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NORMAL DEVELOPMENT

Development in Infancy and Early Childhood


Dale F Hay

This contribution highlights some recent psychological research on infants and young children, rst by describing some important attainments in the early years of life, then by looking at ways in which early risk factors disrupt normal psychological development. Although psychologists no longer regard the rst year of life as the single most important period for human development, recognizing that what happens later in childhood and adolescence is also significant, experiences in infancy do predict adverse outcomes, and precursors to later problems can be discerned.

acquire rudimentary language by the third year of life. Non-verbal communication is achieved much earlier than this, through gaze, gesture and babbling. There are links between early communicative abilities and language; for example, infants who develop non-verbal babbling late also show language delay. Verbal skills are enhanced by positive early motherinfant interaction and breast-feeding. Language problems individuals with speech or language problems in early childhood are at risk for later psychiatric problems. For example, retrospective analyses suggest that the majority of children who develop a schizophrenic disorder had major problems in early language acquisition. Children with speech and language decits in early childhood are at increased risk for substance misuse in adolescence. Forming relationships Infants demonstrate a keen interest in others (Figure 1), and soon recognize familiar people. Focused attachments to the parents are in place by the rst birthday and they may be more or less secure, as measured by home observations and a laboratory procedure termed the Strange Situation, in which an infant meets a stranger and is separated and then reunited with the mother. Infants also form attachments to their fathers, foster parents and paid caregivers, and these relationships also vary in security. The fact that security with one parent does not equate to security with the other demonstrates that attachment does not reduce to characteristics of infants that transcend different relationships. At the same time, the infants own temperament does inuence the attachment process. Secure attachment relationships are thought to derive from sensitive mothering in the early months of life. However, the correlation between sensitivity and security is modest. The closer in time sensitivity and security are measured, the higher they correlate, which suggests that maternal sensitivity may be a feature, not a direct cause, of a secure motherinfant relationship. Secure attachments arise in a number of different family contexts. For example, infants born as a result of IVF treatment are as likely as comparison infants to be secure, and mothers who experience a manic episode in the post-partum period can form secure relationships with their babies. In some contexts, infants are at risk of developing disorganized attachment patterns e.g. an infant whose birth follows that of a stillborn sibling.

Attainments in infancy
Important developments take place in the rst 3 years of life. Individual differences in each of the attainments below have long-term implications for childrens psychological adjustment. Self-regulation One of the infants major tasks is to manage its attention and emotion. Some infants are able to control their attention especially efciently, taking relatively little time to decide that an object or an event is unfamiliar; this early form of informationprocessing predicts IQ 18 years later. Some infants cry more than others, are more rhythmic in their actions and are more easily comforted by their caregivers. These aspects of infant behaviour are often discussed in terms of the concept of temperament, which is heritable. Dimensions of infant temperament, including the regulation of activity and anger, have been linked to dopamine and serotonin receptor genes. A difcult temperament in infancy predicts later behavioural problems. As they grow older, some infants are particularly likely to be wary in new situations and shy in response to social challenges. Highly wary children show excitability of the auditory pathways in the brainstem. They are more likely than other children to be socially wary 4 years later. Communication and language The word infant comes from the Latin without speech, and the ability to speak is the main achievement of infancy. Most children

Dale F Hay is Professor of Psychology at Cardiff University, UK. She studies social development in infancy and childhood, with special emphasis on cooperation, conict, interpersonal relationships and the development of psychopathology.

1 Very young children are remarkably interested in other human beings.

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Secure motherinfant attachment predicts good psychological adjustment later in childhood. However, recent long-term follow-up studies have shown that the security of attachment changes in the face of life circumstances, such as parental divorce, and that the predictive power of secure attachment is moderated by the childs later social environment. In other words, a secure attachment is a good start, but does not inoculate a child against the vicissitudes of life. Peer relationships infants also form focused relationships with peers, and early peer interaction reveals many of the same skills shown in infants interactions with adults. Early peer relationships differ in quality, and have long-term consequences. For example, toddlers aggressive behaviour towards peers is a significant predictor of later aggression and behavioural problems. Social understanding During the rst 3 years of life, children become aware of other peoples emotions, desires and intentions. By 4 years of age, the childs understanding of others has consolidated into what psychologists call a theory of mind. This is often assessed by tasks that measure whether a child can understand that other people can have incorrect beliefs, even though the child has access to the truth of the matter. One type of theory-of-mind test uses simple drawings to ask young children about a characters thoughts or feelings (see Figure 2). Children who do well in such tasks demonstrate their understanding that other people have mental lives. Conversely, autistic children have difculty with theory-of-mind tests. Social behaviours in infancy such as mutual gaze, pointing to and sharing of objects and pretend play have been suggested as precursors to later theory-of-mind skills. Children who do not use these forms of communication and play in infancy are at risk for autism. Gazing as a form of communication between infants and caregivers is especially predictive of later theory of mind. Social understanding is advanced through ordinary interactions between toddlers and other family members. Interactions

between siblings are particularly important for the development of social understanding.

Some risk factors


Development in each of the above domains can be disrupted by the infants prenatal and post-natal experiences. Prenatal experiences The effects of prenatal teratogens on infant morphology and physiology are well known. Prenatal insults also affect infants behaviour, temperament and cognition. For example, children born with HIV infection show delays in cognitive and motor development, and prenatal exposure to environmental toxins can lead to cognitive decits. Prenatal insults may lead to perinatal complications that place the infant at increased risk. Infants exposed to cocaine prenatally, for example, experience more medical complications in the neonatal period, an effect that appears to be mediated by their low birth weight. In one study, mothers who were depressed in pregnancy had higher levels of cortisol and adrenaline, and lower dopamine levels, than non-depressed women. After birth, their babies mirrored this pattern and showed decits on the Brazelton Neonatal Assessment, a standardized test of reflexes and temperament for newborns. Children whose mothers are depressed in pregnancy are at elevated risk for conduct problems in early adolescence (Figure 3). Global deprivation Follow-up studies of children adopted from Romanian orphanages have revealed considerable levels of resilience and recovery but also the long-term effects of inadequate care in infancy. Cognitive development shows a pattern of catch-up growth but

Prenatal depression and childrens conduct disorder


40

35

Not depression
30

Depression

25

20

15

10

Girls 2 A method for studying childrens theory of mind: which one does Charlie want? (Adapted from Baron-Cohen S et al. Are children with autism blind to the mentalistic signicance of the eyes? Br J Dev Psychol 1995; 13: 37998) 3
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Boys

Prenatal factors put children at risk for conduct disorder; associations between maternal mental health in pregnancy and childrens conduct problems at age 11 in a London community sample.

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also some lingering problems, especially in children who were older than 6 months when adopted. Some of the children who had spent their early lives in orphanages showed quasi-autistic symptoms. Post-natal depression Just as maternal anxiety and depression before birth affects the fetus, so maternal depression after birth affects the childs development. In infancy, the mothers post-natal depression is associated with changes in the infants behaviour and brain function. Prospective longitudinal studies have demonstrated that the mothers post-natal illness has long-term effects on socio-emotional development. In early adolescence, children whose mothers were depressed after childbirth have reduced intellectual ability and lower school achievement, even when the mothers later history of mental illness is taken into account. Infant day-care Some investigators argue that non-maternal care in infancy disrupts attachment and increases the risk of later behavioural problems. However, high-quality day-care does not adversely affect attachment relationships with parents; rather, it promotes secure attachments between infants and carers, and enhances cognitive development. Children who enter day-care early in infancy are more likely to respond positively.

Development in Middle Childhood


Gordon T Harold Dale F Hay

Middle childhood (612 years of age) is marked by gradual change in terms of physical growth, but signicant change in psychological development. This contribution reviews recent research that highlights some of these changes, and notes some factors operating in middle childhood that are linked to later mental health problems. Physical growth and motor skill During middle childhood, muscle bres increasingly replace the proportion of cellular uid in tissue and bones continue to strengthen. Figure 1 shows boys and girls height and weight by age percentiles. Girls outpace boys in skeletal development; by 12 years of age, bone ossication in girls is 2 years ahead of that in boys. Childrens physical strength also develops. For example, the average 10-year-old can throw a ball twice as far as the average 6-year-old. The physical changes of middle childhood affect the childs emerging awareness of the self as a physical and social being. The self-concept becomes differentiated, as children come to understand that they are not equally competent in athletic, academic and social domains. Weight gain and loss One physical factor that may affect a childs emotional and physical well-being during middle childhood is weight and its correlate, body image. Children who are overweight are sometimes subject to ridicule, resulting in lower levels of selfesteem. These problems do not augur well for future mental health. Indeed, overweight adults who were obese as children suffer more psychological problems than overweight adults who were of normal weight as children. By the end of middle childhood, many children are concerned about their weight; for example, in a 1999 study of 401 12-year-olds, 20% of girls and 8% of boys were currently dieting. Early-onset anorexia nervosa in the middle childhood years, which may be partly associated with reduced cerebral blood ow, is a serious health problem.

FURTHER READING Bremner J, Slater A, Butterworth G, eds. Infant Development: Recent Advances. Hove: Psychology Press, 1997. (Includes thorough reviews of topics in infant development.) Campbell A, Muncer S, eds. The Social Child. Hove: Psychology Press, 1998. (Reviews current research and current controversies in developmental psychology.) Damon W, ed. Handbook of Child Psychology. Chichester: Wiley, 1998. (The denitive reference work on child development.)

Editorial note
An annotated version of this article with full citations and references can be obtained from the publishers by e-mailing psychiatry@medicinepublishing.co.uk

Gordon T Harold is a Lecturer in the School of Psychology, Cardiff University, UK. His special interests include the role of the family environment in the onset and development of childhood emotional and behavioural problems. Dale F Hay is Professor of Psychology at Cardiff University, UK. She studies social development in infancy and childhood with special emphasis on cooperation, conict, interpersonal relationships and the development of psychopathology.

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Physical growth charts for children aged 612 years


Height by age percentiles: 612 years
160 160 60 55 150 90th 150 50 45 90th

Weight by age percentiles: 612 years


60 55 50 45 40 35 50th 10th 30 25 20 15 10 6 7 8 9 10 11 12

Boys Girls

Height (cm)

Weight (kg)

140

140

40 35 30 25 20 15

130

50th

10th

130

120

120

110

110

100 6 7 8 9 10 11 12

100

10

Age (years) 1

Age (years)

Adapted from Berger K S, Thompson R A. The Developing Person: Through Childhood and Adolescence. 4th edition. New York: Worth, 1995.

Cognitive development in middle childhood


The study of cognitive development in childhood has long been inuenced by Jean Piaget, who characterized middle childhood as a particularly important developmental stage. During this period, children begin to use concrete operations a set of rules or strategies for examining and interacting with the world. Piagets emphasis on cognitive operations drew attention to such abilities as reversibility and inductive logic. More recently, cognitive psychologists have been much inuenced by the Russian theorist, Lev Vygotsky, who emphasized the social and cultural underpinnings of cognitive development and the importance of studying childrens thought in everyday, social situations. Reasoning: current work on childrens reasoning suggests that the ability to appreciate logical argument emerges in the middle childhood years, although the ability to understand complex mental operations increases from early childhood to adolescence. Children apply their emerging reasoning abilities to many real-world issues, including the nature of friendship, environmental disasters and even the naturenurture debate. Thinking about thinking: children in middle childhood show an ability to engage in metacognitive thought. In other words, they can think about their own cognitive processes as well as consider what is required to complete a specic task effectively. Six-year-olds who talk to themselves about what they are doing are more likely than other children to complete challenging tasks. Most children in primary school are able to reect on their own ability to read, and their judgements are consistent with their teachers ratings of success at reading. Memory: while working memory begins to develop during infancy and early childhood, children in middle childhood improve significantly in their ability to store and retrieve information (mnemonic ability). For example, they learn that rehearsing information is a useful aid to memory. They also show an increased ability to reect on and recount

stories about their past (autobiographical memory). This is partly due to an improvement in verbal skills, but is also inuenced by parentchild interaction. However, childrens emotional reactions to traumatic events may inuence the accuracy of their memories, which has implications if they are required to testify in court: when asked for spontaneous memories, children generally report accurately, but may become confused in response to leading questions. Language and literacy: during middle childhood, childrens vocabularies increase, and they can better understand the complexities of other peoples speech, including the use of passive voice, comparatives and metaphoric speech. Development also occurs in the area of pragmatics, which includes the ability to express intentions, participate in conversation, and talk at length on certain subjects. Middle childhood is also the period in which children either master literacy skills or develop reading and writing problems. Reading ability develops more rapidly in some cultures than others, and uent reading is more easily attained in phonetic languages such as Spanish and Welsh. Comparison of adoptive and non-adoptive sibling pairs revealed a moderate genetic contribution to stability in reading performance from 7 to 12 years of age; in contrast, change in reading performance over those years was related to unique environmental inuences, such as particular schoolteachers and methods of instruction.

Socio-emotional development in middle childhood


Understanding and regulating emotions: acquiring an understanding of the emotions expressed by other people, and regulating ones own emotions, are essential for healthy psychological development. Failures of emotional regulation are associated with anxiety, depression, high-aggressive attention decit hyperactivity disorder (ADHD) and conduct disorder in middle childhood. Understanding and regulating emotions depends crucially on social engagement, and particularly on emotional socialization by parents. In later childhood, parents inuence emotional attributes

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such as condence, pride, shame, guilt, and gender-appropriate emotional expression (e.g. big boys dont cry). Children who are exposed to hostile working models of family relationships show decits in the understanding of emotion, and come to assume that other people have generally hostile intentions towards themselves. Maltreated children have problems regulating their emotions, and are more likely children to bully their peers, as well as to be victimized by other bullies. At the same time, maltreatment is itself linked to parents failure to understand their childrens emotions. Parents and childrens relationships in middle childhood: although successful regulation and understanding of emotion may partly derive from secure attachment relationships in infancy, childrens emotional security does not necessarily remain stable over the childhood years. Some children become less secure whereas others become more secure in the face of divorce or other life events. The nature of the relationship between the two parents, particularly the extent to which they engage in destructive conflict, affects the childs emotional security. Parenting style and discipline practices have implications for childrens autonomy, secure emotional development and psychological well-being. For example, children get angry or else withdraw emotionally when parents appear passive and unresponsive to their needs. Inconsistent discipline and harsh parenting predict conduct problems and delinquency. Parental psychopathology has a number of adverse effects on emotional and cognitive development. Economic pressures put parents at risk for depression, and also undermine the quality of parenting and parentchild relationships. Sibling relationships become increasingly important when there is family disruption. Siblings support each other in the face of serious family violence and divorce; indeed, a review of ndings from existing studies revealed that sibling relationships are generally more positive in divorced families than in intact ones. On the other hand, in intact families, marital conict can have adverse effects on sibling relationships. Sibling relationships are also affected by gender composition of the sibling pair and parents own mental health and parenting practices. Sibling relationships are generally more fraught in complex step-family arrangements. Peer relationships increase in importance in middle childhood (Figure 2). There are clear links between peer relationships and family life. Parents social networks inuence their childrens friendships, and secure attachments between children and their mothers foster positive peer relationships, especially in middle childhood. Sibling relationships also influence the quality of peer interaction. Within the classroom, or in other settings where peers meet, friendships and groups soon form, and some children are generally more popular than others. Preferences for same-sex peers begin in late infancy and are marked in the middle childhood years. In addition, children tend to reject other children who behave aggressively. The fact that aggressive children believe that other children are hostile, and act accordingly, further promotes rejection. Peer rejection contributes to a later

2 The importance of peers.

tendency to associate with other aggressive children, which in turn predicts later conduct problems and delinquency. Peer rejection is also linked to childrens depressive symptoms, although this association is less stable over time.

Conclusions
Physical, cognitive and emotional factors, and the quality of relationships with family members and peers collectively inuence the adaptive or maladaptive pathways that children chart from childhood to adulthood. In middle childhood, children reach new levels of cognitive, emotional and social functioning that allow them to interpret and engage with their social worlds, as a preparatory step for the challenges that the next years will inevitably bring.

FURTHER READING Campbell A, Muncer S, eds. The Social Child. Hove: Psychology Press, 1998. (An edited volume that highlights current controversies in developmental psychology.) Durkin K. Developmental Social Psychology. Oxford: Blackwell, 1995. (An exceptionally clear and scholarly textbook on social development.) Hart C, Smith P, eds. Handbook of Childhood Social Development. Oxford: Blackwell, 2002. (An encompassing handbook of research on the middle childhood years, with contributions from leading scholars in the eld.)

Editorial note
An annotated version of this article with full citations and references can be obtained from the publishers by e-mailing psychiatry@medicinepublishing.co.uk

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Development in Adolescence
Simon G Gowers

biological factors the changes in body shape and hormonal activity that precede and continue through puberty. They emphasize the extent to which people are active rather than passive participants in their own development, and refer to the importance of transitions and the existence of chain and strand effects a carry-over from childhood into adolescence and then into adulthood. The developmental tasks of adolescence Adolescence presents the young person and the family with a number of tasks, the successful accomplishment of which is important for mental health. The tasks change over time, and there are clear cultural and gender differences which become more marked with increasing age. The main task of this stage is generally considered to be the achievement of an independent identity. While younger children seek to identify with others who follow the same sports team or idolize the same pop group, for example, by the end of adolescence individuality is prized more highly and successful individuals have greater self-condence to stand out from the crowd. Developing ones identity is set in the context of movement from small, familiar settings to those that are larger and more impersonal (e.g. from primary to secondary school), and the exploration of new possibilities in relationships, leisure and, later, work settings. Subsidiary tasks include the achievement of greater independence, the formation of successful intimate relationships and the achievement of a secure sexual identity. The nal tasks of this stage are considered to be gaining employment and leaving home. Throughout adolescence, although the peer group is of major importance, development takes place against the background of relationships within the family. The wider cultural context and prevailing socio-economic conditions also have an important bearing on development.

Adolescence is generally conceptualized as the stage of development involving substantial physical, social and cognitive change that spans the gap between the dependence of childhood and the independence of adulthood. This rather vague denition illustrates the lack of a clearly dened start or nish point. Physical maturation (i.e. puberty), often taken as a marker for entry into adolescence, occurs at very different ages, and the end of adolescence is even more difcult to dene. Full maturity and independence are inuenced by socio-economic and other culturally dened factors. Western denitions of adolescence have changed markedly since the industrial revolution, and recent educational initiatives have signicantly raised the age that most young people become nancially independent. Legally, the age at which an individual can be deemed responsible for a criminal act, purchase cigarettes or alcohol, get married, vote, join the armed forces or become a justice of the peace varies widely among different countries, reecting inconsistency about the concept of maturity. For more than a century, much work has been preoccupied with the problems associated with adolescence, referred to variously as Sturm und Drang (storm and stress) or adolescent turmoil, terms that indicate the complexity of adolescent development. However, only a minority (up to 15%) of adolescents experience severe psychological disturbance. A high percentage of troubled teenagers will have had difculties earlier in childhood, which suggests that the experience of adolescence is not the sole or even major cause. Adolescent development in the context of the lifespan Coleman and Hendry (1998) have summarized the main principles of lifespan developmental psychology that are relevant to understanding adolescent development. They emphasize the geographical, historical, social and political context, as well as the inuence of the family. They also draw attention to the reciprocal inuence of individuals and families on one another, and the role of adolescents themselves in producing and shaping their environment. Rutter and Rutter (1992) set out a number of principles and concepts that are central to the consideration of development across the lifespan. They note the importance of genetic and

Development in adolescence
Physical development: puberty involves rapid physical change and development of the reproductive and neuroendocrine systems (Figure 1 illustrates the main changes). It is a time of tremendous growth, with a typical spurt at age 11 in girls and age 13 in boys, although there is considerable individual variation. Strength and endurance increase markedly, particularly in boys. Physical changes have different, culturally determined meanings for males and females, and their timing early or late relative to peers has a signicant impact on self-esteem. Girls in the developed world, menarche generally occurs between the ages of 10 and 16, later in less developed societies. Age at puberty tends to follow dietary, workload and morbidity patterns, decreasing as these improve. Social context may also be a factor; girls who grow up in households with family conict and where the father is absent have an early menarche. Such girls tend to start dating, drinking and smoking earlier, showing that biological and behavioural developments are closely linked. Boys the sequence of sexual maturation occurs approximately 1824 months later than in girls and the growth spurt is more marked, peaking at about 10 cm/year at age 14. As well as skeletal growth, there are changes in many internal organs the

Simon G Gowers is Professor of Adolescent Psychiatry at Liverpool University, Liverpool, UK, and Consultant to Chester Young Peoples Centre. He previously held teaching posts at the universities of London and Manchester. His research interests include the treatment of eating disorders, and outcomes of services for adolescents.

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Normal range and average age of development of sexual characteristics


Females Height spurt
9.5 10.3 Mean Mean onset Mean completion 14.5 14.3 Stage 4

Males Height spurt


10.5

Mean onset

Mean completion 17.5

Menarche

10.1 12.10 Stage 3 4

16.5 Mean 5 completion 18.0 10.8 11.7 12.6 11.0 Stage Mean onset 2 3 4 14.6 15.1 Mean completion 5 14.1

5 17.0

Breast development

Mean onset 2 8.0

Genital development

9.5 11.2 12.2 13.1 14.4

Stage 3 4 5 16.0

Pubic hair
8 9

11.0

Pubic hair

12.0 12.1 13.0 13.9 14.4

11.1 11.2 12.012.813.8 14.0 10 11 12 13 14 15 16 17 18 9 10 11

12

13

14

15

16

17

18

Age (years)
Source: Tanner J M. Growing up. Sci Am 1973; 229: 3443

Age (years)

heart almost doubles in weight, the number of red blood cells increases and systolic blood pressure rises. These changes are much more marked in boys than girls. The experience of puberty: puberty is experienced very differently between the sexes. Early pubertal onset appears to be a mixed blessing for girls. Although there might be some social prestige, girls who develop early are not generally popular among their (female) peers and are more likely to mix with older, deviant teenagers. Early maturity is associated with greater psychological distress, particularly negative body image. Late menarche appears to carry far less risk of associated disturbance. For boys, there seems to be a strong association between physical maturation and peer group status. Boys who mature early are perceived more positively by peers and develop better self-image. Late maturation is associated with anxiety, and boys who mature late are less popular with peers and adults. There are probably considerable differences in the ways parents talk to boys and girls about puberty and communicate expectations about changes at this time. While girls generally have some discussion of menstruation with their mother or another condante, boys tend not to discuss sexual development with their fathers. For girls at least, preparation for puberty is associated with better adjustment. Sexual behaviour: the development of sexual awareness is an important accompaniment to the physical changes of adolescence. Recent gures for the UK collected by the Brook Advisory Service (1998) show that 20% of young people report having intercourse before their 16th birthday; most have their rst experience at 17. The age of rst intercourse for boys is related to early physical maturity, antisocial behaviour and substance use. The rate of teenage pregnancy in the UK has fallen since the introduction of freely available contraception in 1975. Low educational attainment, poverty, emotional difculties and being the child of a teenage mother are all associated with teenage

pregnancy. The rates of abortion for pregnant teenagers are related to socio-economic status girls from deprived areas are more likely to continue with a pregnancy. Parents are generally more concerned about their daughters emerging sexuality than their sons, though the value of female chastity varies markedly across cultures. First intercourse for males is subjectively a highly regarded event, while reports from girls are typically more anxious. Prevailing attitudes and behaviour may be changing, however, with the gap between males and females narrowing. Homosexuality tends to cause parents considerable concern. There are great differences in attitudes and prevalence between societies and cultures, and between generations. A recent study estimated that 3040% of men have had some sort of homosexual experience (mostly in adolescence), but only 13% of men describe themselves as having a stable homosexual identity. Young lesbian women often report an inconsistent pattern of sexual attraction through adolescence. A critical factor in the mental health of homosexual adolescents appears to be the anticipated responses of others, particularly the mothers acceptance. Fear of rejection, ridicule and physical assault is especially important. Cognitive and social development Cognitive development: the teenage years are a time of a major shift in thinking and reasoning abilities. Piaget suggested that adolescence was characterized by the ability to perform formal operations and engage in abstract reasoning. The increasing capacity for logical and scientic reasoning is reected in the problems that adolescents are able to solve in mathematics and science. The ability to think in hypothetical terms and to consider a range of possibilities helps in the formulation of arguments and counter-arguments. Abstract ability also enables adolescents to use logical processes to think about issues such as morality, friendships and responsibility. There is likely to be increased self-consciousness and a degree of preoccupation with the self (egocentrism). When assessing adolescents, teachers, social

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workers and healthcare professionals should appreciate that self-centredness is a normal part of development. Social cognition: at the core of good peer relations is the ability to think about people and social relationships. Conceptions of morality and social convention become appreciated more fully, and the moral principles of fairness, justice and equality are considered in more abstract ways. Through the development of these principles, adolescents begin to see that social conventions serve a functional purpose in regulating and coordinating actions between people. Research suggests that boys and girls utilize different moral conventions, and that both sexes use moral arguments that are less mature when addressing dilemmas that are practical or personal rather than abstract. Identity Although achievement of a stable identity is vital in adolescence, identity development is a life-long process that continues through adulthood. Erikson discussed the concept of an identity crisis in adolescence, as the young person struggles to decide who he or she is and wants to become. Cultural factors may protect against identity confusion: Islamic culture, for example, provides a strong sense of place within the extended family and community and within Islam, which may lead to a clear sense of identity. Peer relationships Peer relationships become increasingly important in adolescence as young people pursue a range of activities outside the parental home. As well as providing social support, these relationships provide an alternative set of values and an arena for the development of social skills. Two kinds of peer group have been described cliques and crowds. Cliques are made up of small groups of friends, generally of the same race, sex, age and social class. The members feel they know each other well and appreciate each other. Crowds are larger structures, used to locate oneself in the social context. Adolescents continue to learn social skills within the clique and to feel secure within the wider setting of school, while the crowd provides a sense of identity and self-concept. Social support buffers adolescents against stress and helps with the development of autonomy. Conformity to culturally valued norms is a characteristic of peer group relationships. While conformity to prosocial pressure is greatest at 1112 years, response to antisocial suggestion peaks at 1415 years, probably reecting the struggle for autonomy from parents. Identication with the peer group and the family are not mutually exclusive, though; adolescents who strongly identify with their peers are usually committed to their family. While the significance of peers increases with age, family members are rated as most signicant and remain an important source of advice on major decisions. It is notable that young people often choose friends with views that are similar to their parents (although they would never admit such similarities). During late adolescence, the peer group weakens and is replaced by loosely associated pairs or couples, enabling experimentation with intimate relationships. Peer acceptance, popularity and rejection: adolescents are often

preoccupied with peer group acceptance. Popular adolescents are good-natured, humorous and intelligent, though popularity is not necessarily associated with leadership. Social rejection is associated with poor social skills, tactlessness or aggressive behaviour. As friendship and social acceptance are so important in adolescence, those who are isolated or rejected are especially vulnerable to depression, substance misuse or eating disorders. Anorexia nervosa in particular can be viewed as a disorder that results from a belief that one is unacceptable and the consequent changes in behaviour.

