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Developmental Considerations In Clinical Child Psychology

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Title: Developmental Considerations In Clinical Child Psychology


1
Developmental Considerations In Clinical Child
Psychology
  • September 5, 2006
  • PSYC 4930

2
Introduction
  • From Wenar Kerig (2000) p. 2
  • You are a clinical child psychologist conducting
    an initial interview with a mother who has
    brought her daughter into a child guidance
    clinic. She has always been a sensitive child
    and a loner, but I thought she was getting along
    all right-except that recently she has started
    having some really strange ideas. The other day
    we were driving on the highway to town, and she
    said, I could make all these cars wreck if I
    just raised my hand. I thought she was joking
    but

3
Introduction
  • She had a serious expression on her face and
    wasnt even looking at me. Another time she
    wanted to go outside when the weather was bad,
    and she got furious at me because I didnt make
    it stop raining. And now shes started pleading
    and pleading with me every night to look in on
    her after she has gone to sleep to be sure her
    leg isnt hanging over the side of the bed. She
    says there is some kind of crab creature in the
    dark waiting to grab her if her food touches the
    floor.

4
Introduction
  • What worries me is that she believes all these
    things can really happen. I dont know if shes
    crazy or watching too much T.V. or whats going
    on.
  • What is the first question you would ask?

5
Psychopathology is . . .
  • clinically significant behavioral or
    psychological syndrome or pattern that occurs in
    an individual and that is associated with present
    distress or disability or with a significantly
    increased risk of suffering death, pain,
    disability, or an important loss of freedom
    (DSM-IV-TR)
  • AKA, a mental disorder

6
Relevance of Development to Understanding Child
Psychopathology
  • We can only understand abnormal behavior with
    reference to normal behavior
  • Child Psychopathology Normal development gone
    awry (Wenar, 1982)
  • Development can go awry in a variety of ways
  • Fixation (Arrest of development at a particular
    stage)
  • Regression (return to an earlier stage)
  • Failure to Develop
  • Exaggerated Behavior (e.g., affect
  • Qualitatively Different Behaviors

7
What is Developmental Psychopathology?
  • Sroufe Rutter (1984)
  • The study of the origins and course of individual
    patterns of behavioral manifestation, whatever
    the age of onset, whatever the causes, whatever
    the transformations in behavioral manifestations,
    and however complex the course of the
    developmental pattern may be
  • the study of developmental processes that
    contribute to, or protect against,
    psychopathology (Werner Kerig, 2000)

8
Developmental Psychopathology
  • Attempts to integrate what we know about normal
    development
  • Cognitive development
  • Emotional development
  • Biological development
  • Moral development
  • In order to understand how they may contribute to
    psychopathology

9
Developmental Psychopathology Key Concepts
  • Organizational
  • Not linked to one theoretical orientation
  • Emphasizes the interaction between different
    developmental domains (i.e., motor, language,
    social)
  • Stage oriented
  • Tasks at each developmental stage must be
    confronted and mastered in adaptive or
    maladaptive ways

10
Developmental Psychopathology Key Concepts
  • Probablistic NOT deterministic
  • The likelihood of poor adjustment may increase,
    but psychopathology is not predetermined
  • Other factors may intervene
  • Normal-Abnormal Continuum
  • Psychopathology can be normal development gone
    awry
  • Not a disease process but a deviation from
    healthy development

11
Developmental Psychopathology Key Concepts
  • Risk and Resilience
  • Risk any condition or circumstance that
    increases the likelihood that psychopathology
    will develop (e.g., biological factors, genetics,
    psychosocial factors)
  • Resilience factors prevent/protect a child from
    psychopathology, despite the presence of risk
    factors (intelligence, family support)

12
Types of Biological Risk Factors
  • Among the biological factors that can place the
    child at risk for later problems are factors
    operating before, during or after birth
  • E.g., neuronal migration problem, umbilical cord
    wrapped around neck, infection/high fever
  • In assessing children it is important to obtain
    information about any of these factors that may
    have contributed to the childs presenting
    difficulties

13
Biological Risk Factors
  • Age of the Mother
  • Poor Prenatal Nutrition
  • Maternal Use of Alcohol
  • Maternal Use of Tobacco
  • Use of Other Drugs
  • Prenatal and Postnatal Illnesses
  • Pregnancy and Birth Complications
  • Genetic Factors

14
Age of Mother
  • Research suggest that pregnancies in either very
    young or much older women are at greater risk for
    various types of complication
  • One major risk factor with age is Downs
    syndrome
  • Rates vary with maternal age (Below 30 1 in
    1,500 age 40 44 1 in 130 Over 45 1 in 65
    births).
  • Optimal age for minimal complications seems to be
    between 23 and 28

