern, and,
most importantly, there is no bright line between
normal and abnormal behavior in diagnosing
ADHD.
• Thus, it is reasonable to ask whether we are
overdiagnosing ADHD and overmedicating
schoolchildren.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• Over the last decade, physicians tried
antidepressants with many children with
ADHD who do not respond to
psychostimulants.
• Antidepressants may affect ADHD symptoms
directly for unknown reasons.
• However, antidepressants clearly are a secondline treatment for ADHD.
• Their use is justified only following the failure
of psychostimulants.
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Externalizing Disorders
Treatment of Externalizing Disorders
(continued)
• Behavioral family therapy (BFT) is a
treatment based on learning theory
principles that teaches parents to be very
clear and specific about their expectations
for children’s behavior, to monitor
children’s actions closely, and to
systematically reward positive behavior
while ignoring or mildly punishing
misbehavior.
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Externalizing Disorders
Treatment of Externalizing Disorders
(continued)
• BFT is sometimes used as an adjunct
or alternative to medication in treating
ADHD, although it offers limited
benefits for ADHD symptoms.
• However, BFT is more promising as a
treatment of ODD.
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Externalizing Disorders
Treatment of Externalizing Disorders
(continued)
• Numerous programs have been developed
to treat conduct disorders and juvenile
delinquency.
• Research indicates that conduct disorders
among adolescents are even more resistant
to treatment than are externalizing problems
among younger children.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• Some BFT approaches have shown promise in
treating young people with family or legal
problems.
• These treatments are based on principles
similar to those in programs for younger
children, except that negotiation—actively
involving young people in setting rules—is
central to BFT with adolescents.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• Multisystemic therapy (MST) is another
intervention with conduct disorders that has
received considerable attention.
• In recognition of the diverse causes of
externalizing behavior, MST combines
family treatment with coordinated
interventions in other important contexts of
the troubled child’s life, including peer
groups, schools, and neighborhoods.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• Several studies now document that MST
therapy improves family relationships, and to
a lesser extent, delinquent behavior and
troubled peer relationships.
• Many adolescents with serious conduct
problems or especially troubled families are
treated in residential programs outside the
home.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• One of the most actively researched residential
programs is Achievement Place, a group home that
operates according to highly structured behavior
therapy principles.
• Achievement Place homes, like many similar
residential programs, are very effective in
improving aggression and noncompliance while
the adolescent is living in the treatment setting.
• Unfortunately, the programs do not prevent
recidivism once the adolescent leaves the
residential placement.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• Many delinquent youths are treated in the juvenile
justice system, where rehabilitation is supposed to be
the goal.
• The philosophy of the juvenile justice system in the
United States is based on the principle of parens
patriae—the state as parent.
• In theory, juvenile courts are to help troubled youth,
not to punish them.
• The juvenile justice system often creates delinquency
instead of curing it, and recidivism is lower when
delinquents are diverted away from the courts.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• Individually, therapists need to establish
good relationships with troubled (and often
difficult) children and youth, an important
predictor of treatment outcome for
externalizing problems.
• Another key effort is preventing
externalizing disorders from developing by
easing the family adversity that creates
them.
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Externalizing Disorders
Treatment of Externalizing Disorders (continued)
• For ADHD, hyperactivity generally declines
during adolescence, while attention deficits and
impulsivity are more likely to continue.
• The continuity of symptoms into adult life for
about half of children with ADHD is evident in the
growing interest in adult ADHD.
• Importantly, the prognosis of ADHD depends
substantially on whether there is comorbid ODD
or CD.
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Internalizing and Other Disorders
Symptoms of Internalizing Disorders
• Children’s internalizing symptoms include
sadness, fears, and somatic complaints, as well
as other indicators of mood and anxiety
disorders—for example, feeling worthless or
tense.
• DSM-IV-TR does not have a separate category
for children’s internalizing disorders, but the
manual does identify some unique ways in
which children experience the symptoms.
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Internalizing and Other Disorders
Symptoms of Internalizing Disorders (continued)
• When diagnosing major depressive episodes
among children and adolescents, for example, the
clinician is allowed to substitute “irritable mood”
for “depressed mood.”
• DSM-IV-TR offers only a few, scattered
developmental considerations in diagnostic
criteria.
• This is due in large part to the fact that the course
of children’s normal emotional development is not
well charted.
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Internalizing and Other Disorders
Symptoms of Internalizing Disorders (continued)
• The assessment of depression in children can be
particularly difficult.
• For example, in one study of children hospitalized
for depression, clinicians found a correlation of
zero between children’s and parents’ ratings on
identical measures of the children’s depression.
• Parents systematically underestimate the extent of
depression reported by their children and
adolescents.
