LEARNING DISABILITIES AND MENTALRETARDATIONLearning DisabilitiesCausal Factors in Learning DisabilitiesTreatments and OutcomesMental RetardationBrain Defects in Mental RetardationOrganic Retardation SyndromesTreatments, Outcomes, and Prevention

Disorders of Childhoodand Adolescence

MALADAPTIVE BEHAVIOR IN DIFFERENTLIFE PERIODSVarying Clinical PicturesSpecial Vulnerabilities of Young ChildrenThe Classification of Childhood and Adolescent

Disorders

COMMON DISORDERS OF CHILDHOODAttention -Deficit/Hyperactivity DisorderOppositional Defiant Disorder and Conduct

DisorderAnxiety Disorders of Childhood and

AdolescenceChildhood DepressionSymptom Disorders: Enuresis, Encopresis,

Sleepwalking, and TicsPervasive Developmental DisordersAutism

PLANNING BETTER PROGRAMS TO HELPCHILDREN AND ADOLESCENTSSpecial Factors Associated with Treatment for

Children and AdolescentsChild Advocacy Programs

UNRESOLVED ISSUES:Can Society Deal with Delinquent Behavior?

ntil the twentieth century, little account was taken of the special characteristics of psy-chopathology in children; maladaptive patterns considered relatively specific to child-hood, such as autism, received virtually no attention at all. Only since the advent of themental health movement and the availability of child guidance facilities at the beginningof the twentieth century have marked strides been made in assessing, treating, and under-standing the maladaptive behavior patterns of children and adolescents. Still, progress inchild psychopathology has lagged behind that in adult psychopathology.

In fact, the problems of childhood were initially seen simply as downward extensionsof adult-oriented diagnoses. The prevailing view was one of children as "miniatureadults." But this view failed to recognize special problems, such as those associated withthe developmental changes that normally take place in a child or adolescent. Only recentlyhave clinicians come to realize that they cannot fully understand childhood disorderswithout taking these developmental processes into account. Today, even though greatprogress has been made in providing treatment for disturbed children, facilities are stillwoefully inadequate to the task, and most children with problems do not receive psy-chological attention.

The numbers of children affected by psychological problems are considerable. Multisitestudies in several countries have provided estimates of childhood disorder. Verhulst (1995)conducted an evaluation of the overall prevalence based on 49 studies involving over240,000 children across many countries and found the average rate to be 12.3 percent. Inmost studies, maladjustment is found more commonly among boys than among girls. Inone survey of psychological disorder in children, Anderson and colleagues (1987) found that17.6 percent of ll-year-old children studied had one or more disorders, with boys and girlsdiagnosed at a ratio of 1.7 boys to 1 girl. The most prevalent disorders were attention-deficit/hyperactivity disorder and separation anxiety disorders. Zill and Schoenborn (1990)reported that rates of childhood disorders varied by gender, with boys having higher ratesof emotional problems over the childhood and adolescent years. However, for some diag-nostic problems such as eating disorders, rates are higher for girls than for boys.

MALADAPTIVE BEHAVIORIN DIFFERENT LIFEPERIODSSeveral behaviors that characterize maladjustment oremotional disturbance are relatively common in child-hood. Because of the manner in which personality devel-ops, the various steps in growth and development, and thediffering stressors people face in childhood, adolescence,and adulthood, we would expect to find some differencesin maladaptive behavior in these periods. The fields ofdevelopmental science (Hetherington, 1998) and, morespecifically, developmental psychopathology (Cicchetti &Rogosch, 1999) are devoted to studying the origins andcourse of individual maladaptation in the context of nor-mal growth processes.

It is important to view a child's behavior in reference tonormal childhood development (Silk, Nath, et al., 2000).

We cannot consider a child's behavior abnormal withoutdetermining whether the behavior in question is appropri-ate for the child's age. For example, temper tantrums andeating inedible objects might be viewed as abnormal behav-ior at age 10 but not at age 2. Despite the somewhat distinc-tive characteristics of childhood disturbances at differentages, there is no sharp line of demarcation between the mal-adaptive behavior patterns of childhood and those of ado-lescence, or between those of adolescence and those ofadulthood. Thus, although our focus in this chapter will beon the behavior disorders of children and adolescents, wewill find some inevitable overlap with those of later lifeperiods.

Varying Clinical PicturesThe clinical picture in childhood disorders tends to bedistinct from disorders of other life periods. Some of theemotional disturbances of childhood may be relativelyshort-lived and less specific than those occurring in adult-

hood (Mash & Dozois, 1996). However, some childhooddisorders severely affect future development. One studyfound that individuals who had been hospitalized as childpsychiatric patients (between the ages of 5 and 17)showed excess mortality due to unnatural causes (abouttwice the rate of the general population) when followedup from 4 to 15 years later (Kuperman, Black, & Burns,1988). Suicide accounted for most of these deaths, andthe suicide rate was significantly greater than in the gen-eral population.

Special Vulnerabilities ofYoung ChildrenYoung children are especially vulnerable to psychologicalproblems (Ingram & Price, 200l). In evaluating the pres-ence or extent of mental health problems in children andadolescents, one needs to consider the following:

They do not have as complex and realistic a view ofthemselves and their world as they will have later,they have less self-understanding, and they have notyet developed a stable sense of identity or a clearunderstanding of what is expected of them and whatresources they might have to deal with problems.

Immediately perceived threats are tempered less byconsiderations of the past or future and thus tend tobe seen as disproportionately important. As a result,children often have more difficulty than adults incoping with stressful events (Compas & Epping,1993). For example, children are at risk for post-traumatic stress disorder after a disaster, especially ifthe family atmosphere is troubled-a circumstancethat adds additional stress to the problems resultingfrom the natural disaster (La Greca, 2001).

Children's limited perspectives, as might be expected,lead them to use unrealistic concepts to explainevents. For example, a child who commits suicidemay be trying to rejoin a dead parent, sibling, or pet.For young children, suicide or violence againstanother person may be undertaken without any realunderstanding of the finality of death.Children also are more dependent on other peoplethan are adults. Although in some ways this depen-dency serves as a buffer against other dangers,because the adults around might "protect" a childagainst stressors in the environment, it also makesthe child higWy vulnerable to experiences of rejec-tion, disappointment, and failure if these adults,because of their own problems, ignore the child.

Children's lack of experience in dealing with adver-sity can make manageable problems seem insur-mountable. On the other hand, although theirinexperience and lack of self-sufficiency make themeasily upset by problems that seem minor to the aver-

Wecannot understand or consider a child's behavior as abnormalwithout considering the child's age and stage of development.Developmental psychopathology is devoted to studying theorigins and course of maladaptation in the context of normalgrowth processes.

age adult, children typically recover more rapidlyfrom their hurts.

The Classification of Childhood andAdolescent DisordersUntil the 1950s no formal, specific system was availablefor classifying the emotional or behavioral problems ofchildren and adolescents. Kraepelin's (1883) classic text-book on the classification of mental disorders did notinclude childhood disorders. In 1952, the first formalpsychiatric nomenclature (DSM-I) was published andchildhood disorders included. This system was quite lim-ited and included only two childhood emotional disor-ders: childhood schizophrenia and adjustment reaction ofchildhood. In 1966, the Group for the Advancement ofPsychiatry provided a classification system for childrenthat was detailed and comprehensive. In the 1968 revisionof the DSM (DSM-II), several additional categories wereadded. A growing concern remained, however, both amongclinicians attempting to diagnose and treat childhoodproblems and among researchers attempting to broadenour understanding of childhood psychopathology, thatthe then-current ways of viewing psychological disordersin children and adolescents were inappropriate and inac-curate for several reasons. The greatest problem resultedfrom the fact that the same classification system that hadbeen developed for adults was used for childhood prob-lems, even though many childhood disorders (such asautism, learning disabilities, and school phobias) have nocounterpart in adult psychopathology. The early systems

also ignored the fact that in childhood disorders, environ-mental factors play an important part in the expression ofsymptoms-that is, symptoms are highly influenced by afamily's acceptance or rejection of the behavior. In addi-tion, symptoms were not considered with respect to achild's developmentallevei. Some of the problem behav-iors might be considered age-appropriate, and troublingbehaviors might simply be behaviors that the child willeventually outgrow.

In ReVIew~ Define developmental psychopathology.~ What are several of the special psychological

vulnerabilities of children?

COMMON DISORDERS OFCHILDHOODAt present the DSM -IV-TR provides diagnoses on a largenumber of childhood and adolescent disorders diagnosedon Axis 1. In addition, several disorders involving mentalretardation are diagnosed on Axis II. Space limitations donot allow us to explore fully the mental disorders of child-hood and adolescence, so we have selected several disor-ders to illustrate the broad spectrum of problems that canoccur in childhood and adolescence. Some of these disor-ders are more transient than many of the abnormalbehavior patterns of adulthood discussed in earlier chap-ters-and also perhaps more amenable to treatment.Learning disorders and mental retardation, coveredtoward the end of the chapter, are coded on Axis II.

Atte ntion -Deft cit/HyperactivityDisorderAttention-deficit/hyperactivity disorder (ADHD), oftenreferred to as "hyperactivity," is characterized by difficul-ties that interfere with effective task-oriented behavior inchildren-particularly impulsivity, excessive or exagger-ated motor activity such as aimless or haphazard runningor fidgeting, and difficulties in sustaining attention(Brodeur & Pond, 2001). Hyperactive children are highlydistractible and often fail to follow instructions or respondto demands placed on them (Wender, 2000). Perhaps as aresult of their behavioral problems, hyperactive childrenare often lower in intelligence, usually about 7 to 15 IQpoints below average (Barkley, 1997). Hyperactive childrenalso tend to talk incessantly and to be socially intrusive and

immature. Recent research has shown that many ADHDchildren show deficits on neuropsychological testing thatwere related to poor academic functioning (Biederman,Monteaux, et ai., 2004).

Children with ADHD generally have many socialproblems because of their impulsivity and overactivity.Hyperactive children usually have great difficulty in get-ting along with their parents because they do not obeyrules. Their behavior problems also result in their beingviewed negatively by their peers (Hoza, Mrug, et aI., 2005).In general, however, hyperactive children are not anxious,although their overactivity, restlessness, and distractibilityare frequently interpreted as indications of anxiety. Theyusually do poorly in school and often show specific learn-ing disabilities such as difficulties in reading or in learningother basic school subjects. Hyperactive children also posebehavior problems in the elementary grades. The follow-ing case reveals a typical clinical picture.

Gina. a Student withHyperactivity

Gina was referred to a community clinic because of over-active, inattentive, and disruptive behavior. Her hyperac-tivity and uninhibited behavior caused problems for herteacher and for other students. She would impulsively hitother children, knock things off their desks, erase mater-ial on the blackboard, and damage books and otherschool property. She seemed to be in perpetual motion,talking, moving about, and darting from one area of theclassroom to another. She demanded an inordinateamount of attention from her parents and her teacher,and she was intensely jealous of other children, includingher own brother and sister. Despite her hyperactivebehavior, inferior school performance, and other prob-lems, she was considerably above average in intelli-gence. Nevertheless, she felt stupid and had a seriouslydevaluated self-image. Neurological tests revealed nosignificant organic brain disorder.

The symptoms of ADHD are relatively commonamong children seen at mental health facilities. In fact,hyperactive children are the most frequent psychologicalreferrals to mental health and pediatric facilities, and thedisorder is thought to occur in about 3 to 5 percent ofschool-age children (Goldman et ai., 1998). However, onestudy reported a much higher prevalence rate of 16.1 per-cent for ADHD (Wolrich, Hannah, et ai., 1998). The disor-der occurs most frequently among preadolescent boys-itis six to nine times more prevalent among boys thanamong girls. ADHD occurs with the greatest frequencybefore age 8 and tends to become less frequent and to

Children with ADHD are described as averactive, impulsive, andhaving a low tolerance for frustration and an inability to delaygratification. Incessant talkers, they tend not to obey rules andoften run the risk of a multitude of problems with schoolwork,teachers, and other students.

involve briefer episodes thereafter. ADHD has also beenfound to be comorbid with other disorders such as opposi-tional defiant disorder (Drabick, Gadow, et al., 2004),which we discuss later. Some residual effects, such as atten-tion difficulties, may persist into adolescence or adulthood(Odell, Warren, et al., 1997) although, as we will see, someauthorities doubt the authenticity of this syndrome inadults (Bhandary, 1997). ADHD exists in other cultures-for example, among Chinese schoolboys (Leung, Luk,et al., 1996), who show a pattern similar to that of hyper-active youngsters in the United States.

CAUSAL FACTORS IN ATTENTION-DEFICIT !HYPER-ACTIVITY DISORDER The cause or causes of ADHD inchildren have been much debated (Breggin & Breggin,1995). It still remains unclear to what extent the disorderresults from environmental or biological factors, and recentresearch points to both genetic (Nadder, Silberg, et al.,1998) and social environmental precursors (Hechtman,1996). Many researchers believe that biological factors suchas genetic inheritance will turn out to be important precur-sors to the development of ADHD (Durston, 2003). Butfirm conclusions about any biological basis for ADHDmust await further research.

The search for psychological causes of hyperactivityhas yielded similarly inconclusive results, although tem-perament and learning appear likely to be factors. Onestudy suggested that family pathology, particularlyparental personality problems, leads to hyperactivity inchildren. Morrison (1980) found that many parents ofhyperactive children had psychological problems; forexample, a large number were found to have clinical diag-noses of personality disorder or hysteria. Currently, ADHD

:DSM-IV-TRi

Criteria for Attention-Deficit!Hyperactivity Disorder

Either of the following criteria would enable a diagnosis ofADHD:

1. If six (or more) of the following symptoms of inattentionhave persisted for at least 6 months and are maladaptivefor the child's developmental level:Inattention(a) often fails to give close attention to details or makes

careless mistakes in schoolwork, work, or otheractivities

(b) often has difficulty attending in tasks or play activities(c) often does not seem to listen when spoken to directly(d) often does not follow through on instructions and fails

to finish schoolwork, chores, or duties in theworkplace (not due to oppositional behavior or failureto understand instructions)

(e) often has difficulty organizing tasks and activities(f) often avoids, dislikes, or is reluctant to engage in

tasks that require sustained mental effort (such asschoolwork or homework)

(g) is often easily distracted by extraneous stimuli(h) is often forgetful in daily activities

2. If six (or more) of the following symptoms ofhyperactivity-impulsivity have persisted for at least 6months to a degree that is maladaptive:Hyperactivity(a) often fidgets with hands or feet or squirms in seat(b) often leaves seat in classroom or in other situations in

which remaining seated is expected(c) often runs about or climbs excessively in situations in

which it is inappropriate (in adolescents or adults,may be limited to subjective feelings of restlessness)

(d) often has difficulty playing or engaging in leisureactivities quietly

(e) is often "on the go" or often acts as if "driven by amotor"

(f) often talks excessivelyImpulsivity(g) often blurts out answers before questions have been

completed(h) often has difficulty awaiting turn(i) often interrupts or intrudes on others (e.g., butts into

conversations or games)

Source: Adapted with permission from the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition, Text Revision(Copyright 2000). American Psychiatric Association.

is considered to have multiple causes and effects (Hinshaw,Zupan, et al., 1997). Whatever cause or causes are ulti-mately determined to be influential in ADHD, the mecha-nisms underlying the disorder need to be more clearlyunderstood and explored. There is general agreement thatthere are processes operating in the brain that disinhibitthe child's behavior (Nigg, 2001), and some recent researchhas found different EEG patterns occurring in childrenwith ADHD (Barry, Clarke, & Johnstone, 2003). At thistime, however, theorists do not agree what those centralnervous system processes are.

TREATMENTS AND OUTCOMES Although the hyperac-tive syndrome was first described more than 100 years ago,disagreement over the most effective methods of treatmentcontinues, especially regarding the use of drugs to calm ahyperactive child. Yet this approach to treating hyperactivechildren has great appeal in the medical community; onesurvey (Runnheim, Frankenberger, & Hazelkorn, 1996)found that 40 percent of junior high school children and15 percent of high school children with emotional andbehavioral problems and ADHD were prescribed medica-tion, mostly Ritalin (methylphenidate), an amphetamine.In fact, school nurses administer more daily medicationfor ADHD than for any other chronic health problem(E.M. O'Connor, 2001).

Interestingly, research has shown that amphetamineshave a quieting effect on children-just the opposite ofwhat we would expect from their effects on adults (Pelhamet aI., 1992). For hyperactive children, such medicationdecreases overactivity and distractibility and, at the sametime, increases their alertness (Konrad, Gunther, et al.,2004). As a result, they are often able to function much bet-ter at school (Pelham, Hoza, et aI., 2002; Wender, 2000).

Fava (1997) concluded that Ritalin can often lower theamount of aggressiveness in hyperactive children. In fact,many hyperactive children whose behavior has not beenacceptable in regular classes can function and progress in arelatively normal manner when they use such a drug. Ina 5-year follow-up study, Charach, Ickowicz, and Schachar(2004) reported that ADHD children on medicationshowed greater improvement in teacher-reported symp-toms than nontreated children. The possible side effects ofRitalin, however, are numerous: decreased blood flow to thebrain, which can result in impaired thinking ability andmemory loss; disruption of growth hormone, leading tosuppression of growth in the body and brain of the child;insomnia; psychotic symptoms; and others. Althoughamphetamines do not cure hyperactivity, they have reducedthe behavioral symptoms in about one- half to two- thirds ofthe cases in which medication appears warranted.

Ritalin has been shown to be effective in the short-term treatment of ADHD (Baldwin, Chelonis, et aI., 2004;Spencer, 2004a). There are newer variants of the drug,referred to as "extended-release methylphenidate" (Con-certa), that have sim;Iar benefits but with available doses

that may better suit an adolescent's lifestyle (Mott & Leach,2004; Spencer, 2004b).

Two other medications for treating ADHD havereceived recent attention in recent years. Pemoline ischemically very different from Ritalin (Faigel & Heiligen-stein, 1996); it exerts beneficial effects on classroom behav-ior by enhancing cognitive processing but has less adverseside effects (Bostic, Biederman, et aI., 2000). Strattera(atomoxetine), a noncontrolled treatment option that ismore readily obtainable, is a nonstimulant medication thathas recently received FDA approval (FDA, 2002). Thismedication, a norepinephrine reuptake inhibitor, reducesthe symptoms of ADHD (Friemoth, 2005), but its mode ofoperation is not well understood. The side effects for thedrug are decreased appetite, nausea, vomiting, and fatigue.The development of jaundice has been reported, and theFDA (2004) has warned of the possibility of liver damagethat may result from use of Strattera. Although Stratterahas been shown to reduce some symptoms of ADHD, fur-ther research is needed to evaluate its effectiveness andpotential side effects (Barton, Mooney, & Prasad, 2005).

Although the short-term pharmacological effect ofstimulants on the symptoms of hyperactive children is wellestablished, their long-term effects are not well known(Safer, 1997a). Carlson and Bunner (1993) reported thatstudies of achievement over long periods of time failed toshow that the medication has beneficial effects. Some con-cern has been expressed about some effects of the drugssuch as psychotic symptoms, particularly when stimulantsare used in heavy dosages over time (Breggin, 2001). Thepharmacological similarity of Ritalin and cocaine, forexample, has caused some investigators to be concernedover its use in the treatment of ADHD (Volkow et aI.,1995). There have been some reported recreational uses ofRitalin, particularly among college students. Kapner (2003)described several surveys in which Ritalin was reportedlyabused on college campuses. For example, in one survey,16 percent of students at one university reported usingRitalin; and in another study 1.5 percent of the populationsurveyed reported using Ritalin for recreational purposeswithin the past 30 days. In many situations, college stu-dents "share" the prescription medications of friends as ameans of obtaining a "high" (Kapner, 2003).

Some authorities prefer using psychological inter-ventions in conjunction with medications (Stein, 1999).The behavioral intervention techniques that have beendeveloped for ADHD include selective reinforcement inthe classroom (DuPaul & Stoner, et ai. 1998) and familytherapy (Everett & Everett, 2001). Another effectiveapproach to treating hyperactive children involves the useof behavior therapy techniques featuring positive rein-forcement and the structuring of learning materials andtasks in a way that minimizes error and maximizes imme-diate feedback and success (Frazier & Merrill, 1998;Goldstein & Goldstein, 1998). An example is providing ahyperactive boy with immediate praise for stopping to

think through a task he has been assigned before he startsto do it. The use of behavioral treatment methods forhyperactivity has reportedly been quite successful, at leastfor short-term gains.