15
Poor Maternal Nutrition
  • Poor nutrition prior to and during the pregnancy
    can result in a range of developmental delays as
    well as specific types of physical conditions.
  • For example, it has been estimated that the
    standard 400 mg dosage of Folic acid that comes
    in most daily vitamins is capable of reducing the
    rates of spina bifida by a full 50

16
Maternal Alcohol Use
  • Heavy alcohol use by the mother during pregnancy
    can result in Fetal Alcohol Syndrome (FAS)
  • Over 40 of women who drink heavily with have
    children with FAS (but not all)
  • FAS results in developmental delays, growth
    retardation, facial dysmorphisms, learning
    disabilities, behavioral disorders, cognitive
    impairments
  • Lower levels of alcohol intake during pregnancy
    can also lead to significant development delays
  • No safe level of alcohol intake in pregnancy
    has been determined

17
Maternal Tobacco Use
  • Can result in premature birth and associated low
    birth weight, miscarriages, and subtle
    developmental delays
  • There are also data to suggest that heavy smoking
    may relate to later risk for both cancer and
    conduct disorder in the child
  • Several, but not all, studies have found a
    significant association between smoking during
    pregnancy and ADHD
  • There is also some evidence that paternal as well
    as maternal smoking can have effects of the child

18
Other drug use during pregnancy
  • Children born to mothers who use narcotics can be
    born addicted
  • Children of drug abusing mothers often show
    developmental delays, problems with emotional
    regulation, and problems with attention and
    activity level
  • In such cases there are often problems in the
    quality in early mother-child interaction
    patterns
  • Drug effects are often confounded by living in an
    environment where drug abuse is common, as well
    as genetic predispositions.

19
Pre or Postnatal Illnesses and Injuries
  • Viral illnesses like Rubella during the first
    trimester can result in a range of problems
    including deafness, heart problems, cleft palate,
    and mental retardation.
  • Congenital Rubella has also been shown to
    significantly increase the rates of infantile
    autism.
  • Head injuries and childhood illnesses with high
    fevers have also been show to relate to learning
    problems, developmental delays and ADHD.
  • It has also been suggested that early strep
    infections can also be associated with OCD like
    features or tic disorders in children
    (P.A.N.D.A.S. Pediatric Autoimmune
    Neuropsychiatric Disorders Associated with
    Streptococcal Infections)

20
Pregnancy and Birth Complications
  • A variety of pregnancy and birth complications
    (e.g., anoxia, prematurity, toxemia, low birth
    weight, meconium aspiration) have been found to
    be associated with a wide range of childhood
    problems
  • General developmental delays
  • Speech and language problems
  • School difficulties
  • Attention-Deficit/Hyperactivity Disorder (ADHD)

21
Genetic Factors
  • Disorders with significant genetic loadings
    include Autism, ADHD, Tourettes, Schizophrenia,
    and Bipolar disorder
  • Genetics may interact with environmental factors
  • The significant role of genetic contributions to
    childhood disorders makes it necessary to
    thoroughly assess family history of mental
    illness when conducting interviews with parents

22
Biological Risk/Resilience
  • Childhood temperament can be thought in terms of
    inborn individual differences in behavioral style
    that are reflected in the childs interaction
    with his/her environment.
  • A childs temperament makeup can make him or her
    either easy or difficult to parent.

23
Childhood Temperament
  • Temperament refers to basic dimensions of
    personality that are grounded in biology
  • Thomas and Chess (1968) conducted the New York
    Longitudinal Study
  • Attempted to delineate individual differences in
    the behavioral style of infants and young
    children
  • Studied 141 children from infancy through
    adolescence
  • Found 9 dimensions of temperament that
    differentiated children as young as 2 - 3 months
    of age
  • These were assumed to reflect biologically based
    individual differences in temperament

24
9 Temperament Dimensions in New York Longitudinal
Study Model
  • Rhythmicity
  • Degree of regularity of repetitive biological
    functions, sleeping, waking, feeding, elimination
  • Approach-Withdrawal
  • Nature of initial response to a new stimulus,
    such as new food, toys, people
  • Adaptability
  • Sequential course of the childs responses to new
    stimuli or altered situations
  • Intensity of Response
  • Energy level of response
  • Quality of Mood
  • Amount of pleasant, joyful, friendly behavior as
    contrasted with unpleasant, crying, unfriendly
    behavior
  • Activity Level
  • Level, tempo, and frequency of motor functioning
  • Distractibility
  • Effectiveness of extraneous environmental stimuli
    in interfering with or altering the direction of
    ongoing behavior
  • Persistence
  • Continuation of an activity in the face of
    obstacles to its continuation and length of time
    an activity is pursued
  • Threshold of Responsiveness
  • Level of extrinsic stimulation necessary to evoke
    a noticeable response, regardless of the nature
    of the response

