distinguishing normal from abnormal...

DISTINGUISHING NORMAL FROM ABNORMAL BEHAVIOR

Although many of the professional skills and competencies required to distin-guish normal from abnormal behavior are shared by clinicians who serve adultand child populations, there are also several unique skills and competencies thatdistinguish these two populations as separate clinical fields.

Determining whether a behavior pattern is normal or abnormal requires, at aminimum, a fundamental understanding of normal expectations and the range ofbehaviors that constitute the broad limits of the average or normal range. In or-der to determine whether a behavior falls outside the normal range, clinical judge-ment is often based on a series of decision-making strategies. One way of mea-suring how the behavior compares to normal expectations is the use of “the fourDs” as a guideline to evaluating the behavior: deviance, dysfunction, distress, and dan-

ger (Comer, 2001).Rachel, the psychologist’s 3-year-old daughter, was previously observed throw-

ing a temper tantrum at the day care center. Consider the severity of Rachel’stantrum behavior in relation to the tantrum behavior of another 3-year-oldchild, Arty.

The psychologist observes Rachel throwing a temper tantrum because Arty hastaken her favorite toy. Rachel is lying on the floor, crying and kicking her legs intothe floor mat. This behavior occurs whenever Arty takes this toy away (about twicea week) and lasts until the teacher intervenes. Rachel’s mother has not seen this be-havior at home. Arty also causes a similar reaction from Sara, another child in theprogram. Arty is constantly fighting with other children. Arty takes what he wants,when he wants it. If stopped, Arty throws temper tantrums that escalate in pro-portion and can last up to half an hour. On two occasions, Arty has injured a teacherby throwing an object wildly into the air. When frustrated, Arty will strike out, andhe has bitten others to get his way. Arty’s mother has asked for help with managingArty’s behavior. She is afraid Arty willinjure his new baby brother.

In evaluating Rachel’s and Arty’sbehaviors, we know that tantrum be-havior peaks at 3 years of age and thatbiting is not uncommon amongpreschoolers. However, althoughRachel’s tantrum behavior wouldlikely be considered to fall within therange of normal expectations, Arty’sbehaviors are more concerning, be-

INTRODUCTION TO CHILD PSYCHOPATHOLOGY 9

DON’T FORGETClinical decisions are often based onmeasures of the intensity, duration, andfrequency of a behavior relative to thenorm. In addition, evaluating whethera behavior is pervasive across situa-tions can also provide information re-garding the nature and severity of thebehavior in terms of eliciting mild,moderate, or severe levels of concern.

cause the behaviors demonstrate deviance from the norm on all measures: inten-sity ( he has injured others); frequency ( he has done so repeatedly), and duration( his tantrums last at least a half hour). In contrast, Rachel’s behaviors are isolatedto the school situation and to Arty’s advances in particular. Rachel’s tantrumswould likely elicit a mild level of concern and possibly result in the developmentof a behavioral intervention plan to assist Rachel in coping with Arty’s advances.However, in addition to all the aforementioned concerns, Arty’s behaviors wouldalso be considered more severe due to the pervasive nature of the behavior, whichis evident at home as well as at school. Furthermore, the behaviors pose a dangerto those around him ( he has injured a teacher), and Arty has not developed ap-propriate skills in areas of self-control or social relationships (dysfunction).Arty’s ease of frustration, low frustration tolerance, and habitual tantrum be-havior all signal high levels of distress. In addition, Arty’s behaviors are disturb-ing and distressing to others. Based on the nature of Arty’s problem behaviors, amore intensive treatment program would be required to modify his behavior.

The use of the four Ds can provide helpful guidelines in determining normalfrom abnormal behavior in the fol-lowing ways.

Deviance. Determining the degreethat behaviors are deviant from thenorm can be assisted through the useof informal assessment (interviews,observations, symptom rating scales)or more formal psychometric testbatteries (personality assessment).Classification systems can also pro-vide clinicians with guidelines forevaluating the degree of deviance.

Clinicians working with childrenand adults must also be aware thatseveral disorders can share commonfeatures, and often additional datagathering is required to rule out orconfirm the existence of a specificdisorder (differential diagnosis). In addi-tion to disorders sharing similar fea-tures, some disorders also occur to-gether more frequently, a conditionknown as comorbidity.

