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44 Chapter 3 Principles and Practices ofDevelopmental Psychopathology
many noteworthy ways, detailed in upcoming chapters, it is
clear that “resilience rests on relationships” (Luthar et al., 2014).
Families are not only sources of support for at-risk
youth. Families themselves (as units) may experience
challenges and stressors and may display adaptation and
successful functioning as a family (Walsh, 2016). Family
resilience may appear different for different families. The
protective factors that influence family resilience include
shared belief systems (such as positive outlook, meaning
making, spirituality or religiosity), organizational processes
(such as connectedness, flexibility, mobilizing support
and resources), and communication and problem-solving
processes (such as sharing information, collaboration).
A prevention-based parenting program for families with
a parent serving in the National Guard or the Reserves
provides an example of a family-level approach to resilience
(Pinna et al., 2017). The effects of deployment are, of
course, observed in parents and in children as well as in
family functioning. Adapting parenting programs to meet
the needs of a specific type of family resulted in better
engagement with the parenting program and positive
individual and group experiences.
Sociocultural protective factors are also important.
Children and adolescents whose lives are embedded in
religious, ethnic, and cultural groups where their wellbeing is a communal responsibility have access to support
and resources that other youth do not. In addition, these
resources and advantages may be “provided and experienced
in culturally meaningful ways” (Ungar et al., 2013,
p. 349). Specific examples of sociocultural protective factors
include economic support for families, primary health care,
enhancing educational opportunities and achievement, and
community empowerment (Slopen & Williams, 2021).
Investigations of the well-being of youth who have
immigrated, for example, suggest that sociocultural
protective factors involve support for these youth and their
families, educational and community support, positive
peer relationships, and a larger cultural setting that values
diversity (Masten et al., 2021; Motti-Stefanidi, 2019). Keep
in mind, as well, the findings from differential impact
studies that suggest that the protective effects of social,
cultural, and environmental factors may have more effect
on youth experiencing higher levels of risk (Unger, 2021).
A list of key factors associated with resilience at individual,
family, school, and community levels is provided in Table
3.2 (Masten et al., 2021). The table illustrates the similar
factors and processes observed across systems.
Patterns and Pathways
of Protective Factors
Rutter (1987, 1990, 2012) suggests that protective factors
influence children’s outcomes by (1) reducing the impact
of risk, (2) reducing the negative chain reactions that
follow exposure to risk, (3) serving to establish or maintain
self-esteem and self-efficacy, and/or (4) opening up
opportunities for improvement or growth. Reducing the
impact of risk involves exposing children to fewer negative
events; this is especially critical given the data on the
negative effects of cumulative risk. Reducing the impact
also may involve altering the meaning of exposure, so
children think about risk factors in less harmful ways. For
example, children who have experienced a traumatic event
may be encouraged to view themselves as strong or brave in
dealing with adversity.
Reducing negative chain reactions has to do with
intervening before a series of negative responses or
additional negative events occurs. For example, a child
who experiences separation anxiety and misses school may
be quickly referred for therapy, and a plan may be put into
place to return the child to the classroom. With this plan,
the consequence of avoiding anxiety by staying home is not
reinforced, and academic difficulties resulting from missed
Table 3.2 List of Resilience Factors
across Systems
Protective factors such as a supportive parent promote
resilience in the face of stress.
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●
Sensitive caregiving, close relationships,
social support
●
Sense of belonging, cohesion
●
Self-regulation, family management, group or
organizational leadership
●
Agency, beliefs in system efficacy, active
coping
●
Problem-solving and planning
●
Hope, optimism, confidence in a better future
●
Mastery motivation, motivation to adapt
●
Purpose and a sense of meaning
●
Positive views of self, family, or group
●
Positive habits, routines, rituals, traditions,
celebrations
Source: Masten et al. (2021). Resilience in development and
psychopathology: Multisystem perspectives.
Risk and Resilience 45
class assignments are avoided. As another example, children
at risk because they or their siblings have a chronic illness
such as diabetes or asthma may be helped to recognize the
range of emotional reactions associated with the waxing and
waning of severe symptoms. Family members or friends may
provide support before children become overwhelmed by
frustration or panic.
Developing and maintaining self-esteem and self-efficacy
is clearly related to understanding the role of personality
characteristics in moderating distress and dysfunction.
As an example, a student with dyslexia who is given the
opportunity to meet other students with dyslexia is less
likely to view information-processing problems as evidence
of personal inferiority, lack of intelligence, or insufficient
effort.
Opening up opportunities for improvement and growth
involves the appreciation of turning points in children’s lives.
