Lecture Notes in Child and Adolescent Psychiatry

BASIC CONCEPTS IN MENTAL HEALTH

OBJECTIVES

This chapter will provide the definition and dimensions of mental health. In addition, the common causes of mental disorders, populations affected by mental disorders, and how mental disorders impact an individual’s daily functioning will be covered.

INTRODUCTION

Definition of mental health: The psychological state of someone who is functioning at a satisfactory level of emotional and behavioural adjustment

DIMENSIONS OF MENTAL HEALTH

Happiness: Unhappiness is often the presenting feature of mental disorder

Efficiency: A mentally healthy person has the drive necessary to fulfill his/her needs

Lack of anxiety: Anxiety has been proven to be the chief trait of a wide range of mental disorders

Lack of guilt: Guilt may reflect a propensity for self-punishment

Maturity: Refers to the trajectory from inner disorganization to the development of self-control

Adjustment: Refers to an individual’s capacity to adjust to the demands of society in a flexible and resilient way

Autonomy: Implies independence, self-control, and self-sufficiency

Self-esteem: Healthy awareness of positive attitudes and feelings of confidence

Ability to establish adequate emotional bonds with others: Capacity for love and to have relationships is central to effective social functioning

Contact with reality: Individual can clearly perceive and cope adequately with the realities of his/her social groups

WHAT IS A MENTAL DISORDER?

A mental disorder is an illness with psychological or behavioural manifestations associated with impairment in functioning.

Each illness has characteristic signs and symptoms.

WHAT CAUSES MENTAL DISORDERS?

Genetic factors

Developmental disorders

Environmental factors

Stress

Life events

Family as a pathogenic institution

Medical illness

WHAT POPULATIONS ARE COMMONLY AFFECTED BY MENTAL DISORDERS?

Studies suggest that women are more susceptible to mental disorder than men, e.g., pre-menstrual period, puerperium, and following a hysterectomy. Women are less inhibited than men in discussing emotional problems. While marriage seems to be a protective factor for men, it may place women at a greater risk for mental disorder.

There is a strong relationship between social class and mental disorder: the lowest social classes are at a higher risk of mental disorders.

Age and susceptibility: Schizophrenia tends to manifest in the adolescent years; suicide risk tends to increase with age.

The incidence of paranoia and depressive illness increases in middle age.

Transcultural studies reveal variations in concepts of health and disorder.

HOW DO MENTAL DISORDERS AFFECT PEOPLE?

Mental disorders may cause disturbance of thought, perception, mood, and behaviour.

Most common thought disturbance: Delusion

Most common perceptual disturbance: Hallucination

Mood (affect) is subject to a wide range of disturbances, ranging from mania to depression and anxiety.

General behaviour and activity are also subject to a variety of disturbances.

CONCLUSION

The dimensions of mental health are diverse. Each illness has characteristic signs and symptoms. Gene-environment interactions are the most common causal factors of mental illness. Certain populations may be at a higher risk of mental illness than others.

REFERENCES

Jacobs, S. C. & Steiner, J. L. (Eds.). (2016). Yale Textbook of Public Psychiatry. New York, NY, USA: Oxford University Press.

Lyttle, J. (1986). Mental Disorder: Its Care and Treatment. London, UK: Bailliere Tindall.

Pilgrim, D., Rogers, A, & Pescosolido, B. A. (Eds.). (2011). The SAGE Handbook of Mental Health and Illness. London, UK: Sage Publications.

Thornicroft, G. & Szmukler, G. (Eds.). (2001). Textbook of Community Psychiatry. New York, NY, USA: Oxford University Press.

2

DEVELOPMENTAL PSYCHIATRY

OBJECTIVES

This chapter will describe human developmental domains, developmental theories, child development (cognitive, language, social, etc.), developmental disorders, and the developmental transformation from childhood to adolescence.

DEVELOPMENTAL DOMAINS

1)Physical domain: Involves changes in the brain’s shape, size, and structure, sensory capabilities, and motor skills

2)Cognitive domain: Includes acquiring skills in perception, thinking, reasoning, and problem-solving, as well as the complex development and use of language

3)Personality domain: Segment of development that includes acquiring relatively stable, enduring traits and a sense of self as an individual

4)Sociocultural domain: Segment of development comprised of socialization and enculturation

DEVELOPMENTAL PROCESSES

Interaction between biology and experience (environment)

Nature vs. Nurture

Theorists still disagree about the relative contributions of nature and nurture and the manner of their interaction.