10 ESSENTIALS OF CHILD PSYCHOPATHOLOGY

C A U T I O N

There has been an increasing aware-ness of the need to integrate culturalvariations into our understanding ofdeviant behaviors and psychopathol-ogy (Fabrega, 1990; Rogler, 1999).TheDSM-IV-TR (APA, 2000) includes sec-tions acknowledging cultural factorsand cultural reference groups in de-scribing disorders.

DON’T FORGETSymptoms of inattentiveness, lack ofconcentration, restlessness, fidgeting,forgetfulness, and disorganization maysignal a case of ADHD. However, dif-ferential diagnosis may be required torule out anxiety, depression, Post-traumatic Stress Disorder, child abuse,learning problems, and a host of otherpotential problems that share similarfeatures.

Dysfunction. Once a disorder is identified, the relative impact of the disorder onthe individual’s functioning must be determined. Child clinicians may be inter-ested in the degree of dysfunction in such areas as school performance (academicfunctioning) or social skills.

Distress. An area closely related to dysfunction is the degree of distress the dis-order causes. Children often have difficulty articulating feelings and may providelittle information to assist the clinician in determining distress. Interviews withparents and teachers can provide additional sources of information. Some disor-ders may present little distress for the individual concerned but prove very dis-tressing to others.

Danger. In order to determine whether a given behavior places an individual atrisk, two broad areas are evaluated: risk for self-harm and risk of harm to others.Historically the focus has been on victimization and maltreatment of children(abuse or neglect) or the assessment of risk for self-harm (suicide intent). How-ever, more recent events, such as the 1999 Columbine shootings and increasedawareness of bullying, have increased concerns regarding children as perpetratorsof harm. Accordingly, increased emphasis has been placed on methods of identi-fying potentially dangerous children and conducting effective threat assessments.

Normal and Abnormal Behaviors: Developmental Considerations

Evaluation of psychopathology from a developmental perspective requires theintegration of information about child characteristics (biological and genetic)and environmental characteristics (family, peers, school, neighborhood). There-fore, understanding child psychopathology from a developmental perspective re-quires an understanding of the nature of cognitive, social, emotional and physicalcompetencies, limitations, and task expectations for each stage of development.This understanding is crucial to an awareness of how developmental issues im-pact psychopathology and treatment. Examples of developmental tasks, compe-tencies, and limitations are presented in Rapid Reference 1.2.

The Impact of Theoretical Perspectives

The ability to distinguish normal from abnormal behavior and select develop-mentally appropriate child interventions can be guided by information obtainedfrom various theoretical frameworks. Different theoretical perspectives can pro-vide the clinician with guidelines concerning expectations for social, emotional,cognitive, physical, and behavioral outcomes. In addition, a therapist’s theoretical



Examples of Developmental Tasks, Competencies,and Limitations

Age or Stage of Development Task or Limitations

Birth to 1 year Trust vs. mistrust (Erikson)Secure vs. insecure attachment (Bowlby)Differentiation between self and othersReciprocal socializationDevelopment of object permanence (Piaget: objects existwhen out of sight)First steps; first word

Toddler : 1–2.5 Autonomy vs. shame and doubt (Erikson)Increased independence, self-assertion, and prideBeginnings of self-awarenessSocial imitation and beginnings of empathyBeginnings of self-controlDelayed imitation and symbolic thoughtLanguage increases to 100 wordsIncrease in motor skills and exploration

Preschool: 2.5–6 Initiative vs. guilt (Erikson)Inability to decenter (Piaget: logic bound to perception;problems with appearance/reality)Egocentric (emotional and physical perspective; oneemotion at a time)Increased emotion regulation (under-regulation vs. over-regulation)Increased need for rules and structureCan identify feelings: Guilt and conscience are evidentEmergent anxieties, phobias, fears

School age: 6–11 Industry vs. inferiority (Erikson)Sense of competence, mastery, and efficacyConcrete operations (Piaget: no longer limited by ap-pearance, but limited by inability to think in the abstract)Can experience blends of emotions (love-hate)Self-concept and moral conscienceRealistic fears (injury, failure) and irrational fears (mice,nightmares)

Rapid Reference 1.2

assumptions will also influence how the disorder is conceptualized and guide thecourse of the treatment focus.

