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CHAPTER 9 The Status of Research Related to Psychopathology Thomas M. Achenbach Several factors make the study of psychopathology of schoolmate children especially important. First, referrals for mental health services rise rap- idly after the age of 5 (Baldwin et al., 1971; Rosen, 1979~. Second, mental health problems become closely intertwined with children's functioning in school and their general educational development. Third, mental health problems appear to crystallize into more tenacious patterns during middle childhood than in the preschool years. And mental health problems in- crea~ingly extend into the world outside the family, often hindering chil- dren's integration into age-appropriate social networks. Aside from the broad impact of mental health problems and the sharp rise in referrals from the preschool to the elementary school period, what is distinctive about the psychopathology of middle childhood? Unlike major adult disorders, such as schizophrenia and manic-depressive conditions, most disorders of middle childhood involve exaggerations of behavior that nearly all children show in some degree. Many disorders of middle childhood also involve a failure to develop age-appropriate behavior, rather than the decline or deviation from attained levels of functioning often seen in disorders of adolescence and adulthood. And most disorders of middle childhood appear at first glance to be less ominous and more tractable than disorders of adolescence, in which physical size, sexual maturity, suicidal behavior, de- linquency, bizarre ideation, and the waning of parental control play larger roles. Whether disorders of middle childhood actually are less ominous or 370
THE STATUS OF RESEARCH RELATED TO PSYCHOPATHOLOGY 371 more tractable is an empirical question that can be answered only through longitudinal research. On one hand, existing longitudinal evidence suggests that many disorders of adolescence are direct outgrowths of childhood disorders rather than emerging de novo (Rutter, 1980; Rutter et al., 19761. On the other hand, some childhood behavior problems that have attracted abundant clinical attention, such as phobias and bed-wetting, may in fact be relatively benign, transitory, and easily treated (see Achenbach, 1982~. A major task for research is to distinguish between those childhood problems that are typically self~correcting without intervention, those that are best handled by parents or teachers, and those that require professional help to prevent interference with further development. As this chapter emphasizes, research on the psychopathology of middle childhood requires a blending of traditional developmental research with its focus on developmental processes and sequences and clinically oriented research with its focus on individual differences. The traditional separation of these contrasting but equally necessary approaches has limited our un derstanding of the relationships between normal developmental mechanisms and pathological deviations of development. To elucidate the current status of research related to psychopathology, ~ first consider two key aspects of recent research: the role of recent research in dispelling myths of earlier eras and some new directions taken by recent research efforts. ~ then consider the conceptual implications of paradigms that shape the study of child psychopathology. Thereafter, ~ consider research needs in terms of the prospects for blending clinical and developmental approaches; the methodological and theoretical challenges and contributions of the developmental study of psychopathology; the effects of buffers, pre- vention, and intervention on the development of disorders; and the training needed to advance developmental research on psychopathology. IMPLICATIONS OF RECENT RESEARCH: DISPELLING MYTHS Although there has long been a vast literature on behavior disorders of childhood, little of it was firmly grounded in programmatic research. Instead, it was a potpourri of practitioners' personal experiences, theoretical dogma, and isolated empirical findings, often extrapolated far beyond their original context. The fragility of the research base was reflected in cycles of changing advice about childrearing and behavior problems. Successive editions of the Infant Care Bullean of the U.S. Children's Bureau (1981), for example, show drastic changes in advice to parents and in the consequences imputed
372 DEVELOPMENT DURING MIDDLE CHILDHOOD to various practices, despite the lack of data to support either the initial views or the later reversals (see Achenbach, 1982, Ch. 2, for examples). The research base is still too weak to provide definitive guidelines for understanding, preventing, ant] treating most behavior disorders, yet the research of the 1970s and 1980s has helped combat certain influential myths. This is an essential step in creating a sounder basis for unclerstanding and treating childhood disorders. As the simple and sovereign assumptions of earlier years give way to a more empirical orientation, there is an increasing need for research methods and paradigms geared specifically to child psy- chopathology. This section illustrates the role of research in dispelling myths and considers the emergence of new approaches to research. MBD/Hyperactivity/Attention Deficit Disorder Throughout the 1960s and 1970s the most publicized behavior disorder of childhood was at first known as MBD, then as hyperactivity or hyper- kinesis, and most recently as attention deficit disorder with hyperactivity. This disorcler exemplifies the following key aspects of behavior problems of middle childhood: 1. The onset of schooling brings a sharp rise in referrals for the disorder, with a peak at about age 9. 2. The problem behaviors are not blatantly pathognomonic in themselves but rather are exaggerations of behavior that most children show in milder degrees. 3. The problem behaviors do not represent a decline from previously attained levels but rather an impediment to the development of important new behaviors. 4. Clinical referrals are prompted by adults' discomfort with the child's behavior rather than by the child's own requests for help. Historical Context During the 1930s and 1940s, Alfred E. Strauss, Heinz Werner, and Laura Lehtinen developed methods for diagnosing and educating brain-damaged children (Strauss end Lehtinen, 1947~. Normalchildren, retarded children with brain damage, and retarded children without known brain damage were compared on various perceptual and cognitive tasks. The behavioral differ- ences that were found between the brain-damaged and other children were interpreted as signs of brain damage. Strauss's work helped to foster a stereotype of the brain-damaged child. The stereotype featured hyperactivity, impuIsivity, distractibility, short at
THE STATUS OF RESEARCH RELATED TO PSYCHOPATHOLOGY 373 tension span, emotional lability, poor performance on perceptual-motor tasks, and clumsiness. Children who showed these behaviors but for whom there was no direct evidence of brain damage were assumed to have subtle brain damage and were labeled with such terms as the following: Strauss syndrome, diffuse brain damage, minimal brain damage, minimal brain dys- function, and minimal cerebral dysfunction. MBD (minimal brain damage or dysfunction) was soon invoked as an explanation for many forms of problem behavior. Problems of Diagnostic Criteria The early attempts to identify children with subtle brain damage soon gave way to an indiscriminate use of MBD as a label for a heterogeneous group who had little in common with the brain-damaged children originally studied by Strauss and his colleagues. Hyperactive behavior, in particular, became virtually synonymous with MBD. The concept of MBD was further broadened to encompass school learning problems. Some people used MBD interchangeably with the terms LD (learning disability) and SED (specific learning disability; e.g., Ochroch, 1981~. Under the assumption that an attention deficit is a core problem in hyperactivity, the official psychiatric nosology eventually adopted the diagnostic category of attention deficit disorder with hyperactivity (American Psychiatric Association, 19801. During the 1970s a flood of publications on hyperactivity suggested that there was a national epidemic, and American children were diagnosed as hyperactive at 60 times the rate of British children (Weiss and Hechtman, 1979~. Yet behavioral ratings by teachers, who often instigate referrals for hyperactivity, showed that American schoolchildren were not perceived as more hyperactive than schoolchildren in Canada, West Germany, or New Zealand (Trites, 19791. The popularity of the diagnosis of hyperactivity in this country, thus, did not appear to reflect significant behavioral differences between American children and those in other Westem countries. Fur- thermore, research on children diagnosed as hyperactive showed that many were not exceptionally or consistently deviant in activity level, although they might be deviant in other ways, such as aggressiveness (e.g., Loney and Milich, 19821. It seems that the concepts of MBD and hyperactivity had expanded far beyond the phenomena the terms were originally coined to designate. A lack of standardized diagnostic data was partly to blame for the overuse of the diagnosis. Yet even when clinicians were given identical data about putative cases, agreement on the diagnosis of hyperactivity was poor. Anal- yses of diagnoses made from standardized case materials, for example, showed that individual clinicians differed in the cues they relied on, the way in
