Tag: Child Development

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

Published on by Andrew Marshall1 Comment

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?

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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?

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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.

On This Day … 02 May

Published on by Andrew MarshallLeave a comment

People (Births)

  • 1946 – Peter L. Benson, American psychologist and academic (d. 2011).

Peter L. Benson

Peter Lorimer Benson (02 May 1946 to 02 October 2011) was a psychologist and CEO/President of Search Institute. He pioneered the developmental assets framework, which became the predominant approach to research on positive facets of youth development.

According to Scales and Roehlkepartain (2012, p.322):

When [Benson] introduced the developmental assets [approach] in 1989, the predominant approach to youth development was naming youth problems and trying to prevent them. In contrast, the assets approach focused on building strengths. The developmental assets framework became the predominant positive youth development approach in the world, cited more than 17,000 times, and the framework and surveys developed to measure the assets have been used with more than 3 million youths in more than 60 countries.

Reference

Scales, P.C. & Roehlkepartain, E.C. (2012) Peter Lorimer Benson (1946-2011). American Psychologist. 67(4), pp.322. doi:10.1037/a0028171

What is the Negativistic Personality Disorder?

Published on by Andrew Marshall1 Comment

Introduction

Negativistic personality disorder is characterised by procrastination, covert obstructionism, inefficiency and stubbornness.

The current version of the Diagnostic and Statistical Manual of Mental Disorders no longer uses this phrase or label, and it is not one of the ten listed specific personality disorders. The previous edition, the revision IV (DSM-IV) describes passive-aggressive personality disorder as a proposed disorder involving a “pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance” in a variety of contexts.

Passive-aggressive behaviour is the obligatory symptom of the passive-aggressive personality disorder. Persons with passive-aggressive personality disorder are characterised by procrastination, covert obstructionism, inefficiency and stubbornness.

Brief History

In the first version of the Diagnostic and Statistical Manual of Mental Disorders, DSM-I, in 1952, the Passive-aggressive was defined in a narrow way, grouped together with the passive-dependent.

The DSM-III-R stated in 1987 that Passive-aggressive disorder is typified by, among other things, “fail[ing] to do the laundry or to stock the kitchen with food because of procrastination and dawdling.”

Causes

Passive-aggressive disorder may stem from a specific childhood stimulus (e.g. alcohol/drug addicted parents, bullying, abuse) in an environment where it was not safe to express frustration or anger. Families in which the honest expression of feelings is forbidden tend to teach children to repress and deny their feelings and to use other channels to express their frustration. For example, if physical and psychological punishment were to be dealt to children who express anger, they would be inclined to be passive aggressive.

Children who sugarcoat hostility may have difficulties being assertive, never developing better coping strategies or skills for self-expression. They can become adults who, beneath a “seductive veneer,” harbour “vindictive intent,” in the words of Timothy F. Murphy and Loriann Oberlin. Alternatively individuals may simply have difficulty being as directly aggressive or assertive as others. Martin Kantor suggests three areas that contribute to passive-aggressive anger in individuals: conflicts about dependency, control, and competition, and that a person may be termed passive-aggressive if they behave so to few people on most occasions.

Murphy and Oberlin also see passive aggression as part of a larger umbrella of hidden anger stemming from ten traits of the angry child or adult. These traits include making one’s own misery, the inability to analyse problems, blaming others, turning bad feelings into angry ones, attacking people, lacking empathy, using anger to gain power, confusing anger with self-esteem, and indulging in negative self-talk. Lastly, the authors point out that those who hide their anger can be nice when they wish to be.

Diagnosis

Diagnostic and Statistical Manual

With the publication of the DSM-5, this label has been largely disregarded. The equivalent DSM-5 diagnostic label would be “Other specified personality and unspecified personality disorder,” as the individual may meet general criteria for a personality disorder, but does not meet the trait-based diagnostic criteria for any specific personality disorder (p.645).

Passive-aggressive [personality disorder] was listed as an Axis II personality disorder in the DSM-III-R, but was moved in the DSM-IV to Appendix B (“Criteria Sets and Axes Provided for Further Study”) because of controversy and the need for further research on how to also categorise the behaviours in a future edition. According to DSM-IV, people with passive-aggressive personality disorder are “often overtly ambivalent, wavering indecisively from one course of action to its opposite. They may follow an erratic path that causes endless wrangles with others and disappointment for themselves.” Characteristic of these persons is an “intense conflict between dependence on others and the desire for self-assertion.” Although exhibiting superficial bravado, their self-confidence is often very poor, and others react to them with hostility and negativity. This diagnosis is not made if the behaviour is exhibited during a major depressive episode or can be attributed to dysthymic disorder.