Biomedical Theories

Biological and physiological theories are concerned with the impact of biologicaland genetic factors on individual differences. There has been increasing recogni-tion of the interactive contribution of environmental ( health, nutrition, stress)and genetic influences. Emphasis has been placed on several factors in this area,including temperament, genetic transmission, and brain structure and function.

In defining abnormal behavior, a biomedical model would seek to determinewhich parts of the body or brain were malfunctioning, whether genetics, brainchemistry, or brain anatomy. Twin studies have been instrumental in providing in-formation concerning the role of genetics, while refined neurological approaches,such as magnetic resonance imaging (MRI), have also contributed to our knowl-edge of underlying brain-based differences in some disorders.

Psychodynamic Theories

Freud initially envisioned abnormalbehavior resulting from fixations orregressions based on earlier unre-solved stages of conflict. His psy-chosexual stages provide potentialinsight into unconscious drives andconflicts that may influence theunderlying dynamics of certainpathologies. The role of uncon-scious defense mechanisms thatserve to protect the vulnerable egostem from battles between the id(more primitive pleasure principle)and the superego (moral con-


Teen years Identity vs. role diffusion (Erikson)Abstract reasoning (Piaget)Emotional blends in self and others (ambiguity)Return of egocentricity (Piaget /Elkind: imaginary audienceand personal fable)Self-concept relative to peer acceptance and compe-tence

DON’T FORGETHistorically, psychoanalytic applica-tions have been very difficult tosupport empirically. Influenced byBowlby’s theories of self-developmentand attachment, recent research byFonagy and Target (1996) has pro-vided empirical support for psycho-dynamic developmental therapy forchildren (PDTC). Working throughthe medium of play, therapists assistchildren to develop skills in the self-regulation of impulses and enhancedawareness of others.

science). These defense mechanisms add depth to our understanding of moreprimitive child defenses, such as denial, or more socially constructive defenses,such as humor.

Erik Erikson (1902–1994) also supported the notion of stages; however, hispsychosocial stages outline socioemotional tasks that must be mastered to allowfor positive growth across the lifespan. As can be seen in Rapid Reference 1.2,theorists have adapted the concept of developmental tasks and stages of devel-opment to explain and predict a wide variety of behaviors based on competenciesand limitations (social, emotional, cognitive, and physical) evident at each of thestages.

According to Erikson, in the first year of life, the major task is to develop asense of basic trust versus mistrust. From the foundation of a secure attachment,the preschooler is free to explore the environment. Either a growing sense ofautonomy develops or the insecure child may shrink from these experiences,producing feelings of shame and self-doubt. The school-age child mastersschool-related subjects and peer socialization, which increase a sense of industryversus inferiority. In adolescence, the task becomes one of identity versus roleconfusion.

Behavioral Theories

Behavioral theory is based on the fundamental credo that behavior is shaped byassociations (contingencies) resulting from positive (reinforcement) and negative(punishment) consequences. Consequences are positive if

• They add a benefit (positive reinforcement; e.g., finish your work inclass and you will be given ten minutes of free activity time), or

• They remove or avoid (escape) a negative consequence (negative re-inforcement; e.g., if you finish your work in class, you will not have tostay after school).

Consequences are negative if

• They add an adverse or nega-tive consequence (punish-ment), or

• They remove or avoid a posi-tive consequence (penalty).

Some punishments can be so severethat behavior is eliminated alto-gether, a condition known as extinc-


DON’T FORGETThe concept of negative reinforce-ment is more difficult to understandthan positive reinforcement becausenegative reinforcement is often con-fused with punishment. Rememberthat punishments deliver negative con-sequences and serve to reduce ratherthan increase behaviors.

tion. If behavior is no longer re-inforced and continually punished,extinction is often the result. Deter-mining whether the behavior is an ex-cess or deficit also requires knowl-edge of what to expect based ondevelopmental level. Optimally, a be-havioral plan will target increasing adeficit behavior rather than reducingan excessive behavior. For example,it is preferable and often more suc-cessful to attempt to increase on-task behavior than to attempt toreduce off-task behavior, since in-creasing the positive behavior willultimately reduce negative conse-quences.