Recognizing the age-related challenges that children face
and then taking advantage of both expected and unexpected
bumps in the road of development may have noticeable
effects. For a straightforward example, consider that a move
to a new neighborhood may allow a child to make new
friends. Taking a more life span–oriented approach, we also
can look toward later developmental stages (e.g., adolescence
or young adulthood) for experiences that help compensate
for poor outcomes in childhood. As Rutter (2012, p. 341)
explains, “appropriate experiences in adulthood can do
much to counter the effects of earlier adversities. It needs
to be noted, however, that such experiences are not simply
pleasurable happenings but, rather, experiences that create a
helpful discontinuity with the past.”
Keeping in mind the emphasis on resilience across
systems, it is especially important to note, again, that
resilience is not all-or-nothing, and it is not always
observed at each system level. In fact, resilience observed
at one level may mask or even contribute to lack of
resilience at another level. For example, a longitudinal
study of risk and resilience in African American youth
from 11 years of age to 27 years of age revealed that certain
individual protective factors such as high self-control and
persistence predicted academic success in late adolescence
and, at the same time, poorer physiological functioning.
For these individuals, conventional academic success
came at a price because it required more and different
resources relative to their immediate contexts. This “skindeep” pattern of resilience persisted into adulthood for
the most disadvantaged youth (Brody et al., 2013; Brody
et al., 2020).
Positive youth development perspectives and the
developmental assets framework provide another way to
think about risk and resilience over time. A mix of internal
and external assets have been identified that contribute to
positive outcomes for children and adolescents. Overlapping
the list of resilience factors in Table 3.2, internal assets
include positive identity, academic engagement, positive
values (caring, social justice, integrity, responsibility), and
social competencies. External assets include support, parent
involvement in school, other adult relationships, a sense
of mattering and belonging, boundaries (family, school,
neighborhood), and extracurricular activities (Syvertsen
et al., 2021).
Research focused on developmental pathways displayed
by Latinx youth is an example of how a developmental
assets framework emphasizes a holistic and strength-based
(rather than deficit-based) approach (Azmitia, 2021).
Azmitia explores the positive development, academic and
career pathways, and civic and cultural engagement of
Latinx youth, with attention paid to individual and group
differences related to immigration status, ethnic and racial
identities, peer and neighborhood contexts, educational
opportunities, families as sources of support as well as stress,
and varied experiences of discrimination and racism.
The adaptation-based approach to resilience reflects
another shift from a deficit-focused model of risk and poor
outcomes. “Implicit in the deficit approach is the assumption
that youth from high-risk backgrounds are broken and
need to be fixed” (Ellis et al., 2017, p. 561). The adaptationor strength-based approach proposes that children and
adolescents who grow up in high-risk, adverse, or harsh
and unpredictable environments are “stress-adapted” rather
than vulnerable. This model emphasizes the child’s or
adolescent’s cognitive, emotional, and behavioral skills that
are useful or enhanced in specific environments. We know,
for example, that exposure to stress in early development
improves certain kinds of attention strategies, memory,
and problem-solving. These strategies and skills may be
helpful in the short term (in the stressful environment) but
problematic in later, less-stressful environments. It is also
possible that certain stress-adapted skills are evidence of
hidden talents and contribute to long-term positive outcomes
(Ellis et al., 2022). Hidden talents will be discussed in more
detail in Chapter 8.
Resilience: The Example of Child
Maltreatment
Returning to the example of child maltreatment, concerned
adults must focus on ways to promote well-being in at-risk
children, and both theory and research can guide adults in
their efforts. Data from numerous studies suggest that many
children and adolescents who experience physical or sexual
abuse display resilience throughout their lives. This resilience,
of course, in no way minimizes the moral or legal wrongfulness
of maltreatment. Rather, it shows us that parents, teachers,
and mental health professionals must work together to
identify protective factors at individual, familial, and social
levels: resources such as child and adolescent strengths,
family and peer support, a positive school climate, the
presence of other caring adults, and access to both shortand long-term treatments. Facilitating good outcomes also
involves recognition of the stress-adapted skills that children
who experience maltreatment display.
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46 Chapter 3 Principles and Practices ofDevelopmental Psychopathology
Resilience, then, reflects the combined contributions
of protective factors from the individual, family, and
sociocultural levels. A child described as resilient in the face
of early maltreatment may receive immediate care, exhibit
intelligence and problem-solving abilities, and have strong
family and peer support. Equally important are environmental
factors such as safe and stable living situations and positive
neighborhood and cultural communities. We will return to
the topic of resilience in maltreated children in Chapter 8.