The use of behavior therapy with medication in a totaltreatment program has reportedly shown good success.Pelham and colleagues (1993) found that both behaviormodification and medication therapy significantly reducedADHD. Medication, however, appeared to be the moreeffective element in the treatment.

The use of behavior modification alone in the treat-ment of ADHD has shown positive results. Van Lier,Muthen, et a1.(2004) conducted a school-based behavioralintervention program aimed at preventing disruptivebehavior in elementary school children using positive rein-forcement. They found this program to be effective withADHD children with different levels of disorder but mosteffective with children at lower or intermediate levels.

ADHD BEYOND ADOLESCENCE Some researchers havereported that many hyperactive children retain ADHDinto early adulthood (Nigg, Butler, et a1., 2002; Wender,2000) or go on to have other psychological problems suchas overly aggressive behavior or substance abuse in theirlate teens and early adulthood (Barkley, Fischer, et a1.,2004). For example, Carroll and Rounsaville (1993) foundthat 34.6 percent of treatment-seeking cocaine abusers intheir study met the criteria for ADHD when they were chil-dren. In a 16-year follow-up study of ADHD children,about 25 percent never completed high school, comparedwith 2 percent for controls (Mannuzza, et a1., 1993).

More longitudinal research is clearly needed beforewe can conclude that children with ADHD go on todevelop similar or other problems in adulthood. Man-nuzza, Klein, and Moulton (2003) reported that estimatesof the numbers of children with ADHD who will experi-ence later symptoms of ADHD in adulthood are likely tovary considerably. However, some of theresearch cited suggests that a significantpercentage of adolescents continue tohave problems in later life.

important to distinguish between persistent antisocialacts-such as setting fires, where the rights of others areviolated-and the less serious pranks often carried out bynormal children and adolescents. Also, oppositional defi-ant disorder and conduct disorder involve misdeeds thatmayor may not be against the law; juvenile delinquency isthe legal term used to refer to violations of the law com-mitted by minors. (See the "Unresolved Issues" section atthe end of this chapter.)

THE CLINICAL PICTURE IN OPPOSITIONAL DEFIANTDISORDER An important precursor of the antisocialbehavior seen in children who develop conduct disorderis often what is now called oppositional defiant disorder(Webster-Stratton, 2000). The essential feature is a recur-rent pattern of negativistic, defiant, disobedient, and hos-tile behavior toward authority figures that persists for atleast 6 months (American Psychiatric Association, DSM-IV- TR, 2000, p. 102). This disorder usually begins by theage of 8, whereas full-blown conduct disorders typicallybegin from middle childhood through adolescence.Prospective studies have found a developmental sequencefrom oppositional defiant disorder to conduct disorder,with common risk factors for both conditions (Hinshaw,1994). That is, virtually all cases of conduct disorder werepreceded developmentally by oppositional defiant disor-der, but not all children with oppositional defiant disor-der go on to develop conduct disorder within a 3-yearperiod (Lahey, McBurnett, & Loeber, 2000). The risk fac-tors for both include family discord, socioeconomic dis-advantage, and antisocial behavior in the parents(Hinshaw, 1994).

THE CLINICAL PICTURE IN CONDUCT DISORDER Theessential symptomatic behavior in conduct disorderinvolves a persistent, repetitive violation of rules and a dis-regard for the rights of others. Conduct-disordered chil-

dren show a deficit in social behavior(Happe & Frith, 1996). In general, theymanifest such characteristics as overt orcovert hostility, disobedience, physicaland verbal aggressiveness, quarrelsome-ness, vengefulness, and destructiveness.Lying, solitary stealing, and tempertantrums are common. Such childrentend to be sexually uninhibited andinclined toward sexual aggressiveness.Some may engage in cruelty to animals(Becker, Stuewig, et ai, 2004), bullying(Coolidge, DenBoer, & Segal, 2004), fire-setting (Becker, Stuewig, et ai, 2004;Slavkin & Fineman, 2000; Stickle &Blechman, 2002), vandalism, robbery,and even homicidal acts. Conduct -disor-

dered children and adolescents are also frequently comor-bid for substance-abuse disorder (Grilo, Becker, et a1.,1996)

Longitudinal research involvesstudying and collecting baselineinformation on a specific group ofinterest (patients with a givendisorder, high-risk children, etc.)and then following them up at afuture date (e.g., 1,5, or even 20

years later) to determine thechanges that have occurred overthe intervening period.

Oppositional DefiantDisorder and ConductDisorderThe next group of disorders involves achild's or an adolescent's relationship tosocial norms and rules of conduct. Inboth oppositional defiant disorder andconduct disorder, aggressive or antiso-cial behavior is the focus. As we will see,oppositional defiant disorder is usuallyapparent by about age 8, and conductdisorder tends to be seen by age 9. These disorders areclosely linked (Stahl & Clarizio, 1999). However, it is

A. This disorder is a repetitive and persistent pattern of behavior inwhich the basic rights of others or major age-appropriate societalnorms or rules are violated, as manifested by the presence of three(or more) of the following criteria in the past 6 months:

Aggression to People and Animals(1) often bullies, threatens, or intimidates others

(2) often initiates physical fights

(3) has used a weapon that can cause serious physical harm toothers (e.g., a bat, brick, broken bottle, knife, gun)

(4) has been physically cruel to people

(5) has been physically cruel to animals

(6) has stolen while confronting a victim (e.g., mugging, pursesnatching, extortion, armed robbery)

(7) has forced someone into sexual activity

Destruction of Property(8) has deliberately engaged in firesetting with the intention of

causing serious damage

(9) has deliberately destroyed others' property (other than byfiresetting)

Deceitfulness or Theft(10) has broken into someone else's house, building, or car

(11) often lies to obtain goods or favors or to avoid obligations(i.e., "cons" others)

(12) has stolen items of nontrivial value without confronting a victim(e.g., shoplifting, but without breaking and entering; forgery)

Serious Violations of Rules(13) often stays out at night despite parental prohibitions,

beginning before age 13 years

(14) has run away from home overnight at least twice while livingin parental or parental surrogate home (or once withoutreturning for a lengthy period)

(15) is often truant from school, beginning before age 13 years

B. The disturbance in behavior causes clinically significantimpairment in social, academic, or occupational functioning.

C. If the individual is age 18 years or older, criteria are not met forAntisocial Personality Disorder.

The severity of the disorder should be specified as follows:

Mild: few if any conduct problems in excess of those required to makethe diagnosis and conduct problems cause only minor harm to others

Moderate: number of conduct problems and effect on othersintermediate between "mild" and "severe"

Severe: many conduct problems in excess of those required to make thediagnosis or conduct problems cause considerable harm to others

Source: Adapted with permission from the Diagnostic and Statistical Manualof Mental Disorders, Fourth Edition, Text Revision (Copyright 2000).American Psychiatric Association.

Hostility and aggressive behavior have beenfound to playa role in the development ofconduct disorder. Children who develop thisdisorder early in childhood are at special risk forproblems later in life.

or depressive symptoms (O'Connor et al., 1998).Zoccolillo, Meyers, and Assiter (1997) found thatconduct disorder was a risk factor for unwed preg-nancy and substance abuse in teenage girls.

CAUSAL FACTORS IN OPPOSITIONAL DISORDERAND CONDUCT DISORDER Understanding of thefactors associated with the development of conductproblems in childhood has increased tremendouslyin the past 20 years. Several factors will be covered inthe sections that follow.

A Self-Perpetuating Cycle Evidence has accumu-lated that a genetic predisposition (Pliszka, 1999;Simonoff, 200l) leading to low verbal intelligence,mild neuropsychological problems, and difficulttemperament can set the stage for early onset con-duct disorder through a set of self-perpetuatingmechanisms (Moffitt & Lynam, 1994; Slutsky, Heath,et al., 1997). The child's difficult temperament maylead to an insecure attachment because parents findit hard to engage in the good parenting that wouldpromote a secure attachment. In addition, the lowverbal intelligence and/or mild neuropsychologicaldeficits that have been documented in many ofthese children-some of which may involve defi-ciencies in self-control functions such as sustainingattention, planning, self-monitoring, and inhibitingunsuccessful or impulsive behaviors-may help setthe stage for a lifelong course of difficulties. Inattempting to explain why the relatively mild neu-ropsychological deficits typically seen can have suchpervasive effects, Moffitt and Lynam (1994) providethe following scenario: A preschooler has problemsunderstanding language and tends to resist hismother's efforts to read to him. This deficit thendelays the child's readiness for school. When he doesenter school, the typically busy curriculum does not

allow teachers to focus their attention on students at hislow readiness level. Over time, and after a few years ofschool failure, the child will be chronologically older thanhis classmates, setting the stage for social rejection. Atsome point, the child might be placed into remedial pro-grams that contain other pupils who have similar behav-ioral disorders as well as learning disabilities. Thisinvolvement with conduct-disordered peers exposes himto delinquent behaviors that he adopts in order to gainacceptance.

Age of Onset and Links to Antisocial PersonalityDisorder Children who develop conduct disorder at anearlier age are much more likely to develop psychopathyor antisocial personality disorder as adults than areadolescents who develop conduct disorder suddenly inadolescence (Hinshaw, 1994; Moffitt, 1993b). The linkbetween conduct disorder and antisocial personality isstronger among lower-socioeconomic-class children(Lahey, Loeber, et aI., 2005). It is the pervasiveness of theproblems first associated with oppositional defiant disor-der and then with conduct disorder that forms the pat-tern associated with an adult diagnosis of psychopathy orantisocial personality. Although only about 25 to 40 per-cent of cases of early onset conduct disorder go on todevelop adult antisocial personality disorder, over 80 per-cent of boys with early onset conduct disorder do con-tinue to have multiple problems of social dysfunction (infriendships, intimate relationships, and vocational activi-ties) even if they do not meet all the criteria for antisocialpersonality disorder (Hinshaw, 1994; Zoccolillo et aI.,1992). By contrast, most individuals who develop con-duct disorder in adolescence do not go on to becomeadult psychopaths or antisocial personalities but insteadhave problems limited to the adolescent years. Theseadolescent-onset cases also do not share the same set ofrisk factors that the child-onset cases have, including lowverbal intelligence, neuropsychological deficits, andimpulsivity and attentional problems (Hinshaw, 1994;Moffitt & Lynam, 1994).

Environmental Factors In addition to the genetic orconstitutional liabilities that may predispose a person toconduct disorder and to adult psychopathy and antisocialpersonality, Kazdin (1995) underscored the importance offamily and social context factors as causal variables. Forexample, having a confused "idea" or relationship with theprimary caregiver can result in disorganized early attach-ment and can signal later aggression in the child (Lyons-Ruth, 1996). Children who are aggressive and sociallyunskilled are often rejected by their peers, and such rejec-tion can lead to a spiraling sequence of social interactionswith peers that exacerbates the tendency toward antisocialbehavior (Coie & Lenox, 1994). Severe conduct problemscan lead to other mental health problems as well. Mason,Kosterman, et al. (2004) found that children who reported

higher levels of conduct problems were nearly four timesmore likely to experience a depressive episode in earlyadulthood.

This socially rejected subgroup of aggressive childrenis also at the highest risk for adolescent delinquency andprobably for adult antisocial personality. In addition, par-ents and teachers may react to aggressive children withstrong negative affect such as anger (Capaldi & Patterson,1994), and they may in turn reject these aggressive chil-dren. The combination of rejection by parents, peers, andteachers leads these children to become isolated and alien-ated. Not surprisingly, they often turn to deviant peergroups for companionship (Coie & Lenox, 1994), at whichpoint a good deal of imitation of the antisocial behavior oftheir deviant peer models may occur.

Investigators generally seem to agree that the familysetting of a conduct-disordered child is typically character-ized by ineffective parenting, rejection, harsh and inconsis-tent discipline, and oftenparental neglect (Frick,1998; Patterson, 1996). Fre-quently, the parents have anunstable marital relation-ship (Osborn, 1992), areemotionally disturbed orsociopathic, and do not pro-vide the child with consis-tent guidance, acceptance,or affection. Even if the fam-ily is intact, a child in a con-flict-charged home feelsovertly rejected. For exam-ple, Rutter and Quinton(1984b) concluded thatfamily discord and hostilitywere the primary factorsdefining the relationshipbetween disturbed parentsand disturbed children; thisis particularly true withrespect to the developmentof conduct disorders in chil-dren and adolescents. Such discord and hostility contributeto poor and ineffective parenting skills, especially ineffec-tive discipline and supervision. These children are "trained"in antisocial behavior by the family-directly via coerciveinterchanges and indirectly via lack of monitoring and con-sistent discipline (Capaldi & Patterson, 1994). This all toooften leads to association with deviant peers and the oppor-tunity for further learning of antisocial behavior.

In addition to these familial factors, a number ofbroader psychosocial and sociocultural variables increasethe probability that a child will develop conduct disorderand, later, adult psychopathy or antisocial personality dis-order. Low socioeconomic status, poor neighborhoods,parental stress, and depression all appear to increase the

Ineffective parenting, harsh andinconsistent discipline, parentalneglect, and marital discord can allcontribute to oppositional defiantdisorder (ODD) and conduct disorders.So can poverty and parental stressand depression.

likelihood that a child will become enmeshed in this cycle(Capaldi & Patterson, 1994).

TREATMENTS AND OUTCOMES By and large, our soci-ety tends to take a punitive, rather than a rehabilitative,attitude toward an antisocial, aggressive youth. Thus theemphasis is on punishment and on "teaching the child alesson." Such treatment, however, seems to intensify ratherthan correct the behavior.

Treatment for oppositional defiant disorder and con-duct disorder tends to focus on dysfunctional family pat-terns described above and on finding ways to alter thechild's aggressive or otherwise maladaptive behaviors(Behan & Carr, 2000; Milne, Edwards, et aI., 2001).

The Cohesive Family Model Therapy for a child withconduct disorder is likely to be ineffective unless some waycan be found to modify the child's environment. Oneinteresting and often effective treatment strategy with con-duct disorder is the cohesive family model (Patterson,Reid, & Dishion, 1998; Webster-Stratton, 1991). In thisfamily-group-oriented approach, parents of children withconduct disorder are viewed as lacking in parenting skillsand as behaving in inconsistent ways, thereby reinforcinginappropriate behavior and failing to socialize the chil-dren. Children learn to escape or avoid parental criticismby escalating their negative behavior. This tactic, in turn,increases their parents' aversive interactions and criticism.The child observes the increased anger in his or her parentsand models this aggressive pattern. The parental attentionto the child's negative, aggressive behavior actually servesto reinforce that behavior instead of suppressing it. View-ing conduct problems as emerging from such interactionsplaces the treatment focus squarely on the interactionbetween the child and the parents (Patterson, Capaldi, &Bank, 1991).

Obtaining treatment cooperation from parents whoare themselves in conflict with each other is difficult. Often,an overburdened parent who is separated or divorced andworking simply does not have the resources, the time, orthe inclination to learn and practice a more adequateparental role (Clarke-Stewart, Vandell, et aI., 2000). Inmore extreme cases, the circumstances may call for a childto be removed from the home and placed in a foster homeor institution, with the expectation of a later return to thehome if intervening therapy with the parent or parentsappears to justify it.

Unfortunately, children who are removed to new envi-ronments often interpret this removal as further rejection,not only by their parents but by society as well. Unless thechanged environment offers a warm, kindly, and acceptingyet consistent and firm setting, such children are likely tomake little progress. Even then, treatment may have only atemporary effect. Faretra (1981) followed up 66 aggressiveand disturbed adolescents who had been admitted to aninpatient unit. She found that antisocial and criminal

behavior persisted into adulthood, though with a lesseningof psychiatric involvement. Many children with conductdisorder go on to have personality disorders as adults (Rut-ter' 1988; Zeitlin, 1986).

Behavioral Techniques The advent of behavior therapytechniques has made the outlook brighter for children whomanifest conduct disorder (Kazdin & Weisz, 2003; Nock,2003). Teaching control techniques to the parents of suchchildren is particularly important, so that they can func-tion as therapists in reinforcing desirable behavior andmodifying the environmental conditions that have beenreinforcing maladaptive behavior. The changes broughtabout when parents consistently accept and reward theirchild's positive behavior and stop focusing on the negativebehavior may finally change their perception of and feel-ings toward the child, leading to the basic acceptance thatthe child has so badly needed.

Although effective techniques for behavioral manage-ment can be taught to parents, they often have difficultycarrying out treatment plans. If this is the case, other tech-niques, such as family therapy or parental counseling, areused to ensure that the parent or person responsible for thechild's discipline is sufficiently assertive to follow throughon the program.

Anxiety Disorders of Childhood andAdolescenceIn modern society, no one is totally insulated from anxi-ety-producing events or situations, and the experience oftraumatic events can predispose children to develop anxi-ety disorders (Bandelow, Spaeth, et aI., 2002). Most chil-dren are vulnerable to fears and uncertainties as a normalpart of growing up, and children can get generalized panicdisorder just as adults do. Children with anxiety disorders,however, are more extreme in their behavior than thoseexperiencing "normal" anxiety. These children appear toshare many of the following characteristics: oversensitiv-ity, unrealistic fears, shyness and timidity, pervasive feel-ings of inadequacy, sleep disturbances, and fear of school(Goodyer, 2000). Children diagnosed as suffering from ananxiety disorder typically attempt to cope with their fearsby becoming overly dependent on others for support andhelp. In the DSM, anxiety disorders of childhood and ado-lescence are classified similarly to anxiety disorders inadults (Albano, Chorpita, & Barlow, 1996). Research hasshown that anxiety disorders are often comorbid withdepressive disorders (Manassis & Monga, 2001) or may beinfluential in later depression (Silberg, Rutter, & Eaves,2001); children who have these comorbid conditionsoften have significantly more symptoms than childrenwho have anxiety disorders without depression (Masi,Favilla, et aI., 2000).

Anxiety disorders are common among children. Infact, 9.7 percent of one community-based school sample

clearly met diagnostic criteria for an anxiety-based disorder(Dadds, Spence, et aI., 1997). There is a greater preponder-ance of anxiety-based disorder in girls than in boys (Lewin-sohn et aI., 1998). Among adolescents, Goodwin and Gotlib(2004) reported that panic attacks occurred in 3.3 percentin a large community-based epidemiological study.

SEPARATION ANXIETY DISORDER Separation anxi-ety disorder is the most common of the childhood anxietydisorders, reportedly occurring in 2 to 4 percent of chil-dren in a population health study and accounting for 50percent of children seen at mental health clinics for anxietydisorders (Goodyer, 2000). Children with separation anxi-ety disorder exhibit unrealistic fears, oversensitivity, self-consciousness, nightmares, and chronic anxiety. They lackself-confidence, are apprehensive in new situations, andtend to be immature for their age. Such children aredescribed by their parents as shy, sensitive, nervous, sub-missive, easily discouraged, worried, and frequently movedto tears. Typically, they are overly dependent, particularlyon their parents. The essential feature in the clinical pic-ture of this disorder is excessive anxiety about separationfrom major attachment figures, such as mother, and fromfamiliar home surroundings. In many cases, a clear psy-chosocial stressor can be identified, such as the death of arelative or a pet. The following case illustrates the clinicalpicture in this disorder.

Johnny's SevereSeparation Anxiety

Johnny was a highly sensitive 6-year-old who sufferedfrom numerous fears, nightmares, and chronic anxiety.He was terrified of being separated from his mother, evenfor a brief period. When his mother tried to enroll him inkindergarten, he became so upset when she left the roomthat the principal arranged for her to remain in the class-room. After 2 weeks, however, this arrangement had to bediscontinued, and Johnny had to be withdrawn fromkindergarten because his mother could not leave himeven for a few minutes. Later, when his mother attemptedto enroll him in the first grade, Johnny manifested thesame intense anxiety and unwillingness to be separatedfrom her. At the suggestion of the school counselor,Johnny's mother brought him to a community clinic forassistance with the problem. The therapist, who initiallysaw Johnny and his mother, was wearing a white clinicjacket, which led to a severe panic reaction on Johnny'spart. His mother had to hold him to keep him from run-ning away, and he did not settle down until the therapistremoved his jacket. Johnny's mother explained that hewas terrified of doctors and that it was almost impossibleto get him to a physician even when he was sick.