25
Temperament Dimensions
  • Easy vs. Difficult Temperament
  • Five distinguishing dimensions Difficult temp.
  • Rhythmicity (irregularity of biological
    functions)
  • Approach-Withdrawal (withdrawal from novel
    stimuli)
  • Adaptability (slow adaptation)
  • Mood (negative mood)
  • Intensity of Response (high intensity)
  • Slow-to-Warm-Up
  • Low activity, tendency to withdraw, and slow to
    adapt may show negative mood but with low
    intensity

26
Temperament Dimensions
  • Distributions of temperament in children
  • More Easy than Difficult Children
  • In the 141 children in the New York Longitudinal
    Study (NYLS)
  • 10 Difficult Temperament
  • 30 Easy Temperament
  • 15 Slow-to-Warm-Up Temperament

27
Temperament as a Risk Factor
  • Relationship to adjustment problems
  • 70 of difficult temperament children in the NYL
    study developed behavior problems in adolescence
  • Only 18 of easy children developed problems in
    adolescence
  • Follow-up into adulthood documented a significant
    relationship between temperament at age 3-5 and
    adult psychiatric disorder
  • Still dimensions of temperament are subject to
    change with maturation, environment, and
    experience

28
Temperament Goodness-of-Fit
  • The greatest contribution of the NYLS was the
    emphasis on "goodness of fit," that is, that the
    temperament of the child alone was not the most
    important consideration in the child's growth and
    development, but the extent to which that
    temperament fit with the values, expectations,
    and style of the child's family. (Doreen Arcus,
    Ph.D. University of Massachusetts Lowell)
  • The Concept of Goodness-of-Fit
  • the meshing between the childs temperament
    style and the demands the environment places on
    the child
  • Clinical Child Psychologists Intervening with
    children with difficult temperaments

29
Psychosocial Risk Factors
  • Effects of Cumulative Life Stress
  • Effects of Divorce
  • Marital Violence
  • Physical Abuse
  • Sexual Abuse
  • Parenting Style

30
Cumulative Life Stress
  • Experiencing numerous life changes within a
    restricted period of time has been found to be
    associated with a range of child health and
    adjustment problems
  • Anxiety
  • Depression
  • Drug Use
  • Recurrent Abdominal Pain
  • Poor health status for children with diabetes
  • General Problems with Health and Adjustment

31
Cumulative Life Stress
  • There is also evidence that high levels of stress
    in expectant mothers can impact offspring
  • Animal Studies Stressed rats have longer
    pregnancies and more spontaneous abortions.
  • Expectant mothers show links between life stress
    and pregnancy and birth complications
  • There is also some evidence to suggest links
    between stress during pregnancy and the
    development of difficult temperament and delays
    in motor and mental development

32
Divorce
  • Divorce is not a single event
  • A range of associated stressors/transitions can
    impact the child
  • Changes in Residence
  • Changes in School
  • Loss of Friends
  • Possible Separation From One Parent
  • Possible Economic Hardships
  • Continued Parental Conflict
  • Possible Remarriage and new Step-family
  • All of these can serve as significant risk
    factors that can impact the child in multiple
    ways

33
Divorce Short Term Effects
  • Short term effects usually take the form of
    Emotional Problems and Behavioral Difficulties
  • This may elicit anger and possibly guilt
  • Also, many of the rules that have previously
    served to control the childs behavior may have
    been disrupted

34
Divorce Long Term Effects
  • Wallerstein notes that, as children grow older,
    they often continue to view their parents divorce
    as the single most formative experience in their
    lives, with major divorce-related issues arising
    as they approach adulthood.
  • Divorce, which involves a major falling apart of
    the prototypic relationship of the childs early
    life can have negative and pervasive effects that
    may affect the childs view of relationships and
    the world

35
Domestic Violence
  • Observing violence between parents can have a
    significant impact on the child and his/her
    behavior
  • Increase overall adjustment problems
  • Increase anxiety, depression and other
    internalizing problems such as fearfulness and
    insecurity
  • Children who have been abused themselves show
  • Increased levels of aggression
  • Greater willingness to use violence as a means of
    resolving conflict themselves

36
Effects of Child Abuse
  • Effects can include
  • Impaired self esteem
  • Decreased empathy
  • Anxiety and depression
  • Aggressive behavior
  • Post-Traumatic Stress Disorder (PTSD)
  • Abuse, like divorce, can also impact on the
    childs general view of relationships and of the
    world

37
Sexual Abuse Statistics
  • 1/4 to 1/3 of females and 1/10 of males
    experience sexual abuse of some type before
    adulthood
  • Most common age is between 8 and 12
  • Perpetrators most often males
  • Seldom an isolated occurrence

38
Effects of Sexual Abuse
  • Some evidence that younger children have more
    internalizing problems while older children have
    more externalizing problems
  • Findings suggest that 40-60 of sexually abused
    children show evidence of emotional/behavioral
    disturbance with around 15-20 displaying
    severe disturbance