Although the majority of learnedbehavior occurs through operantconditioning or observational learn-ing, behaviorists use the paradigm ofclassical conditioning to explain the development of irrational fears or phobias.For example, a child may develop a fear of sleeping alone if awakened by a veryloud thunderstorm. Furthermore, the fear might generalize to fear of the dark,fear of loud noises, or fear of his or her own bed or bedroom. Pairing the loudnoise with sleeping alone can result in the child’s developing a conditioned re-sponse of fear of his or her own bed.

Cognitive Theories

Cognitive theorists are primarily interested in the relationship between thoughtsand behaviors and how faulty assumptions can impact on social relationships aswell as influencing self-attributions in a negative way. Jean Piaget’s stages of cog-nitive development are outlined in Rapid Reference 1.2. Piaget was highly influ-ential in his attempts to chart the course of cognitive development. According toPiaget, children in the preoperational stage (ages 2 to 7) can be easily mislead bydominant visual features due to their inability to consider two aspects simulta-neously, what Piaget calls an inability to decenter. A very young child will say thatthere is more liquid in a tall thin glass than a short fat one, even though the childwitnessed the same amount of liquid being poured into the two glasses. Visual


DON’T FORGETBehaviors can also be categorized as abehavioral excess (externalizing, acting-out behaviors) or a behavioral deficit(internalizing, withdrawn behaviors).

C A U T I O N

Parents or teachers can be very frus-trated when a child continues to en-gage in repeated negative behaviorsdespite warnings, punishments, andvarious other acts of negative conse-quences. However, what they fail tounderstand is that all the nagging andcajoling serves as a positive reinforce-ment to the child because the out-come is increased adult attention.Therefore, the more nagging contin-ues, the more the behavior is re-inforced and will be sustained.

dominance also contributes to difficulties separating appearance and reality (adog wearing a cat mask is now a cat). Taking another’s perspective or point ofview is also very limited due to the child’s egocentrism or self-focus. The school-aged child (the concrete operations stage) is capable of reasoning beyond thatof the preschool child; however, this stage is limited by concrete observations.According to Piaget, abstract thinking is not achieved until adolescence, whenhypothetical and deductive reasoning emerges. Although Piaget believed that allchildren progress through a series of fixed stages, recent research has recognizedthat children of differing abilities may progress at different rates and that Piaget’sstage theories may not be universal.

Social cognitive theories. Albert Bandura’s (1977, 1986) contributions to the field ofsocial cognition stem from his early work on social learning processes, observa-tional learning, and aggression. Bandura’s (1977) understanding of the socialaspects of learning has been instrumental in increasing our awareness of obser-

vational learning. Children’s obser-vation and subsequent modeling ofadult behavior can have positive (nur-turing and empathic caring behav-iors) or negative consequences (ag-gressive responses; e.g., witness todomestic violence).

Research concerning children’sunderstanding of social relationshipshas also been applied to the develop-ment of social skills and problemsolving in social situations. Studies inthis area have revealed that childrenrejected by peers are often aggressive,argumentative, and retaliatory to-wards others (Dodge, Bates, & Pettit,1990). Furthermore, negative behav-iors often resulted from tendencies tomisinterpret ambivalent social situa-tions as hostile, or what has come tobe known as the hostile attribution bias.

Cognitive behavioral theories. The cog-nitive behavioral approach seeks to


DON’T FORGETThe concept of triadic reciprocity wasdeveloped by Bandura to explain thecomplex nature of people, behaviors,and the environment. According toBandura behavior not only is the out-come of the person in a given envi-ronment or situation but also itselfserves to influence the person andthe environment.

Person Environment↑↓

Behavior

DON’T FORGETAggression from the social cognitiveperspective might be explained by ob-servational learning (the child is po-tentially a witness to violence athome; Bandura) or as resulting froman interpretation of a situation basedon faulty attributions, hostile attributionbias (Dodge et al., 1990).

understand associations between thoughts and behaviors. Therefore, emphasis isplaced on understanding how the child’s faulty belief system contributes to mal-adaptive behaviors, such as aggression, depression, and anxiety. Cognitive theo-rists, such as Aaron Beck (1976), posit that depression develops and is sustainedby self-attributions arising from a cognitive triad producing thoughts of helpless-ness, hopelessness, and worthlessness. Seligman and Peterson (1986) suggest thatlearned helplessness can develop from repeated negative self-attributions, whichproduce feelings of powerlessness and lack of control that ultimately become aself-fulfilling prophecy.