ICD-10

The 10th revision of the International Classification of Diseases (ICD-10) of the World Health Organisation (WHO) includes passive-aggressive personality disorder in the “other specific personality disorders” rubric (description: “a personality disorder that fits none of the specific rubrics: F60.0-F60.7”). ICD-10 code for “other specific personality disorders” is F60.8. For this psychiatric diagnosis a condition must meet the general criteria for personality disorder listed under F60 in the clinical descriptions and diagnostic guidelines.

The general criteria for personality disorder includes markedly disharmonious behaviour and attitudes (involving such areas of functioning as affectivity – ability to experience affects: emotions or feelings, involving ways of perceiving and thinking, impulse control, arousal, style of relating to others), the abnormal behaviour pattern (enduring, of long standing), personal distress and the abnormal behaviour pattern must be clearly maladaptive and pervasive. Personality disorder must appear during childhood or adolescence and continue into adulthood.

Specific diagnostic criteria of the passive-aggressive personality disorder in the “Diagnostic criteria for research” by WHO is not presented.

Millon’s Subtypes

The psychologist Theodore Millon has proposed four subtypes of ‘negativist’ (‘Passive-aggressive’). Any individual negativist may exhibit none or one of the following:

SubtypeDescriptionPersonality Traits
Vacillating negativistIncluding borderline featuresEmotions fluctuate in bewildering, perplexing, and enigmatic ways; difficult to fathom or comprehend own capricious and mystifying moods; wavers, in flux, and irresolute both subjectively and intrapsychically.
Discontented negativistIncluding depressive featuresGrumbling, petty, testy, cranky, embittered, complaining, fretful, vexed, and moody; gripes behind pretence; avoids confrontation; uses legitimate but trivial complaints.
Circuitous negativistIncluding antisocial and dependent featuresOpposition displayed in a roundabout, labyrinthine, and ambiguous manner, e.g. procrastination, dawdling, forgetfulness, inefficiency, neglect, stubbornness, indirect and devious in venting resentment and resistant behaviours.
Abrasive negativistIncluding sadistic featuresContentious, intransigent, fractious, and quarrelsome; irritable, caustic, debasing, corrosive, and acrimonious, contradicts and derogates; few qualms and little conscience or remorse (no longer a valid diagnosis in DSM).

Treatment

Psychiatrist Kantor suggests a treatment approach using psychodynamic, supportive, cognitive, behavioural and interpersonal therapeutic methods. These methods apply to both the passive-aggressive person and their target victim.

On This Day … 14 April

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People (Deaths)

  • 2010 – Alice Miller, Polish-French psychologist and author (b. 1923).

Alice Miller

Alice Miller, born as Alicija Englard (12 January 1923 to 14 April 2010), was a Polish-Swiss psychologist, psychoanalyst and philosopher of Jewish origin, who is noted for her books on parental child abuse, translated into several languages. She was also a noted public intellectual.

Her book The Drama of the Gifted Child caused a sensation and became an international bestseller upon the English publication in 1981. Her views on the consequences of child abuse became highly influential. In her books she departed from psychoanalysis, charging it with being similar to the poisonous pedagogies.

Life

Miller was born in Piotrków Trybunalski, Poland into a Jewish family. She was the oldest daughter of Gutta and Meylech Englard and had a sister, Irena, who was five years younger. From 1931 to 1933 the family lived in Berlin, where nine-year-old Alicija learned the German language. Due to the National Socialists’ seizure of power in Germany in 1933 the family turned back to Piotrków Trybunalski. As a young woman, Miller managed to escape the Jewish Ghetto in Piotrków Trybunalski, where all Jewish inhabitants were interned since October 1939, and survived World War II in Warsaw under the assumed name of Alicja Rostowska. While she was able to smuggle her mother and sister out, in 1941, her father died in the ghetto.

She retained her assumed name Alice Rostovska when she moved to Switzerland in 1946, where she had won a scholarship to the University of Basel.

In 1949 she married Swiss sociologist Andreas Miller, originally a Polish Catholic, with whom she had moved from Poland to Switzerland as students. They divorced in 1973. They had two children, Martin (born 1950) and Julika (born 1956). Shortly after his mother’s death Martin Miller stated in an interview with Der Spiegel that he had been beaten by his authoritarian father during his childhood – in the presence of his mother. Miller first stated that his mother intervened, but later that she did not intervene. These events happened decades before Alice Miller’s awakening about the dangers of such childrearing methods. Martin also mentioned that his mother was unable to talk with him, despite numerous lengthy conversations, about her wartime experiences, as she was severely burdened by them.

