Abnormal Psychology

Alan Carr

• Publisher: Psychology Press
• Year: 2003
• ISBN:
  9781135430795
• Edition: 1
• Topic: Psicología
• Subtopic: Historia y teoría en psicología

This book presents a clear and in-depth account of abnormal psychology. It focuses on both clinical descriptions, using illustrative case studies at the beginning of each section, and on the implications of the major theoretical perspectives and relevant empirical evidence for clinical treatment. It provides a very readable and up-to-date review of topics including childhood behaviour disorders, anxiety, depression, schizophrenia, personality disorders and models of abnormal behaviour. Alan Carr illustrates a scientific approach to the understanding of these aspects of abnormal psychology. Both the content and style of this book will help students understand a complex area of psychology.

Chapter 1
Childhood behaviour disorders

• Introduction
• Attention deficit hyperactivity disorder
• Clinical features
• Epidemiology
• Ethiological theories
• Intervention
• Conduct disorder and oppositional defiant disorder
• Clinical features
• Epidemiology
• Ethiological theories
• Intervention
• Controversies
• Summary
• Further reading

Introduction

A WIDE VARIETY OF PSYCHOLOGICAL problems may occur in childhood. These include problems that compromise children’s capacities to learn and communicate, such as intellectual disability; language delay; specific learning disabilities; and pervasive developmental disorders including autism. Problems developing bowel and bladder control, sleeping and waking routines, and feeding and eating disorders such as anorexia nervosa may also occur in childhood and adolescence. Children and adolescents may develop neuropsychological problems and adjustment difficulties secondary to conditions such as epilepsy or head injury. All of these difficulties are of concern to psychologists who study abnormal behaviour (Carr, 1999). However, in addition to these difficulties, two broad classes of conditions have been a focus for psychologists who study abnormal behaviour in childhood. These are disruptive behaviour disorders (such as attention deficit hyper-activity disorder, 6, conduct disorder) and emotional disorders (such as anxiety and depression).

In Chapters 2 and 3 the emotional disorders—anxiety and depression—in children, adolescents and adults will be addressed.

In this chapter, disruptive behaviour disorders will be the central focus for three main reasons. First, disruptive behaviour disorders in children and adolescents are particularly prevalent in the community. Second, these disorders are among the most common referrals to child mental health services. Third, in the long term if left untreated, these disorders are extremely costly both to the children who suffer from them and to society. The principal clinical features of attention deficit hyperactivity disorder, oppositional defiant disorder and conduct disorder are given in Table 1.1. It is noteworthy that all three of these conditions entail behaviour that is troublesome for others as well as for the child.

After considering the clinical features and epidemiology of attention deficit hyperactivity disorder, oppositional defiant disorder and conduct disorder, theoretical explanations for these problems are presented in this chapter. Each of these specific explanations has been developed within the context of one of four broad theories. These are the biological, psychodynamic, cognitive-behavioural and family systems theories of psychological problems. In Chapter 6, these four broad theories are reviewed with reference to their main attributes, their contributions to our understanding and treatment of psychological problems, and their limitations.

Attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder, attention deficit disorder, hyperkinetic disorder, hyperkinesis and minimal brain dysfunction are some of the terms used for a syndrome characterized by persistent overactivity, impulsivity and difficulties in sustaining attention (Hinshaw, 1994; Taylor, 1994a; Barkley, 1998). In this chapter preference will be given to the term attention deficit hyperactivity disorder (ADHD) since this is currently the most widely used.

Case example

Timmy, aged 6, was referred for assessment because his teachers found him unmanageable. He was unable to sit still in school and concentrate on his schoolwork. He left his chair frequently and ran around the classroom shouting. This was distracting for both his teachers and classmates. Even with individual tuition he could not apply himself to his schoolwork. He also had difficulties getting along with other children. They disliked him because he disrupted their games. He rarely waited for his turn and did not obey the rules. At home he was consistently disobedient and according to his father ran ‘like a motorboat’ from the time he got up until bedtime. He often climbed on furniture and routinely shouted rather than talked.

Family history.

Timmy came from a well-functioning family. The parents had a very stable and satisfying marriage and together ran a successful business. Their daughter, Amanda, was a well-adjusted and academically able 8-year-old. The parents were careful not to favour the daughter over her brother or to unduly punish Timmy for his constant disruption of his sister’s activities. However, there was a growing tension between each of the parents and Timmy. While they were undoubtedly committed to him, they were also continually suppressing their growing irritation with his frenetic activity, disobedience, shouting and school problems. Within the wider family there were few resources that the parents could draw on to help them cope with Timmy. The grandparents, aunts and uncles lived in another county and so could not provide regular support for the parents. Furthermore, they were bewildered by Timmy’s condition, found it very unpleasant and had gradually reduced their contact with Timmy’s nuclear family since his birth.

