What is Parentification?

Introduction

Parentification is the process of role reversal whereby a child is obliged to act as parent to their own parent or sibling. In extreme cases, the child is used to fill the void of the alienating parent’s emotional life.

Two distinct types of parentification have been identified technically: instrumental parentification and emotional parentification.

  • Instrumental parentification involves the child completing physical tasks for the family, such as looking after a sick relative, paying bills, interpreting foreign language, or providing assistance to younger siblings that would normally be provided by a parent.
  • Emotional parentification occurs when a child or adolescent must take on the role of a confidante or mediator for (or between) parents or family members.

Background

Melitta Schmideberg noted in 1948 how emotional deprivation could lead parents to treat their children (unconsciously) as substitute parent figures. “Spousification” and “parental child” (Minuchin) offered alternative concepts exploring the same phenomenon; while the theme of intergenerational continuity in such violations of personal boundaries was further examined. Eric Berne touched on the dangers of parents and children having a symmetrical, rather than asymmetrical relationship, as when an absent spouse is replaced by the eldest child; and Virginia Satir wrote of “the role-function discrepancy…where the son gets into a head-of-the-family role, commonly that of the father”.

Object relations theory highlighted how the child’s false self is called into being when it is forced prematurely to take excessive care of the parental object; and John Bowlby looked at what he called “compulsive caregiving” among the anxiously attached, as a result of a parent inverting the normal relationship and pressuring the child to be an attachment figure for them.

All such aspects of disturbed and inverted parenting patterns have been drawn under the umbrella of the wider phenomenon of parentification – with the result (critics suggest) that on occasion “ironically the concept of parentification has…been as over-burdened as the child it often describes”

Choice of Child

For practical reasons, elder children are generally chosen for the familial “parental” role – very often the first-born children who were put in the anomalous role. However, gender considerations mean that sometimes the eldest boy or eldest girl was selected, even if they are not the oldest child overall, for such reasons as the preference to match the sex of the missing parent.

Thus where there is a disabled child in the family to be cared for, “older siblings, especially girls, are at the greatest risk of parentification”; where a father-figure is missing, it may be the eldest son who is forced to take on his father’s responsibilities, without ever obtaining the autonomy that normally accompanies such adult roles.

Alternatively a widower may put a daughter into the social and emotional role of his deceased wife – “spousification”; or a mother can oblige her daughter to play the caring role, in a betrayal of the child’s normal expectation of love and care

Narcissistic

Narcissistic parentification occurs when a child is forced to take on the parent’s idealised projection, something which encourages a compulsive perfectionism in the child at the expense of their natural development. In a kind of pseudo-identification, the child is induced by any and all means to take on the characteristics of the parental ego ideal – a pattern that has been detected in western culture since Homer’s description of the character of Achilles.

Disadvantages

The almost inevitable byproduct of parentification is losing one’s own childhood. In destructive parentification, the child in question takes on excessive responsibility in the family, without their caretaking being acknowledged and supported by others: by adopting the role of parental care-giver, the child loses their real place in the family unit and is left lonely and unsure. In extreme instances, there may be what has been called a kind of disembodiment, a narcissistic wound that threatens one’s basic self-identity.

In later life, parentified children often experience anxiety over abandonment and loss, and demonstrate difficulty handling rejection and disappointment within interpersonal relationships.

Case Studies

  • Carl Jung in his late autobiography reports that his mother always spoke to him as an adult, confiding in him what she could not share with her husband. Laurens van der Post commented on the grown-up atmosphere surrounding the young Jung, and considered that “this activation of the pattern of the “old man” within himself…was all a consequence of the extent to which his father and mother failed each other”.
  • Patrick Casement reports on a patient – Mr T – whose mother was distressed at any and all his feelings, and who therefore protected her from them – mothering her himself.

Literary Examples

The Tale of Genji tells that for “Kaoru’s mother…her son’s visits were her chief pleasure. Sometimes he almost seemed more like a father than a son – a fact which he was aware of and thought rather sad”.

Charles Dickens’ “Angel in the house” characters, particularly Agnes Wickfield in David Copperfield, are parentified children. Agnes is forced to be the parent of her alcoholic father and seems to strive for perfection as a means of reaching the “ego ideal” of her deceased mother (who died upon child-birth). Agnes marries late, has relationship and intimacy problems (she has a hard time expressing her love for David until he reveals his own love for her), and has some self-defeating attitudes; in one scene she blames her own father’s misfortunes on herself. However, she proves to be resilient, resourceful, responsible and even potentially career-driven (she forms her own school). She also manages to marry the protagonist David and the two live happily together for 10 years with children by the end of the novel.

The theme of parentification has also been explored in the Twilight series, with particular but not exclusive reference to the character of Bella Swan.

An Overview of Bipolar Disorder in Children

Introduction

Bipolar disorder in children, or paediatric bipolar disorder (PBD), is a controversial mental disorder in children and adolescents that is mainly diagnosed in the United States, and is hypothesized to be like bipolar disorder (BD) in adults, thus is proposed as an explanation for extreme changes in mood and behaviour accompanying periods of depressed or irritable moods and periods of elevated moods so called manic or hypomanic episodes.

These shifts are sometimes quick, but usually are gradual. The average age of onset of paediatric bipolar disorder is unclear, but the risk increases with the onset of puberty. Bipolar disorder is rare in childhood. Paediatric bipolar disorder is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

The DSM has specified that the criteria for bipolar disorder can be applied to children since 1980. However, the exact criteria for diagnosing paediatric bipolar disorder remains controversial and heavily debated. There are big differences in how commonly it is diagnosed across clinics and in different countries. There has been a rapid increase in research on the topic, but training and clinical practice lag behind.

Identifying bipolar disorder in youth is challenging. Children often exhibit chronic rather than episodic mania periods. Almost always, these chronic problems have causes other than bipolar disorder. The criteria for paediatric bipolar disorder can also often be masked by developmental differences. Comorbid disorders make determining what symptoms are signs of bipolar disorder and which are due to other disorders (e.g. OCD, ADHD, disruptive behaviour problems) difficult, leading to complications in treatment. For example, a common treatment for OCD are serotonin re-uptake inhibitors (SRIs), however, SRIs can lead to mood instability and worsening bipolar disorder.[5] The most common misdiagnosis for ADHD in the USA is paediatric bipolar disorder due to hyperactivity being described as prolonged periods of mania. Empirical research conducted in 2004 found that “bipolar disorder (in preadolescence) was initially misdiagnosed in 12 out of 24 youths” (Mahoney, 2004). This is a dangerous misdiagnosis due to the vastly different treatment forms. Firstly, ADHD does not require mood stabilisers like paediatric bipolar disorder. Secondly, the stimulants given to treat ADHD have been shown to cause psychosis and exacerbate mania in paediatric bipolar disorder (Wendling, 2009). This misuse of medication can lead to mood episodes, suicidality, and hospitalisation.

Brief History

Descriptions of children with symptoms similar to contemporary concepts of mania date back to the 18th century. In 1898, a detailed psychiatric case history was published about a 13-year-old that met Jean-Pierre Falret and Jules Baillarger’s criteria for folie circulaire, which is congruent to the modern conception of bipolar I disorder.

In Emil Kraepelin’s descriptions of bipolar disorder in the 1920s, which he called “manic depressive insanity”, he noted the rare possibility that it could occur in children. In addition to Kraepelin, Adolf Meyer, Karl Abraham, and Melanie Klein were some of the first to document bipolar disorder symptoms in children in the first half of the 20th century. It was not mentioned much in English literature until the 1970s when interest in researching the subject increased. It became more accepted as a diagnosis in children in the 1980s after the DSM-III (1980) specified that the same criteria for diagnosing bipolar disorder in adults could also be applied to children.

Recognition came twenty years after, with epidemiological studies showing that approximately 20% of adults with bipolar disorder already had symptoms in childhood or adolescence. Nevertheless, onset before age 10 was thought to be rare, below 0.5% of the cases. During the second half of the century misdiagnosis with schizophrenia was not rare in the non-adult population due to common co-occurrence of psychosis and mania, this issue diminishing with an increased following of the DSM criteria in the last part of the 20th century.

Epidemiology

The prevalence of bipolar in youth is estimated at 2%.

Diagnosis

Diagnosis is made based on a clinical interview by a psychiatrist or other licensed mental health practitioner. There are no blood tests or brain scans to diagnose bipolar disorder. Obtaining information on family history and the use of questionnaires and checklists are helpful in making an accurate diagnosis. Commonly used assessment tools include the:

Signs and Symptoms

In both the American Psychiatric Association’s DSM-5 and the World Health Organisation’s ICD-10, the same criteria used to diagnose bipolar disorder in adults are used to make the diagnosis in children with some adjustments to account for differences in age and developmental stage. For example, the DSM-5 specifies that in children, depressive episodes can manifest as persistently irritable moods.

In diagnosing manic episodes, it is important to compare the changes in mood and behaviour to the child’s normal mood and behaviours at baseline instead of to other children or adults. For example, grandiosity (i.e. unrealistic overestimation of one’s intelligence, talent, or abilities) is normal at varying degrees during childhood and adolescence. Therefore, grandiosity is only considered symptomatic of mania in children when the beliefs are held despite being presented with concrete evidence otherwise or when they lead to a child attempting activities that are clearly dangerous, and most importantly, when the grandiose beliefs are an obvious change from that particular child’s normal self-view in between episodes.

Controversy

The diagnosis of childhood bipolar disorder is controversial, although it is recognised that bipolar disorder typical symptoms are dysfunctional and have negative consequences for minors suffering them. Main discussion is centred on whether what is called bipolar disorder in children refers to the same disorder than when diagnosing adults, and the related question on whether adults’ criteria for diagnosis are useful and accurate when applied to children. More specifically, main discussion over diagnosis in children circles around mania symptomatology and its differences between children and adults.

Diagnostic criteria may not correctly separate children with bipolar disorder from other problems such as ADHD, and emphasize fast mood cycles.

Treatment

Medications can produce important side effects, so interventions have been recommended to be closely monitored and families of patients to be informed of the different possible problems that can arise. Atypical antipsychotics are more effective than mood stabilizers, but have more side effects. Typical antipsychotics may produce weight gains as well as other metabolic problems, including diabetes mellitus type 2 and hyperlipidaemia. Extrapyramidal secondary effects may appear with these medications. These include tardive dyskinesia, a difficult-to-treat movement disorder (dyskinesia) that can appear after long-term use of antipsychotics. Liver and kidney damage are a possibility with mood stabilisers.

Psychological treatment usually includes some combination of education on the disease, group therapy and cognitive behavioural therapy (CBT). Children with bipolar disorder and their families are informed, in ways accordingly to their age and family role, about the different aspects of bipolar disorder and its management including causes, signs and symptoms and treatments. Group therapy aims to improve social skills and manage group conflicts, with role-playing as a critical tool. Finally, cognitive-behavioural training is directed towards the participants having a better understanding and control over their emotions and behaviours.

  • BPD I, manic or mixed, without psychosis:
    • Stage 1: Monotherapy with a mood stabiliser (lithium, Divalproex, or carbamazepine), or atypical antipsychotic (olanzapine, quetiapine, or risperidone).
      • Lithium or Divalproex is recommended for first-line treatment.
      • Partial (minimal to moderate) improvement with monotherapy, augment with another of the first-line recommendations.
    • Stage 2: Monotherapy with an alternative drug, then augmentation.
    • Stage 3: Possible medication combinations – lithium plus Divalproex, lithium plus atypical, or Divalproex plus atypical.
    • Stage 4: Combination of 2-3 mood stabilisers.
    • Stage 5: Alternate monotherapy with oxcarbazepine, ziprasidone, or aripiprazole (all Level D).
    • Stage 6: For nonresponse or intolerable side effects – clozapine for children or adolescents, or electroconvulsive therapy (ECT) for adolescents only.
  • BPD I, manic or mixed, with psychosis:
    • Stage 1: Same as BPD I without psychosis except for first-line treatment warrants a combination of mood stabiliser and an atypical antipsychotic.
    • Stages 2-4: Varying combinations and augmentations.
    • Stage 5: Alternate monotherapy (oxcarbazepine) plus an atypical antipsychotic.

Prognosis

Chronic medication is often needed, with relapses of individuals reaching rates over 90% in those not following medication indications and almost to 40% in those complying with medication regimens in some studies. Compared to adults, a juvenile onset has in general a similar or worse course, although age of onset predicts the duration of the episodes more than the prognosis. A risk factor for a worse outcome is the existence of additional (comorbid) pathologies.

Children with bipolar disorder are more likely to suicide than other children.

What is the Behaviour Analysis of Child Development?

Introduction

The behavioural analysis of child development originates from John B. Watson’s behaviourism.

