ADHD is defined in many different ways. In the 1950s, the emphasis was on the hyperactivity characteristic of the disorder. Various terms were used at the time, such as hyperkinetic syndrome and hyperactive child syndrome . Over time, attention for hyperactivity and concentration problems decreased. In the DSM-III it was recognized that attention deficit disorder (ADD) could occur with and without hyperactivity. Attention Deficit Hyperactivity Disorder (ADHD) was not included in the revised version of the DSM-III . This disorder is also recognized by dimensional classification systems.
Research suggested that ADHD consists of two components: inattention and hyperactivity-impulsivity. There is a lot of cross-cultural evidence for the validity of these factors. Although both components have unique genetic influences, they are interrelated as a result of shared genetic influences.
DSM classification
The DSM states that the two factors (inattention and hyperactivity-impulsivity) together form three subtypes of ADHD:
The diagnostic criteria state that there must be symptoms of inattention and hyperactivity-impulsivity, respectively. the diagnostic criteria state that some symptoms must be present before the age of 12 and for at least six months. Because all symptoms occur to some extent in normally developing children and may vary with the level of development, the diagnosis is only made if the symptoms are excessive and occur in at least two different settings (for example at home and at school). The symptoms must also interfere with the social and academic functioning of the child.
Inattention
Adults see different signs of inattention in children with ADHD. An apparently special aspect of the disorder is the situational attention of children: the child can concentrate well if he or she is interested or motivated, while it has concentration problems when performing a boring, strenuous or repeated task. Research shows that children and adolescents with ADHD do indeed have more concentration problems than children with learning disabilities or normally developing children. Specific deficits have been identified, including a lack of selective attention: the ability to focus on relevant stimuli and not be distracted by irrelevant stimuli. Children with ADHD are more easily distracted if the task is boring or difficult or if irrelevant stimuli are new or striking. Children with ADHD also have deficits when it comes to attentional alerting (the ability to immediately focus on something important) and retained attention (staying focused on a task or stimulus for a longer period of time).
Hyperactivity
Children with ADHD are hyperactive. In general, motor hyperactivity and restlessness are more common in structured situations, where children have to sit still and regulate their behaviour, especially while they are only minimally endorsed for this.
Impulsivity
Another important aspect of ADHD is impulsiveness: a deficiency in inhibiting or controlling their own behaviour. Children with ADHD often do things without first thinking about it, such as interrupting others or displaying risky behaviour. Impulsivity can be measured with, among other things, the stop task. For example, two letters may appear on a screen, such as the letter X and the letter O. The child should only press the button when the letter X is visible on the screen and he or she hears a beep. Children with ADHD have a hard time performing this task.
Secondary characteristics of ADHD
In addition to the core problems of ADHD, children with ADHD experience secondary problems: problems in various areas of functioning. It should be noted, however, that most of the study results discussed below are based on children with the combined subtype of ADHD. It is therefore unclear to what extent these results can be applied to children with ADHD-I or ADHD-HI.
Children with ADHD-C may experience problems in the following areas:
Children with ADHD also often have social problems. Limitations in social behaviour are often associated with two behavioural elements:
Although this is not often recognized, inattention can also be related to social problems because it is associated with not listening, being easily distracted and a tendency towards anxious, shy and withdrawn behaviour.
There are various explanations for the social problems of children and adolescents with ADHD:
Many children with ADHD are rejected by peers. Children with only attention problems are often ignored. In addition, children with ADHD often have difficulty making and keeping friends. The child-teacher relationship and family relationships are also influenced by ADHD.
DSM subtypes
There are several issues related to the different subtypes of ADHD in the DSM. For example, only a few children are diagnosed with ADHD-HI. ADHD-HI may be an early stage of ADHD-C instead of a separate subtype. In other cases, ADHD-HI seems to be better regarded as ODD.
Some studies of the subtype -I have found a factor called a slow (sluggish) cognitive pace . This is characterized by daydreams, confusion and social withdrawal. However, these behaviours are not mentioned in the diagnostic criteria of the DSM.
Subtypes are considered valid if there are not only differences in symptoms, but also in other important characteristics. ADHD-I differs from ADHD-C in several respects. ADHD-I develops at a later age and girls with ADHD are more often diagnosed with ADHD-I than with other subtypes. In addition, ADHD-I is associated with fewer externalizing symptoms, but more with internalizing symptoms than ADHD-C. Inattentive children are rejected less often, but more often ignored by peers than children with ADHD-C. There is also evidence of differences in the genetic and neurobiological factors associated with both subtypes.
The validity of ADHD-I is nevertheless questioned. For example, no differences are found on tests of inattention and impulsiveness. In addition, prenatal smoking behaviour of the mother seems to be related to ADHD, regardless of the subtype. Such findings suggest that the subtypes do not differ from each other that much and that ADHD-I may be a milder form of ADHD-C.
Nigg has done family research in which it shows that children with ADHD-I do not have a family member with ADHD-C more often than control children, while children with ADHD-C tend to, more often, have a family member with ADHD-I. This suggests that some children with ADHD-I do form a separate subtype and that some children with ADHD-I actually have a milder form of ADHD-C.
A more general issue regarding the subtypes of ADHD has to do with the instability of the diagnosis. Children who are diagnosed with a certain subtype at a certain time often receive a different subtype at a different time. Although actual changes may occur, this is probably due to methodological factors.