In 1953 Miller gained her doctorate in philosophy, psychology and sociology. Between 1953 and 1960, Miller studied psychoanalysis and practiced it between 1960 and 1980 in Zürich.

In 1980, after having worked as a psychoanalyst and an analyst trainer for 20 years, Miller “stopped practicing and teaching psychoanalysis in order to explore childhood systematically.” She became critical of both Sigmund Freud and Carl Jung. Her first three books originated from research she took upon herself as a response to what she felt were major blind spots in her field. However, by the time her fourth book was published, she no longer believed that psychoanalysis was viable in any respect.

In 1985 Miller wrote about the research from her time as a psychoanalyst: “For twenty years I observed people denying their childhood traumas, idealising their parents and resisting the truth about their childhood by any means.” In 1985 she left Switzerland and moved to Saint-Rémy-de-Provence in Southern France.

In 1986, she was awarded the Janusz Korczak Literary Award for her book Thou Shalt Not Be Aware: Society’s Betrayal of the Child.

In April 1987 Miller announced in an interview with the German magazine Psychologie Heute (Psychology Today) her rejection of psychoanalysis. The following year she cancelled her memberships in both the Swiss Psychoanalytic Society and the International Psychoanalytic Association, because she felt that psychoanalytic theory and practice made it impossible for former victims of child abuse to recognise the violations inflicted on them and to resolve the consequences of the abuse, as they “remained in the old tradition of blaming the child and protecting the parents”.

One of Miller’s last books, Bilder meines Lebens (“Pictures of My Life”), was published in 2006. It is an informal autobiography in which the writer explores her emotional process from painful childhood, through the development of her theories and later insights, told via the display and discussion of 66 of her original paintings, painted in the years 1973-2005.

Between 2005 and her death in 2010, she answered hundreds of readers’ letters on her website, where there are also published articles, flyers and interviews in three languages. Days before her death Alice Miller wrote: “These letters will stay as an important witness also after my death under my copyright”.

Miller died on 14 April 2010, at the age of 87, at her home in Saint-Rémy-de-Provence by suicide after severe illness and diagnosis of advanced stage of pancreatic cancer.

Work

Miller extended the trauma model to include all forms of child abuse, including those that were commonly accepted (such as spanking), which she called poisonous pedagogy, a non-literal translation of Katharina Rutschky’s Schwarze Pädagogik (black or dark pedagogy/imprinting).

Drawing upon the work of psychohistory, Miller analysed writers Virginia Woolf, Franz Kafka and others to find links between their childhood traumas and the course and outcome of their lives.

The introduction of Miller’s first book, The Drama of the Gifted Child, first published in 1979, contains a line that summarises her core views:

Experience has taught us that we have only one enduring weapon in our struggle against mental illness: the emotional discovery and emotional acceptance of the truth in the individual and unique history of our childhood.

In the 1990s, Miller strongly supported a new method developed by Konrad Stettbacher, who himself was later charged with incidents of sexual abuse. Miller came to know about Stettbacher and his method from a book by Mariella Mehr titled Steinzeit (Stone Age). Having been strongly impressed by the book, Miller contacted Mehr in order to get the name of the therapist. From that time forward, Miller refused to make therapist or method recommendations. In open letters, Miller explained her decision and how she originally became Stettbacher’s disciple, but in the end she distanced herself from him and his regressive therapies.

In her writings, Miller is careful to clarify that by “abuse” she does not only mean physical violence or sexual abuse, she is also concerned with psychological abuse perpetrated by one or both parents on their child; this is difficult to identify and deal with because the abused person is likely to conceal it from themselves and may not be aware of it until some event, or the onset of depression, requires it to be treated. Miller blamed psychologically abusive parents for the majority of neuroses and psychoses. She maintained that all instances of mental illness, addiction, crime and cultism were ultimately caused by suppressed rage and pain as a result of subconscious childhood trauma that was not resolved emotionally, assisted by a helper, which she came to term an “enlightened witness.” In all cultures, “sparing the parents is our supreme law,” wrote Miller. Even psychiatrists, psychoanalysts and clinical psychologists were unconsciously afraid to blame parents for the mental disorders of their clients, she contended. According to Miller, mental health professionals were also creatures of the poisonous pedagogy internalised in their own childhood. This explained why the Commandment “Honour thy parents” was one of the main targets in Miller’s school of psychology.

