Title: Childhood abnormal psychology article analysis
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Journal of Child and Family Studies, Vol. 15, No. 1, February 2006 (?C 2006), pp. 1?12 DOI: 10.1007/s10-9
Freud was Right. . . About the Origins of Abnormal Behavior
Peter Muris, Ph.D.1,2 Published online: 24 February 2006
Freud?s psychodynamic theory is predominantly based on case histories of pa- tients who displayed abnormal behavior. From a scientific point of view, Freud?s analyses of these cases are unacceptable because the key concepts of his theory cannot be tested empirically. However, in one respect, Freud was totally right: most forms of abnormal behavior originate in childhood. In this paper various factors are discussed that play a role in the etiology of abnormal behavior in chil- dren and adolescents. Furthermore, problems are signaled that hinder effective interventions for disordered youths.
KEY WORDS: psychological disorders; etiology; children and adolescents.
Freud?s psychoanalytic theory is still one of the most influential theoretical models of abnormal human behavior. On the basis of a series of intriguing case studies, Freud illustrated the key constructs of his theory thereby attempting to explain why his patients were exhibiting aberrant behaviors. For example, take the case of Little Hans, which was described by Freud as the ?Analysis of a phobia in a five-year-old boy? (Freud, 1909/1955). Little Hans was afraid of horses. He was so terrified that he did not dare to go outside anymore, a phenomenon that current clinical psychologists would label as ?agoraphobia.? Freud?s analysis of this case was crystal clear. Hans suffered from a so-called Oedipus complex. That is, Hans wanted to have sex with his mother and therefore expected to be punished by his father. As a result, Hans became afraid of his father. However, this was considered as unacceptable by his Ego and, therefore, the fear was displaced to another object,
1Professor, Institute of Psychology, Erasmus University Rotterdam, The Netherlands. 2Correspondence should be directed to Peter Muris, Ph.D., Institute of Psychology, Erasmus University
??1062-1024/06/0200-0001/1 ?C 2006 Springer Science+Business Media, Inc.
resulting in a phobia of horses. In another case, Freud described an adult lawyer, Paul Lorentz, also known as the Ratman (Freud, 1909/1955). The Ratman was plagued by the obsession that his father had to undergo the rat punishment. This rat punishment implied that a cooking pot was attached to his father?s backside in which rats were placed. The rats ate their way into the anus of his father. How is it possible that Lorentz was plagued by such disturbing thoughts about his beloved father? Freud?s analysis was again clear: the obsessions of the Ratman had to do with sex-related, hostile impulses against his father.
THE HOLY GRAIL
Freud?s theory is largely based on case studies of abnormal human behavior. Without exceptions, these cases are fascinating and interesting. However, from a scientific point of view, Freud?s analyses of these cases are unacceptable, as the main concepts of his theory cannot be validated empirically (Eysenck, 1985). Since Freud, a lot of researchers in the field of clinical psychology have devoted their attention to what can be called ?the quest of the Holy Grail.? The purpose of this quest is to find an answer on two questions: (1) where does abnormal human behavior come from? and, (2) how can we use this knowledge to help people who show clear signs of aberrant behavior?
Abnormal behavior or psychopathology is concerned with various types of disorders, including eating disorders, depression, disruptive behavior, and anxi- ety disorders (American Psychiatric Association [APA], 2000). In their quest for the Holy Grail, an increasing number of researchers are focusing on the study of abnormal behavior in children and adolescents. The reason for this is obvious and has to do with what is known about the age of onset of many disorders. For example, specific phobias usually start in childhood (O ? st, 1987). Social phobia, depression, and eating disorders frequently have their onset during adolescence (Burke, Burke, Regier, & Rae, 1990; Mussell, Mitchell, Weller et al., 1995), while people who suffer from a personality disorder by definition already show signs of their problems before the age of 18 (APA, 2000). In other words, many types of abnormal behavior that are seen in adults have already started in youth. Re- cent epidemiological research with children and adolescents has demonstrated that psychopathology indeed is a serious problem in this age group (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). In a large sample of youths from the general population, the one-year prevalence of internalizing (i.e., anxiety disor- ders, depression) as well as externalizing disorders (i.e., oppositional-defiant and conduct disorders) was about 5%. The most striking finding of this study was that before their 16th birthday, 36.7% of all youths at some point in time had suffered from a psychological problem. It is important to note that these prob- lems concerned clinical diagnoses, which implies that youths really experienced considerable discomfort in their daily functioning.