A. Developmentally inappropriate and excessive anxietyconcerning separation from home or from those to whomthe individual is attached, as evidenced by three (or more)of the following:

(1) recurrent excessive distress when separation fromhome or major attachment figures occurs or isanticipated

(2) persistent and excessive worry about losing, or aboutpossible harm befalling, major attachment figures

(3) persistent and excessive worry that an untoward eventwill lead to separation from a major attachment figure(e.g., getting lost or being kidnapped)

(4) persistent reluctance or refusal to go to school orelsewhere because of fear of separation

(5) persistently and excessively fearful or reluctant to bealone or without major attachment figures at home orwithout significant adults in other settings

(6) persistent reluctance or refusal to go to sleep withoutbeing near a major attachment figure or to sleep awayfrom home

(7) repeated nightmares involving the theme of separation

(8) repeated complaints of physical symptoms (such asheadaches, stomachaches, nausea, or vomiting) whenseparation from major attachment figures occurs or isanticipated

B. The duration of the disturbance is a least 4 weeks.

C. The onset is before age 18 years.

D. The disturbance causes clinically significant distress orimpairment in social, academic, occupational, or otherimportant areas of functioning.

Source: Adapted with permission from the Diagnostic andStatistical Manual of Mental Disorders. Fourth Edition, Text Revision(Copyright 2000). American Psychiatric Association.

When chiluren with separation anxiety disorder areactually separated from their attachment figures, they typ-ically become preoccupied with morbid fears, such as theworry that their parents are going to become ill or die.They cling helplessly to adults, have difficulty sleeping,and become intensely demanding. Separation anxiety ismore common in girls (Majcher & Pollack, 1996), and thedisorder is not very stable over time (Poulton, Milne, etaI., 2001). One study, for example, reported that 44 per-cent of youngsters showed recovery at a 4-year follow-up(Cantwell & Baker, 1989). However, some children go onto exhibit school refusal problems (a fear of leavinghome and parents to attend school) and continue to have

When children with separation anxietydisorder are actually separated fromtheir attachment figures, they typicallybecome preoccupied with morbid fears,such as the worry that their parents aregoing to become ill or die.

subsequent adjustment difficulties. Adisproportionate number of childrenwith separation anxiety disorder alsoexperience a high number of otheranxiety-based disorders such as pho-bia and obsessive-compulsive disorder(Egger, Costello, &Angold, 2003; Kear-ney, Sims, et aI., 2003).

SELECTIVE MUTISM Anotheranxiety-based disorder sometimesfound in children is selectivemutism, a condition that involves thepersistent failure to speak in specificsocial situations-for example, inschool or in social groups-that isconsidered to interfere with educa-tional or social adjustment. In manycases, children with selective mutismalso have a diagnosis of developmen-tal disorder/delay (Standart & LeCouteur, 2003). Selective mutismshould be diagnosed only if the childactually has the ability to speak andknows the language. Moreover, inorder for this disorder to be diag-nosed, the condition must have lastedfor a month and must not be limitedto the first month of school, whenmany children are shy or inhibited.

Selective (formerly referred to as"elective") mutism is apparently quite rare in clinical pop-ulations and is most typically seen at preschool age. Thedisorder occurs in all social strata, and in about one-thirdof the cases studied, the child showed early signs of theproblem such as shyness and internalizing behavior (Stein-hausen & Juzi, 1996).

Both biological and learning factors have been cited aspossible causal factors underlying the disorder. Bar-Haim,Henkin, et aI. (2004) reported that specific deficiencies inauditory nerve activity was found among children withselective mutism, and Steinhausen and Adamek (1997)reported some evidence that genetic factors playa part inselective mutism in that cases tend to occur more fre-quently in families in which taciturn behavior is promi-nent. Evidence for cultural or learning factors has also beenpresented. Elizur and Perednik (2003) found that bothstress and family environmental factors were involved incases of selective mutism.

Selective mutism is treated much like other anxiety-based disorders. One study reported that the symptomswere reduced substantially with fluoxetine (Motavalli,1995), and another successful report involved a drug called"moclobemide," an MAO inhibitor (Maskey, 2001). How-ever, family-based psychological treatment is the most

commonly used therapeutic approach(Tatem & DelCampo, 1995).

CAUSAL FACTORS IN ANXIETY DIS-ORDERS A number of causal factorshave been emphasized in explanationsof the childhood anxiety disorders.Parental behavior has been particu-larly noted as a potential influentialfactor in the origin of anxiety disor-ders in children; however, broader cul-tural factors are also importantconsiderations.

Anxious children often manifestan unusual constitutional sensitivitythat makes them easily conditionableby aversive stimuli. For example, theymay be readily upset by even smalldisappointments-a lost toy or anencounter with an overeager dog. Theythen have a harder time calming down,a fact that can result in a buildup andgeneralization of surplus fear reactions.

The child can become anxiousbecause of early illnesses, accidents, orlosses that involved pain and discom-fort. The traumatic effect of experi-ences such as hospitalizations makessuch children feel insecure and inade-quate. The traumatic nature of certainlife changes such as moving away from

friends and into a new situation can also have an intenselynegative effect on a child's adjustment. Kashani and col-leagues (1981) found that the most common recent lifeevent for children receiving psychiatric care was moving toa new school district.

Overanxious children often have the modeling effectof an overanxious and protective parent who sensitizes achild to the dangers and threats of the outside world.Often, the parent's overprotectiveness communicates alack of confidence in the child's ability to cope, thus rein-forcing the child's feelings of inadequacy (Dadds, Heard, &Rapee, 1991; Woodruff-Borden et aI., 2002).

Indifferent or detached parents (Chartier, Walker, &Stein, 2001) or rejecting parents (Hudson & Rapee, 2001)also foster anxiety in their children. The child may not feeladequately supported in mastering essential competenciesand in gaining a positive self-concept. Repeated experi-ences of failure, stemming from poor learning skills, maylead to subsequent patterns of anxiety or withdrawal in theface of "threatening" situations. Other children may per-form adequately but may be overcritical of themselves andfeel intensely anxious and devalued when they perceivethemselves as failing to do well enough to earn their par-ents' love and respect.

The role that social-environmental factors might playin the development of anxiety-based disorders, thoughimportant, is not clearly understood. A cross-cultural studyof fears (Ollendick et al., 1996) found significant differ-ences among American, Australian, Nigerian, and Chinesechildren and adolescents. These authors suggested that cul-tures that favor inhibition, compliance, and obedienceappear to increase the levels of fear reported. In anotherstudy in the United States, Last and Perrin (1993) reportedthat there were some differences between African-Ameri-can and white children with respect to types of anxiety dis-orders. White children were more likely to present withschool refusal than were African-American children, whoshowed more PTSD symptoms. This difference might resultfrom differing patterns of referral for African-Americanand white families, or it might reflect differing environ-mental stressors placed on the children. Several studies havefound a strong association between exposure to violenceand a reduced sense of security and psychological well-being (Cooley-Quille, Boyd, et al., 2001; Kliewer et al.,1998). The child's vulnerability to anxiety and depressionmay be induced by his or her early experiences of feeling alack of "control" over reinforcing environmental events(Chorpita & Barlow, 1998). Children who experience asense of diminished control over negative environmentalfactors may become more vulnerable to the development ofanxiety than those children who achieve a sense of efficacyin managing stressful circumstances.

TREATMENTS AND OUTCOMES The anxiety disordersof childhood may continue into adolescence and youngadulthood, leading first to maladaptive avoidance behaviorand later to increasingly idiosyncratic thinking and behav-ior or an inability to "fit in" with a peer group. Typically,however, this is not the case. As affected children grow andhave wider interactions in school and in activities withpeers, they often benefit from experiences such as makingfriends and succeeding at given tasks. Teachers who areaware of the needs of both overanxious and shy, with-drawn children are often able to ensure that they will havesuccessful experiences that help alleviate anxiety.

Biologically Based Treatments Psychopharma-cological treatment of anxiety disorders in children andadolescents is becoming more common today. Birmaher,Axelson, et al. (2003) evaluated the efficacy of using fluox-etine in the treatment of a variety of anxiety-based disor-ders and found the medication useful. However, thecautious use of medications with anxiety-based disordersinvolves obtaining diagnostic clarity since these conditionsoften coexist with other disorders.

Psychological Treatment Behavior therapy proce-dures, sometimes used in school settings, often help anx-ious children (Kashdan & Herbert, 2001). Such procedures

include assertiveness training to provide help with master-ing essential competencies, and desensitization to reduceanxious behavior. Kendall and his colleagues have reportedthe successful use of manual-based cognitive-behavioraltreatment (well-defined procedures using positive rein-forcement to enhance coping strategies to deal with fears)for children with anxiety disorders (Chu & Kendall, 2004).Behavioral treatment approaches such as desensitizationmust be explicitly tailored to a child's particular problem,and in vivo methods (using real-life situations graded interms of the anxiety they arouse) tend to be more effectivethan having the child "imagine" situations. Svensson, Lars-son, and Oest (2002) reported successful treatment of pho-bic children using brief exposure.

An interesting and effective cognitive-behavioral anx-iety prevention and treatment study was implemented inAustralia. In an effort to identify and reduce anxiousness inyoung adolescents, Dadds, Spence, and colleagues (1997)identified 314 children who met the criteria for an anxietydisorder, out of a sample of 1,786 children 7 to 14 years oldin a school system in Brisbane, Australia. They contactedthe parents of these anxious children to engage them in thetreatment intervention, and parents of 128 of the childrenagreed to participate. The treatment intervention involvedholding group sessions with the children, in which theywere taught to recognize their anxious feelings and dealwith them more effectively than they otherwise wouldhave. In addition, the parents were taught behavioral man-agement procedures to deal more effectively with thechild's behavior. Six months after therapy was completed,significant anxiety reduction was shown for the treatmentgroup, compared with an untreated control sample.

Childhood DepressionChildhood depression includes behaviors such as with-drawal, crying, avoidance of eye contact, physical com-plaints, poor appetite, and even aggressive behavior andin some cases suicide (Pfeffer, 1996a, 1996b). One epi-demiological study (Cohen et al., 1998) reported an asso-ciation between somatic illness and childhood depressiveillness, suggesting that there may be some common etio-logic factors.

Currently, childhood depression is classified accordingto essentially the same DSM diagnostic criteria as are usedfor adults (American Psychiatric Association, DSM-IV- TR,2000). However, recent research on the neurobiologicalcorrelates and treatment responses of children, adolescents,and adults has shown clear differences in hormonal levelsand in the response to treatment (Kaufman, Martin, et al.,2001). Future neuroimaging studies are needed to explorethese differences further. One modification used for diag-nosing depression in children is that irritability is oftenfound as a major symptom and can be substituted fordepressed mood, as seen in the following case.

Joey is a 10-year-old boy whose mother and teacher haveshared their concerns about his irritability and tempertantrums displayed both at home and at school. With lit-tle provocation, he bursts into tears and yells and throwsobjects. Inclass he seems to have difficulty concentratingand seems easily distracted. Increasingly shunned by hispeers, he plays by himself at recess, and at home hespends most of his time in his room watching TV. Hismother notes that he has been sleeping poorly and hasgained 10 pounds over the past couple of months fromconstant snacking. A consultation with the school psy-chologist has ruled out learning disabilities and attention-deficit disorder; instead, she says, he is a deeply unhappychild who expresses feelings of worthlessness and hope-lessness-and even a wish that he would die. Theseexperiences probably began about 6 months ago whenhis father, divorced from Joey's mother for several years,remarried and moved to another town, with the resultthat he spends far less time with Joey. (Adapted fromHammen & Rudolph, 1996, pp. 153-54.)

Childhood depression includesbehaviors such as withdrawal, crying,avoiding eye contact, physicalcomplaints, poor appetite, and in someextreme cases, aggressive behaviorand suicide.

Depression in childrenand adolescents occurs withhigh frequency. The pointprevalence (the rate at thetime of the assessment) ofmajor depressive disorderhas been estimated to bebetween 0.4 and 2.5 percentfor children and between 4.0and 8.3 percent for adoles-cents (Birmaher, Ryan, et al.,1996). The lifetime preva-lence for major depressivedisorders in adolescents isbetween 15 and 20 percent(Harrington et al., 1996).One review of the epidemiol-ogy of depression in childrenand adolescents concludedthat major depression is rela-tively rare in young childrenbut more common in adoles-cents, with up to 25 percentlifetime prevalence (Kessler,Avenevoli, & Merikangas,2001). A survey of 1,710 highschool students found thatpoint prevalence was 2.9 per-

cent, that lifetime prevalence was 20.4 percent, and thatsuicidal ideation at some time in life was high-19 per-cent-in this sample (Lewinsohn et aI., 1996). Before ado-lescence, rates of depression are somewhat higher in boys,but depression occurs at about twice the rate for adoles-cent girls as for adolescent boys (Hankin et aI., 1998).Lewinsohn and colleagues (1993) also reported that 7.1percent of the adolescents surveyed reported havingattempted suicide in the past, and in another epidemio-logical study, Lewinsohn, Rohde, and Seeley (1994)pointed out that 1.7 percent of adolescents between 14and 18 had made a suicide attempt.

CAUSAL FACTORS IN CHILDHOOD DEPRESSION Thecausal factors implicated in the childhood anxiety disor-ders are pertinent to the depressive disorders as well.

Biological Factors There appears to be an associationbetween parental depression and behavioral and moodproblems in children (Hammen, Shih, & Brennan, 2004).Children of parents with major depression were moreimpaired, received more psychological treatment, and hadmore psychological diagnoses than children of parentswith no psychological disorders (Kramer, Warner, et aI.,1998). This is particularly the case when the parent'sdepression affected the child through less-than-optimalinteractions (Carter, Garrity-Rokous, et aI., 2001). A con-trolled study of family history and onset of depressionfound that children from mood-disordered families hadsignificantly higher rates of depression than those fromnondisordered families (Kovacs, Devlin, et aI., 1997). Thesuicide attempt rate has also been shown to be higher forchildren of depressed parents (7.8 percent) than for theoffspring of control parents (Weissman et aI., 1992). Allthese correlations suggest a potential genetic componentto childhood depression, but in each case, learning couldalso be the causal factor.

Other biological factors might also make children vul-nerable to psychological problems like depression. Thesefactors include biological changes in the neonate as a resultof alcohol intake by the mother during pregnancy. Onerecent study reported that prenatal exposure to alcohol isrelated to depression in children. M. J. O'Connor's (2001)study of children exposed to alcohol in utero revealed acontinuity between alcohol use by the mother and infantnegative affect and early childhood depression symptoms.(See Developments in Research 12.1 on p. 417 for a discus-sion of fetal alcohol syndrome.)

Learning Factors Learning of maladaptive behaviorsappears to be important in childhood depressive disorders.There are likely to be learning or cultural factors in theexpression of depression. A recent article by Stewart, Ken-nard, et al. (2004) reported that depression symptoms andhopelessness were higher in Hong Kong than in the United

States. In addition, a number of studies have indicated thatchildren's exposure to early traumatic events can increasetheir risk for the development of depression. Children whohave experienced past stressful events are susceptible tostates of depression that make them vulnerable to suicidalthinking under stress (Silberg, Pickles, et al., 1999). Intenseor persistent sensitization of the central nervous system inresponse to severe stress might induce hyperreactivity andalteration of the neurotransmitter system, leaving thesechildren vulnerable to later depression (Heim & Nemeroff,2001). Children who are exposed to negative parentalbehavior or negative emotional states may developdepressed affect themselves (Herman-Stahl & Peterson,1999). For example, childhood depression has been foundto be more common in divorced families (Palosaari &Laippala,1996).

One important area of research is focusing on the roleof the mother-child interaction in the transmission ofdepressed affect. Specifically, investigators have been eval-uating the possibility that mothers who are depressedtransfer their low mood to their infants through theirinteractions with them (Jackson & Huang, 2000). Depres-sion among mothers is not uncommon and can resultfrom several sources. Some women become depressed dur-ing pregnancy or following the delivery of their child, inpart because of exhaustion and hormonal changes that canaffect mood. Several investigators have reported that mar-ital distress, delivery complications, and difficulties withthe infant are also associated with depression in mothers(Campbell et al., 1990).

Depressed mothers do not respond effectively to theirchildren (Goldsmith & Rogoff, 1997). Depressed motherstend to be less sensitively attuned to, and more negativetoward, their infants than nondepressed mothers (Murray,Fiori-Cowley, et al., 1996). Other research has shown thatnegative (depressed) affect and constricted mood on thepart of a mother, which shows up as unresponsive facialexpressions and irritable behavior, can produce similarresponses in her infant (Cohn & Tronick, 1983; Tronick &Cohn, 1989). Interestingly, the negative impact ofdepressed mothers' interaction style has also been studiedat the physiological level. Infants have been reported toexhibit greater frontal brain electrical activity during theexpression of negative emotionality by their mothers(Dawson, Pan agio tides, et al., 1997). Although most ofthese studies have implicated the mother-child relation-ship in development of the disorder, depression in fathershas also been related to depression in children (Jacob &Johnson, 2001).

Another important line of research in childhooddepression involves the cognitive-behavioral perspective.Considerable evidence has accumulated that depressivesymptoms are positively correlated with the tendency toattribute positive events to external, specific, and unstablecauses and negative events to internal, global, and stable

Mothers who are depressed may transmit their depression to theirchildren by their lack of responsiveness to the child as a result oftheir own depression. Unfortunately, depression among mothersis all too common. Exhaustion, marital distress as a result of thearrival of children in a couple's lives, delivery complications, andthe difficulties of particular babies may all playa part.

causes (Hinshaw, 1992); with fatalistic thinking (Roberts,Roberts, & Chen, 2000); and with feelings of helplessness(Kistner, Ziegert, et al., 2001). For example, the child mayrespond to peer rejection or teasing by concluding that heor she has some internal flaw. Hinshaw (1994) considersthe tendency to develop distorted mental representationsan important cause of disorders such as depression andconduct disorder. In addition, children who show symp-toms of depression tend to underestimate their self-com-petence over time (Cole et al., 1998).

TREATMENTS AND OUTCOMES The view that child-hood and adolescent depression is like adult depressionhas prompted researchers to treat children displayingmood disorders-particularly adolescents who are viewedas suicidal (Greenhill & Waslick, 1997)-with medica-tions that have worked with adults. Research on the effec-tiveness of antidepressant medications with children isboth limited (Emslie & Mayes, 2001) and contradictory at

best, and some studies have found them to be only mod-erately helpful (Wagner & Ambrosini, 2001). Some recentstudies using fluoxetine (Prozac) with depressed adoles-cents have shown the drug to be more effective than aplacebo (DeVane & Sallee, 1996; Emslie, Rush, et al.,1997), and recent studies have shown fluoxetine to beeffective in the treatment of depression along with cogni-tive-behavioral therapy (Treatment for Adolescents withDepression Study (TADS) Team, US, 2004) althoughcomplete remission of symptoms was seldom obtained.Antidepressant medications may have some undesirableside effects (nausea, headaches, nervousness, insomnia,and even seizures) in children and adolescents. Four acci-dental deaths with a drug called "desipramine" have beenreported (Campbell & Cueva, 1995). However, the use ofantidepressant medication for depressed adolescents hasincreased from three- to fivefold over the past 10 years(Zito & Safer, 2001).

Depressed mood has come to be viewed as an impor-tant risk factor in suicide among children and adolescents(Fisher, 1999; Houston, Hawton, & Sheppard, 2001).About 7 to 10 percent of adolescents report having madeat least one suicide attempt (Safer, 1997b). Children whoattempt suicide are at greater risk for subsequent suicidalepisodes than are nonattempters, particularly within thefirst 2 years after their initial attempt (Pfeffer et al., 1994).Among the childhood disorders, depression especiallymerits aggressive treatment. Recent attention is being paidto the increased potential of suicidal ideation and behav-ior in children and adolescents who are taking SSRIs fortheir depression (Whittington, Kendall, et al., 2004). Somerisk of suicide for those taking the medication has beennoted (Couzin, 2004). The extent to which these medica-tions represent an additional threat of suicide is beinginvestigated.

An important facet of psychological therapy with chil-dren, whether for depression or anxiety or other disorders,is providing a supportive emotional environment in whichthey can learn more adaptive coping strategies and effec-tive emotional expression. Older children and adolescentscan often benefit from a positive therapeutic relationshipin which they can discuss their feelings openly (Stark, Lau-rent, et al., 1999). Younger children and those with lessdeveloped verbal skills may benefit from play therapy.Controlled studies of psychological treatment withdepressed adolescents have shown significantly reducedsymptoms with cognitive-behavioral therapy (Brent,Holder, et al., 1997) derived from Beck's cognitive-behav-ioral approach (Ackerson et al., 1998), which is discussedin Chapter 7. Rawson and Tabb (1993) showed that short-term residential treatment was effective with depressedchildren aged 8 to 14. The predominant approach fortreating depression in children and adolescents over thepast few years has been the combined use of medicationand psychotherapy (Skaer, Robison, et al., 2000).