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Internalizing and Other Disorders
Symptoms of Internalizing Disorders (continued)
• In assessing children’s internalizing problems,
mental health professionals must obtain
information from multiple informants—parents,
teachers, and the children themselves.
• When assessing children directly, child clinical
psychologists are sensitive to different signs that
may be indicative of depression at different ages.
• Depression in children and adolescents often is
comorbid both with externalizing problems and
with anxiety.
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Internalizing and Other Disorders
Symptoms of Internalizing Disorders
(continued)
• As with depression, children often have
trouble identifying their anxiety, but they
are more aware of their fears, which are
immediate and have a clear environmental
referent.
• Research on the development of children’s
fears is more advanced than it is for their
anxiety.
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Internalizing and Other Disorders
Symptoms of Internalizing Disorders (continued)
• Three findings from fear research are
important to note.
• First, children develop different fears for the
first time at different ages, and the onset of
new fears may be sudden and have no
apparent cause in the child’s environment.
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Internalizing and Other Disorders
Symptoms of Internalizing Disorders (continued)
• A second finding is that some fears,
particularly fears of uncontrollable events such
of disasters, are both common and relatively
stable across different ages.
• Third, many other fears, especially specific
ones like fears of monsters or normal worries
about death, become less frequent as children
grow older.
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Internalizing and Other Disorders
Symptoms of Internalizing Disorders
(continued)
• DSM-IV-TR contains a diagnosis for
separation anxiety disorder, which is
defined by symptoms such as persistent and
excessive worry for the safety of an
attachment figure, fears of getting lost or
being kidnapped, nightmares with
separation themes, and refusal to be alone.
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Internalizing and Other Disorders
Symptoms of Internalizing Disorders (continued)
• Separation anxiety disorder is especially
problematic when it interferes with school
attendance.
• School refusal, also known as school phobia, is
characterized by an extreme reluctance to go to
school, and is accompanied by various symptoms
of anxiety, such as stomachaches and headaches.
• Children with internalizing or externalizing
problems often have troubled peer relationships.
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Internalizing and Other Disorders
Symptoms of Internalizing Disorders
(continued)
• A number of troubling symptoms of
children’s psychological disorders are best
understood as specific developmental
deviations, significant departures from ageappropriate norms in some specific area of
functioning.
• In fact, some developmental deviations are
considered disorders in their own right.
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Internalizing and Other Disorders
Diagnosis of Internalizing and Other Disorders
• In 1896, the psychologist Lightner Witmer
established the first psychological clinic for
children in the United States.
• Despite the early origins of child clinical
psychology, children were largely ignored in early
classifications of mental disorders.
• DSM-I contained only two separate diagnoses for
children, and DSM-II listed only seven childhood
disorders.
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Internalizing and Other Disorders
Diagnosis of Internalizing and Other
Disorders (continued)
• DSM-III recognized a much wider range of
childhood disorders, and in fact, contained a
proliferation of diagnostic categories, 40 in
all.
• Although laudable, the new effort was
overly ambitious.
• Many of the new diagnoses were severely
criticized and subsequently were dropped.
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Internalizing and Other Disorders
Diagnosis of Internalizing and Other Disorders
(continued)
• Pica is the persistent eating of nonnutritive
substances, such as paint or dirt.
• Many infants and toddlers put nonnutritive
substances in their mouths, but the feeding
disorder pica is rarely diagnosed, except among
mentally retarded children.
• Rumination disorder, the repeated regurgitation
and rechewing of food, is another infrequent
feeding disorder.
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Internalizing and Other Disorders
Diagnosis of Internalizing and Other Disorders
(continued)
• Tourette’s disorder is a rare problem (4 to 5 cases
per 10,000 people) that is characterized by
repeated motor and verbal tics.
• Stereotypic movement disorder is selfstimulation or self-injurious behavior that is
serious enough to require treatment, as may occur
in mental retardation or pervasive developmental
disorder.
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Internalizing and Other Disorders
Diagnosis of Internalizing and Other Disorders
(continued)
• Selective mutism involves the consistent failure
to speak in certain social situations (for example,
in school) while speech is unrestricted in other
situations (for example, at home).
• Reactive attachment disorder is another rarely
diagnosed problem, although it may be more
prevalent than we would hope.
• Reactive attachment disorder is characterized by
severely disturbed and developmentally
inappropriate social relationships.
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Internalizing and Other Disorders
Diagnosis of Internalizing and Other Disorders
(continued)
• Encopresis and enuresis are common problems.
• The terms refer, respectively, to inappropriately
controlled defecation and urination.
• According to DSM-IV-TR, enuresis may be
considered abnormal beginning at age 5, as most
children have developed bladder control by this
age.