Drugs and alcohol


Drug and alcohol use in the UK are now so prevalent as to be a feature of normal adolescence. Goddard (1996) showed that about 45% of boys and 35% of girls drink alcohol at least weekly by the age of 15. In the UK (unlike North America), buying alcohol under age is relatively easy; one study reported that a quarter of 15-year-olds said they had bought alcohol from a shop in the previous week. Drinking is related to availability and acceptability within the peer group. Young people give the same reasons for drinking as adults namely sociability, relaxation, companionship and excitement. They tend to learn their limits from experience, and drunkenness is a common feature of late adolescence. Illicit drug use has increased in the last decade in all Western countries. Cannabis is by far the commonest drug, with 40% of British 1416-year-olds reporting having used it (Parker et al., 1998). Use of all drugs increases with age up to 18 years, apart from solvent use, which peaks at 1415. Most drug use among teenagers is experimental and short-term, with no evidence of long-term harm. However, early and increased use of cannabis is related to greater subsequent psychological and emotional problems.

Adolescent development and the family


There is little empirical evidence for a generation gap. While there are likely to be numerous arguments over the setting of limits, families that function well can usually agree on such issues, and adolescents generally accept parental values. Conict Several studies show that parentchild conict does increase in adolescence, and this is not surprising given the many changes that the young person is going through. Most conicts involve mothers, siblings, friends, fathers and other adults, in descending order of frequency. Adolescents tend to argue with parents over autonomy, authority and responsibility. With peers, interpersonal behaviour and relationship difculties are the focus. The sibling relationship is distinguished by the degree of conict adolescents argue more with siblings than they do with anyone else. Adolescent development and the family life cycle Middle adulthood can be a time of difculty for parents, with anxieties over changes in their physical state and attractiveness. At the time when the adolescent child is beginning to explore possibilities for the future, the parents may feel increasingly trapped or be concerned about their own ageing parents.

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Parenting styles Social concern about increasing adolescent antisocial behaviour has led a number of researchers to consider the role of parenting practices. Hess (1995) has drawn attention to a growing uncertainty among Western parents regarding their authority and responsibility; little consensus exists about what is expected of them in terms of monitoring and supervision or the setting of limits for their children. Baumrind (1987) suggested that two relatively independent aspects of parenting can be described, parental responsiveness and parental demandingness, leading to a four-way classication of parenting: indulgent (high responsiveness, low demand) authoritative (high responsiveness, high demand) authoritarian (low responsiveness, high demand) indifferent (low responsiveness, low demand). Subsequent studies have shown that these styles of parenting are associated with different adolescent outcomes (Figure 2).

Styles of parenting and their effects


Authoritative Parents are warm and rm; they value autonomy, but take ultimate responsibility. Adolescents tend to be more responsible, self-assured, adaptive, creative, curious and socially skilled, and are more successful in school. Authoritarian Parents value obedience and conformity, and are more punitive and more absolute in their demands. The child is expected to accept rules without question, and autonomy is restricted. Adolescents tend to be dependent and passive, less socially skilled and assured, and less curious. Indulgent Parents are accepting and benign, making little demand on the child. The imposition of rules or control is seen as an infringement of the childs rights. They are more likely to see themselves as available resources for the child to use. Adolescents are more irresponsible and less mature. Indifferent Parents minimize the demands of the child on themselves. They are possibly neglectful and take little interest in the childs school work or other activities. Adolescents are more likely to be impulsive and to engage in delinquent behaviour and precocious experimentation with drugs, sex and alcohol. 2

School
The school environment Adolescents actively choose the extent to which they t in with the demands of school, and the school environment is an important factor. Adolescents value being treated as intelligent, responsive individuals, and their motivation to work needs careful management and understanding by teachers and the school system. Good schools will: work towards keeping school organizational structures small, ensuring that adults are accessible; promote healthy peer relations; and allow authentic experiences of success and self-responsibility. Educational attainment family and school environments both contribute to academic attainment: a stable, affluent, stimulating home with parents who value education and who agree with the schools values is associated with better outcome. From education to employment Educational attainment is directly linked to attainment at work, and chain effects are very apparent, with links observed from childhood behaviour through to educational success, occupational status and success in marriage and parenting. Clearly, children whose attainment declines in adolescence or who leave school at times of economic recession and high unemployment can be disadvantaged throughout life.

life. The course of development can be greatly inuenced by family, peers and the wider social context, while the adolescent as an individual makes a substantial contribution to the course of his or her own development and relationships.

Moving towards adulthood


Active planning for the future can protect mental health. Adolescents who show a future time perspective are aware of the future and the relationship between their current activities and later outcomes. This is, in turn, associated with family factors: when parents express interest, adolescents develop clearer and more positive plans. Peer relationships are also important; as they get older, adolescents come to share a view of the future and their part in it. Adolescence is characterized by the movement from the family into the wider world. It is a time when the young person matures rapidly and undergoes a number of transformations in physical state, thinking and behaviour, which are a preparation for adult

REFERENCES Baumrind D. Parental disciplinary patterns and social competence in children. Youth Soc 1987; 9: 23976. Brook Advisory Centres. Teenagers and Sex: A Brieng Paper. London: Brook Advisory Centres, 1998. Erikson E. Identity and the life cycle. Psychol Issues 1959; 1: 1171. Goddard E. Teenage Drinking in 1994. London: HMSO, 1996. Hess L. Changing family patterns in Western Europe: opportunity and risk factors for adolescent development. In: Rutter M, Smith D, eds. Psychosocial Disorders in Young People. Chichester: Wiley, 1995. Parker H, Aldridge J, Measham F. Illegal Leisure: The Normalisation of Adolescent Recreational Drug Use. London: Routledge, 1998. FURTHER READING Calam R. Normal development in adolescence. In: Gowers S, ed. Adolescent Psychiatry in Clinical Practice. London: Arnold, 2001. Coleman J C, Hendry L The Nature of Adolescence. 3rd edition. London: Routledge, 1998. Rutter M, Rutter M. Developing Minds: Challenge and Continuity Across the Life Span. Harmondsworth: Penguin, 1992.

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Developmental Paediatric Assessment


Gillian Baird

Each aspect of development and skill acquisition has a normal range, and there are variations in the pattern of how children acquire skills in normal development. Development can be measured with two different frames of reference. First, in terms of whether or not specic skills have been acquired; this is a criterion-referenced judgement. Second, by comparison with age-matched peers using norm-based assessment and standard deviations from the mean i.e. at any given age, what proportion of children have the set of skills possessed by the index child? A distinction is made between the concepts of delay, dissociation and deviance. Delay implies that the childs global abilities are different from the average range for the chronological age. Dissociation implies that some skills are significantly impaired relative to others, signalling a specific learning difculty. Groups of impairment may constitute a recognized syndrome. Deviance indicates that the behaviour is either not seen in normal development or not seen at that particular age. Regression and the loss of skills are always signicant, and the reason for such loss demands investigation.

Any history of loss of skills is always abnormal and should lead to further detailed enquiry. Ask for the parents view of causation. If the childs development is indicative of a disorder, reassuring the parents about unwarranted concerns that they may have been responsible (e.g. a belief that autism could be caused by the mother going out to work, or being depressed) can reduce or remove their guilt. It is particularly important that developmental problems are not wrongly attributed to causes that are plausible but improbable, such as MMR immunization or obstetric intervention. Events such as a cord around the neck at birth rarely, if ever, cause problems. Similarly, a forceps delivery alone is an unlikely aetiology of a neurodevelopmental disorder. Nevertheless, it is valuable to establish, from independent enquiry, the reason for obstetric intervention (e.g. fetal distress), the condition of the baby at birth (e.g. Apgar score <5 at 5 or 10 minutes), and any evidence of neonatal encephalopathy. The childs current general health and a history of serious illnesses can be relevant to understanding current abnormalities in behaviour or learning. Developmental differences exist between boys and girls, with boys lagging behind in, for example, language. Boys are on average 1 month delayed in early language development compared to girls, but the difference accounts for less than 2% of the variation within the sexes and across ages. Gestational age should be considered when seeing a child under the age of 24 months, and correction should be made when assessing age-appropriate attainments, especially in the rst post-natal year. Observation and interactive assessment A suitable selection of toys should be made available before meeting the family and interacting with the child. These should be appropriate for the age of the child, and could include toys that enable the childs understanding of cause and effect to be evaluated. In the assessment of infants (under 2 years of age), a bell, bricks, truck, doll or teddy and tea-set might be suitable. For older children, crayons, pencil and paper and books with single pictures and stories would be ne. The materials for play should be quite separate from those required for systematic tests of developmental attainments (Figure 1, pages 1415). Most children function better when a helpful adult interacts with them, but time should be allowed for free play. The childs inability to organize the environment and generate ideas on his or her own is signicant and may be not noticed if an adult is too helpful. The child may not be able to focus his attention, in which case he will it from one object to another, or very repetitive play may be noted. One of the cardinal rules of developmental assessment is to look not only at what the child does, but at how he or she does it. The quality of response should therefore be monitored as well as the actual achievement.

The developmental examination


History-taking should cover family history, social and family environment, and the pre-, peri- and post-natal history. Enquiry should be made about the parents particular concerns and information sought from others who know the child. It used to be thought that parents were not particularly good informants of their childrens development, but this was partly a function of asking too-detailed questions about the age of acquisition of particular skills. Asking open-ended questions and then requesting examples elicits the most reliable history. What all parents are very good at remembering is whether or not they had concerns and, if so, what the concerns were about. They are particularly good at observing current behaviour if the right questions are asked. Parents interpretation of what their child does may be incorrect (e.g. he understands everything I say) but their observations are usually accurate (e.g. he will fetch his shoes only if they are visible). It is not only parents who nd accurate estimates of comprehension difcult; so do professionals, unless a specic test is done.

Physical examination
The physical examination is generally left to the end of the assessment, as the child may become upset and this would interfere with a subsequent developmental examination. The following key guidelines should be observed (see page 17).

Gillian Baird is a Consultant Developmental Paediatrician at Guys Hospital, London, UK. Her special interests include developmental paediatrics and autistic spectrum disorders.

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1
Personal skills Communication/social interaction Smiles responsively when mother talks to/smiles at. Opens and closes mouth imitatively. Vocal turn-taking, gurgles/coos with pleasure. Generally social to friendly adult but knows care-giver. Tries to hold cup/bottle, poor tipping. Shares interest by gaze and gesture in peepbo game. Makes noise to get attention. Tries to imitate (e.g. tongue protrusion). Smiles at image of self in mirror. Situational understanding of familiar phrase and angry/friendly voices. Localizes and recognizes different speakers. Occasionally vocalizes with four or more different syllables at one time. Non-specic indication of emotion/ need etc., but tries to attract attention vocally. Regularly localizes speaker with eyes. Often vocalizes with two or more different syllables. Comprehension Speech Interested in mirror play. Aware of different types of clothing. Finger-feeds and early chewing. Some anticipation of familiar events. Intonated babble with sequences of sounds. Babble more complete with different vowels and consonants. Imitates sounds. Attracts attention to self frequently. Responds to parental indicating gesture. Beginnings of imitation of gesture (e.g. wave bye-bye, claps hands 10 months) and shows joint attention ability to switch gaze between object and person to share interest. Understands and takes part in lap games with anticipation, demanding of repeated games (e.g. peepbo). Now more wary of strangers. Points to indicate need. Separation anxiety on leaving parent common. Quite distractible and switches to new dominant stimulus easily. Repeats performance to be laughed at. Generally shows intense attention and response to speech over prolonged periods of time understands peoples names and familiar words (e.g. shoes/ responds to familiar requests). Regularly stops activity in response to no. Responds to own name and names of familiar people (e.g. daddy). Understands gestures (e.g. gives toys or other objects to a parent on verbal request) but may not yet have skills of release.

PSYCHIATRY

Framework for assessment

Age 68 weeks

Play

3 months

Interested in everything seen/increasing intention to touch objects.

6 months

Reaches for and grasps toys, usually both hands, takes to mouth. Watches objects disappear no sustained searching. Excited by familiar toy.

9 months

ASSESSMENT

14
Cooperates with dressing by putting arms up. Drinks from beaker held by self. Increasing awareness of self/ other shown in shift of object play from self to doll, use of me/mine pronouns and awareness of aspects of self in mirror. Increasingly persistent in attaining goals. May indicate when wet. Frequent communication initiated by child, accompanied by showing and bringing of toys and pointing for interest and need. Follows adult point at object.

Persistent in getting toys. Transfers toys hand-tohand, bangs toys (7 months). Looks for objects that disappear. Stage of sensorimotor play and early cause and effect. Pulls string to get toy.

Around 12 months

Container play putting objects in and out. Interested in picture book. Finds hidden objects. Shows recognition of familiar objects (e.g. brush, telephone, cup and spoon, car). Less mouthing, may cast throw objects on oor. Imitates actions with objects (e.g. clicks bricks, rings bell. tries to build bricks).

Talks to toys and people throughout the day using long verbal patterns protowords or words accompany communicative gesture. Shakes head for no.

Around 15 months

Early denition by use of play on self (e.g. brushes own or mothers hair). Plays to and fro game with ball or truck.

Simple requests in context. Recognizes and identies many objects when they are named in familiar surroundings. Points to pictures in book.

More frequent use of words with meaning, nal or beginning consonant often missing. Asks for objects by vocalizing and pointing.

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table continued on page 15

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continued from page 14 Personal skills


Alternates between clinging and resistance. Feeds self with spoon without rotating it at mouth. Takes off hat/shoes. Bowel control often attained. Attends to own choice of activity, but attention can be caught by calling name and producing new toy. Verbally requests and comments. Watches others play and plays near them. Mainly with adult still watches other children. Simple chase games develop. Wants to please adult/shows off. Recognizes new words daily at an ever-increasing rate. Listens to conversations and responds. Carries out simple instructions. Understands objects by function (e.g. which one do we sit on?). Points to several body parts. Understands on/in/under/big/little. Can give full name, age and sex. Beginning to count. Understands why, who, how many and questions such as what should you do when youre hungry? Speaks more and more new words each week, gesture used less often. Echoes some adult speech. Puts words together in phrases, e.g. me go. Verbally very demanding. Listens to adult and identies 2 or more familiar objects on request from a group of 4 or more familiar objects. Generally understands more than 100 words in familiar setting. Begins repeating words overheard in conversation. Uses minimum of 1020 words spontaneously. Range of vowels and m, p, b, t, d, n (mean 50100).

Age

Play

Communication/social interaction Comprehension

Speech

Around 18 months

Uses real and toy objects appropriately. Briey imitates everyday domestic and personal activities. Shows preference in play. May use doll/teddy to feed/put to bed. Dry by day, pulls pants up and down. Helps with simple putting away when asked. Understands spills and tries to rectify. Behaviour can be active and oppositional.

Around 24 months

Play now more toy-based; linking actions (e.g. feed doll and then put to bed). Turns pages of book singly. Able to play for more lengthy periods of time.

Around 36 months

ASSESSMENT

15
Aware of being in a group and expected behaviours. Can care for most toilet needs independently. Can dress self except for tying shoelaces. Can have conversations, tell jokes and discuss emotions. Able to retell in a different way to assist others understanding. Most children show rst-order theory of mind (i.e. that someone else can know something that is different and may be incorrect). Makes friends and has a preferred friend.

Vivid make-believe. Understands stories, can make plans. Beginning to draw recognizable man with head, eyes, legs. Can do simple inset puzzle (orientate and insert all pieces) and match colours. Can unbutton buttons. Tries to cut with scissors. Able to show sustained concentration. Understands concepts of number up to 3, colours, listens to a short story and can answer simple questions about it. Can listen to and answer two-part question and understand some words relating to feelings. Likes rhymes. Knows simple time concepts, can follow 3 commands together. Can dene common objects in terms of use and answer what if questions. Understands common opposites (e.g. hot/cold). Follows instructions given in a group. Can tell an unfamiliar story from pictures.

Feeds with spoon and fork. Shows a sense of danger. Understands rules, right and wrong behaviour related to self more amenable. Can remove front-opening garment and many other clothes. Attends to toilet needs without help.

Can share, comfort distressed others. Plays with other children. Affectionate and conding . Shows understanding that others can know things. Shows sense of humour. Understands polite behaviour.

Uses sentences of 34 word phrases, personal pronouns, plurals and prepositions. Asks what, where and beginning to ask why? Relates own experiences. Able to have simple conversations. Immaturities of articulation still common but mostly intelligible.

Around 48 months

Able to show sustained concentration. More extended make-believe. Draws man with body. Copies cross.

Sentences of 48 words, mostly grammatically correct. Counts to 10. Talks about experiences and can retell a simple story. Uses approximately 1500 words.

Around 56 years

Copies square and triangle from a model. Draws a man with head, body and features, and a house with windows.

Speech completely intelligible, including consonant blends (e.g. sh, th), rate, pitch and volume.

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Normal developmental progression of motor skills


Skill under Materials needed investigation for measurement Manipulation Attainment Watches movement of own hands, pulls at clothes, shows a desire to grasp objects and holds rattle briey when placed in hands. Hands come together. Approaches objects with hands often fails to reach. Plays for longer periods with object placed in hand. Two-handed scoop for object. Reaches and grasps objects on table surface with raking grasp. Puts hands up to hold bottle, drops one object if holding when another offered. Raking palmar grasp. Transfer from hand to hand. Index nger pokes at toy. Picks up small object between nger and thumb. (Can now hold 2 cubes in one hand, brings 1 cube in each hand together in the midline) Has mature prehension and can release object precisely. Points with index nger for needs. Picks up. Mouth matches. Imitates clicking. Container play. Builds 2 cubes. Builds 3 cubes. Begins simple shape-sorting. Spontaneous scribble, whole-hand grasp. Supine head in midline. Sitting head held up, back curved. Ventral suspension good head control. Good head control on pull to sit. Supine lifts head spontaneously. Pull to sit lifts head in anticipation. Prone chest off hands. Standing bears weight. Can sit independently. Can reach for object while sitting without toppling over. Walks independently with wide-based gait using arms for balance. First steps. Squats down unassisted to retrieve toy. Running, climbing and kicking a stationary ball. Jumps with both feet together. Jumping. Standing momentarily on one leg. Able to catch a well-directed ball with arms out straight. Pedals tricycle. Running, avoid objects easily. Can go up and down stairs one step at a time. Balances on one foot >5 seconds. Skipping, hopping, dancing. Can throw and catch a ball well enough to join in group games. Catching with one hand. Can stand on one leg. Hop repeatedly. Walk heeltoe backwards. Age at which skill is attained 3 months 4 months 4 months 6 months 6 months

Small sweet, raisin

6 months 7 months 9 months 9 months

12 months 13 months 6 months 89 months 1011 months 10+ months 1214 months 16 months (90% by 19 months) 1820 months 1218 months 3 months 3 months 3 months 4 months 6 months 6 months 6 months 6 months 8 months 10 months 13 months (mean) 15 months 2 years 30 months (mean) 3 years 4 years 5 years 910 years 910 years 910 years 10 years continued on page 17

1-inch cube brick

Shape sorter Pencil Gross motor skills

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continued from page 16 Skill under Materials needed investigation for measurement Visuo-motor skills 1-inch cube bricks Attainment Age at which skill is attained 15 months 18 months 24 months (90% by 30 months)

2-cube tower. 3-cube tower. Builds tower of 8+ cubes. (Turns doorknob and unscrews lids)

Copies a 3-brick bridge. Can build 6-brick step model. Can build 10-brick step model. Recognition of shapes. Orientation of pieces. Vertical line. Horizontal line and circle. Cross Square Triangle Diamond Grasp: middle of pencil, pronated grasp middle of pencil, mature grasp end of pencil plus supporting hand Comments
Look at tone and symmetry of posture on pull to sit/sitting/weight-bearing and oblique suspension. Scissoring is abnormal. Denite handedness at this age may be symptomatic of pathology. Head lag on pull to sit is abnormal after 8 months. Sustained clonus is abnormal. 50th centile is 7 months for sitting 1 minute without support. Early walking does not rule out delay in other areas. Motor delay is: a) not walking by 18 months (standard crawler). b) not getting to stand by 18 months (creeper). c) asymmetry of gait by 22 months (shufer).

Jigsaw inset puzzle of approx. 9 pieces Pencil and paper (NB copy is made out of sight of child)

3336 months (80% by 39 months) 3942 months 45 years 30 months 33 months 24 months 3639 months (50% by 36 months) 4648 months (90% by 48 months) 4860 months (50% by 60 months) 66 months 72 months 24 months (50%) 36 months (50%) 4860 months (50%)

1. Determine whether the child has a motor disorder or whether any delay is part of global learning difculty. This is best achieved by observing movement patterns and posture during the developmental examination when the child is walking, speaking and handling material. Observing the child should give a good idea of the nature and extent of any motor problem and the formal examination of tone, reexes and power is largely conrmatory. Guidelines for motor skill assessment are laid out in Figure 2 (pages 1617). 2. Compare the two sides of the body and determine the childs hand preference. The motor skill, tone, reexes or limb size may be signicantly asymmetrical, suggesting hemisphere dysfunction and therefore focal pathology. 3. Measure the head circumference, plot it on a centile chart and

compare its consistency with the childs height. If there is any discrepancy, measure the parents head circumference (familial inheritance is the usual reason for an excessively large head). 4. Examine the optic discs and fundi. This may be difcult in an uncooperative child, but can be very valuable in diagnosing particular disorders (e.g. septo-optic dysplasia) as well as raised intracranial pressure. 5. Look for dysmorphic features and congenital malformations; they may suggest a particular syndrome or aetiology (e.g. fetal alcohol syndrome). 6. Carefully examine the skin for pigmented and depigmented spots and use a Woods ultraviolet light (for visualizing ash-leaf skin patches, which are characteristic of tuberous sclerosis). 7. Measure the childs height, weight and growth rate.

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Normal developmental progression of vision and hearing


Age 4 weeks 8 weeks 12 weeks 16 weeks 20 weeks 24 weeks 36 weeks Vision Watches mother when she talks to him. Looks at a dangling toy in line of vision and follows briey. Follows dangling toy from side to side past midline, eyes show xation and convergence in focusing. Follows dangling toy from one side to the other through 180 and vertically. Recognizes objects, for example familiar toy. Smiles at self in mirror. Recognizes adult at distance. Would watch toy drop out of vision. Sees crumbs on oor. Is able to see familiar adult across a room and follow movement. Would certainly look for toy that had fallen out of sight. Recognizes pictures of objects. Follows pointing gesture with eyes. Can see to recognize familiar adult or child in the distance and nearby. Vision tested with matching letters from 2+ years. Can use the Kay pictures from 24 months (naming pictures) but monocular testing difcult before 42 months. SonksenSilver linear chart from 30 months. Monocular testing by matching/recognizing letters possible in majority. Screening recommended by orthoptists in school. Hearing Quietens to sound of a familiar voice.

Turns head toward a familiar sound when supine. Turns head toward sounds. Turns to sounds when sitting if sounds are at same level as ears. Locates sounds made above and below ear level, and at greater distance than previously: is aware of quiet sounds in a room that cannot be seen. Recognizes familiar tunes and attempts to join in. Hearing tested from 24 months by pointing at toys/pictures chosen for their range of component sounds (e.g. McCormick toys.) Tested by conditioning to sounds from 30 months. (to put an object in a box when a sound is heard); this leads on to puretone audiometry. Individual ears may be tested in some children at 3 years. Speech/word tests and pure-tone audiometry in each ear. Audiometric screening recommended in school.

12 months 24 months

30 months

36 months 4860 months

3 REFERENCES Dorling J, Salt A. Assessing developmental delay: evidence-based case report. Br Med J 2001; 323: 14850. Hall D M B, Hill P, Elliman D The Child Surveillance Handbook. 2nd edition. Oxford: Radcliffe Medical Press, 1994. Harris D B. Childrens Drawings as Measures of Intellectual Maturity. New York: Harcourt, Brace & World, 1963. Illingworth R. Development of the Infant and Young Child. 9th edition. Edinburgh: Churchill Livingstone, 1987. OHare A, Gorzkowska J, Elton R. Development of an instrument to measure manual praxis. Dev Med Child Neurol 1999; 41: 597607. Stanley O, Dolby S. Learning in preschool children with neurological disability. Arch Dis Child 1999; 80: 4814. Wiart L, Darrah J. Review of four tests of gross motor development. Dev Med Child Neurol 2001; 43: 27985.

Assessment of Psychiatric Disorders in Children


Richard Harrington
The assessment of psychiatric disorders in children is divided into the following stages: family interview parental interview interview with the child physical examination and investigations

obtaining other sources of information making a diagnosis understanding the causes of the childs problems. The family interview It is usually helpful to see all members of the family together at the start of the interview. Much can be learned from the way they relate to each other. For example, the interview can be used to determine how the parents respond to the childs communications (e.g. sympathetically or critically), whether the parents have difculties in their own relationship, or whether one family member tends to be scapegoated or ignored. The interviewer needs to avoid exclusive questioning of individuals, but should set up opportunities for interactions between family members. This is often achieved by setting the family a task, such as drawing up a family tree. This is a good time to ask what the family makes of the problem and what they believe the causes are. It can also be helpful to try to establish what kinds of treatment they feel are

Richard Harrington is Professor of Child and Adolescent Psychiatry and Chair of the Department of Child and Adolescent Psychiatry at the University of Manchester, Manchester, UK. His main clinical research interests are depression and suicidal behaviour in young people.