Miller called electroconvulsive therapy “a campaign against the act of remembering”. In her book Abbruch der Schweigemauer (The Demolition of Silence), she also criticised psychotherapists’ advice to clients to forgive their abusive parents, arguing that this could only hinder recovery through remembering and feeling childhood pain. It was her contention that the majority of therapists fear this truth and that they work under the influence of interpretations culled from both Western and Oriental religions, which preach forgiveness by the once-mistreated child. She believed that forgiveness did not resolve hatred, but covered it in a dangerous way in the grown adult: displacement on scapegoats, as she discussed in her psycho-biographies of Adolf Hitler and Jürgen Bartsch, both of whom she described as having suffered severe parental abuse.

A common denominator in Miller’s writings is her explanation of why human beings prefer not to know about their own victimisation during childhood: to avoid unbearable pain. She believed that the unconscious command of the individual, not to be aware of how he or she was treated in childhood, led to displacement: the irresistible drive to repeat abusive parenting in the next generation of children or direct unconsciously the unresolved trauma against others (war, terrorism, delinquency), or against him or herself (eating disorders, drug addiction, depression).

The Roots of Violence

According to Alice Miller, worldwide violence has its roots in the fact that children are beaten all over the world, especially during their first years of life, when their brains become structured. She said that the damage caused by this practice is devastating, but unfortunately hardly noticed by society. She argued that as children are forbidden to defend themselves against the violence inflicted on them, they must suppress the natural reactions like rage and fear, and they discharge these strong emotions later as adults against their own children or whole peoples: “child abuse like beating and humiliating not only produces unhappy and confused children, not only destructive teenagers and abusive parents, but thus also a confused, irrationally functioning society”. Miller stated that only through becoming aware of this dynamic can we break the chain of violence.

Book: A Practical Guide to Mental Health Problems in Children with Autistic Spectrum Disorder

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Book Title:

A Practical Guide to Mental Health Problems in Children with Autistic Spectrum Disorder: It’s Not Just Their Autism!.

Author(s): Alvina Ali, Michelle O’Reilly, and Khalid Karim.

Year: 2013.

Edition: First (1st).

Publisher: Jessica Kingsley Publishers.

Type(s): Paperback and Kindle.

Synopsis:

Exploring the relationship between ASD and mental health difficulties, this book offers practical guidance to help parents and professionals recognise and handle co-morbid conditions, and dispels the myth that they are just a part of autism. The authors cover a wide range of common mental health problems experienced by children with ASD, including Obsessive Compulsive Disorder (OCD), anxiety, ADHD, eating disorders, psychosis, stress, tics and depression, and illustrate these issues with case studies. They also provide vital advice in an accessible format and suggest strategies to ease the difficulties which arise from these co-morbid conditions. This book is essential reading for professionals working with children on the autism spectrum and is an accessible and practical resource for parents and carers.

What is Avoidant Personality Disorder?

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Introduction

Avoidant personality disorder (AvPD) is a Cluster C personality disorder in which the main coping mechanism of those affected is avoidance of feared stimuli.

Those affected display a pattern of severe social anxiety, social inhibition, feelings of inadequacy and inferiority, extreme sensitivity to negative evaluation and rejection, and avoidance of social interaction despite a strong desire for intimacy.

People with AvPD often consider themselves to be socially inept or personally unappealing and avoid social interaction for fear of being ridiculed, humiliated, rejected, or disliked. They often avoid becoming involved with others unless they are certain they will be liked.

Childhood emotional neglect (in particular, the rejection of a child by one or both parents) and peer group rejection are associated with an increased risk for its development; however, it is possible for AvPD to occur without any notable history of abuse or neglect.

Brief History

The avoidant personality has been described in several sources as far back as the early 1900s, although it was not so named for some time. Swiss psychiatrist Eugen Bleuler described patients who exhibited signs of avoidant personality disorder in his 1911 work Dementia Praecox: Or the Group of Schizophrenias. Avoidant and schizoid patterns were frequently confused or referred to synonymously until Kretschmer (1921), in providing the first relatively complete description, developed a distinction.

Signs and Symptoms

Avoidant individuals are preoccupied with their own shortcomings and form relationships with others only if they believe they will not be rejected. They often view themselves with contempt, while showing a decreased ability to identify traits within themselves that are generally considered as positive within their societies. Loss and social rejection are so painful that these individuals will choose to be alone rather than risk trying to connect with others.

Some with this disorder fantasize about idealized, accepting and affectionate relationships because of their desire to belong. They often feel themselves unworthy of the relationships they desire, and shame themselves from ever attempting to begin them. If they do manage to form relationships, it is also common for them to pre-emptively abandon them out of fear of the relationship failing.