ADHD-I is mainly associated with internalizing emotions. These children are passive and shy. Their brains may work differently than those of children with ADHD-C.
Comorbidity is common in children with ADHD and in particular ADHD-C. Children with ADHD only seem to be the exception rather than the rule. ADHD often occurs with the following disorders:
Epidemiology
The prevalence of ADHD can be estimated to vary from 3% to 7%. When looking at prevalence, a distinction must be made between clinically diagnosed ADHD and reporting of symptoms by parents and teachers. In the latter type, the prevalence is often higher and can be as high as 20%. This is partly explained because no criteria apply, such as the age of the onset of symptoms and interference with functioning.
The prevalence of ADHD appears to decrease in adolescence. However, this may also be due to the diagnostic criteria, which may not be appropriate for the way the disorder is expressed in adolescence. ADHD may be under-diagnosed in adolescence.
Boys are diagnosed with ADHD three times as often as girls. This is partly explained by a referral bias because boys exhibit more aggressive and antisocial behaviour. In addition, there is a bias in the diagnostic criteria to behaviour that occurs more often in men. In addition, girls are often diagnosed with ADHD on the basis of inattentive and disorganized behaviour, which is less noticeable than hyperactivity and impulsiveness.
ADHD occurs in all social classes but is sometimes associated with a lower socio-economic status. Finally, the prevalence of ADHD differs between different ethnic and cultural groups.
Baby time and preschool years
In some cases ADHD has its origins in infancy, but the question is how ADHD is expressed so early. Behaviour can occur at preschool age that resembles ADHD symptoms, but little is known about this age group. ADHD may be the result of temperament tendencies, such as poor self-regulation and strongly approaching behaviour. Research is still being conducted into the distinction between early behaviours that are predictive of ADHD and normal misconduct by young children.
Childhood
Most children are diagnosed with ADHD between the ages of 6 and 12. This is partly due to the demands placed on children at school with regard to, among other things, behavioural regulation, such as sitting still and paying attention. Deviations from the norm thus will then stand out.
Adolescence
In many children, the primary symptoms, and especially hyperactive or impulsive behaviour, decrease in adolescence, making the ADHD diagnosis no longer applicable. Yet the disorder is often persistent. Two aspects of the manifestation of symptoms are remarkable. First of all, there is a high risk of heterotypic continuity of symptoms: the core symptoms can be expressed in a different way. Running around inactive during childhood, for example, turns into an inability to relax. Secondly, many children who no longer meet the diagnostic criteria exhibit more ADHD symptoms than peers who have never been diagnosed with ADHD.
Maturity
40-60% of individuals with ADHD still exhibit core symptoms and other problems such as problematic social relationships, drug use, negative self-image and antisocial behaviour.
Variation and prediction of outcomes
When studying the developmental course of ADHD, the general picture must be taken into consideration. First of all, the core symptoms, in particular hyperactivity and impulsivity, decrease with age. In addition, many secondary problems arise which can be persistent. Variables that can predict the outcomes of adolescents and adults are the age of ADHD, the severity of symptoms, the presence of behavioural problems, intelligence, adverse family circumstances, psychopathology in parents, parent-child interactions, parenting practices and genetic factors .
Executive functions and inhibition
Children with ADHD have deficits in executive functions. In Barkley's model, reaction inhibition plays a central role in explaining hyperactivity and impulsivity in ADHD. Behavioural inhibition consists of three skills:
These skills form the starting point for self-regulation. Behavioural regulation is made possible by the following executive functions:
Sensitivity to rewards
Children with ADHD have an unusual sensitivity to rewards. This motivational problem is reflected in excessive reward-seeking behaviour and a reduced sensitivity to punishment. Children with ADHD have a marked preference for immediate over-deferred rewards, even if the immediate reward is smaller. A study has suggested that they have abnormal heart responses to rewards and punishment.
Processing of time and aversion to delay
Children with ADHD somehow always have a shortage of time, which is reflected in various tasks. In this way they underestimate how fast time goes. Processing time is important in controlling and adjusting behaviour and may be related to the problems that children with ADHD have with waiting and planning.
Some argue that children with ADHD have an aversion to procrastination, which is reflected in attempts to avoid procrastination. From this perspective, for children with ADHD an immediate reward has more to do with avoiding delay than with the reward itself. It is claimed that in situations where delay cannot be avoided, children pay attention to aspects of the environment, thereby speeding up the perception of time. For example, they will behave more busily.
Multiple paths
Several neuropsychological factors are probably involved in the development of ADHD. ADHD subtypes may exist based on differences in neuropsychological limitations. A dual path model has been proposed, with two independent paths that lead to the development of ADHD: one path is mediated by deficits in executive functions and the other path by aversion to delay. Both paths are characterized by different brain circuits. There is some evidence for this model. Recently the possibility has been investigated that the processing of time forms a third path. The findings support a three-path model and subtypes of neuropsychological disabilities.
Neurobiological abnormalities
Research shows that the brains of people with ADHD have different patterns. There are various brain structures that are related to ADHD, such as the frontal, parietal and temporal lobes, the corpus callosum, the thalamus and the cerebellum. In some structures there is a reduced brain volume. Deviations in the frontal and striatal areas and the cerebellum appear to play a major role in the core characteristics of ADHD and in many neuropsychological deficits associated with ADHD. In addition, there is underactivity of the brain, which can be derived from, among other things, a lower blood flow, reduced glucose consumption and slow brain waves in children with ADHD. ADHD is also associated with abnormalities in neurotransmitter systems, such as dopamine and norepinephrine: neurotransmitters involved in executive functions, motivation and reward. The question is whether the brain abnormalities in ADHD the result of abnormalities of normal development are or of delayed development. There is some evidence that there is a development delay.