Critical vs. Sensitive Periods

Are there critical periods during which certain types of development must occur or else they will never occur?

•Critical period: The only span of time when a particular environmental factor can have an effect

•Sensitive period: The times during which certain types of learning and development occur best and most efficiently but not exclusively

STUDYING HUMAN DEVELOPMENT

Case Study

A case study is the compilation of often large and intricate amounts of information on an individual, family, or community through interviews, observations, and formal testing, e.g., baby biographies.

Darwin (1809–1882) kept a daily record of his son’s early development.

Freud (1856–1939) authored thorough and systematic case studies.

Systematic Observations

Naturalistic or field observation: The method by which researchers go into everyday settings, observe, and record behaviour while being as unobtrusive as possible

Laboratory observation: The method by which researchers set up controlled situations designed to elicit the behaviour of interest

Limitations:

1)Behaviour of interest may not occur

2)Presence of an observer may inhibit natural behaviour

3)Infants might behave differently in a laboratory setting

Questionnaires and Surveys

Advantages: Information can be objectively and efficiently tabulated; very large numbers of people can be assessed quickly.

Surveys are only valuable if they accurately represent the views of the population in question (representative sample).

Most internet surveys are inaccurate.

Psychological Testing

IQ tests

Personality-related testing

Reliability: They should yield similar scores from one testing occasion to the next.

Validity: They actually measure what they are supposed to measure.

Standardized: They have been administered to representative samples of people to establish norms to which an individual’s responses can be compared.

DEVELOPMENTAL RESEARCH DESIGNS

Longitudinal Design

In a longitudinal case study, the same participants are observed over a period of time.

Drawbacks:

1)Over time, participants can become practiced and familiar with the tests (e.g., studies of intelligence).

2)There is a limit to how many such studies a researcher can conduct in a lifetime.

3)Possibility of bias: Participants can become ill, move away or stop participating in the research project. The remaining participants may no longer be representative of the original target population.

Cross-Sectional Design

In a cross-sectional study, a sample of individuals of one age is compared with one or more samples of other age groups.

Advantages: Quicker, cheaper and more manageable

Drawbacks:

1)Cannot assess individual development

2)Cohort effects: Sociocultural differences between people of different age groups

3)Confounding: The problem of not being able to tell if the effects noticed between cohorts are due to development factors or historical factors

Sequential Cohort Design

In a sequential cohort study, several overlapping cohorts of different ages are studied longitudinally.

Comparisons can be made both longitudinally and cross-sectionally. For example, a research study might start with a group of 4-year-olds, a group of 8-year-olds and a group of 12-year-olds and study each cohort every 2 years for 8 years.

Ethics

Experiments using humans are necessary.

Researchers nowadays must adhere to strict ethical principles.

The most basic principle: Researchers should never knowingly cause significant or lasting harm to anyone.

There must be informed consent.

DEVELOPMENTAL THEORIES

Evolutionary theory

Stage theory

Freud

Erikson

Pavlov and Skinner

Social learning

Piaget

Bell (family)

Kohut

Evolutionary Theory

Charles Darwin (1809–1882)

Not a theory of child development but a theory of the development and adaptation of species.

Adaptation to the environment: A change in a species that increases the species chances of survival in a particular environment

Natural selection: The process by which traits that are well adapted to an environment are selected through reproduction and become increasingly common in a species.

Darwin’s view, that the evolution of species (i.e., the development of species through structural changes over time) is based on an interaction of genes and environment, is widely accepted.

Human development is the product of genes, developmental history, and current environmental conditions.

Darwin’s theory helps focus attention on the genetically based inclinations and abilities common to all humans that have helped our species survive, including a group-living nature and a propensity to form social ties, an ability to create complex systems of communication, a motivation to explore and discover, and an exceptional capacity to learn, reason and solve problems.

Stage Theory

Stage theory proposes discrete periods of developmental changes with abrupt transitions from one period to the next vs. continuity.

However, some developmental changes are clearly gradual and cumulative (e.g., motor development).

Cognitive developmental theorists stress stages.