Brief History

In 1948, Sidney Bijou took a position as associate professor of psychology at the University of Washington and served as director of the university’s Institute of Child Development. Under his leadership, the Institute added a child development clinic and nursery school classrooms where they conducted research that would later accumulate into the are that would be called “Behaviour Analysis of Child Development”. Skinner’s behavioural approach and Kantor’s interbehavioural approach were adopted in Bijou and Baer’s model. They created a three-stage model of development (basic, foundational, and societal). Bijou and Baer looked at these socially determined stages, as opposed to organising behaviour into change points or cusps (behavioural cusp). In the behavioural model, development is considered a behavioural change. It is dependent on the kind of stimulus and the person’s behavioural and learning function. Behaviour analysis in child development takes a mechanistic, contextual, and pragmatic approach.

From its inception, the behavioural model has focused on prediction and control of the developmental process. The model focuses on the analysis of a behaviour and then synthesizes the action to support the original behaviour. The model was changed after Richard J. Herrnstein studied the matching law of choice behaviour developed by studying of reinforcement in the natural environment. More recently, the model has focused more on behaviour over time and the way that behavioural responses become repetitive. it has become concerned with how behaviour is selected over time and forms into stable patterns of responding. A detailed history of this model was written by Pelaez. In 1995, Henry D. Schlinger, Jr. provided the first behaviour analytic text since Bijou and Baer comprehensively showed how behaviour analysis – a natural science approach to human behaviour – could be used to understand existing research in child development. In addition, the quantitative behavioural developmental model by Commons and Miller is the first behavioural theory and research to address notion similar to stage.

Research Methods

The methods used to analyse behaviour in child development are based on several types of measurements. Single-subject research with a longitudinal study follow-up is a commonly-used approach. Current research is focused on integrating single-subject designs through meta-analysis to determine the effect sizes of behavioural factors in development. Lag sequential analysis has become popular for tracking the stream of behaviour during observations. Group designs are increasingly being used. Model construction research involves latent growth modelling to determine developmental trajectories and structural equation modelling. Rasch analysis is now widely used to show sequentially within a developmental trajectory.

A recent methodological change in the behavioural analytic theory is the use of observational methods combined with lag sequential analysis can determine reinforcement in the natural setting.

Quantitative Behavioural Development

The model of hierarchical complexity is a quantitative analytic theory of development. This model offers an explanation for why certain tasks are acquired earlier than others through developmental sequences and gives an explanation of the biological, cultural, organisational, and individual principles of performance. It quantifies the order of hierarchical complexity of a task based on explicit and mathematical measurements of behaviour.

Research

Contingencies, Uncertainty, and Attachment

The behavioural model of attachment recognises the role of uncertainty in an infant and the child’s limited communication abilities. Contingent relationships are instrumental in the behaviour analytic theory, because much emphasis is put on those actions that produce parents’ responses.

The importance of contingency appears to be highlighted in other developmental theories, but the behavioural model recognises that contingency must be determined by two factors:

  • The efficiency of the action; and
  • That efficiency compared to other tasks that the infant might perform at that point.

Both infants and adults function in their environments by understanding these contingent relationships. Research has shown that contingent relationships lead to emotionally satisfying relationships.

Since 1961, behavioural research has shown that there is relationship between the parents’ responses to separation from the infant and outcomes of a “stranger situation.”. In a study done in 2000, six infants participated in a classic reversal design (refer to single-subject research) study that assessed infant approach rate to a stranger. If attention was based on stranger avoidance, the infant avoided the stranger. If attention was placed on infant approach, the infant approached the stranger.

Recent meta-analytic studies of this model of attachment based on contingency found a moderate effect of contingency on attachment, which increased to a large effect size when the quality of reinforcement was considered. Other research on contingency highlights its effect on the development of both pro-social and anti-social behaviour. These effects can also be furthered by training parents to become more sensitive to children’s behaviours, Meta-analytic research supports the notion that attachment is operant-based learning.

An infant’s sensitivity to contingencies can be affected by biological factors and environment changes. Studies show that being placed in erratic environments with few contingencies may cause a child to have conduct problems and may lead to depression (see Behavioural Development and Depression below). Research continues to look at the effects of learning-based attachment on moral development. Some studies have shown that erratic use of contingencies by parents early in life can produce devastating long-term effects for the child.

Motor Development

Since Watson developed the theory of behaviourism, behaviour analysts have held that motor development represents a conditioning process. This holds that crawling, climbing, and walking displayed by infants represents conditioning of biologically innate reflexes. In this case, the reflex of stepping is the respondent behaviour and these reflexes are environmentally conditioned through experience and practice. This position was criticised by maturation theorists. They believed that the stepping reflex for infants actually disappeared over time and was not “continuous”. By working with a slightly different theoretical model, while still using operant conditioning, Esther Thelen was able to show that children’s stepping reflex disappears as a function of increased physical weight. However, when infants were placed in water, that same stepping reflex returned. This offered a model for the continuity of the stepping reflex and the progressive stimulation model for behaviour analysts.

Infants deprived of physical stimulation or the opportunity to respond were found to have delayed motor development. Under conditions of extra stimulation, the motor behaviour of these children rapidly improved. Some research has shown that the use of a treadmill can be beneficial to children with motor delays including Down syndrome and cerebral palsy. Research on opportunity to respond and the building of motor development continues today.

The behavioural development model of motor activity has produced a number of techniques, including operant-based biofeedback to facilitate development with success. Some of the stimulation methods such as operant-based biofeedback have been applied as treatment to children with cerebral palsy and even spinal injury successfully. Brucker’s group demonstrated that specific operant conditioning-based biofeedback procedures can be effective in establishing more efficient use of remaining and surviving central nervous system cells after injury or after birth complications (like cerebral palsy). While such methods are not a cure and gains tend to be in the moderate range, they do show ability to enhance functioning.

Imitation and Verbal Behavior

Behaviourists have studied verbal behaviour since the 1920s. E.A. Esper (1920) studied associative models of language, which has evolved into the current language interventions of matrix training and recombinative generalisation. Skinner (1957) created a comprehensive taxonomy of language for speakers. Baer, along with Zettle and Haynes (1989), provided a developmental analysis of rule-governed behaviour for the listener. and for the listener Zettle and Hayes (1989) with Don Baer providing a developmental analysis of rule-governed behaviour. According to Skinner, language learning depends on environmental variables, which can be mastered by a child through imitation, practice, and selective reinforcement including automatic reinforcement.

B.F. Skinner was one of the first psychologists to take the role of imitation in verbal behaviour as a serious mechanism for acquisition. He identified echoic behaviour as one of his basic verbal operants, postulating that verbal behaviour was learned by an infant from a verbal community. Skinner’s account takes verbal behaviour beyond an intra-individual process to an inter-individual process. He defined verbal behaviour as “behaviour reinforced through the mediation of others”. Noam Chomsky refuted Skinner’s assumptions.

In the behavioural model, the child is prepared to contact the contingencies to “join” the listener and speaker. At the very core, verbal episodes involve the rotation of the roles as speaker and listener. These kinds of exchanges are called conversational units and have been the focus of research at Columbia’s communication disorders department.

Conversational units is a measure of socialisation because they consist of verbal interactions in which the exchange is reinforced by both the speaker and the listener. H.C. Chu (1998) demonstrated contextual conditions for inducing and expanding conversational units between children with autism and non-handicapped siblings in two separate experiments. The acquisition of conversational units and the expansion of verbal behaviour decrease incidences of physical “aggression” in the Chu study and several other reviews suggest similar effects. The joining of the listener and speaker progresses from listener speaker rotations with others as a likely precedent for the three major components of speaker-as-own listener – say so correspondence, self-talk conversational units, and naming.

Development of Self

Robert Kohelenberg and Mavis Tsai (1991) created a behaviour analytic model accounting for the development of one’s “self”. Their model proposes that verbal processes can be used to form a stable sense of who we are through behavioural processes such as stimulus control. Kohlenberg and Tsai developed functional analytic psychotherapy to treat psychopathological disorders arising from the frequent invalidations of a child’s statements such that “I” does not emerge. Other behaviour analytic models for personality disorders exist. They trace out the complex biological-environmental interaction for the development of avoidant and borderline personality disorders. They focus on Reinforcement sensitivity theory, which states that some individuals are more or less sensitive to reinforcement than others. Nelson-Grey views problematic response classes as being maintained by reinforcing consequences or through rule governance.

Socialisation

Over the last few decades, studies have supported the idea that contingent use of reinforcement and punishment over extended periods of time lead to the development of both pro-social and anti-social behaviours. However research has shown that reinforcement is more effective than punishment when teaching behaviour to a child. It has also been shown that modelling is more effective than “preaching” in developing pro-social behaviour in children. Rewards have also been closely studied in relation to the development of social behaviours in children. The building of self-control, empathy, and cooperation has all implicated rewards as a successful tactic, while sharing has been strongly linked with reinforcement.

The development of social skills in children is largely affected in that classroom setting by both teachers and peers. Reinforcement and punishment play major roles here as well. Peers frequently reinforce each other’s behaviour. One of the major areas that teachers and peers influence is sex-typed behaviour, while peers also largely influence modes of initiating interaction, and aggression. Peers are more likely to punish cross-gender play while at the same time reinforcing play specific to gender. Some studies found that teachers were more likely to reinforce dependent behaviour in females.

Behavioural principles have also been researched in emerging peer groups, focusing on status. Research shows that it takes different social skills to enter groups than it does to maintain or build one’s status in groups. Research also suggests that neglected children are the least interactive and aversive, yet remain relatively unknown in groups. Children suffering from social problems do see an improvement in social skills after behaviour therapy and behaviour modification (refer to applied behaviour analysis). Modelling has been successfully used to increase participation by shy and withdrawn children. Shaping of socially desirable behaviour through positive reinforcement seems to have some of the most positive effects in children experiencing social problems.

Anti-Social Behaviour

In the development of anti-social behaviour, aetiological models for anti-social behaviour show considerable correlation with negative reinforcement and response matching (refer to matching law). Escape conditioning, through the use of coercive behaviour, has a powerful effect on the development and use of future anti-social tactics. The use of anti-social tactics during conflicts can be negatively reinforced and eventually seen as functional for the child in moment to moment interactions. Anti-social behaviours will also develop in children when imitation is reinforced by social approval. If approval is not given by teachers or parents, it can often be given by peers. An example of this is swearing. Imitating a parent, brother, peer, or a character on TV, a child may engage in the anti-social behaviour of swearing. Upon saying it they may be reinforced by those around them which will lead to an increase in the anti-social behaviour. The role of stimulus control has also been extensively explored in the development of anti-social behaviour. Recent behavioural focus in the study of anti-social behaviour has been a focus on rule-governed behaviour. While correspondence for saying and doing has long been an interest for behaviour analysts in normal development and typical socialisation, recent conceptualisations have been built around families that actively train children in anti-social rules, as well as children who fail to develop rule control.

Developmental Depression with Origins in Childhood

Behavioural theory of depression was outlined by Charles Ferster. A later revision was provided by Peter Lewisohn and Hyman Hops. Hops continued the work on the role of negative reinforcement in maintaining depression with Anthony Biglan. Additional factors such as the role of loss of contingent relations through extinction and punishment were taken from early work of Martin Seligman. The most recent summary and conceptual revisions of the behavioural model was provided by Johnathan Kanter. The standard model is that depression has multiple paths to develop. It can be generated by five basic processes, including: lack or loss of positive reinforcement, direct positive or negative reinforcement for depressive behaviour, lack of rule-governed behaviour or too much rule-governed behaviour, and/or too much environmental punishment. For children, some of these variables could set the pattern for lifelong problems. For example, a child whose depressive behaviour functions for negative reinforcement by stopping fighting between parents could develop a lifelong pattern of depressive behaviour in the case of conflicts. Two paths that are particularly important are:

  1. Lack or loss of reinforcement because of missing necessary skills at a developmental cusp point; or
  2. The failure to develop adequate rule-governed behaviour.

For the latter, the child could develop a pattern of always choosing the short-term small immediate reward (i.e. escaping studying for a test) at the expense of the long-term larger reward (passing courses in middle school). The treatment approach that emerged from this research is called behavioural activation.

In addition, use of positive reinforcement has been shown to improve symptoms of depression in children. Reinforcement has also been shown to improve the self-concept in children with depression comorbid with learning difficulties. Rawson and Tabb (1993) used reinforcement with 99 students (90 males and 9 females) aged from 8 to 12 with behaviour disorders in a residential treatment program and showed significant reduction in depression symptoms compared to the control group.

Cognitive Behaviour

As children get older, direct control of contingencies is modified by the presence of rule-governed behaviour. Rules serve as an establishing operation and set a motivational stage as well as a discrimintative stage for behaviour. While the size of the effects on intellectual development are less clear, it appears that stimulation does have a facilitative effect on intellectual ability. However, it is important to be sure not to confuse the enhancing effect with the initial causal effect. Some data exists to show that children with developmental delays take more learning trials to acquire in material.