Theories of Attachment and Parenting

John Bowlby’s (1908–1990) adaptation theory was influenced by Darwin’s theory ofevolution and Freud’s emphasis on internal working models. Bowlby believedthat early attachment relationships carry a profound influence throughout thelifespan. Later, Mary Ainsworth explored attachment issues using the strange sit-uation experiments and revealed that securely attached infants were more inde-pendent and better problem solvers than insecurely attached infants. Infants whodemonstrated avoidant attachment rarely showed distress when separated fromcaregivers, while infants who demonstrated resistant attachment often demon-strated clingy behaviors and greater upset at separations from caregivers whoresponded with unpredictable behavioral extremes ( love and anger). In the late1970s, working with a population of maltreated infants, Main and Weston (1981)ultimately added a fourth category of disorganized behavior to describe distress-ful and frightened responses to caregivers.

Baumrind (1991) also investigated parenting styles and found three ap-proaches to parenting that impactedon child behaviors for better orworse. Children raised by authori-tarian parents ( high on structure, lowon warmth) tend to react with behav-iors that are aggressive and uncooper-ative, tend to be fearful of punish-ment, and are generally weak oninitiative, self-esteem, and peercompetence. Children who are raisedin permissive households ( high onwarmth, low on structure) often failto develop a sense of responsibilityand self-control. Authoritative par-


C A U T I O N

Although attachment theory was de-veloped to explain how children de-velop an organized schema of rela-tionships (internal working models),Main and Hesse (1990) reasoned thatdisorganized responses were the re-sult of an inability to construct aschema, since attachment in thesemaltreated infants activated two com-peting and irreconcilable response sys-tems: attachment (approach) and fear(avoidance).

ents ( high on warmth and high on structure) provide the optimum conditions forgrowth, and as a result children often demonstrate high degrees of self-reliance,self-esteem, and self-controlled behaviors.

Family Systems Theory

Family systems theory is represented by a variety of approaches that emphasizethe family unit as the focus of assessment and intervention. This theoreticalframework acknowledges the family system itself, as a unit made up of many sub-systems: parent and child, marriage partners, siblings, extended family, and so on.Within families, behaviors are often directed toward maintaining or changing

boundaries, alignment, and power.Boundaries are the imaginary linesthat serve to define the various sub-systems. Often a family’s degree ofdysfunction can be defined byboundaries that are poorly or incon-sistently defined or those that are tooextreme (too loose or too rigid). Sal-vador Minuchin (1985), a proponentof structural family therapy, has sug-gested that enmeshed families ( lack-ing in boundaries) may interpret achild’s need to individuate as a threatto the family unit.

Influences andDevelopmental Change

Most clinicians today recognize thatin addition to understanding childcharacteristics (temperament, devel-opmental stage) it is equally impor-tant to consider environmental influ-ences (family, peers, school, commu-nity, economics and culture) whenevaluating child and adolescent dis-orders. Ultimately, the importance ofincluding the developmental contextin understanding child and adolescent


DON’T FORGETA theorist from a family systems per-spective might view the aggressive be-haviors of a child in the context of be-haviors motivated to undermine theimportance of the primary marital re-lationship.Triangular relationships thatserve to shift the balance of power in-clude the parent-child coalition (parentand child versus parent), triangulation(child caught between two parents),and detouring (maintaining the childas focus of the problem to avoid ac-knowledging marital problems).

DON’T FORGETAn understanding of developmentalpathways includes an awareness thatthere are several possible pathwaysthat may produce the same outcome,an occurrence known as equifinality(e.g., many factors may cause a singleoutcome, such as childhood depres-sion), and that similar risks may pro-duce different outcomes, which isknown as multifinality (e.g., childhoodneglect may result in aggressive be-havior in one child and withdrawal in another ; Cicchetti & Rogosch,1996).

disorders is crucial to comprehending not only the child’s present level of distressor dysfunction but also how the difficulties came to be (developmental pathway).