Discrete stages: Children see the world in qualitatively different ways compared to adults

Present-day view: We move gradually from one stage to the next and often go back and forth between stages.

Psychoanalytic Theory:

Sigmund Freud (1856–1939)

Free association: The trends of thought that spontaneously arise when restraint and censorship upon logical thinking are removed and subject reports everything that passes through his/her mind (Campbell, 1989)

Resistance: A manifestation of the repressive forces

Id (animal): The primitive, selfish component of personality

Ego (reality-oriented perception of reality and adaptation to it): Defence mechanisms (a way of reducing, or at least disguising, anxiety)

Superego (conscience, ego ideal): Morality principle. It is the representative of society within the psyche.

Freud’s Psychosexual Stages:

Oral (birth to age 1 or 1 ½)

Anal (age 1 or 1 ½ to 3)

Phallic (age 3, 4, or 5 to 6)

Latency (age 5 or 6 to 12)

Genital (age 12+)

Psychosocial Theory

Erik Erikson (1902–1994)

Neo-Freudian; different emphasis

Epigenetic principle: Ground plan that sets the stage for development throughout the organism’s lifespan

Ego identity: A basic sense of who we are as individuals in terms of self-concept and self-image

Erikson’s Psychosocial Stages

Trust vs. mistrust (birth to age 1)

Autonomy vs. shame and doubt (age 1 to 3)

Initiative vs. guilt (age 3 to 6)

Industry vs. inferiority (age 6 to 12)

Ego identity vs. ego diffusion (age 12 to 18+)

Intimacy vs. isolation (age 18 or older to 40)

Generativity vs. self-absorption (age 40 to 65)

Integrity vs. despair (age 65+)

Classical Conditioning

Ivan Pavlov (1849–1936)

Experiments on salivation in dogs

Two or more stimuli are paired and become associated with each other in the subject’s brain

Operant Conditioning

B. F. Skinner (1904–1990)

An animal’s behaviour operates on its environment and is repeated or not repeated because of the consequences (reward or unpleasant outcome)

Environment influences our development

Social Learning Theory

Albert Bandura (born 1952)

Children and adults observe their own behaviour, the behaviour of others and the consequences of behaviour.

Miller (1989): People form opinions about themselves and others and then behave in ways that are consistent with those opinions.

Limitations: Approaches learning as a one-way street. Learning is not always a result of observing and imitating others.

Piaget’s Cognitive-Developmental Theory

Jean Piaget (1896–1980)

Thinking, reasoning, and problem-solving

The mind grows, changes, and adapts to the world.

Thinking is qualitatively different in children and adults.

The mind is an active participant in the learning process.

Assimilation: Interpreting new experiences in terms of existing mental structures—schemas

Accommodation: changing existing schemas to integrate new experiences

Piaget’s Stages of Cognitive Development

Sensorimotor (birth to about age 2): Infants understand the world through sensory information and motor responses.

Pre-operational (age 2 to about age 7): Children use mental representation to reason about the world, but thinking is not yet logical.

Concrete operational (age 7 to age 11 or 12): Children can perform logical operations on concrete objects.

Formal operational (age 11 to 12+): Children can think logically about abstract issues and hypothetical situations.

Piaget´s Account of Object Permanence

Stages 1 and 2 (sensorimotor):

•Birth to 4 months

•Infants respond with interest to objects

•No understanding of object permanence

•Track moving objects and reach for them

Stage 3 (4–8 months):

•Partial view is enough to remind them of the whole

Stage 4 (8–12 months):

•Search for hidden objects

•Understanding of object is still flawed

Stage 5 (12–18 months):

•Cannot make inferences about what happens to an object that is out of sight (i.e., searches for a hidden object where it was before it disappeared from sight).

Stage 6 (18 to 24 months):

•Mature understanding of object permanence

The family context

Bidirectional effects: While the characteristics of the parents help shape the behaviour of their children, the characteristics of the children in turn influence their parents’ behaviour.

Newborns come equipped with certain predispositions that enable them to participate in early social exchanges, provided they receive responsive caregiving.

Predispositions

Innate ability to signal psychological and physiological needs in ways adults can interpret and are likely to respond to.