Symptom Disorders: Enuresis,Encopresis, Sleepwalking, and TicsThe childhood disorders we will deal with in this section-"elimination disorders" (enuresis and encopresis), sleep-walking, and tics-typically involve a single outstandingsymptom rather than a pervasive maladaptive pattern.

FUNCTIONAL ENURESIS The term enuresis refers tothe habitual involuntary discharge of urine, usually atnight, after the age of expected continence (age 5). InDSM-IV-TR, functional enuresis is described as bed-wetting that is not organically caused. Children who haveprimary functional enuresis have never been continent;children who have secondary functional enuresis havebeen continent for at least a year but have regressed.

Enuresis may vary in frequency, from nightly occur-rence to occasional instances when a child is under con-siderable stress or is unduly tired. It has been estimatedthat some 4 to 5 million children and adolescents in theUnited States suffer from the inconvenience and embar-rassment of this disorder. Estimates of the prevalence ofenuresis reported in DSM -IV-TR are 5 to 10 percentamong 5-year-olds, 3 to 5 percent among 10-year-olds,and 1.1 percent of children age 15 or older. An epidemio-logical study in China reported a 4.3 percent prevalence,with a significantly higher percentage of boys than of girls(Liu, Sun, et al., 2000). Research has shown that there areclear sex differences in enuresis, as well as age differences.In one extensive epidemiological study of enuresis in Hol-land, Verhulst and colleagues (1985) determined thatbetween the ages of 5 and 8, enuresis is about two to threetimes more common among boys than among girls. Thepercentages for boys also diminish more slowly; thedecline for girls between ages 4 and 6 is about 71 percent,whereas the decline for boys is only 16 percent. Theresearchers recommended that the upper age limit fordiagnosing enuresis in boys be extended to age 8, becauseit is at about age 9 that approximately the same percentageof boys and girls reach "dryness"-that is, wetting the bedless than once a month.

Enuresis may result from a variety of organic condi-tions, such as disturbed cerebral control of the bladder(Goin, 1998), neurological dysfunction (Lunsing et al.,1991), or other medical factors such as medication sideeffects (Took & Buck, 1996) or having a small functionalbladder capacity and a weak urethral sphincter (Dahl,1992). One group of researchers reported that 11 percentof their enuretic patients had disorders of the urinary tract(Watanabe et al., 1994). However, most investigators havepointed to a number of other possible causal factors:(1) faulty learning, resulting in the failure to acquire inhi-bition of reflexive bladder emptying; (2) personal imma-turity, associated with or stemming from emotionalproblems; (3) disturbed family interactions, particularly

those that lead to sustained anxiety, hostility, or both; and(4) stressful events (Haug Schnabel, 1992). For example, achild may regress to bed-wetting when a new baby entersthe family and becomes the center of attention.

Medical treatment of enuresis typically centers onusing medications such as imipramine. The mechanismunderlying the action of the drug is unclear, but it maysimply decrease the deepest stages of sleep to light sleep,enabling the child to recognize bodily needs more effec-tively (Dahl, 1992). An intranasal desmopressin (DDAVP)has also been used to help children manage urine moreeffectively. This medication, a hormone replacement,apparently increases urine concentration, decreases urinevolume, and therefore reduces the need to urinate (Dahl,1992). The use of this medication to treat enuretic childrenis no panacea. Disadvantages of its use include its high costand the fact that it is effective only with a small subset ofenuretic children, and then only temporarily. Bath, Mor-ton, Ding, and Williams (1996) reported that treatmentwith desmopressin was disappointing but concluded thatthis treatment had some utility as a way to enable childrento stay dry for brief periods of time-for example, at acamp or on a holiday. Moffatt (1997) suggested that

DDAVP had an impor-tant place in treatingnocturnal enuresis inyoungsters who have notresponded well to behav-ioral treatment methods.It is well to rememberthat medications bythemselves do not cureenuresis and that there isfrequent relapse when thedrug is discontinued orthe child habituates to themedication (Dahl, 1992).

Conditioning proce-dures have proved to bethe most effective treat-ment for enuresis (Friman& Warzak, 1990). Mowrerand Mowrer (1938) intro-duced a procedure inwhich a child sleeps on apad that is wired to abattery-operated bell. At

the first few drops of urine, the bell is set off, thus awakeningthe child. Through conditioning, the child comes to associ-ate bladder tension with awakening. Recent evidence sug-gests that a "biobehavioral approach"-that is, using theurine alarm along with desmopressin-is most effective(Mellon & McGrath, 2000).

With or without treatment, the incidence of enuresistends to decrease significantly with age, but many experts

When combined withmedication such asdesmopressin, a urine alarm(shown here) can be veryeffective in treating enuresis.The child sleeps with awetness detector, which iswired to a battery-operateda/arm in his or herundergarment. Throughconditioning, the child comesto associate bladder tensionwith awakening.

still believe that enuresis should be treated in childhoodbecause there is presently no way to identify which chil-dren will remain enuretic into adulthood (Goin, 1998). Inan evaluation of research on the treatment of bed-wetting,Houts, Berman, and Abramson (1994) concluded thattreated children were more improved at follow-up thannontreated children. They also found that learning-basedprocedures were more effective than medications.

FUNCTIONAL ENCOPRESIS The term encopresisdescribes a symptom disorder of children who have notlearned appropriate toileting for bowel movements afterage 4. This condition is less common than enuresis; how-ever, DSM-IV- TR estimated that about 1 percent of 5-year-olds have encopresis. A study of 102 cases of encopreticchildren yielded the following list of characteristics: Theaverage age of children with encopresis was 7, with a rangeof ages 4 to 13. About one-third of encopretic childrenwere also enuretic, and a large sex difference was found,with about six times more boys than girls in the sample.Many of the children soiled their clothing when they wereunder stress. A common time was in the late afternoonafter school; few children actually had this problem atschool. Most of the children reported that they did notknow when they needed to have a bowel movement orwere too shy to use the bathrooms at school.

Many encopretic children suffer from constipation, soan important element in the diagnosis is a physical exami-nation to determine whether physiological factors are con-tributing to the disorder. The treatment of encopresisusually involves both medical and psychological aspects(Dawson et aI., 1990). Several studies of the use of condi-tioning procedures with encopretic children have reportedmoderate treatment success; that is, no additional inci-dents occurred within 6 months following treatment(Huntley & Smith, 1999; Smith et aI., 2000).

SLEEPWALKING (SOMNAMBULISM) Although theonset of sleepwalking disorder is usually between the agesof 6 and 12, the disorder is classified broadly under sleepdisorders in DSM -IV-TR rather than under disorders ofinfancy, childhood, and adolescence (American PsychiatricAssociation, DSM-IV-TR, 2000). The symptoms of sleep-walking disorder involve repeated episodes in which a per-son leaves his or her bed and walks around without beingconscious of the experience or remembering it later.

Statistics are meager, but the incidence of sleepwalkingreported for children in DSM is high for one episode-between 10 and 30 percent. However, the incidence forrepeated episodes is low-from 1 to 5 percent. Childrensubject to this problem usually go to sleep in a normal man-ner but arise during the second or third hour of sleep. Theymay walk to another room of the house or even outside,and they may engage in complex activities. Finally, theyreturn to bed and in the morning remember nothing that

has taken place. While moving about, sleepwalkers' eyes arepartially or fully open; they avoid obstacles, listen whenspoken to, and ordinarily respond to commands, such as toreturn to bed. Shaking them will usually awaken sleepwalk-ers, and they will be surprised and perplexed at findingthemselves in an unexpected place. Sleepwalking episodesusually last only a few minutes (Graham, Turk, & Verhulst,1999). The causes of sleepwalking are not fully understood.Sleepwalking takes place during NREM (non-rapid eyemovement) sleep. It appears to be related to some anxiety-arousing situation that has just occurred or is expected tooccur in the near future (Klackenberg, 1987).

Little attention has been devoted to the treatment ofsleepwalking. Clement (1970), however, reported on thetreatment of a 7-year-old boy through behavior therapy.During treatment, the therapist learned that just beforeeach sleepwalking episode, the boy usually had a night-mare about being chased by "a big black bug." After hisnightmare began, he perspired freely, moaned and talkedin his sleep, tossed and turned, and finally got up andwalked through the house. He did not remember the sleep-walking episode when he awoke the next morning. Assess-ment data revealed no neurological or other medicalproblems and indicated that he was of normal intelligence.He was, however, found to be a very anxious, guilt-riddenlittle boy who avoided performing assertive and aggressivebehaviors appropriate to his age and sex (p. 23). The ther-apist focused treatment on having his mother awaken theboy each time he showed signs of an impending episode.After washing his face with cold water and making sure hewas fully awake, the mother would return him to bed,where he was to hit and tear up a picture of the big blackbug. (At the start of the treatment program, he had madeup several of these drawings.)

Eventually, the nightmare was associated with awak-ening, and he learned to wake up on most occasions whenhe was having a bad dream. Thus the basic behavior ther-apy followed in this case was the same as that used in theconditioning treatment for enuresis, where a wakingresponse is elicited by an intense stimulus just as urinationis beginning and becomes associated with, and eventuallyprevents, nocturnal bed-wetting.

TICS A tic is a persistent, intermittent muscle twitch orspasm, usually limited to a localized muscle group. Theterm is used broadly to include blinking the eye, twitchingthe mouth, licking the lips, shrugging the shoulders, twist-ing the neck, clearing the throat, blowing the nose, and gri-macing, among other actions. Tics occur most frequentlybetween the ages of 2 and 14 (Evans et aI., 1996). In someinstances, as in clearing the throat, an individual may beaware of the tic when it occurs, but usually he or she per-forms the act habitually and does not notice it. In fact,many individuals do not even realize they have a tic unlesssomeone brings it to their attention. A cross-culturalexamination of tics found a similar pattern in research and

clinical case reports from other countries (Staley et aI.,1997). Moreover, the age of onset (average 7 to 8 years) andpredominant gender (male) of cases were reported to besimilar across cultures (Turan & Senol, 2000). The psycho-logical impact that tics can have on an adolescent is illus-trated in the following case.

The Adolescent Who Wantedto Be a Teacher

An adolescent who had wanted very much to be a teachertold the school counselor that he was thinking of givingup his plans. When asked why, he explained that severalfriends had told him that he had a persistent twitching ofthe mouth muscles when he answered questions in class.He had been unaware of this muscle twitch and, evenafter being told about it, could not tell when it took place.However, he became acutely self-conscious and wasreluctant to answer questions or enter into class discus-sions. As a result, his general level of tension increased,and so did the frequency of the tic, which now becameapparent even when he was talking to his friends. Thus avicious circle had been established. Fortunately, the ticproved amenable to treatment by conditioning andassertiveness training.

Tourette's syndrome is an extreme tic disorderinvolving multiple motor and vocal patterns. This disordertypically involves uncontrollable head movements withaccompanying sounds such as grunts, clicks, yelps, sniffs,or words. Some, possibly most, tics are preceded by an urgeor sensation that seems to be relieved by execution of thetic. Tics are thus often difficult to differentiate from com-pulsions, and they are sometimes referred to as "compul-sive tics" (Jankovic, 1997). One recent epidemiologicalstudy in Sweden reported the prevalence of Tourette's syn-drome in children and adolescents to be about 0.56 percent(Khalifa & von Knorring, 2004). About one-third of indi-viduals with Tourette's syndrome manifest coprolalia,which is a complex vocal tic that involves the uttering ofobscenities. Some people with Tourette's syndrome alsoexperience explosive outbursts (Budman, Braun, et aI.,2000). The average age of onset for Tourette's syndrome is7, and most cases have an onset before age 14. The disorderfrequently persists into adulthood. It is about three timesmore frequent among males than among females.Although the exact cause of Tourette's syndrome is unde-termined, evidence suggests an organic basis. Because chil-dren with Tourette's syndrome can have substantial familyadjustment (Wilkinson, Newman, et al., 2001) and/orschool adjustment problems (Nolan & Gadow, 1997),interventions should be designed to aid their adjustment

and to modify the reactions of peers to them. School psy-chologists can play an effective part in the social adjust-ment of the child with Tourette's syndrome (Walter &Carter, 1997) by applying behavioral intervention strate-gies that help arrange the child's environment to be moreaccepting of such unusual behaviors.

There are many types of tics, and many of themappear to be associated with the presence of other psycho-logical disorders (Cardona et al., 1997), particularly obses-sive-compulsive disorder (OCD). Most tics, however, donot have an organic basis but stem from psychologicalcauses such as self-consciousness or tension in social situ-ations, and they are usually associated with severe behav-ioral problems (Rosenberg, Brown, & Singer, 1995). As inthe case of the adolescent boy previously described, anindividual's awareness of the tic often increases tensionand the occurrence of the tic.

Among medications, neuroleptics are the most pre-dictably effective tic-suppressing drugs (KurIan, 1997).Clonazepam, clonidine, and tiapride have all shown effec-tiveness in reducing motor tics; however, tiapride hasshown the greatest decrease in the intensity and frequencyof tics (Drtikova et al., 1996). Campbell and Cueva (1995)reported that both haloperidol and pimozide reduced theseverity of tics by about 65 percent but that haloperidolseemed the more effective of the two medications.Recently, Gilbert, Batterson, Sethuraman, & Sallee (2004)reported that risperidone outperformed pimozide in ticsuppression.

Behavioral intervention techniques have also beenused successfully in treating tics (Woods & Miltenberger,2001). One successful program involved several sequentialelements, beginning with awareness training, relaxationtraining, and the development of incompatible responsesand then progressing to cognitive therapy and modifica-tion of the individual's overall style of action. Finally, per-fectionist expectations about self-image (which are oftenfound in children and adolescents with tics) are addressedthrough cognitive restructuring (O'Connor et al., 1998).

Pervasive Developmental DisordersThe pervasive developmental disorders (PDDs) are agroup of severely disabling conditions that are among themost difficult to understand and treat. They make upabout 3.2 percent of cases seen in inpatient settings (Sverd,Sheth, Fuss, & Levine, 1995). They are considered to be theresult of some structural differences in the brain that areusually evident at birth or become apparent as the childbegins to develop (Siegel, 1996). There is fairly good diag-nostic agreement in the determination of pervasive devel-opmental disorders in children whether one follows theDSM -IV-TR or ICD-l 0 (the International Classification ofDisease, published by the World Health Organization),which have slightly different criteria for some disorders(Sponheim, 1996). Several pervasive developmental disor-

ders are covered in DSM -IV-TR-for example, Asperger'sdisorder, which is a severe and persistent impairment insocial interaction that involves marked stereotypic (repeti-tive) behavior and inflexible adherence to routines (Mesi-bov, Shea, & Adams, 2001). This pattern of behavior usuallyappears later than other pervasive developmental disorderssuch as autism, but it nevertheless involves substantial long-term psychological disability. Asperger's disorder sharesmany features of social impairment disorder, restrictedinterests, and repetitive behaviors with autistic disorderalthough it may become manifest somewhat later thanautism and in most cases is not associated with the severedelay in language development and social interactions thatautism does (Khouzam, EI-Gabalawi, et al., 2004). We willillustrate the developmental disorders by addressing III

some detail the disorder referred to as "autism."

One of the most common and most puzzling and disablingof the pervasive developmental disorders is autistic disor-der, which is often referred to as autism or "childhoodautism" (Schopler, Yirmiya, et al., 2001). It is a develop-mental disorder that involves a wide range of problematicbehaviors including deficits in language, and perceptualand motor development; defective reality testing; and aninability to function in social situations. The following caseillustrates some of the behaviors that may be seen in anautistic child.

Mathew is 5 years old. When spoken to, he turns his headaway. Sometimes he mumbles unintelligibly. He is neithertoilet trained nor able to feed himself. He actively resistsbeing touched. He dislikes sounds and is uncommunica-tive. He cannot relate to others and avoids looking any-one in the eye. He often engages in routine manipulativeactivities such as dropping an object, picking it up, anddropping it again. He shows a pathological need forsameness. While seated, he often rocks back and forthin a rhythmic motion for hours. Any change in routine ishighly upsetting to him.

Autism in infancy and childhood was first describedby Kanner (1943). It afflicts tens of thousands of Americanchildren from all socioeconomic levels and is apparentlyon the increase-estimates range between 30 and 60 peo-ple in 10,000 (Fombonne, 2003; Merrick, Kandel, &Morad, 2004). The reported increase in autism in recentyears is likely due to methodological differences between

studies, and changes in diagnostic practice and public andprofessional awareness in recent years rather than anincrease in prevalence (Williams, Mellis, & Peat 2005).Autism is usually identified before a child is 30 months ofage and may be suspected in the early weeks of life. Onestudy found that autistic behavior such as lack of empathy,inattention to others, and inability to imitate is shown asearly as 20 months (Charman, Swettenham, et aI., 1997).

THE CLINICAL PICTURE IN AUTISM DISORDERAutistic children show varying degrees of impairmentsand capabilities. In this section, we will discuss some of thebehaviors that may be evident in autism. A cardinal andtypical sign is that a child seems apart or aloof from others,even in the earliest stages of life (Adrien et aI., 1992).Mothers often remember such babies as never being cud-dly, never reaching out when being picked up, never smilingor looking at them while being fed, and never appearing tonotice the comings and goings of other people.

A Social Deficit Typically, autistic children do not showany need for affection or contact with anyone, and theyusually do not even seem to know or care who their parentsare. Several studies, however, have questioned the tradi-tional view that autistic children are emotionally flat. Thesestudies (Capps et aI., 1993) have shown that autistic chil-dren do express emotions and should not be considered aslacking emotional reactions (Jones et aI., 2001). Instead,Sigman (1996) has characterized the seeming inability ofautistic children to respond to others as a lack of socialunderstanding-a deficit in the ability to attend to socialcues from others. The autistic child is thought to have a"mind blindness;' an inability to take the attitude of othersor to "see" things as others do. For example, an autistic childappears limited in the ability to understand where anotherperson is pointing. Additionally, autistic children showdeficits in attention and in locating and orienting to soundsin their environment (Townsend et aI., 1996).

The lack of social interaction among autistic childrenhas been well described. A behavioral observation studyby Lord and Magill-Evans (1995) noted that autisticyoungsters engaged in fewer social interactions than otherchildren; however, this study also made the importantobservation that autistic children did not play-particu-larly did not show spontaneous play. In fact, much of thetime, nothing was going on.

Encopresis is common (Siegel, 2003). Radford andAnderson (2003) pointed out that relatively little of theclinical descriptive literature on autistic children addressesthe problem of toilet training. They noted that failing tocooperate in toilet training is a common problem and onethat creates added difficulty for parents of autistic childrenand provided practical advice and training guidelines fordealing with this problem behavior. In addition, a highprevalence of sleep problems has been reported for autisticchildren (Williams, Sears, & Allard, 2004).

An Absence of Speech Autistic children have been con-sidered to have an imitative deficit and do not effectivelylearn by imitation (Smith & Bryson, 1994). This dysfunc-tion might explain their characteristic absence or severelylimited use of speech. If speech is present, it is almost neverused to communicate except in the most rudimentaryfashion, such as by saying "yes" in answer to a question orby the use of echolalia-the parrot-like repetition of afew words. Whereas the echoing of parents' verbal behav-ior is found to a small degree in normal children as theyexperiment with their ability to produce articulate speech,persistent echolalia is found in about 75 percent of autisticchildren (Prizant, 1983).

Self-Stimulation Self-stimulation is often characteris-tic of autistic children. It usually takes the form of suchrepetitive movements as head banging, spinning, androcking, which may continue by the hour. Other bizarrerepetitive behaviors are typical. Such behavior is welldescribed by Schreibman and Charlop-Christie (1998)and illustrated in the case of a young autistic boy.

_____ 1 Two of Everything

A. was described as a screaming, severely disturbed childwho ran around in circles making high-pitched sounds forhours. He also liked to sit in boxes, under mats, and[under] blankets. He habitually piled up all furniture andbedding in the center of the room. At times, he wasthought [to be] deaf, though he also showed extreme fearof loud noises. He refused all food except in a bottle,refused to wear clothes, chewed stones and paper,whirled himself, and spun objects. He played repetitivelywith the same toys for months, lining things in rows, col-lected objects such as bottle tops, and insisted on havingtwo of everything, one in each hand. He became extremelyupset if interrupted and if the order or arrangement ofthings [was] altered. (From Gajzago & Prior, 1974, p. 264.)