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most appropriate. Some families have a very clear view about the kind of treatment that may be necessary, such as stimulant medication. The parental interview At some stage in the assessment the parent/s or guardian should be seen without the child. Like all psychiatric interviews, the parental interview should start with open questions and minimal cross-examination. The interviewer should try to clarify exactly what is meant by terms such as depressed or naughty. What effects have the childs problems had on, for example, schoolwork, peer relationships and the family? It is then necessary systematically to cover the childs recent health and behaviour (bearing in mind that parents do not have direct knowledge of the childs mental state). Direct enquiry should be made about: emotional symptoms (anxiety, fears, depression, suicidality) behavioural problems (deance, stealing, aggression, truancy, running away) attention and concentration motor skills (including activity level) school performance and attendance peer and sibling relationships bladder and bowel control physical health recent adversity (e.g. bereavement). Information about the following areas should then be obtained. The family history including mental illness and personality problems in the parents. The interviewer also needs to nd out about the parents relationship. The childs family life and relationships key areas include disciplinary practices, family activities that involve the child and the childs role in the family. The childs personal history the interviewer should ask where the child was born and whether there were any problems during the pregnancy. Were there any early separations or bonding difculties? What about motor and language milestones? The childs temperamental characteristics should be asked about. Interview with the child With older children and adolescents it may be possible to use procedures similar to those used to examine adults mental state. In young children formal examination of the mental state is impossible. Every opportunity should be taken to observe the young childs behaviour and play. This should be reported systematically (Figure 1 shows the format for recording information). When requesting the childs cooperation, ask for it directly, do not ask may I ? as young children are not used to adults asking their permission. Physical examination Although many children attending child mental health services are never examined medically, there are two important reasons for conducting a physical examination: to nd a physical disorder that could have caused the childs psychiatric disorder, and to detect signs of neglect or abuse. At the very least, the clinician should record height, weight, head circumference, and the appearance of the skin and face

Interview with the child


General behaviour Dress and appearance Parentchild interaction and separation Emotional responsiveness Mannerisms Anxiety and mood Sadness, tension Fears, worries Restless, disinhibited, aggressive Withdrawn or shy Talk (form) Spontaneity and ow Defects of prosody or articulation Coherence Talk (content) Persistence Interests Interruptions of attention Activity level Intellectual function Rough assessment of reading level, spelling, arithmetic, knowledge 1

(see pages 1318 for details of developmental assessments). The main indications for neurological examination are a history suggesting neurological problems (e.g. ts, developmental delay, loss of skills), dysmorphic features, deviation of height or weight from normal, or other features suggestive of a problem affecting the brain, such as skin signs of a neurocutaneous disorder, or abnormal gait. The basic neurodevelopmental examination should include: measurement of head circumference, height and weight plotted on a growth chart examination of the cranial nerves examination of the motor system, including observations while running and heeltoe walking handedness tendon reexes coordination neurocutaneous signs (e.g. caf au lait spots) observation of anomalies such as low-set ears or hypertelorism (excessive distance between the tear ducts). In children with mental retardation, there should also be a full physical examination that includes examination of the back, heart, eyes, ears and genitals. Figure 2 lists some congenital syndromes associated with behavioural or emotional problems. The strongest clues are mental retardation, dysmorphic features (such as unusual facial features) and extreme values for height, weight or head circumference. Physical investigations Physical investigations are not generally needed unless there is a clinical indication, such as abnormalities found on physical

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Examples of congenital syndromes associated with psychiatric disorders in children


Syndrome Fragile-X syndrome Fetal alcohol syndrome Klinefelters syndrome (XXY) Physical features Long face, prominent ears, large testes after puberty Low height and weight and small head circumference; hypoplastic philtrum Height above normal with advancing age, hypoplastic testes Height above normal with increasing age Hypopigmented skin lesions, cutaneous nodules Mental features Mental retardation, gaze avoidance, social anxiety Mild mental retardation; any psychiatric disorder, especially hyperactivity Most individuals show language and reading problems but few are mentally retarded; moderate increase in risk of all psychiatric disorders Many individuals have language problems; possibly some increase in antisocial behaviour Epilepsy and mental retardation; autistic features

XYY syndrome Tuberous sclerosis

examination, mental retardation or a history suggestive of organic brain disorder. Key ndings in the history that suggest an organic cause include: a specic familial disorder; a specic type of insult (e.g. maternal alcohol use during pregnancy, intracranial haemorrhage); developmental regression, abnormal developmental history (e.g. oppy baby); and a history of seizure activity. Physical investigations may be required as part of the preparation for some kinds of therapy. Neurophysiology the most widely used neurophysiological test is electroencephalography (EEG). This is most valuable as an aid to the diagnosis of epilepsy, though it should be remembered that the diagnosis of epilepsy is essentially a clinical one. EEG is also useful in the diagnosis of cerebral degenerative disorders. Non-specic EEG signs, such as diffuse slowing, are not a good guide to an organic basis for a psychiatric disorder. Standard chromosomal/genetic investigations the need to perform such investigations depends on the history and the ndings from the physical examination. All patients with mental retardation (IQ <70) should undergo a cytogenetic investigation and DNA tests for fragile-X syndrome. Chromosome tests are also indicated if there is a strong family history of psychiatric problems or mental retardation. Brain imaging is increasingly used in the evaluation of children with moderate or severe mental retardation, where it may be useful in diagnosing conditions such as tuberous sclerosis. No child psychiatric disorder, however, is consistently associated with specic structural brain abnormalities. Brain imaging should therefore be reserved for cases where the following conditions are suspected: a focal brain lesion, such as a tumour the sequelae of an earlier insult (e.g. neonatal hypoxia) a focal EEG abnormality. A metabolic screen for neurometabolic disorders often has a low yield, even in patients with mental retardation. One of the most common indications for such screening is developmental regression, which is seen in conditions such as metachromatic leukodystrophy. However, the results of metabolic screens can be hard to interpret and such tests, which are often very expensive, should generally be organized only with expert agreement.

Obtaining other sources of information Any agencies involved with the child or the family should be contacted, but practitioners should make sure that they have parental permission to contact the school. Although parents can often give an account of a childs behaviour in school, it is usually best to obtain a report directly from a teacher. Teachers are particularly good informants on problems such as hyperactivity, and a number of standardized questionnaires are available (see pages 2631). However, these scales were never intended to be diagnostic, and are not a substitute for a careful clinical history. Making a diagnosis Most children will have emotional or behavioural symptoms at one time or another, so the rst issue is to consider whether the childs behaviour is abnormal. Symptoms persisting for several months and occurring frequently are more likely to indicate disorder. The simultaneous presence of many symptoms is also an indicator of problems. However, some symptoms are much more likely to point to disorder than others, including poor peer relationships, serious aggression and self-harm. As a general rule, symptoms that are present in one situation only are less likely to presage serious problems than those that are pervasive. Of course, just because a symptom is statistically abnormal it does not necessarily follow that the child has a disorder. It is also necessary to know whether the symptom is doing any harm or whether it is leading to impairment. Four main criteria are used to judge impairment: suffering, social restriction, interference with development and effects on others. Different components of the childs problems are recorded separately using a multi-axial framework.

Understanding the causes of the childs problems


The assessment does not end with the diagnosis. It is important to put together a formulation about the psychological, biological and social mechanisms that might be operating. The practitioner must try to understand the meaning and function of the childs behaviour. Apparently similar behaviours can have entirely different functions, as the following examples demonstrate. In

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Understanding aggression in a 10-year-old boy with autism

Understanding aggression in a 10-year-old boy with behavioural problems

Autism

Parental aggression

Language problems

Social abnormalities

Rigidity and unusual interests

Rejection by non-aggressive peers

Associates with aggressive peers

Peer problems and being bullied

Finds change difficult

Perceives everyone as aggressive

Behaves aggressively

Change of routines

Behaves aggressively

both of these cases, the clinician used the results of the assessment to work out what the mechanisms underlying the behaviour might be. Example 1: Kevin was a 10-year-old boy of above-average intelligence who had autism (Figure 3). He failed to develop normal social relationships and although he had developed speech, it was stereotyped and odd. He had been maintained with a great deal of support from the education authority in a mainstream school until the age of 10, when he became aggressive, shouting and hitting out at other children in class. Observation in the classroom showed that these outbursts occurred only when children sat in different seats or when other children taunted him. Like many people with autism, Kevin needed a daily routine that was structured and well organized. His aggression settled when the teachers made the classroom environment more structured and took measures to stop the taunting. He was subsequently transferred to a special school for children with autism. This example shows how a biological disorder such as autism can lead to behavioural problems. However, in Kevins case both the mechanism and the solution were not biological, but involved his school environment. Example 2: Peters problems (Figure 4) were different. He was a 10-year-old referred because of aggression to his peers; he was also aggressive at home. During the assessment, it became obvious that Peter believed his aggression was justied because everyone was against him. His natural parents had separated when he was an infant and he had been brought up by his mother. She had had a series of stormy relationships with boyfriends, and from

an early age Peter had witnessed rows and physical ghts in the home. His mother and her current partner often beat him when he hit his sister. The school reported that he had few friends apart from another aggressive boy. Peters aggression was caused by a number of factors. From an early age he had witnessed aggression at home and so he had learned that aggression was normal and a way of getting what he wanted. However, this made him unpopular with his nonaggressive peers, which meant that in order to have friends he started to associate with other aggressive children. These children were in turn aggressive towards Peter, with the result that by the age of 10, Peter believed everyone was aggressive, even when they were not. Treatment consisted of advice to his mother and her partner about how to encourage better behaviour and how to discipline Peter more effectively. He was also offered some sessions with a psychologist, with the aim of helping him to identify and change his beliefs about aggression.

Practice points
Always try to interview parents and children separately at some point in the assessment Remember to get parental permission before contacting the school Understanding the causes of childrens problems starts with the diagnosis, rather than ending with it Bring all the information from the assessment into a formulation that attempts to explain the mechanisms underlying the childs behaviour

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Specialist Neuropsychological Assessment Procedures for Children and Adolescents


Jane Gilmour
This contribution is aimed at professionals requiring an introduction to specialist neuropsychological assessment for clinical or research purposes. It discusses measurement issues, a selection of published assessments and their psychometric properties, but is not intended to be an exhaustive review. Why undertake a specialized neuropsychological assessment? For the purposes of this review, specialized tests are those that describe specic aspects of brain function, such as memory and language, as opposed to tests of general ability (IQ). Many specic areas of cognitive functioning contribute to IQ; therefore one would predict that an individual with an IQ below 70, for example (where the mean is 100 and the standard deviation is 15), would score in the low performance bands of specialized tasks. On the other hand some individuals, including those with average or high-range IQ scores, have a markedly low test performance in one or more area of specic brain functioning relative to general ability. Such individuals are described as having a specific learning difficulty (SLD). Specialized neuropsychological assessment is therefore likely to be important in identifying the nature of an SLD for single clinical cases or groups in research. Who should be tested? Assessments of IQ and attainments are reviewed in pages 1922. Obtaining an objective measure of IQ and attainment is usually the rst stage of a clinical or research investigation into cognitive functioning. In many cases no further testing is warranted, e.g. when an IQ test indicates that a child has general learning difculties. However, there are two common scenarios where additional specialized neuropsychological assessment is justied. Groups or individuals with a markedly uneven IQ prole may require an assessment of specific cognitive functioning. Differences in general ability domains that have statistical signicance are, by denition, relatively common, but discrepancies that have clinical signicance are usually notably larger and may warrant further investigation. For example, individuals with a disproportionately low perceptual organization (PO) factor score relative to other factor scores (verbal comprehension, processing speed and freedom from distractibility) on the Wechsler Intelligence Scales for Children (WISC-III-UK)

(Wechsler, 1992) may have visual difficulties, dyspraxia (clumsiness), visual motor integration problems or since a high PO score depends on a swift response simply low motivation. Tests of specialized neuropsychological functioning can be used to exclude competing explanatory hypotheses. A child who has an attainment level signicantly below the predicted level given their measured IQ may have an SLD such as primary language or literacy dysfunction. It is important to note that low attainment relative to IQ is common in children of school age. Many factors could explain this prole, including emotional and behavioural difculties or school-based variables. In other words, an SLD is a possible cause for poor school performance relative to general ability, but it is not the only feasible explanation. Measurement considerations A number of issues should be considered when assessing paediatric and clinical populations. As there are few specialized tests appropriate for young children, it is difcult to obtain a comprehensive picture of specic functioning in pre-school children (reviewed in Figure 1). Some children may catch up in their test performance over time because of neural plasticity or behavioural compensation strategies. For research studies in particular it is often interesting to take a developmental approach in the assessment of specic areas of functioning. The non-specic abilities required to complete a given task should be considered, as there are many routes to failure. Many clinical populations have complex neuropsychological cognitive proles. For example, reading problems are proportionately more common in children with attention decit hyperactivity disorder (ADHD) (Dykman and Ackerman, 1991). Many, but not all, children with ADHD perform poorly on the Continuous Performance Task (CPT) (Conners, 2000), a test of selective attention. McGee et al. (2000) report that children with reading disorder score signicantly lower than non-reading-disordered groups on the CPT. For such reading-disordered children it would be wrong to conclude that a low score on the CPT necessarily indicates difculty with the target skill i.e. selective attention. Reading-disordered children have difculty processing moving visual stimuli (Eden et al., 1996). The CPT includes such stimuli but the aim of the task is to capture the ability to attend to pertinent information and screen out irrelevant data, rather than to assess generic visual processing abilities. In other words, the CPT identies children with target function difculties (selective attention) and those who have problems with the non-specic demands of the test (processing dynamic visual stimuli). Where possible, clinical populations should be assessed using a number of tests, presented in a variety of modalities that purport to assess the same target function. Some published tests have questionable psychometric properties. In some cases, the reference populations are inadequate (see Figure 1), and it is important to look at the ns before interpreting scores with confidence. Another major limitation of specialist neuropsychological assessments for children is that the coverage of functions is rather patchy, and there are no published tests for some aspects of specific functioning. One such notable omission is social cognition the understanding and use of higher-order social information such as the pragmatics of language or non-verbal social cues.

Jane Gilmour is a Lecturer at the Behavioural and Brain Sciences Unit of the Institute of Child Health, London, UK, and an Honorary Clinical Psychologist at Great Ormond Street Hospital for Children, London.

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Domains of specialist assessment Figures 1 to 6 review a selection of published tasks assessing specic aspects of brain function. They include target functions and some of the non-specic skills required to complete the task. General ability: any specialized neuropsychological assessment relies on measured IQ. In clinical practice, a full IQ assessment is usually required, although for research purposes a short version of a test can often be used from which to calculate a pro rata full-scale IQ score. Memory: standardized tests (Figure 1) assess explicit memory or conscious recollection (memory for facts or events) as opposed to implicit (memory for skills or procedures) traces. There are separate dimensions of memory working (short-term), stored (long-term), verbal, spatial (visual) and learning capacity. Individuals may have impairment in one domain but no difculty in another. In addition, it is important to test both delayed recall and recognition. Children who do poorly on a test of recall but accurately recognize previously presented items can often store information successfully but have problems accessing it.

Language: tests of language assessment fall into two categories: receptive and expressive. Visual language channels are independent from spoken language channels, and so assessments that focus on spoken language (reviewed in Figure 2) do not necessarily exclude written language problems. However, specic written language impairment and spoken language vulnerabilities often co-occur (Snowling et al., 2001). Assessments of written language are likely to be classed as assessments of attainment, such as sub-tests of the Wechsler Objective Language Dimensions (Rust et al., 1996). Attention has two main components: sustained (effortful processing over a significant period of time) and selective (vigilance for a target stimuli while ignoring distractor stimuli). Many children with ADHD do poorly on these tests but there is no diagnostic cognitive test for the condition. It is identied on the basis of a pervasive behavioural profile rather than performance on a cognitive task. Until recently, many tests of attention for children were rather theoretical, attempting to dene a core cognitive deficit in children who have the ADHD behavioural prole (the debate about the existence and nature of such a core decit continues). The Test of Everyday Attention

Memory assessment measures


Assessment Target function Reference population (n) in each age band 3081 Non-specic abilities1 Age range (to nearest whole year) Comments

Childrens Auditory Verbal Learning Test 2 (Talley, 1993)

Memory verbal, immediate and delayed recall and recognition Memory verbal and visual, delayed and immediate, recall and recognition Memory visual, immediate, delayed and recognition Memory visual, verbal, immediate, delayed recall, attention, recognition, learning Memory auditory working Memory everyday tasks

617

Wide Range Assessment of Memory and Learning (Sheslow and Adams, 1990) ReyOsterrieth Complex Figure (Kolb and Wishaw, 1990)

110117

515

116353

Planning, visuo-motor skills

615

Childrens Memory Scale (Cohen, 1997)

100

216

It is possible to predict a General Memory Index Score from WISC FS IQ

Digit Span (WISC-III-UK) (Weschler, 1992) Rivermead Behavioural Memory Test (Aldrich, and Wilson, 1991; Wilson et al., 1990) The Visual Memory Battery (CeNeS, 2001)

74

616

100

514

Memory working and stored, recognition and learning

40

Sustained attention (Matching to Sample subtest)

4adult

Computer administration and scoring. Motor speed is controlled

Intact senses and motivation are assumed in all cases

1
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Language assessment measures


Assessment Target function Reference population (n) in each age band 151267 Non-specic abilities1 Age range (to nearest whole year) Comments

Clinical Evaluation of Language Fundamentals 3 (Semel et al., 1995) Clinical Evaluation of Language Fundamentals preschool (Wiig et al., 1992) Test for the Reception of Grammar (Bishop, 1989) British Picture Vocabulary Scale (Dunn et al., 1997)

Language spoken expressive and receptive

Auditory attention

5adult

Testretest reliability on some sub-tests is low

Language spoken expressive and receptive

100

Auditory attention

36

Testretest reliability on some subtests is low

Language spoken receptive grammar Language spoken receptive naming vocabulary Language spoken comprehension, word nding, expression, narrative speech Language spoken receptive comprehension of language concepts

120217

412

83611

Visual discrimination

315

1997 stimuli are less ambiguous than those in previous editions

Renfrew Language Scales (Renfrew, 1995)

58101

38

Token Test (De Renzi and Faglioni, 1978; Gaddes and Crockett, 1975)
1

2953

Short-term (working) 613 auditory memory

Intact senses and motivation are assumed in all cases

for Children (TEACh, Manly et al., 1999) provides a battery of tests of attention and inhibition presented in a variety of visual and auditory modalities (see Figure 3). Spatial ability: spatial skills include the ability to mentally rotate visual configurations in space and to recognize that same conguration, regardless of its orientation. The Benton Face Recognition Test (Benton, 1994) (see Figure 4) is a good example of a visual orientation task that uses meaningful stimuli. The Mental Rotation sub-test of the British Ability Scales (Elliot, 1983) note that this is not the most recent version assesses orientation using abstract stimuli. Spatial ability includes the naming of objects though it could be argued that naming makes such high demands on visual memory that it is better described as a visual memory skill rather than a spatial ability per se. The Gestalt Closure subtest of the Kaufman Assessment Battery for Children (Kaufman and Kaufman, 1983) is a test of visual naming that is appropriate for children. Motor skills: motor tests (see Figure 5) assess a number of separate elements strength, speed and dexterity. Many tests of motor dexterity include a visual component, such as the copy condition of the ReyOsterrieth Complex Figure (Osterrieth, 1944; Rey, 1941). The Visual Motor Integration Test (Beery, 1997) is a useful tool to assess visual, motor and visuo-motor integration skills.

Executive function (EF) (see Figure 6) includes initiation, planning, inhibition, flexibility, self-regulation, concept generation and working memory. It could be argued that grouping these together into a unitary concept is awed as the abilities described are so diverse. There is also controversy over the construct validity of the tasks that profess to assess EF (Kafer and Hunter, 1997). There is strong clinical and theoretical justification to develop more refined classifications of the functions associated with EF, particularly as investigations of EF are often central to the assessment of many clinical conditions. Decits in EF are implicated in many disorders such as ADHD (Kempton et al., 1999), autistic spectrum disorders (Ozonoff et al., 1994) and schizophrenia (Bryson et al., 2001). Social cognition (see Figure 6) covers many high-order brain functions, such as the expression and understanding of emotion, facial expression and subtleties of language embedded in social interaction. Theory of mind describes the ability to mentalize and infer another persons state of mind. For the purposes of this review, theory of mind is not considered an aspect of social cognition, but is regarded as a theoretical concept. Describing theory of mind as a concept rather than a brain function is not an attempt to disregard the signicant empirical data showing that children with autistic spectrum disorders, particularly low-functioning individuals, perform poorly on theory-of-mind tasks.

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Attention assessment measures


Assessment Target function Reference population (n) in each age band 40 Non-specic abilities1 Age range (to nearest whole year) Comments

Continuous Performance Test (Conners, 2000)

Attention visual sustained attention and impulsivity (behavioural inhibition) Attention auditory and visual sustained and selective attention, response inhibition

Age-appropriate reading

6adult

Gender-differentiated norms

Test of Everyday Attention for Children (Manly et al., 1999)

2958

Basic numeracy is required for some sub-tests

615

Cambridge Neuropsychological Attention sustained, Test Automated Battery selective and divided (CeNeS, 2001)
1

40

4adult

Computer administration and scoring Motor speed is controlled

Intact senses and motivation are assumed in all cases

Spatial/visual assessment measures


Assessment 3 Developmental Test of VisualMotor Integration (Beery, 1997) Trail Making A and B (Reitan, 1971; Spreen and Gaddes 1969; Army Individual Test Battery, 1944) Mental RotationBritish Ability Scales (Elliot, 1983) Gestalt Closure Kaufman Assessment Battery for Children (Kaufman and Kaufman, 1983) Face Recognition Test (Benton, 1994) Judgement of Line Orientation (Lindgren and Benton, 1980) Rey-Osterrieth Complex Figure Test (copy condition) (Rey, 1941; Osterrieth,1944; Kolb and Wishaw, 1990) Right-Left Orientation (Benton, 1959)
1 2

Target function

Visual discrimination, motor skill and visuomotor integration Visual search and sequencing/ motor output Visual rotation of abstract gures Visual meaningful stimuli naming

Reference population (n) in each age band 616

Non-specic abilities1

Age range (to nearest whole year) 214

Comments

Impulsivity may interfere with performance in the motor skill sub-test Knowledge of number and alphabet sequence

Some debate regarding the gradation of test item difculty Parts A and B measure independent functions (Heilbronner et al., 1991)

10101

615

90189

Conceptual ability to take another persons perspective Knowledge of industrialized world objects

814

200300

213

Visual/spatial ability face recognition Visual spatial judgement

1959 2350

614 714 615

Visual/motor planning 116353

Spatial discrimination

76

6162

Intact senses and motivation are assumed in all cases Some extrapolated norms

4
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Motor assessment measures


Assessment Target function Reference population (n) in each age band 20 Non-specic abilities1 Age range (to nearest year) 614 Comments

Finger Tapping Test (Finlayson and Reitan, 1976)

Motor speed

Gender-differentiated norms. Boys are signicantly better at this task Practice effects are notable

Purdue Pegboard Test (Tifn 1968; Gardner and Broman, 1979) Cambridge Neuropsychological Test Automated Battery (CeNeS, 2001) Grip Strength (Finlayson and Reitan, 1976)
1

Motor dexterity (ne)

2340

515

Motor speed and reaction time

40

4adult

Computer administration and scoring Motor speed is controlled Sex and hand preference differentiated norms

Motor strength

20

614 (no norms for 911)

Intact senses and motivation are assumed in all cases

Executive function and social cognition assessment measures


Assessment Target function Reference population (n) in each age band EF working memory 40 and planning Non-specic abilities1 Age range (to nearest whole year) 4adult Comments

Cambridge Neuropsychological Test Automated Battery (CeNeS, 2001)

Sustained attention (Matching to Sample subtest)

Computer administration and scoring. Motor speed is controlled Parts A and B measure independent functions (Heilbronner et al., 1991)

Trail Making A and B EF motor planning (Reitan, 1971; Spreen and and disinhibition Geddes 1969; Army Individual Test Battery, 1944) Rey-Osterrieth Complex EF visual planning Figure Test (copy condition only) (Rey, 1941; Osterrieth, 1944; Kolb and Wishaw, 1990) Wisconsin Card Sorting Test (Heaton et al., 1993) EF cognitive exibility; concept formation EF inhibition of a pre-potent response

10101

Number and alphabet 615 (some sequence ability extrapolated norms)

116353

Visuo-motor skills

615

2755

Colour vision, basic numeracy

6adult

There is a positive relationship between years in education and performance All three conditions must be administered to control for speed of processing Body language subtest has been dropped from the most recent edition

Stroop Word and Colour Test (Golden, 1978; Comalli et al., 1962) Diagnostic Analysis of Non-verbal Accuracy 2 (Nowicki and Duke, 1994)

1429

Colour vision, literacy

Collated norms for 716 32adult (collated norms)

Social cognition 25305 receptive non-verbal ability; voice and face recognition

Sustained auditory attention

1 2

Intact senses and motivation are assumed in all cases Child faces only

6
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The measurement of social cognition relies on consensus opinion, in contrast to other brain functions, which can be quantied using objective right or wrong answers. The complex nature of social cognition may explain why there are few standardized tests assessing this aspect of functioning, but the paucity of standardized measurement is a challenge to those working in the specialist assessment of cognitive functions.

REFERENCES Aldrich F K, Wilson B. Rivermead Behavioural Memory Test for Children: a preliminary evaluation. Br J Clin Psychol 1991; 30: 1618. Army Individual Test Battery. Trail Making B Manual of Directions and Scoring. Washington, DC: War Department, Adjutant Generals Ofce, 1944. Baron-Cohen S, Leslie A M, Frith U. Does the autistic child have a theory of mind? Cognition 1985; 21: 3746. Beery K E. The Visual Motor Integration Test: Administration, Scoring and Teaching Manual. 4th edition. Cleveland: Modern Curriculum Press, 1997. Benton A L. Right-Left Discrimination and Finger Localization. New York: Hoeber, 1959. Benton A L. Neuropsychological assessment. Annu Rev Psychol 1994; 45: 123. Bishop D V M. Test for the Reception of Grammar. Manchester: Chapel Press, 1989. Bryson G, Whelahan H A, Bell M. Memory and executive function impairments in decit syndrome schizophrenia. Psychiatry Res 2001; 102: 2937. CeNeS. The Cambridge Neuropsychological Test Automated Battery (CANTAB). Cambridge: CeNeS Pharmaceuticals PLC, 2001. Cohen M. The Childrens Memory Scale. San Antonio: The Psychological Corporation, 1997. Comalli P E, Wapner S, Werner H. Interference effects of the Stroop Colour Word Test in childhood, adult and aging. J Genet Psychol 1962; 100: 635. Conners C K, Multi-Health Systems Staff. Conners Continuous Performance Test Version 3.0. Toronto: Multi-Health Systems, 2000. De Renzi E, Faglioni P. Development of a shortened version of the token test. Cortex 1978; 14: 419. Dunn L M, Whetton C, Burley T. The British Picture Vocabulary Scale. 2nd edition. Windsor: NFER-Nelson, 1997. Dykman R A, Ackerman P T. Attention decit disorder and specic reading disability: separate but often overlapping disorders. J Learn Disabil 1991; 24: 96103. Eden G F et al. Abnormal processing of visual motion in dyslexia revealed by functional brain imaging. Nature 1996; 382: 669. Elliot C. British Ability Scales Manual II. Windsor: NFER-Nelson, 1983. Finlayson M A J, Reitan R M. Handedness in relation to measures of motor and tactile function in normal children. Percept Mot Skills 1976; 43: 47581. Gaddes W H, Crockett D J. The Spreen-Benton aphasia test: normative data as a measure of normal language development. Brain Lang 1975; 4: 25780. Gardner R A, Broman M. The Purdue Pegboard: normative data on 1334 school children. J Clin Child Psychol 1979; 8: 15662. Golden J C. Stroop Word and Colour Test. Chicago: Stoelting, 1978. Heaton R K et al. Wisconsin Card Sorting Test Manual Revised and Expanded. Psychological Assessment Resources, 1993.