The child clinician must also consider the impact of environmental influencesas predisposing, precipitating, and maintaining (reinforcing) factors regardingthe behavior in question. While theoretical assumptions can guide our under-standing of the nature of developmental change, our knowledge of individualdifferences (stage of development, personality or temperament) can refine ourunderstanding of a child’s unique nature. Ultimately, our awareness andunderstanding of how these forces are embedded in the child’s environmentalcontext provide the key to fully comprehending child psychopathology.

According to Bronfenbrenner (1979, 1989), developmental contexts consistof a series of concentric circles emanating from the child, who occupies the in-nermost circle. At the core are the child’s individual characteristics (biologicalcontext, such as genetic makeup, temperament, intelligence). Moving outward,the child’s immediate environment (family, school, peers, community, neighbor-hood), the surrounding social and economic context (poverty, divorce, familystress), and the cultural context provide additional ripples and sources of influ-ence. Within this framework, understanding a child’s mental disorder requires anunderstanding of the influences of all contextual variables.

Understanding multiple levels of influence also requires emphasizing the dualnature of influence, since child and parent mutually influence each other. There-fore, the bidirectional nature of these influences, or reciprocal determinism (Ban-dura, 1985), becomes a crucial aspect of interpreting how interactive effects ofthese influences may be instrumental in constructing different developmentalpathways.

Sameroff ’s transactional model (Sameroff & Chandler, 1975) captures the ongo-ing and interactive nature of developmental change between the child and the en-vironment. A transactional model isalso crucial to understanding the dy-namics of various disorders in orderto trace the developmental pathwayand construct meaningful case for-mulations and relevant treatment al-ternatives. For example, in their dis-cussion of depressive disorders inchildren and adolescents, Cicchettiand Toth (1998) stress the need to usean ecological transactional model inorder to comprehend the complex


C A U T I O N

One major influence that has oftenbeen overlooked is the compatibilitybetween the environmental systems.According to Bronfenbrenner, themesosystem, which represents the in-teraction between two microsystems(e.g., home and school environment),predicts the degree to which a systemremains healthy, functional, and in bal-ance.

nature of depressive disorders in children and youth and understand the diverseand multiple influences that contribute to the emergence of the disorder.

Theories in Context

Viewing the child within the contexts of developmental influences provides anenhanced level of insight into the underlying dynamics of potentially disorderedbehaviors and can guide and improve our ability to make case formulations thathave ecological validity.


DON’T FORGETSeveral theories have been developed to assist our understanding of the complexdynamics that exist between individual and environmental influences. Bandura de-veloped the concepts of triadic reciprocity (1977) and reciprocal determinism(1985) to emphasize the bidirectional nature of the influence. Bronfenbrenner(1979, 1989) envisioned ecological influences from the inner child to the outerworld (family, community, culture). Sameroff ’s transactional model (Sameroff &Chandler, 1975) focuses on how interactive forces can shape the course of devel-opmental change, while Cicchetti and Toth (1998) have applied the model to ex-plain potential pathways for the development of depressive disorders in childrenand adolescence.

TEST YOURSELF

1. The establishment of child psychology as a unique discipline

(a) occurred early in the 1900s.(b) was ushered in by the reform movement.(c) met with many road blocks.(d) was assisted by the intelligence testing movement.

2. Which of the following is not considered one of the four Ds of clinical deci-sion making?

(a) Dysfunction(b) Distress(c) Danger(d) Denial

S S


3. According to Erikson, the first psychosocial task sets the stage for devel-opment of

(a) autonomy versus shame.(b) trust versus mistrust.(c) industry versus inferiority.(d) identity versus role confusion.

4. The existence of several possible pathways that may produce the sameoutcome (e.g., many factors may be responsible for depression) is an ex-ample of

(a) multifinality.(b) equifinality.(c) triadic finality.(d) triadic reciprocity.

5. According to Bronfenbrenner, the outermost circle of influence is repre-sented by

(a) culture.(b) school and family.(c) the child.(d) economics.

6. Negative reinforcement is the same as

(a) punishment.(b) a negative consequence.(c) a penalty.(d) escape.

7. According to Piaget, preschool children’s reasoning is faulty because

(a) they have limited memories.(b) they can only consider one visual feature at a time.(c) vision acuity is not clearly established.(d) they have limited attention spans.

Answers: 1. c; 2. d; 3. b; 4. b; 5. a; 6. d; 7. b

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