Developmental psychopathology is a complex approach to studying childhood problems and atypical development, in the context of human development. There are many issues in defining and classifying abnormality, such as different levels of intensity of the problem. It is possible the child could outgrow the symptoms, this could be a phase the child is going through, for example being in a new environment as this can affect children more than it may affect adults. Another problem with defining and classifying abnormality is the parental views of the behaviour, it needs to be established if the child’s parents and parents of other children with similar behaviour have the same views of the behaviour. It needs to be considered if treatment could prevent the child growing up to be abnormal and reduce the likelihood of problems later on in life. The affects of being labelled as abnormal for the child can affect children differently. To overcome these problems a model was required, which considered biological, psychological and social factors. The developmental psychopathology approach is a multidisciplinary, and therefore fulfilling the criteria. Developmental psychopathology uses the dimensional approach, which focuses on a range of behaviours rather than a diagnostic classification. Whether the behaviour is a problem is dependant upon the age of the child, as it is necessary to take into account the age related changes children go through. This is needed to consider what is normal and adaptive, as some behaviour can be normal at one age but may be seen as a problem at another (Hudziak et al., 2007). However some children may develop certain skills later than other children of the same age, what is important is the child develops the skills properly rather than when they are developed. The perception of the child’s level of cognitive development will need to be taken into consideration because it will lead to how the behaviour is perceived, interpreted and labelled by adults. It must be known what is normal development and the stages of development before atypical development can be diagnosed. Atypical development can occur at any stage of development with different problems at different ages.
Another factor the developmental psychopathology approach takes into account is stability. A child’s behaviour can depend on stability, as their behaviour is more responsive to environmental changes. This can include which adults are present in the child’s environment, because it can impact upon their behaviour. Clinician’s have to decide whether the child has a problem or whether the issue is part of an intolerance, ignorance, or misconception on behalf of the adult (Campbell, 1983).
Psychometric tests uses sample behaviour, which are usually scores on a test, to generalise and allow comparisons of an individual to a norm of their sample population. An example of a psychometric test is the Wechsler Intelligence Scale for Children uses a variety of different task to generate an IQ, without using reading or writing ability. This can be used to diagnose different problems, such as learning difficulties and attention deficit hyperactive disorder (ADHD). However there is no specific pattern of scores for ADHD, therefore it would be difficult to diagnose a child using this test. Although it can be useful to show discrepancies in attention and emotional difficulties it should not be used as a diagnostic tool. Tests, such as the Wechsler Intelligence Scale for Children, are then used in conjunction with other relevant tests, such as measure of achievement and observations, to assess the effects of the context and give a diagnosis. From this clinicians can recommend intervention or treatments that are best for the child, and the interventions can be assessed throughout time using these testing methods. However the tests used need to be valid and reliable because the tests will be used for diagnosis and classification of individuals.
The childhood condition to be discussed is Attention Deficit Hyperactivity Disorder (ADHD), a disruptive behaviour. ADHD was first described by Still (1902, as cited in Barkley, 2003) with symptoms including aggressiveness, defiant, overly emotional and cruelty towards others. In the 1950’s it was labelled as “Hyperactive Child Syndrome”, with researchers, such as Chess (1960), empathising the hyperactivity as the defining feature. The disorder was first recognised by the DSM II (American Psychiatric Association, 1968), as Hyperkinetic Reaction of Childhood disorder. This was changed to empathise the importance of inattention and impulsivity in ADHD in the DSM III-TR (American Psychiatric Association, 1987) by labelling the disorder as Attention Deficit Disorder with/without hyperactivity. According to the DSM IV-TR, (American Psychiatric Association, 2000) the essential features of ADHD are the patterns of inattention and/or hyperactivity and impulsivity. As more research has taken place, from first being described the definition of ADHD has changed greatly. This report will focus on how ADHD is diagnosed, treatment and the factors that may affect children with ADHD in social and academic contexts.
ADHD is a condition that develops in some children during early childhood, and may continue into adulthood. ADHD effects 3-5% of all school aged children, leading to it being the most commonly diagnosed behavioural disorder in children. There are three subtypes of ADHD, which are
ADHD predominantly inattention
ADHD predominantly hyperactivity and impulsivity
ADHD combined inattention, hyperactivity and impulsivity
Inattention refers to trouble orienting to stimuli, or even a failure to detect stimuli. It can be seen in responding to the wrong aspects of a stimulus or to an entirely inappropriate stimulus. As well as a failure to sustain attention to task-relevant stimuli, they also show that they are easily distracted or have a short attention span. Impulsivity includes the failure to inhibit responding, or quick responding with numerous errors made in the response. A failure to fully appreciate all aspects of instructions given is a feature of impulsivity. Children with ADHD with symptoms of impulsivity do not stop to think about consequences of their actions, this can sometimes place themselves in dangerous and risky situations. They often do not consider the impact of their actions or statements on others. These children are more likely to respond aggressively, this could be verbally or physically, when frustrated or emotionally hurt by others. Hyperactivity is often a problem when the child is in a restrictive environment where concentration is required. It has been noted that hyperactive behaviours can be evoked by novel or unfamiliar situations (Barkley, 1981).