374 DEVELOPMENT DURING MIDDLE CHILDHOOD which they weighted the cues, and their awareness of the diagnostic "pol- icies" guiding their judgments of hyperactivity (UlIman et al., 1981~. Despite individual variations in their use of data, however, the clinicians in the UlIman study generally weighted teachers' and parents' reports of hyperactivity more heavily than data obtained from clinical assessments. Other research also has shown that reports by "significant others" in a child's everyday environment are typically weighted more heavily in clinical di- agnoses than are clinical observations of behavior (McCoy, 19761. This suggests that one antidote to the misuse of popular diagnostic concepts is to make better use of data on behavior occurring outside the clinical setting. Etiological Assumptions As hyperactivity became a catchall term for a wide variety of problem behaviors, the assumption of an organic etiology remained dominant, but different versions of it were propagated with great conviction. One version was based on the apparent efficacy of stimulant drugs in reducing hyper- activity. In a book written for parents, Wender and Wender (1978:21) state that: In virtually all instances hyperactivity is the result of an inborn temperamental difference in the child. How the child is treated and raised can affect the severity of his problem but it cannot cause the problem. Certain types of raising may make the problem worse, certain types of raising may make the problem better. No forms of raising can produce [such problems] in a child who is not temperamentally predisposed to them. Wender and Wender have argued that hyperactive children have a specific deficiency in the functioning of the neurotransmitter dopamine and that the efficacy of stimulant drugs indicates that they compensate for this de ~. tlclency. Another organic explanation for hyperactivity concerns abnormal sensi- tivities to foods. The leading proponent of this explanation is the allergist Ben Feingold. According to Feingold, heightened sensitivity to naturally occurring salicylates and artificial colors, flavors, and other food additives causes hyperactivity in many children. Diets free of these substances are said to produce dramatic results (Feingold, 1976:24, 26~: The child who was abusive, disobedient, incorrigible, and disdainful of attention moves coward becoming affectionate, lovable, and responsive to guidance.... In [mentalI"' retardation the clinical response may be dramatic, as evidenced by improved behavior, better coordination of both fine and gross muscles, and improved reaming ability. All of these gains induce a marked transformation in the patient, whose expression becomes more alert and bright, his social adjustment improves, permitting him to function as a self-sufficient person who does not require one~to~one attention or instruction.
THE STATUS OF RESEARCH RELATED TO PSYCHOPATHOLOGY 375 The Wender and FeingoIc} positions reflect widespread assumptions that specific organic abnormalities cause diverse behavior problems labeled as hyperactivity, despite a lack of well-validated diagnostic criteria. The impact of these assumptions on treatment is illustrated by survey findings that stimulant medication was used to treat 85 percent of children whose phy- sicians considered them hyperactive (Sandoval et al., 1980~. Parents of other children have joined Feingold associations around the country and attempted to abide by the Feingold dietary strictures. Research Findings Although specific causes have not been identified for hyperactivity, re- search conducted in the 1970s and 1980s has cast doubt on popular etio' logical assumptions. Diverse studies have shown, for example, that brain damage does not necessarily cause hyperactivity and that most children diagnosed as hyperactive are probably not brain damaged (see Achenbach, 1982, for a review of the evidence). Although stimulant medication has been shown to reduce activity levels and to improve attention, it has the same effects on well~functioning nonhyperactive children (Rapoport et al., 1980~. This casts doubt on the assumption that behavioral responses to stimulant medication substantiate neurotransmitter deficits unique to hy- peractive children. Furthermore, follow-up studies show that medication alone does little to improve the long-term social or academic functioning of hyperactive children (e.g., Gittelman, 1982~. With respect to Feingold's claims, carefully controlled studies show neg- ligible differences in hyperactivity when children are on I;eingold versus normal diets (e.g., Harley et al., 1978; Weiss et al., 1980~. If food sensi- tivities actually play any role at all, it is restricted to a very small proportion of hyperactive children. Inattentive and overactive behaviors are undoubtedly of concern in their own right since organic abnormalities may well be involved. Yet the as- sumption of a disease-like entity with a single organic cause seems less fruitful at this point than systematic study of the broader contexts in which the maladaptive behavior occurs. Findings that children treated for hyperactivity vary greatly in activity level and other behaviors and that the different behaviors predict different aspects of outcome call for a stronger focus on overall adaptive patterns. The Role of Research in Dispelling Myths Dispelling myths may seem like a prosaic task for research, yet false assumptions about the causes and cures of psychopathology are pernicious
376 DEVELOPMENT DURING MIDDLE CHILDHOOD and must be unmasked through programmatic research. Only in the last decade has child psychopathology attracted enough serious research to test influential assumptions. Such research is needed to produce the measures, constructs, and basic data for a positive science able to generate valid theories as well as to dispel myths. Although research on hyperactivity is a key example, some instructive parallels are evident in recent research on a strikingly different disorder: infantile autism, which begins much earlier but typically remains a per- manent handicap. The role of research in dispelling myths about autism is especially pertinent because the popular assumptions about autism were the reverse of the assumptions about hyperactivity. When Kanner ~ 1943) initially described the syndrome of autism, he care- fully distinguished it from other disorders, such as schizophrenia. Yet others soon used the term interchangeably with schizophrenia, childhood psychosis, and atypical personality, which they blamed largely on environmental fac- tors, especially parental behavior and attitudes. Despert (1947) and Rank (1949), for example, implicated mothers who were immature, narcissistic, overintellectual, and incapable of mature emotional relationships. Bettel- heim ~ 1967) indicted mothers who "wish that [their] child should not exist" (p. 125), and Wolman (1970) cited "parents [who] inadvertently hated one another and use the child emotionally" (p. vii). These claims were buttressed mainly by the authors' psychodynamic interpretations of cases they had seen. An absence of research support did not prevent such claims from dominating the field until the 1970s, with the result that many parents were personally blamed for their child's condition (e.g., Kysar, 1968~. As~with hyperactivity, a growing body of research has shown that widely held assumptions about the etiology of autism were not justified. However, in this case, doubt was cast on unsupported assumptions of an environmental rather than an organic etiology. Research on parents of autistic children, for example, shows no evidence that parental personalities or child-rearing practices cause autism but, instead, that certain parental characteristics may be responses to the stress of having an autistic child (see Achenbach, 1982, for a review of evidence). Although research on organic factors has not firmly supported alternative explanations for autism (see Cohen and Shay- witz, 1982), it now seems abundantly clear that it was wrong to blame parents for autism. L~PL~ICATIONS OF RECENT RESEARCH: SOME NEW DIRECTIONS Recent research has not only helped to dispel myths but has also opened new perspectives on the developmental aspects of psychopathology. Al