Research Strategies in Developmental Psychopathology
Research in developmental psychopathology makes use of
all the core research methodologies, including case studies,
correlational approaches, experimental and quasi-experimental
designs, and innovative strategies and technologies related
to neuroscience and interdisciplinary research. There are a
number of distinctive methodologies with special importance
for investigators in developmental psychopathology. We
focus on three especially relevant issues related to these
methodologies: cross-sectional versus longitudinal approaches;
complex hypotheses and complex models; and research in realworld settings with practical applications.
Cross-Sectional and Longitudinal
Approaches
Cross-sectional research involves the collection of data
at a single point in time, with comparisons made among
groups of participants. For example, we might ask children
in the first, fourth, and seventh grades, in the middle of the
school year, about the types of stress they experience. We
then compare the children’s replies, looking for age-related
differences among the younger and older children. How are
the first graders different from the fourth graders, and are
either or both groups different from the seventh graders?
Longitudinal research, in contrast, involves the ongoing
collection of data from the same group of participants, for
the study of individuals over time. With this approach, we
also recruit first graders in the middle of their school year and
talk with them about their stressful experiences, but then we
wait until this same group is in the fourth grade before we
collect more data, and then we wait again until the group
is in the seventh grade. The longitudinal approach allows
us to interpret and discuss data with respect to age (e.g.,
first versus fourth versus seventh graders) and individual
differences (i.e., specific children or groups of low-stress and
high-stress children over the course of their school years;
refer again to Figure 3.4). The research goals for the two
types of studies are different. The cross-sectional study
focuses on identifying age-related differences (or outcomes
at a particular point in childhood). Cross-sectional research
has the advantage of providing answers more quickly but the
disadvantage of sampling different individuals at different
ages. The longitudinal study provides additional data and
highlights the developmental processes that occur for the
same children across a significant span of time.
Longitudinal research in developmental psychopathology
has become an increasingly common research methodology.
Murphy’s groundbreaking studies of children’s coping
(Murphy, 1962, 1974; Murphy & Moriarty, 1976) and
Robins’s work on distressed and dysfunctional children
(Robins, 1966) are important early examples of longitudinal
investigations of adaptive and maladaptive developmental
pathways. More contemporary examples extend over
decades and include the Minnesota Longitudinal Study
of Risk and Adaptation, a transformative investigation of
attachment and early relationships and developmental
outcomes; the Louisville Twin Study, a pioneering study
of transactions between genes and environments; and the
Great Smoky Mountains Study, an epidemiological study of
risk and prevalence of disorder and the outcomes of disorder
for youth in North Carolina.
Research on developmental cascades provides several
excellent examples of longitudinal methodologies and goals.
Developmental cascades refer to “the cumulative consequences
for development of the many interactions and transactions ...
that result in spreading effects across levels, among domains
at the same level, and across different systems or generations”
(Masten & Cicchetti, 2010, p. 491). Because the construct of
cascades assumes effects that spread over time, longitudinal
research is required. Developmental cascades may be positive
or negative. In examples with positive outcomes, “effectiveness
in one domain of competence in one period of life becomes the
scaf fold on which later c ompetence in newly emerging domai ns
develops: in other words, competence begets competence” (p. 492).
In an example with a negative outcome, “behavior problems
arising in the family prior to the school years ... are carried
forward into the school context by the child, leading to
problems in two new domains of academic and social
competence” (p. 492). Developmental cascades are observed
for individuals, in families, and across generations. More
examples of these cascades will be provided in upcoming
chapters.
Complex Hypotheses and Complex
Models
It is very clear that our research designs are becoming ever
more complicated (refer again to Figure 3.1). We not only
stretch our data collection over months, years, and decades,
but also examine multiple variables at each particular
point in time. In keeping with the interdisciplinary
model of developmental psychopathology, researchers
are including genetic, physiological, psychological, and
sociocultural variables in their studies. While we once
focused our investigations on children and their immediate
environments, we now routinely broaden our approaches to
include macrosystems such as regions of the world.
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Research Strategies in Developmental Psychopathology 47
Studies of child maltreatment provide other examples of
research complexity. Instead of examining a single variable
(such as maltreatment versus no maltreatment) and its
association with an outcome, investigators account for
multiple characteristics of that variable (type of maltreatment,
frequency of maltreatment, and source of maltreatment),
leading to a better understanding of risk and resilience. Other
studies of maltreatment have focused on the interplay between
genes and environments over time. And others seek out
information about the complexity of outcomes, acknowledging
distress and dysfunction as well as stress-adapted skills and the
development of strengths during adverse experiences.