Heilbronner R L et al. Lateralized brain damage and performance on Trail Making A and B, Digit Forward and Backward, and TPT and memory and location. Arch Clin Neuropsychol 1991; 6: 2518. Kafer K L, Hunter M. On testing the face validity of planning/problemsolving tasks in a normal population. J Int Neuropsychol Soc 1997; 3: 10819. Kaufman A S, Kaufman N L. Kaufman Assessment Battery for Children. Minnesota: American Guidance Service, 1983. Kempton S et al. Executive function and attention decit hyperactivity disorder: stimulant medication and better executive function performance in children. Psychol Med 1999; 29: 52738. Kolb B, Wishaw I. Fundamentals of Human Neuropsychology. 3rd edition. New York: Freeman, 1990. Lindgren S D, Benton A L. Developmental patterns of visuospatial judgement. J Pediatr Psychol 1980; 5: 21725. McGee R A, Clark S E, Symons D K. Does the Conners Continuous Performance Test aid in ADHD diagnosis? J Abnorm Child Psychol 2000; 28: 41524. Manly T, Robertson I H, Anderson V. Test of Everyday Attention for Children (TEACh). Bury St Edmunds: Thames Valley Test Co., 1999. Meyers F E, Meyers K R. The ReyOsterrieth Complex Figure. Odessa, FL: Psychological Assessment Resources, 1995. Nowicki S, Duke M P. Individual differences in the non-verbal communication of affect. The diagnostic analysis of a non-verbal accuracy scale. J Non-Verbal Behav 1994; 18: 935. Osterrieth P A. Le test de copie dune gure complex: contribution ltude de la perception et de la mmoire. Arch Psychol 1944; 30: 286356. Ozonoff S et al. Executive function abilities in autism and Tourette syndrome: an information processing approach. J Child Psychol Psychiatry 1994; 35: 101532. Reitan R M. Trail making test results for normal and brain-damaged children. Percept Mot Skills 1971; 33: 57581. Renfrew C. The Renfrew Language Scales. Oxford: Winslow, 1995. Rey A. Lexamen psychologique dans un cas dencephalopathie traumatique. Arch Psychol 1941; 28: 286340. Rust J, Golombok S, Trickey G. Wechsler Objective Language Dimensions. London: The Psychological Corporation, 1996. Semel E, Wiig E H, Secord W A. Clinical Evaluation of Language Fundamentals. 3rd edition. San Antonio: The Psychological Corporation, 1995. Sheslow D, Adams A. Wide Range Assessment of Memory and Learning (WRAML). Wilmington, DE: Wide Range, 1990. Snowling M J et al. Educational attainments of school leavers with a preschool history of speech-language impairments. Int J Lang Commun Disord 2001; 36: 17383. Spreen O, Gaddes W H. Developmental norms for 15 neuropsychological tests age 6 to 15. Cortex 1969; 5: 17091. Talley J L. Childrens Auditory Verbal Learning Test 2. Professional Manual. Lutz, FL: Psychological Assessment Resources, 1993. Tifn J. Purdue Pegboard: Examiner Manual. Chicago: Science Research Associates, 1968. Wechsler D. Manual for Wechsler Intelligence Scales for Children (WISC-III-UK). Sidcup: The Psychological Corporation, 1992. Wiig E H, Secord W, Semel E. The Clinical Evaluation of Language Fundamentals Pre-school Version. San Antonio: The Psychological Corporation, 1992. Wilson B A et al. Performance of 1114-year-olds on the Rivermead Behavioural Memory Test. Clin Psychol Forum 1990; 30: 810.

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FAMILY INFLUENCE

Family Inuence on Psychological Development


Judy Dunn
The idea that childrens early family relationships are central to their development is a key part of the major theories of psychological development (such as attachment theory and Freudian theory). Many clinicians consider the parentchild relationship to be a crucial inuence on later relationships. But families are changing, and childrens relationship experiences both within and outside the family are receiving increased attention in the light of such change. This contribution looks at what has been learned about the signicance of family inuences and changes in the family for childrens adjustment. Patterns of relationships within families For clinicians to understand the impact of family experiences on children, and to offer help and support for children and their parents, four key principles (which are consistently highlighted in recent research) about the links between family members must be taken into account. Conict between parents is linked to poor parentchild relationships and to problems in childrens adjustment. This link is probably in part mediated via the parentchild relationship, and in part by a direct effect on children who witness such conict between the adults in their family. Quality of sibling relationships is linked to childrens adjustment outcome, and also to the quality of parentchild relationships. Differences in parents relationships with children in the family are also linked with childrens adjustment: children who perceive themselves as more negatively treated than their siblings show more problems. Relationship of both parents with the child how one parent gets along with a child inuences how the other parent relates to the child. Parents own early experiences what happens early in parents lives is linked to whom they form partnerships with as adults, to how they relate to their children, and to their childrens adjustment outcome. These inter-generational patterns are important. The mechanisms that underlie them are not yet clear, though certain life-course markers of risk factors for later and inter-generational effects, such as teenage pregnancy, are important predictors of later family problems. Families and family change Changing structure: parental separation is increasing (Figure 1). By the age of 16, 1 in 8 children in Britain will have experienced parental separation or divorce, and will be living with a new parent as a result of remarriage or repartnering. Twenty per

cent of children are currently growing up with a single parent. Parental separation is frequently part of a sequence of multiple potentially stressful changes for children, such as a period with a single parent; parents new partners; the presence of step- and half-siblings; life in two households; a reduction in nancial support; changes in neighbourhood and schools; changes in contact with grandparents. These changes begin early: most children (72%) in step-families in a recent UK Ofce for National Statistics survey had experienced parental separation and formation of the step-family before they were 10 years old. Impact of separation studies of parental separation from all over the world report consistently that rates of adjustment problems are higher in children whose parents have separated (Figure 2 gives a UK example). Children from separated families are at almost twice the risk of adverse outcomes, compared with children from intact families. A second key nding is that individual differences in childrens response to these changes are very wide. Within groups of children who have experienced parental separation and divorce, some do very well, while others are much more vulnerable. Risks faced by children following family transitions range from broad social adversities (reduction in family income, lack of social support) to family issues (e.g. poor parental mental health the prevalence of parental depressive symptomatology is twice as high in single-parent families and in step-families than in intact families; see Figure 3 for a UK example), and to problems in parent-relationships within the family. Children who have experienced multiple family transitions are at particular risk: their adjustment, educational achievement, behaviour and relationships are all likely to suffer. Processes affecting children after family transitions Childrens relationships with parents and step-parents, and with the parent who has left the household, are centrally important. There is increasing evidence that contact with the non-resident parent, and good relationships between the child and both the resident and non-resident parent, are important for a positive outcome.

Divorce rates in Anglo-American countries, 195198


25

Per 1000 married women or couples

20

15

England & Wales New Zealand USA Australia Canada N. Ireland

10

Judy Dunn is Professor of Psychology and MRC Research Professor at the Social, Genetic and Developmental Psychiatry Research Centre, Institute of Psychiatry, London, UK. 1
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1956

1961

1966

1971

1976

1981

1986

1991

1996

From Pryor & Rodgers, 2001

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Adjustment problems in children from different family settings


Older child: standardized adjustment difficulties scale scores by family type (significance of group differences and Tukey Test) Conduct problems (p < .01) Emotional problems (p < .01)

Prevalence of depressive symptoms


a Total N = 10389 12.8% No resident partner N = 741 25.6% Resident partner N = 9648 11.8%

b Hyperactivity (p < .01) Peer problems (p < .01) All bio 10.9% Married Cohabiting

Step 19.9%

All bio 16.7%

Step 24.3%

0.1

0.1

0.2

0.3

0.4

0.5

0.6

Single mum

Other step

Step-dad

Non-step 3

Prevalence of depressive symptomatology in mothers who: a live alone or with a partner prevalence rates are twice as high for those without a partner (p < .001); b are married or cohabiting and have either their own biological children only or have step-children prevalence rates are much higher in families with step-children.
(Adapted from OConnor et al., 1998)

Data on 4000 children (mean age 7 years, s.d. 2.7) from the Avon Longitudinal Study of Parents and Children using the Strengths and Difficulties Questionnaire (Goodman, 1997). Other step refers to complex stepfamilies in which mother and partner both have children from previous relationships.
(Adapted from Dunn et al., 1998)

Parental mental health illness in the mother and father is linked to childrens adjustment, directly and via the quality of the parentchild relationship. Depressed parents are likely to be less positive and responsive to their children, and more irritable and critical of them. Financial adversities while these are important, and are usually particularly serious for single-parent families, there are few overall differences in outcome for children from singleparent and from step-parent families. The latter are at less financial risk, but suffer additional stresses of step-parent relationships and family transitions. Closeness to grandparents is an important protective factor for children, as are their close friendships. Both are important sources of support even for very young children, and they are the people to whom children often turn to conde their problems, rather than their parents. Why are siblings so different? Children within the same family differ in their response to family change. This illustrates a major challenge for family researchers: why do siblings differ from each other? Children who grow up in the same family differ markedly in personality and adjustment, even though they share the same parents and family experiences (Figure 4). This challenges the idea that parental factors such as mothers mental health or education act in the same way to inuence all the children in the family.

There are a number of possible explanations for the differences between siblings: differences in how parents relate to their different children genetic differences as well as similarities between siblings siblings have different experiences outside the family as well as within (with peers, for example) and these may be especially important in inuencing their development siblings experience their relationships with each other differently. The general conclusion is not that families do not inuence childrens development, but that each sibling has different experiences within and outside the family world. To understand the impact of family-level experiences, more than one child needs to be studied, and each childs separate experiences considered. Other recent changes in families Working mothers: another notable change from traditional families involves womens employment: increasing numbers of mothers are working during their childrens early years. Between 1950 and 1990 employment rates for women with children increased to over 70%. This does not usually have negative effects on children if the childcare is adequate; in fact positive consequences have been described, especially for girls. However, the impact depends on: the reason why a mother is working her satisfaction with the role the demands placed on other family members the attitudes of other family members to her working the quality and timing of childcare the children experience the timing of childcare is most crucial in the early years. Time outside the home: children are spending more time in non-parental care outside the home. How the experience of care

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Sibling differences in psychological traits


Religiosity School achievement Juvenile delinquent acts Traditionalism IQ in childhood Attitudinal measures Vocabulary IQ in adulthood Alcohol consumed monthly Verbal fluency Spatial ability Extroversion Adult criminality Alcoholism Unipolar depression Most personality traits Memory Schizophrenia Neuroticism Bipolar manic depression
0 10 20 30 40 50 60 70 80 90 100

ships with their families; these influences can be positive or negative. Parenting styles and intervention programmes Clinicians hold various ideas on what is ideal parenting. Based on studies of how variations in parents behaviour are associated with different outcomes for children, different styles of parenting have been distinguished (see page 9). Authoritative parenting is repeatedly found to be associated with low levels of antisocial behaviour, high self-esteem, popularity, and moral development, in studies of both community and clinic samples. The studies are correlational, so the association may well reect childrens impact on parents as well as vice versa. The positive aspects of parentchild relationships with young children are especially important; for example, in coping with conduct-disordered children. Intervention programmes designed to promote authoritative and positive parenting styles have been developed in the USA and the UK with some (short-term) success. However, it is not known whether they have long-term effects in inuencing offending or antisocial behaviour years later, for example. Furthermore, such programmes focus on mothers, and fathers have been neglected in both research and programme development. Causeeffect relations Although it is tempting to see the flow of family influence as passing one way only from parent to child this cannot be assumed. Children in a family differ strikingly in their characteristics, temperament and affectionate expressiveness. The differences are evident from early infancy, and contribute to differences in the childrens relationships with their parents. Genetics plays a part in these differences, and in the similarities between parents and children. In most studies of family inuence, no account is taken of the genetic relatedness of the individuals (parents, children or siblings), which is inevitably confounded with the impact of parents actions.

Sibling difference (% = 1 correlation)


(Adapted from Dunn & Plomin, 1990)

outside the family affects childrens development has been a contested social policy issue for several decades. One lesson from recent large-scale research is that family factors and processes are more predictive of child functioning than the timing or quality of childcare. However, adverse family factors are often associated with poor-quality childcare. A further lesson is that early, extensive and poor-quality childcare in infancy shows some association with less harmonious patterns of motherchild interaction and high levels of assertiveness and non-compliance in later childhood. This is, however, more a matter for concern than alarm: there is much disagreement among researchers over whether this assertiveness should be seen as potential aggressive behaviour, and about the interpretation of the association. Families and the wider world Poverty, housing circumstances and income matter for family relationships. Different cultural communities differ in the nature of family values that they hold to be important; clearly these differences must be respected. Socially supportive relationships outside the family help to foster positive parentchild relationships. Government-supported childcare programmes such as Sure Start are particularly important for vulnerable families, such as single-parent families. Work experiences outside the family affect parents relation-

REFERENCES Dunn J et al. Childrens adjustment and pro-social behaviour in stepsingle and non-step family settings: ndings from a community study. J Child Psychol Psychiatry 1998; 39: 108395. Dunn J et al. Parents and partners life course and family experiences: links with parent-child relationships in different family settings. J Child Psychol Psychiatry 2000; 41: 9558. Dunn J, Plomin R. Separate Lives: Why Siblings are so Different. New York: Basic Books, 1990. Harris J R. The Nurture Assumption. New York: Free Press, 1998. Haskey J. Stepfamilies and stepchildren in Great Britain, Popul Trends 1994; 76: 1727. Haskey J. One-parent families and their dependent children in Great Britain. Popul Trends 1998; 91: 514. OConnor T G, Hawkins N, Dunn J, Thorpe K, Golding J. Family type and maternal depression in pregnancy: factors mediating risk in a community sample, J Marriage Fam 1998; 60: 75770. Pryor J, Rodgers B. Children in Changing Families: Life After Parental Separation. Oxford: Blackwell, 2001.

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Genetic Inuences on the Development of Childhood Psychiatric Disorders


Emily Simonoff

The nature of genetic inuences


Most behavioural traits and child psychiatric disorders are thought to be inuenced by genetic factors. The evidence for this comes primarily from behaviour genetic family, twin and adoption studies (Figure 1). Family studies often show that relatives of affected probands are at increased risk for the disorder, but that the segregation of disease fails to conform to Mendelian patterns of inheritance. Unlike family studies, which cannot easily disentangle genetic from environmental risk, both twin and adoption designs separate these effects, allowing their relative impact to

Emily Simonoff is Professor of Child and Adolescent Psychiatry at Guys, Kings and St Thomas Medical School and the Institute of Psychiatry, London, UK. Her special interests include genetic epidemiology and behaviour genetics, as well as geneenvironment interplay in child psychiatric disorders and learning disabilities.

be quantied. In the most common adoption study design, the resemblance of adopted children to their biological, as opposed to adoptive, parents is compared, with the assumption that similarity to biological parents is genetic and that to adoptive parents is environmental in origin. Early adoption is now rare in western societies, and the family background of adopted children may be more behaviourally deviant, raising questions about the generalizability of ndings from adoption studies to the broader population. Classical twin studies compare monozygotic (MZ) twins, who share all their genes, with dizygotic (DZ) twins, who share, on average, half their genes. An assumption of the twin method is that both twin types share their environment to the same extent. Although there are examples of this equal environments assumption being violated, there is little evidence that these violations affect behaviour or twin concordance for behaviour. Because twins come from all social strata and twinning is, in general, not associated with behavioural deviance, ndings from twin studies can usually be generalized to the wider population. Twin and adoption studies conrm a role for genetic factors as one cause of familial aggregation in almost all behavioural traits and psychiatric disorders. The most plausible explanation is that multiple genes are responsible for the genetic component, with each gene exerting a small effect. Genes of small effect have been termed quantitative trait loci (QTL) in the context of behavioural traits, or susceptibility genes when referring to disorders. The proportion of phenotypic variance that is due to genetic factors is referred to as the heritability of the phenotype. The heritability and sibling recurrence rate of a number of child psychiatric disorders are shown in Figure 2.

Behaviour genetic study designs


Design characteristics Primary comparisons Rate of disorder in relatives of probands versus controls. Pattern of occurrence (mode of inheritance, penetrance rate). Cosegregation of different disorders within families. Comparison of MZ vs. DZ twinpair similarity to estimate relative importance of genetic and environmental effects. Advantages Findings generalizable. Effective at elucidating mode of inheritance. Can give information about developmental changes in behaviour with relatives of different ages. Findings generalizable. Effective at disentangling shared and non-shared environment. Powerful in estimating heritability. Good for childhood studies because retrospective information from adults is not required. Powerful in examining gene environment interaction. Disadvantages Difcult to separate genetic from diagnostic/trait information on relatives. May be less accurate if retrospective or indirect information used.

Family

Twin

Geneenvironment correlations and interactions usually included in heritability. Equal environments assumption may be violated.

Adoption

Comparison of similarity of adoptive to biological vs. adoptive relatives to estimate importance of genetic and environmental effects.

Generalizability of ndings uncertain. Information on biological relatives often limited.

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Psychiatric disorders with childhood onset and probable signicant genetic aetiology
Disorder Autism Idiopathic mental retardation Heritability >90% Unknown Sibling recurrence risk 5%; broader phenotype up to 30% in males, 10% in females Mild retardation: no family history: 535%, higher when male index case positive family history in rst-degree relative: 3739% Severe retardation: no family history: 310% positive family history: 515% Uncertain, perhaps as high as 25% 9% for TS, 17% for chronic tics, 11% for obsessivecompulsive disorder 1520% risk of severe affective disorder Variable, from no increased risk to 17%, 10% best estimate 10% if no rst-degree relative affected; up to 4050% if both parents affected Uncertain: 010% Uncertain

Attention decit hyperactivity disorder Tourette syndrome Bipolar disorder Obsessivecompulsive disorder Schizophrenia Anorexia nervosa Conduct disorder

6090% Unknown ~80% Unknown 6070% Uncertain 570% (variable across studies)

The nature of environmental inuences


Twin and adoption studies can also distinguish between shared and non-shared environmental inuences. Shared or common environmental inuences make family members more similar to each other, while non-shared or unique environmental influences make family members different. Most behaviour genetic studies have not measured individual environmental effects and therefore cannot say whether specic factors act as shared or non-shared effects. While shared inuences must affect all family members, non-shared inuences may either affect one individual only, or may be experienced by the entire family but with varying effects on different members. To date, many studies have suggested that non-shared environmental inuences predominate over shared ones, questioning the importance of family-wide experiences (Plomin and Daniels, 1987). Recent work taking account of other factors that may affect the measurement of behaviour (often reported by a parent rating several children) has highlighted other factors that might falsely reduce estimates of shared environment. More work is required to determine the relative importance of shared versus non-shared environment.

Geneenvironment interplay
Genes and environment act together to inuence phenotypes. For example, the effect of dietary phenylalanine is harmful only in individuals who have the phenylketonuria mutation. Geneenvironment interplay has been difcult to measure in behaviour genetics because few individual genes for behaviour have been identied, making it difcult to distinguish individuals based on genetic risk. Nevertheless, adoption studies have pointed to a substantially increased rate of antisocial behaviour among individuals with both genetic and environmental risk factors compared to those with only one. Other work found that adopted children whose biological parents had

criminal records were not only more antisocial themselves but also had adoptive parents with harsher disciplinary practices, suggesting that these practices resulted from the experience of raising a child prone to antisocial behaviour (Ge et al., 1996). This harsh discipline itself further increased the childs antisocial behaviour, closing the loop between genetic and environmental effects. Another example of geneenvironment interplay is the relationship between adverse life events and depression (Silberg et al., 1999). Among adolescent girls, genetic factors inuenced the occurrence of life events; this was because behaviours that are genetically inuenced will affect the probability of experiencing life events. The same genes predisposing to life events also influenced depressive symptoms, leading to a geneenvironment correlation. Finally, experiencing adverse life events was found to increase subsequent depressive symptoms, causing a geneenvironment interaction. Children with conduct disorder are at higher risk of experiencing family-based psychosocial adversity. In the past, it was assumed that these adversities were themselves risk factors for conduct disorder. However, one study has shown that not only was family disharmony a risk factor in itself, it was also an index of parental qualities that are genetically inuenced and transmitted to children as a genetic risk factor for conduct disorder (Meyer et al., 2000). Fragile-X syndrome is an X-linked disorder that causes moderate-to-severe mental retardation and a range of behavioural problems. The disorder is caused by an abnormal increase in the number of cytosine-guanine-guanine (CGG) trinucleotide repeats in the FMR1 gene that prevents normal expression. Fragile-X syndrome occurs in 1 in 40005000 births and may be the most common form of inherited mental retardation. Aspects of the childs environment, such as the quality of the home environment and parental psychopathology, affect the extent of behaviour problems (Hessl et al., 2001). This highlights

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that even conditions caused by single genes are susceptible to environmental inuences. A commonly held misconception is that genetic inuences are greatest at birth and the importance of environmental factors increases with age. The empirical nding that genetic inuences increase with age is probably mainly due to geneenvironment interplay, in which genetic influences on behaviour shape environmental exposure.

the more severe a problem, the greater the genetic inuences, however. Among adults with major depressive disorder (excluding bipolar disorder), more inclusive diagnostic categories are more heritable (Kendler et al., 2001).

Molecular approaches to identifying genes


The revolution in molecular genetics has made it possible to identify individual genes and their function. The key study designs are summarized in Figure 3. For Mendelian disorders, linkage or positional cloning is the favoured strategy. Linkage studies of large families involve classifying family members as affected or unaffected and identifying individual genotypes at a number of locations within the genome. If a marker is close to the gene causing the disorder then, within individual families, one particular haplotype will be associated with the disorder, and not present in those who are unaffected. The relationship is probabilistic because of recombination during meiosis. The statistic used to describe the probability that an individual marker is linked to the disease gene is the LOD (log of the odds) score: a score of 3 (equivalent to 103 or a 1 in 1000 probability of obtaining the observed results by chance) is the convention for evidence in favour of linkage, when a

Genetic inuences on dimensions and disorders


Behavioural and cognitive disorders are often conceptualized as lying at the extreme end of the normal continuum and it could be assumed that behaviour genetics studies of dimensional symptom scores will shed light on the disorder, but this is not always the case. With respect to severe mental retardation, about 80% of cases are due to a major genetic abnormality or environmental insult, as opposed to the QTL that contribute to intelligence in the average range. Early speech and language delay provides another example. While there is no evidence that most such cases are due to single gene disorders, the heritability of signicant delay is much greater than that for individual variation in the average range (Dale et al., 1998). It may not always be the case that

Molecular genetic study designs


Design characteristics Assumptions about Advantages genotypephenotype link

Individuals sampled Linkage Large pedigrees

Disadvantages

Affected and unaffected family members

Inheritance must be unilineal. Gene frequency and penetrance must be estimated

Statistically powerful for major gene effects

Results may be highly dependent on inferences made about certain individuals in pedigrees. Inaccurate specication of gene frequency and penetrance may produce misleading results Statistically less powerful at detecting minor effects. Statistically weak at accounting for genetic heterogeneity. For common disorders, cannot assume identity by state occurs only because of identity by descent False-positive results due to genetic differences between case and control populations (genetic stratication)

Affected sib pair

Affected family members only

Relative pairs who are identical by state (share disorder) are identical by descent (have disorder because they inherited same susceptibility genes)

Does not require phenotypic classication of uncertain or unaffected family members

Association

Single affected individuals with controls (who may be parents)

Control population is genetically similar

Samples easily ascertained (only singletons required). True positive results occur only when marker close to susceptibility gene. Relatively powerful at detecting genes of small effect

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limited number of markers has been tested and where the gene is thought to exert a major effect on the disorder. The affected sibling pair (or affected relative pair) method is often used for disorders that are not dominantly inherited or where classication of some individuals as affected or not affected may be difcult. This design makes use of siblings who are concordant for the disorder to detect genes that are shared. For any completely polymorphic locus, siblings have a 1 in 4 probability of being identical by chance; therefore, many pairs are needed to achieve statistical signicance when a number of loci are being examined. Association studies use case-control comparisons where the risk factor is genotype. Because only single individuals are needed, samples are easy to obtain. When a positive result is conrmed, the genetic marker is likely to be close to the susceptibility gene, making it easier to identify the causal gene. However, false-positive results are a common problem, mainly due to genetic differences between the case and control populations (genetic stratication). This is overcome by using parents as controls for allele frequency, in the haplotype relative risk (HRR) method. The transmission distortion test (TDT) combines linkage and association methods using cases and controls with their parents (trios). This method examines not only case-control differences but also determines linkage in families by assessing whether the high-risk alleles from parents are preferentially transmitted to affected offspring.

Autism and language disorders


Autism is characterized by abnormalities in three domains: reciprocal social interaction language and social communication stereotyped, repetitive interest patterns. Twin studies in autism reveal much greater concordance rates for MZ compared with DZ co-twins. These studies also show that genetic susceptibility does not predetermine the presence of autism (because not all MZ co-twins develop the disorder, but almost all have some degree of social and/or cognitive impairment), but rather that it increases the risk of a range of social and communication abnormalities, of which autism is the most extreme form. Molecular genetic research in autism has implicated at least four genomic regions on chromosomes 2q, 7q, 15q and 16p. A large number of other regions have produced suggestive ndings in at least one study, including areas on chromosomes 4, 8, 9, 10, 11, 12, 17, 18, 19, 20 and X. Of particular interest is that the FOXP2 gene, located on 7q and identied as causing a severe speech and language disorder, overlaps with the area of linkage reported in autism (Liu et al., 2001). The possibility of shared genetic risk factors for autism and speech and language disorders is consistent with the ndings that a range of language disorders comprise part of the broader phenotype for autism and that there is an increased rate of autism in siblings of those affected with speech and language disorders.

relatively rare cases, by coprolalia and/or copropraxia. Family studies have highlighted the recurrence of Tourette syndrome (510%), milder but chronic tic disorders (17%) and obsessivecompulsive disorder (10%) in rst-degree relatives. Findings from complex segregation analysis (a statistical technique to clarify the causes of familial resemblance and mode of transmission) have been inconsistent in reporting either major or susceptibility genes as the most likely mode of inheritance. Several decades of molecular genetic studies have failed to detect possible loci; this may be because the assumptions made regarding mode of inheritance, gene frequency and penetrance were incorrect. However, several recent studies have suggested linkage to a locus on 11q (Pauls, 2001). Recently, a possible role has been postulated for infections with group A haemolytic streptococcus (GABHS) in relation to a range of paediatric neuropsychiatric disorders, including Tourette syndrome. It is well known that such infections can trigger an autoimmune response with subsequent central nervous system involvement, classically Sydenhams chorea. Some cases of Tourette syndrome and obsessivecompulsive disorder may constitute part of a distinct clinical entity referred to as paediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS). This is supported by elevated levels of the B-cell marker DD7/18, which is present in almost all patients with rheumatic fever and a clinical history of GABHS upper respiratory tract infections. Should this turn out to be an environmental trigger for Tourette syndrome, it may be a distinct subgroup with differing genetic risk factors.