THE STATUS OF RESEARCH RELATED TO PSYCHOPATHOLOGY 377 though oriented largely toward the study of psychopathology per se, the new approaches invite a closer alliance with the study of normal development, and they may shed more light on developmental processes than traditional clinical research has. To highlight the new directions, ~ consider research on children assumed to be at high risk for psychopathology, behavioral assessment, and taxonomic research. Research on High-Risk Children Major adult disorders, such as schizophrenia, have been intensively studied for decades, but research on people who already manifest such disorders cannot tell us which of their abnormalities are intrinsic to the disorder and which ones might reflect consequences of the disorder, such as rejection of other people, institutionalization, and drug therapies. Experimental manip- ulation of hypothesized causes would be the method of choice for pinpointing etiologies, but the hypothesized causes cannot ethically be inflicted on peo ple. As an alternative to studying people who already manifest a major disorder, Mecinick proposed longitudinal research on children who are statistically at high risk for developing certain disorders (Mednick et al., 1981~. By com- paring the developmental course of children at risk who eventually manifest a disorder, at-risk children who do not manifest it, and control children who are not at risk, Mednick hoped to identify specific etiological factors. Mednick applied this strategy to longitudinal research on children who have schizophrenic mothers. Such children are considerably more likely to man- ifest schizophrenia in adulthood than are the children of nor~achizophrenics, although most children of schizophrenics do not become schizophrenic. Mednick's research began with a cohort of Danish children who had schizophrenic mothers and a demographically matched comparison group whose families were free of mental disorders. Denmark was chosen because it has public health services that can aid in the identification and longitudinal study of groups at risk, plus centralized case registers of mental disorders. As Mednick's subjects were followed into young adulthood, some mani- fested severe psychopathology. The findings implicate different precursors of major disorders in males and females. Among males psychophysiological lability was a significant precursor, whereas among females early onset of schizophrenia in their mothers was a precursor (Mednick et al., 1978~. Teacher ratings also showed different relationships to later schizophrenia in males and females. Boys who later became schizophrenic were reported by their teachers to behave inappropriately and to present disciplinary problems. By contrast, girls who later became schizophrenic were reported to be poorly controlled, anhedonic, withdrawn, and isolated (John et al., 19821. A
378 DEVELOPMENT DURING MIDDLE CHILDHOOD further finding was that, among high-risk males who showed psychophys- iological lability, those who became schizophrenic had experienced more paternal absences ant! more institutional care, especially in the first and sixth through tenth years of life (Walker et al., 1981~. In addition to identifying possible precursors of major disorders and sex differences in the precursors, studies of high-risk children have demonstrated the importance of comparing the developmental courses of children who are at risk for different disorders. It has been found, for example, that certain attentional deficits shown by children of schizophrenics are also shown by children of parents having unipolar affective disorders (Harvey et al., 19811. This indicates that abnormalities found in high-risk children are not nec- essarily unique to the condition for which the children are thought to be at risk. Instead, some abnormalities may reflect a general psychopathology or vulnerability factor. Or they may reveal links among disorders that appear separate in adults. Behavioral Assessment Behavioral research has stimulated another type of approach. Several reports of behavioral therapies for children were published in the 1920s and 1930s. There was then a general eclipse of behavioral interventions until the late 1950s. By the 1970s, however, behavioral methods had spawned a large body of literature on case studies and clinical series illustrating particular techniques. Controlled comparisons with other approaches were rarer, but the behavioral emphasis on explicit documentation of problems and out- comes nevertheless yielded a far more objective data base than decades of literature on psychotherapy had. One of the main rallying points for behavior modifiers was their rejection of traditional assessment in favor of behavioral assessment. By traditional assessment they meant mainly psychodynamic, medically oriented, and per venality-trait approaches. A fundamental contrast was drawn between the traditional emphasis on inferences about underlying variables such as psy- chodynamic constructs, disease entities, and personality and the behav- ioral emphasis on observable behaviors and the environmental contingencies supporting them (Mash and Terdal, 19811. The behavioral assessment method par excellence is the structured re- cording of behaviors as they occur in natural settings. From published reports of behavior therapy, we might conclude that direct observations are not only easy and routine for behavior modiDers but also that they somehow avoid all the reliability and validity problems raised by traditional assessment. Such is not the case, however. Because it is seldom practical to have trained
THE STATUS OF RESEARCH RELATED TO PSYCHOPATHOLOGY 379 observers record problem behaviors for routine clinical assessment, there is often a gap between the idealized mode! of behavioral assessment and what behavioral clinicians really do (Wade et al., 1979~. Furthermore, many problem behaviors, such as stealing, setting fires, and fighting, are unlikely to occur under the watchful eyes of trained observers. And even where exceptionally thorough observations have been done in the homes of very cooperative families, the observed contingencies seem to account for little of the variance in problem behaviors (Patterson, 19801. The limitations of direct observations under natural conditions and the lack of perfect agreement among various assessment methods have led be' havior modifiers to advocate multimethod behavioral assessment (Nay, 19791. For assessments of children the multiple methods include interviews, stan- dardized tests, checklists and log books completed by parents and teachers, observations in natural and clinical settings, and simulation of problem . situations. The advent and broadening of behavioral assessment has greatly enriched the study and treatment of psychopathology by workers of many persuasions. Nevertheless, in dispensing with psychodynamic, disease, and personality constructs, behavioral assessment faces a major problem in "how to reduce the plethora of fine objective behavioral categories into fewer, more mean' ingfu! and interpretable categories" (Hetherington and Martin, 1979:1541. This raises questions of taxonomy, to which ~ now rum. Taxonomic Research Research on children at risk, behavioral assessment, and most other as- pects of psychopathology concerns individual differences. In studies of chill dren at risk, for example, the goal is to identify variables differentiating children having poor outcomes from those having good outcomes. In be- havioral assessment the goal is to pinpoint specific behaviors and the en- vironmental contingencies that must be modified to improve a child's functioning. But the study of individual differences must ultimately find a basis for conceptually grouping children according to higher order patterns of similarities and differences. A common strategy is to form groups of children whose behavior patterns are similar in the hope that they will be found similar in other important ways, such as the etiology, prognosis, and optimal treatments for their dis- orders. Grouping children according to behavioral similarities is also nec' essary for clinical communication, program planning, and the training of clinicians. In short, taxonomies of behavior are fundamental to the study and treatment of psychopathology.