In addition to the emphasis on complex hypotheses and
complex models, we pay more attention to the variety of
available methods for collecting data. Quantitative methods
have been the standard for years, but there is renewed
interest in qualitative methods such as diaries, narratives,
and holistic observations (Lerner & Tolan, 2016). We are
also explicit about including participants in research studies
that reflect the diversity of children and families (e.g.,
Nketia et al., 2021). Box 3.1 provides a summary of a largescale study of excessive stress activation, or toxic stress, in
early childhood that is an excellent example both of complex
hypotheses and complex models and research in real-world
settings with practical applications.
Research in Real-World Settings
with Practical Applications
One of the more compelling aspects of research in
developmental psychopathology is its concern with
practical applications and public policy implications
and its focus on child advocacy (Luthar & Eisenberg,
2017). These concerns are at the core of discussions of
translational research, or research designed, conducted,
and interpreted with meaningful applications and social
value in mind. The goal of translational research is “to
move basic findings more rapidly through the pipeline
into novel treatments and preventive efforts to reduce
or alleviate physical, emotional, and behavioral health
problems” (Gunnar & Cichetti, 2009, p. 6). Cooperation
and collaboration are required: between researchers
who work with animals and researchers who work with
humans; between researchers who focus on adults and
researchers who focus on children; between researchers
who investigate typical development and researchers who
investigate atypical development; and between researchers
and clinicians.
Research projects designed to prevent maltreatment
provide one example of collaboration and cooperation
focused on providing interventions with immediate
and powerful effects. Valentino (2017) examines
maternal sensitivity and attachment organization as core
components of the mother–child relationship that are
targets of change in families at risk for maltreatment.
Improvements in maternal sensitivity and attachment
interrupt the negative cascades that are often observed
in cases of maltreatment. Relationship interventions
are described as the most promising for increasing
resilience in children, parents, and families. These
types of intervention will be discussed in more detail in
Chapter 8.
Box 3.1 Risk and Resilience
The Pediatric Innovation Initiative: Research, Policy, and Practice
The Pediatric Innovation Initiative (PII), coordinated through
Harvard University, is a national network of research scientists,
pediatric clinicians, and community leaders dedicated to
understanding and ameliorating the developmental effects of
early childhood adversity (also called “toxic stress”). The PII
serves as a good example of a research design of sufficient
complexity to match that of the developmental issue being
studied. Toxic stress refers to excessive stress activation in
early childhood, experienced in the absence of buffering
relationships, and has become a prominent area of concern
throughout the pediatric community.
Clinical and epidemiological studies clearly demonstrate
that adversity experienced early in life increases the risk for a
variety of physical and mental disorders accruing over the
lifespan. This includes the premature onset of diseases of aging
such as metabolic syndrome, cardiovascular disease, and type II
diabetes. Additionally, early life adversity, operating through
impacts on stress-mediating systems, may compromise early
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neurodevelopment and impede children’s ability to function
well at school and later in life. These medical and neurocognitive
challenges also confer significant health and economic burdens
on society over time and contribute to a wide range of health
disparities resulting from conditions such as poverty and
structural racism. If addressed early, however, the negative
outcomes resulting from early adversity can be ameliorated or
prevented. With this in mind, a group of dedicated child
development experts established the PII collaborative network
(Harvard Center for the Developing Child, 2019).
Recognizing the need for multiple areas of expertise, the
initial network membership included developmental scientists,
pediatric practitioners, and community leaders, including many
representing communities of color. The ultimate goal of this
network is to develop a validated set of biological and behavioral
measures that can be employed in pediatric practice to identify
children experiencing the effects of toxic stress and to do so long
before they reach kindergarten. The PII network developed a
(Continued)
48 Chapter 3 Principles and Practices ofDevelopmental Psychopathology
robust set of measures to screen young children for individual
differences in sensitivity to context through the use of biological
measures of stress activation and behavioral measures of
resilience. These measures, in turn, can be used to make referrals
to well-matched services and measure intervention effects to
inform ongoing, individualized treatment. Additionally, the
results of early screening will also provide reassurance for parents
of children who are doing well.
The toxic stress assessment will make it possible to identify,
within the context of pediatric primary care, the effects of
adversity and promote resilience and to do this beginning in
infancy and continuing throughout early childhood. Examples
of the metrics in the assessment include markers of immune
system activation found in saliva, evidence of epigenetic aging
measured in cells collected with a simple cheek swab, behavioral
measures of executive functioning, and questionnaire data
related to family and community risks and resources.
One example of the work of the PII network is the collaboration
of the University of Minnesota and Children’s Hospital
of Minnesota on a series of studies conducted over 7 years.