39
Effects of Sexual Abuse
  • Common Responses to Sexual Abuse Include
  • Anger and hostility
  • Guilt and depression
  • Physical and somatic complaints
  • Problems in school and social functioning
  • Effects on sexuality
  • Highly sexualized behaviors
  • Fearful/inhibited behaviors

40
Effects of Sexual Abuse
  • Without treatment, effects often continue into
    adulthood
  • Studies have suggested that
  • One-half of women requesting therapy in
    outpatient crisis centers and over two-thirds of
    women seen in psychiatric emergency rooms have
    been sexually abused
  • Diagnoses of delayed PTSD are not uncommon
  • Affects future social relationships and
    influences how the person deals with issues of
    trust and both physical and emotional intimacy

41
Parenting Style Risk or Resilience?
  • Baumrind (1991)
  • Two parenting dimensions
  • Warmth/support
  • Control/structure
  • Four parenting styles
  • Authoritarian Do what I say because I say so
  • High on structure, Low on warmth
  • Can lead to aggression, low self-esteem

42
Parenting Style Risk or Resilience?
  • Permissive/Indulgent Parent
  • Low on structure, High on warmth
  • May lead to dependent, irresponsible child
  • Neglectful Parent
  • Low on structure, Low on warmth
  • May lead to antisocial behavior
  • Authoritative Parent
  • High on structure (firm consistent)
  • High on warmth
  • May lead to self-reliant, secure child

43
Parenting Style Risk or Resilience?
  • Using Baumrinds system, research has found that
  • Adolescents with authoritative parents faired
    best, those with neglectful parents faired worst
  • Adolescents with authoritarian parents were doing
    well in school and avoiding problem behaviors,
    but had poor self-concepts
  • Those with permissive parents perceived
    themselves positively, but engaged in misconduct
    and performed poorly in school
  • These findings may not apply to ethnically
    diverse samples

44
Risk Factors The Big Picture
  • The presence of one or more risk factors does not
    always lead to child psychopathology
  • Biological, genetic, psychosocial, and other
    factors can also promote resilience, which may
    help a child overcome risk factors
  • Intelligence
  • Easy temperament
  • Authoritative parents
  • Social support
  • Self-esteem

45
Developmental Considerations Normal Problems
  • The difficult infant
  • The defiant toddler
  • The aggressive or withdrawn preschooler
  • The oppositional adolescent
  • The overly dramatic/impulsive youth
  • The egocentric teenager

46
Developmental Course of Psychopathology
  • Psychopathology may present differently depending
    on the age of the child
  • ADHDhyperactivity
  • Conduct Disorderdelinquent behaviors
  • Depressionwithdrawal, somatic complaints,
    irritability vs. hypersomnia, depressed mood
  • Phobiasmay be transient in children

47
Other issues before we continue . . .
  • A note on terminologyin recent years the trend
    has been to discontinue the use of phrases such
    as
  • Autistic child
  • Depressed teenager
  • Schizophrenic
  • It is thought that this terminology does not
    consider the individual, but only defines them by
    their mental disorder
  • Thus, it is more accepted to use
  • Child with autism
  • Teenager with depression
  • Patient with schizophrenia

48
The DSM
  • Diagnostic and Statistical Manual of Mental
    Disorders (DSM-IV TR)
  • the system of classification of mental disorders
    used by most psychologists
  • First published in 1952
  • Early editions were strongly influenced by
    psychoanalytic theories Phobias are generally
    attributed to fears displaced to the phobic
    object or situation from some other object of
    which the patient is unaware (APA, 1968, p. 60)

49
The DSM
  • Beginning with the DSM-III (1980), the diagnostic
    categories were
  • Atheoretical
  • Based upon explicit criteria (e.g., certain
    number of criteria must be met)
  • The Multiaxial system was also introduced

50
The DSM Multiaxial System
  • Clinical Syndromes
  • Personality Disorders and Mental Retardation
  • General Medical Conditions
  • Psychosocial and Environmental Problems
  • Global Assessment of Functioning

51
The DSM
  • Strengths
  • Systematic classification is good for patients
    and helps with insurance reimbursement
  • Allows for well-controlled research and the
    integration of this research into clinical
    practice
  • Multiaxial system emphasizes importance of other
    factors (e.g., physical symptoms, situational
    factors)
  • Can help guide treatment

52
The DSM
  • Weaknesses
  • Categories do not always reflect scientific
    research, but sometimes social mores
  • Homosexuality was a mental disorder in DSM-I and
    II, and III (if it caused marked distress)
  • Premenstrual Dysphoric Disorder (DSM-IV)
  • Negative social stigma Danger of Labels
  • Poor reliability??
  • Evolving and Not Definitive
  • DSM-IV 1994 In current use
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