Developmental psychopathology

Developmental psychopathology emerged in the 1980s to bridge the rift between academic and clinical child psychology. (2,°,21) 'The developmental psychopathologist is concerned with the time course of a given disorder, its varying manifestations with development, its precursors and sequelae, and its relation to non-disordered patterns of behaviour.'(21) Developmental psychopathologists, like social learning theorists, look to normal development to illuminate pathological development. They are interested in continuities and changes in behaviour across time. This fits in well with the tradition of risk research (22) and attempts to answer questions not only about why some children are more vulnerable than others, but also about what protective factors operate to lessen the impact of stressors.

Sroufe and Rutter,(21) following Santostefano,(23) articulated several propositions that are broadly agreed across the many different theories alluded to above.

• Holism: '...the meaning of behaviour can only be determined within the total psychological context'. (21) Thus, a behaviour such as crying can only be evaluated according to the age of the child and the circumstances in which it occurs. Crying on separation would be seen as usual for a 3-year-old, but unusual in a 15-year-old. One cannot simply judge the significance of a behaviour simply on the basis of its physical, stimulus properties, but one has to evaluate it within the broader social context.

• Qirectedness: children are not passive reactors to the demands of the environment. Development consists of a reorganization of previous elements, skills, and behaviour, not just a linear addition of skills.

• Qifferentiation of modes and goals: over time, children's reactions to their environment become both more flexible and increasingly complex in organization. Thus, one sign of pathology is for children to get stuck in a particular way of trying to solve a problem.

• Mobility of behavioural functions: earlier behaviour becomes integrated into later patterns, and '...the individual does not operate only in terms of behaviours that define a single stage. Especially in periods of stress, early modes of functioning may become manifest'. (21> In other words, under stress, those patterns of behaviour that have most recently become integrated into the child's repertoire are most susceptible of disruption. This is very different from the unsatisfactory concept of 'regression' in that all skills achieved remain available in the child's repertoire; some earlier ones also manifest at times of stress.

• The problem of continuity and change: above all, development is seen as lawful, even though we are still far from understanding the processes involved in these laws. Sroufe and Rutter(21> emphasize: 'The continuity lies not in isomorphic behaviours over time but in lawful relations to later behaviour, however complex the links'. As noted, Thomas et al.(16) were among the first to demonstrate continuities in the style of behaviour (temperament) rather than continuities of behaviour per se.

It is now recognized that there are many complex ways in which child behaviour is related to later and even adult adjustment. (24) One of the most powerful predictors of later adult psychopathology is inadequate peer relations. The mechanism by which these work may be due to two interacting processes: poor peer relations are signs of failure to adapt during childhood, and that failure persists; social support later acts as a buffer against adult stressors. (21)

Clearly, this view of development, with its implications for psychopathology, is far removed from the lessons learned from the Skinner box. And yet what has been learned from the paradigms of classical and operant conditioning must also be integrated into ways that child therapists assess children's problems if we are to provide better treatments. This holistic view manages to incorporate ideas on the biological basis for behaviour and the notion of the child as an active participant interacting with his or her effective social environment within a broad social learning framework. (25,26) Understanding how a problem has arisen may provide useful guidance on what aspects to focus on, but the treatment will still focus on the present. There will be implications for maintaining treatment gains and preventing future problems, as well as implications for preventing such problems arising in other children.

For clinicians more used to working with adult patients, it is worth pointing out children differ in many ways from their grown-up counterparts. This has implications for improving diagnostic classificatory systems in that both DSM and ICD are still too adult oriented and pay insufficient attention to developmental aspects of disorders/2,28 and 29)

Garber(39 makes the point that children differ from adults in cognition, language, physiology, and emotions: 'Such maturational differences may impact children's abilities to experience or express certain affects, cognitions, or behaviours, and thus the manner in which symptoms are expressed may differ over the course of development'. In the author's recent work on the effects of major disasters and acute stress on children's adjustment, it became evident that children as young as 8 years old showed most of the symptoms of post-traumatic stress disorder (PTSQ), with unpleasant thoughts, poor concentration, and sleep disorders predominating/3. 32) Parents and teachers were often unaware of the nature and extent of the children's subjective distress, and only sympathetic but direct questioning elicited the full spectrum of symptomatology.

The criteria for PTSD are less appropriate for children under 8 years of age. Preschool children often react with more repetitive play and drawing than older ones. Even the youngest children will report very disturbing intrusive thoughts about the disaster. Almqvist and Brandell-Forsberg (33) report on one way of eliciting developmentally appropriate symptoms of stress reactions using standard play material, while Scheeringa et al.(34) suggest varying criteria for making the diagnosis of PTSD in young children. Leaving aside the logical problem of altering criteria but keeping the same name for the supposed underlying condition, this clearly is one aspect of the isomorphism mentioned earlier. It is also interesting to speculate whether the repetitive play seen in 6-year-olds is functionally equivalent to the intrusive thoughts seen in 10-year-olds, and when the one changes into the other.

Garber(30) also notes that some disorders, such as mental handicap and autism, first manifest in childhood and persist into adulthood. Others, such as encopresis and enuresis manifest in childhood, but rarely persist into adulthood unless part of a more global developmental delay. Some, such as anorexia and bulimia, are more typical of adolescence. Suicide, although rare before puberty, is rapidly becoming the major cause of death in adolescence, but peaks in old age. Major depression and schizophrenia are rare in childhood, although precursors are being more firmly established. While the wish to treat disorders in childhood so as to prevent them continuing to adulthood is laudable, treating them to improve adjustment during childhood is equally valid.

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