These studies specifically focused on the development of executive
function skills (EF), including the development of a brain region
highly sensitive to toxic stress, the prefrontal cortex. Executive
functions include skills such as working memory and the ability
to balance cognitive flexibility with persistence; these skills are
foundational to academic success. The roots of executive function
skills begin in late infancy and develop rapidly through the
preschool years. Consequently, these studies began by looking at
early executive functioning in the developmental context of
attachment security and the timely emergence of joint attention
skills. In addition, investigators explored new ways to measure
the executive function skills of preschool children during routine
pediatric appointments. Key findings from the Minnesota studies
contributing to the larger Pediatric Innovation Initiative are
summarized here.
● In the first study, family income correlated both with how
many stressors families experienced and with the security of
the child’s attachment relationship. Further, among families
with lower incomes, attachment security was especially
salient in the face of the brief stress of a vaccination shot. In
families with lower incomes, insecurely attached toddlers came
into the clinic with higher cortisol levels (a stress biology
marker) to begin with, and these levels rose over the course
of the visit. Securely attached toddlers from lower-income
families arrived with cortisol levels that actually were lower
than those of children from families with higher incomes
and fewer stresses. This suggests that parents who manage
to create secure relationships with their babies under trying
circumstances may be even better stress buffers than those
parenting under less harsh circumstances. Since we know
that a secure attachment relationship protects developing
brain circuitry crucial to the development of later EF skills,
early support for the caregiver-infant relationship, especially
under conditions of heightened stress, is especially important
(Johnson et al., 2018).
● The second study, involving a different cohort of toddlers,
focused on the role of joint attention as early developmental
scaffolding for later executive function skills. Joint attention
refers to two individuals sharing attention to the same thing
in the same moment and the awareness they are doing so. This
is a basic building block for executive function skills essential
to language and cognitive development. This study found
that family income was associated with the development of
toddler joint attention skills and may contribute to the SESlinked disparities in language and cognitive skills found later
in childhood (Reilly, Stallworthy et al., 2022).
● The third study was conducted over several years beginning
with 2- and 3-year-old children. Among the important findings
was validation of a brief, tablet-based measure of executive
function that can be reliably administered as part of pediatric
well-child visit. Additionally, and consistent with the earlier
studies, family income was negatively correlated with early
development of executive function skills (Reilly et al., 2022).
Key Terms
Psychopathology (35)
Developmental psychopathology (35)
Developmental pathways (36)
Equifinality (36)
Multifinality (36)
Coherence (38)
Competence (38)
Risk (40)
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Risk factors (40)
Resilience (40)
Protective factors (40)
Differential impact theory (42)
Child maltreatment (42)
Cross-sectional research (46)
Longitudinal research (46)
Developmental cascades (46)
Translational research (47)
Chapter Summary
●
Developmental psychopathology focuses on the
developmental context within which maladaptive
patterns of emotion, cognition, and behavior occur.
●
The study of developmental pathways highlights patterns
of adaptation and maladaptation over time.
●
Equifinality refers to developmental pathways in which
differing circumstances lead to the same diagnosis,
whereas multifinality refers to developmental pathways
in which similar beginnings lead to different outcomes.
●
The developmental pathways model emphasizes the
ongoing possibility of change over time.
●
Coherence in development reflects the logical links
between early developmental variables and later
outcomes. Continuity is found in understanding the
relationship between outcomes and the variables that
lead to stability or change.
●
Competence, from a developmental perspective, reflects
effective functioning in relation to relevant developmental
tasks and issues; evaluations of competence are embedded
in the environment within which development is occurring.
●
Risk is defined as increased vulnerability to disorder, while
risk factors are the individual, family, and sociocultural
characteristics that are associated with this increased
Research Strategies in Developmental Psychopathology 49
vulnerability. The types of risk factors, the numbers of
risk factors, and the timing of risk factors contribute to
overall risk.
●
Resilience is defined as adaptation despite adversity,
and protective factors are the individual, family, and
sociocultural characteristics that are associated with this
positive adaptation.
●
The multisystemic approach to resilience emphasizes
that resilience is observed at multiple levels, from the
physiological level to the psychological level to the
community level.
●
Cross-sectional research involves the collection of data
from comparison groups at a single point in time.
Longitudinal approaches involve the ongoing collection
of data from the same individual or group of participants
over time.
●
Complex models of development and disorder influence
research investigations of the emergence, course, and
prevention of psychopathology in children and adolescents.
●
The purpose of translational research is to facilitate the
application of basic research to clinical practice, and to
inform research with findings and insights drawn from
applied practice.