Learned Units and Developmental Retardation

Behaviour analysts have spent considerable time measuring learning in both the classroom and at home. In these settings, the role of a lack of stimulation has often been evidenced in the development of mild and moderate mental retardation. Recent work has focused on a model of “developmental retardation,”. an area that emphasizes cumulative environmental effects and their role in developmental delays. To measure these developmental delays, subjects are given the opportunity to respond, defined as the instructional antecedent, and success is signified by the appropriate response and/or fluency in responses. Consequently, the learned unit is identified by the opportunity to respond in addition to given reinforcement.

One study employed this model by comparing students’ time of instruction was in affluent schools to time of instruction in lower income schools. Results showed that lower income schools displayed approximately 15 minutes less instruction than more affluent schools due to disruptions in classroom management and behaviour management. Altogether, these disruptions culminated into two years worth of lost instructional time by grade 10. The goal of behaviour analytic research is to provide methods for reducing the overall number of children who fall into the retardation range of development by behavioural engineering.

Hart and Risely (1995, 1999) have completed extensive research on this topic as well. These researchers measured the rates of parent communication with children of the ages of 2-4 years and correlated this information with the IQ scores of the children at age 9. Their analyses revealed that higher parental communication with younger children was positively correlated with higher IQ in older children, even after controlling for race, class, and socio-economic status. Additionally, they concluded a significant change in IQ scores required intervention with at-risk children for approximately 40 hours per week.

Class Formation

The formation of class-like behaviour has also been a significant aspect in the behavioural analysis of development. This research has provided multiple explanations to the development and formation of class-like behaviour, including primary stimulus generalisation, an analysis of abstraction, relational frame theory, stimulus class analysis (sometimes referred to as recombinative generalisation), stimulus equivalence, and response class analysis. Multiple processes for class-like formation provide behaviour analysts with relatively pragmatic explanations for common issues of novelty and generalisation.

Responses are organised based upon the particular form needed to fit the current environmental challenges as well as the functional consequences. An example of large response classes lies in contingency adduction, which is an area that needs much further research, especially with a focus on how large classes of concepts shift. For example, as Piaget observed, individuals have a tendency at the pre-operational stage to have limits in their ability to preserve information. While children’s training in the development of conservation skills has been generally successful, complications have been noted. Behaviour analysts argue that this is largely due to the number of tool skills that need to be developed and integrated. Contingency adduction offers a process by which such skills can be synthesized and which shows why it deserves further attention, particularly by early childhood interventionists.

Autism

Ferster (1961) was the first researcher to posit a behaviour analytic theory for autism. Ferster’s model saw autism as a by-product of social interactions between parent and child. Ferster presented an analysis of how a variety of contingencies of reinforcement between parent and child during early childhood might establish and strengthen a repertoire of behaviours typically seen in children diagnosed with autism. A similar model was proposed by Drash and Tutor (1993), who developed the contingency-shaped or behavioural incompatibility theory of autism. They identified at least six reinforcement paradigms that may contribute to significant deficiencies in verbal behaviour typically characteristic of children diagnosed as autistic. They proposed that each of these paradigms may also create a repertoire of avoidance responses that could contribute to the establishment of a repertoire of behaviour that would be incompatible with the acquisition of age-appropriate verbal behaviour. More recent models attribute autism to neurological and sensory models that are overly worked and subsequently produce the autistic repertoire. Lovaas and Smith (1989) proposed that children with autism have a mismatch between their nervous systems and the environment, while Bijou and Ghezzi (1999) proposed a behavioural interference theory. However, both the environmental mismatch model and the inference model were recently reviewed, and new evidence shows support for the notion that the development of autistic behaviours are due to escape and avoidance of certain types of sensory stimuli. However, most behavioural models of autism remain largely speculative due to limited research efforts.

Role in Education

One of the largest impacts of behaviour analysis of child development is its role in the field of education. In 1968, Siegfried Englemann used operant conditioning techniques in a combination with rule learning to produce the direct instruction curriculum. In addition, Fred S. Keller used similar techniques to develop programmed instruction. B.F. Skinner developed a programmed instruction curriculum for teaching handwriting. One of Skinner’s students, Ogden Lindsley, developed a standardized semilogrithmic chart, the “Standard Behaviour Chart,” now “Standard Celeration Chart,” used to record frequencies of behaviour, and to allow direct visual comparisons of both frequencies and changes in those frequencies (termed “celeration”). The use of this charting tool for analysis of instructional effects or other environmental variables through the direct measurement of learner performance has become known as precision teaching.

Behaviour analysts with a focus on behavioural development form the basis of a movement called positive behaviour support (PBS). PBS has focused on building safe schools.

In education, there are many different kinds of learning that are implemented to improve skills needed for interactions later in life. Examples of this differential learning include social and language skills. According to the NWREL (Northwest Regional Educational Laboratory), too much interaction with technology will hinder a child’s social interactions with others due to its potential to become an addiction and subsequently lead to anti-social behaviour. In terms of language development, children will start to learn and know about 5-20 different words by 18 months old.

Critiques of Behavioural Approach and New Developments

Behaviour analytic theories have been criticized for their focus on the explanation of the acquisition of relatively simple behaviour (i.e. the behaviour of nonhuman species, of infants, and of individuals who are intellectually disabled or autistic) rather than of complex behaviour. Michael Commons continued behaviour analysis’s rejection of mentalism and the substitution of a task analysis of the particular skills to be learned. In his new model, Commons has created a behaviour analytic model of more complex behaviour in line with more contemporary quantitative behaviour analytic models called the model of hierarchical complexity. Commons constructed the model of hierarchical complexity of tasks and their corresponding stages of performance using just three main axioms.

In the study of development, recent work has been generated regarding the combination of behaviour analytic views with dynamical systems theory. The added benefit of this approach is its portrayal of how small patterns of changes in behaviour in terms of principles and mechanisms over time can produce substantial changes in development.

Current research in behaviour analysis attempts to extend the patterns learned in childhood and to determine their impact on adult development.

Professional Organisations

The Association for Behaviour Analysis International has a special interest group for the behaviour analysis of child development.

Doctoral level behaviour analysts who are psychologists belong to American Psychological Association’s division 25: behaviour analysis.

The World Association for Behaviour Analysis has a certification in behaviour therapy. The exam draws questions on behavioural theories of child development as well as behavioural theories of child psychopathology.

What is Oppositional Defiant Disorder?

Introduction

Oppositional defiant disorder (ODD) is listed in the DSM-5 under Disruptive, impulse-control, and conduct disorders and defined as “a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness” in children and adolescents.

This behaviour is usually targeted toward peers, parents, teachers, and other authority figures. Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit. It has certain links to Attention Deficit Hyperactivity Disorder (ADHD) and as much as one half of children with ODD will also diagnose as having ADHD as well.

Brief History

Oppositional defiant disorder was first defined in the DSM-III (1980). Since the introduction of ODD as an independent disorder, the field trials to inform the definition of this disorder have included predominantly male subjects. Some clinicians have debated whether the diagnostic criteria presented above would be clinically relevant for use with females. Furthermore, some have questioned whether gender-specific criteria and thresholds should be included. Additionally, some clinicians have questioned the preclusion of ODD when conduct disorder is present. According to Dickstein, the DSM-5 attempts to:

“redefine ODD by emphasizing a ‘persistent pattern of angry and irritable mood along with vindictive behavior,’ rather than DSM-IV’s focus exclusively on negativistic, hostile, and defiant behavior.’ Although DSM-IV implied, but did not mention, irritability, DSM-5 now includes three symptom clusters, one of which is ‘angry/irritable mood’—defined as ‘loses temper, is touchy/easily annoyed by others, and is angry/resentful.’ This suggests that the process of clinically relevant research driving nosology, and vice versa, has ensured that the future will bring greater understanding of ODD”.

Epidemiology

ODD, is a pattern of negativistic, defiant, disobedient and hostile behaviour, and is one of the most prevalent disorders from preschool age to adulthood. ODD is marked by defiant and disobedient behaviour towards authority figures. This can include: frequent temper tantrums, excessive arguing with adults, refusing to follow rules, acting in a way to purposely upset others, getting easily irked, having an angry attitude, and acting vindictive. Children with ODD usually begin showing symptoms around 6 to 8, although the disorder can emerge in younger children, too. Symptoms can last throughout the teen years. The pooled prevalence is approximately 3.6% up to age 18. There has been research to support that ODD is more common in boys than girls with a 2:1 ratio.

ODD has a prevalence of 1% to 11%. The average prevalence is approximately 3.3%. Gender and age play an important role in the rate of the disorder. In fact, ODD gradually develops and becomes apparent in preschool years; often before the age of eight years old. However, it is very unlikely to emerge following early adolescence. There is difference in prevalence between boys and girls. The ratio of this prevalence is 1.4 to 1 with it being more prevalent in boys than in girls, before adolescence. On the other hand, girls’ prevalence tends to increase after puberty. When researchers observed the general prevalence of oppositional defiant disorder throughout cultures, they noticed that it remained constant. However, the sex difference in ODD prevalence is only significant in Western cultures. There are two possible explanations for this difference which are that in non-Western cultures there is a decreased prevalence of ODD in boys or an increased prevalence of ODD in girls. Other factors can influence the prevalence of the disorder. One of these factors is the socioeconomic status. Youths living in families of low socioeconomic status have a higher prevalence. Another factor is based on the criteria used to diagnose an individual. When the disorder was first included in the DSM-III, the prevalence was 25% higher than when the DSM-IV revised the criteria of diagnosis. The DSM-V made more changes to the criteria grouping certain characteristics together in order to demonstrate that ODD display both emotional and behavioural symptomatology. In addition, criteria were added to help guide clinicians in diagnosis because of the difficulty found in identifying whether the behaviours or symptoms are directly related to the disorder or simply a phase in a child’s life. Consequently, future studies may obtain results indicating a decline in prevalence between the DSM-IV and the DSM-V due to these changes.

Signs and Symptoms

DSM-IV-TR) (now replaced by DSM-5) stated that a child must exhibit four out of the eight signs and symptoms to meet the diagnostic threshold for oppositional defiant disorder. These symptoms include:

  1. Often loses temper.
  2. Is often touchy or easily annoyed.
  3. Is often angry and resentful.
  4. Often argues with authority figures or for children and adolescents, with adults.
  5. Often actively defies or refuses to comply with requests from authority figures or with rules.
  6. Often deliberately annoys others.
  7. Often blames others for his or her mistakes or misbehaviour.
  8. Has been spiteful or vindictive at least twice within the past 6 months.

These behaviours are mostly directed towards an authority figure such as a teacher or a parent. Although these behaviours can be typical among siblings, they must be observed with individuals other than siblings for an ODD diagnosis. Children with ODD can be verbally aggressive. However, they do not display physical aggressiveness, a behaviour observed in conduct disorder. Furthermore, they must be perpetuated for longer than six months and must be considered beyond a normal child’s age, gender and culture to fit the diagnosis. For children under 5 years of age, they occur on most days over a period of 6 months. For children over 5 years of age they occur at least once a week for at least 6 months. It is possible to observe these symptoms in only one setting, most commonly home. Thus the severity would be mild. If it is observed in two settings then it would be characterised as moderate and if the symptoms are observed in 3 or more settings then it would be considered severe.

These patterns of behaviour result in impairment at school and/or other social venues.

Aetiology

There is no specific element that has yet been identified as directly causing ODD. Researchers looking precisely at the etiological factors linked with ODD are limited. The literature often examines common risk factors linked with all disruptive behaviours, rather than specifically about ODD. Symptoms of ODD are also often believed to be the same as CD even though the disorders have their own respective set of symptoms. When looking at disruptive behaviours such as ODD, research has shown that the causes of behaviours are multifactorial. However, disruptive behaviours have been identified as being mostly due either to biological or environmental factors.

Genetic Influences

Research indicates that parents pass on a tendency for externalising disorders to their children that may be displayed in multiple ways, such as inattention, hyperactivity, or oppositional and conduct problems. Research has also shown that there is a genetic overlap between ODD and other externalising disorders. Heritability can vary by age, age of onset, and other factors. Adoption and twin studies indicate that 50% or more of the variance causing antisocial behaviour is attributable to heredity for both males and females. ODD also tends to occur in families with a history of ADHD, substance use disorders, or mood disorders, suggesting that a vulnerability to develop ODD may be inherited. A difficult temperament, impulsivity, and a tendency to seek rewards can also increase the risk of developing ODD. New studies into gene variants have also identified possible gene-environment (G x E) interactions, specifically in the development of conduct problems. A variant of the gene that encodes the neurotransmitter metabolising enzyme monoamine oxidase-A (MAOA), which relates to neural systems involved in aggression, plays a key role in regulating behaviour following threatening events. Brain imaging studies show patterns of arousal in areas of the brain that are associated with aggression in response to emotion-provoking stimuli.