Aetiology
Genetic factors
There is strong evidence for the influence of genetic factors on ADHD. For example, family members of children with ADHD have an increased risk of psychopathology. About 10 to 35% of the immediate family members of a child with ADHD also have ADHD themselves. There even is a small component of it visible in the brains of brothers and sisters of a child with ADHD, although they do not have ADHD. Twin research shows that the hereditary component of ADHD is 0.80.
Prenatal influences and birth complications
The research findings regarding the relationship between prenatal influences and ADHD are inconsistent. Prenatal smoking and alcohol consumption are probably risk factors. Premature births and low birth weights are also risk factors.
Diet and lead
Eating patterns do not play a role in the cause of ADHD. Lead exposure is related to ADHD and deficits in various executive functions. However, the influence of lead on ADHD is probably small.
Psychosocial factors
Few researchers believe that psychosocial factors are a primary cause of ADHD. Psychosocial factors probably have an influence on the nature, severity and continuity of symptoms and on additional problems. Various family factors, such as stress, family conflicts and parental psychopathology, are associated with ADHD. There is evidence that ADHD in children can influence parenting behaviour and that parenting behaviour can influence the nature and development of ADHD. However, research results on family factors are contradictory and it is not clear how these factors interact with genetic predisposition. The behaviour of teachers can play a role in the manifestation and outcomes of ADHD.
The development of ADHD
A model that shows the development of ADHD states that various risk genes (possibly in interaction with prenatal and perinatal influences) lead to brain abnormality and associated neuropsychological deficits. Different paths can lead to ADHD. This model shows three hypothetical paths. Postnatal environmental influences play an important role in these paths. Secondary influences, such as a diet or exposure to toxic substances, can have a direct influence on brain processes. Tertiary influences, such as a negative upbringing, can mediate or moderate the outcomes through social interaction. This entire process can not only lead to ADHD, but also to comorbid disorders.
Various aspects of ADHD provide guidelines for the assessment:
The interview is a commonly used assessment method. ADHD assessment often takes place at a young age, so parents are important informants. It is important to pay attention to family relationships and specific parent-child interactions, as this has implications for treatment. The child itself must also be interviewed. In addition, interviews with teachers are valuable for obtaining information about problems at school.
In addition to interviews, one can also make use of questionnaires and observations. Other aspects of functioning can also be assessed, such as general intelligence, adaptive behaviour and academic functioning.
Interventions
Prevention
The most effective way to reduce prevalence is to focus on treating the early symptoms of ADHD and on reducing secondary problems (for example, reducing social problems through social skills training).
Pharmacological treatment
In most cases, children with ADHD are treated with medication, behavioural therapy, or a combination of both. Prescribing stimulants often happens. These drugs affect the neurotransmitters dopamine and norepinephrine. There are different variants: a variant with a slow and longer-lasting effect that only needs to be taken once a day and a variant with a fast, but shorter effect that needs to be taken more often. The slow variant is prescribed more often. Medication helps to reduce the primary problems of ADHD. About 75% of children with ADHD have fewer concentration problems and become less hyperactive and impulsive after using stimulants. Aggressive and disobedient behaviour is also reduced. In addition, medication has some effect on academic skills.
Medication is less effective in the pre-school period and adolescence than in the primary school period. Yet there is much evidence for its effectiveness at different ages and in different settings.
One of the concerns about medication concerns the side effects, such as sleeping problems, loss of appetite, stomach pain and headache. These are mild to moderate side effects that often disappear in two to three weeks. The use of stimulant drugs also appears to be hampering the growth of a child. However, this effect is small. In addition, some fear that the use of stimulants is a risk factor for drug use and drug abuse. However, it is not clear whether this is a cause-effect relationship. For example, it is possible that the link can be explained by a shared genetic influence. Some scientists believe that stimulants are prescribed far too soon to children and that it appears to be used by some parents and schools as a quick and easy solution.
Behavioural therapy
Behavioural therapy focuses on the primary symptoms of ADHD and on improving functioning in various areas such as social relationships and school performance. Many treatments are performed at school or at home.
Parent training is a method to teach parents how to deal with their child with ADHD. For example, parents learn effective parenting skills. Parent training is mainly used for children between four and twelve years of age and can partially reduce the symptoms of ADHD in children or at least the expression of them.
It is also possible to conduct behavioural therapy at school. In that case, the teacher uses methods such as timeouts and point systems. It also appears that children with different types of ADHD benefit from different strategies from their teachers. Children with ADHD-I, for example, mainly benefit from a teacher who encourages slow work in the classroom. Therapy should focus on problems of individual children. Some children mainly have organizational difficulties and must be taught skills to keep their table tidy. Other children mainly have social deficits and need to improve their social skills. In addition, the therapy must be adjusted to the developmental level of the child. For example, young children should receive help with basic skills such as arithmetic, while older children need to be supervised in other academic areas. Problem situations (such as breaks at school) must also be addressed.