380 DEVELOPMENT DURING MIDDLE CHILDHOOD Nosolog~cal Approaches One approach to taxonomy is an outgrowth of traditional medical no- sology. This approach assumes that each disorder consists of an underlying disease entity that manifests a distinctive symptom pattern. According to this view, the goal of taxonomic research is to obtain precise descriptions of symptom patterns in order to form groups of individuals who all have the same disorder and to discriminate them from individuals who have different disorders. Once this is done, individuals who have the same disorder can be studied to determine the underlying nature, cause, and optimal treatment of the disorder. Because it is assumed that a specific disease underlies each symptom pattern, the nosological approach puts great emphasis on identi- fying each disorder in a present versus absent fashion. The dominant version of the nosological approach to behavior disorders is the Amerian Psychiatric Association's Diagnostic and Statistics Manual of Mental Disorders (the "DSM"~. The first two editions of the DSM (DSM- I, 1952; DSM-~l, 1968) were composed mainly of narrative descriptions and inferred psychodynamics of purported disorders, as negotiated by committees of psychiatrists. The newest edition (DSM-~l, 1980) bases the taxonomy of adult disorders on research diagnostic criteria (RDC) that have been evolved for discriminating between long-established taxa, such as schizo- phrenia and manic-depressive conditions. In a major departure from the narrative descriptions and inferred dynamics of disorders in DSM-l and DSM-~l, DIM- specifies decision rules for the diagnosis of each disorder. However, the lack of well-established taxa of childhood disorders left the job of specifying criteria for childhood disorders largely to the process of committee negotiations. Although successive drafts of DIM- showed improvements in the in- terjudge reliability of adult diagnoses, there was a decline in the reliability of child diagnoses from early drafts to later drafts (see DSM-~l, Appendix F). Furthermore, two studies have shown poorer reliability for DIM- diagnoses of children than for DSM-~l diagnoses, which were themselves not very reliable (Mattison et al., 1979; Mezzich and Mezzich, 1979~. The innovations that improved the reliability of adult diagnoses thus seem to have made the nosological diagnoses of childhood disorders even less reliable than before. Better reliability has been obtained for some specific disorders (Edelbrock et al., 1983), and standardized clinical interviews may help improve the reliability of DSM diagnoses in general (Costello and Edelbrock, 1982~. However, it remains to be seen whether the DSM categories validly discriminate between children whose disorders actually differ in important ways.
THE STATUS OF RESEARCH RELATED TO PSYCHOPATHOLOGY 381 Multivariate-Descr~ptive Approaches Lacking well-established diagnostic categories, students of child psycho- pathology fumed to statistical methods for empirically identifying behavioral syndromes. After a few rudimentary efforts in the 1940s and 1950s, the advent of electronic computers spawned a host of multivariate studies in the 1960s and 1970s. In most of these studies, ratings of behavior were factor analyzed to identify behavior problems that covaried to form syndromes. Despite differences in the rating instruments, raters, samples, and methods of analysis, there was considerable convergence in the identification of particular syndromes (see Achenbach and Edelbrock, 1978, and Quay, 1979, for detailed reviews). Some of these resemble syndromes that are also evident in nosological approaches, whereas others do not have clear counterparts in psychiatric nosology. Even where the multivariate findings do resemble no- sological syndromes, there are some important differences. 1. The nosological syndromes are negotiated formulations of clinicians' concepts of disorders (Spitzer and Cantwell, 1980), whereas the multivariate syndromes are derived statistically from covariation among scores on items rated for samples of children. 2. The nosological syndromes require yes-or-no judgments of the presence or absence of each relevant attribute, whereas multivariate syndromes gen- erally utilize quantitative gradations in the assessment of each attribute. 3. Starting from yes-or-no judgments of each relevant attribute, a no- sological diagnosis ultimately culminates in a yes-or-no decision about whether a child has a particular disorder. Multivariate syndromes, by contrast, reflect variations in the degree to which children manifest the characteristics of a syndrome. Thus, a child gets a score that shows how high he or she stands on a particular dimension rather than a yes-or-no diagnosis. However, cutoff points can also be established on such dimensions to discriminate between different groups of children in a categorical fashion, if desired. 4. Although the criteria for nosological diagnoses imply comparisions with "normal" children of the same age, no operational basis is provided for determining how a child compares with normal age-mates. The quantitative nature of multivariate syndromes, by contrast, makes it possible to use a metric derived from normative samples, thereby showing how much a child deviates from normal age-mates. 5. Because the taxa of a nosology are assumed to embody discrete types of disorders, children who show characteristics of several taxa must either receive multiple categorical diagnoses or must be placed in a single category on the basis of preemptive criteria for choosing one diagnosis over another.