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4
Classification, Assessment and
Diagnosis, and Intervention
Chapter Outline
Classification 51
Categorical Classification
Dimensional Classification
Developmental Contributions to Classification Systems
Heterogeneity, Comorbidity, and Transdiagnostic Symptoms
Alternative Approaches to Classification
Assessment and Diagnosis 55
Definitions of Assessment and Diagnosis
Emerging Science: A Comparison of the Research
Box 4.1
Domain Criteria (RDoC) and the Hierarchical Taxonomy of
Psychopathology (HiTOP) Models
Learning Objectives
1. Identify the strengths and challenges of the categorical
approach to classification.
2. Identify the strengths and challenges of the dimensional
approach to classification.
3. Explain how the constructs of reliability and validity
influence approaches to classification.
4. Describe the factors and processes that contribute to
heterogeneity in classification.
5. Describe the factors and processes that contribute to
comorbidity in classification.
Methods and Processes of Assessment
The Case of Eden
The Case of Kai
The Case of Rohan
Intervention 62
The Efficacy of Psychotherapy for Children and Adolescents
Primary, Secondary, and Tertiary Interventions
Working with Parents and Families
Working with Schools and Communities
6. Using a new case example, appraise the usefulness of three
assessment techniques.
7. Summarize the evidence related to efficacy of psychotherapy
for children and adolescents.
8. Compare primary, secondary, and tertiary prevention.
9. Describe the roles played by parents and families in child
and adolescent interventions.
10. Describe the roles played by schools and communities in
child and adolescent interventions.
50
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Classification 51
On the one hand, we have infants, children, and adolescents
who are struggling, distressed, and deeply pained. On the
other hand, we have theories about typical and atypical
development, research on risk and resilience, and beliefs
about psychotherapy. In this chapter, we are going to make
specific and practical connections between the children and
the theories. The most basic questions are addressed: What
kinds of disorders do children experience? Which disorder
best describes a particular child’s distress and dysfunction?
And what can be done to help?
Classification
Given that it is useful to conceptualize some forms of children’s
struggles, distress, and pain in terms of disorder, we need to
have some reasonably organized way to think about different
kinds of disorders. We need classification. Classification is
defined as a system for describing the important categories,
groups, or dimensions of disorder. Classification is
differentiated from diagnosis, which is the method of assigning
children to specific classification categories.
A good classification system serves several clinical, research,
and theoretical purposes. It enhances clinical utility; that is, it
helps clarify thinking about the expression and emergence of
particular disorders as well as about prognosis and treatment
decisions. For example, if we know that a child’s pattern of
cognitive, emotional, and behavioral difficulties is consistent
with the clinical presentation of autism spectrum disorder,
then we know something important about the cause and
course of the disorder, and we know something useful about
effective interventions. Classification also allows mental health
professionals to communicate effectively about their clients and
various disorders. If we are working with a child with autism
spectrum disorder, then we can discuss relevant options for
treatment with parents, other clinicians, or teachers.
Classification also improves research efforts. Different
investigators with similar understandings of disorders are
better able to develop theories about the nature of specific
psychopathologies, explain hypotheses, recruit participants,
and talk about data. Finally, efforts to improve classification
contribute to the ongoing revisions of the principles and
practices of developmental psychopathology discussed in
the previous chapter. Across all these classification purposes,
we want to create and/or increase order and organization to
meaningfully inform our work with children.
As we consider various classification schemes, it is
important to keep in mind that any classification results
in the loss of individual information. Classification in
developmental psychopathology is focused on the many ways
in which children with particular disorders are alike. But we
know, of course, that each child is unique in his, her, or their
pattern of difficulties (and strengths). Knowing, for instance,
that a child displays the distress and dysfunction associated
with depression (in contrast to anxiety) is one significant
source of information, but it is also important to evaluate the
unique circumstances of each child with depression.
Categorical Classification
Categorical classification depends on identifying sets of
symptoms that co-occur (or are often observed together)
and that collectively are best understood as distinct,
different disorders connected to the categorical models
discussed in Chapter 2. Categorical classification assumes
that there are groups of individuals with relatively similar
patterns of disorder. With an ideal categorical scheme, each
disorder would have its own specific etiology, course, and
treatment.