The structure and organization of the classroom and learning tasks are important for children with ADHD. With regard to the class, for example, it can be effective to have the child sit close to the teacher, so that the teacher can supervise the child more closely. With regard to learning tasks, among other things, it is important to keep the tasks short and to introduce variation in the way the task is offered. In general, knowledge, ideas, attitudes, flexibility, tolerance and the interaction style of the teacher are important factors in determining the effectiveness of behavioural therapy at school.
Multimodal treatment
Due to the advantages and disadvantages of both pharmacological and behavioural treatment, both are often combined in a multimodal treatment. The Multimodal Treatment Assessment Study (MTA) examines the long-term effects of various treatments. For this, four groups of children are looked at:
The research results show that medication and combined treatment are the most effective. The research findings are nevertheless complex. For example, children with combined treatment exhibit fewer internalizing and externalizing symptoms after the examination. For children with both ADHD and an anxiety disorder, behavioural therapy, on the other hand, is just as effective as medication or a combination of both. In addition, some outcomes are moderated by the social class. Children from families with a higher level of education benefit relatively more from a combination of behavioural therapy and medication. In the longer term, some research results weaken a little. This confirms that the treatment of ADHD must be maintained over time. In the longer term, some research results may weaken a little. This confirms that the treatment of ADHD must be maintained over time.
When is behaviour abnormal? - Chapter 1You can use many varying terms to describe abnormal behaviour. Consider, for example, ‘mental disorder’, ‘psychological disorder’, ‘psychopathology’ of ‘developmental disorder’. This is thus why guidelines have been developed to help identify abnormality. What does abnormal behaviour actually mean?
Abnormal behaviour occurs when the actions of a significant person deviate from the normal standard of behaviour. According to this definition, a child with a far above average IQ is thus also considered abnormal. So, abnormal doesn’t immediately mean ‘bad’. Psychopathology research involves abnormal behaviours that are harmful to the individual. The APA (American Psychiatric Association) defines a disorder as a ‘clinically significant pattern in an individual’ (psychological and behavioural). This pattern causes frustration, disruptions, an increased risk of harm or danger to one’s wellbeing. Psychopathology interferes with the adaptation to the environment and impedes the individual from completing developmental tasks. A disorder can be seen as an internal problem or as a person's response to circumstances. The final explanation tend to be more obvious to recognise.
Age can be considered as an index for the level of development and is important in assessing behaviour. Assessments of behaviour depend on developmental norms , which say something about the growth of motor skills, language, cognition and socio-emotional behaviour. These standards serve as a benchmark when looking at the (abnormal) development of a child. There are different ways to regard behaviour as deviating from the norms:
There is culture when groups of people are organized in specific ways, live in a specific environment and share specific beliefs, norms, values and customs. Cultural norms influence the expectations, assessments and ideas regarding the behaviour of young people. What is very normal in one culture can be very strange in another culture. As a result, disorders can be culturally specific.
Ethnicity is about shared values, beliefs and customs in an area. Race , on the other hand,
.....read more What does developmental psychopathology include? - Chapter 2Kuhn, among others, has shown us that science is not entirely objective. To study phenomena, scientists all take a perspective from which they view it. If a perspective is shared by researchers, this is called a paradigm. It is a kind of cognitive frame of reference that includes assumptions and concepts. The advantage of such a (subjective) perspective is that it provides guidelines for the way in which a problem is approached, investigated and interpreted. A disadvantage is that researchers can limit themselves by assuming this perspective and are confined within the boundaries of it. They can limit themselves in the type of research questions or in the interpretation of research results. Despite these disadvantages, it is still smart to take a perspective.
Theories and models
A theory is a formal, integrated set of principles that explains a phenomenon (or multiple phenomena). Scientific theories are supported by evidence. In addition, they offer formal assumptions that can be tested, which can lead to an increase in knowledge. A model provides a description of what is being studied. Models that show that many factors lead to psychopathology are especially interesting for psychology. Interactional models assume that several variables together lead to an outcome. An example of this is the vulnerability stress model. This model is based on multiple vulnerability factors and stress factors that together cause psychopathology. Vulnerability (diathesis) is often regarded as a biological factor and stress as an environmental factor. The biological vulnerability of a child to anxiety (meaning you’re more likely to get anxiety than others), for example, can lead to psychological problems in interaction with the stress of a divorce.
Transactional models are used to investigate both normal and abnormal behaviour. These models assume that the development is the result of continuous, reciprocal transactions between the individual and the environment. The individual is seen as an active being formed by past experiences. The environmental context includes variables that are close to (proximal) or far (distal) away from the person.
Transactional models fall under the system models. System models assume different levels of functioning. The development is the result of interactions between the different levels. Changes at one level affect the other levels. An example of this is the biopsychosocial model, which integrates brain functioning, genes and behaviour with aspects of the social environment. Another example is the ecological model, which states that the individual and the environment influence each other.
What influence do genes and environment have on behaviour? - Chapter 3The early development of the brain and nervous system is largely determined by biological factors, but the influence that experience has is also fairly large. The nervous system begins to develop shortly after conception, as the neural plate (a group of cells) thickens, folds in and forms the neural tube. The cells start to migrate to fixed locations. The brain contains millions of multifunctional cells, glial cells , and neurons . Neurons carry messages within the nervous system and to and from other body parts. The extensions of these neurons, called nerves, get a layer of myelin, a white substance that promotes the efficiency of communication in the brain. An excess of neurons and connections is produced both before and after birth to ensure the flexibility of the brain. Some parts of the brain develop faster than others. For example, the development of brain parts for vision and hearing is faster than the development of the frontal brain area, which is involved in complex thinking.