382 DEVELOPMENT DURING MIDDLE CHILDHOOD The multivariate approach, by contrast, lends itself to a profile-format in which a child's scores on all syndromes of the taxonomy are retained, ob- viating the need for forced choices between categories. Because multivariate descriptions are neutral with respect to the etiologies of disorders, further research may reveal associations between organic ab- normalities and certain multivariate descriptions. For example, if a virus is consistently associated with a particular syndrome, its presence could become one criterion for diagnosis. Yet as pointed out by Shonkoff (in this volume), many diseases having known organic causes cannot be defined exclusively by an etiological agent, because there are major individual differences in the clegree and manner of response to the same etiological agent. Even if an organic abnormality is implicated, multivariate approaches may make better use of a larger array of potentially relevant data than hit-or-miss categorical approaches do. CONCEPTUAL IMPLICATIONS OF TAXONOMIC PARADIGMS So far, this chapter has viewed recent research on psychopathology largely in terms of efforts to obtain data. However, lurking beneath the surface of all empirical research are conceptual paradigms that shape the questions asked and the answers sought. To link previous research with future research needs, it is important to examine some contrasting tenets of the taxonomic paradigms that may dictate very different research agendas. Neither the nosological nor the multivariate-descriptive paradigm con- stitutts a theory of psychopathology designed to explain why particular problems occur. Nevertheless, taxonomic paradigms affect the ways in which disorders are conceptualized and the types of explanations sought. The Nosological Paradigm The nosological paradigm implies that each disorder exists as a discrete categorical entity that can be discriminated from other categorical entities and that each disorder will ultimately be found to have a specific cause. Although categorical nosologies need not necessarily imply organic causes for all disorders, the DAM- conveys a heavy presumption in favor of organic etiologies by repeatedly referring to disorders as illnesses (American Psy- chiatric Association, 1980~. While organic determinants may eventually be found for some disorders, rigid adherence to a disease mode} may prematurely impose conceptual categories on children who are not well served by the concept of a specific illness. For example, nosological assumptions promoted
THE STATUS OF RESEARCH RELAUD TO PSYCHOPATHOLOGY 383 the widespread labeling of children as MBD and hyperactive, even though there were no operational criteria for the behavioral phenotype and the children's behavior problems were, in fact, diverse. More recently, the concept of childhood depression has been cast in a similar role, which has promoted diagnoses of depressive illness despite a lack of well-validated operational criteria diagnosing for childhood depres- sion (Achenbach, 1982, in press; Caflson and Cantwell, 1982~. The growing enthusiasm for inferring-depression from many different behaviors prompted one observer to dub childhood depression "the MBD of the 1980s." Other childhood problems that may likewise be prematurely cast into the nosh logical mold include antisocial behavior, which DSM ~l categorizes as "con- duct disorders" (e.g., undersocialized aggressive conduct disorder), and school learning deficiencies, which DSM-~T categorizes as "specific developmental disorders" (e.g., developmental arithmetic disorder). The nosological ca- tegorization of reaming deficiencies contrasts with current multidimensional views of even relatively circumscribed reading disorders, which were pre- viously viewed as specific developmental dyslexia (Goldberg et al., 19831. The Multivariate-Descuptive Paradigm The lack of satisfactory diagnostic schemes for children's disorders is what initially prompted researchers to apply multivariate methods to the deri- vation of syndromes. The multivariate syndromes represent a conceptual level roughly analogous to nosological syndromes in the sense that both purport to represent groupings of attributes that tend to co-occur. However, besides being empirically derived and quantifiable, the multivariate sync dromes can be cast in a profile format that simultaneously displays a child's standing on each syndrome. Furthermore, profiles can be used as a basis for taxonomy by grouping children according to similarities in their profile pattems. This can be done via multivariate methods such as cluster analysis, which quantifies the degree of similarity between individual profiles and forms groups according to precisely specified algorithms. Once clusters of similar profiles have been formed, each cluster represents a type of behavioral pattern. The clusters collectively constitute a taxonomy of patterns reflecting children's standings on multiple syndromes, rather than ciassi*ing children on each syndrome judged categorically in a yes~or~no fashion. Furthermore, the similarity of an individual child's profile pattern to each profile type can be quantitatively assessed by computing a correlation coefficient between the two. Thus, rather than being constrained by yes' Porno judgments of whether a child fits a particular type, we can system' atically determine which children are highly similar to particular types and
384 DEVELOPMENT DURING MIDDLE CHILDHOOD which children are less similar or not at all similar. (For detailed illustrations of cluster-analytic taxonomies of profiles, see Achenbach and Edelbrock, 1983, and Edelbrock and Achenbach, 1980. ) Implications for Future Research The nosological and multivariate-descriptive paradigms differ in how they use data to form a picture of the child. A nosology requires the clinician to mentally weigh and combine various kinds of data into a diagnostic judgment; differences in the way individual clinicians obtain, weigh, and combine data contribute to the unreliability of diagnoses. In the multivariate-descriptive approach, by contrast, data are obtained, weighted, and combined according to standardized procedures that are sim- ilar for all cases. The standardization of procedures facilitates comparison of data obtained on a particular case with data obtained in the same fashion by other clinicians and on other cases and normative groups. Typically, the multivariate approach analyzes data from one informant at a time, such as a parent. Data from any informant may be biased with respect to the in- formant's influence on the child, opportunities to observe particular behav- iors, ant! subjective standards of judgment. Yet this is also true of other approaches to assessing children's behavior. Despite inevitable biases in data from any one source, however, the standardizaton of procedures makes it possible to explicitly compare the pictures of the child obtained from different informants, such as the child's mother, father, and teacher. The reasons for differences in perceptions of the child can then be explored. The multivariate-descriptive approach can thus contribute standardiza- tion, rigor, and reliability to the gathering of data as well as to integrating the data and relating it to noes for a child's age-mates. It has also yielded evidence for patterns of behavior problems that have not been identifier] through nosological approaches. Factor analyses of behavior problems re- ported by parents of disturbed 6- to 11-year-old girls, for example, have revealed a syndrome comprised of items such as cruelty to animals, cruelty, bullying or meanness to others, and physical attacks on people, which has been given the descriptive label cruel (Achenbach and Edelbrock, 19791. This syndrome is distinct from a general aggressive syndrome that was found in the same research and is quite similar for both sexes at several age levels. The detection of the "cruel" syndrome among girls may seem surprising, because hurtful behavior toward animals and people is stereotyped in our culture as being more masculine than feminine. Yet empirically derived syndromes reflect the covariation among reported behaviors rather than just their prevalence rates. Thus, although cruelty to animals was reported for
