Childhood: Clinical and School Psychology – Lecture 1 (UNIVERSITY OF AMSTERDAM)

A case formulation refers to a hypothesis about why the problem behaviour exists and how it is maintained. This should be based on the longevity of the problems (1), consistency of problematic behaviour across situational contexts (2) and family history (3). Problematic behaviour is characterized by the four d’s:

1. Deviance from the norm
   This refers to determining the degree to which behaviours are deviant from the norm. This can be assessed using informal testing (e.g. interview) or formal tests (e.g. test batteries).
2. Distress
   This refers to assessing the relative impact of a disorder after the disorder has been identified.
3. Dysfunctional
   This refers to assessing the distress that a disorder causes. For children, multiple sources of information may need to be used.
4. Dangerous
   This refers to assessing whether there is a risk for self-harm and a risk of harm to others.

The duration should also be taken into account. Clinical decisions are often taken based on measures of intensity (1), duration (2) and frequency of the behaviour relative to the norm. To have a valid diagnosis, several things need to be taken into account:

• It is important to have knowledge of normal behaviour and deviant behaviour during development.
• It is important to take equifinality (i.e. different factors having the same outcome) into account.
• It is important to take multifinality (i.e. the same factor leading to different outcomes) into account.
• It is important to make use of a multimethod approach (i.e. a variety of informants and procedures).

It is essential to take the developmental stage of a child into account when assessing behaviour. According to Erikson, children develop through psychosocial stages with socioemotional tasks that must be mastered to allow for positive growth across the lifespan (e.g. trust vs. mistrust). Behavioural theories state that behaviour is shaped by associations (i.e. contingencies) resulting from positive and negative reinforcement.

There are three questions that need to be answered by the clinician after assessment:

1. “What are the characteristics of the child’s problem?”
2. “How should the problem be evaluated?”
3. What are appropriate intervention strategies?”

The adaptation theory states that early attachment relationships have an impact throughout the lifespan. Triadic reciprocity refers to the dynamic system between the person, the environment and behaviour where all three influence each other.

Family systems theory states that the family is a system made up of subsystems (e.g. parent and child; parent and parent). The behaviours in a system are aimed at maintaining or changing boundaries, alignment and power. A family’s degree of dysfunction can be determined by boundaries that are poorly or inconsistently defined.

The DSM is a categorical diagnostic system. It makes use of clear-cut categories as this is needed for health care service (e.g. insurance). However, there are several problems with this:

• It focuses on symptoms and not on causes which makes treatment more difficult.
• Disorders rarely fall within clear-cut categories but are more likely to fall on the far continuum of normal development.
• There is a lot of comorbidity between disorders.
• Pathology may change over time.
• Individual differences (e.g. multifinalty; severity of the problems) are not always taken into account.

The dimensional classification systems (e.g. BASC) reflect continuums or clusters of problems. It states that a single deficit can have many causes and interactions between them (i.e. network system). It can compare the present status of a child to normative peers and can compare the degree of change between pre-and post-treatment.  However, this classification system cannot always be used as clear-cut categories are necessary for health care (e.g. insurance).

It may be necessary to integrate the two systems as the categories are necessary but the measures typically make use of continuums. One method of integrating the two systems is by using a measure of severity within categories. Furthermore, the development across time needs to be taken into account.

The developmental framework is better suited by a severity approach (e.g. dimensional classification) as the categorical approach does not take the developmental stage and symptom presentations changing with age into account. However, the DSM-5 improves on this:

• The DSM-5 includes lifespan orientation starting with the early onset disorders to adolescence, adulthood and later life.
• The DSM-5 has more emphasis on dimensional aspects of diagnosis and contextual factors are taken into account more (i.e. comorbidity and clustering of disorders along internalizing and externalizing dimensions).
• The DSM-5 recommends targeting general symptoms common to several psychological disorders which supports collecting information beyond matching symptom presentation to a diagnostic category.
• The DSM-5 has reconceptualized several disorders to fit better with childhood disorders and included some unique diagnostic criteria (e.g. PTSD criteria for 6 years and younger).
• The DSM-5 includes a section on risk and prognostic factors.
• The DSM-5 emphasizes that a clinical case formulation must be developed (i.e. looking at predisposing, precipitating and perpetuating factors).

It is useful to use a multimethod assessment model. This takes the nature of the problem (1), developmental limitations (2) and the need to verify the impact of environmental influences into account.

The Achenbach system of empirically-based assessment (ASEBA) includes rating scales for both parents and youth. It makes use of empirically validated behavioural categories (1), clinical cut-off scores (2) and T-scores (3). It has syndrome scales and broadband scales (e.g. internalizing problems; externalizing problems; total problems). It also takes adaptive functioning and social competence into account.

Bronfenbrenner’s bio-ecological model consists of several parts:

1. Inner circle
   This refers to the child self and reflects genetics and temperament. Risk factors include low birth weight (1), difficult temperament (2), birth trauma (3), intellectual level (4), genetic links to psychopathology (5) and the male gender (6). Protective factors include normal ability and good health.
2. Micro-system
   This refers to a child’s immediate environment (e.g. family, school, peers). It is the interaction of the child with the direct surroundings. Risk factors include maternal depression (1), insecure attachment (2), poor parenting style (3), domestic violence (4), poor peer relations (5) and academic lags (6). Protective factors include successful peer relations (1), involvement in extracurricular activities (2) and having supportive parents (3).
3. Mesosystem
   This refers to the interaction between two microsystems (e.g. family and school).
4. Exosystem
   This refers to the social and economic context of a child (e.g. poverty, divorce). It is the influence of systems without the direct involvement of the child on the active context. Risk factors include poverty (1), unsafe neighbourhoods (2), lack of opportunities (3), limited access to healthcare (4), limited access to nutrition (5) and low parent education (6).
5. Macrosystem
   This refers to the cultural context of the child (e.g. beliefs; laws; language). Risk factors include being part of an ethnic minority and having a conflicting set of beliefs from the culture of origin.
6. Chronosystem
   This refers to the child’s cumulative experience (i.e. time).