Prenatal Factors and Birth Complications

Many pregnancy and birth problems are related to the development of conduct problems. Malnutrition, specifically protein deficiency, lead poisoning or exposure to lead, and mother’s use of alcohol or other substances during pregnancy may increase the risk of developing ODD. In numerous research, substance use prior to birth has also been associated with developing disruptive behaviours such as ODD. Although pregnancy and birth factors are correlated with ODD, strong evidence of direct biological causation is lacking.

Neurobiological Factors

Deficits and injuries to certain areas of the brain can lead to serious behavioural problems in children. Brain imaging studies have suggested that children with ODD may have hypofunction in the part of the brain responsible for reasoning, judgment, and impulse control. Children with ODD are thought to have an overactive behavioural activation system (BAS) and an underactive behavioural inhibition system (BIS) (both discussed here). The BAS stimulates behaviour in response to signals of reward or non-punishment. The BIS produces anxiety and inhibits ongoing behaviour in the presence of novel events, innate fear stimuli, and signals of non-reward or punishment. Neuroimaging studies have also identified structural and functional brain abnormalities in several brain regions in youths with conduct disorders. These brain regions are the amygdala, prefrontal cortex, anterior cingulate, and insula, as well as interconnected regions.

Social-Cognitive Factors

As many as 40% of boys and 25% of girls with persistent conduct problems display significant social-cognitive impairments. Some of these deficits include immature forms of thinking (such as egocentrism), failure to use verbal mediators to regulate his or her behaviour, and cognitive distortions, such as interpreting a neutral event as an intentional hostile act. Children with ODD have difficulty controlling their emotions or behaviours. In fact, students with ODD have limited social knowledge that is based only on individual experiences, which shapes how they process information and solve problems cognitively. This information can be linked with the social information processing model (SIP) that describes how children process information to respond appropriately or inappropriately in social settings. This model explains that children will go through five stages before displaying behaviours: encoding, mental representations, response accessing, evaluation, and enactment. However, children with ODD have cognitive distortions and impaired cognitive processes. This will therefore directly impact their interactions and relationship negatively. It has been shown that social and cognitive impairments result in negative peer relationships, loss of friendship, and an interruption in socially engaging in activities. Children learn through observational learning and social learning. Therefore, observations of models have a direct impact and greatly influence children’s behaviours and decision-making processes. Children often learn through modelling behaviour. Modelling can act as a powerful tool to modify children’s cognition and behaviours.

Environmental Factors

Negative parenting practices and parent-child conflict may lead to antisocial behaviour, but they may also be a reaction to the oppositional and aggressive behaviours of children. Factors such as a family history of mental illnesses and/or substance use disorders as well as a dysfunctional family and inconsistent discipline by a parent or guardian can lead to the development of behaviour disorders. Parenting practices not providing adequate or appropriate adjustment to situations as well as a high ratio of conflicting events within a family are causal factors of risk for developing ODD.

Insecure parent-child attachments can also contribute to ODD. Often little internalisation of parent and societal standards exists in children with conduct problems. These weak bonds with their parents may lead children to associate with delinquency and substance use. Family instability and stress can also contribute to the development of ODD. Although the association between family factors and conduct problems is well established, the nature of this association and the possible causal role of family factors continues to be debated.

In a number of studies, low socioeconomic status has also been associated with disruptive behaviors such as ODD.

Other social factors such as neglect, abuse, parents that are not involved, and lack of supervision can also contribute to ODD.

Externalising problems are reported to be more frequent among minority-status youth, a finding that is likely related to economic hardship, limited employment opportunities, and living in high-risk urban neighbourhoods. Studies have also found that the state of being exposed to violence was also a contribution factor for externalizing behaviours to occur.

Diagnosis

For a child or adolescent to qualify for a diagnosis of ODD, behaviours must cause considerable distress for the family or interfere significantly with academic or social functioning. Interference might take the form of preventing the child or adolescent from learning at school or making friends or placing him or her in harmful situations. These behaviours must also persist for at least six months. Effects of ODD can be greatly amplified by other disorders in comorbidity such as ADHD. Other common comorbid disorders include depression and substance use disorders.

Management

Approaches to the treatment of ODD include parent management training, individual psychotherapy, family therapy, cognitive behavioural therapy, and social skills training. According to the American Academy of Child and Adolescent Psychiatry, treatments for ODD are tailored specifically to the individual child, and different treatment techniques are applied for pre-schoolers and adolescents.

Children with oppositional defiant disorder tend to exhibit problematic behaviour that can be very difficult to control. An occupational therapist can recommend family based education referred to as Parent Management Training (PMT) in order to encourage positive parents and child relationships and reduce the child’s tantrums and other disruptive behaviours. Since ODD is a neurological disorder that has biological correlates, an occupational therapist can also provide problem solving training to encourage positive coping skills when difficult situations arise, as well as offer cognitive behavioural therapy (CBT).

Psychopharmacological Treatment

Psychopharmacological treatment is the use of prescribed medication in managing oppositional defiant disorder. Prescribed medications to control ODD include mood stabilisers, anti-psychotics, and stimulants. In two controlled randomised trials, it was found that between administered lithium and the placebo group, administering lithium decreased aggression in children with conduct disorder in a safe manner. However, a third study found the treatment of lithium over a period of two weeks invalid. Other drugs seen in studies include haloperidol, thioridazine, and methylphenidate which also is effective in treating ADHD, as it is a common comorbidity.

The effectiveness of drug and medication treatment is not well established. Effects that can result in taking these medications include hypotension, extrapyramidal symptoms, tardive dyskinesia, obesity, and increase in weight. Psychopharmacological treatment is found to be most effective when paired with another treatment plan, such as individual intervention or multimodal intervention.

In one case, a 16-year-old boy was given oestrogen at an L.A. juvenile jail due to allegedly having ODD due to somewhat elevated testosterone levels, developing gynecomastia and requiring breast reduction surgery as a result.

Individual Interventions

Individual interventions are focused on child-specific individualised plans. These interventions include anger control/stress inoculation, assertiveness training, and child-focused problem-solving skills training programme, and self-monitoring skills.

Anger control and stress inoculation help prepare the child for possible upsetting situations or events that may cause anger and stress. It includes a process of steps they may go through.

Assertiveness training educates individuals in keeping a balance between passivity and aggression. It is about creating a response that is controlled, and fair.

A child-focused problem-solving skills training programme aims to teach the child new skills and cognitive processes that teach how to deal with negative thoughts, feelings, and actions.

Parent and Family Treatment

According to randomised trials evidence shows that parent management training is most effective. It has strong influences over a longer period of time and in various environments.

Parent-child interaction training is intended to coach the parents while involving the child. This training has two phases. The first phase being child-directed interaction, whereby it is focused on teaching the child non-directive play skills. The second phase is parent-directed interaction, where the parents are coached on aspects including clear instruction, praise for compliance, and time-out for noncompliance. The parent-child interaction training is best suited for elementary-aged children.

Parent and family treatment has a low financial cost, which can yield an increase in beneficial results.

Multimodal Intervention

Multimodal intervention is an effective treatment that looks at different levels including family, peers, school, and neighbourhood. It is an intervention that concentrates on multiple risk factors. The focus is on parent training, classroom social skills, and playground behaviour programmes. The intervention is intensive and addresses barriers to individuals’ improvement such as parental substance use or parental marital conflict.

An impediment to treatment includes the nature of the disorder itself, whereby treatment is often not complied with and is not continued or stuck with for adequate periods of time.

Comorbidity

ODD can be described as a term or disorder with a variety of pathways in regard to comorbidity. High importance must be given to the representation of ODD as a distinct psychiatric disorder independent of conduct disorder.

In the context of oppositional defiant disorder and comorbidity with other disorders, researchers often conclude that ODD co-occurs with an ADHD, anxiety disorders, emotional disorders as well as mood disorders. Those mood disorders can be linked to major depression or bipolar disorder. Indirect consequences of ODD can also be related or associated with a later mental disorder. For instance, conduct disorder is often studied in connection with ODD. Strong comorbidity can be observed within those two disorders, but an even higher connection with ADHD in relation to ODD can be seen. For instance, children or adolescents who have ODD with coexisting ADHD will usually be more aggressive, will have more of the negative behavioural symptoms of ODD and thus, inhibit them from having a successful academic life. This will be reflected in their academic path as students.

Other conditions that can be predicted in children or people with ODD are learning disorders in which the person has significant impairments with academics and language disorders in which problems can be observed related to language production and/or comprehension.

What is Resignation Syndrome?

Introduction

Resignation syndrome (also called traumatic withdrawal syndrome or traumatic refusal; Swedish: uppgivenhetssyndrom) is a possibly factitious, dissociative syndrome that induces a catatonic state, first described in Sweden in the 1990s. The condition affects predominately psychologically traumatised children and adolescents in the midst of a strenuous and lengthy migration process.

Refer to Pervasive Refusal Syndrome (PRS).

Young people reportedly develop depressive symptoms, become socially withdrawn, and become motionless and speechless as a reaction to stress and hopelessness. In the worst cases, children reject any food or drink and have to be fed by feeding tube; the condition can persist for years. Recovery ensues within months to years and is claimed to be dependent on the restoration of hope to the family.

More recently, this phenomenon has been called into question, with two children witnessing that they were forced by their parents to act apathetic in order to increase chances of being granted residence permits. As evidenced by medical records, healthcare professionals were aware of this scam, and witnessed parents who actively refused aid for their children but remained silent at the time. Later Sveriges Television, Sweden’s national public television broadcaster, were severely critiqued by investigative journalist Janne Josefsson for failing to uncover the truth. In March 2020, a report citing the Swedish Agency for Medical and Social Evaluation, SBU, said “There are no scientific studies that answer how to diagnose abandonment syndrome, nor what treatment works.”

Signs and Symptoms

Affected individuals (predominantly children and adolescents) first exhibit symptoms of anxiety and depression (in particular apathy, lethargy), then withdraw from others and care for themselves. Eventually their condition might progress to stupor, i.e. they stop walking, eating, talking, and grow incontinent. In this stage patients are seemingly unconscious and tube feeding is life-sustaining. The condition could persist for months or even years. Remission happens after life circumstances improve and ensues with gradual return to what appears to be normal function.

Nosology

Refusal syndrome and pervasive refusal syndrome shares common features and etiologic factors; however, the former is more clearly associated with trauma and adverse life circumstances. Neither is included in the standard psychiatric classification systems.

Pervasive refusal syndrome (also called pervasive arousal withdrawal syndrome) has been conceptualised in a variety of ways, including a form of post-traumatic stress disorder, learned helplessness, ‘lethal mothering’, loss of the internal parent, apathy or the ‘giving-up’ syndrome, depressive devitalisation, primitive ‘freeze’, severe loss of activities of daily living and ‘manipulative’ illness. It was also suggested to be on the ‘refusal-withdrawal-regression spectrum’.

Acknowledging its social importance and relevance, the Swedish National Board of Health and Welfare recognised the novel diagnostic entity resignation syndrome in 2014. While others argue that already-existing diagnostic entities should be used and are sufficient in the majority of cases, i.e. severe major depressive disorder with psychotic symptoms or catatonia, or conversion/dissociation disorder.

Currently, diagnostic criteria are undetermined, pathogenesis is uncertain, and effective treatment is lacking.

Causes

Resignation syndrome appears to be a very specialised response to the trauma of refugee limbo, in which families, many of whom have escaped dangerous circumstances in their home countries, wait to be granted legal permission to stay in their new country, often undergoing numerous refusals and appeals over a period of years.

Experts proposed multifactorial explanatory models involving individual vulnerability, traumatisation, migration, culturally conditioned reaction patterns and parental dysfunction or pathological adaption to a caregiver’s expectations to interplay in pathogenesis. Severe depression or conversion/dissociation disorder has been also suggested (as best diagnostic alternatives).

However, the currently prevailing stress hypothesis fails to account for the regional distribution (see Epidemiology) and contributes little to treatment. An asserted “questioning attitude”, in particular within the health care system, it has been claimed, may constitute a “perpetuating retraumatization possibly explaining the endemic” distribution. Furthermore, Sweden’s experience raises concerns about “contagion”. Researchers argue that culture-bound psychogenesis can accommodate the endemic distribution because children may learn that dissociation is a way to deal with trauma.

A proposed neurobiological model of the disorder suggests that the impact of overwhelming negative expectations are directly causative of the down-regulation of higher order and lower order behavioural systems in particularly vulnerable individuals.

Epidemiology

Depicted as a culture-bound syndrome, it was first observed and described in Sweden among children of asylum seekers from former Soviet and Yugoslav countries. In Sweden, hundreds of migrant children, facing the possibility of deportation, have been diagnosed since the 1990s. For example, 424 cases were reported between 2003 and 2005; and 2.8% of all 6547 asylum applications submitted for children were diagnosed in 2004.