For ADHD to be diagnosed six or more symptoms of inattention must be present for at least 6 months, the symptoms must be disruptive and inappropriate for developmental level.
A few inattention symptoms are listed:
Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
Often has trouble keeping attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions).
Often has trouble organizing activities.
For ADHD to be diagnosed six or more symptoms of impulsivity and hyperactivity must be present for at least 6 months, the symptoms must be disruptive and inappropriate for developmental level
A few hyperactivity symptoms are listed:
Often fidgets with hands or feet or squirms in seat.
Often gets up from seat when remaining in seat is expected.
Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
A few impulsivity symptoms are listed:
Often blurts out answers before questions have been finished.
Often has trouble waiting one’s turn.
Often interrupts or intrudes on others.
DSM IV-TR (American Psychiatric Association, 2000).
Some of the symptoms must have been present before the age of 7 years, as well as being present in two or more setting, such as at home and school. For ADHD to be diagnosed the symptoms must make a significant impairment in the child’s social or academic functioning. The disorder must be diagnosed separate of other conditions, such as mood disorder, or a personality disorder. ADHD is associated with other disorders, for example 20-25% of children with ADHD have learning disabilities. Other associated disorders are anxiety disorder, oppositional defiant disorder, conduct disorder, Tourette Syndrome, depression, sleep problems, and epilepsy.
There are a variety of different ideas on the possible causes of ADHD. These include environmental factors, such as food additives and refined sugars. Psychosocial factors suggest ADHD being a result of poor parenting skills with inconsistent rules, an over-reliance on punishment and excessive commands. According to Barkley (1981) hyperactive children can be found to be noncompliant, attention seeking and aggressive. These children need supervision. It was also found their mothers were overly directive negative as well as being less responsive to the child in general.
Biological factors may include pre-frontal cortex abnormalities, neurotransmitter abnormalities, and neurological immaturity.
Diagnosis is made through medical and family history; this starts with a physical exam, and interviews with the parents, child and teachers (as the symptoms must be present in at least two settings). The parents and teachers also completed behaviour rating scales. Professionals carry out observations of the child’s behaviours. Finally psychological tests, such as social and emotional adjustment tests, are completed to see if the potential ADHD symptoms may be better labelled as another disorder.
Children with ADHD are commonly prescribed Ritalin, an amphetamine (methylphenidate hydrochloride) that increases dopamine levels that are deficient in those with ADHD. Ritalin has side effects, which include irritability, anxiousness, sleep problems, loss of appetite, dizziness, stomachache, headaches, and marked crying. The use of medication can be helped with behavioural therapy. A multisystemic approach, including psychoeducation, family intervention, school intervention, self-regulation skills training, would be appropriate.
There are many factors that may influence individual differences that can affect ADHD, for example the severity of ADHD. The severity may be the amount of symptoms that the individual has as they need a minimum of six symptoms per category, therefore some children may have more symptoms than others. The children with combined inattention, hyperactivity and impulsivity may have a severer ADHD because they will have more symptoms and a larger range of symptoms. The type of symptoms that the individual has may affect the severity of ADHD, as some symptoms may be more problematic than others, for example in inattention having trouble organising is not as much of a problem as having issues with listening when being spoken to directly.
Risk and Protective Factors
Risk factors are any characteristic, condition, or circumstance that may increase the likelihood of developmental difficulty or disorder, in a direct or indirect way. For example, the gender of the individual can increase the likelihood of developing ADHD, as it is more prevalent in males than females, with ratios from 4:1 to 9:1.
According to Sykes (1997) ADHD is due to early physiological problems; however this may be associated with other factors, such as maternal factors. A maternal circumstance may be the heavy use of alcohol during pregnancy that can lead to attention problems (Linnet et al., 2003). Also there has been found to be a significant association between smoking during pregnancy and ADHD (Thapar, et al., 2003). Pregnancy and birth complications, especially maternal bleeding, can lead to ADHD (Milberger, 1997). Childhood illnesses that involve high fevers have been shown to relate to ADHD (Dale, 2003). An important factor is the individual’s social environment; adults in the individual’s life (such as parents and teachers) do not always appreciate the distractions that children with ADHD can cause other children, as well as struggling to keep the individuals attention. Individuals who have ADHD combined with other disorders, such as learning difficulties and Tourette Syndrome, can be more socially isolated. Protective factors are characteristics, events or processes that seem to protect the child from developing psychological problems. Ritalin can help to reduce the symptoms of ADHD, along with behavioural therapy. Children with ADHD can be taught strategies and techniques for coping with stressful situations.
