Introduction to Abnormal Child and Adolescent Psychology. Robert Weis

(e.g., sweaty palms, flushed face), we usually need to measure distress by asking children how they feel. Some young children are unable to report their feelings. For example, they may complain of physical symptoms like headaches or stomachaches instead of negative emotions. Other children have trouble differentiating their feelings. For example, they might not be able to tell the difference between feeling “angry” and “hurt.” To complicate things further, there is no objective criterion by which we can evaluate the intensity of children’s distress. For example, a child who reports feeling “bad” might be experiencing more distress than another child who reports feeling “terrible.”

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      A second problem with defining abnormality based on distress is that many youths with serious behavior problems do not experience negative emotions. For example, some adolescents who engage in harmful and destructive behavior show no signs of anxiety or depression. They may only experience sadness or remorse when they are caught and punished. Similarly, younger children with oppositional and defiant behavior toward adults rarely express psychological distress. Instead, their disruptive behavior causes distress in others, like their parents or teachers (Image 1.2).

      A Harmful Dysfunction

      Jerome Wakefield (1992, 1997) offers an alternative, influential approach to defining abnormal behavior based on the notion of harmful dysfunction. According to this approach, a behavior is abnormal when two criteria are met. First, the person must show a dysfunction—that is, a failure of some evolutionarily selected internal mechanism to work in the correct manner. Second, the dysfunction must cause harm; it must limit the person’s life activities or threaten their health and well-being in some way (Widiger & Mullins-Sweatt, 2018).

      To understand the two criteria, let’s look at an example from the field of medicine. Heart disease is a medical disorder because (1) it involves an abnormality in the functioning of the body’s circulatory system and (2) this underlying dysfunction can cause disability or death. Similarly, Wakefield argues that the harmful dysfunction criteria can be used to identify mental health problems. For example, depression is a disorder because (1) it involves an inability to effectively regulate one’s emotions and (2) this underlying dysfunction can cause impairment, distress, and self-harm (Wakefield, Lorenzo-Luaces, & Lee, 2018).

       Review

       Professionals disagree about the best way to define abnormal behavior in children and differentiate it from normal childhood functioning.

       Three features of abnormality include (1) statistical deviation or infrequency, (2) disability or impairment, and (3) distress.

       Jerome Wakefield proposed the harmful dysfunction definition of abnormal behavior. A behavior is abnormal if it reflects an underlying dysfunction in a biological or psychological system and it causes disability or distress.

      How Does DSM-5 Define Abnormality?

      Definition

      In the United States, most mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to diagnose mental health problems in children and adults (American Psychiatric Association, 2013). The DSM-5 definition of a mental disorder reflects Wakefield’s notion of harmful dysfunction and emphasizes the role of disability and distress in differentiating normal and abnormal behavior:

      A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above. (American Psychiatric Association, 2013, p. 20)

      It is worth noting that DSM-5 describes people with mental disorders as “usually” experiencing significant disability or distress—they may not always show both characteristics. As we have seen, some youths experience tremendous emotional pain, but they do not show marked impairment in their social or academic functioning. Other youths drop out of school, abuse alcohol and other drugs, and/or engage in criminal behavior but do not report anxiety, depression, or low self-esteem. Although most youths with mental health problems experience both distress and impairment, only one feature is required for most DSM-5 diagnoses.

      Limitations

      DSM-5 is published by the American Psychiatric Association and reflects a medical approach to identifying mental health problems. According to the DSM-5 definition, mental disorders reside within the individual, just like medical illnesses. For example, if someone is diagnosed with smallpox, we know that the illness is caused by a virus that has infected the person’s body. The virus causes symptoms (e.g., fatigue, fever, rash) that lead to severe impairment and an increased risk of death. Similarly, practitioners who adopt the medical model for mental disorders assume that if a child exhibits behavioral, cognitive, or emotional symptoms, these problems are caused by some underlying dysfunction within the child that causes distress or impairment (Stein et al., 2010c).

      There are at least three limitations with the DSM-5 medical conceptualization of mental disorders, especially when it is applied to children and adolescents. First, we often do not know the underlying cause for children’s psychological problems. When physicians first described smallpox in the 15th century, they diagnosed the illness based on its symptoms: small blisters (i.e., pox) on the skin. It was not until many years later that researchers discovered that smallpox is caused by a viral infection, not the blisters themselves. Similarly, when a mental health professional diagnoses a child with ADHD, they are describing the child’s symptoms (i.e., hyperactivity and/or inattention), not the underlying cause of the disorder. Although researchers have identified several risk factors for ADHD, a single underlying cause for the disorder remains elusive (Pliszka, 2016).

      Second, many childhood disorders are relational in nature—that is, they occur between people rather than within an individual. Consequently, childhood disorders are best understood in an interpersonal context. For example, young children with oppositional and defiant behavior argue with adults, refuse to comply with requests, and throw tantrums when they do not get their way. Interestingly, their defiant behavior is often directed at some adults (e.g., parents) but not others (e.g., teachers). Therefore, the disorder seems to be dependent on the relationship between the child and specific people; it does not merely reside within the child. Relationships may be especially important to mental disorders in children and adolescents, who are highly dependent on other people for their well-being (Heyman & Slep, 2020).

      Third, children’s behavior can only be understood in terms of their social–cultural surroundings. Behaviors that people would consider “dysfunctional” in one context might be adaptive in a different setting. For example, consider a girl named Nia who lives with her parents on a military base in California. Upon hearing that her mother will soon be deployed to a combat area, Nia becomes excessively clingy with both parents, has problems eating and sleeping, and refuses to go to school. According to the harmful dysfunction criteria, Nia would likely be diagnosed with an anxiety disorder because (1) she has problems regulating her emotions and (2) these problems limit her social and academic functioning. However, her anxiety might be justified given her social context—that is, the imminent deployment of her mother. Behavior is best understood in the context of children’s social–cultural surroundings, never in isolation (Achenbach, 2019).