The Diagnostic and Statistical Manual
The best-known example of categorical classification is
the Diagnostic and Statistical Manual (DSM) of the
American Psychiatric Association. Introduced in 1952, the
DSM was designed as a practical tool for clinicians. Despite
that era’s pervasive psychoanalytic influence, the DSM
was intended to be atheoretical and primarily descriptive,
providing useful information about the clinical picture
and the course of psychopathology. The DSM is tied, in
large part, to the medical model of psychopathology. Key
assumptions of the medical model are that (1) disorders
are categorical (i.e., reflecting clear distinctions between
healthy and disordered adjustments); (2) disorders are
associated with “constitutional dysfunction” (i.e., the
idea that the child somehow fails to display his, her, or
their natural function) (Wakefield, 1992, 1997); and
(3) disorders are endogenous (i.e., a characteristic of the
individual rather than the result of individual–environment
interactions).
The 1952 DSM included only one separate childhood
disorder: adjustment reaction of childhood and adolescence,
listed in the section on “transient situational disorders.” All
other classifications of children’s disorders were understood
as identical to adult disorders, with the same clinical
presentation and prognosis. DSM-II, published in 1968,
included nine different disorders observed in children,
with two of them—mental retardation and childhood
schizophrenia—in a separate childhood section. By 1980,
with DSM-III (and 1987, with DSM-III-Revised), 44 child
and adolescent disorders were described, with a much larger
section specifically focused on disorders diagnosed in early
development. DSM-III introduced the system of multiple
axes, in which individuals were evaluated with respect to
clinical symptoms as well as important contextual factors
such as physical disease and level of stress. Following
extensive literature reviews, data analyses, and field trials,
DSM-IV was released in 1994, with over 350 different
categories of adult and child disorders. DSM-IV again
increased the number of classification categories for
children and made special efforts to incorporate more
developmental data. In 2000, DSM-IV-TR (Text Revision)
was distributed, with additional information provided
about many disorders but with few changes to diagnostic
categories or criteria.
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52 Chapter 4 Classification, Assessment and Diagnosis, and Intervention
DSM-5, published in 2013, involved more significant
reorganization and revision. In this edition, the arrangement
of categories reflected a more developmental perspective.
For example, the section on neurodevelopmental disorders
(typically first diagnosed in childhood) comes before the
section on neurocognitive disorders (typically diagnosed
later in adulthood). Descriptions of disorders included agerelated factors relevant to diagnosis as well as information
about how symptoms may vary across the lifespan.
DSM-5 also represented an attempt to group disorders
based on empirical findings from studies of genetics and
neuroimaging. DSM-5-TR (Text Revision) was published
in 2022, with updates to descriptions and diagnostic criteria
for many disorders and increased attention to culture,
racism, and discrimination.
With any system of classification, we are concerned
with measures of reliability and validity. Reliability has
to do with whether different clinicians, using the same set
of criteria, classify children into the same, clearly defined
categories. Interrater reliability is noted when, for
example, two or more psychologists, gathering information
about one child’s developmental history and current
difficulties, come to the same decision about the type of
disorder. For example, a child who experiences classroom
difficulties may be assessed by a school psychologist who
identifies attention-deficit hyperactivity disorder and
a learning disorder. If that same child receives another
assessment by a child clinical psychologist who is doing a
more comprehensive assessment related to family conflict,
interrater reliability means that the child will be diagnosed
again with ADHD and a learning disorder. Cross-time
reliability is noted when a child is similarly classified by
psychologists at two different points in time. A classification
system that includes descriptions of both continuity and
change is important, especially for disorders that are
chronic, such as intellectual developmental disorder. With
a reliable classification system, a child with intellectual
developmental disorder would be similarly classified at age
3 and at age 10, even though there would be somewhat
different patterns of symptoms and adjustments.
Validity has to do with whether the classification gives us
true-to-life, meaningful information. Specifically, internal
validity tells us something important about the etiology of
a disorder or the core patterns of symptoms or difficulties
experienced by children with a particular type or subtype of
disorder. An 8-year-old child with a diagnosis of obsessivecompulsive disorder (OCD) and a 14-year-old adolescent
with a diagnosis of OCD, for example, should each display
a similarly distinctive pattern of distress and dysfunction
that helps us understand their current inability to be
comfortable with themselves and in their everyday lives.
External validity tells us something important about the
implications of the disorder. For example, most children and
adolescents diagnosed with obsessive-compulsive disorders
might be expected to respond favorably to evidence-based
interventions for OCD.
Dimensional Classification
The DSM approach initially grew out of the subjective
impressions and descriptions of experienced clinicians.