Autistic children seem to actively arrange the environ-ment on their own terms in an effort to exclude or limitvariety and intervention from other people, preferringinstead a limited and solitary routine. Autistic children oftenshow an active aversion to auditory stimuli, crying even atthe sound of a parent's voice. The pattern is not always con-sistent, however; autistic children may at one moment beseverely agitated or panicked by a very soft sound and atanother time be totally oblivious to loud noise.

Intellectual Ability Much has been learned in the lastfew years about the cognitive abilities of autistic children(Bennetto, Pennington, et aI., 1996). Compared with the

Autistic children seem to actively exclude or limit intervention fromother people.

performance of other groups of children on cognitive orintellectual tasks, autistic children often show markedimpairment. For example, autistic children are signifi-cantly impaired on memory tasks when compared withboth normal and retarded children. Autistic children showa particular deficit in representing mental states-that is,they appear to have deficits in social reasoning but canmanipulate objects (Scott & Baron-Cohen, 1996). Carpen-tieri and Morgan (1996) found that the cognitive impair-ment in autistic children is reflected in greater impairmentin adaptive behaviors than is seen in mentally retardedchildren without autism.

Some autistic children are quite skilled at fittingobjects together; thus their performance on puzzles orform boards may be average or above. Even in the manip-ulation of objects, however, difficulty with meaning isapparent. For example, when pictures are to be arranged inan order that tells a story, autistic children show a markeddeficiency in performance. Moreover, autistic adolescents,even those who are functioning well, have difficulty withsymbolic tasks such as pantomime, in which they are askedto recall motor actions to imitate tasks (e.g., ironing) withimagined objects, in spite of the fact that they might per-form the task well with real objects (Rogers, Bennetto,et aI., 1996).

Maintaining Sameness Many autistic children becomepreoccupied with and form strong attachments to unusualobjects such as rocks, light switches, film negatives, or keys.In some instances, the object is so large or bizarre thatmerely carrying it around interferes with other activities.When their preoccupation with the object is disturbed-for example, by its removal or by attempts to substitutesomething in its place-or when anything familiar in the

DSM-IV-TR

A. Six (or more) of the following criteria from (1), (2), and (3),with at least two from (1), and one each from (2) and (3):

(1) qualitative impairment in social interaction, asmanifested by at least two of the following:

(a) marked impairment in the use of multiplenonverbal behaviors such as eye-to-eye gaze,facial expression, body postures, and gestures toregulate social interaction

(b) failure to develop peer relationships appropriate todevelopmental level

(c) a lack of spontaneous seeking to share enjoyment,interests, or achievements with other people (e.g.,by a lack of showing, bringing, or pointing-outobjects of interest)

(d) lack of social or emotional reciprocity

(2) qualitative impairments in communication asmanifested by at least one of the following:

(a) delay in, or total lack of, the development ofspoken language (not accompanied by an attemptto compensate through alternative modes ofcommunication such as gesture or mime)

(b) in individuals with adequate speech, markedimpairment in the ability to initiate or sustain aconversation with others

(c) stereotyped and repetitive use of language oridiosyncratic language

(d) lack of varied, spontaneous make-believe play orsocial imitative play appropriate to developmentallevel

(3) restricted repetitive impairments and stereotypedpatterns of behavior, interests, and activities, asmanifested by at least one of the following:

(a) encompassing preoccupation with one or morestereotyped and restricted patterns of interest thatis abnormal either in intensity or focus

(b) apparently inflexible adherence to specific,nonfunctional routines or rituals

(c) stereotyped and repetitive motor mannerisms(e.g., hand or finger flapping or twisting, orcomplex whole-body movements)

(d) persistent preoccupation with parts of objects

B. Delays or abnormal functioning in at least one of thefollowing areas, with onset prior to age 3 years: (1) socialinteraction, (2) language as used in social communication,or (3) symbolic or imaginative play

Source: Adapted with permission from the Diagnostic andStatistical Manual of Mental Disorders, Fourth Edition, Text Revision(Copyright 2000). American Psychiatric Association.

environment is altered even slightly, these children mayhave a violent temper tantrum or a crying spell that con-tinues until the familiar situation is restored. Thus autisticchildren are often said to be "obsessed with the mainte-nance of sameness."

CAUSAL FACTORS IN AUTISM The precise cause orcauses of autism are unknown although most investiga-tors agree that a fundamental disturbance of the centralnervous system is involved (Volkmar & Klein, 2000).Many investigators believe that autism begins with sometype of inborn defect that impairs an infant's perceptual-cognitive functioning-the ability to process incomingstimuli and to relate to the world. Recently, Fein (2001)presented the view that the psychological deficits in chil-dren with autism stem from a primary impairment in thedomains of social attachment and communication fail-ures. She postulated that the problem arises from deficitsin the functioning of the amygdala, the almond-shapedneural structure that is believed to coordinate the actionsof the autonomic nervous system and the endocrine sys-tems. Recent MRI research has suggested that abnormali-ties in the brain anatomy may contribute to the brainmetabolic differences and behavioral phenotype in autism(McAlonan, Cheung, et al., 2005). Whatever the physio-logical mechanisms or brain structures involved, evidencehas accumulated that defective genes or damage fromradiation or other conditions during prenatal develop-ment may playa significant role in the etiologic picture(Nicolson & Szatmari, 2003; Rutter, 2000; Waterhouse &Fein, 1997). Evidence for a genetic contribution to autismcomes from examining the risk for autism in the siblingsof autistic children (Micali, Chakrabarti, & Fombonne,2004). The best estimates are that in families with oneautistic child, there is a 3 to 5 percent risk of a siblingbeing autistic as well. Although this figure may seem lowin an absolute sense, it is in fact extremely high, given thefrequency of autism in the population.

Twin studies have also consistently shown higher con-cordance rates among monozygotic than dizygotic twins(Bailey, Le Couteur, & Gottesman, 1995). The conclusionfrom family and twin studies is that 80 to 90 percent of thevariance in risk for autism is based on genetic factors; thusit is probably the most heritable form of psychopathologydiscussed in this text (Le Couteur et aI., 1996). Nevertheless,the exact mode of genetic transmission is not yet under-stood, and it seems likely that relatives may also show anincreased risk for other cognitive and social deficits that aremilder in form than true autism (Smalley, 1991). In otherwords, just as in schizophrenia, there may be a spectrum ofdisorders related to autism (Gottesman & Hanson, 2005).

Some investigators have pointed to the existence of apossible genetic defect known as "fragile X;' a constrictionor breaking off of the end portion of the long arm of the Xsex chromosome that appears to be determined by a spe-cific gene defect (Eliez, Blasey, et al., 2001; Mazzocco, 2000;Tsai & Ghaziuddin, 1992). The fragile X syndrome occurs

in about 8 percent of autistic males (Smalley, 1991). Inaddition, 15 to 20 percent of males with the fragile X syn-drome are also diagnosed with autism, further suggesting alink between the two syndromes.

TREATMENTS AND OUTCOMES OF AUTISM The treat-ment prognosis for autistic disorder is poor, and because ofthe severity of their problems, those diagnosed with autismare often insufficiently treated (Wherry, 1996). Moreover,because of the typically poor response to treatment, autisticchildren are often subjected to a range of fads and "novel"approaches, which turn out to be equally ineffective.

Medical Treatment In the past, the use of medicationsto treat autistic children has not proved effective (Rutter,1985). The drug most often used in the treatment ofautism is haloperidol (Haldol), an antipsychotic medica-tion (Campbell, 1987), but the data on its effectiveness donot support its use unless a child's behavior is unmanage-able by other means (Sloman, 1991). More recently, cloni-dine, an antihypertensive medication, has been used withreportedly moderate effects in reducing the severity of thesymptoms (Fankhauser et aI., 1992). If irritability andaggressiveness are present, the medical management of acase might involve use of medications to lower the level ofaggression (Fava, 1997; Leventhal, Cook, & Lord, 1998).Although there are no surefire medications approved forthis purpose, the drug clomipramine has had some benefi-cial effect. However, no currently available medicationreduces the symptoms of autism enough to encouragegeneral use. We will thus direct our attention to a variety ofpsychological procedures that have been more successfulin treating autistic children.

Behavioral Treatment Behavior therapy in an institu-tional setting has been used successfully in the eliminationof self-injurious behavior, the mastery of the fundamentalsof social behavior, and the development of some languageskills (Charlop-Christie et aI., 1998). Ivar Lovaas (1987), apioneer in behavioral treatment of autistic children,reported highly positive results from a long-term experi-mental treatment program. The intervention developed byLovaas and colleagues is very intensive and is usually con-ducted in the children's homes rather than in a clinical set-ting. The children are usually immersed in a one-to-oneteaching situation for most of their waking hours over sev-eral years. The intervention is based on both discrimina-tion training strategies (reinforcement) and contingentaversive techniques (punishment). The treatment plantypically enlists parents in the process and emphasizesteaching children to learn from and interact with "normal"peers in real-world situations. Of the treated children, 47percent achieved normal intellectual functioning, andanother 40 percent attained the mildly retarded level. Incomparison, only 2 percent of the untreated control chil-dren achieved normal functioning, and 45 percent attainedmildly retarded functioning. These remarkable results did,

however, require a considerable staffing effort, with well-qualified therapists working with each child at least 40hours per week for 2 years.

Some of the other impressive results with autistic chil-dren have also been obtained in projects that involve par-ents, with treatment in the home (Siegel, 2003). Treatmentcontracts with parents specify the desired behaviorchanges in their child and spell out the explicit techniquesfor bringing about these changes. Such "contracting"acknowledges the value of the parents as potential agentsof change (Huynen, Lutzker, et al., 1996).

The Effectiveness of Treatment It is too early to evalu-ate the long-term effectiveness of the newer treatmentmethods or the degree of improvement they actually bringabout. The prognosis for autistic children, particularly forchildren showing symptoms before the age of 2, is poor.Commonly, the long-term results of autism treatmentshave been unfavorable. A great deal of attention has beengiven to high-functioning autistic children (children whomeet the criteria for autism yet develop functional speech).Ritvo and colleagues (1988) studied 11 parents who theybelieved met diagnostic criteria for autism (they wereidentified through having had children who were autistic).These individuals had been able to make modest adjust-ments to life, hold down jobs, and get married. But theoutcome in autism, particularly in more severe cases, isusually not as positive.

One important factor limiting treatment success is thedifficulty that autistic children have in generalizing behav-ior outside the treatment context (Handleman, Gill, &Alessandri, 1988). Children with severe developmental dis-abilities do not transfer skills across situations very well.Consequently, learning behavior in one situation does notappear to help them meet challenges in others.

In spite of a few remarkable cases of dramatic success,the overall prognosis for autistic children remainsguarded. Less than one-fourth of the autistic children whoreceive treatment attain even marginal adjustment in laterlife. Even with intensive long-term care in a clinical facility,where gratifying improvements in specific behaviors maybe brought about, autistic children are a long way frombecoming normal. Some make substantial improvementduring childhood, only to deteriorate, showing symptomaggravation, at the onset of puberty (Gillberg & Schau-mann, 1981).

Providing parental care to autistic children is moretrying and stressful than providing it to normal or men-tally retarded children (Dunn, Burbine, et al., 2001). Par-ents of autistic children often find themselves in theextremely frustrating situation of trying to understandtheir autistic child, providing day-to-day care, and search-ing for possible educational resources for their child in thepresent health and educational environment. An unusuallyinformative book on the topic of autism is The World of theAutistic Child (Siegel, 1996). Siegel discusses the impactthat having an autistic child can have on the family-both

Some studies show that intensive behavioral treatment ofautistic children, requiring a significant investment of time andenergy on the part of therapist and parents, can bringimprovement, particularly if this treatment continues at homerather than in an institution.

parents and siblings-and describes ways of dealing withthe problems that can arise, including the possible need ofpsychological treatment for other family members. Thebook is a particularly valuable guide to accessing theresources available for educating and treating autistic chil-dren and negotiating the confusing educational environ-ment. Whether to seek residential placement, clearly anecessity in some situations and families, is also an impor-tant decision that parents of many autistic children mustaddress. Efforts are being made to promote the develop-ment and growth of autistic people over their life span, inwhat has been referred to as the "Eden Model" (Holmes,1998). In this approach, professionals and families recog-nize that autistic individuals may need to have differenttherapeutic regimes at different periods of their lives andthat the available resources need to be structured to pro-vide for their changing needs.

In ReVIew~ Distinguish among conduct disorder,

oppositional defiant disorder, and juveniledelinquency.

~ Describe two common anxiety disordersfound in children and adolescents.

~ How do the symptoms of childhooddepression compare to those seen in adultdepression?

~ Identify four common symptom disordersthat can arise in childhood.

~ What is known about the causes andtreatments of autistic disorder?

LEARNING DISABILITIESAND MENTALRETARDATIONIn the next two sections, we address two general condi-tions that can occur in children and can persist over theirlife span, greatly limiting their future development andpsychological growth: learning disorders and mentalretardation.

The inadequate development found in learning disabili-ties, a term that refers to retardation, disorder, or delayeddevelopment, may be manifested in language, speech,mathematical, or motor skills, and it is not due to any reli-ably demonstrable physical or neurological defect. Ofthese types of problems, the best known and most widelyresearched are a variety of read-ing/writing difficulties known col-lectively as dyslexia. In dyslexia,the individual manifests problemsin word recognition and readingcomprehension; often he or she ismarkedly deficient in spelling aswell. On assessments of readingskill, these persons routinely omit,add, and distort words, and theirreading is typically painfully slowand halting.

The diagnosis of learning dis-ability or disorder is restricted tothose cases in which there is clearimpairment in school performanceor (if the person is not a student) indaily living activities-impairmentnot due to mental retardation or toa pervasive developmental disordersuch as autism. Skill deficits due toattention -deficit/hyperactivity dis-order are coded under that diagno-sis. This coding presents anotherdiagnostic dilemma, because someinvestigators hold that an atten-tional deficit is basic to many learn-ing disorders; evidence for the latterview is equivocal (see Faraone et al.,1993). Children (and adults) withthese disorders are more generally said to be "learning dis-abled" (LD). Significantly more boys than girls are diag-nosed as learning disabled, but estimates of the extent of thisgender discrepancy have varied widely from study to study.

Children with learning disabilities are initially identi-fied as such because of an apparent disparity between

their expected academic achievement level and theiractual academic performance in one or more school sub-jects such as math, spelling, writing, or reading. Typically,these children have overall IQs, family backgrounds, andexposure to cultural norms and symbols that are consis-tent with at least average achievement in school. They donot have obvious crippling emotional problems, nor dothey seem to be lacking in motivation, cooperativeness, oreagerness to please their teachers and parents-at leastnot at the outset of their formal education. Nevertheless,they fail, often abysmally and usually with a stubborn,puzzling persistence.

It is unfortunately the case that LD, despite its havingbeen recognized as a distinct and rather common type ofdisorder for more than 40 years, and despite its having gen-erated a voluminous research literature, still fails to beaccorded the status it deserves in many school jurisdic-tions. Instead, many classroom teachers and school admin-istrators resort to blaming the victim and attributing theaffected child's problems to various character deficiencies

(see Bearn & Smith, 1998; Fischer,1993; Moats & Lyon, 1993). Wherelockstep uniformity is the rule, as itis in most public and many alter-native educational systems, ayoungster who learns academicskills slowly or in a different way istreated as a troublemaker.

The consequences of theseencounters between LD childrenand rigidly doctrinaire or regi-mented school systems can be dis-astrous to a child's self-esteem andgeneral psychological well-being,and research indicates that theseeffects do not necessarily dissipateafter secondary schooling ends(Aspis, 1997; Cooper, 1997; Ferri,Gregg, & Heggoy, 1997). Thus evenwhere LD difficulties are no longera significant impediment, an indi-vidual may bear, into maturity andbeyond, the scars of many painfulschool-related episodes of failure.

But there is also a brighterside to this picture. High levels ofgeneral talent and of motivation toovercome the obstacle of a learn-ing disorder sometime produce alife of extraordinary achievement.

Sir Winston Churchill, British statesman, author, andinspiring World War II leader, is said to have been dyslexicas a child. The same attribution is made to Woodrow Wil-son, former university professor and president of theUnited States, and to Nelson Rockefeller, former governorof New York and vice president of the United States. Such

A person with dyslexia has problems with wordrecognition, spelling, and reading comprehension.Dyslexic people routinely omit, add, and distortwritten words, and their reading is typicallypainfully slow and halting.

examples remind us that the "bad luck" and personaladversity of having a learning disorder need not be uni-formly limiting; quite the contrary.

Causal Factors in Learning DisabilitiesProbably the most widely held view of the causes of spe-cific learning disabilities is that they are the products ofsubtle central nervous system impairments. In particular,these disabilities are thought to result from some sort ofimmaturity, deficiency, or dysregulation limited to thosebrain functions that supposedly mediate, for normal chil-dren, the cognitive skills that LD children cannot effi-ciently acquire. For example, many researchers believe thatlanguage-related LDs such as dyslexia are associated with afailure of the brain to develop in a normally asymmetricalmanner with respect to the right and left hemispheres.Specifically, portions of the left hemisphere, where lan-guage function is normally mediated, for unknown rea-sons appear to remain relatively underdeveloped in manydyslexic individuals (Beaton, 1997). Recent work withfunctional magnetic resonance imaging (see Chapter 4)has suggested that dyslexic individuals may have a defi-ciency of physiological activation in a brain center believedto be involved with rapid visual processing (Travis, 1996).

Some investigators believe that the various forms ofLD, or vulnerability to develop them, may be geneticallytransmitted. This issue seems not to have been studiedwith the same intensity or methodological rigor as inother disorders. Identification of a gene region fordyslexia on chromosome 6 has been reported (Schulte-

Children with learning disorders can experience deep emotionaltension under normal learning circumstances.

Koerne, 2001). Although it would be somewhat surprisingif a single gene were identified as the causal factor in allcases of reading disorder, the hypothesis of a genetic con-tribution to at least the dyslexic form of LD seems promis-ing. One twin study of mathematics disability has alsoturned up evidence of some genetic contribution to thisform ofLD (Alarcon et aI., 1997).

Despite the seeming multitude of factors involved inLD, there may be some common elements. This is the posi-tion of Worden (1986), who argues that we should studythe approaches taken by good learners in order to identifythe areas where LD children are weak. Specialized trainingcould then be employed to remedy the specific deficien-cies. Even precise information on the manner in which LDchildren's learning approaches differ from those of normalchildren would leave unanswered questions about thesources of these differences. Nevertheless, pursuit of thisidea might produce a set of rational, fine-tuned strategiesfor intervening to correct LD children's inefficient modesof learning.

Because we do not yet have a confident grasp of what is"wrong" with the average LD child, we have had limitedsuccess in treating these children. Many informal and sin-gle-case reports claim success with various treatmentapproaches, but direct instruction strategies often do notsucceed in transforming these children's abilities (Get-tinger & Koscik, 2001), and there are few well-designedand well-executed outcome studies on specific treatmentsfor LD.

Ellis (1993) has offered a comprehensive interventionmodel to facilitate learning in LD. This Integrative StrategyInstruction (ISI) has generated considerable interestamong professionals in the field (see Houck, 1993;Hutchinson, 1993). Organized according to particularcontent areas, it envisions a variety of teacher-directedinstructional strategies directed at key aspects of the learn-ing process: orienting, framing, applying, and extending.Although the model appears not to have been rigorouslytested for efficacy, its knowledge-based and systematiccharacter is a welcome addition to analysis of the problemsthat LD children face. However, its application woulddemand high levels of administrative flexibility, teacherskill, and teacher motivation, none of which can be takenfor granted in the average school environment (see Bearn& Smith, 1998; Male & May, 1997).

We have only limited data on the long-term, adultadjustments of people who grew up with the personal, aca-demic, and social problems that LD generally entails. Twostudies of college students with LD (Gregg & Hoy, 1989;Saracoglu et aI., 1989) suggested that as a group they con-tinue to have problems-academic, personal, and social-into the postsecondary education years. In a communitysurvey of LD adults, Khan, Cowan, and Roy (1997) found

that some 50 percent of them had personality abnormali-ties. Cato and Rice (1982) extracted from the available lit-erature a lengthy list of problems experienced by thetypical LD adult. These include-in addition to expecteddifficulties with self-confidence-continuing problemswith deficits in the ordinary skills such as math that thesepeople had trouble with as children. The authors did note,however, that there are considerable individual differencesin these outcomes and that some adults with LD are able tomanage very well.