It has also been observed in refugee children transferred from Australia to the Nauru Regional Processing Centre. The Economist wrote in 2018 that Doctors without Borders (MSF) refused to say how many of the children on Nauru may be suffering from traumatic withdrawal syndrome. A report published in August 2018 suggested there were at least 30. The National Justice Project, a legal centre, has brought 35 children from Nauru this year. It estimates that seven were suffering from refusal syndrome, and three were psychotic.

What is Pervasive Refusal Syndrome?

Introduction

Pervasive refusal syndrome (PRS), also known as pervasive arousal withdrawal syndrome (PAWS) is a rare hypothesized paediatric mental disorder. PRS is not included in the standard psychiatric classification systems; that is, PRS is not a recognised mental disorder in the World Health Organisation’s current (ICD-10) and upcoming (ICD-11) International Classification of Diseases and the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Refer to Resignation Syndrome.

Purported Signs and Symptoms

According to some authors, PRS symptoms have common characteristics with other psychiatric disorders, but (according to these authors), current psychiatric classification schemes, such as the DSM cannot account for the full scope of symptoms seen in PRS. Purported symptoms include partial or complete refusal to eat, move, talk, or care for oneself; active and angry resistance to acts of help and support; social withdrawal; and school refusal.

Hypothesized Causes

Trauma might be a causal factor because PRS is repeatedly seen in refugees and witnesses to violence. Viral infections might be a risk factor for PRS.

Mechanism

Some authors hypothesize that learned helplessness is one of the mechanisms involved in PRS. A number of cases have been reported in the context of eating disorders.

Hypothesized Epidemiology

Epidemiological studies are lacking. Pervasive refusal syndrome is reportedly more frequent in girls than boys. The average age of onset is purported to be 7-15.

What is the Diagnostic Classification of Mental Health and Developmental Disorder of Infancy and Early Childhood?

Introduction

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC) is a developmentally based diagnostic manual that provides clinical criteria for categorising mental health and developmental disorders in infants and toddlers.

It is organised into a five-part axis system. The book has been translated into several languages and its model is widely adopted for the assessment of children of up to five years in age.

The DC 0-3R is meant to complement, but not replace, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) of the World Health Organisation (WHO). It is intended to enhance the understanding of young children by making it possible to assess, diagnose, and treat mental health problems in infants and toddlers by allowing for the identification of disorders not addressed in other classification systems.

The DC is organised around three primary principles:

  1. That children’s psychological functioning unfolds in the context of relationships;
  2. That individual differences in temperament and constitutional strengths and vulnerabilities play a major role in how children experience and process events; and
  3. That the family’s cultural context is important for the understanding of the child’s developmental course.

Brief History

Originally published in 1994, ZERO TO THREE’s Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:03) was the first developmentally based system for diagnosing mental health and developmental disorders of infants and toddlers (i.e. 0 to 3).

The revised DC:03, published in 2005 (DC:03R) drew on empirical research and clinical practice that had occurred worldwide since the 1994 publication and extended the depth and criteria of the original DC:03.

DC:05 captures new findings relevant to diagnosis in young children and addresses unresolved issues in the field since DC:03R was published in 2005.

DC:05 is designed to help mental health and other professionals: recognize mental health and developmental challenges in infants and young children, through 5 years old; understand that relationships and psychosocial stressors contribute to mental health and developmental disorders and incorporate contextual factors into the diagnostic process; use diagnostic criteria effectively for classification, case formulation, and intervention; and facilitate research on mental health disorders in infants and young children. DC:05 enhances the professional’s ability to prevent, diagnose, and treat mental health problems in the earliest years by identifying and describing disorders not addressed in other classification systems and by pointing the way to effective intervention approaches. Individuals across disciplines, mental health clinicians, counsellors, physicians, nurses, early interventionists, social workers, and researchers will find DC:05 to be an essential guide to evaluation and treatment planning with infants, young children, and their families in a wide range of settings.

The Diagnostic Process

The diagnostic process is one that is ongoing and done over a period of time. The process includes gathering a series of information regarding the child’s behaviour and presenting problems. The information is collected by a clinician and pertains to the child’s adaptation and development across different occasions and contexts.

According to the DC, the diagnostic process consists of two aspects:

  1. The classification of disorders; and
  2. The assessment of individuals.

One of the primary reasons for the classification of disorders is to facilitate communication between professionals. Once a diagnosis has been made, a clinician can then make associations between their clients’ symptoms and previously existing knowledge regarding the disorders’ aetiology, pathogenesis, treatment, and prognosis. Furthermore, using the classification of disorders can facilitate the process of finding existing services and mental health systems that are appropriate for the particular needs of the affected child. The assessment of children thus becomes a pivotal process that is undertaken by clinicians in order to grant access to treatment and intervention services related to specified disorders.

Clinical assessment and diagnosis involves making observations and gathering information from multiple sources relating to the child’s life in conjunction with a general diagnostic scheme. Both the DSM and ICD classification systems have evolved to use a multiaxial scheme, thus, clinicians have been using them not only for the classification of disorder but also as a guide for assessment and diagnosis. The first three axes of the DSM and ICD relate to the classification of disorder, and the fourth and fifth relate to the assessment of the individual within their personal environment. Similarly, the DC also follows a multiaxial scheme.

Classification

The DC 0-3R provides a provisional diagnosis system, focusing on multi-axial classification. The system is a provisional system because it recognises the fluidity and change that may occur with more knowledge in the field. This classification system is not entirely synonymous with the DSM-IV and the ICD-10, because it concentrates on developmental issues. There is also an emphasis placed on dynamic processes, relationships, and adaptive patterns within a developmental framework. The use of this classification system imparts knowledge about the diagnostic profile of a child, and the various contextual factors that may contribute to difficulties.

The DC functions as a reference for the earlier manifestations of problems in infants and children, which can be connected to later problems in functioning. Secondly, the categorisation focuses on types of difficulties in young children that are not addressed in other classification models.

The diagnostic categories vary in description, with more familiar categories described less. Categories that are more specific to young childhood and infancy, and newly based on clinical approaches are described in more detail. Furthermore, some categories may have subtypes to promote research, clinical awareness, and intervention planning, whereas others do not. This is important information to keep in mind when reading the DC.

The Multi-Axial System

Axis I: Clinical Disorders

Axis 1 of the DC provides diagnostic classifications for the most primary symptoms of the presenting difficulties. These diagnoses focus on the infant or child’s functioning. The primary diagnoses include:

  1. Posttraumatic Stress Disorder:
    • This refers to children who may be experiencing or have experienced a single traumatic event (e.g. an earthquake), a series of traumatic events (e.g. air raids), or chronic stress (e.g. abuse).
    • Furthermore, the nature of the trauma and its effect on the child must be understood in the context of the child. Specifically, attention must be paid to factors such as social context, personality factors, and the caregivers’ ability to assist with coping.
  2. Disorders of Affect:
    • This classification of disorders is related to the infant or child’s affective and behavioural experiences.
    • This group of disorders includes mood disorders and deprivation/maltreatment disorder.
    • This classification focuses on the infant or child’s functioning in its entirety rather than a specific event or situation (refer to Affective spectrum).
  3. Adjustment Disorder:
    • When considering a diagnosis of adjustment disorder, one has to examine the situational factors to determine if it is a mild disruption in the child’s usual functioning (e.g. switching schools).
    • These difficulties must also not meet the criteria for other disorders included in the categories.
  4. Regulation Disorders of Sensory Processing:
    1. The child manifests difficulties in regulating behavioural, motor, attention, physiological, sensory, and affective processes.
    2. These difficulties can affect the child’s daily functioning and relationships (refer to Sensory processing disorder).
  5. Sleep Behaviour Disorder:
    • To diagnose a sleep disorder, the child should be showing a sleep disturbance and not be demonstrating sensory reactive or processing difficulties.
    • This diagnosis should not be used when sleep problems are related to issues of anxiety or traumatic events.
  6. Eating Behaviour Disorder:
    • This diagnosis may become evident in infancy and young childhood as the child may show difficulties in regular eating patterns.
    • The child may not be regulating feeding with physiological reactions of hunger. This diagnosis is a primary diagnosis in the absence of traumatic, affective, and regulatory difficulties (refer to eating disorder).
  7. Disorders of Relating and Communicating:
    • These disorders involve difficulties in communication, in conjunction with difficulties in regulation of physiological, motor, cognitive, and many other processes.

Axis II: Relationship Classification

Axis II focuses on children and infants developing in the context of emotional relationships. Specifically, the quality of caregiving can have a strong impact in nurturance and steering a child on a particular developmental course, either adaptive or maladaptive. This particular axis concentrates on the diagnosis of a clinical issue in the relationship between the child and the caregiver. The presence of a disorder indicates difficulties in relationships. These disorders include various patterns that highlight behaviour, affective, and psychological factors between the child and the caregiver.

  • Overinvolved.
  • Underinvolved.
  • Anxious/Tense.
  • Angry/Hostile.
  • Mixed Relationship Disorder.
  • Abusive.

Axis III: Medical and Developmental Disorders and Conditions

Axis III focuses on physical, mental, or developmental classification using other diagnosis methods. These disorders and conditions are not treated as a single diagnosis, but as a problem that may co-exist with others, as it may involve developmental difficulties.

Axis IV: Psychosocial Stressors

This axis allows clinicians to focus on the intensity of psychosocial stress, which may act as influencing agents in infant and childhood difficulties/disorders. Psychosocial stress can have direct and indirect influences on infants and children, and depends on various factors.

Axis V: Emotional and Social Functioning

Emotional and social functioning capacities can be assessed using observations of the child with primary caregivers. The essential domains of functioning can be used in these observations on a 5-point scale, that describes overall functional emotional level.

Rating Scales and Checklists

The DC contains four forms that aid clinicians in identifying disorders in infants and toddlers, in examining the extent of problem behaviours, and in determining the nature of external factors influencing the child.

  • Functional Rating Scale for Emotional and Social Functioning Capacities: to evaluate the child’s communication skills and expressions of thoughts and feelings.
  • The Parent-Infant Relationship Global Assessment Scale (PIR-GAS; from Axis II): to evaluate the quality of a caregiver-child relationship and identify relationship disorders.
  • Relationship Problems Checklist (RPCL; from Axis II): allows the clinician to identify the extent to which a caregiver-child relationship can be described by a number of criterion-based qualities.
  • Psychosocial and Environmental Stressors Checklist (from Axis IV): to provide information on the stressors experienced by the child in various contexts.

The Future of DC

Important questions remain to be answered, in spite of the revisions made in the DC. Such questions include the following:

  • How can the functional adaptation of infants and children be evaluated and described independent of diagnosis?
  • How can disruptive behaviours of typical development in infants and children be distinguished from disordered behaviours that lead to atypical development?
  • Should Excessive Crying Disorder be considered as a functional regulatory disorder? Other functional regulatory disorders include Sleeping Behaviour and Feeding Behaviour Disorders.
  • Should future editions of the DC include a Family Axis containing information about family history of mental illness, family structure and available supports, and family culture? These aspects are all central to assessment and treatment planning.

What is Child Psychopathology?

Introduction

Child psychopathology refers to the scientific study of mental disorders in children and adolescents.

Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. Mental health providers who work with children and adolescents are informed by research in developmental psychology, clinical child psychology, and family systems. Lists of child and adult mental disorders can be found in the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), published by the World Health Organisation (WHO) and in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA). In addition, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC) is used in assessing mental health and developmental disorders in children up to age five.

Causes

The aetiology of child psychopathology has many explanations which differ from case to case. Many psychopathological disorders in children involve genetic and physiological mechanisms, though there are still many without any physical grounds. It is absolutely imperative that multiple sources of data be gathered. Diagnosing the psychopathology of children is daunting. It is influenced by development and contest, in addition to the traditional sources. Interviews with parents about school, etc., are inadequate. Either reports from teachers or direct observation by the professional are critical. (author, Robert B. Bloom, Ph.D.) The disorders with physical or biological mechanisms are easier to diagnose in children and are often diagnosed earlier in childhood. However, there are some disorders, no matter the mechanisms, that are not identified until adulthood. There is also reason to believe that there is co-morbidity of disorders, in that if one disorder is present, there is often another.

Stress

Emotional stress or trauma in the parent-child relationship tends to be a cause of child psychopathology. First seen in infants, separation anxiety in root of parental-child stress may lay the foundations for future disorders in children. There is a direct correlation between maternal stress and child stress that is factored in both throughout adolescent development. In a situation where the mother is absent, any primary caregiver to the child could be seen as the “maternal” relationship. Essentially, the child would bond with the primary caregiver, and may exude some personality traits of the caregiver.

In studies of child in two age groups of pregnancy to five years, and fifteen years and twenty years, Raposa and colleagues (2011) studied the impact of psychopathology in the child-maternal relationship and how not only the mothers stress affected the child, but the child’s stress affected the mother. Historically, it was believed that mothers who suffered from post partum depression might be the reason their child suffers from mental disorders both earlier and later in development. However this correlation was found to not only reflect maternal depression on child psychopathology, but also child psychopathology could reflect on maternal depression.