Table 1.1 Clinical features of childhood behaviour disorders

Psychometric assessment and child interview.

Psychometric evaluation showed that his overall IQ was within the normal range but Timmy was highly distractible and had literacy and numeracy skills that were significantly below his overall ability level. Timmy perceived himself to be a failure. He believed that he could not do anything right at home or at school and he was sad that the other children did not want to play with him. He believed that his teacher disliked him and doubted his parents’ love for him.

Developmental history.There were a number of noteworthy features in Timmy’s developmental history. He had suffered anoxia at birth and febrile convulsions in infancy. He had also had episodes of projectile vomiting. His high activity level and demandingness were present from birth. He also displayed a difficult temperament, showing little regularity in feeding or sleeping; intense negative emotions to new stimuli; and was slow to soothe following an intense experience of negative emotion.

Formulation.Timmy was a 6-year-old boy with home- and school-based problems of hyperactivity, impulsivity and distractibility of sufficient severity to warrant a diagnosis of attention deficit hyper-activity disorder. Possible predisposing factors included anoxia at birth, subtle neurological damage due to febrile convulsions in infancy, and a difficult temperament. In Timmy’s case ADHD had led to academic attainment difficulties; peer relationship problems; and tension within the family. This wider constellation of difficulties underpinned Timmy’s diminishing self-esteem which in turn exacerbated his problems with attainment, peer relationships and family relationships. The absence of an extended family support system for the parents to help them deal with Timmy’s difficulties was also a possible maintaining factor. Important protective factors in this case were the commitment of the parents to resolving the problem and supporting Timmy, and the stability of Timmy’s nuclear family.

Treatment. Treatment in this case involved both psychosocial and pharmacological intervention. The psychosocial intervention included parent and teacher education about ADHD; behavioural parent training; self-instructional training for the child; a classroom-based behavioural programme, and provision of periodic relief care/holidays with specially trained foster parents. Timmy was also given stimulant therapy, specifically a twice-daily dose of methylphenidate.

Clinical features

The clinical features of ADHD in the domains of cognition, affect, behaviour, physical health and interpersonal adjustment are given in Table 1.1. Timmy, in the case example, showed all of these. With respect to cognition, short attention span, distractibility and an inability to foresee the consequences of action are the main features. There is usually a poor internalization of the rules of social conduct and in some instances low self-esteem may be present. With respect to affect, excitability associated with lack of impulse control is the dominant emotional state. This may be coupled with depressed mood associated with low self-esteem in some cases. With ADHD it is the high rate of activity, common comorbid aggressive antisocial behaviour, excessive risk-taking and poor school performance associated with inattention that are the cardinal behavioural features. With respect to physical health in ADHD, in some instances food allergies may be present. Injuries or medical complications associated with antisocial behaviour such as fighting and drug-abuse may also occur. Relationship difficulties with parents, teachers and peers are the principal interpersonaladjustment problems. Difficulties with turn-taking in games due to impulsivity make children with ADHD poor playmates. The failure of children with ADHD to internalize rules of social conduct at home and to meet parental expectations for appropriate social and academic behaviour leads to conflictual parent-child relationships. In school, youngsters with ADHD pose classroom management problems for teachers, and these children invariably have problems benefiting from routine teaching and instructional methods. For these reasons, their relationships with teachers tend to be conflictual.

Historically, a narrow definition of ADHD has been included in the ICD classification system which is widely used in the UK, with great emphasis being placed on the stability of the overactivity problems across home and school contexts. In contrast, in the US, this cross-situation stability has not been a core diagnostic criterion within early editions of the DSM (Hinshaw, 1994). In view of this historical difference in diagnostic practices, it is particularly noteworthy that currently in both the North American DSM IV and the ICD 10 which is used widely in Europe, it is stipulated that symptoms must be present in two or more settings such as home and school for a positive diagnosis of ADHD to be made.

Epidemiology

Reviews of epidemiological studies of ADHD report overall prevalence rates varying from 1 to 19 per cent depending upon the stringency of the diagnostic criteria applied and the demographic characteristics of the populations studied (Hinshaw, 1994). Using DSM IV criteria a prevalence rate of about 3–5 per cent has been obtained. The prevalence of ADHD varies with gender and age. ADHD is more prevalent in boys than girls and in preadolescents than in late adolescents. Comorbidity for conduct disorder and ADHD is about 20 per cent in community populations and possibly double this figure in clinical populations. Comorbidity for emotional disorders, such as anxiety or depression, and ADHD is about 10 per cent in community populations. In clinical populations the comorbidity rate is maybe twice this figure. Virtually allchildren with ADHD have attainment problems. However, comorbid severe specific learning difficulties have been estimated to occur in 10–25 per cent of cases. A proportion of youngsters with ADHD have comorbid developmental language delays and elimination problems although reliable epidemiological data are unavailable.