There are many developments in the brain during adolescence. In this way the connections between brain areas increase. Also, the amount of grey matter in the frontal brain area decreases, while the white matter shows an increase, which is a reflection of constant myelination. These changes have implications for psychological and behavioural functioning.
The development of the brain depends on the interaction between biological predisposition and experiences (activity-dependent processes). There is pruning occurring both before and after birth, which means unnecessary cells and connections between cells are broken down. This process is probably the cause of the decline in grey matter in adolescence.
Structure
The brain and backbone together form the central nervous system . The peripheral nervous system is formed by the nerves outside the central nervous system, which carry signals to and from the central nervous system. The peripheral nervous system has two subsystems:
The entire nervous system
.....read more What kind of research is involved in this field of psychology? - Chapter 4The general purpose of science is to describe and explain phenomena. Scientific knowledge comes from a systematic formulation of a problem, observation and data collection and interpretation of research results. Theoretical assumptions and concepts are used to choose variables, procedures and research goals. Often hypotheses are tested that are derived from theories. Testing hypotheses is valuable because knowledge is then obtained in a systematic manner. When finished, a study does not prove that a hypothesis is true or false but it does offer evidence in favour or against the hypothesis. If a hypothesis is not supported, this can lead to an adjustment of the underlying theory.
Research participants
Researchers often try to make statements about their entire population of interest. Because it is not possible to examine everyone in a population, a representative sample is used. Representativeness can be achieved through random selection: every person from the population has an equal chance of being selected. Sometimes certain groups of people are systematically excluded from selection. But even though it’s handy, trying to get a true random sample is not always feasible because it is impossible to draw a random sample of, for example, all children with intellectual disabilities. However, there are ways to approach representativeness. The extent to which this is successful influences the interpretation of the research findings.
Research into psychological disorders often uses clinical populations: participants from, for example, hospitals or institutions. Such clinical populations are usually not representative of the entire population because they exclude children who, for example, cannot be treated due to financial circumstances. Clinical populations can also offer an overrepresentation of young people with more severe symptoms or with symptoms that affect the environment. In this case there is a selection bias.
Measurements
A researcher must make an operational definition of the behaviour or concept that is being studied, so that it becomes clear which observable behaviour or concept is involved in the research. For example, aggression can be operationalized as the frequency with which children threaten their peers.
Validity
A measurement must be valid. Validity refers to the accuracy of the measurement: the extent to which a measurement is an accurate indicator of the behaviour being studied. A distinction can be made between internal validity and external validity. Internal validity refers to the degree to which the statement/hypothesis is correct. Depending on the research design and research methods used, there are various
.....read more How can disorders be classified? - Chapter 5The terms classification, assessment and diagnosis are used to describe the process of description and grouping. Classification (or taxonomy) stands for creating large categories or dimensions of behavioural disorders. It is a system for describing phenomena. These systems are mostly for clinical or scientific purposes. A diagnosis is when a category or classification is considered applicable to an individual. Assessment refers to evaluating (young) people to facilitate classification and diagnosis and to make treatment plans.
Classification systems try to systematically describe a phenomenon. For example, biologists have classification systems for organisms, such as cold and warm-blooded animals. There are also systems for classifying psychological problems. These systems describe categories or dimensions of problem behaviour, emotions and / or cognitions.
A category is a discrete grouping, for example anxiety disorders, to which an individual belongs or does not belong. A dimension , on the other hand, is a continuous property that can occur in various sizes. For example, there are different degrees to which a child is anxious.
The categories or dimensions in a classification system must be clearly defined: the criteria must be explicitly named. In addition, a distinction must be made between the different categories. It must also be proven that a category or dimension actually exists, meaning that the characteristics used to describe a category or dimension must regularly occur together.
Classification systems must be reliable and valid. There are two types of reliability:
Validity refers to the extent to which a diagnosis provides us with more information
.....read more What are the anxiety disorders and what are their characteristics? - Chapter 6There is a difference between anxiety and fear. Anxiety is an emotion that is focused on the future. This emotion is characterized by the feeling that someone has no control over possible negative events. The events also seem to be unpredictable for the person in question. If someone is confronted with potentially dangerous events, there is immediately a lot of attention for the dreaded (or for the emotions that accompany it).
Stress is a response to an existing threat. It is characterized by an alarm response. stress and fear are considered a complex pattern of three types of responses to perceived threat:
Anxiety is a cognitive component of stress and is difficult to control. Worries are thoughts about possible negative consequences that are difficult to control.
It is difficult for clinicians to determine whether the anxiety of a child or adolescent is normal and temporary, or atypical and persistent. Anxiety is part of normal development, as a result of which children develop certain competencies and become more autonomous, for example. For example, children learn how to cope with the dark, while adolescents learn how to cope with dating fears.
Age differences, gender differences and cultural differences
Both the number and the intensity of fears decrease with age. Concern becomes prominent around the age of 7 and becomes more complex and varied as development progresses. Certain fears appear to be more common at certain ages, such as the fear of strangers between 6 and 9 months after birth and social anxiety and fear of failure in adolescence. Changes in the content of fears and worries are probably a reflection of cognitive, social and emotional development.