THE STATUS OF RESEARCH RELATED TO PSYCHOPATHOLOGY 385 more boys than girls, it covaried consistently with a particular set of other behaviors to form a syndrome among disturbed girls but not among boys. Furthermore, cluster analyses of profiles that include the "cruel" syndrome reveal groups of disturbed girls who are more deviant in terms of this syn- drome than any other (Edelbrock and Achenbach, 1980~. Regardless of their source, various kinds of data must ultimately be com- bined into a judgment of what action to take. This requires knowledge of the likely outcome of each disorder under different conditions of intervention and nonintervention, which will be discussed below in the context of re- search needs. RESEARCH NEEDS Developmental research on psychopathology offers rich opportunities for improving our understanding of both development and psychopathology. It also raises methodological and theoretical challenges for combining two enterprises that have differed in their choice of topics, preferred research strategies, research training, reward systems, and consumer audiences. Ad- vancing our knowledge requires people who are well versed in both clinical and developmental issues and who are prepared to ask new questions and forge new approaches that may not win immediate accolades in either field. For this reason, it is worth specifying research needs only if there are re- searchers who can meet the needs. After considering research needs, ~ will consider the need for training people to do developmental research on psychopathology. Developmental Perspectives Research on psychopathology typically stems from concern for a particular disorder or a particular type of treatment. The ultimate goal is to identify the etiology, course, outcome, and most appropriate treatment of each dis- order. Although clinical researchers tend to view these questions in terms of the temporal history of disorders per se, they are developmental questions as well, for the following reasons: 1. The definition of deviance requires a clear picture of what is no~al for children of a particular developmental level growing up under particular environmental conditions. 2. Determining which deviant behaviors are maladaptive and which are benign requires longitudinal comparisons of children manifesting the dif- ferent behaviors over developmentally significant periods in order to deter- mine which ones actually impede development.
with normal development. 386 DEVELOPMENT DURING MIDDLE CHILDHOOD 3. Assessing the course and outcome of disorders requires longitudinal comparisons with children manifesting other disorders and no clisorders, so that variance unique to a particular disorder can be distinguished from variance associated with psychopathology in general and variance associated To answer these clinical-developmental questions, we need more than just a general knowledge of developmental and clinical phenomena. We need research specifically targeted at putative clinical disorders that uses clinically meaningful operational definitions of the disorders and that assesses the same parameters in developmentally similar normative groups. Such research should take account of cohort, age, and time-of-measure' ment effects, as emphasized by life-span developmentalists (Baltes et al., 1977~. This does not necessarily mean that the elaborate longitudinal-se- quential and cross-sectional-sequential designs prescribed by life-span de- velopmentalists offer the only approach to developmental research on psychopathology. In fact, full-scale life-span designs are seldom practical because they require such large numbers of observations on large samples of subjects selected according to complex permutations of age, cohort, and time of assessment. The limited pool of subjects available for longitudinal study of a particular disorder and the difficulty of comparing well-matched subjects who lack the disorder require compromises with the ideal designs. Furthermore, it now seems clear that the life-span designs cannot disen- tangle age, cohort, and time-of-assessment effects as fully as had been hoped (Adam, 1978; Hom and Donaldson, 1977~. Instead, multiple approaches must be coordinated to answer questions about particular disorders. For example, suppose we want to know whether the surge of diagnoses of hy- peractivity in the 1970s actually reflected an epidemic of the disorder, pos- sibly because of an increase in environmental or dietary pollutants; a lowering of adult tolerance for behavior that had previously been more acceptable; a decline in the quality of parenting; or cultural changes that made high activity more incompatible with new demands placed on children. To find out we would initially need cross-sectional studies to obtain good measures of the behavioral phenotype of hyperactivity under various con- ditions. Examples of practical measures include devices that directly assess physical activity under standard conditions (e.g., in an experimental play- room situation) and under ecologically representative conditions (e.g., cIass- rooms), plus standardized ratings by the significant others who ultimately decide whether a child has a problem, such as parents and teachers (see Eaton, 1983~. Once we have satisfactory measures of behavior across the target age range (e.g., ages 6-~), children at each age can be compared cross sectionally
THE STATUS OF RESEARCH RELATED TO PSYCHOPATHOLOGY 387 to see whether there are possible developmental or cohort effects. If there are no significant age differences, any developmental or cohort effects across this particular age span may be negligible. If there are significant age dif- ferences, however, it may be worth conducting a longitudinal~sequential study in which children of several cohorts are assessed as they age from 6 to 11 in order to see whether there are uniform changes with age in all cohorts or whether changes occur in all cohorts at the same points in time, regardless of age. Although feasible for one or two distinctive disorders, such as hyperac- tivity, this strategy would~ be impractical for many of the behavior problems that afflict school-age children. Furthermore, because the necessary studies of a specific disorder are not likely to be launched until there is already widespread alarm about the disorder, it would be too late for the most informative comparisons between periods of apparent low prevalence and apparent high prevalence. As an altemative, it would~ be preferable to have periodic normative-epidemiological assessments of a broad range of behavior problems in large representative samples, as discussed in the next section. Normative Epidemiological Research Developmental research seeks to identify the mechanisms and sequences of development that characterize children in general. Yet developmental studies seldom obtain normative data on representative samples using pro' cedures that are widely replicable. Instead, most developmental studies em- ploy procedures devised to suit a particular conception of theoretical variables, as assessed in samples chosen for convenience rather than representativeness. The practical utility of the procedures and their generalizability to other situations are seldom considered, even though the aim is to derive generalized conclusions. Clinical research, by contrast, is often spurred by the need for quick, practical procedures that can be readily applied in a variety of settings. This is exemplified by the abundance of procedures for assessing hyperactivity. Few of these procedures, however, are based on normative data that show how individual children compare with representative samples of their peers. Lacking either native data or a litmus test for the positive diagnosis of disorders such as hvDeractivirv. we cannot place much faith in the meaning ~ --I r ---~- - -' ' ~ ~ of particular scores. Both developmental research and clinical research seek conclusions that are generalizable beyond the samples that are actually studied. Yet their research samples and procedures seldom justify generalization of their find' ings. There is thus a basic need for standardized assessment procedures to