About the Origins of Abnormal Behavior 3 THE ORIGINS OF ABNORMAL BEHAVIOR IN YOUTHS
Why do a substantial proportion of children and adolescents come to suffer from a psychological disorder? Briefly, the answer to this question can be found in four groups of factors. The first group of factors is concerned with characteristics of the child. The second group of factors involves the family, and especially the interaction between children and their parents. The third group of factors has to do with influences of the environment and from the child?s point of view can be labeled as learning experiences. The fourth and final group of factors pertains to societal influences.
Genetics and Temperament
Genetic make-up is one important child factor that is involved in the origins of psychopathology. The influence of genetics is typically established in twin studies. Based on the fact that monozygotic twin pairs share 100% of the genetic material, whereas dizygotic twin pairs only share 50%, one can determine the level of agreement and compute a hereditary factor for each type of psychopathology. For most disorders, the agreement in psychopathology is larger in monozygotic than in dizygotic twins, which points in the direction of a genetic influence. More precisely, for the three most common psychological disorders in youths (i.e., anxiety disorders, depression, and disruptive behavior disorders), twin studies have demonstrated that about 50% of the variance in these problems can be attributed to heredity (Rutter, Silberg, O?Conner, & Siminoff, 1999).
In what way does heredity contribute to the etiology of psychopathology in youths? One factor that is thought to play a role in this respect is the child?s tem- perament and, in particular, the temperament factor of emotionality (also known as neuroticism or negative affectivity). Emotionality refers to emotional instability and there are clear indications that this temperament factor has a genetic basis (Eysenck, 1990). Research has also shown that children and adolescents with high levels of emotionality are at greater risk for developing psychological disorders (Asendorpf & Van Aken, 2003; Barbaranelli, Caprara, Rabasca, & Pastorelli, 2003; Erler, Evans, & McGhee, 1999; Huey & Weisz, 1997; John, Caspi, Robins, Moffitt, & Stouthamer-Loeber, 1994; Muris, Winands, & Horselenberg, 2003). Further, it is important to note that emotionality consists of various lower-order components of which fear, anger/frustration, and sadness can be considered as most relevant as they seem to play an important role in the type of psychopathology from which children eventually come to suffer (Rothbart & Bates, 1998). That is, a child with a fearful temperament is more prone to develop an anxiety disorder, a child with a temperament characterized by high anger/frustration runs greater risk to develop a disruptive behavior disorder, whereas a child with a sad temperament is more susceptible to develop a depression (Muris & Ollendick, 2005).
It is important to note that the contribution of temperament to the etiology of child psychopathology should not merely be viewed as a reactive process
guided by the temperament factor of emotionality. In the past five years, an increasing amount of research has focused on ?effortful control,? which is viewed as a regulative temperament factor that enables children and adolescents to modulate their emotional reactions. Effortful control can be defined as ?the ability to inhibit a dominant response to perform a subdominant response? (Rothbart & Bates, 1998), and essentially consists of two important components: inhibitory control, which pertains to the ability to inhibit one?s behavior if necessary, and attention control, which can be defined as the ability to focus and shift attention as needed.