Individuals with the disorder tend to describe themselves as uneasy, anxious, lonely, unwanted and isolated from others. They often choose jobs of isolation in which they do not have to interact with others regularly. Avoidant individuals also avoid performing activities in public spaces for fear of embarrassing themselves in front of others.

Symptoms include:

  • Extreme shyness or anxiety in social situations, though the person feels a strong desire for close relationships;
  • Heightened attachment-related anxiety, which may include a fear of abandonment; and
  • Substance abuse and/or dependence.

Comorbidity

AvPD is reported to be especially prevalent in people with anxiety disorders, although estimates of comorbidity vary widely due to differences in (among others) diagnostic instruments. Research suggests that approximately 10-50% of people who have panic disorder with agoraphobia have avoidant personality disorder, as well as about 20-40% of people who have social anxiety disorder. In addition to this, AvPD is more prevalent in people who have comorbid social anxiety disorder and generalised anxiety disorder (GAD) than in those who have only one of the aforementioned conditions.

Some studies report prevalence rates of up to 45% among people with GAD and up to 56% of those with obsessive-compulsive disorder. Posttraumatic stress disorder is also commonly comorbid with AvPD.

Avoidants are prone to self-loathing and, in certain cases, self-harm. In particular, avoidants who have comorbid PTSD have the highest rates of engagement in self-harming behaviour, outweighing even those with borderline personality disorder (with or without PTSD). Substance use disorders are also common in individuals with AvPD – particularly in regard to alcohol, benzodiazepines and heroin – and may significantly affect a patient’s prognosis.

Earlier theorists proposed a personality disorder with a combination of features from borderline personality disorder and avoidant personality disorder, called “avoidant-borderline mixed personality” (AvPD/BPD).

Causes

Causes of AvPD are not clearly defined, but appear to be influenced by a combination of social, genetic and psychological factors. The disorder may be related to temperamental factors that are inherited.

Specifically, various anxiety disorders in childhood and adolescence have been associated with a temperament characterised by behavioural inhibition, including features of being shy, fearful and withdrawn in new situations. These inherited characteristics may give an individual a genetic predisposition towards AvPD.

Childhood emotional neglect and peer group rejection are both associated with an increased risk for the development of AvPD. Some researchers believe a combination of high-sensory-processing sensitivity coupled with adverse childhood experiences may heighten the risk of an individual developing AvPD.

Subtypes

Millon

Psychologist Theodore Millon notes that because most patients present a mixed picture of symptoms, their personality disorder tends to be a blend of a major personality disorder type with one or

more secondary personality disorder types. He identified four adult subtypes of AvPD as outlined below.

SubtypePersonality Traits/Features
Phobic Avoidant (including dependent features)General apprehensiveness displaced with avoidable tangible precipitant; qualms and disquietude symbolised by a repugnant and specific dreadful object or circumstances.
Conflicted Avoidant (including negativistic features)Internal discord and dissension; fears dependence; unsettled; unreconciled within self; hesitating, confused, tormented, paroxysmic, embittered; and unresolvable angst.
Hypersensitive Avoidant (including paranoid features)Intensely wary and suspicious; alternatively panicky, terrified, edgy, and timorous, then thin-skinned, high-strung, petulant, and prickly.
Self-Deserting Avoidant (including depressive features)Blocks or fragments self-awareness; discards painful images and memories; casts away untenable thoughts and impulses; ultimately jettisons self (suicidal).

Others

In 1993, Lynn E. Alden and Martha J. Capreol proposed two other subtypes of avoidant personality disorder, as outlined below.

SubtypePersonality Traits/Features
Cold-AvoidantCharacterised by an inability to experience and express positive emotion towards others.
Exploitable-AvoidantCharacterised by an inability to express anger towards others or to resist coercion from others. May be at risk for abuse by others.

Diagnosis

ICD

The World Health Organisation’s ICD-10 lists avoidant personality disorder as anxious (avoidant) personality disorder (F60.6).

It is characterised by the presence of at least four of the following:

  1. Persistent and pervasive feelings of tension and apprehension.
  2. Belief that one is socially inept, personally unappealing, or inferior to others.
  3. Excessive preoccupation with being criticised or rejected in social situations.
  4. Unwillingness to become involved with people unless certain of being liked.
  5. Restrictions in lifestyle because of need to have physical security.
  6. Avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection.

Associated features may include hypersensitivity to rejection and criticism.