Children with a predisposition to psychopathology may cause higher stress in the relationship with their mother, and mothers who suffer from psychopathology may also cause higher stress in the relationship with their child. Child psychopathology creates stress in parenting which may increase the severity of the psychopathology within the child. Together, these factors push and pull the relationship thus causing higher levels of depression, ADHD, defiant disorder, learning disabilities, and pervasive developmental disorder in both the mother and the child. The outline and summary of this study is found below:

In looking at child-related stress, the number of past child mental health diagnoses significantly predicted a higher number of acute stressors for mothers as well as more chronic stress in the mother-child relationship at age 15. These increased levels of maternal stress and mother-child relationship stress at age 15 then predicted higher levels of maternal depression when the youth were 20 years old.

Looking more closely at the data, the authors found that it was the chronic stress in the mother-child relationship and the child-related acute stressors that were the linchpins between child psychopathology and maternal depression. The stress is what fuelled the fires between mother and child mental health. Going one step further, the researchers found that youth with a history of more than one diagnosis as well as youth that had externalizing disorders (e.g. conduct disorder) had the highest number of child-related stressors and the highest levels of mother-child stress. Again, all of the findings held up when other potentially stressful variables, such as economic worries and past maternal depression, were controlled for.

Additionally, siblings- both older and younger and of both genders, can be factored into the aetiology and development of child psychopathology. In a longitudinal study of maternal depression and older male child depression and antisocial behaviours on younger siblings adolescent mental health outcome. The study factored in ineffective parenting and sibling conflicts such as sibling rivalry. Younger female siblings were more directly affected by maternal depression and older brother depression and anti social behaviours when the indirect effects were not place, in comparison to younger male siblings who showed no such comparison. However, if an older brother were anti-social, the younger child – female or male would exude higher anti-social behaviours. In the presence of a sibling conflict, anti social behaviour was more influential on younger male children than younger female children. Female children were more sensitive to pathological familial environments, thus showing that in a high-stress environment with both maternal depression and older- male sibling depression and anti social behaviour, there is a higher risk of female children developing psychopathological disorders. This was a small study, and more research needs to be done especially with older female children, paternal relationships, maternal-paternal-child stress relationships, and/or caregiver-child stress relationships if the child is orphaned or not being raised by the biological child to reach a conclusive child-parent stress model on the effects of familial and environmental pathology on the child’s development.

Temperament

The child-parent stress and development is only one hypothesis for the aetiology of child psychopathology. Other experts believe that child temperament is a large factor in the development of child psychopathology. High susceptibility to child psychopathology is marked by low levels of effortful control and high levels of emotionality and neuroticism. Parental divorce is often a large factor in childhood depression and other psychopathological disorders. This is more so when the divorce involves a long-drawn separation and one parent bad-mouthing the other. That is not to say that divorce will lead to psychopathological disorders, there are also other factors such as temperament, trauma, and other negative life events (e.g. death, sudden moving of home, physical or sexual abuse), genetics, environment, and nurture that correlate to the onset of a disorder. Research has also shown that child maltreatment may increase risk for various forms of psychopathology as it increases threat sensitivity, decreases responsivity to reward, and causes deficits in emotion recognition and understanding.

Found in “The Role of Temperament in the Etiology of Child Psychopathology”, a model for the aetiology of child psychopathology by Vasey and Dadds (2001) proposed that the four things that are important to the development of psychopathological disorders is:

  1. Biological factors: hormones, genetics, and neurotransmitters;
  2. Psychological: self-esteem, coping skills, and cognitive issues;
  3. Social factors: family rearing, negative learning experiences, and stress; and
  4. Child’s temperament.

Using an array of neurological scans and exams, psychological evaluations, family medical history, and observing the child in daily factors can help the physician find the aetiology of the psychopathological disorder to help release the child of the symptoms through therapy, medication use, social skills training, and life style changes.

Child psychopathology can cause separation anxiety from parents, attention deficit disorders in children, sleep disorders in children, aggression with both peers and adults, night terrors, extreme anxiety, anti social behaviour, depression symptoms, aloof attitude, sensitive emotions, and rebellious behaviour that are not in line of typical childhood development. Aggression is found to manifest in children before five years of age, and early stress and aggression in the parental-child relationship correlates with the manifestation of aggression. Aggression in children causes problematic peer relationships, difficulty adjusting, and coping problems. Children who fail to overcome acceptable ways of coping and emotion expression are put on tract for psychopathological disorders and violent and anti social behaviours into adolescence and adulthood. There is a higher rate of substance abuse in these children with coping and aggression issues, and causes a cycle of emotional instability and manifestation psychopathological disorders.

Neurology and Aetiology

Borderline personality disorder (BPD) is one of many psychopathology disorders a child can suffer from. In the neurobiological scheme, borderline personality disorder may have effects on the left amygdala. In a 2003 study of BPD patients versus control patients, when faced with expressions that were happy, sad, or fearful BPD patients showed significantly more activation versus control patients. In neutral faces, BPD patients attributed negative qualities to these faces. As stated by Gabbard, an experimenter in this study:

“A hyperactive amygdala may be involved in the predisposition to be hyper vigilant and over reactive to relatively benign emotional expressions. Misreading neutral faces is clearly related to transference misreadings that occur in psychotherapy and the creation of bad object experiences linked with projective identification.”

Also linked to BPD, is the presence of serotonin transporter (5-HTT) in a short allele demonstrated larger amygdala neuronal activity when presented with fearful stimuli as in comparison to individuals with a long allele of 5-HTT. As found in the Dunedin Longitudinal Study a short allele of 5-HTT predisposes the person to have hyperactivity in the amygdala in response to trauma, and thus moderated the impact of stressful life events leading to a higher risk of depression and suicidal idealities. These same qualities were not observed in individuals with long alleles of 5-HTT. However, the environment the child is in can change in impact of this gene, proving that correct treatment, intensive social support, and a healthy and nurturing environment can modify genetic vulnerability.

Possibly the most studied or documented of the child psychopathologies is attention deficit hyperactivity disorder (ADHD) which is marked with learning disabilities, mood disorders, and/or aggression. Though believed to be over diagnosed, ADHD is highly comorbid for other disorders such as depression and obsessive compulsive disorder. In studies of the prefrontal cortex in ADHD children, which is responsible for the regulation of behaviour, cognition, and attention; and in the dopamine system there has been identified a hidden genetic polymorphisms. More specific, the 7-repeat allele of the dopamine D4 receptor gene, responsible for inhibited prefrontal cortex cognition and less efficient receptors, causes more externalised behaviours such as aggression since the child has trouble “thinking through” seemingly ordinary and at level childhood tasks.

Agenesis of the Corpus Callosum and Aetiology

Agenesis of the corpus callosum (ACC) is used to determine the frequency of social and behavioural problems in children with a prevalence rate of about 2-3%. ACC is described as a defect in the brain where the 200 million axons that make the corpus collosum are either completely absent, or partially gone. In many cases, the anterior commissure is still present to allow for the passing of information from one cerebral hemisphere to the other. The children are of normal intelligence level. For younger children, ages two to five, Agenesis of the corpus callosum causes problems in sleep. Sleep is critical for development in children, and lack of sleep can set the grounds for a manifestation of psychopathological disorders. In children ages six to eleven, ACC showed manifestation in problems with social function, thought, attention, and somatic grievances. In comparison, of children with autism, children with ACC showed less impairment on almost all scales such as anxiety and depression, attention, abnormal thoughts, and social function versus autistic children. However, a small percentage of children with ACC showed traits that may lead to the diagnosis of autism in the areas of social communications and social interactions but do not show the same symptoms of autism in the repetitive and restricted behaviours category. The difficulties from ACC may lead to the aetiology of child psychopathological disorders, such as depression or ADHD and manifest many autistic-like disorders that can cause future psychological disorders in later adolescence. The aetiology of child psychopathology is a multi-factor path. A slew of factors must be taken into account before diagnosis of a disorder.

The child’s genetics, environment, temperament, past medical history, family medical history, prevalence of symptoms and neuro-anatomical structures are all factors that should be considered when diagnosing a child with a psychopathological disorder. Thousands of children each year are misdiagnosed and put on the wrong treatment, which may result in the manifestation of other disorders the child would have not have gotten else wise. There are hundreds of causes of psychopathological disorders, and each one manifests at different ages and stages in child development and can come out due to trauma and stress. Some disorders may “disappear” and reappear in the presence of a trauma, depression, or stress similar to the one that brought the disorder out in the child in the beginning.

Treatment

It is estimated that 5% of children under the age of eight suffer from a psychopathology disorder. Girls more frequently manifested disorders than boys in similar situations. By age sixteen about thirty percent of children will have fit the criteria for at least one psychopathology disorder. Only a small number of these children receive treatment for their disorder. Anxiety and depression disorders in children- whether noted or un-noted, are found to be a precursor for similar episodes in adulthood. Usually a large stressor similar to the one the person experienced in childhood brings out the anxiety or depression in adulthood.

Multifinality refers to the idea that two children can react to same stressful event quite differently, and may display divergent types of problem behaviour. Psychopathological disorders are extremely situational- having to take into account the child, the genetics, the environment, the stressor, and many other factors to tailor the best type of treatment to relieve the child of the psychopathology symptoms.

Many child psychopathology disorders are treated with control medications prescribed by a paediatrician or psychiatrist. After extensive evaluation of the child through school visits, by psychologists and physicians, a medication can be prescribed. A patient may need to go through several trials of medicines to find the best fit, as many cause uncomfortable and undesired side effects – such as dry mouth or suicidal thoughts can occur. There are many classes of drugs a physician can choose from and they are: psychostimulants, beta blockers, atypical antipsychotics, lithium, alpha-2 agonists, traditional antipsychotics, SSRIs, and anticonvulsant mood- stabilisers. Given the multifinality of psychopathological disorders, two children may be on the same medication for two completely different disorders, or have the same disorder and be taking two completely different medications.

ADHD is the most successfully treated disorder of child psychopathology, and the medications used have a high- abuse rate especially among college-aged students. Psycho stimulants such as Ritalin, amphetamine- related stimulant drugs: e.g. Adderall, and antidepressants such as Wellbutrin have been successfully used to treat ADHD with a 78% success rate. Many of these drug treatment options are paired with behavioural treatment such as therapy or social skills lessons.

Lithium has shown to be extremely effective in treating ADHD and bipolar disorder. Lithium treats both mania and depression and helps prevent relapse. The mechanism of lithium include the inhibition of GSK-3, it is a glutamate antagonism at NMDA receptors that together make lithium a neuroprotective medicine. The drug relieves bipolar symptoms, aggressiveness and irritability. Lithium has many, many side effects and requires weekly blood tests to tests for toxicity of the drug.

Medications that act on cell membrane ion channels, are GABA inhibitory neurotransmission, and also inhibit excitatory glutamate transmission have shown to be extremely effective in treating an array of child psychopathological disorders. Pharmaceutical companies are in the process of creating new drugs and improving those on the market to help avoid negative and possibly life altering short term and long term side effects, making drugs more safe to use in younger children and over long periods of time during adolescent development.

Psychotherapy Treatments for Common Psychological Disorders in Children

Some psychological disorders commonly found in children include depression, anxiety, and conduct disorder. For adolescents with depression, a combination of antidepressants and cognitive-behavioural or interpersonal psychotherapy is recommended, in contrast there is not much evidence for the efficacy of antidepressants in children under 12 years of age, therefore a combination of parent training and cognitive-behavioural psychotherapy is recommended. For children and adolescents suffering from anxiety disorders, cognitive-behavioural therapy in combination with exposure-based techniques is a highly recommended and evidence-based treatment. Research suggests that children and adolescents with conduct disorder or disruptive behaviour may benefit from psychotherapy that includes both a behavioural component and parental involvement.

Future of Child Psychopathology

The future of child psychopathology-aetiology and treatment has a two-way path. While many professionals agree that many children who suffer from a disorder do not receive proper treatment, at the rate of 5-15% that receive treatment leaving many children in the dark. In the same boat are the physicians who also say that not only do more of these disorders need to be recognised in children and treated properly, but also even those children who show some qualifying symptoms of a disorder but not to the degree of diagnosis should also receive treatment and therapy to avoid the manifestation of the disorder. By treating children even with slight degrees of a psychopathological disorder, children can show improvements in their relationships with peers, family, and teachers and also improvements in school, mental health, and personal development. Many physicians believe the best prevention and help starts in the home and the school of the child, before physicians and psychologists are contacted.

So while there is more awareness of child psychopathological disorders and more research to prevent and effectively treat these disorders to maintain healthy emotional health in children, there is also a negative factor in that parents, schools, and psychologists may be more sensitive and therefore over-diagnose children with these disorders. Mental health professionals and pharmaceutical marketing companies need to be cautious of making disorders too readily diagnosed and treated with medications.