ADHD: evidence for susceptibility genes


Attention decit hyperactivity disorder (ADHD) is an enduring disorder characterized by the early childhood onset of overactivity, inattentiveness and impulsivity. Twin studies estimate a heritability of 6080%. Children with ADHD generally show symptomatic improvement when treated with stimulants such as dexamphetamine or methylphenidate, whose mode of action is to alter central nervous system availability of dopamine, noradrenaline and serotonin. Genetic studies implicating the dopamine system include several replications of an association between ADHD and the dopamine D4 receptor (DRD4) and the dopamine transporter (DAT1). The ndings indicate that certain alleles behave as risk factors for ADHD but that they are not necessary for the disorder to occur, because many affected individuals do not have the high-risk genotype. Similarly, presence of the high-risk genotype is not sufcient, because some unaffected individuals have the risk allele. The presence of the high-risk DRD4 allele increases the chance of ADHD approximately 1.5 times (Thapar et al., 1999). The role of dopamine genes in ADHD is one of the most clear-cut examples of susceptibility genes.

Tourette syndrome and PANDAS


Tourette syndrome is a socially impairing disorder characterized by motor and vocal tics that persist over time and, in severe but

REFERENCES Dale P S, Simonoff E, Bishop D V M et al. Genetic inuence on language delay in two-year-old children. Nat Neurosci 1998; 1: 3248. Ge X J, Conger R D, Cadoret R J et al. The developmental interface

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between nature and nurture: a mutual inuence model of child antisocial behavior and parent behaviors. Dev Psychol 1996; 32: 57489. Hessl D, Dyer-Friedman J, Glaser B et al. The inuence of environmental and genetic factors on behavior problems and autistic symptoms in boys and girls with fragile X syndrome. Pediatrics 2001; 108: U69U77. Kendler K S, Gardner C O, Neale M C, Prescott C A. Genetic risk factors for major depression in men and women: similar or different heritabilities and same or partly distinct genes? Psychol Med 2001; 31: 60516. Liu J, Nyholt D R, Magnussen P et al. A genomewide screen for autism susceptibility loci. Am J Hum Genet 2001; 69: 32740. Meyer J M, Rutter M, Silberg J L et al. Familial aggregation for conduct disorder symptomatology: the role of genes, marital discord and family adaptability. Psychol Med 2000; 30: 75974. Pauls D L. Update on the genetics of Tourette syndrome. Adv Neurol 2001; 85: 28193. Plomin R, Daniels D. Why are children in the same family so different from one another? Behav Brain Sci 1987; 10: 160. Silberg J, Pickles A, Rutter M et al. The inuence of genetic factors and life stress on depression among adolescent girls. Arch Gen Psychiatry 1999; 56: 22532. Thapar A, Holmes J, Poulton K, Harrington R. Genetic basis of attention decit and hyperactivity. Br J Psychiatry 1999; 174: 10511. FURTHER READING Rutter M, Plomin R. Opportunities for psychiatry from genetic ndings. Br J Psychiatry 1997; 171: 20919. Rutter M, Silberg J, OConnor T J, Simonoff E. Genetics and child psychiatry: I Advances in quantitative and molecular genetics. J Child Psychol Psychiatry 1999; 40: 318. Rutter M, Silberg J, OConnor T, Simonoff E. Genetics and child psychiatry: II. Empirical research ndings. J Child Psychol Psychiatry 1999; 40: 1955.

Specic Learning Difculties


Margaret J Snowling

The term specific learning difficulty (SLD) is commonly used to describe the unexpected problems that some children experience academically. These childrens difculties are out of line with what might be expected given their age and general cognitive ability. In contrast, the term learning disabilities (mental retardation in the USA) is used to describe learning problems that occur in the context of more global delays in cognitive development, indicated by low IQ. SLD is an umbrella denition for a range of disorders, each with different core features. A problem for clinicians is that the behavioural manifestations of these disorders vary across the lifespan and differ when there are associated comorbidities. It is therefore advisable to take careful case histories from patients presenting with SLD; information about family history, speech, language and motor development can provide important pointers to the causes of the difculties these children have with learning. Comprehensive management programmes should also take account of current attainments in reading, spelling, number skills and written work, relative to age and ability. It is important to state that describing a child as having a specic learning difculty carries no implication about the nature or aetiology of his or her problems. Rather, SLD is a statistical denition that should be regarded as the starting point for a more detailed assessment of the childs strengths and difficulties. Of the many different kinds of SLD, this contribution focuses on: reading and spelling difculties (dyslexia and dysgraphia) arithmetic problems (dyscalculia) problems of motor coordination (dyspraxia). The syndrome of non-verbal learning disabilities is also discussed. Dyslexia The discrepancy definition: it is conventional in clinical practice to distinguish children who have specific reading difficulties from those who have reading difficulties in the context of more general learning problems. A child is deemed to have a specic problem with reading if their reading attainment is significantly below that predicted from their mental age

Practice points
Most childhood behaviours and psychiatric disorders are inuenced by genes, although the effect of each (susceptibility) gene is likely to be small Genes and environment act together, rather than separately, in complex and often reciprocal ways Behaviour genetic designs such as twin and adoption studies are important not only in estimating the relative importance of genetic and environmental risk factors but also in demonstrating the mechanisms of their joint risk Molecular genetic studies can identify genes of both major and minor effect, although the statistical power to identify minor susceptibility genes is much weaker

Margaret J Snowling holds a Personal Chair in Psychology at the University of York, UK, where she directs the Centre for Reading and Language. After completing a doctorate on developmental dyslexia at the Developmental Psychology Unit in London, she subsequently qualied as a clinical psychologist. Her research focuses on the interface of spoken and written language.

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on the basis of the correlation between reading and IQ in the same population. Such children show a discrepancy between expected and actual attainment. Prevalence the prevalence of specic reading difculties depends on the cut-off point taken as indicative of reading disability, and estimates range from 1.2% to 9.3%. The most recent epidemiological data from a longitudinal study of children in Connecticut, USA, reported prevalence rates of between 5.4% and 7%, depending on age (Shaywitz et al., 1992). In contrast to earlier studies, which reported 34 males to every female affected, this study found a more even sex distribution. However, more boys than girls in the sample had been referred for assessment by their schools, suggesting that boys with reading difculties come to the notice of teachers more frequently than girls, perhaps because they behave less well in class. The term dyslexia is often used as a synonym for specic reading difculties, but this practice is problematic as a child can full the criteria for specic learning difculties for several reasons; for example, because of absence from school, because of poor engagement with learning or as a consequence of poor teaching. Furthermore, discrepancy denitions tell us nothing about the manifestations of dyslexia in the pre-school years or in adulthood when reading difculties may have subsided but spelling problems persist. Causes of dyslexia: in spite of continuing debate about the precise criteria for the diagnosis of dyslexia, advances have been made in the understanding of its biological substrate. Gene markers for dyslexia have been identied on chromosomes 6 and 15 in several independent studies, and dyslexic readers seem to have differences in brain structure and function compared to normal readers, particularly in left hemisphere temporal regions. At the cognitive level, dyslexic people show a decit in phonological (speech) processing. The manifestation of this decit at the behavioural level changes as the child develops. Figure 1 summarizes the key features in children (pre-school and school-age) and adults. It has been suggested that dyslexic difculties are the result of low-level visual impairments. However, reports of raised thresholds for contrast sensitivity and visual motion detection in dyslexia, or problems with ocular motor control, have not been consistently replicated.

Another influential hypothesis is that the phonological deficit in dyslexia can be traced to impairments of (rapid) auditory processing mechanisms, but evidence for this proposal is also equivocal. An alternative view traces the phonological decits observed in dyslexia to a difculty in the mental representation of the spoken structures of words (see Snowling, 2000, for a review). These difficulties compromise the childs ability to learn alphabetic mappings between sounds and letters for reading and for spelling. Increasing evidence suggests that the English orthography (system of spelling), being highly inconsistent in these mappings, may aggravate dyslexia; dyslexic readers of German, Italian and other transparent (consistently spelled) languages display phonological decits but have more accurate (but slow) reading and spelling. Figure 2 presents a framework to illustrate the role of the cognitive decit in dyslexia as the mediator of the brainbehaviour relationship and environmental interactions. Treatment: research shows that the most effective interventions for dyslexia combine training in oral phonological awareness with highly systematic reading of text-based materials, and linking phonological units to sounds through writing. Children at risk of reading failure need individualized intervention from the time they start school to prevent them falling behind their peers. Dysgraphia Spelling skills in dyslexia: the spelling skills of dyslexic children are almost always impaired; moreover, dyslexic children often commit dysphonetic spelling errors that are phonetically unacceptable, e.g. geography > georafy. A second source of spelling difficulty is poor knowledge of orthographic conventions. Since English has an opaque (irregular) orthography in which spellingsound correspondences are not consistent, phonetic spelling errors are common: e.g. biscuit > biskit; chaos > kaos. Specific spelling disabilities: spelling problems can be experienced by children who are not dyslexic. Children who read well but have specic spelling problems have been described as dysgraphic, and they have the following characteristics:

Manifestation of dyslexia across the lifespan


Pre-school Delayed speech. Immature sentence formation. Poor expressive language relative to comprehension. Poor rhyming skills. Little interest in or knowledge of letters. Early school years Poor memory for verbal instructions. Difculties with common sequences (e.g. days of the week). Poor letter knowledge. Poor phonological awareness. Poor phonics (word-attack skills) even if reasonable sight vocabulary. Idiosyncratic spelling. Problems with copying. Middle school years Subtle speech problems (e.g. on polysyllabic words). Word-nding difculties. Difculty learning tables and number facts. Slow reading. Poor decoding skills when faced with new words. Phonetic spelling. Slow at copying. Adulthood Poor verbal memory. Word-nding difculties/makes malapropisms. Slow reading. Slow speed of writing. Poor proof-reading skills. Difculty committing ideas to paper. Poor organization of written work.

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they tend to have higher verbal than performance IQ they spell phonetically they have difficulty selecting the correct spelling from two plausible alternatives, e.g. successful/succesful; necessary/necessery. Causes: it has been proposed that dysgraphia may arise as the consequence of a subtle reading problem that is undiagnosed; indeed, people with poor spelling do not read in a detailed way. They appear to rely heavily on context and are bad at tasks such as proof-reading. There is also some evidence that people with dysgraphia have subtle visual memory decits. Dyscalculia Dyscalculia refers to specic difculties with numeracy skills, and is characterized by a problem in learning number facts and hence with arithmetic. The incidence of underachievement in arithmetic is less well documented than that for reading. Figures of around 6% have been reported; however, arithmetic problems commonly co-occur with specic reading difculties and not all studies have considered this comorbidity. One exception is a UK study by Lewis, Hitch and Walker (1994), which recorded specic arithmetic difculties in only 1.3% of an epidemiological sample of 910-year-olds. Normal development of number skills: adopting a developmental framework provides a useful way of considering childrens problems with arithmetic (see Geary, 1993, for a review). By the age of 6, most children can use a counting on strategy to add, sometimes using their ngers to monitor this process. Later, as they learn number facts, they can begin to retrieve these automatically. Importantly, the development in long-term memory of an association between the problem integers (e.g. 3+4) and the answer that is generated (7) requires practice in the execution of basic computations. With each execution, the probability of direct retrieval of that number fact increases. It follows that children who have difficulty with basic computation will have difficulty establishing a database of number knowledge, and hence in becoming numerate. Moreover, since more advanced mathematics builds on a foundation of basic arithmetic skills, children who fall behind in the early stages have difculty understanding and using more advanced concepts, and are often anxious about mathematics. Nature and causes of dyscalculia: children with dyscalculia typically: use the same strategies as younger children for calculating but are error-prone are slow at counting and at calculating have difculty retrieving number facts do not know their times tables are poor at monitoring their counting and at detecting computational errors have problems switching between different strategies in the completion of mathematical problems. The cognitive causes of dyscalculia are not as extensively researched as those of dyslexia. Theoretically, there are grounds for distinguishing a non-verbal magnitude system (thought to be controlled by right hemisphere processes) from a verbal number

Causal modelling framework for brainbehaviour relationships in dyslexia


Genes

BIOLOGY ENVIRONMENT Left hemisphere

Orthography

Phonological deficit COGNITION

Speech delay

Poor grapheme-phoneme

Poor phonological awareness

BEHAVIOUR

The right-hand side of the figure shows three different levels of explanation. At the biological level of description, there are genetic and brain theories of dyslexia. The symptoms of dyslexia can be seen at the level of behaviour. The intermediate level of cognition mediates relationships between biology and behaviour, and in dyslexia a phonological deficit is inferred. The left-hand side of the figure shows that at every level, there are interactions with the environment. A specific example is that the writing system of a language (orthography) plays a role in modifying the symptoms of dyslexia. (Adapted from Morton and Frith, 1995) 2

system (putatively in the left hemisphere). In line with this theory, some children have difculties in learning mathematical concepts, while others have selective decits of the calculation system. Some researchers view working memory difficulties as candidate causes of arithmetic problems, since numbers have to be held in short-term memory during the process of mental calculation, and a spatial representation of the problem to be solved can be helpful in some forms of problem-solving. One reason that many dyslexic children are also dyscalculic is that they have verbal short-term memory difculties that compromise arithmetic skill (Hulme and Roodenrys, 1995). Importantly, a range of control processes is also involved in selecting appropriate algorithms and in the monitoring of performance; for example, checking that the solution to a problem is within the estimated range.

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Dyspraxia The term dyspraxia is used to describe problems of motor coordination that can occur in isolation in otherwise normal children (developmental coordination disorder, or DCD) or which co-occur with other developmental disorders such as language impairment or autism. In fact, Hill (1998) showed that children with specic language impairment had dyspraxic difculties equivalent in magnitude to those of children with DCD on a task requiring the production of familiar hand postures (e.g. making a st). There is little agreement among professionals about terminology or about assessment criteria for DCD (Peters, Barnett and Henderson, 2001). Its symptoms can vary considerably and may include gross motor difculties (such as problems with running, hopping, jumping, catching a ball and balancing) and ne motor difculties (including a lack of manual dexterity, difculty in doing up buttons and laces, in dressing and in using eating utensils). Speechmotor skills (articulation) are often affected, and problems of pencil control are widespread. The view that dyspraxic children grow out of their clumsiness is mistaken; follow-up studies have shown that such children remain less physically competent throughout adolescence. The difculties they have at secondary school include problems with handwriting and the presentation of work, and difculties in science, art, design and technology. Indeed, there is some evidence that they do less well academically than their IQs predict. Causes and treatment: given its heterogeneity, it is unlikely that dyspraxia has a single cause. It is well established that dyspraxic children have visuo-spatial difculties; however, some cognitive theories of DCD have emphasized problems of kinaesthetic sensitivity, cross-modal transfer or timing. The lack of consensus has made it difcult to make progress in the evaluation of treatments. Children with coordination difculties need to have a comprehensive assessment of both gross and ne motor skills and of how their clumsiness affects the completion of everyday tasks. Their educational attainments should also be assessed so that a management plan usually involving a physiotherapist or occupational therapist as well as a teacher can be devised.

Clinical characteristics of non-verbal learning difculties


Early years Language development Motor development Attention

Slow to develop but catches up. Poor gross and ne motor skills except when skill is well practised. Hyperactive when young, becoming hypoactive

Primary school years Visuo-perceptual and spatial problems Reading (word level) Reading comprehension Spelling Arithmetic Later school years and adolescence Pragmatic language skills Social skills and peer relationships Socio-emotional adjustment

Present Good Impaired Good or phonetic Impaired

Impaired Impaired Poor

(Source: Rourke, 1995; Klin et al., 1995)

Comorbidity of specic learning difculties


SLDs commonly co-occur both with one another and with other disorders. For example, many dyslexic children also have motor difculties or attention decit hyperactivity disorder (ADHD). Theoretical accounts of specic developmental disorders that posit core cognitive decits can provide a useful way of thinking about SLDs without needing to classify them discretely. Thus, knowing that the core deficit in dyslexia is a phonological decit explains why reading difculties are experienced by some children with oral language difculties (Snowling, Bishop and Stothard, 2000). Non-verbal learning difculties: as yet, cognitive models of dyscalculia and dyspraxia are not well specied. In the absence of these, an overarching syndrome of non-verbal learning difculties (NVLD) has been proposed to explain the frequent

co-occurrence of such problems, together with dysgraphia (Rourke, 1995). In Scandinavia, the term disorders of attention and motor perception (DAMP) is preferred to describe children of normal intelligence with dyspraxic tendencies and ADHD (Gillberg, 1999); however, the syndrome has not been fully validated. While the symptoms of NVLD are not yet agreed (see Figure 3), it is generally believed that affected children have deciencies in visualspatial organization and non-verbal integration, and that they usually gain higher scores on verbal than performance IQ tests. Although it is described as a non-verbal syndrome, many affected children have reading comprehension difculties, mild speechlanguage impairments and pragmatic deficits (Bishop and Baird, 2001). Indeed, the high incidence of social and pragmatic impairments in NVLD suggests a continuum of this disorder, with Asperger syndrome at the severe end (Klin et al., 1995).

REFERENCES Bishop D V M, Baird G. Parent and teacher report of pragmatic aspects of communication: use of the Childrens Communication Checklist in a clinical setting. Dev Med Child Neurol 2001; 43: 80918. Geary D C. Mathematical disabilities: cognitive, neuropsychological and genetic components. Psychol Bull, 1993; 114: 34562. Gillberg C. Clinical Child Neuropsychiatry. Cambridge: Cambridge University Press, 1999.

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Hill E L. A dyspraxic decit in specic language impairment and developmental coordination disorder? Evidence from hand and arm movements. Dev Med Child Neurol 1998; 40: 38895. Hulme C, Roodenrys S. Practitioner review: verbal working memory development and its disorders. J Child Psychol Psychiatry 1995; 36: 37398. Klin A, Volkmar F R, Sparrow S S, Cicchetti D V, Rourke B P. Validity and neuropsychological characterization of Asperger Syndrome: convergence with Nonverbal Learning Disabilities Syndrome. J Child Psychol Psychiatry 1995; 36: 7, 112740. Lewis C, Hitch G J, Walker P. The prevalence of specic arithmetic difculties and specic reading difculties in 9- to 10-year-old boys and girls. J Child Psychol Psychiatry 1994; 35: 28392. Morton J, Frith U. Causal modelling: a structural approach to developmental psychopathology. In: Cicchetti D, Cohen D J. Manual of Developmental Psychopathology. New York: Wiley, 1995: 35790. Peters J M, Barnett A L, Henderson S E. Clumsiness, dyspraxia and developmental co-ordination disorder: how do health and education professionals in the UK dene the terms? Child Care Health Dev 2001; 27: 399412. Rourke B P, ed. Syndrome of Nonverbal Learning Disabilities: Neurodevelopmental Manifestations, New York: Guilford, 1995. Shaywitz S E, Escobar M D, Shaywitz B A, Fletcher J M, Makugh R. Evidence that dyslexia may represent the lower tail of a normal distribution of reading ability. N Eng J Med 1992; 326: 14550. Snowling M J. Dyslexia. 2nd edition. Oxford: Blackwell, 2000. Snowling M J, Bishop D V M, Stothard S E. Is pre-school language impairment a risk factor for dyslexia? J Child Psychol Psychiatry 2000; 41: 587600.

Developmental Language Disorders


Kate Nation

By the time most children start school, the basic building blocks of language are in place and they are able to use it to communicate appropriately with others in a variety of social settings. Considering the complexities of language (Figure 1), it is remarkable that most children master it with such ease. Some children, however, find language-learning less straightforward. Concern over language development is one of the most common reasons for referral to health professionals during the pre-school years, and language delay is associated with many developmental disorders, such as autism and Down syndrome. In addition, there are some children who fail to acquire language normally, despite having normal intelligence and reaching other developmental milestones on time. According to DSM-IV and ICD-10 criteria, the diagnosis developmental language disorder or specic language impairment (SLI; previously known as developmental dysphasia) is applied when speech and language skills fall below non-verbal intelligence for no obvious reason (sensory impairment, gross neurological abnormality and pervasive developmental disorder are exclusionary criteria). SLI is relatively common, with an incidence estimated at between 3% and 10% of the population.

Biological bases of specic language impairment


Genetic factors There is clear evidence that SLI is a genetically transmitted neurodevelopmental disorder. It runs in families and children are at greater risk of developing it if there is a family history of language impairment. Perhaps the strongest evidence for a genetic link comes from twin studies; a number of studies have now demonstrated a much higher concordance for SLI between identical twins relative to non-identical twins. However, patterns of inheritance are complex. Although the pedigree of one family, the KE family, is consistent with a single dominant gene pattern of inheritance of speech and language impairment (and linkage analysis has located the affected gene to a region on the long arm of chromosome 7), this family is atypical. Generally, studies are more consistent with the view that SLI is caused by multiple genes operating in a probabilistic manner, alongside multiple environmental risk factors (see Bishop, 2001, for review).

Practice points
Specic learning difculties (SLDs) take many forms Dyslexia is a specic reading difculty associated with phonological (speech) difculties Dysgraphia is a specic spelling difculty that can occur with dyslexia or alone Dyscalculia is a specic difculty with numeracy associated either with spatial difculties or with verbal short-term memory problems Dyspraxia refers to problems of motor coordination and frequently co-occurs with language disorders There are frequent comorbidities between developmental cognitive disorders SLD is only the starting point in the assessment and management of children with developmental disorders of learning

Kate Nation is a Lecturer in Psychology at the University of York, UK, where she is also a member of the Centre for Reading and Language. Her research interests include the development of language and literacy, both in normal and atypical development, with particular reference to childrens language comprehension difculties.

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What is language?

Phonology The sound of a language. Phonology concerns both the individual sounds that are used and the rules for how these sounds can be combined into words. Phonological patterns relate the sounds of speech (their phonetic forms) to the grammar of the language

Grammar and syntax The structure and rules of the language system that specify how the formation and combination of words relate together in sentences. Components of grammar include factors such as word order and grammatical affixes that mark tense and number (e.g. past tense, plural)

LANGUAGE

Semantics The part of the language system that specifies meaning of words and utterances. This includes both the meaning of individual words (lexical semantics) and how these may change according to the specific context in which the words occur

Pragmatics How language is used in a social context, including how listeners uncover a speakers intentions. A wide domain that includes anything relating to the way people communicate that cannot be captured by conventional linguistic analysis, such as how sentences are made to fit with the flow of the conversation, how unspoken premises are inferred and how degrees of formality and politeness are signalled

Brain development Although progress has been made at the genetic level, relatively little is known about the nature of brain development in SLI. Children with SLI make an interesting contrast with children who have acquired neurological damage. Most studies of young children with early focal damage nd little evidence for subsequent language difculties, even when the lesion involves substantial damage to the major areas involved in language processing. Clearly, the plasticity seen in such children is not evident in children who go on to develop SLI. The few imaging studies of SLI that have been conducted alongside post-mortem studies of brain morphology reveal remarkably few atypicalities in brain structure and organization. Moreover, some of the differences that have been reported (such as reduced leftward asymmetry of the planum temporale, a region which is involved in the understanding and use of language) are not specic to SLI but have also been implicated in other disorders. A challenge for future research is to understand how genetic and environmental factors impinge on brain development in neurodevelopmental disorders such as SLI.

The nature of SLI


A major difculty facing researchers and clinicians is that the behavioural manifestation of SLI varies enormously.

Speech and language difculties some children with SLI have clear difculties with speech and language: they may have unintelligible speech, or struggle to nd the words they are looking for; many children with SLI make grammatical errors and fail to comprehend complex sentences. With regard to the language subsystems described in Figure 1, these children may have difculty with phonology, grammar and semantics. Difculties with language use in contrast to these obvious speech and language impairments, some children have disproportionate difculties with using language appropriately; although their speech can be relatively well formed and intelligible, they have trouble participating in conversation owing to problems with maintaining the thread of a topic or dealing with intended (as opposed to literal) meaning. These children may have mastered language form and structure, but are clearly struggling with the aspects of language concerned with pragmatics. One approach to dealing with this heterogeneity has been to search for subtypes of SLI (Figure 2). Although this approach provides descriptive labels that may be useful clinically, the validity of proposing qualitatively distinct subtypes is far from clear. As SLI is a developmental disorder, its manifestations change over time and it is not unusual for children to fit different subtypes at different points in time. Complicating factors include severity, amount of intervention received and

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Varieties of developmental language development


DSM-IV and ICD-10 distinguish between two main types of specic language disorder: Mixed expressive and receptive disorder Children have difculty with both producing and comprehending language. Utterances tend to be short and error-prone (in terms of both phonology and grammar). Vocabulary is limited and understanding is poor, especially of complex sentences. Expressive language disorder Mutually exclusive from mixed disorder: language difculties seem more restricted to language expression rather than language comprehension. However, most children with expressive difculties are thought to have subtle problems with comprehension if tested using sensitive enough tests. It is not clear whether these two diagnostic categories are qualitatively distinct rather than different points on a continuum of severity. There has been a move in the literature to describe a childs difculty in terms of the domains of language (see Figure 1) they nd most troublesome, rather than forcing a distinction to be made between receptive and expressive abilities. As discussed in the text, however, these are currently descriptive subtypes rather than valid diagnostic categories: Grammatical SLI Children who have disproportionate difculties with grammar, especially with word order, tense and agreement marking as well as with producing and comprehending complex sentences. Other aspects of language, although impaired, are relative strengths compared with grammatical abilities. Word-nding difculties Production of speech sounds is relatively normal in terms of phonology and grammar, but the child has difculty nding the appropriate word and, as a consequence, language production is impoverished and immature. Comprehension is usually impaired but perhaps to a lesser degree. Semantic pragmatic impairment (or pragmatic language impairment) Although the child may produce complex, uent and well-formed sentences, language is not really used for social communication. Utterances can be verbose or over-formal, and have a bizarre or odd quality, similar to the language of some children with autistic disorder. Vocabulary and grammar can be relatively strong, but comprehension of extended discourse is poor. Non-verbal communication weaknesses are also apparent (e.g. lack of eye contact, poor turn-taking skills, unusual intonation). Other categories of specic language difculties include: Phonological disorder (DSM-IV) or specic articulation disorder (ICD-10) Although childs use of speech sounds is below appropriate level, language skills are normal. The difculties should be linguistic in nature and not due to structural impairment (e.g. cleft palate) or motor difculties (when a diagnosis of dysarthria or dyspraxia may be appropriate). Acquired aphasia with epilepsy (Landau Kleffner syndrome) Following normal progress in language development, language regresses causing severe receptive and expressive impairments. Usually associated with atypical electrical activity in the temporal lobes.

other strengths and weaknesses a child may possess (in general cognitive ability, for example). While it is generally agreed that SLI is a heterogeneous disorder, there is as yet no objective rationale for defining subtypes, and in most studies it is treated as a unitary disorder.