It is a requirement of ICD-10 that all personality disorder diagnoses also satisfy a set of general personality disorder criteria.

DSM

The Diagnostic and Statistical Manual of Mental Disorders (DSM) of the APA also has an avoidant personality disorder diagnosis (301.82). It refers to a widespread pattern of inhibition around people, feeling inadequate and being very sensitive to negative evaluation. Symptoms begin by early adulthood and occur in a range of situations.

Four of the following seven specific symptoms should be present:

  1. Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.
  2. Is unwilling to get involved with people unless certain of being liked.
  3. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
  4. Is preoccupied with being criticised or rejected in social situations.
  5. Is inhibited in new interpersonal situations because of feelings of inadequacy.
  6. Views self as socially inept, personally unappealing, or inferior to others.
  7. Is unusually reluctant to take personal risk or to engage in any new activities because they may prove embarrassing.

Differential Diagnosis

In contrast to social anxiety disorder, a diagnosis of AvPD also requires that the general criteria for a personality disorder are met.

According to the DSM-5, avoidant personality disorder must be differentiated from similar personality disorders such as dependent, paranoid, schizoid, and schizotypal. But these can also occur together; this is particularly likely for AvPD and dependent personality disorder. Thus, if criteria for more than one personality disorder are met, all can be diagnosed.

There is also an overlap between avoidant and schizoid personality traits and AvPD may have a relationship to the schizophrenia spectrum.

Epidemiology

Data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions indicates a prevalence of 2.36% in the US general population. It appears to occur with equal frequency in males and females. In one study, it was seen in 14.7% of psychiatric outpatients.

Criticism

There is controversy as to whether avoidant personality disorder (AvPD) is distinct from generalised social anxiety disorder. Both have similar diagnostic criteria and may share a similar causation, subjective experience, course, treatment and identical underlying personality features, such as shyness.

It is contended by some that they are merely different conceptualisations of the same disorder, where avoidant personality disorder may represent the more severe form. In particular, those with AvPD experience not only more severe social phobia symptoms, but are also more depressed and more functionally impaired than patients with generalised social phobia alone. But they show no differences in social skills or performance on an impromptu speech. Another difference is that social phobia is the fear of social circumstances whereas AvPD is better described as an aversion to intimacy in relationships.

Treatment

Treatment of avoidant personality disorder can employ various techniques, such as social skills training, psychotherapy, cognitive therapy, and exposure treatment to gradually increase social contacts, group therapy for practicing social skills, and sometimes drug therapy.

A key issue in treatment is gaining and keeping the patient’s trust since people with an avoidant personality disorder will often start to avoid treatment sessions if they distrust the therapist or fear rejection. The primary purpose of both individual therapy and social skills group training is for individuals with an avoidant personality disorder to begin challenging their exaggerated negative beliefs about themselves.

Significant improvement in the symptoms of personality disorders is possible, with the help of treatment and individual effort.

Prognosis

Being a personality disorder, which is usually chronic and has long-lasting mental conditions, an avoidant personality disorder is not expected to improve with time without treatment. Given that it is a poorly studied personality disorder and in light of prevalence rates, societal costs, and the current state of research, AvPD qualifies as a neglected disorder.

What is a Neurodevelopmental Disorder?

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Introduction

Neurodevelopmental disorders are a group of disorders that affect the development of the nervous system, leading to abnormal brain function which may affect emotion, learning ability, self-control, and memory. The effects of neurodevelopmental disorders tend to last for a person’s lifetime.

Types

Neurodevelopmental disorders are impairments of the growth and development of the brain and/or central nervous system. A narrower use of the term refers to a disorder of brain function that affects emotion, learning ability, self-control and memory which unfolds as an individual develops and grows.

The neurodevelopmental disorders currently considered, recognised and/or acknowledged to be as such are:

  • Attention deficit hyperactivity disorder (ADHD).
  • Communication, speech, or language disorders, including autism spectrum disorder (ASD), expressive language disorder, fluency disorder, social (pragmatic) communication disorder, and speech sound disorder.
  • Intellectual disabilities (IDs) or intellectual development disorder (IDD, previously called mental retardation) and global developmental delay (GDD).
  • Motor disorders including developmental coordination disorder, stereotypic movement disorder, and tic disorders (such as Tourette’s syndrome).
  • Neurogenetic disorders, such as fragile-X syndrome, Down syndrome, Rett syndrome, hypogonadotropic hypogonadal syndromes.
  • Specific learning disorders, like dyslexia or dyscalculia.
  • Traumatic brain injury (including congenital injuries such as those that cause cerebral palsy) and disorders due to neurotoxicants like foetal alcohol spectrum disorder, Minamata disease caused by mercury, behavioural disorders including conduct disorder etc. caused by other heavy metals, such as lead, chromium, platinum etc., hydrocarbons like dioxin, PBDEs and PCBs, medications and illegal drugs, like cocaine and others.

