Treatment of Childhood Disorders

Evidence-Based Practice in Christian Perspective

Sarah E. Hall, Kelly S. Flanagan

• Publisher: IVP Academic
• Year: 2021
• ISBN:
  9780830828692
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Caring for the mental health of children and their families is complex and challenging—and meaningful. For Christian clinicians who work with childhood disorders, however, few resources exist to address such treatment from a research-based Christian integration perspective.Treatment of Childhood Disorders fills this gap by combining biblical and theological understanding with current psychological literature on empirically supported treatments for children. Sarah E. Hall and Kelly S. Flanagan present an integrated approach based in developmental psychopathology, which offers a dynamic, multifaceted framework from which to understand the processes that affect children's development.In this unique textbook, Hall and Flanagan consider a variety of disorders commonly diagnosed in children and adolescents, including anxiety, depression, ADHD, and autism spectrum disorder. After discussing prevalence, risk and causal factors, patterns throughout development, and assessment, they focus on evidence-based practices that have been found to be effective in treating the disorders. Each chapter also features ideas for Christian integration in treatment and an extended case study that brings the content to life.Christian Association for Psychological Studies (CAPS) Books explore how Christianity relates to mental health and behavioral sciences including psychology, counseling, social work, and marriage and family therapy in order to equip Christian clinicians to support the well-being of their clients.

Part One

Foundations

Chapter One

Developmental
Psychopathology and
Evidence-Based Practice

DEVELOPMENTAL PSYCHOPATHOLOGY

In 1984, Child Development, a prominent scientific journal, dedicated its first issue of the year to articles describing a burgeoning framework known as developmental psychopathology. This unique perspective combined the strengths of the previously largely separate fields of developmental psychology and clinical psychology in an effort to understand the complex dynamics that affect children’s well-being (Sroufe & Rutter, 1984). In contrast to traditional, adult-oriented approaches to understanding psychopathology, developmental psychopathology focuses on individual pathways toward or away from disorder, taking into account the multitude of influences on the course of development from childhood through adulthood. Developmental psychopathologists recognize the value in studying youth who thrive throughout development, those who experience early hardship and subsequent or later disorder, children who survive highly adverse experiences yet bounce back, and individuals with seemingly low-risk early experiences but who develop psychopathology later in their lives. Prior to these initial writings in developmental psychopathology, clinicians and researchers generally only focused on the presentation of disorder at a given point in time in understanding psychopathology and treatment, missing the rich information that could be provided by a developmentally informed perspective that considers both normal and abnormal development. Since research based in a developmental psychopathology framework began in the 1970s, our understanding of the factors and processes that influence the course of development has increased exponentially. Still, much work remains to be done as we seek to understand how to treat and prevent psychopathology in youth in a manner thoughtfully informed by both research and clinical experience. In this chapter, we outline several key features of a developmental psychopathology–based approach to disorder and treatment and describe evidence-based practice in psychology.

NORMALCY AND ABNORMALITY

Though normal development and abnormal behavior have traditionally been studied separately, developmental psychopathology brings them together as developmental models are used to understand maladaptation over time. In other words, the study of normal development and the study of abnormal development inform one another (Hinshaw, 2017). On one hand, we cannot identify abnormalities unless we first understand the range of what is considered normal. We can only understand whether an older child’s fears may be problematic if we understand the typical emotional experiences of similar-age youth. In order to identify toddlers whose delayed language development suggests that they are at risk for autism spectrum disorder (ASD), we need to know what communication skills are typical or normative at a given age. Indeed, the American Academy of Pediatrics recommends that all children be screened at eighteen- and twenty-four-month well-child visits for social and communication delays that may be signs of an ASD (Zwaigenbaum et al., 2015). On the other hand, research with youth who experience developmental abnormalities, including psychological disorders, contributes to our understanding of normal development. For example, studies of how maternal depression negatively affects infants’ well-being gives us a better understanding of the dynamic, reciprocal interchanges between mother and baby that support the typical development of secure attachment, social communication, emotion regulation, stress reactivity, and even cognitive abilities (Goodman & Brand, 2009). This perspective emphasizes continuities in development, even in the case of maladaptation, rather than the discontinuity between health and disorder traditionally highlighted in the study of psychopathology (Rutter & Garmezy, 1983). Therefore, a developmental psychopathology–based approach to treatment considers the literature on both normal and abnormal development.