Anxiety disorders are more common among girls than among boys. This gender difference also becomes larger with older children. It is suggested that the intensity of anxiety in girls is also higher. However, research findings regarding gender differences should be interpreted with caution because they may be (partly) the result of gender-specific
.....read more What are the mood disorders and what are their characteristics? - Chapter 7An important aspect of internalizing disorders are mood problems. Children and adolescents who have an unusually sad or euphoric mood, which are extreme or persistent and interfere with functioning, can be diagnosed with a depressed or manic mood disorder. Nowadays there is increasing attention for mood disorders, for various reasons:
It is difficult to distinguish between different sub-categories of mood disorders, because many people meet the criteria of more than one disorder.
For many years the orthodox psychoanalytic perspective has been dominant. According to this perspective, depression was the result of the functioning of the superego and adult ego. For example, because the superego punishes the ego, a certain type of depression occurs. Because the superego in children is not yet fully developed, depression could not occur in them. That is why this subject received little attention.
A second important perspective contributed to the controversy regarding the existence of childhood depression. The concept of masked depression meant that child depression did exist, but that the sad mood and other characteristics of depression were often not present in children. There might have been an underlying depression, but this was masked by other problems (depressive equivalents), such as hyperactivity or delinquency. The idea of a masked depression was problematic because there were no clear guidelines for deciding whether or not a particular symptom was a sign of depression.
This perspective was nevertheless important, because it was at least recognized that depression could also be a major and common problem in children. Moreover, the central idea of masked depression is still really relevant in the terms that depression can exist in children and that this can be expressed in age-related forms that differ from depression in an adult.
The idea that depression and expression are expressed differently in children and adults has contributed to the evolution of a developmental psychopathology perspective. Initially, this perspective stated that behaviours that led to the diagnosis of depression were only temporary developmental phenomena that were common among
.....read more When is something a behavioural problem and how do they affect people? - Chapter 8While anxiety and depression arise from internalizing problems, behavioural disorders are often the result of externalizing them. The term ‘behavioural problems’ refers to the general group of disruptive and antisocial behavioural problems. The terms behavioural disorder and disruptive behavioural disorder are used to refer to specific diagnostic groups. The term delinquency is mainly used in the legal system and refers to young people who exhibit antisocial behaviour or other behavioural problems. It refers to a minor who is caught performing an index crime (an act that is illegal for both adults and minors, such as theft) or a status crime (an act that is only illegal for minors, such as alcohol consumption).
Classification and description
Disruptive behaviour occurs at different moments in the development. Children of preschool age will beat, kick or bite other children. In the primary school period there is talk of bullying and various forms of aggression, which can definitely also be physical. In adolescence, young people display risky behaviour and / or use illegal drugs. The table below provides an overview of the types of behavioural problems that adults often describe as problematic and the DSM disorders associated with them.
Development period | Problem behaviours | Related DSM disorder |
Early childhood | Disobedience Oppositional behaviour Temper tantrums | Oppositional Defiant Disorder (ODD) |
Middle childhood | Open or covert antisocial behaviour Relational aggression | Oppositional Defiant Disorder (ODD) Conduct disorder (CD) |
Adolescence | Delinquency Drug use Risky sexual behaviour | Conduct disorder (CD) Disruptive Impulse Control |
The DSM category Disruptive Impulse control and Conduct disorders include, among other things, the diagnosis of ODD and CD, as well as, among others, kleptomania and antisocial personality disorder. The latter diagnosis applies to people who show a persistent pattern of aggressive and antisocial behaviour after the age of 18. This pattern must be present from the age of 15. In addition, there must have been a conduct disorder (CD) before the age of 15 .
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What characterizes ADHD disorder? - Chapter 9ADHD is defined in many different ways. In the 1950s, the emphasis was on the hyperactivity characteristic of the disorder. Various terms were used at the time, such as hyperkinetic syndrome and hyperactive child syndrome . Over time, attention for hyperactivity and concentration problems decreased. In the DSM-III it was recognized that attention deficit disorder (ADD) could occur with and without hyperactivity. Attention Deficit Hyperactivity Disorder (ADHD) was not included in the revised version of the DSM-III . This disorder is also recognized by dimensional classification systems.
Research suggested that ADHD consists of two components: inattention and hyperactivity-impulsivity. There is a lot of cross-cultural evidence for the validity of these factors. Although both components have unique genetic influences, they are interrelated as a result of shared genetic influences.
DSM classification
The DSM states that the two factors (inattention and hyperactivity-impulsivity) together form three subtypes of ADHD:
The diagnostic criteria state that there must be symptoms of inattention and hyperactivity-impulsivity, respectively. the diagnostic criteria state that some symptoms must be present before the age of 12 and for at least six months. Because all symptoms occur to some extent in normally developing children and may vary with the level of development, the diagnosis is only made if the symptoms are excessive and occur in at least two different settings (for example at home and at school). The symptoms must also interfere with the social and academic functioning of the child.