About a third of children with ADHD have a good prognosis, about a third have a moderate prognosis and a third have a poor prognosis (Hinshaw, 1994). For two-thirds of cases, the primary problems of inattention, impulsivity and hyperactivity persist into late adolescence and for some of these the primary symptoms persist into adulthood. Roughly a third develop significant antisocial behaviour problems in adolescence including conduct disorder and substance abuse, and for most of this subgroup these problems persist into adulthood leading to criminality.
Occupational adjustment problems and suicide attempts occur in a small but significant minority of cases.

Etiological theories

Biological, cognitive-behavioural and family systems theories have been developed to explain the etiology and maintenance of symptomatology in ADHD.

Biological theories

Biological theories which focus on the role of genetic factors, structural brain abnormalities, neurotransmitter dysregulation, dietary factors and hypo-arousal have guided much research on the etiology of ADHD.

Genetic hypotheses Genetic theories suggest that a predisposition to hyperactivity is inherited by children who develop ADHD. Twin and family studies support the view that genetic factors play an important role in determining temperamental activity levels in the normal population. However, other environmental factors (either intrauterine or psychosocial) would be required in addition to a genetic predisposition to high activity levels to account for the development of the clinical syndrome of ADHD (Stevenson, 1992; Hinshaw, 1994). It may be that, in some cases, temperamentally overactive children sustain a prenatal or early childhood neurological insult and go on to develop ADHD, whereas others with an overactive temperament develop the syndrome following participation in particular non-optimal types of parent-child interaction. For a small subgroup of children with ADHD, the syndrome appears to be caused by a genetic condition resulting in a generalized resistance to thyroid hormone (Hauser et al., 1993).

Organic deficit hypothesis. Early work on ADHD was premised on the hypothesis that the syndrome reflected an organic deficit: probably some form of minimal brain damage (Strauss and Lehtinen, 1947). Sophisticated neuroimaging studies have failed to reveal a specific structural brain abnormality which typifies cases of ADHD, and neuropsychological studies have failed to reveal a unique pattern of cognitive deficits associated with either localized or diffuse brain damage characteristic of youngsters with ADHD (Tannock, 1998; Barkley et al., 1992a). However, a number of factors which might lead to brain damage during the prenatal or perinatal periods are more prevalent among youngsters with ADHD than normal controls. These include: prenatal difficulties, maternal smoking during pregnancy, maternal alcohol use during pregnancy, low foetal heart rate during delivery, small head circumference at birth, minor physical abnormalities, low birth weight, a high rate of diseases of infancy, lead poisoning and early neurological insult or brain damage (Taylor, 1994a; Cantwell and Hannah, 1989; Barkley, 1998). It is important to point out that these factors which may contribute to the development of an organic deficit are not unique to ADHD and occur also in youngsters with other disorders. Therefore they probably interact with other factors in contributing to the development of ADHD.

Neurotransmitter dysregulation hypothesis. The neurotransmitter dysregulation hypothesis attributes the symptoms of ADHD to abnormalities in neurotransmitter functioning at the synapses affected by psychostimulants which ameliorate the symptomatology of ADHD. McCracken (1991) has shown that a dysregulation of the dopamine system in the ventral tegmental areas of the brain and norepinephrine and epinephrine systems in the locus coeruleus may be present in ADHD and it is probably these systems that are influenced by effective stimulant therapy with drugs such as methylphenidate and dextroamphetamine. Approximately 60–90 per cent of children with ADHD respond to these stimulants. They show a reduction in symptomatology and an improvement in both academic and social functioning, although positive effects dissipate when treatment ceases (Taylor, 1994b; Hinshaw, 1994; Gadow, 1992).

Dietary hypotheses. The dietary hypothesis attributes the symptoms of ADHD to children’s reaction to certain features of their daily diet. Originally Feingold (1975) argued that artificial food additives such as colourants accounted for a substantial proportion of ADHD symptomatology. However, controlled trials of additive-free diets did not support his position (Taylor, 1994a). Egger et al., (1985) refined Feingold’s original allergy theory and argued that particular children with ADHD may have unique allergy profiles and if their diet is modified so as to exclude the precise substances to which they are allergic, then their activity and attention problems may improve. Carefully controlled dietary studies have supported Egger’s theory (Egger et al., 1985).

Hypo-arousal hypotheses. The hy...