Mental RetardationThe American Psychiatric Association (2000) in DSM-IV-TR defined mental retardation as "significantly subaver-age general intellectual functioning ... that is accompaniedby significant limitations in adaptive functioning" (p. 41)in certain skill areas such as self-care, work, health, andsafety. For the diagnosis to apply, these problems musthave begun before the age of 18. Mental retardation is thusdefined in terms of level of performance as well as intelli-gence. The definition says nothing about causal factors,which may be primarily biological, psychosocial, sociocul-tural, or a combination of these. By definition, any func-tional equivalent of mental retardation that has its onsetafter age 17 must be considered a dementia rather thanmental retardation. The distinction is an important one,because the psychological situation of a person whoacquires a pronounced impairment of intellectual func-tioning after attaining maturity is vastly different from thatof a person whose intellectual resources were subnormalthroughout all or most of his or her development.

Mental retardation occurs among children through-out the world (Fryers, 2000). In its most severe forms, it isa source of great hardship to parents as well as an eco-nomic and social burden on a community. The pointprevalence rate of diagnosed mental retardation in theUnited States is estimated to be about 1 percent, whichwould indicate a population estimate of some 2.6 millionpeople. In fact, however, prevalence is extremely difficult topin down, because definitions of mental retardation varyconsiderably (Roeleveld, Zielhuis, & Gabreels, 1997). Moststates have laws providing that persons with IQs below 70who show socially incompetent or persistently problem-atic behavior can be classified as "mentally retarded" and, ifjudged otherwise unmanageable, may be placed in aninstitution. Informally, IQ scores between about 70 and 90are often referred to as "borderline" or (in the upper part ofthe range) as "dull-normal:'

Initial diagnoses of mental retardation occur veryfrequently at ages 5 to 6 (around the time that schoolingbegins for most children), peak at age 15, and drop offsharply after that. For the most part, these patterns in ageof first diagnosis reflect changes in life demands. Duringearly childhood, individuals with only a mild degree ofintellectual impairment, who constitute the vast majority

Diagnosed Levelof MentalRetardationMild retardation

CorrespondingIQ Range50-55 to

approximately 7035-40 to 50-5520-25 to 35-40below 20-25

Moderate retardationSevere retardationProfound retardation

of the mentally retarded, often appear to be normal. Theirsubaverage intellectual functioning becomes apparentonly when difficulties with schoolwork lead to a diagnosticevaluation. When adequate facilities are available for theireducation, children in this group can usually master essen-tial school skills and achieve a satisfactory level of sociallyadaptive behavior. Following the school years, they usuallymake a more or less acceptable adjustment in the commu-nity and thus lose the identity of being mentally retarded.

The various levels of mental retardation, as defined inDSM-IV-TR, are listed in Table 16.1 and described ingreater detail in the following sections.

MILD MENTAL RETARDATION Mildly retarded indi-viduals constitute by far the largest number of thosediagnosed as mentally retarded. Within the educationalcontext, people in this group are considered "educable,"and their intellectual levels as adults are comparable tothose of average 8- to ll-year-old children. Statements

Mildly retarded individuals constitute the largest number of thoselabeled mentally retarded. With help, a great majority of theseindividuals can adjust socially, master simple academic andoccupational skills, and become self-supporting citizens.

such as the latter, however, should not be taken too literally.A mildly retarded adult with a mental age of, say, 10 (thatis, intelligence test performance is at the level of the aver-age lO-year-old) may not in fact be comparable to thenormal lO-year-old in information-processing ability orspeed (Weiss, Weisz, & Bromfield, 1986). On the otherhand, he or she will normally have had far more experiencein living, which would tend to raise the IQ score.

The social adjustment of mildly retarded people oftenapproximates that of adolescents, although they tend tolack normal adolescents' imagination, inventiveness, andjudgment. Ordinarily, they do not show signs of brainpathology or other physical anomalies, but often theyrequire some measure of supervision because of their lim-ited abilities to foresee the consequences of their actions.With early diagnosis, parental assistance, and special edu-cational programs, the great majority of borderline andmildly retarded individuals can adjust socially, master sim-ple academic and occupational skills, and become self-sup-porting citizens (Maclean, 1997).

MODERATE MENTAL RETARDATION Moderatelyretarded individuals are likely to fall in the educational cat-egory of "trainable;' which means that they are presumedable to master certain routine skills such as cooking orminor janitorial work if provided specialized instruction inthese activities. In adult life, individuals classified as moder-ately retarded attain intellectual levels similar to those ofaverage 4- to 7-year-old children. Although some can betaught to read and write a little and may manage to achievea fair command of spoken language, their rate oflearning isslow, and their level of conceptualizing is extremely limited.They usually appear clumsy and ungainly, and they sufferfrom bodily deformities and poor motor coordination.Some of these moderately retarded people are hostile andaggressive; more typically, they are affable and nonthreat-ening. In general, with early diagnosis, parental help, andadequate opportunities for training, most moderatelyretarded individuals can achieve partial independence indaily self-care, acceptable behavior, and economic suste-nance in a family or other sheltered environment.

SEVERE MENTAL RETARDATION Severely retardedindividuals are sometimes referred to as "dependentretarded." In these individuals, motor and speech develop-ment are severely retarded, and sensory defects and motorhandicaps are common. They can develop limited levels ofpersonal hygiene and self-help skills, which somewhatlessen their dependency, but they are always dependent onothers for care. However, many profit to some extent fromtraining and can perform simple occupational tasks undersupervision.

PROFOUND MENTAL RETARDATION The term "life-support retarded" is sometimes used to refer to pro-foundly retarded individuals. Most of these people are

severely deficient in adaptive behavior and unable to mas-ter any but the simplest tasks. Useful speech, if it developsat all, is rudimentary. Severe physical deformities, centralnervous system pathology, and retarded growth are typi-cal; convulsive seizures, mutism, deafness, and other phys-ical anomalies are also common. These individuals mustremain in custodial care all their lives. They tend, however,to have poor health and low resistance to disease and thusa short life expectancy. Severe and profound cases of men-tal retardation can usually be readily diagnosed in infancybecause of the presence of obvious physical malforma-tions, grossly delayed development (e.g., in taking solidfood), and other obvious symptoms of abnormality. Theseindividuals show a marked impairment of overall intellec-tual functioning.

Some cases of mental retardation occur in association withknown organic brain pathology (Kaski, 2000). In thesecases, retardation is virtually always at least moderate, andit is often severe. Profound retardation, which fortunatelyis rare, always includes obvious organic impairment.Organically caused retardation is, in essential respects,similar to dementia, except for a different history of priorfunctioning. In this section, we will consider five biologicalconditions that may lead to mental retardation, notingsome of the possible interrelationships among them. Thenwe will review some of the major clinical types of mentalretardation associated with these organic causes.

GENETIC-CHROMOSOMAL FACTORS Mental retarda-tion, especially mild retardation, tends to run in families.Poverty and sociocultural deprivation, however, also tendto run in families, and with early and continued exposureto such conditions, even the inheritance of average intel-lectual potential may not prevent subaverage intellectualfunctioning.

Genetic-chromosomal factors playa much clearer rolein the etiology of relatively infrequent but more severetypes of mental retardation such as Down syndrome (dis-cussed below) and a heritable condition known as frag-ile X. The gene responsible for the fragile X syndrome(FMR-l) was identified in 1991 (Verkerk, Pieretti, et al.,1991). In such conditions, genetic aberrations are respon-sible for metabolic alterations that adversely affect thebrain's development. Genetic defects leading to metabolicalterations may, of course, involve many other develop-mental anomalies besides mental retardation-for exam-ple, autism (Wassink, Piven, & Patil, 2001). In general,mental retardation associated with known genetic-chromosomal defects is moderate to severe.

INFECTIONS AND TOXIC AGENTS Mental retardationmay be associated with a wide range of conditions due toinfection such as viral encephalitis or genital herpes

(Kaski, 2000). If a pregnant woman is infected withsyphilis or HIV-l or if she gets German measles, her childmay suffer brain damage.

A number of toxic agents such as carbon monoxideand lead may cause brain damage during fetal develop-ment or after birth (Kaski, 2000). In rare instances,immunological agents such as antitetanus serum ortyphoid vaccine may lead to brain damage. Similarly, iftaken by a pregnant woman, certain drugs, including anexcess of alcohol (West, Perotta, & Erickson, 1998; seeChapter 12), may lead to congenital malformations. Andan overdose of drugs administered to an infant may resultin toxicity and cause brain damage. In rare cases, braindamage results from incompatibility in blood typesbetween mother and fetus. Fortunately, early diagnosis andblood transfusions can minimize the effects of suchincompatibility.

TRAUMA (PHYSICAL INJURY) Physical injury at birthcan result in retardation (Kaski, 2000). Although the fetusis normally well protected by its fluid-filled bag during ges-tation, and although its skull appears designed to resistdelivery stressors, accidents do happen during delivery andafter birth. Difficulties in labor due to malposition of thefetus or other complications mayirreparably damage the infant's brain.Bleeding within the brain is probablythe most common result of such birthtrauma. Hypoxia-lack of sufficientoxygen to the brain stemming fromdelayed breathing or other causes-isanother type of birth trauma that maydamage the brain.

IONIZING RADIATION In recentdecades, a good deal of scientific atten-tion has been focused on the damagingeffects of ionizing radiation on sexcells and other bodily cells and tissues.Radiation may act directly on the fer-tilized ovum or may produce genemutations in the sex cells of either orboth parents, which may lead to defec-tive offspring. Sources of harmful radi-ation were once limited primarily tohigh-energy X rays used in medicinefor diagnosis and therapy, but the listhas grown to include nuclear weaponstesting and leakages at nuclear powerplants, among others.

direct causal link may have been oversimplified. In a reviewof the problem, Ricciuti (1993) cited growing evidencethat malnutrition may affect mental development moreindirectly, by altering a child's responsiveness, curiosity,and motivation to learn. According to this hypothesis,these losses would then lead to a relative retardation ofintellectual facility. The implication here is that at leastsome malnutrition-associated intellectual deficit is a spe-cial case of psychosocial deprivation, which is also involvedin retardation outcomes, as described below.

A limited number of cases of mental retardation areclearly associated with organic brain pathology. In someinstances-particularly of the severe and profound types-the specific causes are uncertain or unknown, althoughextensive brain pathology is evident.

Organic Retardation SyndromesMental retardation stemming primarily from biologicalcauses can be classified into several recognizable clinicaltypes (Murphy, Boyle, et aI., 1998), of which Down syn-drome, phenylketonuria, and cranial anomalies will be dis-cussed here. Table 16.2 presents information on severalother well-known forms.

Physical features found among childrenwith Down syndrome include almond-shaped eyes, abnormally thick skin onthe eyelids, and a face and nose that areoften {lat and broad. The tongue mayseem too big for the mouth and mayshow deep fissures. The iris of the eye isfrequently speckled. The neck is oftenshort and broad, as are the hands. Thefingers are stubby, and the little finger isoften more noticeably curved than theother fingers.

MALNUTRITION AND OTHER BIOLOGICAL FACTORSIt was long thought that dietary deficiencies in protein andother essential nutrients during early development of thefetus could do irreversible physical and mental damage.However, it is currently believed that this assumption of a

DOWN SYNDROME First describedby Langdon Down in 1866, Down syn-drome is the best known of the clinicalconditions associated with moderateand severe mental retardation. About1 in every 1,000 babies is diagnosed ashaving Down syndrome, a conditionthat creates irreversible limitations onsurvivability, intellectual achievement,and competence in managing lifetasks. In fact, among adults with thisdisorder, adaptive abilities seem todecrease with increasing age, especiallyafter 40 (Collacott & Cooper, 1997).The availability of amniocentesis andof chorionic villus sampling has madeit possible to detect in utero the extragenetic material involved in Downsyndrome, which is most often the tri-somy of chromosome 21, yielding 47rather than the normal 46 chromo-somes (see Figure 16.1).

The Clinical Picture in Down Syn-drome A number of physical fea-tures are often found among children

with Down syndrome, but few of these children have all ofthe characteristics commonly thought to typify this group.The eyes appear almond-shaped, and the skin of the eye-lids tends to be abnormally thick. The face and nose areoften flat and broad, as is the back of the head. The tongue,

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Clinical TypeNo. 18 trisomysyndrome

Niemann-Pick'sdiseaseBilirubinencephalopathy

SymptomsPeculiar pattern of multiple congenitalanomalies, the most common being low-setmalformed ears, flexion of fingers, small jaw,and heart defectsHypertonicity, listlessness, blindness,progressive spastic paralysis, and convulsions(death by the third year)In females only; webbing of neck, increasedcarrying angle of forearm, and sexualinfantilismIn males only; features vary from case tocase, the only constant finding being thepresence of small testes after pubertyOnset usually in infancy, with loss of weight,dehydration, and progressive paralysisAbnormal levels of bilirubin (a toxic sub-stance released by red cell destruction) in theblood; motor incoordination frequentVisual difficulties most common, withcataracts and retinal problems oftenoccurring together and with deafness andanomalies in the valves and septa of the heart

CausesAutosomal anomaly ofchromosome 18

Disorder of lipoidmetabolism, carried by asingle recessive geneSex chromosome anomaly(XO); mental retardationmay occur but is infrequentSex chromosome anomaly(XXY)

Disorder of lipoidmetabolismOften, Rh (ABO) bloodgroup incompatibilitybetween mother and fetusThe mother's contraction ofrubella (German measles)during the first few monthsof her pregnancy

Source: Based on American Psychiatric Association (1968, 1972); Clarke, Clarke, & Berg (1985); Holvey & Talbott (1972);Robinson & Robinson (1976),

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which seems too large for the mouth, may show deep fis-sures. The iris of the eye is frequently speckled. The neck isoften short and broad, as are the hands. The fingers arestubby, and the little finger is often more noticeably curvedthan the other fingers. Although facial surgery is some-times tried to correct the more stigmatizing features, itssuccess is often limited (Dodd & Leahy, 1989; Katz &Kravetz, 1989). Also, parents' acceptance of the Down syn-drome child is inversely related to their support of suchsurgery (Katz, Kravetz, & Marks, 1997).

There are special medical problems with Down syn-drome children that require careful medical attentionand examinations (Merrick, Kandel, & Vardi, 2004).Death rates for children with Down syndrome have, how-ever, decreased dramatically in the past century. In 1919the life expectancy at birth for such children was about

Trisomy of Chromosome 21 in Down Syndrome

This is a reproduction (karyotype) of the chromosomes ofa femalepatient with Down syndrome. Note the triple (rather than thenormal paired) representation at chromosome 21.

Source: Reproduced with permission by Custom Medical Stock Photo, Inc.

9 years; most of the deaths were due to gross physicalproblems, and a large proportion occurred in the firstyear. Thanks to antibiotics, surgical correction of lethalanatomical defects such as holes in the walls separatingthe heart's chambers, and better general medical care,many more of these children now live to adulthood (Hijjiet aI., 1997; Jancar & Jancar, 1996). Nevertheless, theyappear as a group to experience an accelerated agingprocess (Hasegawa et aI., 1997) and a decline in cognitiveabilities (Thompson, 2003).

Despite their problems, children with Down syn-drome are usually able to learn self-help skills, acceptablesocial behavior, and routine manual skills that enablethem to be of assistance in a family or institutional setting(Brown, Taylor, & Matthews, 2001). The traditional viewhas been that Down syndrome youngsters are unusuallyplacid and affectionate. Research has called into questionthe validity of this generalization (Pary, 2004). These chil-dren may indeed be very docile, but probably in no greaterproportion than normal youngsters; they may also beequally (or more) difficult in various areas (Bridges &Cicchetti, 1982). In general, the quality of a child's socialrelationships depends on both IQ level and a supportivehome environment (Alderson, 2001). Down syndromeadults may manifest less maladaptive behavior than com-parable persons with other types of learning disability(Collacott et aI., 1998).

Research has also suggested that the intellectualdefect in Down syndrome may not be consistent acrossvarious abilities. Children with Down syndrome tend toremain relatively unimpaired in their appreciation ofspatial relationships and in visual-motor coordination,although some evidence disputes this conclusion (Ueckeret aI., 1993). Research data are quite consistent in show-ing that their greatest deficits are in verbal and language-related skills (Azari et aI., 1994; Mahoney, Glover, &Finger, 1981; Silverstein et al., 1982). Because spatialfunctions are known to be partially localized in the rightcerebral hemisphere, and language-related functions inthe left cerebral hemisphere, some investigators specu-late that the syndrome is especially crippling to the lefthemisphere.

Chromosomal abnormalities other than the trisomy ofchromosome 21 may occasionally be involved in the etiol-ogy of Down syndrome. However, the extra version ofchromosome 21 is present in at least 94 percent of cases. Aswe noted earlier, it may be significant that this is the samechromosome that has been implicated in research onAlzheimer's disease, especially given that persons withDown syndrome are at extremely high risk for Alzheimer'sas they get into and beyond their late thirties (Cole et al.,1994; Janicki & Dalton, 2000; Nelson, Orme, et aI., 2001;Prasher & Kirshnan, 1993). Interestingly, the APOE riskfactor that is prominent in research on Alzheimer's appearsnot to be a significant element in the dementia experiencedby Down syndrome adults (Prasher et aI., 1997).

The reason for the trisomy of chromosome 21 is notclear, but the defect seems definitely related to parental ageat conception. It has been known for many years that theincidence of Down syndrome increases on an acceleratingslope (from the twenties on) with increasing age of themother. A woman in her twenties has about 1 chance in2,000 of conceiving a Down syndrome baby, whereas therisk for a woman in her forties is 1 in 50 (Holvey & Tal-bott, 1972). As in the case of all birth defects, the risk ofhaving a Down syndrome baby is also high for very youngmothers, whose reproductive systems have not yet fullymatured. Research has also indicated that the father's age atconception is implicated in Down syndrome, particularlyat higher ages (Hook, 1980; Stene et aI., 1981). In one studyinvolving 1,279 cases of Down syndrome in Japan, Mat-sunaga and associates (1978) demonstrated an overallincrease in incidence with advancing paternal age whenmaternal age was controlled. The risk for fathers aged 55years and over was more than twice that for fathers in theirearly twenties.

Thus it seems that advancing age in either parentincreases the risk of the trisomy 21 anomaly, although theeffect of maternal age is greater. It is not yet clear how agingproduces this effect. A reasonable guess is that aging isrelated to cumulative exposure to varied environmentalhazards such as radiation that might have adverse effects onthe processes involved in zygote formation or development.

PHENYLKETONURIA In phenylketonuria (PKU), ababy appears normal at birth but lacks a liver enzymeneeded to break down phenylalanine, an amino acid foundin many foods. The genetic error results in retardation onlywhen significant quantities of phenylalanine are ingested,which is virtually certain to occur if the child's condition

Today many more Down syndrome children are living to adulthoodthan in the past and are able to learn self-help, social, and manualskills. It is not unusual for Down syndrome children to bemainstreamed to some extent with unimpaired children, such asthis boy (center, with glasses). Down syndrome children tend toremain relatively unimpaired in their appreciation of spatialrelationships and visual-motor coordination; they show theirgreatest deficits in verbal and language-related skills.

remains undiagnosed (Grodin & Laurie, 2000). This disor-der occurs in about 1 in 12,000 births (Deb & Ahmed,2000). If the condition is not detected, the amount ofphenylalanine in the blood increases and eventually pro-duces brain damage.

The disorder usually becomes apparent between 6 and12 months after birth, although such symptoms as vomit-ing, a peculiar odor, infantile eczema, and seizures mayoccur during the early weeks of life. Often, the first symp-toms noticed are signs of mental retardation, which maybe moderate to severe, depending on the degree to whichthe disease has progressed. Lack of motor coordinationand other neurological problems caused by the brain dam-age are also common, and often the eyes, skin, and hair ofuntreated PKU patients are very pale (Dyer, 1999).

The early detection of PKU by examining urine forthe presence of phenylpyruvic acid is routine in developedcountries, and dietary treatment (such as the eliminationof phenylalanine-containing foods such as diet soda orturkey) and related procedures can be used to prevent thedisorder (Sullivan & Chang, 1999). With early detectionand treatment-preferably before an infant is 6 monthsold-the deterioration process can usually be arrested sothat levels of intellectual functioning may range from bor-derline to normal. A few children suffer mental retardationdespite restricted phenylalanine intake and other preven-tive efforts, however. Dietary restriction in late-diagnosedPKU may improve the clinical picture somewhat, but thereis no real substitute for early detection and prompt inter-vention (Pavone et aI., 1993).