Inattention
Adults see different signs of inattention in children with ADHD. An apparently special aspect of the disorder is the situational attention of children: the child can concentrate well if he or she is interested or motivated, while it has concentration problems when performing a boring, strenuous or repeated task. Research shows that children and adolescents with ADHD do indeed have more concentration problems than children with learning disabilities or normally developing children. Specific deficits have been identified, including a lack of selective attention: the ability to focus on relevant stimuli and not be distracted by irrelevant stimuli. Children with ADHD are more easily distracted if the task is boring
.....read more What disorders are there with regard to language and learning? - Chapter 10From around 1800 on, there has been attention on language-related problems. During this time, a medical orientation was developed, with specific limitations associated with brain abnormalities. For example, Wernicke discovered brain abnormalities in patients who did not understand language well, but who had no language or cognitive impairment – which you might know because there is a brain area named after him. From 1920 on, there was also a psychological orientation. During this period, more emphasis was placed on gaining insight into the characteristics of people with language and learning difficulties and treating them. In 1963, Krik introduced the term 'learning disabilities'. This is considered a milestone in the emergence of the concept of learning disabilities. For example, teachers were no longer accused of causing such problems.
Definition
According to the 'Individuals with Disabilities Education Act (IDEA)', the definition of a learning disability is as follows: “a learning disability is a disorder in one or more psychological processes involved in the understanding or use of (spoken or written) language. The disorder can affect listening, thinking, speaking, reading, writing, spelling or math. This does exclude children who have learning difficulties due to visual problems, hearing problems, a motor impairment, an intellectual disability, emotional problems or a cultural-economic disadvantage. There are no specific criteria for identifying disabilities. So there are different ways to identify learning disabilities. Differences in definitions have led to different prevalence estimates, incomparable research groups and different criteria for determining whether children are eligible for special education.
Discrepancy between the IQ and performance level
There are two common ways to discover learning disabilities. First of all, we can look at the difference between someone's intellectual capacity (IQ) and specific performance level. It is assumed that if there is a specific disorder, the performance on general assets (IQ) is higher than the performance on tests that relate to the specific disability. Often a difference of two or more standard deviations between the scores on the intelligence test and the specific test is considered significant.
Below average performance
Another way to diagnose a disorder is to see if a child performs at least one academic area lower than the average classmate. A problem with this method is that a large discrepancy in younger children is
.....read more When does someone have an intellectual disability? - Chapter 11An intellectual disability (ID, formerly also called mental retardation) is characterized by limitations in both intellectual functioning and adaptive behaviour. This is expressed in conceptual, social and practical skills. ID occurs before the eighteenth year of life. There are three diagnostic criteria:
According to the American Association on Intellectual and Developmental Disabilities (AAIDD) model, the way in which ID is expressed depends on how it works on the five dimensions;
Intellectual limitations are not seen as an absolute trait, because sufficient support can lead to an improvement in functioning.
Initially, the AAIDD made a distinction between four levels of ID: light, moderate, serious and profound. The AAIDD, however, no longer uses this approach because it would not be appropriate for making decisions about the care of individuals with ID. Instead of the ID level, an assessment must be made for each individual of the level of support he or she needs. This approach recognizes that the need for support may be different in different areas of functioning and may change over time. In addition, it emphasizes the perspective in which an ID is seen as dynamically related to the social environment rather than as static quality of the individual.
The DSM approach
The DSM approach to diagnosis has many similarities with the AAIDD approach. A diagnosis requires both intellectual and adaptive limitations, and the disorder must occur during the development phase. The IQ score is usually around 70. The criteria also state that there must be deficits in at least one area of adaptive behaviour.
The DSM in 2013 still classified individuals on the basis of the intelligence level: light (IQ 50-70), moderate (IQ 35-50), severe (IQ 20-40) and profound (IQ <20). About 85% of the cases were only lightly mentally limited. In the past, a light and moderate ID in
.....read more What are the most important characteristics of autism and schizophrenia? - Chapter 12In the past, no distinction was made between schizophrenia and pervasive disorders, such as autism. Nowadays we do differentiate between them. Schizophrenia is rare among children, often develops in adolescence and increases in adulthood. Autism and Asperger's syndrome are non-psychotic disorders that arise at a young age.
The DSM-V contains the Pervasive Developmental Disorders (PDD) category. This category includes:
Rett's disorder is now viewed differently and will not be further discussed for this reason. Criticism, such as whether Autistic Disorder and Asperger's syndrome would not be a single disorder, was common. In the DSM-V, the above-mentioned disorders are no longer considered separate. They now coincide in the Autism Spectrum Disorder (ASD). Two domains with primary symptoms can be distinguished in ASD: Firstly, persistent limitations in social communication and interaction, and secondly, restrictive, repetitive behavioural patterns.
What is Autistic disorder (autism)?
Kanner described autism as a disorder characterized by communication problems, atypical cognitive skills and behavioural problems such as obsessiveness, repetitive behaviour and unimaginative play. However, Kanner saw social inability as the biggest problem.
Primary characteristics
Social interaction
Already before the age of 1, autistic children show subtle differences from normally developing babies. They respond less to visual stimuli, respond less when someone calls their name and often don't like to be touched. They do not follow people with their eyes, avoid eye contact, appear to have an ‘empty’ or unseeing eye and respond little to others with emotional expression and positive emotions. Particularly striking is that autistic children exhibit deficits in joint attention, where the child and parent or caregiver focus attention on the same object or situation, thereby sharing an experience. Joint attention is facilitated by certain gestures, such as pointing, and eye contact. Another component of an atypical social interaction is abnormal processing of social stimuli, particularly the face. Children with autism have difficulty recognizing and remembering faces (and associated expressions of emotion). They also process faces in other ways than normal developing children. All in all, delayed or atypical social behaviours seem to occur at a young age in at least five areas of social behaviour: attention to social stimuli, joint attention, emotion, imitation and facial processing. Although the symptoms may change
.....read more Which disorders have a strong influence on physical functions? - Chapter 13Paediatric psychology is concerned with the investigation of (psychological) problems leading to disruption of physical function and health.
