What can I learn about developmental psychopathology? - Chapter 16

What makes development abnormal?

How to define the line between normal and abnormal behavior?

• Statistical deviance. Thus, does the behavior fall outside the normal range of behavior? 
• Maladaptiveness. 
• Personal distress. 

More specific diagnostic criteria are in the DSM-5, the most recent Diagnostic and Statistical Manual of Mental Disorders. Most disorders have many variations and contributors. 

Depression will be used as an example to show how DSM-5 defines disorders. It's a family of several disorders, and one of the most important is major depressive disorder. To diagnose this, someone must experience at least five of the following symptoms, including one of the first two, and for at least 2 weeks:

• Depressed mood (irritable in children/adolescents) nearly every day
• Greatly decreased interest or pleasure in activities
• Significant weight loss when not dieting or weight gain
• Insomnia or sleeping too much
• Agitation or retlessness, or sluggishness and slowness
• Fatigue, loss of energy
• Feelings of worthlessness or extreme guilt
• Decreased ability to think or concentrate, or indecisiveness
• Recurring thoughts of death or suicide or actual plans or attempts

Both cultural and developmental factors have to be considered when diagnosing: what is normal depends on social/cultural norms and on developmental stage. 

Developmental psychopathology is the study of the origins and course of maladaptive behavior. 

Some people despise DSM-5 and similar diagnostic systems, for being like a medical or disease model of psychopathology, that views psychological problems as diseases that people either have or don't have. However, psychopathology is very much linked to developmental processes. The developmental pathways model believes many developmental pathways can lead to normal and abnormal outcomes. Simplified, one pathway starts off maladaptive, due to genes and early experience, and deviates even further with aging, in one pathway people start off good and get off track later, in one pathway it starts poorly but people return to a more adaptive route later and the fourth pathway consists of people that stay on a route to competence and good adjustment all along. 

Some scholars view psychological disorders as life-span neurodevelopmental disorders. They then focus on brain development and genetics. 

The diathesis-stress model of psychopathology says that psychopathology results from the interaction over time of a vulnerability to psychological disorder (diathesis, which can involve genetic predisposition, physiology, cognition set, personality etc) and the experience of stressful events. For instance: someone can have genetic vulnerability to depression (imbalances in neurotransmitters that affect mood like serotonin and dopamine, personality characteristics like high emotional reactivity to stress, thus producing a lot of stress hormone cortisol), but is unlikely to develop depression unless they also experience stressful life events. However, since both aspects have reciprocal influences on each other, it's quite complex. 

What to learn about abnormal development in infancy?

Few infants develop heavy psychological problems, since their development is strongly channeled by biological maturation, supported by a nurturing family environment. But psychological disorder does exist in infancy. 

Autism spectrum disorder (ASD) usually starts in infancy. It features abnormal social and communication development, and restricted and repetitive interests and behavior and resistance of change. ASD individuals vary a lot in degree, nature and causes of their deficits. In DSM-5, earlier distinct disorders are all put together as ASD which can vary from mild to severe. So now, classic autism as well as Asperger's syndrome is part of ASD. Asperger's syndrome features normal to above-average intelligence, good verbal skills and a desire for sociality but deficient social cognitive and communication skills. Many of us have some of the ASD traits, to some degree.

Autism rates have been rising a lot, probably due to more awareness, a broader defintion, variations in diagnostic practices, and increased diagnosis of children previously diagnosed with language or learning problems or just viewed as odd. 

Researchers are working to improve early diagnosis in ASD because the earlier the received treatment, the better the adjustment. Autism in infants shows by lack of interest and responsiveness to social stimuli. ASD is often comorbid (happening simultaneously) with other disorders like intellectual or language problems, ADHD or epilepsy, and sometimes ASD children show savant abilities. 

Many ASD children show neurological abnormalities, but these are varied. Two abnormalities are early brain overgrowth and later underconnectivity between areas of the brain involved in social cognition. It also seems regions of the brain experience neural loss in adolescence. Keep in mind that while brain can influence deficits, (lack of) experience can also shape the brain. 

