Some children have special needs because of their brain and behavior patterns. Developmental psychopathology links the study of usual development with the study of special needs (Cicchetti, 2013b; Hayden & Mash, 2014). Every topic already described, including “genetics, neuroscience, developmental psychology, … must be combined to understand how psychopathology develops and can be prevented” (Dodge, 2009, p. 413).

At the outset, four general principles should be emphasized.

Developmental psychopathology is relevant lifelong because “[e]ach period of life, from the prenatal period through senescence, ushers in new biological and psychological challenges, strengths, and vulnerabilities” (Cicchetti, 2013b, p. 458). Turning points, opportunities, and past influences are always apparent.

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However in middle childhood, children are grouped by age. For some parents and teachers it suddenly becomes obvious that a particular child differs markedly from others the same age. Fortunately, the effects of most disorders can be mitigated if treatment is early and properly targeted.

Therein lies a problem: Although early treatment is more successful, early and accurate diagnosis is difficult, not only because many disorders are comorbid but also because symptoms differ by age. As you learned in Chapter 7, infants have temperamental differences that might or might not become problems, and Chapter 10 explained that some aggression is normal. Difference is not necessarily deficit, but that does not mean that all differences are benign.

Two basic principles of developmental psychopathology lead to caution in diagnosis and treatment (Hayden & Mash, 2014; Cicchetti, 2013b). First is multifinality, which means that one cause can have many (multiple) final manifestations. For example, an infant who has been flooded with stress hormones may become a hypervigilant or an unusually calm kindergartener, may be easily angered or quick to cry, or may not be affected at all.

The second principle is equifinality (equal in final form), which means that one symptom can have many causes. For instance, a nonverbal child may be autistic, hard of hearing, not fluent in the dominant language, or pathologically shy.

The complexity of diagnosis is evident in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (American Psychiatric Association, 2013), often referred to as DSM-5. A major problem is recognizing the cutoff between normal childish behavior and pathology. Some suggest that childhood psychopathology was underdiagnosed in early editions of the DSM and now is overdiagnosed (Hayden & Mash, 2014). As examples of the many complexities regarding children with special needs, we discuss three particularly common and troubling disorders. Appendix A lists the DSM-5 criteria for these three.

Someone with attention-deficit/hyperactivity disorder (ADHD) is often inattentive and unusually active and impulsive, so much so that his or her ability to function is affected. The diagnosis in DSM-5 says symptoms must start before age 12 (in DSM-IV it was age 7) and must impact daily life. (DSM-IV said impaired, not just impacted.) Thus more children are considered to have ADHD than was the case 10 years ago.

Some impulsive, active, and creative actions are normal for children. However, children with ADHD

are so active and impulsive that they cannot sit still, are constantly fidgeting, talk when they should be listening, interrupt people all the time, can’t stay on task, … accidentally injure themselves.” All this makes them “difficult to parent or teach.”

[Nigg & Barkley, 2014, p. 75]

They tend to have academic difficulties; they are less likely to graduate from high school and college; they become unhappy with themselves and with everyone else.

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There is no biological marker for ADHD. Current research, nonetheless, suggests the origin of the disorder is neurological, with problems in brain regulation either because of genes, complications of pregnancy, or toxins (such as lead) (Nigg & Barkely, 2014).

ADHD is comorbid with other conditions, including biological problems such as sleep deprivation or allergic reactions. Explosive rages, later followed by deep regret, are typical for children with many disorders, including ADHD. One surprising comorbidity is deafness: Children with severe hearing loss often are affected in balance and activity, and that seems to make them prone to developing ADHD (Antoine et al., 2013). In this way, ADHD is an example of equifinality; many causes produce one disorder.

Although the U.S. rates of children with ADHD were about 5 percent in 1980, recent data find that 7 percent of all 4- to 9-year-olds, 13 percent of all 10- to 13-year-olds, and 15 percent of all 14- to 17-year-olds have been diagnosed with ADHD (Schwarz & Cohen, 2013). These numbers are called “astronomical” by one pediatric neurologist (Graf, quoted in Schwarz & Cohen, 2013).