Problems with toilet training and learning sleeping and eating habits are common. Both the ability of the child to master these skills and the skills of parents to guide the child in this are important for the well-being of the child and parents. Sometimes parents seek help if they are unable to learn certain habits.
Potty training
The usual order in which children get toilet training is as follows: control of the intestines at night, control of the intestines during the day, control of the bladder during the day and control of the bladder at night. Although there is considerable variation in the age at which children become toilet-trained, they are often toilet-trained between the ages of 1.5 and 3. Parents disagree about when or at what age it is good to start toilet training. This decision often depends on cultural values, attitudes and daily circumstances, such as requirements for childcare and the presence of other siblings.
There are various factors that contribute to good toilet training. First of all, it is important that parents are able to determine when the child is ready for development. In addition, the parents must be able to properly assess when the child needs to go to the toilet. Thirdly, they must prepare well for toilet training, for example by having the child wear clothing that can be easily taken off. Finally, it is effective to positively reinforce the child.
Enuresis refers to a lack of control over the bladder, during the day and / or at night, that cannot be explained by a physical disorder. Often the diagnosis can only be made after the age of 5. The diagnostic criteria also state that there must be a certain frequency of the control deficiency and this frequency varies with the age of the child. It must be done at least twice a week and for three months or there must be a clinically significant disruption of daily functioning.
A distinction is made between urinating in bed and urinating during the day and between primary and secondary enuresis. Enuresis is called primary, if the child has never been toilet trained, and secondary if the child has been toilet trained. About 85% of the cases belong
.....read more What is the connection between psychology and (physical) health? - Chapter 14Physical disorders that are influenced by psychological factors have been called psychosomatic disorders in the past . In DSM-II this term had been replaced by psychophysiological disorders and in DSM-III this term had again been changed to psychological factors that influence physical conditions. In the DSM-IV this was transformed into psychological factors that influence medical conditions . Now in the DSM-V there is a new chapter called somatic symptoms and related disorders. This includes the psychological factors category that affect other medical conditions. These adjustments are the result of the discussion about the relationship between body (soma) and mind (psyche). During the 20th century, the interest in the effects of psychological processes on the body has resulted in the development of psychosomatic medicine. It became clear that many physical complaints are influenced by psychological factors. Researchers started with psychogenesis: the identification of the psychological cause of physical disorders. More attention is now being paid to multicausality: the idea that biological, social and psychological factors contribute to health. This perspective is holistic and assumes continuous interactions between influences. Pediatric psychology is the field that focuses on these processes in children and adolescents.
In asthma there is a hypersensitivity of the airways to different stimuli. The airways become chronically inflamed and narrower. This causes breathing problems. Serious attacks (status asthmaticus) can be life threatening. The breathing problems and the danger of serious attacks can lead to anxiety for the patient and his family members.
About 10% of children suffer from asthma. The disorder is extra common in children who are poor, live in an urban area and / or belong to a minority group. A bright spot is that asthma can be temporary.
Research shows that genetic factors influence the risk of asthma. In addition, other factors most likely play a role. People who have asthma may be exposed to factors that influence the chance of an asthmatic attack. These influences are considered as triggers or irritants instead of as direct causes of asthma. Every individual has different triggers and over time triggers can change for the same individual. Repeated respiratory infections can play a role in the development of asthma and viral respiratory infections can lead to an asthmatic attack or worsen its severity. An allergy can also increase the chance of an attack. For example, some children are allergic to dust and get an asthmatic attack more quickly when
.....read more What issues are currently affecting young people? - Chapter 15In recent decades, dramatic changes have taken place in families in the US due to an increased number of divorces, families with one parent and families with stepparents.
Working mothers and childcare
Nowadays, with women having more and more jobs outside of the household, children are more often cared for by others than the mother, such as by relatives or at a day-care centre. The effect of this differs based on the quality of care, the amount of care and certain family characteristics. High quality care is positively related to the cognitive, social and language development of children who go to a day-care centre from an early age. The research findings regarding the effects of the amount of care are inconsistent. In general, the amount of care seems to be negatively related to the child's development. With regard to the interaction between childcare and family characteristics, it appears that children from low-income families benefit from care at a day-care. This means that care by others can serve as a protective factor for children from families with a low socio-economic status. It is also important that a good relationship between parents and child remains.
From the age of 9 to 12, an increasing number of children will start taking care of themselves. The effects of self-care depend on the amount of time self-care, the level of development of the child, family factors, neighbourhood characteristics and social support. Participation in after-school programs often has a positive effect on the social and academic behaviour of children.
Adoption
The number of adoptions has risen sharply in recent decades. Adopted children have relatively more issues with psychological problems. This is especially the case if children have were adopted at an older age or because they have been exposed to negative conditions such as poor prenatal care, drug addiction or care in an orphanage.
A study has made a distinction between two types of peers: peers from the past (peers or brothers or sisters from the institution from which the child was adopted) and current peers (peers in the current situation). The following conclusions can be drawn from this study:
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