The underlying nature of SLI


Partly in response to the desire to identify the heritable phenotype of the disorder, efforts have been made to specify the cognitive mechanisms underpinning SLI. A number of hypotheses have been proposed, all of which have received some support from experimental investigations, but as yet there is no conclusive evidence to suggest that any of these factors is the single underlying cause of SLI. One prominent view sees SLI as an impairment caused by a general limited temporal processing capacity (e.g. Tallal et al., 1993). This decit has a huge impact on speech and language development as the child will have difculty dealing

with speech sounds that tend to be very rapid and short in duration. An alternative account proposes that children with SLI have a limited phonological short-term memory (responsible for maintaining active representations of speech sounds for short periods of time) and that this hampers language learning (Gathercole and Baddeley, 1990). A third account argues that SLI is a consequence of an underlying decit in the system responsible for the representation of grammar. There are the beginnings of a move away from the view that there is a single cause of SLI towards one that assumes multiple risk and protective factors contributing to the manifestation of SLI. Bishop et al. (1999) present good behavioural genetic evidence that poor phonological short-term memory may index a genetic risk, and that individuals with this risk may go on to have a clinical language impairment if other risk factors whether environmental or genetic are also present. One consequence of studies addressing the search for the

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heritable phenotype is that efforts are being made to evaluate the validity of diagnostic tests in terms of sensitivity and specicity. Given increasing dissatisfaction with current clinical diagnostic categories, research of this nature will help us understand the complex aetiology of SLI more fully and should help to specify better methods of assessment and intervention.

Prognosis
Many children who present with poor language in the pre-school years are best described as late developers who, after a slow start, make good progress and soon catch up with their peers. This observation presents a number of ethical and practical challenges to the clinician, such as: should all pre-school children with language delay receive therapy? if not, how do we decide who should receive treatment and who should not? when does a normal late developer become a child with a clinical language impairment? A number of longitudinal studies have attempted to distinguish transient from persistent impairment. For example, Bishop and Edmundson (1987) found that of a clinical sample of 4-year-olds with normal non-verbal ability but poor language (most of whom were receiving some speech therapy), 44% had resolved by the time they were 5.6 years old. Although these ndings are encouraging, suggesting that many problems appear to resolve in time and with early intervention, there is a need for caution. When the sample was later recruited at age 15, the children whose language skills had resolved by 5.6 years nevertheless had poorer literacy skills than controls, did less well in formal examinations and had subtle weaknesses on some language measures (Stothard et al., 1998). For children whose speech and language impairments do not resolve by middle childhood, continuing and persistent language difculties seem the norm. Many children with persistent SLI have serious difficulties with literacy and, perhaps related to this, they are also at risk of falling further behind their peers in vocabulary growth over time. Studies also point to a dropping-off in non-verbal ability over time, and children with SLI generally achieve low levels of educational success. In addition to academic failure, children with speech and language difculties are at risk of: behaviour problems, such as poor attention and conduct disorder psychosocial problems, including depression and anxiety poor self-concept rejection by peers. SLI and other problems: around 50% of children with language impairment have some degree of emotional, behavioural or psychiatric difculty. Turning this nding around, Cohen (1996) assessed the language skills of children presenting with primary psychiatric symptoms. After excluding children with known language impairment, sensory impairment or autism-spectrum difculties, 34% of the sample met the criteria for SLI. These children with unrecognized SLI tended to have relatively good expressive language abilities, so their adequate speech might have masked their poor language comprehension.

An important cautionary finding from Cohens study is therefore that good speech should not be taken as an index of good language and that children presenting with complex emotional, behavioural or psychiatric problems may have underlying language difculties that are not recognized. These children seem to be particularly at risk of depression, and of developing aggressive behaviour. Although there is a strong association between language difculties and psychopathology, group data mask considerable individual variation, and the nature and origins of the complex and varied relationship continues to be debated. Comorbidity is potentially a consequence of common neurodevelopmental immaturities, or one disorder could increase the risk of another, either concurrently or later on. The importance of developmental change has been highlighted by a number of longitudinal studies documenting both the long-term prognosis of children with SLI, and how the pattern of difculties changes over time. A long-term follow-up of a comparison between children with a history of SLI and a history of autism points to a very complex picture indeed (Howlin et al., 2000). Not only did the SLI group show greater declines in IQ over time, by adulthood they were experiencing substantial social problems similar in nature to those seen in the autistic group. Although in childhood the two groups were distinct, over time they had become more similar. These ndings demonstrate very clearly the persistent and complex problems experienced by people with developmental language disorders. At a practical level, they highlight the need for greater help and support than is generally available.

REFERENCES Bishop D V M. Genetic and environmental risks for specic language impairment in children. Phil Trans R Soc Lond B Biol Sci 2001; 356: 36980. Bishop D V M, Bishop S J, Bright P, James C, Delaney T, Tallal P. Different origin of auditory and phonological processing problems in children with language impairment: evidence from a twin study. J Speech Lang Hear Res 1999; 42: 15068. Bishop D V M, Edmundson A. Language-impaired four-year-olds: distinguishing transient from persistent impairment. J Speech Hear Res 1987; 52: 15673. Cohen N. Unsuspected language impairments in psychiatrically disturbed children: developmental issues and associated conditions. In: Beitchman J, Cohen N, Konstantareas M, Tannock R, eds. Language, Learning and Behaviour Disorders. Cambridge: Cambridge University Press, 1996. Gathercole S E, Baddeley A D. Phonological memory decits in language disordered children: is there a causal connection? J Mem Lang 1990; 29: 33660. Howlin P, Mawhood L M, Rutter M. Autism and developmental receptive language disorder a follow-up comparison in early adult life. II. Social, behavioural and psychiatric outcomes. J Child Psychol Psychiatry 2000; 41: 56178. Stothard S E, Snowling M J, Bishop D V M, Chipchase B B, Kaplan C A. Language-impaired preschoolers: a follow-up into adolescence. J Speech Lang Hear Res 1998; 41: 40718.

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Tallal P, Miller S, Fitch R H. Neurobiological basis of speech: a case for the pre-eminence of temporal processing. In: Tallal P, Galaburda A M, Llinas R R, von Euler C, eds. Annals of the New York Academy of Science: Temporal Processing in the Nervous System. Vol. 682. New York: New York Academy of Sciences, 1993: 2747.

The Development of Deaf and Blind Children


Peter Hindley

FURTHER READING Altmann G T M. The Ascent of Babel: An Exploration of Language, Mind and Understanding. Oxford: Oxford University Press, 1997. (A readable introduction to the psychology of language.) Bishop D V M. Uncommon Understanding: Development and Disorders of Language Comprehension in Children. Hove: Psychology Press, 1997. (A very comprehensive review of language development and disorders.) Bishop D V M, Leonard L B, eds. Speech and Language Impairments in Children: Causes, Characteristics, Intervention and Outcome. Hove: Psychology Press, 2000. (An up-to-date collection of papers concerned with the key topics in understanding and treating developmental language impairments.)

Severe to profound hearing impairment affects approximately 1 in 1000 children in the developed world; severe visual impairment (SVI) and blindness affect approximately 1 in 10,000 children (see Figure 1 for denitions, Figure 2 for prevalence). The developmental consequences of these severe forms of hearing impairment and visual impairment reect an interaction between four major sets of factors: the response of the childs developmental environment (parents, family, school, etc.) to the child

Denitions of hearing and visual impairment


Hearing impairment Visual impairment

Physical descriptor of degree of impairment mild 2040 dB1 severely visually impaired: moderate 4170 dB less than 6/18, better severe 7195 dB than 3/60 Snellen profound 96 dB blind: less than 3/60 or visual eld defect, less than 20 degrees at maximum diameter Terms used to describe children and adults with severe impairment hard of hearing: moderate to severe visual impairment profound acquired hearing (SVI): sufcient vision for pattern impairment recognition and visually deaf: severe to profound directed reach, can read with congenital or early-onset special visual aids hearing impairment blind: cannot use materials Deaf: culturally deaf, use sign involving sight3 language and member of Deaf community2
1

Practice points
A substantial minority of children experience disproportionate difculties with speech and language Although it is well accepted that SLI is a neurodevelopmental disorder that has a heritable basis, much work is needed to discern how genetic and environmental factors interact and how this affects brain development As speech and language are complex processes, it is not surprising to nd that different children have different proles of strengths and weaknesses. The extent to which this reects distinct subtypes is debated, but it seems likely that SLI is a heterogeneous disorder Many childrens early language problems do resolve, although clinicians need to remain alert as later difculties with literacy are not uncommon Children whose language skills remain poor beyond middle childhood represent a serious clinical problem: in addition to poor educational attainment, they are at high risk of substantial social, emotional and behavioural difculties

Degree of hearing loss is measured in the better ear at 0.25, 0.5, 1, 2 and 4 kHz. Conversational speech is approximately 5070 dB 2 The Deaf community is a group of people sharing the same language and experiencing the world in a visual way (Meadow-Orlans and Erting, 2000) 3 The Blind community constructs the world as a narrative rather than as a gestalt (Fogel, 1997)

Peter Hindley is Consultant for the Deaf Child and Family Services at South West London and St Georges Mental Health NHS Trust, London, UK. His special interests include the provision of services for deaf children, and furthering research into the area.

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Prevalence of deafness and visual impairment and additional impairments


Impairment Prevalence Prevalence of additional impairments Intellectual: 6.9% 2 Motor: 6.8% Visual: 10.3% Other: 10.8% Intellectual: 51% 5 Motor: 15% Epilepsy: 11% Hearing: 9%

1 in 100,000 children. It is important to note that the effects of both impairments is cumulative. Access to developmental experience often has to be mediated by adults in order for deaf-blind children to develop basic communication, language and social and emotional skills.

Deafness Moderateprofound 1.2 in 1000 1 Profound 1 in 2703 1

Denitions
Two broad categories of definition are used with children with hearing or visual impairment: medical/pathological and social/cultural (Figure 1). Children with congenital or early-onset impairments are likely to follow substantially different paths from those with acquired impairments (Figure 3). Visual impairment the main differentiating factor with respect to severity of impairment is the presence of light perception. Severely visually impaired children without light perception (blind children) follow a developmental path substantially different from those with light perception. However, it is important to note that blind children are more likely to have pervasive CNS abnormalities (Hill et al., 1986). Children with cortical blindness (blindness arising from dysfunction of the visual pathways and visual cortices) often present with inconsistent or uctuating visual impairment. Hearing impairment children who cannot perceive speech are more likely to become sign language users and later to join the Deaf community (Meadow-Orlans and Erting, 2000). However, technological change is affecting these processes. The introduction of cochlear implants (electronic devices that input amplied signals directly into the cochlea) is changing the auditory functioning of profoundly deaf children to more like that of children with severe hearing impairment (Meyer et al., 1998). Similar developments in the use of retinal implants are likely to benet children with acquired visual impairment arising from macular degeneration or retinitis pigmentosa, but not those

Visual impairment SVI Blindness

8.1 in 10,000 3 3.2 in 10,000 4

Davis et al., 1995 Sinkkonen, 1994 3 Bryars and Archer, 1977 4 Baird and Moore, 1993 5 Hill et al., 1986
2

differing degrees of impairment the age of onset the existence of concomitant impairments, particularly central nervous system (CNS) abnormalities. The interaction between these factors means that there is no typical development of a blind or a deaf child each child is unique. However, it is possible to describe some common patterns of development, which reect broad groups of children but may not match each childs development. Hearing and visual impairments co-occur in approximately

Aetiologies of deafness and blindness


Aetiology Unknown Hereditary Maternal rubella or cytomegalovirus Perinatal (Rh, severe prematurity, etc.) Post-natal and acquired (mumps, trauma, meningitis, measles) Other % deaf children 49 13 6 11 15 6 % blind children 14 45 24 10 7 Associated impairments Presumably mainly recessive genes, mainly without additional impairments. Primarily without additional impairments. Strong association with additional visual and other CNS impairments. Strong association with additional impairments. Some association with additional impairments. Some syndromes (e.g. CHARGE syndrome) have additional impairments.

TOTAL

100

100

CHARGE syndrome can result in both vision and hearing loss and consists of the following impairments: coloboma of the eye; heart defect; atresia of the choanae; retardation of growth/development; genital hypoplasia; ear malformations www.seecenter.org/causes.htm www.jceh.co.uk/journal/40_1.asp

3
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with early-onset visual impairment or visual impairment arising from abnormalities in higher visual pathways.

Parental and environmental responses


Parents are almost always the rst people to realize that their child is deaf or blind. It is worrying that some doctors and other health professionals dismiss these concerns, often mislabelling understandable worries as inappropriate anxiety (Danek, 1988). All parental concerns about deafness or blindness should be treated seriously. Most parents will also experience some degree of shock and feelings akin to loss when they nd out that their child is deaf or blind. A number of authors have suggested that these feelings are more powerful among parents of blind infants (Warren, 1994). Persistent feelings of sadness and loss in some parents of deaf and blind children appear to affect attachment relationships in particular. The vast majority of parents of deaf or blind children are sighted and hearing and have no prior experience of deafness or blindness. This has important implications for the adaptations parents need to make in order to meet their childrens needs. It is important to note that most of the developmental delays observed in hearing children of deaf parents do not occur in deaf children of deaf parents (Marschark, 1993). This is partly as a result of early language exposure through sign language, and partly because genetic deafness is not associated with pervasive brain abnormalities. Educational policy and deaf children: educational policies vary widely at both regioanl and national level. In the UK, some educational authorities espouse purely oral/aural approaches to deaf children i.e. the encouragement of spoken language only and the exclusion of sign language. Practitioners of the oral/aural approach believe that all children, if they are detected and aided early enough, can develop spoken language. Other areas espouse bilingual/bicultural approaches (bi-bi), encouraging families and children to develop British Sign Language (BSL) by the provision of deaf language aides working in the home, and spoken and written language. BSL is the language of the British Deaf community. It is a naturally occurring language with its own lexicon and syntax, which is completely different from English syntax. There are intermediate approaches, often called Total Communication, whereby spoken and signed language are used simultaneously. There is growing concern, however, that both languages suffer when they are used simultaneously. English and BSL have such different grammatical structures that either one or both are lost in the process. Although some children educated in the oral/aural approach will develop effective spoken language, not all will. Children who fail to develop spoken language are thus at risk of growing up in an environment without access to language. Children growing up in bi-bi environments can access language early through BSL, and go on to develop either spoken language or written language. Early language deprivation has a range of developmental consequences for deaf children (see below). Mainstream education the majority of deaf children are educated in mainstream settings, being taught either in signed or spoken language. Only 5% attend special schools, most of

which use sign language in some form. Deaf children attending mainstream schools may be educated in mainstream classes, with communication support, or in separate units, often called Hearing Impaired Units. Recent changes in education legislation are likely to lead to a further reduction in the numbers of children attending special schools. Mainstream schools with deaf children need to make special efforts to include them fully. Mainstream schools which use sign language need to make extra provision for hearing children and non-specialist staff to acquire signing skills; in practice, many schools do not. Very few children with SVI alone attend special schools. Most are educated in mainstream schools or attached units.

Incidental learning
Children learn in both formal and informal settings. Incidental learning primarily takes place in informal settings when children overhear conversations or pick up information from the radio, television, friends, etc. Incidental learning is especially important in social and emotional development. Effective incidental learning depends on the child being able to access their social environment. Deaf children face barriers because of linguistic differences, either because they have minimal spoken language or are sign language users (Greenberg and Kusche, 1993). Blind and deaf children face barriers if their experience has been excessively limited in order to protect them from harm. This may be particularly so for blind children, for whom early delays in locomotor development may diminish the capacity to explore the world independently (Warren, 1994).

Language development
Deaf children: the sign language development of deaf children of deaf parents appears to follow similar milestones to the spoken language development of hearing children of hearing parents. Language development in deaf children of hearing parents who use sign mirrors that of deaf children of deaf parents, but it is frequently slower because the sign language competency of hearing parents does not match that of deaf parents (Marschark, 1993). Spoken language in deaf children, even with modern aiding, is frequently delayed. Deaf children often have difculty in understanding wh- questions (why, what, where, when, etc.), relative clauses and embedded questions. Clinicians can overestimate deaf childrens language functioning because their expressive language can be more advanced than their receptive language. Early intervention as a result of universal neonatal hearing screening and early cochlear implantation will have a positive impact on both spoken and sign language development (Yoshinaga-Itano and Apuzzo, 1998). Blind children: language development in blind children is far more variable. Some authors argue that blind childrens vocabularies are more restricted than those of sighted children (Dunlea, 1989) and they have more difculty using language in different contexts. Others contend that language development in blind children is adversely affected only in the presence of other impairments (Landau, 1997). The process may be somewhat different, with blind children repeating phrases referring to

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experiences that they cannot access as a means of internalizing them (Warren, 1994). Blind children may be delayed in acquiring I and you (Warren, 1994), although this may reect higher rates of autistic spectrum disorders in blind children (Cass, 1998).

Social and emotional development


Deaf children: parental responses, language delay and difculties in accessing incidental learning are the major factors that can adversely affect deaf childrens social and emotional development. Most deaf children develop secure attachment relationships with their parents, except when the parents have difculty in accepting their childs deafness. Deaf children of hearing parents are more vulnerable to delays in developing theory of mind compared to deaf peers who are the children of deaf parents (Peterson and Siegal, 1998). Deaf childrens early emotional development does not appear to differ from that of hearing children, but as they grow older deaf children are more likely to have restricted emotional vocabularies and restricted understanding of emotional processes (Greenberg and Kusche, 1993). Equally, in primary school deaf children are likely to have the same range of friends as their hearing peers. However, as they approach secondary school age they are more likely to have fewer friends than their hearing peers, or even none at all (Hindley, 2000). This appears to reect the growing importance of verbal interaction in this age group, and deaf childrens difficulty in accessing such interaction. Blind children: as with language development, there is considerable debate about the impact of blindness on blind childrens social and emotional development. Some authors have concluded that although blind childrens social and emotional development may be delayed, with time they achieve the same milestones as sighted children (Warren, 1994). Others argue that blind children are more vulnerable to autistic-like patterns of development because of lack of visual interaction (Hobson et al., 1997). This observation probably arises from an increase in autistic spectrum disorders in blind children as a result of pervasive brain abnormalities associated with the cause of visual impairment (Cass, 1998).

Blind children: intellectual development has been assessed using the verbal subscales of standardized IQ tests and with measures specically developed for blind children. Warren (1994) points out that it is essential that these measures accurately reect blind childrens general experience if they are to provide accurate assessments. In general, it appears that any decits primarily reect associated brain abnormalities rather than the consequences of visual impairment. However, performance and spatial ability appear to be understandably affected (Warren, 1994). As with deaf children, conceptual thinking in blind children is delayed, with conservation of volume being related to degree of visual impairment.

Conclusions
Both deaf and blind children are vulnerable to developmental delays. In deaf children, developmental delays are primarily related to language and experiential deprivation. Many of these delays could be avoided by a combination of early sign language provision and enhancing deaf childrens social and emotional experience (Greenberg and Kusche, 1993). For blind children, the mechanisms appear to be somewhat different. Although experiential deprivation can play a part, most developmental delays associated with blindness appear to be related to associated pervasive brain abnormalities. Early identication of these additional impairments may allow for early intervention and remediation.

REFERENCES
Baird G, Moore A T. Epidemiology of childhood blindness. In: Fielder A, Best A, Bax M, eds. The Management of Visual Impairments in Childhood. Clinics in Developmental Medicine No. 128. London: MacKeith Press, 1993: 18. Bryars J H, Archer D B. Aetiological survey of visually handicapped children in Northern Ireland. Trans Ophthalmol Soc U K 1977; 97: 269. Cass H. Visual impairment and autism: current questions and future research. Autism 1998; 2: 11738. Danek M M. Deafness and family impact. In: Power P, Dell Orto A, Gibsons M, eds. Family Interventions Throughout Chronic Illness and Disability. Springer Series on Rehabilitation, 17. New York: Springer, 1988: 12035. Davis A, Wood S, Healy R, Webb H, Rowe S. Risk factors for hearing disorders: epidemiological evidence of change over time. J Am Acad Audiol 1995; 6: 36570. Dunlea A. Vision and the Emergence of Meaning. New York: Cambridge University Press, 1989. Fogel A. Seeing and being seen. In: Lewis V, Collis G M, eds. Blindness and Psychological Development in Young Children. Leicester: BPS Books, 1997. Greenberg M T, Kusche M T. Promoting Social and Emotional Development in Deaf Children: The PATHS Project. Seattle: University of Washington Press, 1993. Hill A E, McKendrick P, Poole J J, Pugh R E, Rosenbloom L, Turnbull R. The Liverpool Visual Assessment Team: 10 years experience. Child Care Health Dev 1986; 12: 3751.

Cognitive development
Deaf children: studies of their cognitive development suggest that deaf children of hearing parents, when tested using nonverbal measures of IQ, show small but signicant decits in comparison with hearing children (Marschark, 1993). Interestingly, the converse is true of deaf children of deaf parents, who show small but significant advantages in comparison with hearing children (Braden, 1994). Deaf children rely more on visualperceptual thinking and visual memory and less on abstract thinking (Marschark, 1993). Deaf childrens development of conceptual thinking (e.g. the development of conservation) lags behind hearing childrens development by 24 years. Finally, deaf children appear to have short- and long-term memory decits compared with hearing children (Marschark, 1993).

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Hindley P A. Child and adolescent psychiatry. In: Hindley P, Kitson N, eds. Mental Health and Deafness. London: Whurr, 2000. Hobson R, Brown R, Minter E M, Lee, A. Autism revisited: the case of congenital blindness. In: Lewis V, Collis G, eds. Blindness and Psychological Development in Young Children. Leicester: BPS Books, 1997. Landau B. Language and experience in blind children: retrospective and perspective. In: Lewis V, Collis G M, eds. Blindness and Psychological Development in Young Children. Leicester: BPS Books, 1997. Marschark M. Psychological Development of Deaf Children. Oxford: Oxford University Press, 1993. Meadow-Orlans K P, Erting C. Deaf people in society. In: Hindley P, Kitson N, eds. Mental Health and Deafness. London: Whurr, 2000. Meyer T A, Svirsky M A, Kirk K I, Miyamoto R T. Improvements in speech perception by children with profound hearing loss: effects of device, communication, mode and chronological age. J Speech Lang Hear Res 1998; 41: 8468. Peterson C, Siegal M. Changing focus on the representational mind: deaf, autistic and normal childrens concepts of false photos, false drawings and false beliefs. Br J Dev Psychol 1998; 16: 30120. Sinkkonen J. Hearing Impairment, Communication and Personality Development. PhD thesis, University of Helsinki, 1994. Warren D H. Blindness and Children: An Individual Differences Approach. Cambridge: Cambridge University Press, 1994. Yoshinaga-Itano C, Apuzzo M-R L. The development of deaf and hard of hearing children identied early through the high-risk registry. Am Ann Deaf 1998; 143: 41624.

Diagnostic Classication Systems


Richard Harrington

Purposes and limitations of diagnosis


Diagnosis should be an aid to communication. Its main purpose is to bring together illnesses that have the same features. Ideally, a diagnosis should identify disorders with the same underlying aetiology, the same course and the same response to treatment. However, even in general medicine such an ideal is seldom achieved. Many of the most common problems, such as heart disease, have multiple causes. Moreover, a single medical cause, such as smoking, may lead to many different disorders, each with different consequences in terms of morbidity and treatment. Similar issues apply in child psychiatry. Most disorders have a multifactorial causation, and most risk factors can lead to several different types of disorder. Accordingly, the diagnosis and classication of child psychopathology has increasingly focused on the presenting features of the disorder rather than its aetiology. With a few exceptions (e.g. post-traumatic stress disorder), diagnoses tell us about the symptoms and signs of a disorder but not necessarily about its causes or treatment, which must be considered separately. A diagnosis of conduct disorder, for example, will convey the clinical presentation but does not convey which of the different causes are most important, and therefore which treatment is most appropriate. Classications: ICD-10 and DSM-IV The main current diagnostic schemes are ICD-10 (WHO, 1993) and DSM-IV (APA, 1994). Although the schemes differ in many ways, their overall classications are very similar. ICD-10 has a clinical version (used in this contribution), which gives broad prototypic descriptions of disorders, and a research version, which lists clearly dened diagnostic criteria. Both ICD-10 and DSM-IV classify psychopathology into categories. While it is likely that most psychopathology in children is based on continuously distributed underlying liability, categorical systems have particular merits. First, most clinical decisions are categorical in nature, so even if a dimensional approach were used it would be necessary to convert it into a categorical one using cut-off points. Second,

Practice points
Always take parental concerns about possible sensory impairment seriously Early detection and intervention promote maximal development Assess for additional impairments Consider early sign language and spoken language for deaf children There are higher rates of autism in blind children

Richard Harrington is Professor of Child and Adolescent Psychiatry and Chair of the Department of Child and Adolescent Psychiatry at the University of Manchester, UK. His main clinical research interests are depression and suicidal behaviour in young people.

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diagnostic categories provide a simple summary of a large amount of information. Clinical use of diagnostic criteria Lists of diagnostic criteria have been a major step forward in improving agreement among clinicians and investigators. Nevertheless, when using these schemes in clinical work a number of issues should be borne in mind. Diagnostic criteria are no more than a consensus of current concepts in a eld that is changing rapidly; diagnostic schemes are certain to change substantially in the future. Many children who are signicantly impaired by psychiatric problems do not meet diagnostic criteria. Equally, it is quite common to nd children who meet the symptomatic criteria for a psychiatric diagnosis, but who are not suffering greatly from their symptoms and are not impaired. Indeed, when psychiatric disorders are diagnosed using symptom criteria alone, the rate of so-called disorder becomes implausibly high. It is important therefore that clinical judgement is used when applying the criteria they were never meant to be applied rigidly in a cookbook fashion.

Multiaxial diagnosis
Most children with psychiatric problems have multiple difculties. For example, a child with a behavioural problem may also have mental retardation and live in a home with much family discord. No single diagnostic term can describe all of these difculties, yet it is essential to record all of them in the assessment. The multiaxial diagnostic scheme was devised to deal with this issue (the axes used are shown in Figure 1). A diagnosis in this scheme records something about a childs problems on all six axes, even if one or more of them is negative. For instance, the diagnosis could be hyperkinetic syndrome (axis one) leading to moderate social disability (axis six) in a child with mild mental retardation (axis three), who suffers from epilepsy (axis four) and who comes from a family characterized by discord (axis ve). The childs reading problems can be explained by his mental retardation; there is no specic reading retardation (axis two).

