Module 29 - Special Problems of Children and Adolescents

This section gives an overview of some of the special problems which children and
adolescents go through: child abuse and neglect, depression, suicide and anti-social
behaviour. Information on each problem is presented on incidence, assessment, causes,
effects and treatments.

Child abuse and neglect:

The Federal Child Abuse Prevention and Treatment Act (CAPTA), defines child abuse and
neglect as, at minimum: “Any recent act or failure to act on the part of a parent or caretaker
which results in death, serious physical or emotional harm, sexual abuse or exploitation; or
an act or failure to act which presents an imminent risk of serious harm.”

Child abuse and neglect was identified as a social problem which required comprehensive
treatment in early 1960’s (Wolfe, 1988). Some of the issues related with child and abuse are
explained in this section:

Incidence: The occurrence of child abuse and neglect is increasing at a terrifying rate in the
United States with “current estimates to be as high as a two million children a year” (Papalia
and Olds, 2001). A lot of children have been sexually abused (Papalia and Olds, 2001) which
is rapidly increasing in the United States. “Current estimates suggest that one in every four
girls and one in every seven to ten boys will have a sexual experience with an adult before
reaching eight years of age” (England and Thomson, 1988). Furthermore, psychological abuse
may be the most general and damaging form of child abuse (Dworetzky,1996).

Assessment: To reduce the negative effects of child abuse and neglect it’s very important to
identify and provide treatment to the child as early as possible. Salkind (1994) mention about
the warning signs of the various forms of child abuse and neglects.

• Physical abuse: signs of bruises, burns and broken bones.

• Child neglect: poor health and hygiene and excessive school absenteeism.
• Sexual abuse: se of sexually explicit terminology, nightmares, genital injury and
sexually transmitted disease.
• Psychological (emotional) abuse: depression, self-deprecation, somatic (bodily)
complaints such as headaches, stomach aches and fear of adult.

To begin with the assessment of child abuse, the process usually begins by obtaining the
data from referral and reporting source. In the next stage the obtained information is
clarified from the parent and the child during interviews (Wolfe, 1988). The information
associated with the functioning of the parent and child can be acquired from the parent with
semi-structured interview. (Wolfe, 1988). “The parent interview and assessment guide can
be used to structure the interview and provide information on family background, marital
relationship, areas of stress and support’ (Wolfe, 1988). The attitude of the parents on issues
associated with marriage and family can be examined through numerous instruments.” The
child abuse potential Inventory (Milner, 1986) identifies familial patterns associated with
child abuse. The childhood level of living scale (Polansky et al, 1981) measures the degree
of positive negative influences in the home and is particularly useful for assessing neglect
(Wolfe, 1988)”.

Causes: Present day research shows that child abuse is the result of interaction of complex
events. Wolfe (1988) summarizes the research by explaining that “child abuse is a special
type of aggression resulting from proximal and distal events”.

Proximal events: are those which leads to abuse. A proximal event can involve a child’ s
behaviour of an adult conflict that triggers the abuse. There are various number of children‘s
behaviour that can trigger child abuse some of them are aggression, unspecified
misbehaviour, lying and stealing (Kadoshin and Martin 1981). The study by Straus, Gelles
and Steinmetr (1980) explains that child abuse is also associated with the marital problem
and violence.

Distal events are indirectly related with child abuse. Numerous factors which contribute to
child abuse are “low socioeconomic status and poverty, restricted educational and
occupational opportunities, unstable family environment, excessive heat, overcrowding.
Ambient noise level and unemployment “(Wolfe, 1988).

There are several studies who have examined the characteristics of abusive parents in order
to understand the factors that leads to child abuse. Talbutt (1986) explained in his research
that abusive parents are immature who holds unrealistic expectations from children and
suffers from substance abuse problem.

Sroufe and Cooper (1996) interpreted the factors of the parents who are on high risk of child
abuse. Parents who are on high risk of child abuse tends to be the ones those who lacks
social support, are young, single, living in poverty, unintended pregnancies, didn’t have
enough space for the child to sleep, unrealistic expectations upraising the baby