388 DEVELOPMENT DURING MIDDLE CHILDHOOD provide common denominators across diverse research and practical con- texts. It is essential that these procedures be normed on large representative samples of children to provide baselines for comparisons with subsequent research samples and for judgments of how individual children deviate from their peers. Most previous efforts to obtain normative and/or epidemiological data on children's behavior disorders have used a small number of behavior problem items chosen on the basis of convenience or assumed significance. In some cases the assessment procedures have been severely constrained by the over- riding requirements of large-scale surveys, such as the federal government's health examination survey (Roberts and Baird, 19711. In other cases they have been geared to a particular sample of convenience that was selected for ready availability rather than representativeness (e.g., Tuddenham et al., 1974~. Very few studies have obtained data on behavior disorders in representative samples using procedures that could be readily transferred to subsequent research and clinical applications (see Achenbach and Edelbrock, 1981, for a review of studies). However, when this is done, it provides a normative data base with which to compare findings obtained by the same procedures in new contexts. Without such a data base, developmental research on psychopathology tends to be random and noncumulative, unable to relate the findings of one study to those of other studies or to individual children. Periodic repetitions of normative-epidemiological studies at intervals of ap- proximately 10 years would make it possible to reshape the normative data base according to advances in assessment methodology. If certain marker variables were kept standard from one decade to the next, it should be possible to detect major secular changes in behavior disorclers. It is also important to compare data obtained with similar procedures for children of either sex, for children from different ethnic and socioeconomic groups, and for children viewed from different perspectives. For example, despite higher mental health referral rates for school-age boys than girls (Eme, 1979), parents report similar numbers of problems for boys and girls in normative samples. Boys' problems, however, tend more often to involve undercontrolled externalizing behavior, whereas girls' problems tend to in- volve overcontrolled intemalizing behavior (Achenbach and Edelbrock, 1981~. Furthermore, teachers report higher rates of school problems for boys than girls in normative samples (Eclelbrock and Achenbach, 1984~. Where ethnic and socioeconomic differences have been assessed separately, socioeconomic status accounts for much more variance than ethnicity. Parents of lower socioeconomic status, for example, report more problems and fewer compe- tencies than parents of upper socioeconomic status, whereas black and white
THE STATUS OF RESEARCH RELATED TO PSYCHOPATHOLOGY 389 parents matched for socioeconomic status do not differ much in their reports of either problems or competencies (Achenbach ant! Edelbrock, 1981~. Psychopathology and Educational Development During middle childhood, school becomes a central arena for both success ant! failure (see Epps and Smith, in this volume). Children must master not only academic skills but also diverse social skills. Failure to master either type of skill on an age-graded schedule can lead to a pervasive sense of failure that hampers further development. What may at first be merely a delay or weakness in a specific skill, such as reading, listening attentively, or making friends, can become a source of alienation from the entire ecu' cation process. When children do not progress as expected, they are often assigned to bureaucratically defined categories of special services, such as classes for the reaming disabled or social/emotionally disturbed. However, by the time special services creak into action, the problems are often multiple, since what begins as a learning problem usually engenders behavioral and emo' tional problems. Similarly, what begins as a behavioral or emotional problem often impedes reaming. Its central role as a developmental arena during middle childhood and its responsibility for providing appropriate help make the school a key focus for developmental research on psychopathology. Yet not much research has focused on the interactions between children, their families, and their schools that lead to adaptive versus maladaptive development during middle child- hood. Recent government funding cuts and legislation that mandates least restrictive environments have combined to curtail the use of special ecu' cation placements. This further increases our need for understanding the role of school-related variables in healthy development. One requirement for improving research on relationships between psy- chopathology and educational development is the type of normative-epi- demiological data base discussed in the previous section. Because teachers are well situated to observe behavior problems related to educational de- velopment, standardized teachers' assessments of the behavior of represen- tative samples of their pupils can provide a data base on which to build subsequent studies of specific relationships between psychopathology and educational development, as illustrated by the research cited earlier on precursors of schizophrenia (John et al., 1982~. Efforts to form such a data base suggest that teachers apply such terms as hyperactivity too broadly to provide much discriminative validity (Edelbrock and Achenbach, 1984~. A data base for school behavior must therefore seek
390 DEVELOPMENT DURING MIDDLE CHILDHOOD more precise discrimination among behavior patterns than is afforded by popular quasi-diagnostic labels. Once a normative data base is available, research can be more finely tuned to the study of such issues as the way particular patterns of children's problems and competencies interact with particular classroom and teaching styles to facilitate or impede development. The role of molar differences between schools can also be studied, as has been done for the impact of secondary schools on juvenile delinquency in Britain (Rutter et al., 1979~. The Role of Specific Risk and Protective Factors Earlier in this chapter ~ discussed the study of children at high risk for particular disorders as one of the new directions taken by developmental research on psychopathology. Such studies have mainly sought to pinpoint predictors of major adult disorders such as schizophrenia. However, most childhood risk factors do not lead to such gross deviances. The loss of parents through death, divorce, or abandonment, for example, triggers a variety of reactions falling well short of schizophrenia. Aside from the immediate emotional reactions, the loss of parents can affect adaptive development by altering children's economic circumstances and everyday contacts with adults, including opportunities for modeling of adult behavior. Other environmental changes, such as a move to a new home or school and integration with unfamiliar ethnic or socioeconomic groups, likewise constitute risk factors that trigger diverse reactions. Personal characteristics that conflict with the demands of a particular environment and major illnesses are additional risk factors that can impede development. The long-term outcomes may include school failure, identity diffusion, withdrawal, aggression, and delinquency, which are not necessarily recognized as psychopathology. The other side of the coin concerns positive adaptive characteristics of both child and environment that facilitate coping with developmental chal- lenges. Under the banners of social competence and the invulnerable child, positive adaptive characteristics have won considerable fanfare in recent years. Despite the popularity of competence as a theoretical construct, how' ever, much remains to be teamed about the specific strengths that enable some children to deal constructively with major risk factors that would debilitate other children. Social cognition and peer relations may be espe- cially fruitful areas of study in this regard (see the chapters by Fischer and Bullock and Hartup, in this volume). To understand both the preexisting competencies that enable children to cope with threats to their development and the competencies that can be fostered by stress or by therapeutic interventions, we need more than a priori notions of competence, such as children's popularity with peers or favorable