Furthermore, psychopathology is conceptualized not as a disease state but as the result of development (Sameroff, 2014; Sroufe, 1997). Classic medical models understand psychological disorders as parallel to organic diseases, and traditional psychological approaches embrace some of their implicit assumptions. For example, the most commonly used diagnostic manuals contain categories of disorders with discrete names and symptom lists that rarely mention environmental factors. In contrast, developmental psychopathologists understand psychological disorders as the product of developmental progression that unfolds over time within a particular context. Furthermore, normal and abnormal development are not so much different processes as they are reflections of the same process as it is influenced by a variety of factors. Human behavior is understood to be an adaptation to the demands of the environment; some behaviors are healthy and others are problematic, but they all arise out of an individual’s efforts to survive and thrive and navigate developmental tasks within a given context. For example, growing up with sensitive, authoritative parents, a child learns to express and manage anger by taking deep breaths and talking to a trusted adult as her parents teach her these techniques and model them in their own times of anger. In contrast, a child who grows up in an abusive household learns either to express her anger explosively and aggressively (as she imitates her parents) or not to express it in any way (since such expressions may call attention to herself and result in abuse), neither of which is the ideal manner for learning to manage strong emotions. Though these outcomes are dramatically different, the developmental processes therein—learning via modeling, regulating emotions in a way that promotes desired responses from others, and parenting as a significant contributor to children’s behavior—are the same.

In addition, the boundaries between normal and abnormal behavior and development are often blurred (Cicchetti, 2006). Individuals are not best categorized as disordered or nondisordered; rather, states and behaviors at a given point are characterized as more or less adaptive, and individuals move between states of well-being and states of maladaptation depending on the interaction between the demands of the environment and their current development stage. A child with an anxiety disorder may display a high level of functioning at times, even in situations that are often anxiety provoking for her. An eating disorder may occur, remit, and recur as stressors ebb and flow across adolescence. Furthermore, youth at high risk for disorder may develop normally and healthily, whereas others who appear to be at low risk may unpredictably develop psychopathology. Rather than focus on end states of health or disorder, developmental psychopathologists argue that we must understand the pathway a given individual follows across development in order to best understand their outcomes and the factors that affect them.

DEVELOPMENTAL PATHWAYS

In a developmental model of disorder, psychopathology is considered an outcome of development, which suggests that we must understand how developmental processes unfold over time. In other words, individuals follow unique developmental pathways that lead them closer to or further from positive mental health outcomes (Sroufe, 1997). Common images of the variety of developmental pathways among children and even within an individual’s lifespan include the numerous splitting and merging tracks at a train yard or a mature tree with branches reaching in many directions. The concept of developmental pathways necessitates understandings of both normal and abnormal development, as discussed previously. In order to identify progression toward problematic or abnormal outcomes, we must first know what constitutes normal or healthy development. In addition, a pathways-based approach suggests that there are many different courses from early to later development (Cicchetti & Rogosch, 1996; Sroufe, 1997). Two youth can experience similar early circumstances and deviate toward disparate outcomes, a pattern known as multifinality. For example, identical twins have a high concordance for schizophrenia occurrence due to the strong genetic underpinnings of the disorder; however, only about 50% of individuals with an identical twin with schizophrenia will develop symptoms (Gejman et al., 2010). This pattern, while highlighting the high heritability of the disorder, also suggests that differences in environmental exposures and experiences likely affect whether a high-risk genotype is ever expressed as schizophrenia. Similarly, siblings who grow up in the same home (i.e., sharing parents, economic resources, neighborhood variables, and schools) may diverge in mental health and other outcomes, particularly as they age. Alternately, the concept of equifinality explains that individuals with the same disorder may have followed different developmental pathways to arrive at the same end point. For instance, research on the etiology of anxiety suggests that it may develop as the result of a variety of genetic influences, endocrine dysregulation, temperamental predispositions, attachment and parenting patterns, and environmental conditioning (see chapter four).