Genes and even epigenetic effects contribute strongly to autism, but environmental factors also play a part. For instance a complications during pregnancy, or a virus or chemicals in the environment can interact with a genetic vulnerability to cause autism.

A few ASD children can "outgrow" it, but most, while improving in functioning, remain autistic during the life span. The most effective treatment is intensive and highly structured behavioral and educational programming, from as early as possible. The applied behavior analysis (ABA) features applying reinforcement principles to teach skills and change behavior, to ultimately shape social and language skills in ASD kids. ASD children improve their functioning through training, especially when the training occurs early due to their high brain plasticity then, but will still have ASD. 

Infants can show some of the behavioral symptoms of depression (like less interest or psychomotor slowing) and physical symptoms (like weight loss), though the DSM-5 ignores this. They can experience mental health problems, due to maladaptive attachment or parent interaction, though they can not experience negative cognitions yet. Depressive symptoms are most likely in infants that are maltreated, have a damaged attachment, are permanently separated from their moms between 6 and 12 months of age, or have a depressive caregiver. Stress in early life can cause children to have an overactive stress-response system. 

What to learn about abnormal development in children?

Children can have externalizing problems (lacking self-control, acting out, like conduct problems or ADHD) or internalizing problems (negative emotions bottling up instead of being expressed, like anxiety disorders or depression). Externalizing problems (more common in boys) decrease from age 4-18 while internalizing problems (more common in girls) increase, and they are influenced by culture. Psychological disorders come with quite some continuity over the life span, whether it's the same disorder or a different one. While some outgrow their problems, with remarkable resilience, for most some form of continuity is at work. Having psychological problems as a child is a risk factor for later problems, but when the problems are mild and help is received, they can definitely overcome it. So identifying and treating children with psychological problems should happen early so their developmental path can still be influenced. 

Attention deficit hyperactivity disorder (ADHD) is diagnosed if inattention or hyperactivity/impulsivity is present, or when both are. The primarily inattentive form is most common, and ADHD often comes with comorbidity. 

Most ADHD children outgrow the hyperactive behavior, but continue to have trouble with concentrating, impulsivity and restlessness. ADHD is pretty continuous over the life span.

The frontal lobes of ADHD individuals do not function and develop as they do in typical individuals, which results in problems with executive functions (higher level control functions, critical in self-control, like inhibiting responses and regulating emotions and behavior). Problems with the neurotransmitters dopamine and norepinephrine (involved in neuronal communication) seem to relate to the inattention, executive function impairments, and other cognitive functioning differences ADHD kids have. Genes play a big role in ADHD development, but environmental influences of course are important. Low birth weight and teratogens contribute to some ADHD cases. And there's gene-environment interaction: individuals who inherit genes that lower dopamine levels and who also experience family adversity, show more ADHD than children who do not have both things working against them. And parents that do well have a good influence on their child.

Drugs like Ritalin can help children. These are stimulant drugs, since ADHD brains are actually underaroused. The drugs increase dopamine and other neurotransmitters levels and so allow more concentration and attention. This does not cure ADHD and it could have side effects. A combination of medication, behavioral treatment and parent training seems best, with school adjustments for the children. However, achieving long-term improvement is difficult. 

Children as young as 3 can meet the DSM criteria for major depressive disorder, often comorbid, with usually anxiety disorders. Depressed preschoolers are also more likely to display behavioral or somatic symptoms, but some already express feelings of shame or guilt. Some youngsters even have suicidal thoughts  or attempt suicide. 

Carryover of depression from childhood to adulthood is not as strong as carryover of depression from adolescence to adulthood, but children certainly take depressed feelings with them to adolescence. In childhood, major depression in a parent and traumatic early experiences are warning signs for later depression. Biological signs of risk can be found in for instance how the brain responds to rewards or loss of rewards. 

Psychotherapy, especially cognitive behavioral therapy (therapy identifying and changing distorted thinking and the maladaptive behavior and emotions that stem from it), is effective for children with depression and other psychological disorders. Antidepressant drugs like Prozac, that correct for low levels of serotonin, can also help, but are not as effective with children as with adults and it's said they can increase suicidality. Parent-child interaction therapy-emotional development is used for very young children, and focuses on modifying the parent-child relationship, building good parenting skills, and enhancing the child's emotional development and emotion regulation. 