Effects: Number of studies has described the consequences of child abuse and neglect on
the child. In 1996 Sroufe and Cooper identified the effects on child. If the child lacks primary
needs (like food and shelter), it reduces the ability of the child of dealing with the tasks of
daily needs such as personal hygiene. If the child experiences emotional and physical abuse
it results in behavioural and emotional problems. “Psychologically abused children can
develop neurotic traits, conduct disorders, negative self-image and distorted relations with
others” (Craig, 2002; Hart and Brassard, 1987). Children who have been sexually abused
have a high risk of developing psychiatric problems as adults for instance they can
experience Post traumatic stress disorder. (Herman 1986).
Furthermore, O’Brien (1983) identifies several ways that sexual abuse can damage a child.
• Psychological effects: sexual experiences can be confusing for children because
they are unable to understand the strong emotional feelings associated with sex.
• Low self-esteem: children start criticizing themselves for the sexual contact and
feels ashamed and dirty because of the experience.
• Exploitations: sexually abused children may feel used and develops a suspicious
attitude toward others.
• Vulnerability: because children are depending on adults, they are vulnerable to
and trusting of adults. When that trust is broken, children may develop a
negative attitude towards vulnerability, making it difficult to develop trust and
intimacy in relationships.
• Violation of the child’s privacy: after an incestuous relationship is discovered,
the abused child must cooperate with the authorities. This violation of the
child’s privacy can be very traumatic and anxiety provoking.
• Distorted moral development: sexual abuse often occurs between the ages of
nine and eleven when a child’s moral development is also being formulated.
Children can become quite confused about what is right and wrong when an
adult it allowed to violate them sexually.

Treatment: Brockman (1987) has recommended that the most beneficial treatment for
abusive parent involves “resocialization” tasks, which is a process in which parents learn to
rebuild individual’s role and adapt to new socially acceptable norms. These parents are
advised to join parents anonymous or other self-help groups. Brockman also mentioned
about the various preventive programs such as sex education, interpersonal training for
students, adult education and lectures of the speakers from parents’ anonymous
organisations could be promoted in schools.

In their study Thompson and Wilcox (1995) observed that there is a little factual evidence
supporting the social isolation theory of child abuses, referring to the several examples of
parents those who continue to engage in child abuse because of the other triggering factors
for instance substance abuse problems despite of the social support. They evaluated that
the problems like child abuse and neglect can be dealt with the research and interventions
team composed of disciplines such as psychology, social work and sociology because
together they can gain a more comprehensive understanding of the causes and treatment
strategies associated with child mistreatment.

Treatment can also be provided to the abused child. Damon and Waterman (1986) explained
in their study that group counselling can be the most helpful while working with abused
child and adolescents. In addition, Kitchur and Bell (1989) mentioned that group counselling
helps an abused child to rebuild self-esteem, learning self-control skills, resilience and
dealing problems with trust.
Furthermore, White and Allers (1994) also added that play therapy has been used highly
with abused children. Although abused children aren’t very imaginative and their play
doesn’t elevate their anxiety. Numerous studies show a pattern of unique behaviours which
were unfolded while conducting play therapy with abused children. Some of them are
“developmental immaturity, repetitive and compulsive behaviour, opposition and
aggression: withdrawal and passivity; self-depreciation and self-destructive behaviour,
hyper vigilance; sexual behaviour and dissociation (an unconscious denial of abuse)”.
Orenchuk—tomuk, Matthey and Christensen (1990) developed three stage model for
treating sexual abuse called the “resolution model”. The three stages are a) the
noncommittal or oppositional stage., (b) the middle stage and (c) the resolution stage. The
model differentiates treatment issues for the child, the non-offending parent and the
offending parents at each stage as follows:

In noncommittal or oppositional stage: the child feels responsible, angry for the incidence
and experiences symptoms which were associated with post-traumatic stress disorder
during the middle age and during resolution phase they no longer feels responsible for the
sexual abuse.
The non-offending parents are always in the mode of denial and starts blaming the child
for experience and protect the wrongdoer during the noncommittal or oppositional stage.
During the middle stage they start believing that abuse has taken place begins to become a
support for the child and in the resolution stage they become a positive ally for the child and
works through guilt associated with protecting the child.
In case of the offender parent initially during noncommittal or oppositional stage refuse to
take the accept that they are responsible for the abuse but during middle age they accept
the abuse but may blame the child whereas later in resolution stage they accept the
responsibility for the abuse and tries to establish positive parental role.
The resolution model recommends that “individual and group counselling can be useful
during the noncommittal or oppositional stage. Couples and family counselling should not
be useful until the middle or resolution stages and should involve the child only if the child
the ready.”