ICD-10 multiaxial diagnosis


Axis One Two Three Four Five Six Feature of the child Clinical psychiatric syndrome (e.g. hyperkinetic syndrome) Specic disorders of psychological development (e.g. specic reading retardation) Intellectual level (e.g. mild mental retardation) Associated medical conditions (e.g. epilepsy) Associated abnormal psychosocial situations (e.g. family discord) Global assessment of psychosocial disability (e.g. moderate social disability)

Clinical psychiatric syndromes There are ve broad groupings of clinical psychiatric syndromes (Figure 2), the two most common being disruptive behavioural disorders and emotional disorders. However, many other problems do not fall into these broad diagnostic groupings, such as eating disorders (e.g. anorexia nervosa), tic disorders and attachment disorders. Disruptive behavioural disorders are characterized by abnormal behaviour that gives rise to social disapproval. In younger children such behaviour consists of tempers, aggression, and disobedience (oppositional behaviour). In older children and adolescents the category also includes law-breaking and behaviours such as stealing, truancy and running away (conduct disorder). The diagnosis of conduct disorder is unsatisfactory as it depends on social norms, but in spite of this it has proved useful because children with this disorder share many features. Conduct disorders are strongly associated with reading difficulties and often persist into adult life in the form of personality disorders. Emotional disorders are those in which the main problem is an abnormality of emotions such as anxiety, depression, fear and obsessions. These disorders are sometimes referred to as internalizing disorders, as they are believed to be due to the internalization of stress. However, this term is probably best avoided as these disorders are in fact multifactorial. Emotional disorders differ from other child psychiatric disorders in having an equal sex ratio. Indeed, after puberty the incidence of some emotional disorders, most notably depression, becomes more frequent in girls. It used to be thought that emotional disorders had a good adult prognosis, and early-onset cases often do. However, adolescent-onset cases often persist into adult life. Hyperkinetic disorders are dened by the simultaneous presence across situations of motor overactivity, impulsivity and inattention. These disorders typically start before the age of 5 years and are strongly associated with conduct disorders. The outcome is similar to that of conduct disorder, but unlike conduct disorder there is good short-term response to stimulant medication. Autism is the most severe of the pervasive developmental disorders (PDD). It is present from infancy and is characterized by a failure to develop social relationships, severe language delay and compulsive and ritualistic activities. In about threequarters of children with autism there is also mental retardation. Autism is relatively rare, but there are other more common, less severe, forms of PDD. Children with Asperger syndrome resemble children with autism in their social relationship difculties and compulsive interests, but their language is much less impaired and they are of normal intelligence. Schizophrenia is very uncommon in early adolescence, but when it does occur it is often severe and associated with much social impairment. Overlap: there is a great deal of overlap between the various diagnostic categories. For example, around one-quarter of young people with conduct disorder will also develop a depressive disorder at some point. The two diagnostic systems take different approaches to comorbidity. In ICD-10 it is assumed that a mixed clinical picture is more likely to be the result of a single disorder with different

1
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Main axis one diagnostic groups and their distinguishing features


Behavioural disorders Diagnoses Oppositionaldeant disorder Conduct disorder Hyperkinetic disorders Hyperkinetic disorder Hyperkinetic conduct disorder Emotional disorders Mood disorders Anxiety Phobias Obsessivecompulsive disorder M=F Any + Pervasive developmental disorder Autism Asperger syndrome Schizophrenia

Schizophrenia

Sex Age of onset Family discord Mental retardation Specic developmental problems Impairment in adulthood

M Any +++ + ++

M+ <5 years ++ + +++

M ++ <30 months +++ +++

M=F >10 years +/+ +

++

++

+ (++ if adolescent onset)

+++

+++

manifestations than of two or more disorders that happen to occur in the same individual at the same time. ICD-10 therefore has categories for mixed disorders, such as mixed disorders of conduct and emotions and hyperkinetic conduct disorder. DSM-IV, in contrast, usually allows the investigator to diagnose several supposedly separate disorders, with the result that in surveys based on DSM-IV it is quite common to nd individuals with three or more diagnoses. Specic disorders of psychological development The second axis deals with an important group of problems, usually known as developmental disorders (Figure 3). They differ from psychiatric disorders in several respects: the onset is invariably in infancy or childhood their course is steady and does not involve the remissions and relapses that characterize psychiatric disorders there is specic delay in the development of functions that are related to biological maturation of the brain. All disorders in this group are much more common in boys and there is often a family history of similar problems. From a psychiatric perspective, the two most important varieties are developmental disorders of speech and language, and specic reading retardation (also known as dyslexia, see pages 434). Language disorder there is much variation in the age at which children acquire language, and many slow speakers develop perfectly normally. Language delay outside the limits of two standard deviations that cannot be accounted for by mental retardation is usually regarded as abnormal. There is a very strong association between language disorders and psychiatric disorders. In most studies, more than 50% of children with a language disorder also have a psychiatric disorder, often behavioural problems.

Specific reading disorder is characterized by specific impairment of reading skills that cannot be accounted for by mental retardation, visual problems or inadequate educational opportunities. Children with specic reading problems often have a history of language delay. There is a strong association with psychiatric disorders. Around one-third of cases also have an emotional or conduct disorder. Intellectual level In ICD-10 mental retardation (Figure 4) is dened as a state of arrested or incomplete development of the mind. The degree of mental retardation is dened by the intelligence quotient (IQ), which should be estimated from standardized intelligence

Specic disorders of psychological development (ICD-10)


Specic developmental disorders of speech and language: specic articulation disorder expressive language disorder receptive language disorder acquired aphasia with epilepsy other disorders of speech and language Specic developmental disorders of scholastic skills: specic reading disorder specic spelling disorder specic disorder of arithmetical skills mixed disorder of scholastic skills Specic developmental disorder of motor function Mixed specic developmental disorders 3

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Intellectual level (ICD-10)


Intellectual level Mild mental retardation IQ 5069 Degree of impairment in adulthood Most individuals fully independent; lower end of this range may have problems keeping a job and child-rearing Completely independent living seldom achieved Marked impairment

Assessment of psychosocial disability This nal axis reects the childs occupational, psychological and social functioning at the time of the clinical evaluation. Both epidemiological and clinical studies have consistently shown the predictive value of psychosocial disability. This is also a very useful construct in planning mental health services for children. The ICD-10 assessment of psychosocial disability ranges from superior functioning through moderate social disability (impairment on one or two domains) to profound disability (unable to function in any domain).

Moderate mental retardation Severe mental retardation Profound mental retardation

3549

2034

<20

Require constant help and supervision

tests. The IQ level is, however, only a guide and should not be applied too rigidly. Children with mild mental retardation can often manage in mainstream schools, though at the lower end of this range they may require additional support. Children with an IQ below 50 often require more intensive support or special schooling and are likely to require supervision into adulthood. Mental retardation is a strong risk factor for mental health problems. About one-third of children with mild mental retardation have psychiatric disorders, and among children with moderate mental retardation the rate of disorder is about 50%. The mix of psychiatric disorders is similar to that seen in children without mental retardation, but autism and self-injury are particularly common among children with moderate and severe mental retardation. Associated medical conditions Physical disorders not affecting the brain are associated with a moderate increase in the risk of psychopathology. Any medical disorder that affects the brain is associated with a 33% or more increased risk of psychiatric disorder. Associated abnormal psychosocial situations There is a strong association between most child psychiatric disorders and abnormal psychosocial situations. In many instances it is unclear to what extent these connections reect causal relationships, but since this axis is intended to cover situations that have contributed to the causes of the childs problems, situations that are clearly a consequence of the childs psychopathology are excluded. ICD-10 has a total of nine categories of abnormal psychosocial situation. In routine clinical practice, the most commonly encountered situations are: abnormal intrafamilial relationships parental mental disorder abnormal upbringing acute life events.

FURTHER READING American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: APA, 1994. (Describes the US system.) Cantwell D P, Rutter M. Classication: conceptual issues and substantive ndings. In: Rutter M, Taylor E, Hersov L, eds. Child and Adolescent Psychiatry: Modern Approaches. 3rd edition. Oxford: Blackwell Scientic, 1994: 321. World Health Organization. The ICD-10 Classication of Mental and Behavioural Disorders: Diagnostic Criteria for Research. Geneva: WHO, 1993. (Operational diagnostic criteria for research.) World Health Organization. Multiaxial Classication of Child and Adolescent Psychiatric Disorders. Cambridge: Cambridge University Press, 1996. (Detailed description of the ICD-10 system.)

Practice points
Diagnostic criteria are not meant to be applied rigidly, so clinical judgement should be used when applying them There is a great deal of overlap between diagnostic categories Most children with psychiatric problems have multiple difculties, which are therefore best described in a multiaxial diagnostic system Specic developmental disorders are often associated with psychiatric disorders

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CHILD PSYCHIATRY AND THE LAW

Adoption and Fostering


Jill Hodges

commonest diagnoses, and high levels of comorbidity indicated the complexity of these young peoples difficulties. This study did not examine the incidence of post-traumatic stress disorder (PTSD), though this is often comorbid with some of the disorders which were identified. The researchers commented that a significant number of adolescents were suffering from severe, potentially treatable psychiatric disorders that had gone undetected. Emotional difficulties in foster children may relate to: the original reasons for leaving their family, including abuse or neglect the sense of rejection and difference from children growing up in their own families moves and changes between carers the lack of a sense of permanent belonging within the family, even in long-term foster care. Special Guardianship, as proposed in the new Adoption and Children Bill (see Department of Health (DoH) website in Figure 3) may help to address this last issue. The outline of some of the effects of maltreatment given below in relation to later-adopted children is also relevant to this group. A proper medical, family and developmental history is often lacking. Foster carers often have very little information about the childs history with which to make sense of their behaviour less information than is commonly available to adopters, where the giving of information is systematized by the British Agencies for Adoption and Fostering (BAAF) forms. Educational underattainment: according to the DoH figures for September 2000, 78% of looked-after children were of school age, and of these 26% had special educational needs (SEN) statements, compared with 3% in the general population. Compared to school-age children in general, looked-after children show markedly lower educational performance, declining further in older age groups, at Key Stages 1, 2, and 3, and much poorer GCSE or GNVQ attainments. Children who have been in care at any time are already a severely disadvantaged group: they are likely to be from larger, low-income families with a single-parent or with a father in semi-skilled or unskilled manual work, and living in overcrowded housing. Their attainments, even if they have not been in care, would be expected to be lower than the general population, but foster care does not remedy this disadvantage. Moves within care, non-attendance, emotional stress and difficulties, and sometimes lack of liaison between schools and foster carers, all contribute to poor attainment. Educational underattainment among foster children is particularly marked in children who have experienced early abuse and/or neglect, even if they are in settled long-term placements. A study of 814-year-olds concluded that childrens early histories before entry into care can profoundly affect their educational achievement in middle childhood, and that more than normal family life and normal parental interest may be necessary to compensate for earlier deprivation. Greater than average input from schools was associated with some progress, but scarce resources means that this input tends to be discontinued once a childs worst educational problems have been alleviated.

Adopted and foster children are a very heterogeneous group, but what they have in common is that they are brought up in families other than their birth family and have often, though not invariably, suffered earlier maltreatment. Adopted children range from those adopted as infants to those placed as much older children, after periods in foster care and, often, failed attempts at rehabilitation to their family of origin. Infant adoptions of UK-born children by unrelated adopters are now relatively rare, although adoption of infants from overseas has increased. Most children adopted by unrelated adopters will be older, looked-after children who have suffered the damaging experiences which led to their leaving their families of origin, as well as the loss of this family and often of a sequence of care-givers as they move within the care system. In the year to 31 March 2000, 2700 looked-after children were adopted in England. This figure represents 5% of all looked-after children, and 12% of looked-after children under the age of 10. Foster children again represent a wide range. This contribution is not relevant to temporary placements in which there are no concerns about the birth parents care of the children e.g. children who are briefly accommodated in foster homes because other care is unavailable during a parents hospitalization. Rather, it applies to children who may spend considerable time in foster care on interim care orders while care proceedings are under way to determine the childs future placement; or children under a care order in long-term foster placements, where it is intended that they remain until reaching the age of majority (18 years). At 30 September 2000 there were 42,200 children looked after by local authorities in England who had been looked after continuously for at least 1 year, the majority (around two-thirds) in foster care. Foster children Psychiatric difficulties are present in a high proportion of foster children. A study of looked-after children aged 1317 in one local authority found that 57% of those in foster care were suffering from a major psychiatric disorder, compared to 15% in a matched comparison group. Conduct disorder, overanxious disorder and major depressive disorder were the

Jill Hodges is Consultant Child and Adolescent Psychotherapist in the Department of Child and Adolescent Mental Health at Great Ormond Street Hospital for Children, London, UK, and Honorary Senior Lecturer in the Behavioural Sciences Unit at the Institute of Child Health, London. Her special interests include research in attachment and adoption, and the study and treatment of the developmental effects of earlier abuse and adversity.

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Adopted children Children adopted in infancy: studies of community samples, both longitudinal and cross-sectional, show that most infantadopted children are in the normal range of functioning and adjustment. As a group, they do at least as well as children in other situations, and better than children in the kinds of family situation to which adoption might have been an alternative (e.g. single biological parenthood, including single mothers who had initially requested adoption for the child). These studies have not pointed to any consistent pattern of differences in behaviour and adjustment between infant-adopted children and others, but tend to find externalizing problems, including aggression and hyperactive behaviour, and some school adjustment difficulties. The differences found are generally small in relation to differences accounted for by demographic variables. Longitudinal studies indicate that the risk of adjustment problems (relative to non-adopted children) is greater from middle childhood to early adolescence. An adoptive family environment acts as a developmental protective factor for adopted children whose biological parents abused alcohol, had a criminal record or had a heritable mental illness, and who can thus be regarded as genetically at risk. Adopted children have lower rates of criminal/antisocial behaviour, psychiatric hospitalization and alcohol abuse than either their biological parents or siblings who remained with the biological parents. These rates are, however, still higher than for non-adopted children in families equivalent to the adoptive families in socio-economic status. Although in community samples adopted children do not stand out as a group with difficulties, they are over-represented in clinical populations (both out-patient and in-patient) relative to their representation in the population as a whole. This is true even for infant-adopted children. At least part of this overrepresentation probably reflects: a referral bias on the part of adoptive parents, who may be more anxious, more vigilant regarding potential problems, and/or more ready to seek professional help a response bias on the part of mental health professionals, who may perceive behaviours and symptoms as more serious if the child is adopted. As in community samples, studies of clinical populations of infant-adopted children have found no consistent patterns of referral difficulties. Some studies have suggested an increased risk of attention deficit hyperactivity disorder (ADHD), conduct disorder, substance abuse and learning difficulties. Childrens understanding of adoption: in clinical terms, important adoption-related issues for children adopted as infants and their families concern the childs developmentally changing understanding of adoption and feelings about birth parents and reasons for relinquishment. As children develop and the issues concerning them change, they need to revisit the area with their new questions and hypotheses. Children who sense that their adoptive parents are uneasy about discussion of these areas may avoid raising the subject, so parents may come to feel, sometimes with relief, that the child already knows everything they wish to or has no curiosity or interest. Childrens questions, even if not voiced, tend to focus around two areas: the birth parents who were they, what were they like

why the child was given up for adoption. In childrens understanding, the possible answers to the second question all blame one or other party. Children will often have an underlying feeling that something must have been wrong with them, which led the birth parents to reject them, or that the adopters were to blame, for stealing them away from the birth parents. The adoptive parents own understanding and feelings about the birth parents and the adoption affect how comfortably they can discuss these issues with their child and how readily the child may indicate a wish for discussion. Support for the parents including suggesting books they may find helpful to use with the child can help relieve anxiety in both adopters and child (see, for example, Salter, 2002). Children placed after infancy: in addition to the issues noted above relating to adoptive status, later-placed children bring other difficulties to their adoption, as a result of their earlier experiences. There is some recent research on neurological changes associated not only with pre-natal and neonatal stress but with stressful environments in early childhood.

Psychiatric sequelae of maltreatment


Most children will have joined their adoptive or long-term foster families after infancy, and have experienced physical, sexual and/or emotional abuse, neglect and often multiple placements and multiple losses before joining their adoptive or long-term foster family (Figure 1). Post-traumatic symptoms the clinician should be alert to the possibility of post-traumatic symptoms resulting from the abuse, and of depression, often comorbid with PTSD. Traumatic memories may resurface only after the child feels safe in foster care, or after the permanence of adoption. Triggers for resurfacing include later losses or severe stresses, as well as reminders such as anniversaries or places. Children may have only fragmentary memories and may feel crazy or overwhelmed by emotions, flashbacks or dreams, and reassurance is essential. The original traumatic events are often not known to services or foster/ adoptive parents, making it more difficult for adults to help the child make sense of traumatic memories or feelings. Difficulties in forming attachments and relationships normally, children growing up in non-abusing families develop parental attachment relationships which allow them to see parents as a source of safety, security, love and enjoyment. Reciprocally, this allows children to form a view of themselves as worthy of receiving these things (Figure 2). Conversely, children who are maltreated and/or experience multiple changes of care-giver learn a very different set of relationships and self-perceptions, and because of their young age these tend to act as their template for future relationships with parental figures. Thus, on entering adoptive or foster families they may be unable to begin developing new and more secure relationships in their new family. Adoptive families who feel able to manage a childs overt behaviour problems may find it much harder to bear the childs difficulties in forming attachments and giving back emotionally. Attachment difficulties are often linked to other areas of behaviour difficulty. Children may avoid showing parents their need for help, comfort, praise or affection, in order not to reveal

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Factors associated with breakdown of placements (foster and adoptive)


Breakdown rates are an indicator, albeit a crude one, of placement difculty Age. Breakdowns of all types of placement increase with increasing age at placement, with a rapid rise from around age 8 Longer pre-placement periods in care and/or on placement waiting lists Previous placement breakdown Other children in household close in age to the child placed (excluding siblings being placed together) Child ambivalent or opposed to the placement Unrealistic expectations for the child on the part of parents or care-givers Severe behaviour problems Child cut off from everything previously familiar, by a combination of changing schools and neighbourhoods, losing contact with birth family, siblings and friends Child singled out for rejection in family of origin
(Adapted from: DoH. Patterns and Outcomes in Child Placement. London: HMSO, 1991: 689; Quinton D et al. Joining New Families. Chichester: Wiley, 1998)

(or feel) dependence or vulnerability. While this might have been the best available strategy with a maltreating parent, from whom the child could not expect a positive response, in a new foster or adoptive family it robs the new parents of the chance to respond differently, and deprives the child of the chance to experience something that might begin to alter their template. Attachment difficulties are also linked to oppositional and negative behaviour on the part of the child as an attempt to maintain a sense of control and independence from the parents; earlier maltreatment can lead the child to feel that dependence is dangerous or painful and that being in control is essential to survival.

Benets of attachment
Attachment helps the child: attain his/her full intellectual potential sort out what he/she perceives think logically develop social emotions develop a conscience trust others become self-reliant cope better with stress and frustration reduce feelings of jealousy overcome common fears and worries increase feelings of self-worth reduce jealousy
(Source: Fahlberg, 1991)

Treatment approaches The childs history: before the placement, the adoptive family needs full and comprehensibly presented background information about the childs history. This essential form of support helps parents make sense of their childs behaviour and responses. The clinician can use the information with the parents to help them reframe the childs behaviour and alter negative patterns of interaction. The child needs to be helped to construct a coherent story of his or her life (often done in the form of a Life Story Book), which besides providing a chronological account of the persons and changes involved, incorporates the childs own memories and feelings and makes sense of them. The parents need to be fully involved in this, as it can help parents and child talk about the childs history and understand it in relation to the childs own identity. Clinicians need to be wary of pathologizing the adoptive families of children who have suffered abuse, neglect and discontinuity of carers before placement. Specialist adoption services confirm that these children can make previously well-functioning families look like the causes of childrens pathology by the time they reach services. However, models that go too far in seeing the childs behaviour and abuse history as the source of all difficulties and adoptive parents as co-therapists risk locating all the difficulty in the child and denying the importance of the childparent interaction; abused children can push the buttons of particular vulnerabilities in adoptive parents in ways that are not necessarily predictable either by professionals or parents. Adoptive families frequently report feeling let down by local services they have approached for help, feeling that health, child and adolescent mental health (CAMH) and educational psychology staff are not adequately informed in dealing with special needs children. Placement history the first essential is for the clinician to take a history of the placement, starting with the adoptive parents expectations about the child to be placed with them, and continuing with what information about the child they were actually given, what potential difficulties they were led to expect, whether they can identify likeable qualities in the child and what support they have, including extended family. Referral difficulties may stem from a mismatch between these expectations and the actual child. Treating specic areas of difculty An outline of treatment follows, in the two areas of difficulty most specific to adopted and foster children; like any children, they may of course require interventions for other difficulties. Post-traumatic states: intervention with adopted and foster children should be collaborative with parents. Work with these children is more likely to confront repeated trauma, occurring longer before treatment, than is work with other children. However, it follows the same lines, namely: the establishment of a basis of safety the identification of triggers to trauma-linked memories or feelings problem-solving to devise support techniques for parents and others to help children manage trigger situations

2
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identifying coping strategies for the child him/herself to use when traumatic anxieties or memories occur the translation of traumatic memories into narrative memories and the processing of these through discussion and other techniques the facilitation of reality-based perceptions in relation to trauma experiences reduction of self-blame and the development of feelings of mastery rather than helplessness. Attachment difficulties: there are no universally recognized modes of treatment for the behaviour and attachment difficulties often shown by late-adopted or fostered children who have been subject to earlier maltreatment. In the absence of systematic evidence of effectiveness, numerous approaches are used. Behaviour problems linked to attachment difficulties are often very resistant to behavioural management techniques; a child for whom being in control is itself highly reinforcing may well comply with a reward system, but only when he or she chooses, thereby retaining control. Attachment-based therapeutic and re-parenting approaches have been described by various authors (e.g. Hughes, 1997), and many different techniques are used. Examples of particular forms of intervention may include the following. Direct work with parents; for example, in helping them to reconsider and reframe the meaning of a childs behaviour and cope differently with it as a result; or helping them avoid entering automatically into power struggles, pick the issues on which they will stand firm, and develop other strategies including pre-emptive ones for dealing with a childs need to control. Active learning in the childparent interaction, with the therapist directing and facilitating the child in asking for and accepting affection, help and comfort, and accompanied by homework practice between sessions. Holding by the parent, or the therapist accompanied by the parent, while a range of emotionally important areas are explored in the context of physical closeness. Adoptive parents, hard-pressed by their childrens very difficult behaviour, may be drawn toward forms which they see as breaking through the childs defensive stance. Caution is required with techniques which the child may experience as coercive, recognizing the meaning this may have for children who have already experienced helplessness and terror in their original families. Hughes (1997) comments that if while using a holding technique a parent reported that the child demonstrated strong fear about the sessions, he would immediately adopt a more traditional therapeutic stance, and would not use the technique unless there was a positive engagement with the child before, during and after the experience, in spite of the childs ambivalence. Support for families Children in permanent substitute families do remarkably well relative to their past experiences, but at a high cost to families. Families often find that informal support networks of family members and friends are not adequate, and stress the need for post-adoption support from the agency (rather than the childs social worker) and the peer support of adoptive parent groups. There is a great variation in adoption placement breakdown rates between agencies, attesting to the importance of preparation and

Some helpful resources


National: British Agencies for Adoption and Fostering: www.baaf.org.uk (020 7593 2000). Adoption UK (formerly Parent to Parent Information about Adoption Services): www.adoptionuk.org.uk (01327 260295). After Adoption: www.afteradoption.org.uk (helpline: 0800 0586 5780). www.adoption-net.co.uk (Derby-based national website that covers fostering and adoption; 0116 227 3123). London-based: Post-adoption Centre: www.postadoptioncentre.org.uk (020 7284 0555). Family Futures Consortium: www.familyfutures.co.uk (020 7241 0503). Post Protection Team, Dept of Child and Adolescent Mental Health, Great Ormond Street Hospital (020 7829 8679). Other regions and centres: Information from BAAF. Department of Health: Adoption: www.doh.gov.uk/adoption/index.htm Foster care: www.doh.gov.uk/qualityprotects/index.htm 3

post-adoption support for the adoptive family. Support is essential, but its availability varies enormously. While new adoption legislation (the Adoption and Children Bill, see DoH website) specifies that local authorities must provide adoption support services and notify health and education departments of any needs, variation in the level of services provided is likely to continue.

REFERENCES Brodzinsky D M, Smith D W, Brodzinsky A B. Childrens Adjustment to Adoption, Developmental and Clinical Issues. Sage Developmental Clinical Psychology and Psychiatry series, Vol. 38. London: Sage, 1998. Fahlberg V I. A Childs Journey Through Placement. Indianapolis, IN: Perspectives Press, 1991. Howe, D. Patterns of Adoption: Nature, Nurture, and Psychosocial Development. Oxford: Blackwell Science, 1998. Hughes D A. Facilitating Developmental Attachment: The Road to Emotional Recovery and Behavioural Change in Foster and Adopted Children. Northvale, NJ: Aronson, 1997. Livingston Smith S, Howard J A. Promoting Successful Adoptions; Practice with Troubled Families. Sage Sourcebooks for the Human Services series, Vol. 40. London: Sage, 1999. Salter A N. The Adopters Handbook: Information, Resources and Services for Adoptive Parents. London: BAAF, 2002.

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Child Maltreatment
Danya Glaser

Child abuse and neglect are relatively common experiences in childhood which are at the very least unpleasant and at worst, fatal. Non-fatal child abuse and neglect cause a variety of harmful effects, mostly psychological but sometimes also physical. Intention to harm the child is not required for the definition of child abuse and neglect. Different forms of maltreatment are recognized, and they often co-occur. Adult retrospective studies suggest that different forms of abuse and neglect lead to different sequelae (Mullen et al., 1996), but because of their co-occurrence it is difficult definitively to apportion the extent of harm to each of these forms. Nevertheless, some more robust associations are now recognized. Epidemiology depends on definition, but it is accepted that child abuse and neglect are under-reported. In the UK, there are approximately 30,000 children on Child Protection Registers at any one time. However, registration follows a multidisciplinary consensus that the child is unprotected, rather than the discovery of abuse per se. Rates of registration are therefore an underestimate of the actual prevalence of child maltreatment. Definitions and forms of abuse: Figure 1 shows the four types of maltreatment and percentages of their registration in England in 2000, as respective proportions of the total number of registrations (the percentages total more than 100% as registration under more than one category is possible). Most cases of maltreatment occur within the family, where the child is harmed either by parents or primary carers. The exception to this is sexual abuse, which is equally commonly perpetrated by someone who is known to the child or young person, but is not a parent. While physical and sexual abuse may be single or repeated events in the childs life, emotional abuse and neglect, and physical neglect are more appropriately considered as pervasive aspects of the primary carerchild relationship. Figure 2 lists contrasting features and relationships of different forms of child maltreatment.