What to learn about abnormal development in adolescents?

The storm-and-stress view about adolescence seems exaggerated, but still adolescence is a period of risk taking and vulnerability to problems, and of heightened stress and more important life events. Problem behaviors increase in adolescence because of their developmental tasks (finding identity and autonomy and gaining acceptance by peers), hormonal changes that cause an increase in internalizing and externalizing problems, and the timetable of brain development in adolescence that makes risk-taking more likely. They are more vulnerable than children, but not more vulnerable than adults to psychological disorders. 

Eating disorders strike much in adolescence, and are difficult to cure. Anorexia nervosa is characterized by:

• Body weight less than minimally normal for that person's gender, height and age
• Strong fear of becoming overweight or behavior that interferes with gaining weight
• Tendency to feel fat despite being extremely thin, to be overly influenced by weight in evaluating the self, and to fail to appreciate the seriousness of very low body weight

Bulimia nervosa involves repeating episodes of consuming loads of food, followed by activities like self-induced vomiting, using laxatives, dieting or obsessive exercising. And binge eating disorder is just binge eating.

Sociocultural factors are important for developing an eating disorder, for instance the mostly Western "thinness ideal". Genes serve as a diathesis. Biochemical abnormalities like low serotonin levels are at work. The personality profile of great perfectionism and high scores on neuroticism seems to put individuals at risk. Puberty triggers eating disorders as the body changes. A genetically predisposed adolescent girl, living in a weight-conscious culture, during the hormonal changes of puberty, and experiencing an environment with stress or other ways of fostering problems, can get eating disorder.

Preventing is better than treating. Treatment usually happens through first behavior modification to help gain weight and deal with the medical side, and then therapy and maybe medication for depression. Family therapy can also work. 

Substance use disorders occur when someone continues to use a substance despite the adverse consequences. Adolescents start experimenting with substances and this can escalate. Some say the developmental pathway to adolescent substance abuse begins in childhood, and Dodge tried to integrate what is known about the contributions to this in a cascade model of substance use (a transactional model, like a chain of influence):

1. A child who is at risk due to difficult temperament, born into
2. an adverse family environment characterized by problems like poverty, stress and substance use, who is
3. exposed to harsh parenting and family conflict and therefore develops
4. behavior problems, especially aggression and conduct problems, and therefore is
5. rejected by peers and gets into more trouble at school, so that
6. parents give up trying to monitor and supervise their difficult adolescent, which contributes to
7. involvement in a deviant peer group, where the adolescent is exposed to and reinforced for substance use and other risky behavior.

We can and should intervene at each step. This model is quite truthful but should place a bit more emphasis on genetics, and the peer socialization/peer selection issue should be taken into account: both processes seem at work. 

After puberty, rates of depression increase, especially in girls. Adolescent depression is like adult depression, with more cognitive symptoms, but they also show symptoms that seem like delinquency symptoms and show vegetative symptoms (e.g. sleeping all the time). Adolescence may be a depressing period since genetic influences on depression become more powerful after puberty. Girls may be more likely than boys to engage in ruminative coping (unproductively dwelling on their problems, e.g. by coruminating with friends). 

Suicidal behavior also increases, and males are more likely to commit suicide, while females attempt more. Still, adults are more likely to commit suicide than adolescents, but then again, adolescents attempt more. Typically, it's like a "cry for help". Sociohistorical context influences suicide, and it is the product of diathesis-stress. The four key risk factors are youth psychological disorder, family psychopathology, stressful life events, and access to firearms. 

What to learn about abnormal development in adults?

Typically, psychological problems can emerge in adulthood when a vulnerable individual faces overwhelming stress. This is mainly in early adulthood. Life stressors decrease from early to middle adulthood, probably due to a more stable lifestyle. And elderly are generally even less stressed. The only type of disorder that increases with age is cognitive impairment like Alzheimer's. 

The average age of onset of major depression is in the early 20s. Still, there are concerns about depression in old age, since they are more likely than adolescents to take their own lives, and depression symptoms (though not diagnosable disorders) increase as people reach their 70s and beyond. It seems depression is also difficult to diagnose in later life, because the symptoms overlap with normal things that happen while aging. 