Depression:

When children are sad, no longer enjoy things like earlier and becoming irritable day after
day, it may be a symptom that they are suffering from major depressive disorder, commonly
known as depression. It used to be a perception that only adults are prone to depression
but studies shows that depression among children and adolescents is on the rise. More than
one in seven teens experience depression each year. This section reviews some of the major
issues associated with depression in children and adolescents.
Incidence: Recent studies that children are as prone to depression as adults (Alper 1986,
Kovacs 1989), Field et al 1988, Spitz 1946 found depression in infants, preschool and school
aged children (Digdon and Gotlb 1985, Kazdin 1988) and adolescents (Peterson et al 1993,
Rice and Mayer 1994, Wagner 1996). According to Kovack 1989, the average period of
depression lasts an average of three or more years. Whereas it is very difficult and unlikely
to diagnose manic disorders for children and adolescents (Strobe et al 1989).
Assessment: Sakolske and Jansen (1987) mentioned some major symptoms associated with
childhood depression. Changes in mood and affect are the visible indication. For instance,
children who used to be happy and full of positivity are unexpectedly saying that their life is
miserable, they are of no good and have no reason to be happy. other symptoms include:
feeling depressed, sad, tearful, or irritable, doesn’t enjoy things as they used to, likes to stay
by oneself, avoiding friends, sudden change in appetite, change in sleep pattern, feeling of
self-loathing, lacks concentration and rapid thoughts of suicide and death. They may also
experience frequent stomach ache and headache.
Peterson et al (1993) explained the symptoms of adolescent depression. Adolescents are
on higher risk of depression as compared to children. They frequent feels unhappy, full of
fears and worries for being loved, their physical appearances and relationships.
A person (regardless of age) is diagnosed according to the established criteria. For example,
“the DSM-1v-TR (AMERICAN Psychiatric Association 2000), includes such things as
depressed moods, decreased ability to experience pleasure, weight loss or failure to thrive
in children), loss of energy, thoughts of death and so forth. The DSM also notes that “certain
symptoms such as somatic complaints, irritability and social withdrawal are particularly
common in children, whereas psychomotor retardation, hypersomnia, and delusions are
less common in pre puberty than in adolescence and adulthood” (American Psychiatric
Association 2000).
The DSM-1V-TR explains that major depression in children generally does occur with other
mental disorders. “Comorbidity in adolescents is often associated with mental disorder such
as eating disorder, substance abuse disorders and disruptive behavioural disorders
(American Psychiatric Association 2003)”.
Different number of instruments have been developed specifically to assess childhood and
adolescent depression. For instance, children’s depression inventory (Koaet, 1981), which
was developed from the beck depression inventory is used to assess the cognitive, affective,
and behavioural signs of depression. Other instrument includes the short children’s
depression inventory (Carlson and Cornwell 1979), the children’s depression scale (Land and
Tisher 1978) and the schedule for affective disorders and schizophrenia for school age
children (Chambers, Puig-Antich and Tabrizl 1978).

Causes: There are numerous factors associated with childhood depression. These include
parents who have unrealistic high expectations and do not appreciate the child, children
develop negative schema due to self-deprecation (hammer et al 198) and lack of social skill
and difficulty in problem solving (Altman and Gotlb 1988).
Wagner (1994) explained an ecological perspective towards mental health problems of
children. He describes the “povertisation of childhood” have a devastating effect on child’s
well-being, he observed that 25 percent of children of five years or less are living in poverty
moreover are born to single mothers. are born to single mothers.
Peterson et al (1993) explained major factors of adolescent depression which includes
“pessimistic-negative cognitions, genetic predispositions (a parent has a history of
depression) and social systemic factors such as excessive environmental stress, problems
with home, school, and peer group. It is interesting to note that one of the best predictors
of adult depression is impaired peer-group relations during adolescence”.

Effects Children those who experience depression in childhood and adolescents can have
serious consequences. One of the problems with childhood and adolescent depression are
impaired cognition (Kovaes et al 1988, Peterson et al 1993), they experience problems with
social and educational progress and develops suicidal tendencies. Brown and Harris (1978).
evaluated those children who experience death of their mother before the age of 11 are
more prone to depression as adults.
Treatment: There are a number of counselling approaches available to treat childhood
depression. The most effective approach to treat childhood depression is the cognitive
approach (Reynolds and coats 1986). Another approach is providing guidance to the parents
and enhancing their skills for maintaining positive environment in the family. Play therapy is
another option which helps children to work and overcome from traumatic experiences and
enhances their social skills and self-image. Besides these approaches Antidepressant
medication can also be used to treat childhood depression, although there are mixed reports
regarding its efficacy for children.
According to the Peterson et al (1993) there are different number of counselling and
psychotherapeutic approaches which have been used to successfully treat adolescent
depression unlike antidepressant medications. “Some of these approaches include cognitive
behavioural, psychodynamic, family therapy, social skill training and group counselling”. In
addition, Tice and Meyer (1994) developed a psycho educational intervention program in
schools to enhance coping responses to stress.