Child psychopathology is a real thing that thousands of children suffer from. While hundreds of children are diagnosed with a new disorder daily, researchers are developing new strategies to beat these disorders in children to allow all children the right to a happy and healthy childhood. With further education on the symptoms and implications of child psychopathology, psychologists and physicians will improve their accuracy in diagnosing children – giving the right diagnosis and discovering the most helpful treatment and therapies for children.

The current trend in the US is to understand child psychopathology from a systems based perspective called developmental psychopathology. Recent emphasis has also been on understanding psychological disorders from a relational perspective with attention also given to neurobiology. Practitioners who follow attachment theory believe that early attachment experiences of children can promote adaptive strategies or lay the groundwork for maladaptive ways of coping which can later lead to mental health disorders.

Research and clinical work on child psychopathology tends to fall under several main areas: aetiology, epidemiology, diagnosis, assessment, and treatment.

Parents are considered a reliable source of information because they spend more time with children than any other adult. A child’s psychopathology can be connected to parental behaviours. Clinicians and researchers have experienced problems with children’s self-reports and rely on adults to provide the information.

What is School Psychology?

Introduction

School psychology is a field that applies principles from educational psychology, developmental psychology, clinical psychology, community psychology, and behaviour analysis to meet the learning and behavioural health needs of children and adolescents.

It is an area of applied psychology practiced by a school psychologist. They often collaborate with educators, families, school leaders, community members, and other professionals to create safe and supportive school environments.

School psychologists primarily work with students who have learning disabilities, behavioural difficulties, mental disorders, and other health issues. They carry out psychological testing, psychoeducational assessment, intervention, prevention, counselling, and consultation in the ethical, legal, and administrative codes of their profession.

Background

School psychology dates back to the beginning of American psychology in the late 19th and early 20th centuries. The field is tied to both functional and clinical psychology. School psychology actually came out of functional psychology. School psychologists were interested in childhood behaviours, learning processes, and dysfunction with life or in the brain itself. They wanted to understand the causes of the behaviours and their effects on learning. In addition to its origins in functional psychology, school psychology is also the earliest example of clinical psychology, beginning around 1890. While both clinical and school psychologists wanted to help improve the lives of children, they approached it in different ways. School psychologists were concerned with school learning and childhood behavioural problems, which largely contrasts the mental health focus of clinical psychologists.

Another significant event in the foundation of school psychology as it is today was the Thayer Conference. The Thayer Conference was first held in August 1954 in West Point, New York in Hotel Thayer. The 9 day-long conference was conducted by the American Psychological Association (APA). The purpose of the conference was to develop a position on the roles, functions, and necessary training and credentialing of a school psychologist. At the conference, forty-eight participants that represented practitioners and trainers of school psychologists discussed the roles and functions of a school psychologist and the most appropriate way to train them.

At the time of the Thayer Conference, school psychology was still a very young profession with only about 1,000 school psychology practitioners. One of the goals of the Thayer Conference was to define school psychologists. The agreed upon definition stated that school psychologists were psychologists who specialise in education and have specific knowledge of assessment and learning of all children. School psychologists use this knowledge to assist school personnel in enriching the lives of all children. This knowledge is also used to help identify and work with children with exceptional needs. It was discussed that a school psychologist must be able to assess and develop plans for children considered to be at risk. A school psychologist is also expected to better the lives of all children in the school; therefore, it was determined that school psychologists should be advisors in the planning and implementation of school curriculum. Participants at the conference felt that since school psychology is a specialty, individuals in the field should have a completed a two-year graduate training program or a four-year doctoral programme. Participants felt that states should be encouraged to establish certification standards to ensure proper training. It was also decided that a practicum experience be required to help facilitate experiential knowledge within the field.

The Thayer Conference is one of the most significant events in the history of school psychology because it was there that the field was initially shaped into what it is today. Before the Thayer Conference defined school psychology, practitioners used seventy-five different professional titles. By providing one title and a definition, the conference helped to get school psychologists recognised nationally. Since a consensus was reached regarding the standards of training and major functions of a school psychologist, the public can now be assured that all school psychologists are receiving adequate information and training to become a practitioner. It is essential that school psychologists meet the same qualifications and receive appropriate training nationwide. These essential standards were first addressed at the Thayer Conference. At the Thayer Conference some participants felt that in order to hold the title of a school psychologist an individual must have earned a doctoral degree.

The issues of titles, labels, and degree levels are still debated among psychologists today. However, APA and NASP reached a resolution on this issue in 2010.

Social Reform in the Early 1900s

The late 19th century marked the era of social reforms directed at children. It was due to these social reforms that the need for school psychologists emerged. These social reforms included compulsory schooling, juvenile courts, child labour laws as well as a growth of institutions serving children. Society was starting to “change the ‘meaning of children’ from an economic source of labour to a psychological source of love and affection”. Historian Thomas Fagan argues that the preeminent force behind the need for school psychology was compulsory schooling laws. Prior to the compulsory schooling law, only 20% of school aged children completed elementary school and only 8% completed high school. Due to the compulsory schooling laws, there was an influx of students with mental and physical defects who were required by law to be in school. There needed to be an alternative method of teaching for these different children. Between 1910 and 1914, schools in both rural and urban areas created small special education classrooms for these children. From the emergence of special education classrooms came the need for “experts” to help assist in the process of child selection for special education. Thus, school psychology was founded.

Important Contributors to the Founding

Lightner Witmer

Lightner Witmer has been acknowledged as the founder of school psychology. Witmer was a student of both Wilhelm Wundt and James Mckeen Cattell. While Wundt believed that psychology should deal with the average or typical performance, Cattell’s teachings emphasized individual differences. Witmer followed Cattell’s teachings and focused on learning about each individual child’s needs. Witmer opened the first psychological and child guidance clinic in 1896 at the University of Pennsylvania. Witmer’s goal was to prepare psychologists to help educators solve children’s learning problems, specifically those with individual differences. Witmer became an advocate for these special children. He was not focused on their deficits per se, but rather helping them overcome them, by looking at the individual’s positive progress rather than all they still could not achieve. Witmer stated that his clinic helped “to discover mental and moral defects and to treat the child in such a way that these defects may be overcome or rendered harmless through the development of other mental and moral traits”. He strongly believed that active clinical interventions could help to improve the lives of the individual children.

Since Witmer saw much success through his clinic, he saw the need for more experts to help these individuals. Witmer argued for special training for the experts working with exceptional children in special educational classrooms. He called for a “new profession which will be exercised more particularly in connection with educational problems, but for which the training of the psychologist will be a prerequisite”.

As Witmer believed in the appropriate training of these school psychologists, he also stressed the importance of appropriate and accurate testing of these special children. The IQ testing movement was sweeping through the world of education after its creation in 1905. However, the IQ test negatively influenced special education. The IQ test creators, Lewis Terman and Henry Goddard, held a nativist view of intelligence, believing that intelligence was inherited and difficult if not impossible to modify in any meaningful way through education.] These notions were often used as a basis for excluding children with disabilities from the public schools. Witmer argued against the standard pencil and paper IQ and Binet type tests in order to help select children for special education. Witmer’s child selection process included observations and having children perform certain mental tasks.

Granville Stanley Hall

Another important figure to the origin of school psychology was Granville Stanley Hall. Rather than looking at the individual child as Witmer did, Hall focused more on the administrators, teachers and parents of exceptional children He felt that psychology could make a contribution to the administrator system level of the application of school psychology. Hall created the child study movement, which helped to invent the concept of the “normal” child. Through Hall’s child study, he helped to work out the mappings of child development and focused on the nature and nurture debate of an individual’s deficit. Hall’s main focus of the movement was still the exceptional child despite the fact that he worked with atypical children.

Arnold Gesell

Bridging the gap between the child study movement, clinical psychology and special education, Arnold Gesell, was the first person in the United States to officially hold the title of school psychologist, Arnold Gesell. He successfully combined psychology and education by evaluating children and making recommendations for special teaching. Arnold Gesell paved the way for future school psychologists.

Gertrude Hildreth

Gertrude Hildreth was a psychologist with the Lincoln School at Teacher’s College, Columbia then at Brooklyn College in New York. She authored many books including the first book pertaining to school psychology titled, “Psychological Service for School Problems” written in 1930. The book discussed applying the science of psychology to address the perceived problems in schools. The main focus of the book was on applied educational psychology to improve learning outcomes. Hildreth listed 11 problems that can be solved by applying psychological techniques, including: instructional problems in the classroom, assessment of achievement, interpretation of test results, instructional groupings of students for optimal outcomes, vocational guidance, curriculum development, and investigations of exceptional pupils. Hildreth emphasized the importance of collaboration with parents and teachers. She is also known for her development of the Metropolitan Readiness Tests and for her contribution to the Metropolitan Achievement test. In 1933 and 1939 Hildreth published a bibliography of Mental Tests and Rating Scales encompassing a 50-year time period and over 4,000 titles. She wrote approximately 200 articles and bulletins and had an international reputation for her work in education.

Issues Related to School Psychology

Intervention

One of the primary roles and responsibilities of school psychologists working in schools is to ensure the interventions they utilise effectively address students’ behaviour problems. Issues arise when school psychologists do not select interventions with sufficient research-based evidence in being effective for the individual with whom they are working. School psychologists, as researchers and practitioners, can make important contributions to the development and implementation of scientifically based intervention and prevention programmes to address learning and behavioural needs of students (National Association of School Psychologists (NASP).

There is a concern with implementing academic and behavioural interventions prior to the determination for special education services, and it has also been proposed that MTSS (Multi-Tiered Systems of Support) may address these concerns. The National Association of School Psychologists (NASP) recognises the need for evidence-based prevention and intervention practices to address student learning, social emotional development, behavioural performance, instructional methodology, school practices, classroom management, and other areas salient to school-based services and improving student outcomes (National Association of School Psychologists (NASP). Intervention and prevention research needs to address a range of questions related not only to efficacy and effectiveness, but also to:

  • Feasibility given resources (e.g. time, money, staffing);
  • Acceptability (e.g. teacher, student, and community attitudes toward intervention strategies);
  • Social validity (the relevance of targeted outcomes to everyday life of students);
  • Integrity or fidelity (the extent to which individuals responsible for implementing an intervention can do so as intended by its designers); and
  • Sustainability (extent to which school staff can maintain the intervention over time, without support from external agents).

A specific example of an intervention that has recently become popular among school psychologists is the School-wide Positive Behavioural Interventions and Supports (PBIS). Authorised under IDEA, the PBIS offers a “preventative, positive, and systemic framework or approach to affect educational and behavioural change” and can be used in the support of Tiers 1-3 in the education system. Research from single-case design studies and group studies demonstrates that the intervention can result in a reduction of major disciplinary infractions and aggressive behaviour, improvement in academic achievement, an increase in prosocial behaviour, a reduction in bullying behaviour reported by teachers, and much more. Through consistent and strong implementation fidelity, PBIS can provide school psychologists opportunities to assist the administration, teaching staff, and students in broad and specific ways.

Prevention

A way in which school psychologists can help students is by creating primary prevention programmes. Information about prevention should also be connected to current events in the community.

Issues with Assessment Process

Empirical evidence has not confirmed biases in referral, assessment, or identification; however, inferences have been made that the special education process may be oversimplified. The National Research Council has called attention to the questionable reliability of educational decision making in special education as there can be vast numbers of false positives and/or false negatives. Misidentified students in special education is problematic and can contribute to long term negative outcomes.

During the identification process, school psychologists must consider ecological factors and environmental context such as socioeconomic status. Socioeconomic status may limit funding and materials, impact curriculum quality, increase teacher-to-student ratios, and perpetuate a negative school climate.

Technological Issues

With the ever growing use of technology, school psychologists are faced with several issues, both ethical and within the populations they try to serve. As it is so easy to share and communicate over technology, concerns are raised as to just how easy it is for outsiders to get access to the private information that school psychologists deal with everyday. Thus exchanging and storing information digitally may come under scrutiny if precautions such as password protecting documents and specifically limiting access within school systems to personal files.

Then there is the issue of how students communicate using this technology. There are both concerns on how to address these virtual communications and on how appropriate it is to access them. Concerns on where the line can be drawn on where intervention methods end and invasion of privacy begin are raised by students, parents, administrators, and faculty. Addressing these behaviours becomes even more complicated when considering the current methods of treatment for problematic behaviours, and implementation of these strategies can become complex, if not impossible, within the use of technology.

To incorporate topics in a school, utilise lesson plans for students and staff because the teachers need to ensure the content is connected to other meaningful topics covered in the class/school.

Racial Disproportionality in Special Education

Disproportionality refers to a group’s under or overrepresentation in comparison to other groups within a certain context. In the field of school psychology, disproportionality of minority students in special education is a concern. Special Education Disproportionality has been defined as the relationship between one’s membership to a specific group and the probability of being placed in a specific disability category. Systemic prejudice is believed by some to be one of the root causes of the mischaracterisation of minority children as being disabled or problematic.