Women are more likely to get depression and this probably comes from their female hormones and biological reactions to stress, levels of stress (more interpersonal stress for women), ways of expressing distress (women more classic depression symptoms), and styles of coping (more ruminative coping). Hispanic and non-Hispanic whites suffer from depression most.

Adults, especially older ones, take a long time to seek treatment, while this can benefit them. The most effective approach is again medication and psychotherapy (especially cognitive behavioral therapy). 

Dementia is a progressive deterioration of neural functioning, associated with cognitive decline. In DSM-5, dementia is named "neurocognitive disorder". Alzheimer's disease is the most known and common subtype of dementia. This leaves two signs in the brain: senile plaques (masses of dying neural material outside neurons, with a toxi protein called beta-amyloid at the core) and neurofibrillary tangles (made of neural fibers and the protein tau within the bodies of neural cells). These result in loss of connections between neurons, deterioration and death of neurons, more mental functioning problems and personality changes, and this is progressive and irreversible. The disease typically begins affecting the brian in middle age, and it takes long before cognitive functioning is affected and even longer before diagnosis. The first noticeable symptoms, detectable 2-3 years before dementia can be diagnosed, are mainly difficulties remembering recent things. The individual progressing to Alzheimer's is often described as having mild cognitive impairment (MCI); often a warning of coming dementia. Ultimately, an Alzheimer's patient becomes unable to function.

Alzheimer's has a genetic basis, and epigenetic effects seem to be important. Traumatic brain injuries increase risk, and other risk factors are unhealthy lifestyle factors like poor diet, smoking and inactivity and the conditions that come from them like obseity and diabetes. It also seems people with more cognitive reserve (extra cognitive capacity, through more elaborate neural connections, that people can fall back on when they age) continue functioning well for longer. 

A healthy lifestyle is good for staving off Alzheimer's. Researchers are trying to find methods to diagnose it earlier, so an intervention can take place, so that hopefully will play out someday. Some drugs (Aricept to alter neurotransmitter levels and Namenda to combat amyloid plaques) can sometimes slightly improve cognitive functioning, reduce behavioral problems and slow the progression, but it's still not an effective cure. To make the disease more bearable, memory training or help, the use of behavioral management techniques and educational programs for both patients and caregivers can help. 

Other neurocognitive disorders:

• Vascular dementia: usually caused by a series of minor strokes that mess with the blood supply to the brain. It often progresses steplike, with more deterioration after each stroke, and is more associated with lifestyle risk factors than genes. 
• Lewy body dementia: involves fluctuations in cognitive functioning, visual hallucinations, and often motor problems. It's caused by protein deposits in neurons called Lewy bodies. 
• Frontotemporal dementia: early-onset dementia, associated with shrinking of the frontal and temporal loves. Causes executive function problems and poor judgment. Best known type: Pick's disease.
• Parinkson's disease dementia: Starts off as Parkinson's, in later stages Parkinson's dementia. Lewy bodies in subcortical brain areas contribute to motor problems. 
• Huntington's disease: caused by a single dominant gene. Subcortical brain damage results in involuntary movement, hallicinations, paranoia, depression and personality change.
• Alcohol-related dementia: caused by alcohol abuse. In one type, Wernicke-Korsakoff's syndrome, memory problems are the primary symptom.
• AIDS dementia: caused by HIV, and causes behavioral changes, cognitive and motor decline.

There are reversible dementias, thus which can be cured. These can be caused by alcoholism, infections and malnutrition for example. Sometimes adults are also wrongly diagnosed with dementia when they actually experience delirium (a treatable neurocognitive disorder which emerges more rapidly and comes and goes over the course of the day; it is a disturbance of consciousness characterized by disorientation, confusion and hallucination). This can come up in reaction to stressors like illness, drugs or malnutrition, and identification and intervention is critical to help them. Sometimes, depressed elderly are also misdiagnosed as having dementia, and elderly with normal aging declines are sometimes thought to have dementia by their relatives. So, it's critical to find the true cause of the symptoms and rule everything out before diagnosing an irreversible dementia.