Suicide:

Suicides among children and adolescents are rapidly increasing. The second leading cause
of death among children and adolescents is suicide. It is noted that the majority of suicide
among children and adolescents are associated with the mental health disorder usually
depression. This section will explore some of the emerging trends in suicide among children
and adolescents discussed by Capuzzi and Nystuk (1986) and Golman and Beurdsiee (1999).

Incidence: Since 1950 suicide rates among children and adolescents is frequently increasing.
In case of children, it’s the fifth cause of death as compared to the third cause of death
among adolescents. However, the suicide rate among children have recently doubled which
is staggering.
Several factors have been attributed for the difference between suicide rates of children
and adolescents. Children aren’t fully cognitive developed to plan and implement the suicide
successfully than adolescents moreover they don’t have access to lethal weapons as
compared to adolescents. Furthermore, Incidence of suicide may vary according to gender,
sexual orientation and culture. Females are high on planning and implementing suicide than
males. In case of sexual orientation, the gay and lesbian adolescents have higher rate of
suicide than general population due to the lack of acceptance by friends, family and society.
In terms of culture different aspects of childhood and adolescent suicide is related to it. For
instance, the rate of suicide among natives Americans appears higher on tribes because of
the lower emphasis on traditional values.

Assessment: The increased rate of suicide is related with psychopathology, such as

depression and substance use, stress from problems of living for example teen age
pregnancy, lack of family support, insufficient socio emotional support, dysfunctional family,
violence and abuse. “The MMPI (means, motive, plan and intend acronym can also be used
to assess for suicide. For example, an adolescent who issues he wants to kill himself because
of a recent breakup would have high intent and motive. If he had a loaded gun shot in his
car, he would also have the means and plan and would be considered at high risk for
suicide.”

Causes: Suicide can be understood from different aspects. According to the biochemical
model the chemical imbalance in the brain results in depression and increased risk for
suicide. The psychological perspective emphasised on the feelings such as unhappiness,
hopelessness of a child whereas adolescents find suicide a convenient way out of their
problems. On the other hand, developmental theory explains that due to conflict over
identity formation child or adolescent may commit suicide.

Effects: One of the most painful effects of suicide is the loss of the life that can never be
replaced. Loved ones are left to deal with the mixed feelings such as anger and guilt. “It is
also common for friends and family members to spend considerable time and energy
wondering why the act was committed and if there was anything they could have done to
prevent the suicide”. ( Capuzzi and Nystuk (1986) and Golman and Beurdsiee (1999).

Treatment: according to Capuzzi and Nystuk (1986) and Golman and Beurdsiee (1999).
Children and adolescents must be examined and evaluated for suicidal ideations and
actions. The major role in this process can be played by the parents and school officials. For
instance, any child who appears unhappy, sad or depressed should immediately be referred
to the school counsellor suicide evaluation. There are different number of preventive efforts
which can be taken by the schools such as promoting resiliency characteristics among
students to enhance coping mechanisms to stress. After the identification of suicidal
tendency suicide contracts can be used. “These contracts require that a parent and child or
adolescent notify a mental health worker if the child/adolescent becomes actively
suicidal/hospitalisation and treatment should be considered when a child /adolescent
becomes a high risk for suicide”. Counselling should focus on identifying the casual factors
associated with the suicidal tendencies after the stabilization of the child/adolescence in
terms of their suicidal ideations. After identifying the casual factors counsellor should
emphasise on enhancing the overall psychological functioning.

Anti-social behaviour:

Anti-social behaviour in children and adolescents includes acts that violates major social
norms which includes intention violence and aggression towards others, bullying, lying, and
stealing (Karzdin et al 1989). This section provides the overview of the major issues
associated with anti-social behaviour in children and adolescents.

Incidence: “the incidence of children engaging in antisocial behaviour is high and involves
one third to one half of all mental health clinical referral” (Kazdin et al 1989). Rates of
antisocial behaviour in the form of delinquency are also shocking, “6 percent of serious
crimes in the United States being committed by the youth under 15 and 16 percent
committed by adolescents 15 to 18 years of age”. The instances like school shootings are
increasing at a rapid rate. However, there can be numerous factors which are associated
with violence, recently bullying is considered as a contributing factor in school violence.
Bullying has been defined as” unprovoked and repeated aggressive behaviour that causes
distress to its victim and verbal or physical behaviour that disturbs someone who is less
powerful” (Goldstein 1999, Nansel et al 2001). Children and adolescents who were bullied
may later respond with violence. For instance, two of the Colombian High School shooters
and Santé, California, shooter were believed to have been previous victims of bullying.