Rates of ADHD in most other nations are lower than in the United States, but they are rising everywhere (e.g., Al-Yagon et al., 2013; Hsia & Maclennan, 2009; van den Ban et al., 2010). Most research finds the highest rates in North America and lowest rates in East Asia (Erskine et al., 2014), but since diagnosis depends on someone’s judgment, it is probably not helpful to compare nations. Increases everywhere are worrisome for at least three reasons:

Many adults (71 percent in one study) who were diagnosed with ADHD as children say they no longer have the condition (Barbaresi et al., 2013). Do people overcome or outgrow ADHD, or do adults minimize their symptoms, or do parents and teachers over-report?

Treatment for ADHD involves: (1) training for the family and the child, (2) special education for teachers, and (3) medication. But, as equifinality suggests, most disorders vary in causes, so treatment that helps one child does not necessarily work for another (Mulligan et al., 2013).

Because many adults are upset by what young children normally do and because any physician can write a prescription to quiet a child, thousands of children may be overmedicated. But because many parents do not recognize that their child needs help, or they are suspicious of drugs and psychologists (Moldavsky & Sayal, 2013; Rose, 2008), thousands of children may suffer needlessly.

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In the United States, more than 2 million people younger than 18 take prescription drugs to regulate their emotions and behavior (see Figure 11.4). The rates are about 14 percent for teenagers (Merikangas et al., 2013), about 10 percent for 6- to 11-year-olds, and less than 1 percent for 2- to 5-year-olds (Olfson et al., 2010). In China, parents rarely use psychoactive medication for children: A Chinese child with ADHD symptoms is thought to need correction rather than medication (Yang et al., 2013). Wise or cruel?

The most commonly prescribed drug for ADHD is Ritalin, but at least 20 other psychoactive drugs treat depression, anxiety, intellectual disability, autism spectrum disorder, disruptive mood dysregulation disorder, and many other conditions in middle childhood. Many child psychologists believe that drugs can be helpful, and they worry that the public discounts the devastation and lost learning that occur when a child’s serious disorder is not recognized or treated.

But all agree that finding the best drug at the right strength is difficult, in part because each child’s genes and personality are unique, and in part because children’s weight and metabolism change every year. Given all that, it is troubling that only half of all children who take psychoactive drugs are evaluated and monitored by a mental health professional (Olfson et al., 2010). Most experts also believe that contextual interventions (instructing parents and teachers on child management) should be tried first (Daley et al., 2009; Leventhal, 2013; Pelham & Fabiano, 2008) and provide the best long-term solution.

Drugs may help, but they are not a cure. In one careful study, when children with ADHD were given appropriate medication, carefully calibrated, they were more able to concentrate. However, eight years later, many had stopped taking their medicine. At this follow-up, both those on medication and those who had stopped taking it often had learning difficulties (Molina et al., 2009).

Ethnic differences are found in parent responses, teacher responses, and treatment for children with ADHD symptoms. In the U.S., it seems that, when African American and Hispanic children are diagnosed with ADHD, their parents are less likely to give them medication compared to European American parents (Morgan et al., 2013). However, genes, culture, health care, education, religion, and stereo types could all affect ethnic differences. As two experts explain, “disentangling these will be extremely valuable to improving culturally competent assessment in an increasingly diverse society” (Nigg & Barkely, 2014, p. 98).

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When appropriately used, drugs for ADHD may help children make friends, learn in school, feel happier, and behave better. These drugs also seem to help adolescents and adults with ADHD (Surman et al., 2013). However, as the just-cited longitudinal study found, problems do not disappear: Adolescents and adults who were diagnosed with ADHD as children are less successful academically and personally, whether or not they were medicated (Molina et al., 2013). Drugs do not erase special needs. Consider the following case.

The DSM-5 diagnosis of specific learning disorder now includes disabilities in both perception and processing of information, with lower achievement than expected in reading, math, or writing (including spelling) (Lewandowski & Lovett, 2014). Learning disorders make it difficult for children to master a particular skill that most children acquire easily.