The interactions between the systems are of prime importance as they are all interrelated. It is not simply a nesting view as the child does not only sit within a microsystem but interacts with the environment and thus the systems.

The transactional model refers to the ongoing and interactive nature of developmental change between the child and the environment. This means that the development of a child is the product of the continuous dynamic interactions of the child and the experiences provided by the environment (e.g. social setting). There are bidirectional, interdependent effects between the child and the environment.

Action-oriented assessment/diagnosis refers to a decision process in which developmental and learning problems are distinguished, analysed and explanations for problems are sought and solutions are advised. It makes use of a transactional model and there are several characteristics:

1. The aim is not to diagnose but to give useful advice.
2. It makes use of systematic procedures (e.g. diagnostic cycle).
3. It is interactionist (i.e. it adjust needs and approach across contexts).
4. It takes the environmental context (e.g. parents and school) into account.

The focus is on the child in a holistic view rather than on the child in isolation.

In the Dutch school system, the special needs primary schools (i.e. ‘speciaal basisonderwijs, SBO) include children with learning problems and minor behavioural problems. The special needs school (i.e. ‘speciaal onderwijs, SO) requires a diagnosis and consists of four clusters:

1. Cluster 1
   This includes children that are visually handicapped.
2. Cluster 2
   This includes children that have auditory and communication handicaps (e.g. primary language problems; autism).
3. Cluster 3
   This includes children with physical, mental and multiple handicaps (e.g. chronically ill children).
4. Cluster 4
   This includes children with serious behavioural problems (e.g. behavioural problems due to autism).

Dutch inclusive education (i.e. ‘passend onderwijs’) refers to the idea of attempting to provide a good foundation for children (1), providing support when necessary (2) and only using special needs education if other measures are not possible anymore (3). This is done because many children do not leave special needs education after entering.

One result of this is that children receive extra support in a primary school if necessary (e.g. remedial teacher; supporting special needs). There are several steps in the education of a child in case this child requires extra support:

1. Regular primary school education
   At this stage, there are no problems and the child does not receive additional support.
2. Basic care
   This refers to receiving some extra support. At this stage, a psychologist or remedial educationalist is consulted.  
3. Extra care
   This refers to receiving more support on top of basic care. At this stage, a psychologist or remedial educationalist is consulted.
4. Special needs (primary school)
   At this stage, the child moves to a special needs (primary school).
5. Youth care
   At this stage, the child moves into the realm of youth care because the situation is severe.

The steps ‘extra care’, ‘special needs’ and ‘youth care’ are always taken in consultation with the support team.

Behaviour that is problematic should always be compared to behaviour that is normal for that developmental stage. There are several typical challenges of developmental stages according to Erikson:

1. Trust vs. mistrust (0 – 1 years)
2. Autonomy vs. shame (1 – 3 years)
3. Initiative vs. guilt (3 – 6 years)
4. Industry vs. inferiority (school years)
5. Identity vs. role confusion (adolescence)
6. Intimacy vs. role confusion (early adulthood)
7. Generativity vs. stagnation (mid-adulthood)
8. Integrity vs. despair (late-adulthood)

There are several problematic but normal behaviours of children at a certain developmental stage (e.g. difficult temperament of babies; social problems in school). The diathesis-stress model differentiates between predispositions and environmental stress (i.e. a combination of a predisposition and environmental stress is likely to lead to the worst outcome).

Risk factors are factors that have a negative effect on development. It increases the probability of deviant behaviour. There are several types of risk factors;

• Bio-organic risk factor
  This refers to risk factors that include the biology of a person (i.e. genotype) (e.g. biochemical disturbance in the brain).
• Intrapersonal risk factor
  This refers to risk factors that exist within a person (e.g. difficult temperament, insecure attachment, low intelligence).
• Interpersonal risk factors
  This refers to risk factors that are demonstrated in interpersonal situations (e.g. family conflict; stressful experiences).
• Environmental risk factors
  This refers to risk factors that exist in the environment (e.g. poverty; war).

The risk factors can be categorized as static risk factors (i.e. fixed markers; genes) or dynamic risk factors (i.e. changeable and variable). A protective factor decreases the probability of deviant behaviour and strengthens resilience. It protects against the influence of risk factors. There are several common risk and protective factors that influence behavioural problems and school failure.

The differential susceptibility model states that there are two types of children. Fixed individuals (i.e. dandelion children) refer to children who show adaptive behaviour no matter the circumstances. Malleable individuals (i.e. orchid children) refer to children who show adaptive behaviour depending on the circumstances.

Children with externalizing problems are referred more often (1), have lower intelligence (2), academic acceptance (3) and social acceptance (4) compared to children with internalizing problems. However, these problems can co-occur.

In longitudinal studies, people are followed and measured for a long period of time (e.g. 15+ years). This leads to valuable information but is costly and there often is a lot of attrition. In accelerated longitudinal studies several age groups are followed at the same time for a couple of years. It is faster than a longitudinal study and protects against the cohort effects of cross-sectional studies