Presentation

The multitude of neurodevelopmental disorders span a wide range of associated symptoms and severity, resulting in different degrees of mental, emotional, physical, and economic consequences for individuals, and in turn families, social groups, and society.

Causes

The development of the nervous system is tightly regulated and timed; it is influenced by both genetic programs and the environment. Any significant deviation from the normal developmental trajectory early in life can result in missing or abnormal neuronal architecture or connectivity. Because of the temporal and spatial complexity of the developmental trajectory, there are many potential causes of neurodevelopmental disorders that may affect different areas of the nervous system at different times and ages. These range from social deprivation, genetic and metabolic diseases, immune disorders, infectious diseases, nutritional factors, physical trauma, and toxic and environmental factors. Some neurodevelopmental disorders, such as autism and other pervasive developmental disorders, are considered multifactorial syndromes which have many causes that converge to a more specific neurodevelopmental manifestation.

Social Deprivation

Deprivation from social and emotional care causes severe delays in brain and cognitive development. Studies with children growing up in Romanian orphanages during Nicolae Ceauşescu’s regime reveal profound effects of social deprivation and language deprivation on the developing brain. These effects are time-dependent. The longer children stayed in negligent institutional care, the greater the consequences. By contrast, adoption at an early age mitigated some of the effects of earlier institutionalisation (abnormal psychology).

Genetic Disorders

A prominent example of a genetically determined neurodevelopmental disorder is Trisomy 21, also known as Down syndrome. This disorder usually results from an extra chromosome 21, although in uncommon instances it is related to other chromosomal abnormalities such as translocation of the genetic material. It is characterised by short stature, epicanthal (eyelid) folds, abnormal fingerprints, and palm prints, heart defects, poor muscle tone (delay of neurological development) and intellectual disabilities (delay of intellectual development).

Less commonly known genetically determined neurodevelopmental disorders include Fragile X syndrome. Fragile X syndrome was first described in 1943 by J.P. Martin and J. Bell, studying persons with family history of sex-linked “mental defects”. Rett syndrome, another X-linked disorder, produces severe functional limitations. Williams syndrome is caused by small deletions of genetic material from chromosome 7. The most common recurrent Copy Number Variannt disorder is 22q11.2 deletion syndrome (formerly DiGeorge or velocardiofacial syndrome), followed by Prader-Willi syndrome and Angelman syndrome.

Immune Dysfunction

Immune reactions during pregnancy, both maternal and of the developing child, may produce neurodevelopmental disorders. One typical immune reaction in infants and children is PANDAS, or Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection. Another disorder is Sydenham’s chorea, which results in more abnormal movements of the body and fewer psychological sequellae. Both are immune reactions against brain tissue that follow infection by Streptococcus bacteria. Susceptibility to these immune diseases may be genetically determined, so sometimes several family members may suffer from one or both of them following an epidemic of Strep infection.

Infectious Diseases

Systemic infections can result in neurodevelopmental consequences, when they occur in infancy and childhood of humans, but would not be called a primary neurodevelopmental disorder. For example HIV Infections of the head and brain, like brain abscesses, meningitis or encephalitis have a high risk of causing neurodevelopmental problems and eventually a disorder. For example, measles can progress to subacute sclerosing panencephalitis.

A number of infectious diseases can be transmitted congenitally (either before or at birth), and can cause serious neurodevelopmental problems, as for example the viruses HSV, CMV, rubella (congenital rubella syndrome), Zika virus, or bacteria like Treponema pallidum in congenital syphilis, which may progress to neurosyphilis if it remains untreated. Protozoa like Plasmodium or Toxoplasma which can cause congenital toxoplasmosis with multiple cysts in the brain and other organs, leading to a variety of neurological deficits.

Some cases of schizophrenia may be related to congenital infections though the majority are of unknown causes.

Metabolic Disorders

Metabolic disorders in either the mother or the child can cause neurodevelopmental disorders. Two examples are diabetes mellitus (a multifactorial disorder) and phenylketonuria (an inborn error of metabolism). Many such inherited diseases may directly affect the child’s metabolism and neural development but less commonly they can indirectly affect the child during gestation. (See also teratology).