Assessment: children or adolescent who engage in a well-established pattern of anti-social

behaviour for at least six months tends to receive a DSM-1V-TR diagnosis of either conduct
disorder and requires that the individuals has violated the rights of others and age
appropriate are norms or rules of society. Macmohan and Foreash (1988) note that most
behaviours associated with conduct disorder involve (1988) note that most behaviours
associated with conduct disorder involve “direct confrontation or disruption of the
environment” and “are basically the same type of behaviour that Patterson (1982) and Lober
and Schmaling (1985) have labelled “overt anti-social behaviour”. “The major feature of
oppositional deficit disorder “is a recurrent pattern of negativistic, defiant, disobedient and
hostile behaviour toward authority figures that persists for at least 6 months...” American
psychiatric association 1994).
to DSM-1V-TR diagnosis of conduct disorder and oppositional defiant disorder.
There are several behavioural rating scales which are available for evaluating antisocial
behaviour in children and adolescents. “The child behaviour checklist (Achenback and
Edelbrock 1983) is one of the most popular rating scales in use. It can be used with children
ages two to sixteen and provides a comprehensive assessment of behaviourally disordered
children (McMohan and Forehand 1988)”. An advantage of this scale is that it has parallel
forms the child, parent, teacher and observer.
It’s essential to identify the type of aggression present in the child/adolescent. There are
three types of aggression: instrumental, reactive and bullying. In instrumental aggression
individual uses the aggression to counterattack against someone who was caught doing
something wrong. Reactive aggression is impulsive violence in response to a perceived
wrongdoing and involved attributing blame without understanding if the act was intentional
or accidental.” Bullying aggression is a hostile response to others for no apparent reasons.
Brown and Parsons (1998) provide a different perspective of bullying aggression. They refer
to bully aggression proactive aggression. Proactive aggression tends to be well planned and
goal directed and includes bullying or other acts of aggression to achieve a desired goal”.

Causes: Patterson, DeBaryshe and Ramsey (1989) explained that that antisocial behaviour is
developmental that begins during childhood and continues till adolescents and adulthood.
According to this theory initially parents do not force children to adapt a pro-social
behaviour and effectively punish their antisocial behaviours. On the other hand, these
children learn to use antisocial behaviours to stop interruption by other family members.
From this perspective, antisocial behaviour can be seen as the necessary survival skill to cope
with a dysfunctional family.
Causes of aggression have been associated to the punishment given by parents for instance
to spanking as a disciplinary measure by parents. Spanking is associated to reactive
aggression. Children who are spanked use aggression more likely than the children who
were not spanked.
Macmahon and Forehand (1988) provide an overview of studies that identify factors
associated with conduct disorders and antisocial behaviours. These studies suggest that
“children with conduct disorders also tend to exhibit impaired peer relationships,
misattribute hostile intensions to others, have deficits in social problem-solving skills, lack
empathy are prone to hyperactivity and depression, have low levels of academic
achievement and have a genetic predisposition to develop antisocial tendencies “

Effects: Kazzlin et al (1989) suggest that the consequence of antisocial behaviour usually
prevail from childhood to adolescent. Moreover, individuals who are diagnosed with
antisocial behaviour disorders are prone to experience disproportional problems as adults,
for instance criminal behaviour, alcoholism and antisocial personality disorders.
Patterson, De Baryshe and Ramsey (1989) explained in their study that several factors which
are seen as causes of anti-social behaviour for instance academic failure or peer rejection
should be considered as the effects of anti-social behaviour. For instance, research has
shown that childhood aggression leads to rejection by the peer groups not the reverse.

Treatment: it is one the most difficult task to provide counselling to antisocial individuals. It
involves the changes in the pattern of behaviour that has begun since childhood and has
developed into a lifestyle. According to Kazdin 1987; Wilson and Hernstein 1985 when these
individuals become adolescent, they usually are the part of some gang and however getting
out of this is highly undesirable. “One treatment modality that has been successfully used
with antisocial Youth is special education programs, which provide services to seriously
emotionally disturbed behaviourally disordered students”. (Thompson and Rudolph 2000).
In united states, students experiencing behavioural and emotional disturbances are
imparted with the educational experience which involves several procedures such as
behavioural contracting, token economy, individual and group counselling, parent
consultation and individualized instruction. Different studies have provided that evidence
that teachers can play an important role in overcoming anti-social tendencies.