Over the years, a more objective strategy for conceptualizing
disorder has emerged (for both the DSM and other
classification systems). Achenbach (1997, 2009, 2020)
characterizes this empirical approach to classification as a
bottom-up process involving (1) the collection of data from
children, adolescents, and adults with typical and atypical
adjustments, followed by (2) attempts to group the many
distresses and dysfunctions statistically into meaningful
dimensions (or important characteristics) of disorder. This
process contrasts with the top-down approach of clinical
classification, which involves (1) the identification of types
of disorder, and then (2) the specification of symptoms of the
disorders. Owing much to Achenbach’s decades-long work,
this type of classification is based on statistical techniques
that identify key dimensions of children’s functioning and
dysfunction, with the assumption that all children can be
usefully described along these dimensions. Differences
among children, then, reflect differences in degree (or
quantity) of a dimension rather than differences in kinds of
dimensions.
The two most identified dimensions of disorder include
(1) an externalizing dimension, with undercontrolled
behaviors such as oppositional or aggressive behaviors
that are often directed at others; and (2) an internalizing
dimension, with overcontrolled behaviors such as anxiety
or social isolation that are often directed toward the self.
For both externalizing and internalizing dimensions,
children or adolescents would be diagnosed with a disorder
when they exceed a certain number of symptoms or present
a pattern of symptoms that reflect significant impairment.
In addition to the broad internalizing versus externalizing
distinction, descriptions of more specific dimensions
include the following: withdrawal, somatic complaints, social
problems, thought problems, aggressive behavior, delinquent
behavior, attention problems, and anxious/depressed problems.
A third dimension, reflecting thought problems, has
also been described. Figure 4.1 provides a hierarchical
illustration of these dimensions. This dimensional system
has been studied in multiple international samples with
similar patterns of problems observed (Rescorla et al., 2012).
Children and adolescents may display distress and
dysfunction that reflect mostly internalizing difficulties
(e.g., a combination of anxious/depressed problems and
somatic complaints); mostly externalizing difficulties (e.g.,
a combination of rule-breaking behaviors and aggression);
or a mixture of both (e.g., attention problems, aggressive
behavior, and anxious/depressed problems). Figure 4.2
illustrates one way that internalizing and externalizing
dimensions might be mapped to describe the adjustment
and maladjustment. Children and adolescents low on
both internalizing and externalizing dimensions would
include a variety of typically developing children. Those
with moderate scores on either or both internalizing or
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Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.
Classification 53
School-Age (6−18 years)
High scores on
dimension
Low scores on
High scores on
Figure 4.1 Hierarchy of empirically-derived Achenbach System of Empirically Based
Assessment (ASEBA) problem scales
Total Problems
Internalizing
Anxious/
depressed
Source: https://aseba.org/wp-content/uploads/2019/04/catalog.pdf
Withdrawn/
depressed
Somatic
complaints
Social
problems
Figure 4.2 Patterns of Disorders displayed by
children and adolescents along internalizing
and externalizing dimensions
externalizing
dimension
Externalizing
disorders
internalizing
dimension
Typically developing
children
Low scores on
externalizing
externalizing dimensions might warrant extra attention
but would not necessarily meet the clinical or statistical
criteria for actual psychopathology. Only those children
and adolescents with extreme scores on either or both
dimensions would be diagnosed with a disorder. Some
children and adolescents, of course, display thought
problems in combination with either or both internalizing
and externalizing problems; those patterns of difficulties
are not illustrated in this figure.
Mixed internalizing-
externalizing disorders
internalizing
dimension
Internalizing
disorders
Externalizing
Thought
problems
Rule-breaking
behavior
Attention
problems
Aggressive
behavior
Developmental Contributions
to Classification Systems
Beginning with early attempts to devise useful descriptions
of psychopathology, the focus has been on the classification
of adult disorders. For accurate classification of child
and adolescent disorders, it is necessary to integrate a
developmental perspective into classification systems,
emphasizing salient age- and stage-related concerns as well
as descriptions of developmental pathways that incorporate
continuity and/or change.
One example of a classification scheme that illustrates the
connections between typical and atypical development is the
Diagnostic Classification of Mental Health and Developmental
Disorders of Infancy and Early Childhood, published by the
Zero to Three Association (1994, 2005, 2016). Unlike the
DSM, a product of mainly one group of mental health
professionals (i.e., psychiatrists), the Zero to Three manual,
expanded in the 2016 update to provide comprehensive
classifications for young children from birth to five years,
reflects the contributions of multiple disciplines, including
psychology, social work, nursing, early education, and
medical specialties.
Like the DSM, Zero to Three’s system is categorical.
But the Zero to Three system, focused exclusively on the
earliest manifestations of disorders, is much more explicit
in its developmental orientation. For example, the child–
caregiver relationship is identified as a possible locus of
disorder. The clinician considers (1) the behavioral quality
of the relationship between the child and caregiver, (2) the
emotional tone of the relationship, and (3) the degree of
Copyright 2024 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s).
Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.