“Research on disproportionality in the U.S. context has posited two overlapping types of rationales: those who believed disproportionate representation is linked to poverty and health outcomes versus those who believed in the systemwide racist practices that contributed to over-representation of minority students.”

The United States Congress recently received an annual report on the implementation of IDEA which stated that proportionally Native Americans (14.09%) and African Americans (12.61%) were the two most highly represented racial groups within the realm of special education. In particular, African American males have been overidentified as having emotional disturbances and intellectual disabilities. They account for 21% of the special education population with emotional disturbances and 12% with learning disabilities. American Indian and Alaska Native students are also overrepresented in special education. They are shown to be 1.53 times more likely to receive services for various learning disabilities and 2.89 more likely to obtain services targeting developmental delays than all other Non-Native American student groups combined.] Overall, Hispanic students are often overidentified for special education in general; however, it is common for them to be under-identified for Autism Spectrum Disorder and speech and language impairments in comparison to White students.

Minority populations often have an increased susceptibility to economic, social and cultural disadvantages that can affect academic achievement. According to the US Department of Education, “Black children were three times as likely to live in poor families as white children in 2015. 12 percent of white and Asian children lived in poor families, compared with 36 percent of black children, 30 percent of Hispanic children, 33 percent of American Indian children, and 19 percent of others.” There may be other alternative explanations for behaviour and academic performance as well. For example, Black children are twice as likely as Whites to experience heightened levels of lead in the blood due to prolonged lead exposure. Lead poisoning can be known to affect a child’s behaviour by increasing their levels of irritability, hyperactivity, and inattentiveness even in less severe cases.

Cultural Biases

Some school psychologists realise the need to understand and accept their own cultural beliefs and values in order to understand the impact it may have when delivering services to clients and families. For example, these school psychologists ensure that students who are minorities, including African Americans, Hispanics, Asians, and Native Americans are being equally represented at the system level, in the classroom, and receiving a fair education.

For staff, it is important to look at one’s own culture while seeing the value in diversity. It is also vital to learn how to adapt to diversity and integrate a comprehensive way to understand cultural knowledge. Staff members should keep the terms race, privilege, implicit bias, micro aggression, and cultural relevance in mind when thinking about social justice.

Services

Behaviour Interventions

School psychologists are involved in the implementation of academic, behavioural, and social/emotional interventions within a school across a continuum of supports. These systems and policies should convey clear behaviour expectations and promote consistency among educators. Continuous reinforcement of positive behaviours can yield extremely positive results. Schoolwide positive behaviour supports A systematic approach that proactively promotes constructive behaviours in a school can yield positive outcomes. These programs are designed to improve and support students’ social, behavioural, and learning outcomes by promoting a positive school climate and providing targeted training to students and educators within a school. Data should be collected consistently to assess implementation effectiveness, screen and monitor student behaviour, and develop or modify action plans.

Academic Interventions

Academic interventions can be conceptualised as a set of procedures and strategies designed to improve student performance with the intent of closing the gap between how a student is currently performing and the expectations of how they should be performing. Short term and long term interventions used within a problem-solving model must be evidence-based. This means the intervention strategies must have been evaluated by research that utilised rigorous data analysis and peer review procedures to determine the effectiveness. Implementing evidence-based interventions for behaviour and academic concerns requires significant training, skill development, and supervised practice. Linking assessment and intervention is critical for determining that the correct intervention has been chosen. School psychologists have been specifically trained to ensure that interventions are implemented with integrity to maximise positive outcomes for children in a school setting.

Systems-Level Services

Leaders in the field of school psychology recognise the practical challenges that school psychologists face when striving for systems-level change and have highlighted a more manageable domain within a systems-level approach – the classroom. Overall, it makes sense for school psychologists to devote considerable effort to monitoring and improving school and classroom-based performance for all children and youth because it has been shown to be an effective preventive approach.

Universal Screening

School psychologists play an important role in supporting youth mental wellness, but identifying youth who are in distress can be challenging. Some schools have implemented universal mental health screening programs to help school psychologists find and help struggling youth. For instance, schools in King County, Washington are using the Check Yourself digital screening tool designed by Seattle Children’s Hospital to measure, understand, and nurture individual students’ well-being. Check Yourself collects information about lifestyle, behaviour, and social determinants of health to identify at-risk youth so that school psychologists can intervene and direct youth to the services they need. Mental health screening provides school psychologists with valuable insights so that interventions are better fitted to student needs.

Crisis Intervention

Crisis intervention is an integral part of school psychology. School administrators view school psychologists as the school’s crisis intervention “experts”. Crisis events can significantly affect a student’s ability to learn and function effectively. Many school crisis response models suggest that a quick return to normal rituals and routines can be helpful in coping with crises. The primary goal of crisis interventions is to help crisis-exposed students return to their basic abilities of problem-solving so the student can return to their pre-crisis level of functioning.

Consultation

Consultation is done through a problem solving method that will help the consultee function more independently without the intensive support of a school psychologist.

Social Justice

The three major elements that comprise social justice include equity, fairness, and respect. The concept of social justice includes all individuals having equal access to opportunities and resources. A major component behind social justice is the idea of being culturally aware and sensitive. American Psychological Association (APA) and the National Association of School Psychologists (NASP) both have ethical principles and codes of conduct that present aspirational elements of social justice that school psychologists may abide by. Although ethical principles exist, there is federal legislation that acts accordingly to social justice. For example, the Elementary and Secondary Education Act of 1965 (ESEA) and the Individuals with Disabilities Education Improvement Act of 2004 (IDEA) address issues such as poverty and disability to promote the concept of social justice in schools.

Schools are becoming increasingly diverse with growing awareness of these differences. Cultural diversity factors that can be addressed through social justice practice include race/ethnicity, gender, socioeconomic status (SES), religion, and sexual orientation. With the various elements that can impact a student’s education and become a source of discrimination, there is a greater call for the practice of social justice in schools. School psychologists that consider the framework of social justice know that injustices that low SES students face can sometimes be different when compared to high SES students.

Advocacy

A major role of school psychologists involves advocating and speaking up for individuals as needed. Advocacy can be done at district, regional, state, or national level. School psychologists advocate for students, parents, and caregivers.

Consultation and collaboration are key components of school psychology and advocacy. There may be times when school personnel may not agree with the school psychologist. Differing opinions can be problematic because a school psychologist advocates for what is in the best interest of the student. School psychologists and staff members can help facilitate awareness through courageous conversations.

Multicultural Competence

School psychologists offer many types of services in order to be multiculturally competent. Multicultural competence extends to race, ethnicity, social class, gender, religion, sexual orientation, disability, age, and geographic region. Because the field of school psychology serves such a diverse range of students, maintaining representation for minority groups continues to be a priority. Despite such importance, history has seen an underrepresentation of culturally and linguistically diverse (CLD) school psychologists. which may appear alarming given that the diversity of our youth continues to increase exponentially. Thus, current professionals in the field have prioritised the acquisition of CLD school psychologists. School psychologists are trained to use their skills, knowledge, and professional practices in promoting diversity and advocating for services for all students, families, teachers, and schools. School psychologists may also work with teachers and educators to provide an integrated multicultural education classroom and curriculum that allows more students to be represented in learning. Efforts to increase multicultural perspectives among school psychologists have been on the rise to account for the increased diversity within schools. Such efforts include establishing opportunities for individuals representative of minority groups to become school psychologists and implementing a diverse array of CLD training programmes within the field.

Education

In order to become a school psychologist, one must first learn about school psychology by successfully completing a graduate-level training programme. A B.A. or B.S. is not sufficient.

United States

School psychology training programs are housed in university schools of education or departments of psychology. School psychology programmes require courses, practica, and internships.

Degree Requirements

Specific degree requirements vary across training programmes. School psychology training programs offer masters-level (M.A., M.S., M.Ed.), specialist-level degrees (Ed.S., Psy.S., SSP, CAGS), and doctoral-level degrees (Ph.D., Psy.D. or Ed.D.) degrees. Regardless of degree title, a supervised internship is the defining feature of graduate-level training that leads to certification to practice as a school psychologist.

Specialist-level training typically requires 3-4 years of graduate training including a 9-month (1200 hour) internship in a school setting.

Doctoral-level training programs typically require 5-7 years of graduate training. Requirements typically include more coursework in core psychology and professional psychology, more advanced statistics coursework, involvement in research endeavours, a doctoral dissertation, and a one-year (1500+ hour) internship (which may be in a school or other settings such as clinics or hospitals).

In the past, a master’s degree was considered the standard for practice in schools. As of 2017, the specialist-level degree is considered the entry-level degree in school psychology. Masters-level degrees in school psychology may lead to obtaining related credentials (such as Educational Diagnostician, School Psychological Examiner, School Psychometrist) in one or two states.

International

In the UK, the similar practice and study of School Psychology is more often termed Educational Psychology and requires a doctorate (in Educational Psychology) which then enables individuals to register and subsequently practice as a licensed educational psychologist.

Employment in the United States

In the United States, job prospects in school psychology are excellent. Across all disciplines of psychology, the abundance of opportunities is considered among the best for both specialist and doctoral level practitioners. They mostly work in schools. Other settings include clinics, hospitals, correctional facilities, universities, and independent practice.

Demographic Information

According to the NASP Research Committee, 74% of school psychologists are female with an average age of 46. In 2004-2005, average earnings for school practitioners ranged from $56,262 for those with a 180-day annual contract to $68,764 for school psychologists with a 220-day contract. In 2009-2010, average earnings for school practitioners ranged from $64,168 for those with a 180-day annual contract to $71,320 for school psychologists with a 200-day contract. For university faculty in school psychology, the salary estimate is $77,801.

Based on surveys performed by NASP in 2009-2010, it is shown that 90.7% of school psychologists are white, while minority races make up the remaining 9.3%. Of this remaining percentage, the next largest populations represented in school psychology, are African-Americans and Hispanics, at 3% and 3.4% respectively.

Shortages in the Field

There is a lack of trained school psychologists within the field. While jobs are available across the country, there are just not enough people to fill them.

Due to the low supply and high demand of school psychologists, being a school psychologist is very demanding. School psychologists may feel under pressure to supply adequate mental health and intervention services to the students in their care. Burnout is a risk of being a school psychologist.

Bilingual School Psychologists

Approximately 21% of school-age children ages 5-7 speak a language other than English. For this reason, there is an enormous demand for bilingual school psychologists in the United States. The National Association of School Psychologists (NASP) does not currently offer bilingual certification in the field. However, there are a number of professional training opportunities that bilingual LSSPs/School Psychologists can attend in order to prepare to adequately administer assessments. In addition, there are 7 NASP-Approved school psychology programs that offer a bilingual specialisation:

  • Brooklyn College-City University of New York- Specialist Level.
  • Gallaudet University- Specialist Level.
  • Queens College-City University of New York- Specialist Level.
  • San Diego State University- Specialist Level.
  • Texas State University- Specialist Level.
  • University of Colorado Denver- Doctoral Level.
  • Fordham University- Lincoln Centre – Doctoral Level.

New York and Illinois are the only two states that offer a bilingual credential for school psychologists.

International School Psychology

The role of a school psychologist in the United States and Canada may differ considerably from the role of a school psychologist elsewhere. Especially in the United States, the role of school psychologist has been closely linked to public law for education of students with disabilities. In most other nations, this is not the case. Despite this difference, many of the basic functions of a school psychologist, such as consultation, intervention, and assessment are shared by most school psychologists worldwide.

It is difficult to estimate the number of school psychologists worldwide. Recent surveys indicate there may be around 76,000 to 87,000 school psychologists practicing in 48 countries, including 32,300 in the United States and 3,500 in Canada. Following the United States, Turkey has the next largest estimated number of school psychologists (11,327), followed by Spain (3,600), and then both Canada and Japan (3,500 each).

Credentialing

In order to work as a school psychologist, one must first meet the state requirements. In most states (excluding Texas and Hawaii), a state education agency credentials school psychologists for practice in the schools.

The Nationally Certified School Psychologist (NCSP) credential offered by the National Association of School Psychologists (NASP). The NCSP credential is an example of a non-practice credential as holding the NCSP does not make one eligible to provide services without first meeting the state requirements to work as a school psychologist.

State psychology boards (which may go by different names in each state) also offer credentials for school psychologists in some states. For example, Texas offers the LSSP credential which permits licensees to deliver school psychological services within public and private schools.

Subspecialisations

  • Paediatric School Psychology.
  • Systems Level Consultation.
  • School Based Mental Health.
  • Behavioural School Psychology.

Professional Organisations in the United States

  • National Association of School Psychologists.
  • American Psychological Association.

Journals

  • Psychology in the Schools.
  • School Psychology Quarterly.
  • School Psychology Review.
  • School Psychology Forum: Research in Practice.
  • School Psychology International.
  • Canadian Journal of School Psychology.
  • International Journal of School & Educational Psychology.
  • Journal of Psychoeducational Assessment.