It appears that for a baby to inherit PKU, both parentsmust carry the recessive gene. Thus, when one child in afamily is discovered to have PKU, it is especially criticalthat other children in the family be screened as well. Also, apregnant PKU mother whose risk status has been success-fully addressed by early dietary intervention may damageher at-risk fetus unless she maintains rigorous control ofphenylalanine intake.

Patients with PKU are typically advised to follow arestricted diet over their life span in order to prevent cog-nitive impairment. Even with long-term treatment someinvestigators have reported mild deficits in cognitive func-tioning (White, Nortz, et aI., 2002). However, someresearch has found little support for the hypothesis thatdeficits will occur even with dietary restrictions (Channon,German, et aI., 2004).

CRANIAL ANOMALIES Mental retardation is associatedwith a number of conditions that involve alterations inhead size and shape and for which the causal factors havenot been definitely established (Maclean, 1997; Robinson& Robinson, 1976). In the rare condition known asmacrocephaly (large-headedness), for example, there is anincrease in the size and weight of the brain, an enlargementof the skull, visual impairment, convulsions, and otherneurological symptoms resulting from the abnormal

growth of glial cells that form the supporting structure forbrain tissue.

Microcephaly The term microcephaly means "small-headedness." It is associated with a type of mental retarda-tion resulting from impaired development of the brain anda consequent failure of the cranium to attain normal size.

The most obvious characteristic of microcephaly isthe small head, the circumference of which rarely exceeds17 inches, compared with the normal size of approxi-mately 22 inches. Penrose (1963) also described micro-cephalic children as being invariably short in stature buthaving relatively normal musculature and sex organs.Beyond these characteristics, they differ considerably fromone another in appearance, although there is a tendencyfor the skull to be cone-shaped, with a receding chin andforehead. Microcephalic children fall within the moderate,severe, and profound categories of mental retardation, butmost show little language development and are extremelylimited in mental capacity.

Microcephaly may result from a wide range of factorsthat impair brain development including intrauterineinfections and pelvic irradiation during the mother's earlymonths of pregnancy. Miller (1970) noted a number ofcases of microcephaly in Hiroshima and Nagasaki thatapparently resulted from the atomic bomb explosions dur-ing World War II. The role of genetic factors is not clear,although there is speculation that a single recessive gene isinvolved in a primary, inherited form of the disorder(Robinson & Robinson, 1976). Treatment is ineffectiveonce faulty development has occurred; at present, preven-tive measures focus on the avoidance of infection and radi-ation during pregnancy.

Hydrocephaly Hydrocephaly is a relatively rare condi-tion in which the accumulation of an abnormal amount ofcerebrospinal fluid within the cranium causes damage tothe brain tissues and enlargement of the skull (Materro,Junque, et aI., 2001). In congenital cases, the head either isalready enlarged at birth or begins to enlarge soon there-after, presumably as a result of a disturbance in the forma-tion, absorption, or circulation of the cerebrospinal fluid.The disorder can also arise in infancy or early childhood,following the development of a brain tumor, subduralhematoma, meningitis, or other conditions. In these cases,the condition appears to result from a blockage of the cere-brospinal pathways and an accumulation of fluid in certainbrain areas.

The clinical picture in hydrocephaly depends on theextent of neural damage, which, in turn, depends on theage at onset and the duration and severity of the disorder.In chronic cases, the chief symptom is the gradual enlarge-ment of the upper part of the head out of proportion to theface and the rest of the body. While the expansion of theskull helps minimize destructive pressure on the brain,serious brain damage occurs nonetheless. This damage

leads to intellectual impairment and to such other effectsas convulsions and impairment or loss of sight and hear-ing. The degree of intellectual impairment varies, beingsevere or profound in advanced cases.

Hydrocephaly can be treated by a procedure in whichshunting devices are inserted to drain cerebrospinal fluid.With early diagnosis and treatment, this condition canusually be arrested before severe brain damage hasoccurred (Duinkerke, Williams, Rigamonti, & Hillis,2004). Even with significant brain damage, carefullyplanned and early interventions that take into accountboth strengths and weaknesses in intellectual functioningmay minimize disability (Baron & Goldberger, 1993).

Treatments, Outcomes, andPreventionA number of programs have demonstrated that significantchanges in the adaptive capacity of mentally retarded chil-dren are possible through special education and other reha-bilitative measures (Berney, 2000). The degree of changethat can be expected is related, of course, to the individual'sparticular situation and level of mental retardation.

TREATMENT FACILITIES AND METHODS One decisionthat the parents of a mentally retarded child must make iswhether to place the child in an institution (Gath, 2000).Most authorities agree that this should be considered as alast resort, in light of the unfavorable outcomes normallyexperienced-particularly in regard to the erosion of self-care skills (Lynch, Kellow, & Willson, 1997). In general,children who are institutionalized fall into two groups:(1) those who, in infancy and childhood, manifest severemental retardation and associated physical impairmentand who enter an institution at an early age; and (2) thosewho have no physical impairments but show relativelymild mental retardation and a failure to adjust socially inadolescence, eventually being institutionalized chieflybecause of delinquency or other problem behavior (seeStattin & Klackenberg-Larsson, 1993). In these cases, socialincompetence is the main factor in the decision. The fami-lies of patients in the first group come from all socioeco-nomic levels, whereas a significantly higher percentage ofthe families of those in the second group come from lowereducational and occupational strata.

The effect of being institutionalized in adolescencedepends heavily on the institution's facilities as well as onindividual factors. For the many teenagers with retardationwhose families are not in a position to help them achieve asatisfactory adjustment, community-oriented residentialcare seems a particularly effective alternative (Alexander,Huganir, & Zigler, 1985), although great care must betaken in assessing the residents' needs and in the recruit-ment of staff personnel (Petronko, Harris, & Kormann,1994). Unfortunately, many neighborhoods resist the loca-tion of such facilities within their confines and reject inte-

gration of residents into the local society (Short & John-ston,1997).

For individuals with mental retardation who do notrequire institutionalization, educational and trainingfacilities have historically been woefully inadequate. It stillappears that a very substantial proportion of mentallyretarded people in the United States never get access toservices appropriate to their specific needs (Luckassonet al., 1992).

This neglect is especially tragic in view of the ways thatexist to help these people. For example, classes for themildly retarded, which usually emphasize reading andother basic school subjects, budgeting and money matters,and the development of occupational skills, have suc-ceeded in helping many people become independent, pro-ductive community members. Classes for the moderatelyand severely retarded usually have more limited objectives,but they emphasize the development of self-care and otherskills-e.g., toilet habits (Wilder et al., 1997)-that enableindividuals to function adequately and to be of assistancein either a family (e.g., Heller, Miller, & Factor, 1997) or aninstitutional setting. Just mastering toilet training andlearning to eat and dress properly may mean the differencebetween remaining at home or in a community residenceand being institutionalized.

Today, there are probably fewer than 80,000 individu-als in institutions for the retarded, less than half the num-ber that were residents 40 years ago. Even many of thesemore seriously affected persons are being helped to bepartly self-supporting in community-based programs(Bouras & Holt, 2000; Maclean, 1997; McDonnell et al.,1993). These developments reflect both the new optimismthat has come to prevail and, in many instances, new lawsand judicial decisions upholding the rights of retardedpeople and their families. A notable example is Public Law94-142, passed by Congress in 1975 and since modifiedseveral times (see Hayden, 1998, for an update). Thisstatute, termed the "Education for All Handicapped Chil-dren Act," asserts the right of mentally retarded people tobe educated at public expense in the least restrictive envi-ronment possible.

During the 1970s, there was a rapid increase in alter-native forms of care for the mentally retarded (Tyor &Bell, 1984). These included the use of decentralizedregional facilities for short-term evaluation and training;small private hospitals specializing in rehabilitative tech-niques; group homes or halfway houses integrated intothe local community; nursing homes for the elderlyretarded; the placement of severely retarded children inmore enriched foster-home environments; varied formsof support to the family for own-home care; and employ-ment (Conley, 2003). The past 20 years have seen a markedenhancement in alternative modes oflife for retarded cit-izens, rendering obsolete (and often leading to the closingof) many public institutions formerly devoted exclusivelyto this type of care.

EDUCATION AND INCLUSION PROGRAMMINGTypically, educational and training procedures involvemapping out target areas of improvement such as personalgrooming, social behavior, basic academic skills, and (forretarded adults) simple occupational skills (see Forness &Kavale, 1993). Within each area, specific skills are dividedinto simple components that can be learned and rein-forced before more complex behaviors are required. Train-ing that builds on step-by-step progression can bringretarded individuals repeated experiences of success andlead to substantial progress even by those previouslyregarded as uneducable (see McDonnell et aI., 1993).

For mildly retarded youngsters, the question of whatschooling is best is likely to challenge both parents andschool officials. Many such children fare better when theyattend regular classes for much of the day. Of course, thistype of approach-often called mainstreaming or "inclu-sion programming"-requires careful planning, a highlevel of teacher skill, and facilitative teacher attitudes(Kozleski & Jackson, 1993; Stafford & Green, 1993;Wehman, 2003).

In ReVIew~ In what ways do learning disorders differ

from mental retardation?~ Compare and contrast mild, moderate,

severe, and profound mental retardation.~ Describe five biological conditions that may

lead to mental retardation.~ Describe some of the physical characteristics

of children born with Down syndrome. Whatis its cause?

~ What is the cause of and the preventivetreatment for phenylketonuria (PKU)?

PLANNING BETTERPROGRAMS TO HELPCHILDREN AND

__ ADOLESCENTSIn our earlier discussion of several disorders of childhoodand adolescence, we noted the wide range of treatmentprocedures available, as well as the marked differences inoutcomes. In concluding this chapter, we will discuss cer-tain special factors associated with the treatment of chil-dren and adolescents that can affect the success of anintervention.

Special Factors Associated withTreatment for Children andAdolescentsMental health treatment, psychotherapy, and behaviortherapy have been found to be as effective with children andadolescents as with adults (Kazdin & Weisz, 2003; Steiner,1996), but treatments conducted in laboratory-controlledstudies are more effective than "real-world" treatment situ-ations (Weisz, Donenberg, et aI., 1995; see Developments inPractice 16.1 and 16.2 on pp. 590 and 591). There are anumber of special factors to consider in relation to treat-ment for children and adolescents, as follows:

THE CHILD'S INABILITY TO SEEK ASSISTANCE Mostemotionally disturbed children who need assistance arenot in a position to ask for help themselves or to transportthemselves to and from child treatment clinics. Thus,unlike an adult, who can usually seek help, a child is depen-dent, primarily on his or her parents. Adults should realizewhen a child needs professional help and take the initiativein obtaining it. Sometimes, however, adults neglect thisresponsibility.

The law identifies four areas in which treatment with-out parental consent is permitted: (1) in the case ofmature minors (those considered capable of making deci-sions about themselves); (2) in the case of emancipatedminors (those living independently away from their par-ents); (3) in emergency situations; and (4) in situations inwhich a court orders treatment. Many children, of course,come to the attention of treatment agencies as a conse-quence of school referrals, delinquent acts, or parentalabuse.

VULNERABILITIES THAT PLACE CHILDREN AT RISKFOR DEVELOPING EMOTIONAL PROBLEMS Childrenand youth who experience or are exposed to violence are atincreased risk for developing psychological disorders(Seifert, 2003). In addition, many families provide anundesirable environment for their growing children(Ammerman et aI., 1998). Studies have shown that up to afourth of American children may be living in inadequatehomes and that 7.6 percent of American youth havereported spending at least one night in a shelter, publicplace, or abandoned building (Ringwalt, Greene, et aI.,1998). Disruptive childhood experiences have been foundto be a risk factor for adult problems. For example, Rein-gold, Smith, et al. (2004) reported that a high risk of men-tal health problems in children and adolescents has beenassociated with the death of a parent or friend. Anotherepidemiological study (Susser, Moore, & Link, 1993)revealed that 23 percent of newly homeless men in NewYork City reported a history of out-of-home care as chil-dren. Parental substance abuse has also been found to beassociated with vulnerability for children to develop psy-chological disorders (El-Sheikh & Buckhalt, 2003).

6.1 Family Therapy as aMeans of HelpingChildren

To address a child's problems, it is often neces-sary to alter pathological familyinteraction pat-terns that produce or serve to maintain thechild's behavior problems (Cooklin,2000). Sev-eral familytherapy approaches have been

developed (Minuchin,1974; Patterson, Capaldi,& Bank,1991). These differ in some important ways-for example,in terms of howthe familyis defined (whether to includeextended familymembers); what the treatment processwillfocus on (whether communications between the familymembers or the aberrant behavior of the problemfamilymembers is the focus); and what procedures are used intreatment (analyzingand interpreting hidden messages in

High-risk behaviors or difficult life conditions needto be recognized and taken into consideration (Harring-ton & Clark, 1998). For example, there are a number ofbehaviors such as engaging in sexual acts or delinquencyand using alcohol or drugs that might place young peopleat great risk for developing later emotional problems.Moreover, physical or sexual abuse, parental divorce,family turbulence, and homelessness (Cauce, Paradise, etaI., 2000; Spataro, Mullen, et aI., 2004) can place youngpeople at great risk for emotional distress and subsequentmaladaptive behavior (see The World Around Us 8.1 onp. 291 on factitious disorder by proxy and The WorldAround Us 16.3 on p. 592). Dodge, Lochman, and col-leagues (1997) found that children from homes withharsh discipline and physical abuse, for example, weremore likely to be aggressive and conduct-disordered thanthose from homes with less harsh discipline and thosefrom nonabusing families.

NEED FOR TREATING PARENTS AS WELL AS CHILDRENBecause many of the behavior disorders specific to child-hood appear to grow out of pathogenic family interactionsand result from having parents with psychiatric problemsthemselves (Johnson, Cohen, et al., 2000), it is often essen-tial for the parents, as well as their child, to receive treat-ment. In some instances, in fact, the treatment programmay focus on the parents entirely, as in the case of childabuse.

Increasingly, then, the treatment of children has cometo mean family therapy, in which one or both parents,along with the child and siblings, may participate in allphases of the program. This is particularly important insituations in which the family situation has been identified

the familycommunicationsor altering the reward and pun-ishment contingencies through behavioral assessment andreinforcement).Butwhatever their differences, all familytherapies viewa child's problems, at least in part, as anoutgrowth of pathological interaction patterns within thefamily,and they attempt to bringabout positive change infamilymembers through analysis and modificationof thedeviant familypatterns (Everett& Everett,2001).

Treatmentoutcome research strongly supports theeffectiveness of familytherapy in improvingdisruptive fam-ilyrelationships and promotinga more positive atmos-phere for children (Hazelrigg,Cooper,& Borduin,1987;Shadish et aI., 1993).

as involving violence (Chaffin, Silvosky, et aI., 2004). Manytherapists have discovered that fathers are particularly dif-ficult to engage in the treatment process. For working par-ents and for parents who basically reject the affected child,such treatment may be hard to arrange (Gaudin, 1993),especially in the case of poorer families who lack trans-portation and money. Thus both parental and economicfactors help determine which emotionally disturbed chil-dren will receive assistance.

POSSIBILITY OF USING PARENTS AS CHANGEAGENTS In essence, parents can be used as changeagents by training them in techniques that enable them tohelp their child. Typically, such training focuses on helpingthe parents understand the child's behavior disorder andteaching them to reinforce adaptive behavior while with-holding reinforcement for undesirable behavior. Encour-aging results have been obtained with parents who careabout their children and want to help (Forehand, 1993;Webster-Stratton, 1991). Kazdin, Holland, and Crowley(1997) described a number of barriers to parental involve-ment in treatment that resulted in dropout from therapy.For example, coming from a disadvantaged background,having parents who were antisocial, or having parents whowere under great stress tended to result in premature ter-mination of treatment.

PROBLEM OF PLACING A CHILD OUTSIDE THE FAMILYMost communities have juvenile facilities that, day ornight, will provide protective care and custody for youngvictims of unfit homes, abandonment, abuse, neglect, andrelated conditions. Depending on the home situation andthe special needs of the child, he or she will later be either

16.2 Using Play Therapy toResolve Children'sPsychological Problems

Children can often express their feelings moredirectly through play than in words, as shown inthis play therapy session.

even if a child's problems are viewed as primaryand in need of specific therapeutic intervention,he or she may not be motivated for therapy orbe sufficiently verbal to benefit from psy-chotherapeutic methods that work with adults.

Consequently, effective psychological treatment with chil-dren may involve using more indirect methods of therapyor providing individual psychological therapy for childrenin a less intrusive and more familiar way through play ther-apy (Hollins, 2001; Johnson,2001).

As a treatment tech-nique, play therapy emergedout of efforts to apply psycho-dynamic therapy to children.Because children are not ableto talk about their problems inthe way adults are, having notyet developed the self-aware-ness necessary, the applica-bility of traditionalpsychodynamic therapy meth-ods to children is limited. Chil-dren tend to be oriented tothe present and to lack thecapability for insight and self-scrutiny that therapy requires.Their perceptions of their therapist differ from those ofadult patients, and they may have the unrealistic view thatthe therapist can magically change their environment.

Through their play, children often express their feel-ings, fears, and emotions in a direct and uncensored fash-ion, providing a clinician with a clearer picture of problemsand feelings (Perry & Landreth, 2001). The activity of playhas become a valuable source of information about chil-dren, particularly when the sessions are consistent withtheir developmental level (Lewis, 1997).

In a play therapy session, the therapist usually needsto provide some structure or to guide play activities so that

returned to his or her parents or placed elsewhere. In thelatter instance, four types of facilities are commonly reliedon: (1) foster homes, (2) private institutions for the care ofchildren, such as group homes, (3) county or state institu-tions, and (4) the homes of relatives. At anyone time,more than half a million children are living in foster-carefacilities.

The quality of a child's new home is, of course, a cru-cial determinant of whether the child's problems will be

the child can express pertinent feelings. This might meanthat the therapist asks direct questions of the child duringthe play session, such as "Is the doll happy now?" or"What makes the doll cry?" In addition to being a means ofunderstanding a troubled child's problems, play activityalso offers a medium for bringing about change in thechild's behavior. A central process in play therapy is thatthe therapist, through interpretation, emotional support,and clarification of feelings (often by labeling them for the

child), provides the child witha corrective emotional experi-ence. That is, the therapistsupplies the child with anaccepting and trusting rela-tionship that promoteshealthier personality and rela-tionship development. Theplay therapy situation enablesthe child to reexperience con-flict or problems in the safetyof the therapy setting, therebygaining a chance to conquerfears, to acclimate to neces-sary life changes, or to gain afeeling of security to replaceanxiety and uncertainty.

How effective is playtherapy in reducing children's problems and promoting bet-ter adjustment? When compared with adult treatment stud-ies, play therapy compares quite favorably. Casey andBerman (1985) conducted a careful study of treatmentresearch with children and concluded that such treatment"appears to match the efficacy of psychotherapy withadults" (p. 395). Play therapy was found to be as effectiveas other types of treatment such as behavior therapy. Inanother study, in which play therapy was integrated into an8-week intervention program to treat children with conductdisorder, the subjects showed significant gains at a 2-yearfollow-up (McDonald, Bellingham, et aI., 1997).

alleviated or made worse, and there is evidence to suggestthat foster-home placement has more positive effectsthan group-home placement (Buckley & Zimmermann,2003; Groza, Maschmeier, Jamison, & Piccola, 2003).Efforts are usually made to screen the placement facilitiesand maintain contact with the situation through follow-up visits, but even so, there have been cases of mistreat-ment in the new home (Dubner & Motta, 1999; Wilson,Sinclair, & Gibbs, 2000). In cases of child abuse, child

16.3

Children who are physically or sexually abusedshow problems in social adjustment (Beard-slee & Gladstone, 2001) and are particularlylikely to feel that the outcomes of events aredetermined by external factors beyond their

own control (Kinzl& Biebl, 1992; Toth, Manly, & Cicchetti,1992). They are also more likely to experience depressivesymptoms (Bushnell, Wells, & Oakley-Browne, 1992; Emery& Laumann-Billings, 1998). As a result, abused children aredramatically less likely to assume personal responsibilityfor themselves, and they generally demonstrate less inter-personal sensitivity than control children. Child abuse andneglect may initiate a chain of violence. Child abuse is alsoassociated with delinquent and criminal behavior when thevictim grows up. Maxfield and Widom (1996), in a follow-upstudy of 908 people who were abused as children, foundthat their arrest rate for nontraffic offenses was signifi-cantly higher than that of a control sample of people whohad not been abused as children.