Bowlby (1982) believed that the parent-child relationship during infancy is a central causal factor in the child’s personality. This can be an upsetting theory for mothers whose children have ADHD, as they begin to feel responsible for their child’s disorder. The parents of children with ADHD may suffer from chronic sorrow, this is a term used to describe that the feelings of grief and sorrow that do not fully resolve when raising a child with developmental difficulties (Olshansky, 1962). Families may feel guilt about their possible genetic contribution to their child’s condition, or feel guilty for bad parenting of ‘naughty’ children. Parents may feel physically exhausted by some of the child’s behaviours, especially with children that are overly active and don’t concentrate very well. This makes it difficult to find things that will interest and keep the individual busy. Parents may become upset by thoughts of their child being stigmatised or socially isolated at school because of the behavioural characteristics of ADHD.
From Bronfenbrenner’s (1982) ecological systems perspective, culture plays a role in how childhood disorders are diagnosed and interpreted within the social context. For example, Jacobson (2002) found that teachers in both the United States and the United Kingdom identify ADHD characteristic behaviours; however they differed significantly in what they believed to be appropriate behaviour for the classroom. This shows that cultural differences are seen in the interpretation of behaviours, and whether the behaviour is seen as being disordered. A cultural difference can be seen between the criteria of ADHD for the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM IV-TR, 2000), which says essential features of ADHD are the patterns of inattention and/or hyperactivity and impulsivity, and the ICD-10 (World Health Organization, 1993), which says attention, hyperactivity and impulsivity symptoms must all be present for ADHD to be diagnosed. This makes comparisons across cultures difficult as it depends on the criterion that was used to make the diagnosis. However the prevalence rates of males to females having ADHD is consistent across all cultures (Cantwell, 1996). ADHD Working Group, consisting of clinicians and researchers from different countries, stated that ADHD is found in both developed and developing cultures, however in many countries it is under diagnosed (Remschmidt, 2004). Researchers, such as Timimi (2004), believe that the construction and higher rates of ADHD has emerged over recent years due to the stresses of modern Western culture, for example loss of extended family support. There has not been any large scale comparative cross-cultural studies conducted, which would be needed to establish whether ADHD is a universally experienced disorder.
A supportive environment both at home and at school is important for the individual’s development, for example support at school will help the child with their academic learning and their social skills with peers and teachers. Therefore whether the individual has a supportive environment will have an effect on how they develop with ADHD. As well as support for the child, the family may benefit from having good social support; parents with children with ADHD may find comfort, and even guidance, talking to other parents in the same position. It may also be beneficial for the parents of children with ADHD to have a close extended family, as well as a good friend’s network, because taking time out from looking after the child for an hour may prevent the parent from becoming physically exhausted.
A large debate surrounding ADHD is whether it is caused by genetics. ADHD is a failure in the brain circuitry occurring in development, which underlies inhibition and self-control (Barkley, 1998). According to Barkley (1998) the children with ADHD whose brains have portions that are smaller than in normal children is due to genetics. Tannock (1998) suggested that ADHD was the result of a brain dysfunction, which may be of genetic origin. A delayed or abnormal development of the nervous system, specifically the frontal lobe and executive functions may be a cause of ADHD. The neuro-developmental model suggests a biochemical imbalance, which is caused by the dopaminergic pathways from the brainstem to the basal ganglia in the frontal cortex. However disorders can run in families because of either environmental or genetic factors (Faraone, Tsuang, & Tsuang, 1999). It can be argued that environmental factors affect the course and outcome, but are not the cause. There have been no genes isolated, and no neuro-anatomical abnormalities have been found.
Children may not know they have problems and need help; this means the responsibility to identify these issues is that of the adults. This can be difficult, especially for adults who are not the parent of the child, as it can be seen as intruding into the life of a child and their family. The effect of diagnosing a child with ADHD can have a profound impact on a child. The affects of stigmatism, prejudice and discrimination can exaggerate the severity of ADHD. It needs to be considered if the labelling of ADHD will help or be a hindrance for each individual child.
The developmental psychopathology approach uses multiple perspectives, therefore giving a more eclectic diagnosis than using just one perspective. It takes into account the interplay of a range of influences, leading to a range of outcomes that gives a better diagnosis. It uses a great breadth of theory, methodology and possible mechanisms of development to give an accurate diagnosis of symptoms. It also considers maladaption as an outcome of development, not a disease.
Diagnostic classification systems are not very reliable for children and adolescents, bringing the debate of whether these systems should be used for diagnosing children. The systems may be unreliable due to a lack of developmental sensitivity, as they are not based on a firm knowledge of developmental norms. The cultural validity of diagnostic classification systems needs to be examined, as it has been found that there are cultural differences in the interpretation of behaviours (Jacobson, 2002). The cultural background and experience of the clinician involved can influence how they interpret the behaviours of the children. Therefore this can affect the diagnosis.