THE STATUS OF RESEARCH RELATED TO PSYCHOPATHOLOGY 391 impressions they make on adults. Instead, we need to study situations likely to be debilitating and to pinpoint the variables that predict good and poor outcomes when children's coping abilities are severely tested. Both the best and the worst outcomes must be analyzed if we are to understand what distinguishes between competence and incompetence and how we might enhance the coping abilities of children who would otherwise suffer poor outcomes. Evaluation of Prevention and Intervention Efforts Like the current emphasis on competence, current enthusiasm for pre' vention rather than treatment of psychopathology reflects a reaction against illness models. Although it is easy to advocate prevention, it i often much harder to carry it out. Even though thousands of tragic deaths are known to be caused by voluntary behaviors (smoking, drunken driving, overeating, the use of guns), for example, massive efforts at changing behaviors have met with little success. Where the specific causes of behavior disorders are unknown, the call for prevention hardly seems more likely to be answered with success. In fact, some of the most ambitious efforts to prevent problem behaviors in children, such as delinquency, seem to have inadvertently increased the behaviors (McCord, 1982; O'Donnell et al., 19791. Yet prevention is on a continuum with intervention efforts designed to ameliorate problems after they emerge. Secondary prevention, for example, refers to preventing conditions that are evident from causing further harm. Considering the massive outlays for unproven interventions, more priority needs to be given to evaluating the outcomes of efforts to overcome male' captive development, whether they are called primary or secondary preven- tion or therapeutic intervention. Behavioral and drug therapies for psychopathology in middle childhood have been accompanied by more scientific evaluation of outcomes than the previously dominant psychodynamic therapies were. Nevertheless, most out' come evaluations compare the effect of a particular treatment with no treat' ment or one other treatment on samples of subjects regarded as homogeneous because they manifest particular target symptoms. Unfortunately, such stud' ies cannot detect potentially important interactions between characteristics of the subjects and particular treatments. Thus, if a treatment shows a statistically significant superiority for a group of subjects, it may be wrongly viewed as the treatment of choice for all children manifesting the problem used to define the group. Yet in the very few studies that have analyzed interactions between subject and treatment variables, interactions with such gross variables as age and socioeconomic status have been found to account for more variance than
392 DEVELOPMENT DURING MIDDLE CHILDHOOD the main effects of treatment. Love and Kaswan (1974), for example, found that a treatment that was beneficial for upper-cIass children actually seemed harmful for lower-cIass children. Exactly the reverse pattern was found for a second treatment. Although controlled evaluations of the outcome of interventions for child psychopathology are difficult, expensive, and lengthy, such evaluations should be mandatory for all efforts at prevention and ther- apeutic intervention. Training for Developmental Research on Psychopathology Developmental research on psychopathology requires skills and interests spanning two areas that have differed in training programs, occupational roles, reward systems, and consumer audiences. Developmental psychologists are mainly trained to carry out research on developmental processes and sequences defined in terms of theoretical and laboratory-based concepts. They are oriented toward academic careers built on scholarly publications intended for an academic audience. Clinicians, by contrast, are trained mainly in the use of clinical assessment and intervention procedures. They are oriented toward the delivery of clinical services in which interpersonal relationships with patients and other practitioners are paramount. Day-to- day coping with practical problems usually takes precedence over abstract research issues. How can developmentally sophisticated research be used to help troubled children? Because so many different problems remain to be solved, a wide range of personal orientations can contribute. For example, the more the- oretically or methodologically oriented researcher can find abundant chal- lenges in devising rigorous assessment procedures for complex clinical phenomena and evolving research designs to untangle interwoven devel- opmental and clinical problems. At the other extreme, the more clinically oriented researcher can find challenges in trying to translate detailed knowI- edge ~ ~ individual cases into researchable general questions. Because not every researcher can be expected to master all the skills relevant to developmental research on psychopathology, it is unrealistic to expect the same people to be expert clinicians and statisticians and meth- odologists and theoreticians. Furthermore, work with children takes second place to work with adults in most clinical training programs, while clinical research is relatively peripheral to most research training programs. People who want to do developmental research on psychopathology must therefore piece together the necessary training experiences for themselves. As a con- sequence, potential workers in this field have diverse and checkered back- grounds. The fact that they span two areas having different professional
THE STATUS OF RESEARCH RELATED TO PSYCHOPATHOLOGY 393 trajectories also necessitates piecing together employment that will enable them to work at the interface of developmental research and clinical services. This can be difficult at all times but especially during a period of scarce funds for both research and clinical services. The number of people doing developmental research on the psychopath- ology of middle childhood is small; their employment prospects and research support are tenuous; and they are not sufficiently concentrated in any one place to provide comprehensive training programs. It is, therefore, important to find ways to facilitate research in this area and to train new researchers. Even a small cadre of serious researchers who are able to pursue long-term programmatic research could greatly improve our knowledge and treatment of the psychopathology of childhood. SUMMARY During middle childhood, mental health referrals rise rapidly as mental health problems become intertwined with school functioning, crystallize into more tenacious patterns, and hinder integration into social networks outside the family. Psychopathology in middle childhood typically involves exaggerations of bed - ors that most children show to some degree and failures to develop age-appropriate behaviors. A major task for research is to distinguish between childhood problems likely to be self-correcting, those that can be handled by parents or teachers, and those that require professional help to prevent interference with further development. The study of psychopathology in middle childhood requires a blending of research on developmental processes and sequences with clinically oriented research on individual differences. Recent research has helped dispell influential myths about the origins and nature of certain disorders, such as hyperactivity and autism. It has also stimulated new approaches to the developmental understanding of psycho- pathology, as exemplified by studies of children at high risk for psycho- pathology, by behavioral assessment, and by taxonomic research. The nosological and multivariate-descriptive taxonomic paradigms can lead to very different ways of conceptualizing the psychopathology of middle child- hood. REFERENCES Achenbach, T.M. 1982 Developmental Psychopathology. Second ed. New York: John Wiley & Sons. In Developmental psychopathology. In M.E. Lamb and M.H. Bernstein, eds., Developmental press Psychology: An Advanced Textbook. Hillsdale, N.J.: Lawrence Erlbaum.
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