Child abuse is an increasing concern in the UnitedStates (Crosson-Tower, 2002). A survey of reported inci-dents of child abuse in the United States found that suchreports increased 1.7 percent in 1995, the total number ofincidents exceeding 3.1 million. An estimated 1,215 chil-dren were killed in 1995 in child abuse incidents (NationalCommittee to Prevent Child Abuse, 1996). The excessiveuse of alcohol or drugs in a family appears to increase therisk of violent death in the home (Rivera, Muellar, et aI.,1997). Some evidence suggests that boys are more oftenphysically abused than girls. It is clear that many childrenbrought to the attention of legal agencies for abuse havebeen abused before. Moreover, the significantly higher

abandonment, or a serious childhood behavior problemthat parents cannot control, it has often been assumedthat the only feasible action was to take the child out of thehome and find a temporary substitute. With such a child'sown home so obviously inadequate, the hope has beenthat a more stable outside placement will be better for thechild. But when children are taken from their homes andplaced in an institution (which promptly tries to changethem) or in a series of foster homes (where they obviouslydo not really belong), they are likely to feel rejected bytheir own parents, unwanted by their new caretakers,rootless, constantly insecure, lonely, and bitter.

Accordingly, the trend today is toward permanentplanning. First, every effort is made to hold a familytogether and to give the parents the support and guidance

The Impact of Child Abuse onPsychological Adjustment

rates among psychiatric inpatients of having been abusedas children suggest that such maltreatment plays acausal role in the development of severe psychopathol-ogy (Read, 1997).

When the abuse involves a sexual component such asincest or rape, the long-range consequences can be pro-found (Paolucci, Genuis, & Violato, 2001). Adults who weresexually abused as children often show serious psychologi-cal symptoms such as a tendency to use dissociativedefense mechanisms to excess, excessive preoccupationwith bodily functions, lowered self-esteem (Nash et aI.,1993), or a tendency to disengage as a means of handlingstress (Coffey,Leitenberg, et aI., 1996).

The role of sexual abuse in causing psychologicalproblems has been the subject of several longitudinal stud-ies. A large percentage of sexually abused children experi-ence intense psychological symptoms following theincident (for example, the 74 percent reported by Ben-tovim, Boston, & Van Elburg, 1987). At follow-up, however,the improvement often seems dramatic (Bentovim et aI.,1987; Conte, Berliner, & Schuerman, 1986). Several investi-gators have conceptualized the residual symptoms of sex-ual abuse as a type of post-traumatic stress disorder(PTSD)because the symptoms experienced are similar-for example, nightmares, flashbacks, sleep problems, andfeelings of estrangement (Donaldson & Gardner, 1985;Koltek, Wilkes, & Atkinson, 1998).

Child abuse all too frequently produces maladaptivesocial behavior in its victims (Winton & Mara, 2001). Thetreatment of abused children needs to address their prob-lems of inadequate social adjustment, depression, andpoor interpersonal skills.

they need for adequate childrearing. If this is impossible,then efforts are made to free the child legally for adoptionand to find an adoptive home as soon as possible. This, ofcourse, means that the public agencies need speciallytrained staffs with reasonable caseloads and access toresources that they and their clients may need. Childrenand adolescents in foster homes tend to require moremental health services than other children (dos Reis, Zito,et aI., 2001).

VALUE OF INTERVENING BEFORE PROBLEMSBECOME ACUTE Over the last 25 years, a primary con-cern of many researchers and clinicians has been to iden-tify and provide early help for children who are at specialrisk (Athey, O'Malley, et a!', 1997). Rather than waiting

until these children develop acute psychological prob-lems that may require therapy or major changes in livingarrangements, psychologists are attempting to identifyconditions in the children's lives that seem likely to bringabout or maintain behavior problems and, where suchconditions exist, to intervene before development hasbeen seriously distorted (Schroeder & Gordon, 2002). Anexample of this approach is provided in the work ofSteele and Forehand (1997). These investigators foundthat children of parents who had a chronic medical con-dition (the fathers were diagnosed as having hemophilia,and many were HIV positive) were vulnerable to develop-ing internalizing problems and avoidant behavior, par-ticularly when the parent-child relationship was weak.These symptoms in the child were associated withdepression in the parent. The investigators concludedthat clinicians may be able to reduce the impact ofparental chronic illness by strengthening the parent-childrelationship and decreasing the child's use of avoidantstrategies.

As described in Chapter 5, another type of early inter-vention has been developed in response to the special vul-nerability children experience in the wake of a disaster ortrauma such as a hurricane, accident, hostage-taking, orshooting (Shaw, 2003). Children and adolescents oftenrequire considerable support and attention to deal withsuch traumatic events, all too frequent in today's world.Individual and small-group psychological therapy mightbe implemented for victims of trauma (Gillis, 1993), sup-port programs might operate through school-basedinterventions (Klingman, 1993), or community-basedprograms might be implemented to reduce the post-trau-matic symptoms.

Early intervention has the double goal of reducing thestressors in a child's life and strengthening the child's cop-ing mechanisms. It can often reduce the incidence andintensity of later maladjustment, thus averting problemsfor both the individuals concerned and the broader soci-ety. It is apparent that children's needs can be met only ifadequate preventive and treatment facilities exist and areavailable to the children who need assistance.

Child Advocacy ProgramsToday there are over 70 million people under age 18 in theUnited States (Bureau of the Census, 2001). Unfortu-nately, both treatment and preventive programs for oursociety's children remain inadequate to dealing with theextent of psychological problems among children andadolescents. In 1989 the United Nations General Assemblyadopted the "U.N. Convention on the Rights of the Child,"which provides a detailed definition of the rights of chil-dren in political, economic, social, and cultural areas. Thisinternational recognition of the rights of children canpotentially have a great impact in promoting the humane

treatment of children (Wilcox & Naimark, 1991). How-ever, implementing those high ideals on a practical level isdifficult at best.

In the United States, one approach that has evolved inrecent years is mental health child advocacy. Advocacy pro-grams attempt to help children or others receive servicesthat they need but often are unable to obtain for them-selves. In some cases, advocacy seeks to better conditionsfor underserved populations by changing the system(Pianta, 2001). Federal programs offering services for chil-dren are fragmented in that different agencies serve differ-ent needs; no government agency is charged withconsidering the whole child and planning comprehen-sively for children who need help. Consequently, childadvocacy is often frustrating and difficult to implement(Zigler & Hall, 2000).

Outside the federal government, advocacy efforts forchildren have until recently been supported largely by legaland special-interest citizen's groups such as the Children'sDefense Fund, a public-interest organization based inWashington, D.C. Mental health professionals have typi-cally not been involved. Today, however, there is greaterinterdisciplinary involvement in attempts to provide effec-tive advocacy programs for children (Carlson, 2001; Singer& Singer, 2000).

Although such programs have made important localgains toward bettering conditions for mentally disabledchildren, a great deal of confusion, inconsistency, anduncertainty still persist in the advocacy movement as awhole (Beeman & Edleson, 2000), and there is still a needto improve the accountability of mental health services forchildren (Carlson, 2001). In addition, the tendency at bothfederal and state levels has for some time been to cut backon funds for social services. Even so, some important stepshave been taken toward child advocacy, and new efforts toidentify and help high-risk children have been made(National Advisory Mental Health Council, 1990). If thedirection and momentum of these efforts can be main-tained and if sufficient financial support for them can beprocured, the psychological environment for childrencould substantially improve.

In ReVIew~ What special factors must be considered in

providing treatment for children andadolescents?

~ Why is therapeutic intervention a morecomplicated process with children thanwith adults?

One of the most troublesome and widespreadproblems in childhood and adolescence isdelinquent behavior. This behavior includessuch acts as destruction of property, violenceagainst other people, and various behaviors

contrary to the needs and rights of others and in violation ofsociety's laws. The term juvenile delinquency is a legal one; itrefers to illegal acts committed by individuals between theages of 8 and 18 (depending on state law). It is not recognizedin DSM-IV-TR as a disorder. The actual incidence of juveniledelinquency is difficult to determine because many delinquentacts are not reported. However, some data are available:

~ Of the more than 2 million young people who go throughthe juvenile courts each year in the United States, abouta million and a half are there for delinquent acts and theremainder for status offenses such as running away thatare not considered crimes for adults.

~ In 2002, there were over 2.3 million juveniles arrested inthe United States, which accounts for about 17 percentof all arrests; and 1,700 juveniles were involved in 1,400murders (Federal Bureau of Investigation, 2003).

~ Although most juvenile crime is committed by males, therate has also risen for females. Female delinquents arecommonly apprehended for drug use, sex offenses, run-ning away from home, and incorrigibility, but crimesagainst property such as stealing have also markedlyincreased among this group.

~ Both the incidence and the severity of delinquent behav-ior are disproportionately high for lower-class adoles-cents (Federal Bureau of Investigation, 2003).

Causal FactorsAs noted in the text, only a small group of "continuous" delin-quents actually evolve from oppositional defiant behavior toconduct disorder and then to adult antisocial personality;most people who engage in delinquent acts as adolescentsdo not follow this path (Moffitt, 1993a). The individuals whoshow adolescence-limited delinquency are thought to do soas a result of social mimicry. As they mature, they lose theirmotivation for delinquency and gain rewards for more sociallyacceptable behavior. Several key variables seem to playapart in the genesis of delinquency. They fall into the generalcategories of personal pathology, pathogenic family patterns,and undesirable peer relationships.

PERSONAL PATHOLOGY

Genetic Determinants Although the research on geneticdeterminants of antisocial behavior is far from conclusive,some evidence suggests possible hereditary contributions tocriminality. Bailey (2000) pointed out that genetic factors in

More than two million children a year go through the juvenilejustice system for committing delinquent acts.

individual differences might operate through "an effect onhyperactivity and inattention, impulsivity, and physiologicalreactivity rather than through aggression." (p. 1861).

Brain Damage and Learning Disability In a distinctminority of delinquency cases (an estimated 1 percent orless), brain pathology results in lowered inhibitory controlsand a tendency toward episodes of violent behavior. Suchadolescents are often hyperactive, impulsive, emotionallyunstable, and unable to inhibit themselves when stronglystimulated. The actual role that intellectual factors play injuvenile delinquency is still being debated (Lynam, Moffitt, &Stouthamer-Loeber, 1993).

Psychological Disorders Some delinquent acts appear tobe directly associated with behavior disorders such as hyper-activity (Lyons, Griffin, et aI., 2003) or pervasive developmen-tal disorders (Palermo, 2004). One recent study reported thatover half of delinquents showed evidence of mental disordersand 14 percent were judged to have mental disorder with sub-stantial impairment that required a highly restrictive environ-ment (Shelton, 2001).

Antisocial Traits Many habitual delinquents appear toshare the traits typical of antisocial personalities (Bailey,2000). They are impulsive, defiant, resentful, devoid of feel-ings of remorse or guilt, incapable of establishing and main-taining close interpersonal ties, and seemingly unable toprofit from experience. In essence, these individuals areunsocialized.

Drug Abuse Many delinquent acts-particularly theft,prostitution, and assault-are directly associated with alco-hol or drug use (Leukefeld et aI., 1998). Most adolescentswho abuse hard drugs such as heroin are forced to steal tomaintain their habit, which can be very expensive. In the caseoffemale addicts, theft may be combined with or replaced byprostitution as a means of obtaining money.

PATHOGENIC FAMilY PATTERNS Of the various family pat-terns that have been implicated in contributing to juveniledelinquency, the following appear to be the most important.

Parental Absence or Family Conflict Delinquencyappears to be much more common among youths fromhomes in which parents have separated or divorced thanamong those from homes in which a parent has died, sug-gesting that parental conflict may be a key element in causingdelinquency. The effects of parental absence vary-for exam-ple, parental separation or divorce may be less troubling forchildren than parental conflict and dissension. It is parentaldisharmony and conflict in lieu of a stable home life thatappears to be an important causal variable.

Parental Rejection and Faulty Discipline In many cases,one or both parents reject a child. When the father is therejecting parent, it is difficult for a boy to identify with him anduse him as a model for his own development. The detrimentaleffects of parental rejection and inconsistent discipline are byno means attributable only to fathers. Adolescents who expe-rience alienation from their parents have been found to bemore prone to delinquent behavior (Leas & Mellor, 2000).

UNDESIRABLE PEER RElATIONSHIPS Delinquency tends tobe an experience often shared by cultural group (O'Donnell,2004). In a classic study, Haney and Gold (1973) found thatabout two-thirds of delinquent acts were committed in asso-ciation with one or two other people, and most of the remain-der involved three or four others. Usually the offender and thecompanion or companions were of the same sex. Interest-ingly, girls were more likely than boys to have a constantfriend or companion in delinquency.

Broad social conditions may also tend to produce or sup-port delinquency (Ward & Laughlin, 2003). Interrelated factorsthat appear to be of key importance include alienation andrebellion, social rejection, and the psychological supportafforded by membership in a delinquent gang. A recent reportby the Office of Juvenile Justice and Delinquency Preventionestimated that there are 23.388 youth gangs with 664,906members in the United States. Every state and every large cityhas a gang problem, and gangs are cropping up in small ruraltowns across the United States as well. The gang experience ismale-oriented; only about 3 percent of gang members arefemale. In 1995 there were 46.359 gang-related crimes and1,072 gang-related murders reported (Office of Juvenile Justiceand Delinquency Prevention, 1995). The problem of gangmembership is most prevalent in lower-SES areas and morecommon among ethnic minority adolescents (48 percent areAfrican-Americans; 43 percent are Hispanic Americans) than

among Caucasians. Although young people join gangs formany reasons, most members appear to feel inadequate inand rejected by the larger society. One recent study (Yoder,Whitlock, & Hoyt, 2003) found that a significant number ofhomeless youth (32 percent of the sample) become gangmembers. Gang membership gives them a sense of belongingand a means of gaining some measure of status and approval.

Dealing with DelinquencyIf juvenile institutions have adequate facilities and personnel,they can be of great help to youth who need to be removedfrom aversive environments. These institutions can give ado-lescents a chance to learn about themselves and their world,to further their education and develop needed skills, and tofind purpose and meaning in their lives. In such settings,young people may have the opportunity to receive psycholog-ical counseling and group therapy. The use of "boot camps"Guvenile facilities designed along the lines of army-stylebasic training) has received some support as a means ofintervening in the delinquency process. One recent studyreported that youth in boot camps viewed their environmentas more positive and therapeutic than did those enrolled intraditional programs and that they showed less antisocialbehavior at the end of the training (MacKenzie, Wilson, et aI.,2001). However, the harsh, punitive programs favored bymany "law and order" politicians (as noted by the Washing-ton State Institute for Public Policy, 1995, 1998) often failbecause they do not bring about the necessary behaviorchanges by reinforcing alternative behaviors (Huey &Henggeler, 2001).

Behavior therapy techniques based on the assumptionthat delinquent behavior is learned, maintained, and changedaccording to the same principles as other learned behaviorhave shown promise in the rehabilitation of juvenile offend-ers who require institutionalization (Ammerman & Hersen,1997). Counseling with parents and related environmentalchanges are generally of vital importance in a total rehabilita-tion program (Perkins-Dock, 2001), but it is often difficult toget parents involved with incarcerated delinquents.

Probation is widely used with juvenile offenders andmay be granted either in lieu of or after a period of institution-alization. Many delinquents can be guided into constructivebehavior without being removed from their family or commu-nity. It is essential that peer group pressures be channeled inthe direction of resocialization, rather than toward repetitivedelinquent behavior (Carr & Vandiver, 2001). The recidivismrate for delinquents, the most commonly used measure forassessing rehabilitation programs, depends heavily on thetype of offender and on the facility or procedures used. Othervariables including the type of offense, family problems, hav-ing delinquent peers, ineffective use of leisure time, and con-duct problems have also been related to reoffending (Cottle,Lee, & Heilbrun, 2001). The overall recidivism rate for delin-quents sent to training schools has been estimated to be high(Federal Bureau of Investigation, 1998). Because juvenileswho have recently been released from custody commit manycrimes, it is important to intervene to provide a more positivepeer culture (Springelmeyer & Chamberlain, 2001).

~ Children used to be viewed as "miniature adults." Itwas not until the second half of the twentieth centurythat a diagnostic classification system focused clearlyon the special problems of children.

~ In this chapter, the DSM-IV-TRclassification system isfollowed in order to provide clinical descriptions of awide range of childhood behavior problems.

~ Attention-deficit/hyperactivity disorder is one of themore common behavior problems of childhood. Inthis disorder, the child shows impulsive, overactivebehavior that interferes with his or her ability toaccomplish tasks.

~ The major approaches to treating hyperactivechildren have been medication and behavior therapy.Using medications such as amphetamines withchildren is somewhat controversial. Behavior therapy,particularly cognitive-behavioral methods, has showna great deal of promise in modifying the behavior ofhyperactive children.

~ In conduct disorder, a child engages in persistentaggressive or antisocial acts. The possible causes ofconduct disorder or delinquent behavior includebiological factors, personal pathology, familypatterns, and peer relationships.

~ Children who suffer from anxiety or depressivedisorders typically do not cause trouble for othersthrough their aggressive conduct. Rather, they arefearful, shy, withdrawn, and insecure and havedifficulty adapting to outside demands.

~ The anxiety disorders may be characterized byextreme anxiety, withdrawal, or avoidance behavior.A likely cause is early family relationships thatgenerate anxiety and prevent the child fromdeveloping more adaptive coping skills.

~ Several other disorders of childhood involve behaviorproblems characterized by a single outstandingsymptom rather than pervasive maladaptive patterns.The symptoms may involve enuresis, encopresis,sleepwalking, or tics.

~ In autistic children, extreme maladaptive behavioroccurs during the early years and prevents affectedchildren from developing psychologically.

~ It has not been possible to normalize the behavior ofautistic children through treatment, but newerinstructional and behavior modification techniques

have been helpful in improving the ability of lessseverely impaired autistic children to function.

~ When serious organic brain impairment occurs beforethe age of 18, the cognitive and behavioral deficitsexperienced are referred to as "mental retardation."Relatively common forms of such mental retardation,which in these cases is normally at least moderate inseverity, include Down syndrome, phenylketonuria(PKU), and certain cranial anomalies.

~ This organic type of mental deficit accounts for onlysome 25 percent of all cases of mental retardation.Mental retardation diagnoses, regardless of theunderlying origins of the deficit, are coded on Axis IIof DSM-IV-TR.

~ Specific learning disorders are those in which failureof mastery is limited to circumscribed areas, chieflyinvolving academic skills such as reading. Generalcognitive ability may be normal or superior.

~ Affected children are commonly described as"learning disabled" (LD). Some localized defect inbrain development is often considered the primarycause of the disorder. Learning disorders create greatturmoil and frustration in victims, their families,schools, and professional helpers.

~ We reviewed a number of potential causes for thedisorders of childhood and adolescence. Althoughgenetic predisposition appears to be important inseveral disorders, parental psychopathology, familydisruption, and stressful circumstances (such asparental death or desertion and child abuse) can alsocontribute.

~ Recent research has underscored the importance ofmultiple risk factors in the development ofpsychopathology.

~ There are special problems, and specialopportunities, involved in treating childhooddisorders. The need for preventive and treatmentprograms for children is always growing, and inrecent years child advocacy has become effective insome states. Unfortunately, the financing andresources necessary for such services are not alwaysreadily available, and the future of programs forimproving psychological environments for childrenremains uncertain.

Asperger's disorder (Po 575)

attent ion -defi cit / hy pe ract ivitydisorder (ADHD) (Po 560)

autism (P. 575)

conduct disorder (Po 563)

developmental psychopathology(P. 558)

Down syndrome (Po 584)

dyslexia (P. 580)

echolalia (P. 576)

encopresis (Po 573)

enuresis (P. 572)

hydrocephaly (Po 587)

juvenile delinquency (P. 563)

learning disabilities (Po 580)

macrocephaly (P. 587)

mainstreaming (Po 589)

mental retardation (Po 582)

microcephaly (Po 587)

oppositional defiant disorder(P. 563)

Pemoline (Po 562)

pervasive developmental disorders(PDDs) (Po 575)

phenylketonuria (PKU) (Po 586)

Ritalin (Po 562)

selective mutism (Po 568)

separation anxiety disorder (Po 567)

sleepwalking disorder (P. 573)

Strattera (Po 562)

tic (Po 574)

Tourette's syndrome (Po 574)