Associated factors Social and family factors: child physical abuse and neglect are more clearly associated with social disadvantage in the families of the children. People who abuse children, including parents who abuse their own children, are troubled individuals, a proportion of whom have experienced abuse or neglect in childhood. Adolescent boys who sexually abuse children are more likely to have suffered or witnessed physical violence and to have experienced emotional abuse or disruption to their care. Emotional abuse and neglect, either on their own or in association with physical abuse or neglect, are often found in families where a single parent, or both parents, suffer from mental illness or drug/alcohol abuse, or where there is violence between the parents. However, no adult psychopathology is consistently associated with child maltreatment. Sexual abusers are mostly male. Children of all ages may experience abuse and neglect. Physical neglect and emotional abuse and neglect often start early in the childs life and become enduring patterns of care and interaction during their childhood. Physical abuse in infancy may result from the parents inability to cope with the demands of the baby; this sometimes causes serious injury or even death. Later in childhood, physical abuse is more associated with inappropriate and harsh punishment. Sexual abuse is commoner in adolescence and in girls, although young boys and girls are also abused. Fabricated or induced illness (previously known as Munchausen syndrome by proxy or facititious disorder by proxy) is nearly always perpetrated by mothers, and the child may already have had a genuine illness. Abuse and neglect may be self-limiting or occur as single events, but often continue over many years either as a pattern of interaction within a particular parentchild relationship, as a pattern of child-rearing, or (in child sexual abuse only) as an addiction-like propensity that the same abuser extends towards many children.

Harm to the child


Physical: the harm resulting from the different forms of maltreatment is wide-ranging and affects all domains of the childs development. Physical abuse can cause serious injury (e.g. head injury following the shaking of a baby), and in some cases leads to death or lasting disability. Failure to thrive and short stature may also result from abuse and neglect. Children experience unnecessary investigations and treatment when subject to fabricated or induced illness; induced illness can even cause death. Sexually transmitted diseases and unwanted pregnancy may result from sexual abuse. Some abuse is first recognized by the physical signs, even when these do not lead to lasting physical harm. Psychological: the greatest morbidity associated with child maltreatment is psychological and emotional. There is now sound evidence that brain/neurobiological changes accompany the psychological manifestations following abuse and neglect (Glaser, 2000). For example, physical abuse is associated with aggressive behaviour and low self-esteem. Emotional neglect leads to educational under-achievement and difficulties in peer

Danya Glaser is Consultant Child Psychiatrist at Great Ormond Street Hospital for Children, London, UK. Her special interests include the assessment and treatment of emotional abuse and neglect; the application of attachment theory to the management of child abuse and neglect; the effect of child abuse and neglect on the development of the brain; expert evidence in Children Act cases; and the early recognition of fabricated or induced illness.

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relationships as well as to oppositional behaviour. Sexual abuse is particularly associated with: later depression substance abuse and self-harm post-traumatic phenomena inappropriate sexual behaviour this is particularly troublesome in young children. Outcome: subtype, severity, frequency and chronicity of the abuse all contribute to the later outcome for the child. Some protective factors contribute to determining the severity of the outcome. For example, secure attachments that the child has been able to form before abuse or neglect commence protect against the worst psychological sequelae of abuse. Children over the age of 2 years are less vulnerable to the enduring physical effects of non-accidental injury. Brief duration of abuse or neglect is clearly important and, although self-evident, this indicates the need for early recognition of maltreatment. Educational achievement enhances the childs self-esteem and sense of agency. Having a meaningful and trustworthy relationship with another adult also protects against the worst effects of maltreatment; living within an extended family therefore affords a degree of protection. Finally, some children are temperamentally more able to adjust and find creative solutions to their plight, which is also helped by good intellectual ability.

Recognizing maltreatment
As shown in Figure 2, some forms of maltreatment are readily visible, such as neglect and emotional abuse. However, the

hallmark of sexual abuse is its secrecy; physical abuse is sometimes observed as it occurs, but is usually recognized by the marks which it leaves. Thus, the mode of recognition of abuse and neglect differs according to the form which the maltreatment takes (see Figure 3). Parents and abusers do not as a rule report their actions. When a child presents with difficulties suggestive of abuse or neglect, the process of diagnosis and investigation is usually marked by: an absence of acceptable explanation some degree of denial of the possibility of abuse an immediate assumption of responsibility for the childs difficulties, although this is rare. This response by the parents or alleged abusers constitutes the basic context for the investigation, recognition and management of child abuse and neglect. Many professionals, in turn, find it difficult to accept the possibility that a parent (who may also be a patient) has harmed their own child. Almost invariably, therefore, there is some degree of dispute or doubt during the process of recognizing child maltreatment. This is important not so much for apportioning blame, but rather for the subsequent process of protecting the child and bringing about change in the relationship between the child and their abuser, if they are to remain living together or in contact. The fact that child maltreatment may also require criminal prosecution further complicates matters (see pages 6770). The onus of proof often falls on paediatricians, child psychiatrists and social workers, sometimes clouding the issue of child welfare seemingly in favour of parental innocence. In physical abuse (including failure to thrive and fabricated

Forms of maltreatment and percentage of registration


Type of maltreatment Physical neglect Variants within type of maltreatment Lack of provision Lack of supervision Causing death, actual injury or visible marks such as bruises Fabricated or induced illness: by false reporting of the childs symptoms by interfering with investigations, specimens and treatment by directly interfering with/harming the child Genital or oral penetrative contact Non-penetrative genital or oralgenital contact Non-contact sexual exposure and photography Emotional unavailability Hostility and rejection Developmentally inappropriate interactions Using child for the fullment of the adults needs Failing to promote the childs socialization % of registrations on child protection registers 46

Physical abuse (non-accidental injury)

29

Sexual abuse

18

Emotional abuse and neglect

18

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Differences between forms of child abuse and neglect


Sexual abuse Hidden Usually questioned Usually different persons Yes Physical abuse Hidden or observed Sometimes known Same or different persons Usually Emotional abuse/neglect Observable Known Same person Rarely

Abusive act/interaction Identity of abuser Abuser and primary carer Immediate protection indicated 2

Modes of recognition of child abuse and neglect


Physical neglect Physical abuse and neglect (a) a (a) Emotional abuse Sexual abuse

Ill-treatment of child observed Harm to child observed Ill-treatment reported (by child)

a a

a (a) a

or induced illness) the diagnosis is usually made by paediatricians. Physical neglect is recognized by the absence of social norms of basic child care and provision. Sexual abuse relies most strongly on the childs verbal descriptions; 50% or more of cases have no physical signs, and when these are found they are rarely conclusive proof of abuse, being regarded merely as compatible with the childs own account of sexual abuse. It is therefore the childs words and credibility that are closely tested and challenged. The ill-treatment and harmful interactions in emotional abuse and neglect are observable, but it is the extent of their harmfulness that is disputed. Emotional abuse and neglect cannot be reliably recognized by the effects on the child, since these are not specific to this form of maltreatment. Other explanations: it is always important to exclude alternative explanations for the childs difficulties. The mental state of the parent or suspected abuser and any psychopathology are of little value in arriving at a recognition of child maltreatment, since not all troubled adults are responsible for child abuse and neglect. Any parental difficulties whether mental ill-health, substance abuse or domestic violence are, however, risk factors for maltreatment that are of central importance in understanding how abuse has come to occur and in planning further management.

may well express about this. It is vital that a record is made of the conversation. Immediate treatment: some children who have been abused will require immediate medical or psychiatric treatment, including those who have been seriously injured or infected with a sexually transmitted disease, or who are acutely traumatized by the abuse. Child protection: beyond immediate treatment, the first step in managing child maltreatment is an assessment to determine whether the child is in need of immediate protection, whether the child is already being protected from further abuse, or whether the chronic nature of the abuse calls for an approach towards achieving longer-term protection. This assessment is a multidisciplinary endeavour, led by social services in collaboration with other agencies (Department of Health, Home Office, Department for Education and Employment, 1999). Protection can, in theory, be achieved by one of the following: a change in the abuser or their circumstances that led to maltreating the child supervision of all contact between the child and the abuser separation of the child from the abuser. Although apparently simple, achieving any of these is often very difficult in practice. The circumstances and cumulative experiences that lead parents or other abusers to abusive acts and interactions with children are not amenable to immediate change. Relying on psychotherapeutic or other work to bring about significant changes in the abuser leaves the child at risk in the meantime. Meaningful supervision can be sustained only for short periods of time in confined physical settings and is ineffective in safeguarding children whose maltreatment is part of an ongoing relationship.

Management
Responding to disclosure: professionals may receive unexpected disclosures of abuse, usually from children. The appropriate response is to listen but not probe, not to promise confidentiality, to explain that this information will need to be passed on to social services and to explore misgivings which the child

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Separation of the child from the abuser is therefore the only way of ensuring the immediate safety of the child. However, if the abuser is also the childs primary care-giver, there is a significant cost to achieving immediate protection as separation leaves the child without their attachment person. Even when the person/s caring for the child are not the maltreating ones, it is nevertheless necessary to assess their capacity to protect the child. The most important factor is the nature of the relationship between the non-abusing care-giver/s and the abuser the closer this is, the more precarious will the childs position be. Closeness here includes love, but may also mean fear or dependency. Ensuring protection may therefore require statutory measures, either by a protection plan after placing the child on the Child Protection Register, or through court proceedings. Treatment for the effects of abuse and neglect A comprehensive treatment plan includes: appropriate help for the child, the non-abusing care-giver/s and the abuser therapeutic attention to their relationships work with the whole family, including siblings who may not be (or appear not to be) immediately involved. The deficits and effects following neglect need to be reversed and made up for, as far as this is possible. This may be achievable by supporting the childs parents, providing they are willing to accept help, and may include the treatment of the adults mental ill-health and substance abuse. Experience shows that such help often needs to be maintained for long periods, and that change is not sustained following a short but intensive course of intervention. Many children also require educational remediation for the associated educational underachievement. Treatment for the children depends on the nature of the maltreatment and the sequelae. There is no unitary post-abuse syndrome, even following specific forms such as sexual abuse. There are, however, certain difficulties that are commonly associated with some forms of abuse. Behavioural difficulties require help both for the children and their carers. Children who have suffered trauma, including sexual abuse, may experience post-traumatic stress disorder (PTSD) and require specific treatment, such as cognitivebehavioural therapy, either in a group or individually. Sexualized behaviour following sexual abuse is particularly difficult to change. Cognitivebehavioural therapy may be effective. Special attention is needed for the depression, substance abuse and self-harm that develop in adolescence. Some of the difficulties are well managed in group therapy. As well as emotional and behavioural difficulties, many maltreated children also undergo social disruption as part of the necessary protection process. These children are preoccupied with separations and impermanence, and require active support through this process. The childs parents may initially oppose professional intervention. Acknowledging responsibility for the maltreatment, and sometimes for their inability to protect the child, is a difficult and painful process for the parents. They too require support and specific therapy towards change.

Conclusion
Effective recognition and management of child maltreatment is a complex process that requires alertness and a coordinated, multidisciplinary approach. While the importance of the family is central to the childs well-being, the childs own interests are paramount, and sometimes they may not be achievable within the original family environment.

REFERENCES Briere R, Berliner L, Bulkley J, Jenny C, Reid T, eds. The APSAC Handbook on Child Maltreatment. London: Sage, 1996. (A well-referenced collection summarizing both research and treatment approaches to various forms of child maltreatment.) Cicchetti D, Carlson V, eds. Child Maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect. Cambridge: Cambridge University Press, 1989. (A seminal volume on the causes and effects of child maltreatment, including relationship with attachment.) Department of Health, Home Ofce, Department for Education and Employment. Working Together to Safeguard Children. London: The Stationery Ofce, 1999. (UK government guidance on multidisciplinary responsibilities for the protection of children.) Glaser D. The effects of child abuse and neglect on the brain: a review. J Child Psychol Psychiatry 2000; 41: 97116. Mullen P, Martin J, Anderson S, Romans S, Herbison G. The long-term impact of the physical, emotional, and sexual abuse of children: a community study. Child Abuse Negl 1996; 20: 721. (A review of associations in adulthood with childhood abuse and neglect.)

Practice points
Different forms of maltreatment often coexist There is considerable psychological morbidity following abuse and neglect The closeness and nature of the relationship between the childs abuser and care-giver is an important determinant in the protection of the child following the nding of abuse The optimal investigation of child maltreatment and the subsequent management depend on coordinated multidisciplinary and multi-agency work

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Child Protection Issues and the Law


Danya Glaser

Differences between criminal and civil legal proceedings


Criminal law Subject Function Defendant To establish innocence or guilt of defendant If guilty (non) custodial sentence Civil law Child To protect child

Within the field of child protection, different aspects of medicine and law come together. Psychiatrists (as well as some psychologists) make an important contribution to ensuring the welfare of children and adults, primarily in civil proceedings but also in criminal law. Knowledge of the legal context is therefore a prerequisite for this important work. This contribution examines the interface between child maltreatment and the law in England and Wales, as it relates to psychiatry.

Outcome

If signicant harm found order concerning child likely Childs interest paramount; child does not appear in court Balance of probabilities As expert (+/professional) witness

Child

Appears as witness; has no legal rights

Standard of proof

Beyond reasonable doubt

The law
Both the criminal and civil arms of the law may be involved in child protection: criminal law because all forms of child abuse and neglect are potentially criminal offences, and civil law because of child protection. There are, however, significant differences between these two aspects of the law. Criminal law the function of the criminal law is to establish the innocence or guilt of a particular defendant in this context, an alleged abuser. Sentencing may indirectly influence the protection of the child, since one purpose of imprisonment is protection of the public from the offender. However, the child is only an accessory to the criminal legal process, being a witness who has no legal rights. The standard of proof in criminal law is stringent, namely beyond reasonable doubt. In practice, this amounts to 80% certainty. Civil law the civil standard of proof, on balance of probabilities, is lower. The civil law is concerned with ensuring the welfare of the child, and the childs interests are paramount within the Children Act 1989. Criminal law, which serves the public interest, takes precedence over civil law, and the two arms proceed in parallel with greater or lesser coordination of the proceedings. Different outcomes may result from criminal and civil legal processes relating to the same case. Families understandably find this very confusing. The differences between criminal and civil proceedings are summarized in Figure 1. In practice, relatively few cases of child maltreatment reach criminal prosecution. Nevertheless, such prosecution is a
Child mental Rarely permitted health expert

possibility from the outset of the professional intervention that seeks to protect the child, and influences the process of investigation. Cases reach the criminal courts if the police, in consultation with the Crown Prosecution Service, consider there to be sufficient evidence for the likelihood of securing a conviction. Responsibility for child protection in England and Wales rests with each local authoritys social services department. While there is no mandatory reporting law in England that compels clinical professionals to report suspected or actual child abuse, professional guidelines (Department of Health, Home Office, Department for Education and Employment, 1999) and codes of practice stress the need to report such cases to social services. Cases of child maltreatment are initially dealt with by social services; this includes working in partnership with the family, possibly placing the childs name on the Child Protection Register, and implementing a protection plan. Cases reach the civil courts only if social services consider that their child protection procedures fail to secure the childs safety from harm. Social services then initiate public law care proceedings under the Children Act, in which the courts help is enlisted to protect the child. Private law proceedings within the Children Act are initiated when there are disputes between family members over who the child should live with (residence), and over contact between the child and parents or other family members. These proceedings usually occur in the course of parental divorce, but disputes may also arise between parents and

Danya Glaser is Consultant Child Psychiatrist at Great Ormond Street Hospital for Children, London, UK. Her special interests include the assessment and treatment of emotional abuse and neglect; the application of attachment theory to the management of child abuse and neglect; the effect of child abuse and neglect on the development of the brain; expert evidence in Children Act cases; and the early recognition of fabricated or induced illness.

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grandparents or other family members who have an interest in the child when, for example, one of the parents has a serious mental illness or has died. Allegations or concerns about child abuse are sometimes raised in the course of private law proceedings. However, the state is not concerned with the welfare of the child in private law proceedings as the dispute is within the family.

Dening signicant harm


Ill-treatment Sexual abuse Physical abuse Non-physical abuse Impairment of health Physical or mental Impairment of development Physical Intellectual Emotional Social Behavioural

Civil law
Care proceedings In care proceedings, the adjudicators may be magistrates or a judge, depending on the complexity of the case. The court has two roles: the first is to establish whether the threshold enabling the court to grant an order has been reached; if the threshold is reached, the second is the power to grant an order, either a care order or a supervision order. The threshold is termed significant harm from which the child concerned is suffering, or is likely to suffer. Harm, or likelihood of harm, is attributable to: the care given to the child or likely to be given to him if the order were not made, or the childs being beyond parental control. Harm is subdivided into ill-treatment and the impairment of health or development (Figure 2). The Children Act states that where the question of whether harm suffered by a child is significant turns on the childs health or development, his health or development shall be compared with that which could reasonably be expected of a similar child. Even if the threshold is reached, the court may decide not to grant an order, although in practice an order is almost always granted to the local authority. Before this can happen, the local authority has to present the court with a Care Plan, in which

it details how it would ensure the childs welfare. The main elements of the Care Plan are concerned with: where the child will reside what contact there will be between the child and family members if the child will not live with the whole original family what the childs health, therapeutic and other developmental needs are. While the local authority is the author of the Care Plan, the judge may decide not to grant a full order if the Care Plan is found to be lacking in some way. However, the ultimate decision regarding the nature of the Care Plan rests with the local authority. Private (residence and contact) proceedings In private law proceedings, the judge may be requested by one of the parties to make a finding about whether abuse or neglect have occurred. This is determined by the judge on the basis of written and oral submissions by the respective parties, and

Steps to the involvement of an expert


Significant harm suspected Child showing signs of harm Ill-treatment observed Child describes abuse

Joint investigation planned by social services and police Assessment by social worker assessment framework Medical examination of child Child protection conference Child protection not required Child protection required Child interviewed by social worker/police

If social services consider that the child requires protection by inviting the courts authority Care proceedings Childs guardian appointed +/- child mental health expert instructed by guardian and/or social services Expert reads documents and meets with professionals, child and family Expert produces report If no agreement reached, expert gives oral evidence in court 3
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by reports and oral evidence given by a member of CAFCASS (Children and Family Court Advice and Support Service), and possibly an expert witness

The psychiatrists role in civil proceedings


Psychiatrists and other mental health professionals have specific functions in civil legal proceedings. They may act as witnesses to fact or, more commonly, as expert witnesses. In the course of an interview or therapy with a child, the child may describe abuse that he or she has experienced. Alternatively, a psychiatrist or other child and adolescent mental health (CAMH) professional may be requested to interview a child who is suspected of having been abused. This requires an interviewer who has special skills in communicating with children who are severely traumatized or troubled or have a disability. An account of the childs description could form factual evidence given by the interviewer in court. Expert evidence is sought in more than 40% of care proceedings, most commonly from child and adolescent psychiatrists (Brophy et al., 2001). Their task is to help the magistrates or the judge make their decision regarding the threshold and the Care Plan, in the context of adversarial proceedings. The courts permission is required before an expert can be instructed (see Figure 3). In order to avoid proliferation of experts in a case, the parties (consisting of the child represented through their guardian, the parents and sometimes grandparents, and the local authority) jointly select and appoint an expert. The letter of instruction, which details the questions and issues for the expert to address, is also agreed by all parties, and they pay the experts fees jointly. Rarely, the parents may instruct their own expert, who is then more likely to prepare a report based on a paper assessment of the documents, rather than re-interview the child and parents. A number of children and their families will already have been seen by a CAMH service, which will therefore have considerable knowledge about them. However, this knowledge is considered by the legal system to render the treating psychiatrist or other CAMH professional not independent, and therefore a neutral expert is usually instructed. It is, however, important that the treating psychiatrists views are obtained. Reports: when preparing their reports, expert witnesses are bound by certain rules. They include an overriding duty to the court, confining the report to an experts area of expertise, and giving reasons for the experts opinion in the light of the range of opinion available. Oral evidence by the CAMH professional will be required at the final hearing when there is not agreement about the threshold and the Care Plan. The oral evidence is substantially based on the report, on which the expert is examined and cross-examined in court. In addition, the judge will often ask the experts opinion on issues that have not been dealt with sufficiently during the questioning by the advocates. When there is more than one expert, an experts meeting is held before the final hearing, in order to clarify common ground.

The assessment In preparing the report, the CAMH professional interviews: the child and his or her carers (if the child is not living at home) the family members (including parents and siblings) the professionals involved, especially social workers and the childs guardian, who will have information about previous help offered to the family and its outcome. The assessment process includes interviews and observations of interactions between family members, possibly during contact (i.e. specified occasions when the child meets family members) if the child is not living with them. It is important to obtain school reports, and information should be sought from other colleagues about the childs physical health and development and, where appropriate, intellectual development and functioning. If the child has received an injury, a paediatricians report is important. Parental assessment: information is often also required about the parents, including their mental health, substance abuse status, intellectual ability and/or risk of future physically or sexually abusive behaviour. Mental health an assessment should be obtained from an adult psychiatrist, to report on the presence of any diagnosable disorder, requisite treatment and its course, and prognosis. As with a child and adolescent psychiatrist, it is preferable to request an assessment from an independent psychiatrist. A report prepared by the adult patients doctor may, however, indicate mental health difficulties that impair the parents ability to care for the child. Although this may cause a professional/ethical conflict for the adult psychiatrist, it is recognized that there is a duty to the well-being of others, which permits the providing of adverse information about ones own patient (Royal College of Psychiatrists, 2000). Parents will be aware of the context of the adult psychiatrists report and cannot be compelled to undergo the assessment. Intellectual ability if there are concerns about the cognitive ability of a parent sufficient to impair parenting capacity, an assessment from a clinical psychologist is helpful. Risk of future abusive behaviour/alcohol or drug abuse this information is sought most often when sexual abuse has occurred or is strongly suspected but denied by the alleged abuser, and when a parent has injured a child seriously. An assessment is needed from a forensic psychiatrist or psychologist to give a prognosis about the future risk that the parent poses to children in their care. The report The psychiatrists report consists of: details of the information on which the reports conclusions are based conclusions and recommendations. The information about concerns, the familys history and professional involvement is found in the documents provided, and is expanded further in interviews with family members and professionals, as outlined above. The documents include statements and affidavits by professionals, including social workers and the childs guardian, and by family members. They also include reports by other professionals such as psychiatrists

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and paediatricians. It is important that in descriptions of meetings, observations are distinguished from inferences. The conclusions need to address the questions posed in the letter of instruction. Since these questions vary in their comprehensiveness and may not reflect the clinical process of analysing and synthesizing the complex information, it is useful to include a discussion of the following issues. Profile of the child an assessment is required of the childs mental health and current functioning, describing his/her emotional, behavioural, social, cognitive, educational and physical development and difficulties. The latter includes growth, wetting and soiling, appetite and sleep. There is often a specific question about the childs attachments to the parents. Causes of the childs difficulties the court is interested in understanding the causes of the childs difficulties, especially the respective contribution of environmental and innate factors. Amplification of nature of harm there is sometimes dispute about the nature of the ill-treatment (abuse and/or neglect) that the child has experienced and the expert may express an opinion about this. This is particularly helpful in emotional abuse and neglect, which are difficult to define (Glaser, 2002), and sometimes when sexual abuse is alleged but denied. The expert may express an opinion about the likelihood of sexual abuse having occurred. The expert is required to explain the effect (harm) which these experiences have had on the child, including the possibility of posttraumatic stress disorder (PTSD). The expert is often also requested to discuss future likelihood of harm, or risk to the child. Unless specifically requested, it is not the experts role to say whether the maltreatment reaches the threshold of significant harm. Childs needs based on the assessment of the child, it is possible to outline the childs needs in terms of: safety from harm the nature of care-giving required what services (including education) and therapy the child requires what sort of contact with family members, if the child is to be placed away from the family, would benefit the child. This addresses the main issues in the Care Plan. Childs wishes having met the child, the mental health professional is able to comment on the childs wishes and the likely effect on the child of not fulfilling these wishes. Profiles of parents the report needs to describe the parents strengths and difficulties, and will rely on the adult psychiatric and psychological assessments. It is then possible to comment on the parents capacity to fulfil the childs future needs, what help would be required to enable them to do this, and whether the time-scale required for sufficient change meets the childs needs.

The psychiatrists role in criminal proceedings


There are two child protection issues involving criminal proceedings that interface with psychiatry: the prosecution of adults accused of offending against a child the prosecution of adolescent abusers or offenders. In child sexual abuse cases, the childs evidence often forms an important part of the prosecutions case. Concerns have been raised about the effects on the childs testimony of pre-trial therapy. A child and adolescent psychiatrist may need to advise on the child witnesss mental health, including PTSD and the childs therapeutic needs, which may take precedence over the giving of evidence. It is the jurys task to decide whether witnesses are credible, and experts are not therefore called on in criminal trials. Adult forensic psychiatric or psychological assessments may be requested after conviction as pre-sentencing reports. Adolescent abusers may be prosecuted within the juvenile justice system. An adolescent psychiatrist or psychologist may be called on when the judge decides the most appropriate sentence for and treatment needs of the adolescent, who may himself be a victim of past abuse.

REFERENCES Brophy J, Brown L, Cohen S, Radcliffe P. Child Psychiatry and Child Protection Litigation. London: Gaskell, 2001. Department of Health, Home Ofce, Department for Education and Employment. Working Together to Safeguard Children. London: The Stationery Ofce, 1999. (UK government guidance on multidisciplinary responsibilities for the protection of children.) Glaser D. Emotional abuse and neglect: a conceptual framework. Child Abuse Negl 2002; 26: 697714. Home Ofce, Crown Prosecution Service, Department of Health. Provision of Therapy for Child Witnesses Prior to a Criminal Trial. London: Department of Health, 2001. Royal College of Psychiatrists. Good Psychiatric Practice 2000. Council Report CR83. London: Royal College of Psychiatrists, 2000.

Practice points
Child protection may involve both the criminal and civil law, which differ considerably and which may proceed in parallel Child mental health professionals are mainly involved in civil child protection proceedings, as expert witnesses, carrying out a child and family assessment, producing a report and sometimes also giving evidence in court Adult psychiatrists and psychologists may be called both in civil and criminal cases to provide an assessment of the mental health, prognosis and treatment needs of the parents or abuser respectively

Private law proceedings


Similar considerations to those in care proceedings apply for the assessment and report for private law proceedings. There is no social work involvement, but a member of CAFCASS may be involved.

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