• Encopresis, a much less common problem, may be
diagnosed beginning at age 4.
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Internalizing and Other Disorders
Diagnosis of Internalizing and Other
Disorders (continued)
• Beginning with DSM-III, the manual
became overinclusive in its listing of
childhood disorders, and included too many
“disorders” that are not in fact mental
disorders.
• Many “disorders” have been dropped, but
there seem to be other “childhood
disorders” that are not disorders.
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Internalizing and Other Disorders
Diagnosis of Internalizing and Other Disorders
(continued)
• Children’s behavior is intimately linked with the
family, school, and peer contexts.
• Because of this, some experts have suggested that
diagnosing individual children is misleading and
misguided.
• Instead, children’s psychological problems could
be classified within the context of key
relationships, particularly the family.
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Internalizing and Other Disorders
Frequency of Internalizing Disorders
• The prevalence of externalizing disorders
generally decreases as children grow older, but the
opposite is true for internalizing disorders.
• Depression increases dramatically during
preadolescence and adolescence, especially among
girls.
• Anxiety disorders also are very common, and may
occur among as many of 5 to 10 percent of all
young people.
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Internalizing and Other Disorders
Frequency of Internalizing Disorders (continued)
• Suicide is the third leading cause of death among
teenagers, trailing only automobile accidents and
natural causes.
• In comparison to adult suicide attempts, suicide
attempts among adolescents are more impulsive,
are more likely to follow a family conflict, and are
more often motivated by anger rather than
depression.
• Cluster suicides also can occur among teenagers.
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Internalizing and Other Disorders
Causes of Internalizing Disorders
• Most research on the causes of mood and
anxiety disorders among children is based
on the same theories of etiology we have
discussed in relation to adults.
• Evidence simply is lacking or inadequate on
the development of many other
psychological problems of childhood.
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Internalizing and Other Disorders
Causes of Internalizing Disorders (continued)
• Except for some research documenting genetic
influences on childhood onset obsessive–
compulsive disorder, few behavior genetic studies
have been conducted on children’s internalizing
disorders.
• In the few studies completed to date, widely
different estimates of genetic contributions are
obtained based on children’s versus parents’
reports.
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Internalizing and Other Disorders
Causes of Internalizing Disorders (continued)
• Jerome Kagan and colleagues have conducted
some important basic research that suggests a
more general, biological predisposition to
anxiousness.
• Extreme parental neglect deprives infants of the
opportunity to form a selective attachment.
• Such neglect can cause reactive attachment
disorder, or what attachment researchers
sometimes call anaclitic depression—the lack of
social responsiveness found among infants who do
not have a consistent attachment figure.
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Internalizing and Other Disorders
Causes of Internalizing Disorders (continued)
• A number of longitudinal studies have
demonstrated that anxious attachments during
infancy foreshadow difficulties in children’s social
and emotional adjustment throughout childhood.
• However, an insecure attachment does not seem to
result in the development of any particular
emotional disorder.
• Rather, insecure attachments predict a number of
internalizing and social difficulties, including
lower self-esteem, less competence in peer
interaction, and increased dependency on others.
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Internalizing and Other Disorders
Causes of Internalizing Disorders
(continued)
• Separation or loss is another threat to
attachment, one that clearly causes distress
among children, in the short run.
• However, research fails to find a
relationship between childhood loss and
depression during adult life.
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Internalizing and Other Disorders
Causes of Internalizing Disorders (continued)
• Emotion regulation is a process in which
children learn to identify, evaluate, and control
their feelings based on the reactions, attitudes, and
advice of their parents and others in their social
world.
• Our understanding of children’s emotional
development is far from complete, and only
scattered research has linked troubles with
emotion regulation to children’s internalizing
disorders.
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Internalizing and Other Disorders
Treatment of Internalizing Disorders
• Relatively few treatments for anxiety or
mood disorders have been developed or
studied specifically as they apply to
children.
• For example, medications known to
alleviate depression in adults have rarely
been studied among children and
adolescents, and may be no more effective
than placebos in treating their depression.
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Internalizing and Other Disorders
Treatment of Internalizing Disorders (continued)
• Researchers already have begun to correct the
neglect of treatment research on children’s
internalizing disorders.
• Some forms of cognitive behavior therapy and
interpersonal therapy show promise for
treating children’s depression, and cognitive
behavior therapy and family therapy have
produced positive results in treating children’s
anxiety.
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Internalizing and Other Disorders
Treatment of Internalizing Disorders
(continued)
• Until recently, psychologists believed that
children “outgrew” internalizing problems.
• Prospective research demonstrates,
however, that some internalizing disorders
persist over time.
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