The capacity to detect contingencies in the environment

Built-in attraction to social stimuli

The baby’s inclination to fall into step (i.e., align) with the caregiver’s behaviour

Kohut’s Self Psychology

Heinz Kohut (1913–1981)

Object relations theory emphasizes the relationships between representations of self and object.

Self psychology stresses how external relationships help maintain self-esteem and self-cohesion.

It describes a person as being in desperate need of certain responses from other persons to maintain a sense of well-being.

Evolved from Kohut’s study of narcissistically disturbed outpatients.

Different from neurotic patients (hysterical, obsessive-compulsive)

These patients presented with nondescript feelings of depression or dissatisfaction in relationships.

Also characterized by a vulnerable self-esteem

Formed two kinds of transferences: The mirror transference and the idealizing transference

Ego psychology: A model of conflict

Freud’s model proposed a transition from a state of primary narcissism to object love as part of the normal maturational process (i.e., to outgrow narcissistic strivings and be more concerned about the needs of others).

Kohut asserted that narcissistic needs persist throughout life and parallel development in the realm of object love.

Transferences

Mirror transference: The patient looks to the analyst for a confirming, validating response.

Phase-appropriate displays of exhibitionism: the grandiose-exhibitionistic self

These approving responses are essential for normal development; provide the child with a sense of self-worth.

Idealizing transference: The patient perceives the therapist as an all-powerful parent whose presence soothes and heals.

With adequate parenting, the grandiose self is transformed into healthy ambitions, and the idealized parent imago becomes internalized as ideals and values.

First book: Applicable primarily to narcissistic character pathology

Last book: Greatly expanded the scope of self psychology

Self psychology is now attempting to demonstrate … that all forms of psychopathology are based either on defects in the structure of the self, on distortions of the self, or on weakness of the self. It is trying to show, furthermore, that all these flaws in the self are due to disturbances of self-selfobject relationships in childhood (Kohut, 1984, p.53).

Selfobject: the role that other persons perform for the self in regard to mirroring, idealizing, and twinship needs

The Beginnings of Attachment Theory

An enduring emotional tie between an infant and a caregiver (Bowlby, 1969/1982)

Works in both directions

Calming down after birth

Prolactin and oxytocin

Involvement of the father

Attachment Process

Mary Ainsworth (1983) defined attachment behaviours as those that primarily promote nearness to a specific person.

Include signalling (crying, smiling, vocalizing), orienting (looking), moving in relation to another person (following, approaching), and actively attempting physical contact (embracing, clinging)

Behaviours critical to attachment: If they do not occur, attachment can be difficult to establish

When a baby dislikes being touched or has a disability such as blindness, mutual attachment is at risk.

Thus, infant and caregiver alike must behave in ways that foster attachment.

The baby’s behaviour prompts the caregiver to act in certain ways, and the caregiver’s actions prompt the baby as well.

Is attachment a conditioned response or are innate needs involved?

Bowlby and Ainsworth were convinced that the nature of the parent-child interaction that emerges from the development of attachment in the first 2 years of life forms the basis for all future relationships.

Hallmarks of Attachment

Sign that attachment is emerging: Separation distress

Greeting reaction

Secure-base behaviour

Patterns of Attachment

Secure attachment

Anxious-resistant attachment

Anxious-avoidant attachment

Disorganized-disoriented attachment

Secure Attachment

Good balance between play and exploration on the one hand and a desire for proximity to the caregiver on the other (Ainsworth’s strange situation)

A pattern of attachment in which the infant is confident about the caregiver’s availability and responsiveness and can use the caregiver as a secure base for exploration

Anxious-Resistant Attachment

Infants seek a great deal of contact with their caregiver

They are quite upset when their mothers leave, yet they cannot be readily comforted by them at the reunion.

They tend to mix bids for physical closeness with resistance to such contact.

Anxious-Avoidant Attachment

Their response when their mothers return is striking: they actively avoid their mothers, turning away, moving away or studiously ignoring them.

Avoidance of their mothers is even more pronounced, following a second separation

Disorganized-Disoriented Attachment

In the Strange Situation, infants with this kind of attachment show contradictory features of several patterns or appear dazed and disoriented.

The caregiver is a source of threat, as in the case of abusive parents or parents whose behaviour is otherwise frightening or bizarre.

This pattern, especially in combination with avoidance, has been strongly linked to later psychopathology.