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Some learning disabilities are not debilitating (e.g., the off-key singer learns to be quiet in chorus), but as DSM-5 notes, every schoolchild is expected to read, calculate, and write. Disabilities in these areas undercut academic achievement, destroy self-esteem, and qualify a child for special education (according to U.S. law) or formal diagnosis (according to DSM-5). Hopefully, such children find (or are taught) ways to compensate, and other abilities shine. Winston Churchill, Albert Einstein, and Hans Christian Andersen are all said to have had learning disabilities.

The most commonly diagnosed learning disorder is dyslexia—unusual difficulty with reading. No single test accurately diagnoses dyslexia (or any learning disability) because every academic achievement involves many distinct factors (Riccio & Rodriguez, 2007). One child with a reading disability might have trouble sounding out words but might excel in comprehension and memory of printed text; another child might have the opposite problem. Dozens of types and causes of dyslexia have been identified, so no single strategy will help every child with dyslexia (O’Brien et al., 2012).

Early theories hypothesized that visual difficulties—for example, reversals of letters (reading god instead of dog) and mirror writing (b instead of d)—were the cause of dyslexia, but we now know that dyslexia more often originates with speech and hearing difficulties (Gabrieli, 2009; Swanson, 2013). An early warning occurs if a 3-year-old does not talk clearly or has not had a naming explosion. (Developmental Link: Both explained in Chapter 6.) Early therapy improves speech and might also reduce or prevent later dyslexia.

Traditionally, dyslexia was diagnosed only if a child had difficulty reading despite normal IQ, normal hearing and sight, and normal behavior. This approach usually meant waiting until the third grade or so, when the reading difficulty became apparent. Now difficulty with the basic skills for beginning reading (naming letters and sounds, hearing rhymes) is recognized in kindergarten, and children receive earlier remediation.

Another common learning disorder is dyscalculia, unusual difficulty with math. For example, when asked to estimate the height of a normal room, second-graders with dyscalculia might answer “200 feet,” or, when asked which card is higher, the 5 or the 8 of hearts, the child might correctly answer 8—but only after using their fingers to count the number of hearts on each card (Butterworth et al., 2011).

Dyslexia and dyscalculia are often comorbid, although each originates from several distinct parts of the brain. Early encouragement with counting and calculating (long before first grade) can teach a child math basics, limiting dyscalculia and avoiding the emotional stress children feel if other children grasp math more easily (Butterworth et al., 2011).

Similar concerns regard very poor spelling and writing, known as dysgraphia, and again early remediation is useful, because the origin is probably in the brain as well as the social context. Remediation is best done early, at age 6 not age 10, not only because the brain is more flexible but also because the young child’s eagerness to learn has not yet been crushed by failure. Every person, learning disabled or not, has strengths and interests, and almost everyone can learn basic skills if they are given extensive and targeted teaching, encouragement, and practice.

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Of all the children with special needs, those with autism spectrum disorder (ASD) are probably the most troubling. Their problems are severe, but both causes and treatments are hotly disputed. Thomas Insel, director of the National Institute of Mental Health, describes the parents and other advocates of children with autism as “the most polarized, fragmented community I know” (quoted in Solomon, 2012, p. 280).

Many children with ASD show symptoms in the first year of life, but some seem normal and then suddenly regress at about age 2 or 3, perhaps because a certain level of brain development, or a particular medical insult, occurs (Klinger et al., 2014). Most are diagnosed at age 4 or later (MMWR, March 28, 2014).

Autism spectrum disorder is characterized by woefully inadequate social understanding, coupled with repetitive or restrictive patterns of behavior, such as lining up toys by color rather than playing with them, or fascination with trains, lights, or spinning objects. More than a century ago, autism was considered rare, affecting fewer than 1 in 1,000 children with “an extreme aloneness that, whenever possible, disregards, ignores, shuts out anything … from the outside” (Kanner, 1943).

Years ago, children who developed slowly, and who would now be likely to be diagnosed with ASD, were usually diagnosed as being “mentally retarded” or as having a “pervasive developmental disorder.” (The term “mental retardation,” which was used in DSM-IV, has been replaced with “intellectual disability” in DSM-5.)

Much has changed. Far more children are diagnosed with autism spectrum disorder, and far fewer with intellectual disability. In the United States, among 8-year-olds, one child in every 68 is said to have an autism spectrum disorder (MMWR, March 28, 2014). Almost five times as many boys as girls, and about one-third more European Americans than Hispanic, Asian, or African Americans, are diagnosed with autism.