The variety of developmental pathways that exist from early to later experiences and outcomes also highlights two competing ideas: development is both subject to change and constrained by prior development. On the one hand, there are many points in development when an individual’s course may change. A child with a close relationship with her parents becomes distant and withdrawn following a period of bullying at school; an adolescent who lives in a poor, violent neighborhood seems increasingly likely to join a gang until an after-school job connects him with positive role models who help him consider a variety of choices. As we will discuss in more detail below, children are both vulnerable and resilient, and there are essentially an infinite number of pathways along which development can proceed as it is influenced by a wide variety of internal and external factors. However, development does not generally turn on a dime. Early developmental milestones and patterns set the stage for future behaviors and outcomes. Many classic developmental theorists describe this continuity (e.g., Erikson, 1950), and more recent research supports it as well (e.g., Halligan et al., 2013; Neppl et al., 2010). This pattern of continuity is especially true for maladaptation; long periods of problematic behavior and negative environmental influences may deprive an individual of the opportunity to master developmentally appropriate tasks and gain the skills necessary to respond to the demands of their environment in an adaptive manner (Sroufe, 1997). For instance, a child who experiences ongoing abuse that disrupts her attachment to her parents may have trouble interacting appropriately with peers and teachers when she begins school, and as a result, she may miss out on crucial opportunities to build social skills and self-confidence in relationships with others; by adolescence, she is completely socially isolated and lacks both the social skills and support that teenagers typically rely on as they navigate the developmental challenges of this period.

RISK AND PROTECTIVE FACTORS

The course of an individual developmental pathway is not random or unpredictable; rather, it is affected by a multitude of influences within and around a child across development. These influences are known generally as risk and protective factors. A risk factor is any characteristic, influence, or experience that heightens the likelihood of a negative outcome. Risk factors can originate from many sources, including individual-level characteristics, the prenatal environment, families, peers, and the broader culture in which a child is embedded. In the disorder-focused chapters of this book, we explore a wide variety of risk factors, including certain genotypes, prenatal toxin exposure, dysfunctional family dynamics, and individual cognitive patterns. The goals of studying risk factors include both understanding the dynamics of how disorder develops and identifying who is at the highest risk for negative outcomes. To these ends, risk research is most useful for prevention and intervention when it identifies risk factors that are truly causal (rather than merely correlated with or markers of risk) as well as the mechanisms by which these factors raise the likelihood of maladaptation (Cicchetti, 2006; Grant et al., 2003).

Risk is both complex and dynamic. For many youth exposed to stressors, risk factors do not occur in isolation but alongside other risks (Sameroff et al., 1993; Sameroff, Seifer, Zax, & Barocas, 1987). Furthermore, risk has a cumulative effect, such that exposure to multiple risk factors exponentially increases the risk of a negative outcome, beyond what would be expected based on the individual effects of each risk factor by itself (Biederman et al., 1995; Sameroff et al., 1993; Sameroff, Seifer, Barocas, Zax, & Greenspan, 1987). Cumulative risk may negatively impact development by overwhelming a child’s ability to cope with repeated and/or chronic stress (Evans et al., 2013; Evans & Kim, 2007). In addition, risk is generally nonspecific; particular variables raise an individual’s risk of experiencing not only one but multiple disorders or negative outcomes (Atkinson et al., 2015). For example, maltreatment raises an individual’s risk for a wide variety of mental health problems throughout childhood, adolescence, and adulthood (Jaffe, 2017). Similarly, disorders are not usually caused by a single risk factor but by exposure to variables that affect multiple developmental processes, often in interaction with one another. For example, posttraumatic stress disorder (PTSD) does not automatically develop after exposure to a trauma; rather, whether PTSD develops is likely the result of a combination of biological, psychological, and interpersonal factors (see chapter five). Youth are at heightened risk for eating disorders when their exposure to a thin-body ideal in the media interacts with parental criticism of their weight to produce internalized body dissatisfaction (see chapter nine). Finally, risk factors are dynamic. When researchers operationalize a risk factor and consider individuals to be exposed or not exposed, they may oversimplify how risk is experienced differently by different individuals, depending on both the characteristics of the risk factor in question and how it interacts with other variables. For example, it is clear from decades of research that poverty has a deleterious effect on children’s development. However, the experience of poverty is multifaceted and variable, and factors such as length of exposure (i.e., transient versus chronic poverty) and timing of exposure (i.e., early versus later childhood) may both affect youth differently and reflect the degree to which other risk factors (e.g., parental unemployment, housing instability, low levels of social support) are present (Kimberlin & Berrick, 2015).