In a child, type 1 diabetes can produce neurodevelopmental damage by the effects of excess or insufficient glucose. The problems continue and may worsen throughout childhood if the diabetes is not well controlled. Type 2 diabetes may be preceded in its onset by impaired cognitive functioning.

A non-diabetic foetus can also be subjected to glucose effects if its mother has undetected gestational diabetes. Maternal diabetes causes excessive birth size, making it harder for the infant to pass through the birth canal without injury or it can directly produce early neurodevelopmental deficits. Usually the neurodevelopmental symptoms will decrease in later childhood.

Phenylketonuria, also known as PKU, can induce neurodevelopmental problems and children with PKU require a strict diet to prevent mental retardation and other disorders. In the maternal form of PKU, excessive maternal phenylalanine can be absorbed by the foetus even if the foetus has not inherited the disease. This can produce mental retardation and other disorders.

Nutrition

Nutrition disorders and nutritional deficits may cause neurodevelopmental disorders, such as spina bifida, and the rarely occurring anencephaly, both of which are neural tube defects with malformation and dysfunction of the nervous system and its supporting structures, leading to serious physical disability and emotional sequelae. The most common nutritional cause of neural tube defects is folic acid deficiency in the mother, a B vitamin usually found in fruits, vegetables, whole grains, and milk products (Neural tube defects are also caused by medications and other environmental causes, many of which interfere with folate metabolism, thus they are considered to have multifactorial causes). Another deficiency, iodine deficiency, produces a spectrum of neurodevelopmental disorders ranging from mild emotional disturbance to severe mental retardation.

Excesses in both maternal and infant diets may cause disorders as well, with foods or food supplements proving toxic in large amounts. For instance in 1973 K.L. Jones and D.W. Smith of the University of Washington Medical School in Seattle found a pattern of “craniofacial, limb, and cardiovascular defects associated with prenatal onset growth deficiency and developmental delay” in children of alcoholic mothers, now called foetal alcohol syndrome, It has significant symptom overlap with several other entirely unrelated neurodevelopmental disorders.

Physical Trauma

Brain trauma in the developing human is a common cause (over 400,000 injuries per year in the US alone, without clear information as to how many produce developmental sequellae) of neurodevelopmental syndromes. It may be subdivided into two major categories, congenital injury (including injury resulting from otherwise uncomplicated premature birth) and injury occurring in infancy or childhood. Common causes of congenital injury are asphyxia (obstruction of the trachea), hypoxia (lack of oxygen to the brain) and the mechanical trauma of the birth process itself.

Placenta

Although it not clear yet as strong is the correlation between placenta and brain, a growing number of studies are linking placenta to foetal brain development.

Diagnosis

Neurodevelopmental disorders are diagnosed by evaluating the presence of characteristic symptoms or behaviours in a child, typically after a parent, guardian, teacher, or other responsible adult has raised concerns to a doctor.

Neurodevelopmental disorders may also be confirmed by genetic testing. Traditionally, disease related genetic and genomic factors are detected by karyotype analysis, which detects clinically significant genetic abnormalities for 5% of children with a diagnosed disorder. As of 2017, chromosomal microarray analysis (CMA) was proposed to replace karyotyping because of its ability to detect smaller chromosome abnormalities and copy-number variants, leading to greater diagnostic yield in about 20% of cases. The American College of Medical Genetics and Genomics and the American Academy of Paediatrics recommend CMA as standard of care in the US.

Book: Listen Mama

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Book Title:

Listen Mama.

Author(s): MSP Williams.

Year: 2021.

Edition: First (1st).

Publisher: Bowker.

Type(s): Paperback and Kindle.

Synopsis:

Through a series of letters at times heart-breaking, poetic, and unexpectedly humorous, come explore this true teen and young adult journey of a lost soul searching for the love of his mentally ill mother. While facing seemingly insurmountable odds, Manny ultimately becomes her caretaker and guardian while also parenting his four younger siblings in 1990’s Houston, Texas.

Witness his transformation in this coming-of-age story of a forgotten and disfigured black child, born into spirit-crushing poverty, and thrust into adult life all too soon. Manny’s teen years are spent battling the silent and treacherous enemy of mental illness in his mother’s erratic and terrifying behavior. Years of bullying and abuse finally take their toll, and Manny soon finds himself at war with his own demons of depression, anxiety, and suicide attempts as he struggles to find his place in the world, and the true meaning of unconditional love.

Experience this inspirational story of loss, faith, love, and redemption that is guaranteed to bring forth both tears and laughter, heartache and happiness, as it captures your imagination, ignites your soul, and soon has you racing from page to page, breathlessly waiting to discover what happens.