Infant Attachment and Later Development

Internal working models: an infant’s generalized expectations about the social world, including caregiver responsiveness, the infant’s own ability to obtain care, and the nature of social relationships

An infant who experiences reliable, responsive care develops a model of the caregiver as available, a model of the self as worthy of care and effective in obtaining it, and a model of social relationships as pleasurable and rewarding.

Bowlby: These representations are carried forward and influence later behaviour and relationships, colouring the child’s interpretations of events and influencing the kinds of experiences the child seeks or avoids.

In summary, attachment theories focus on the organization of an infant’s behaviour toward the principal caregiver, who becomes an attachment figure. The quality of this attachment relationship results from the history of interaction with the caregiver. That interaction, in turn, is influenced by the overall context of care, which includes the stress and social support the caregiver experiences as well as the characteristics of the particular child. The attachment relationship then provides a framework for later development and is reflected in the child’s degree of self-confidence, sociability, and capacity to cope with challenges.

Emotional Communication and Attachment

Focus is on the mutual expectations of parents and infants

Demonstration of strength and importance of emotional communication between caregiver and infant as young as 3 months of age.

When it fails, for example when the primary caregiver is chronically depressed or ill, the infant cannot achieve his or her interactive goals.

How can attachment be impeded?

Child abuse: Psychological or physical (sexual) injuries intentionally or unintentionally inflicted on a child by an adult; in the case of unintentional child abuse, it is often at the hands of a critically dysregulated caregiver

Child neglect: Failure of the caregiver to respond to or care for a child (usually unintentional)

Failure to thrive syndrome (FTT): A condition in which infants are small for their age and are often sick as a result of malnutrition or unresponsive caregiving

Weight in the lower 3% of the normal weight range for their age group.

Show no evidence of disease or abnormality that would explain their failure to grow.

Lack of affection and attention, including poor quality of attachment.

Family systems are at the heart of the development.

Influence on the kind of person the child becomes and the child’s place in society.

Expectations, roles, beliefs and relationships

Physical, cognitive, emotional, and social development

Transmitter of culture

The parent’s tasks:

•Adjust

•Support their child’s exploration of the world

•Set appropriate limits for the child

Scaffolding: The process by which parents support the child in new tasks by offering developmentally appropriate guidance, hints, and advice.

Becoming A Separate Person

Separation-individuation process: Mahler’s term for the child’s psychological separation from the caregiver and growing awareness of being an individual

Erikson’s theory: A major factor affecting how smoothly development unfolds is the way parents impose limits on the child.

Autonomy vs. shame and doubt: When a toddler’s sense of self begins to emerge and the child confronts parental limits, there is a potential either to develop a positive sense of independence and competence, based on feeling supported, or a sense of feeling shamed by parents and experiencing profound self-doubt.

Basic Trust

When trust is strong the toddler can seek autonomy and still feel secure.

Confidence is the product of each child’s history of interactions with the caregiver.

The parent’s reliability during infancy breeds a basic trust, which later enables the toddler to make initiatives toward independence.

The Influence of Parent-Child Relationships

The attachment history:

Studies show a clear association between the quality of the infant-caregiver relationship and independent measures of how well the child later functions as a toddler.

As a group, 2-year-olds who had been securely attached as infants were more enthusiastic in approaching problems, showed more positive emotions and less frustration, were more persistent and flexible, and cooperated more with their mother to reach a solution (not related to earlier measures of temperament).

Insecure attachment: Showed a variety of maladaptive responses. Some were intermittently clingy and dependent or whiny and prone to tantrums, quickly becoming frustrated or embroiled in conflict with their mother while the problem to be solved faded into the background.

Most common in anxious-resistant attachment

Other anxiously attached toddlers showed no enthusiasm or pleasure and little involvement in the problem. They either ignored or refused to act on their mother’s suggestions.

Most common in anxious-avoidant attachment

Parental support:

Securely attached: Caregivers were more likely to be supportive of their toddler in a problem-solving situation. They tended to adjust their behaviour depending on the particular demands of the situation and the child’s needs (anticipatory behaviour).

Anxious-avoidant attachment: Caregivers failed to increase the amount of help they offered as their toddler struggled to solve the problem. Many remained rather uninvolved throughout the child’s