However, risk factors are not deterministic; exposure to even a high level of a variable associated with negative outcomes does not guarantee them. Rather, risk factors interact with protective factors, influences linked with positive developmental outcomes (Luthar & Cicchetti, 2000). Protective factors can occur in all realms of influence on a child, including within the individual herself (e.g., good emotion regulation skills; Lengua, 2002), within the family (e.g., authoritative parenting; Fletcher et al., 2004), and in school or neighborhood contexts (e.g., sense of connection to school; Hawkins et al., 1999). These positive influences also impact risk exposure in different ways (Luthar, Cicchetti, & Becker, 2000). First, some factors are promotive, being linked with positive outcomes no matter the level of risk. For example, secure attachment in infancy predicts higher social competence and lower rates of emotional and behavioral problems later in childhood (Groh et al., 2014). Second, protective-stabilizing factors ameliorate the effects of risk on outcomes; inner-city adolescents who are exposed to violence do not experience increases in emotional distress when they report high levels of family support, in contrast to peers who feel less supported (Howard et al., 2010). Third, the presence of protective-enhancing factors leads to higher levels of competence in the presence of higher (versus lower) levels of stress. For example, among adolescent girls in Columbia, disclosure of thoughts and feelings to their mothers reduces feelings of hopelessness more in those who are exposed to violence than in those who are not (Kliewer et al., 2001). Fourth, protective-reactive factors ameliorate some but not all of the negative effects of risk exposure. For instance, parental aspirations for their children’s education are correlated with adolescents’ exam performance, but this link is weaker for youth from lower socioeconomic status (SES) backgrounds (Schoon et al., 2004). However, like risk factors, protective or promotive factors are probabilistic, linked statistically with a lower likelihood of negative outcomes but interacting with other variables to produce unique outcomes for any given youth. Also like with risk factors, research on protective factors is likely most impactful when it explores not only markers of protection but the mechanisms by which these factors promote positive outcomes; when mechanisms are identifiable, researchers and clinicians can incorporate them into interventions and prevention programs. For example, the Fast Track project was developed to promote positive outcomes in young children at high risk for academic and behavioral problems, including delinquency; a multifaceted intervention was designed to target emotional competence, social skills, self-control, reading abilities, and parenting skills through both school- and home-based treatment components. By targeting the mechanisms by which these youth were more likely than their peers to develop conduct problems, Fast Track has been found to be effective in reducing these negative outcomes even into early adulthood (Conduct Problems Prevention Research Group, 2011; Sorensen et al., 2016).

Some youth exhibit resilience, adapting well and displaying competence despite threats to healthy development (Masten, 2014; Masten & Coatsworth, 1998). Many youth who are born small or experience abuse or grow up in very impoverished families will not develop the negative outcomes for which these life experiences put them at heightened risk. These individuals display resilience due to the effect of protective factors that ameliorate the negative effects of risk. The definition of competence, commonly considered to be evidence of resilience, has varied widely in the literature (Masten & Coatsworth, 1995, 1998; Masten, 2014; Werner & Smith, 1992). Youth are generally considered competent when they adapt successfully to the demands of their environments; practically, competence may be operationalized as successfully navigating developmental tasks, including displaying socially acceptable behavior, succeeding in academics or ...

Table of contents

• Cover
• Title Page
• Dedication Page
• Contents
• Introduction
• Part One - Foundations
• Part Two: Internalizing Disorders
• Part Three: Externalizing Disorders
• Part Four: Other Disorders in Childhood and Adolescence
• Conclusion
• References
• Subject Index
• Scripture Index
• Also Available
• Praise for Treatment of Childhood Disorders
• About the Authors
• More Titles from InterVarsity Press
• Copyright