The DSM-5 autism diagnosis, formerly reserved for children who were mute or violent, now includes mild, moderate, or severe categories. Children who once were said to have Asperger syndrome are now said to have “autism spectrum disorder without language or intellectual impairment” (American Psychiatric Association, 2013, p. 32).

Children with any form of ASD find it difficult to understand the emotions of others, which makes them feel alien, like “an anthropologist on Mars,” as Temple Grandin, an educator and writer with ASD, expressed it (quoted in Sacks, 1995). Consequently, they are less likely to talk or play with anyone, and they are delayed in developing theory of mind. Severely impaired children never speak, rarely smile, and play for hours with one object (such as a spinning top or a toy train). Mildly impaired children appear normal at first, and may be talented in some specialized area, such as drawing or geometry. Many (46 percent) score in the ‘normal’ or ‘above normal’ range on IQ tests (MMWR, March 28, 2014).

Most children with autism spectrum disorder show signs in early infancy (no social smile, for example, or less gazing at faces and eyes than most toddlers). Some improve by age 3; others deteriorate. Late onset occurs with several brain disorders, including Rett syndrome, in which a newborn girl (boys with the Rett gene never survive) has “normal psychomotor development through the first 5 months after birth,” but then her brain develops very slowly, severely limiting movement and language (Bienvenu, 2005).

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Many children with ASD have an opposite problem—too much neurological activity, not too little. Their head grows too fast, and by age 2 it is larger than average. Their sensory cortex may be hypersensitive, making them unusually upset by noise, light, and other sensations. That suggests that the core problem in ASD is neurological. Literally hundreds of genes and dozens of brain abnormalities are more common in people diagnosed with autism than in the general population.

As mentioned above, in the United States far more children are found to have ASD now than in 1990. The incidence of this disorder may have actually increased, or the definition has expanded, or more children receive that diagnosis because educational services are more available (Klinger et al., 2014).

Underlying the estimate of frequency is the problem that no definitive measure diagnoses autism spectrum disorder: Many adults are socially inept, insensitive to other people’s emotions, and poor at communication—are they all on the spectrum? One expert believes that the reason so many more boys than girls are designated with autism is that females are naturally more empathetic and males more likely to systematize, so biological sex differences protect girls who are genetically vulnerable (Baron-Cohen, 2010).

A related issue is whether autism is a disorder needing a cure, or whether the real problem is in parents and society that expect everyone to be fluent talkers, gregarious, and flexible—the opposite of people with autism. Advocates of neurodiversity, suggests that the neurological diversity of human beings is to be accepted, appreciated, even celebrated (Kapp et al., 2013). Do typical humans foolishly want no one to be atypical?

The neurodiversity perspective is one reaction to the many treatments that converge on autism. When a child is diagnosed with ASD, parental responses vary from irrational hope to deep despair, from blaming doctors and chemical additives to feeling guilty for what they did wrong. Many parents sue schools, or doctors, or the government; many spend all their money and change their lives; many subject their children to treatments that are, at best, harmless, and at worst, painful and even fatal.

Andrew Solomon (2012) writes about one child, who was medicated with

Abilify, Topamax, Seroquel, Prozac, Ativan, Depakote, trazodone, Risperdal, Anafranil, Lamictal, Benadryl, melatonin, and the homeopathic remedy, Calms Forté. Every time I saw her, the meds were being adjusted again…. [He also describes] physical interventions—putting children in hyperbaric oxygen chambers, putting them in tanks with dolphins, giving them blue-green algae, or megadosing them on vitamins … usually neither helpful nor harmful, though they can have dangers, are certainly disorienting, and cost a lot

[p. 229, 270]

Equifinality certainly applies to ASD: A child can have autistic symptoms for many reasons; no single gene causes the disorder. That makes treatment difficult; an intervention that seems to help one child proves worthless for another. It is known, however, that biology is crucial (genes, copy number abnormalities, birth complications, prenatal injury, perhaps chemicals during fetal or infant development) and that family nurture is not the cause of ASD but may modify it. Social and language engagement of the child early in life seems the most promising treatment.

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