Current temperament researchers assume that vulnerability to psychopathol- ogy is characterized by a combination of high levels of emotionality and low levels of effortful control (Calkins & Fox, 2002; Lonigan & Phillips, 2001). More specif- ically, high levels of emotionality make children prone to develop psychological disorders, but it may well be the case that the negative impact of this reactive temperament factor can be buffered by effortful control. That is, a stressful life event will elicit negative emotions in children and particularly in those who are characterized by high levels of emotionality. However, only children with low levels of effortful control will experience difficulties to deal adequately with these negative feelings and hence will react with avoidance behavior, aggression, and depression. In contrast, children with high levels of effortful control are capa- ble of regulating these negative emotions by employing more strategic, flexible and effective coping strategies (Muris & Ollendick, 2005). Recent research has indeed demonstrated that reactive and regulative temperament factors of respec- tively emotionality and effortful control each make a unique contribution to the frequency of psychopathological symptoms in youths (Muris, De Jong, & Engelen, 2004). Finally, it should be mentioned that different aspects of effortful control are allied to specific psychopathological symptoms (Muris, Meesters, & Rompelberg, submitted). More precisely, a lack of attentional control was more strongly linked to internalizing symptoms, whereas a deficiency of inhibitory control was more clearly related to externalizing symptoms. Note that these differential relations are in keeping with the clinical observation that internalizing disorders are typically characterized by uncontrollable negative thoughts, while externalizing disorders are frequently marked by impulsive and disinhibited behavior (see APA, 2000).
Parental Rearing and Modeling
The second group of factors that is involved in the etiology of child psy- chopathology is concerned with the family and, in particular, with parental rear- ing practices. In the context of abnormal behavior, two important dimensions in parental rearing behaviors can be discerned. The first dimension is parental care and has two opposite poles: an accepting and warm rearing style on one side and a rejecting and cold rearing attitude on the other side. The second dimension is concerned with parental control and actually opposes an autonomy-promoting and
About the Origins of Abnormal Behavior 5
an overprotective rearing style to each other (Rapee, 1997). Various studies have found that specific types of abnormal behavior in children are associated with particular types of parental rearing. For example, anxiety symptoms in youths are generally linked to high levels of parental control (i.e., overprotection), depressive symptoms are related to low levels of parental care (i.e., lack of emotional warmth and rejection), whereas behavioral problems are associated with high levels of control as well as low levels of care (Muris, Bo ?gels, Meesters, Van der Kamp, & Van Oosten, 1996; Muris, Meesters, Merckelbach, & Hu ?lsenbeck, 2000; Muris, Meesters, Schouten, & Hoge, 2004; Muris, Meesters, & Van den Berg, 2003). As an aside, it should be mentioned that it is difficult to find out what is cause and what is effect in the relation between parental rearing behavior and child psychopathol- ogy. It may well be that negative rearing behaviors contribute to the development of abnormal behavior. Otherwise, it is also possible that children who display abnormal behavior elicit negative rearing behaviors in their parents. Currently, researchers assume that both scenarios are applicable, which means that parental rearing behaviors are thought to play a role in the etiology and maintenance of psychopathology in youths.
More specific parental rearing behaviors also seem to be involved in the origins of psychological problems in children. For example, it is a common fact that children learn by observing and imitating the behaviors of their parents, a phenomenon that is known as modeling. Experimental research has convincingly demonstrated that modeling is involved in the acquisition of fear in children. In a study by Gerull and Rapee (2002), toddlers were shown a rubber snake and spider, which were alternately paired with either a negative or a positive facial expression by their mother. Next, both stimuli were presented again after a brief delay, and fear and avoidance reactions were assessed. Results clearly indicated that children displayed less fear and more approach behavior when their mothers had responded positively to the stimuli. Conversely, children showed more fear and avoidance following negative reactions from their mother. Other examples that suggest a link between modeling and child psychopathology are numerous and can be observed inside as well as outside the clinic: obese children often have fat parents, aggressive children frequently have antisocial parents, and children with developing personality problems tend to have weird parents (Adshead, 2003; Bandura, 1976; Gable & Lutz, 2000). Of course, modeling is not the only factor that contributes to these phenomena but at least seems to play a significant role.
Life Events and Negative Information
A third group of factors that is relevant in the context of the genesis of abnormal behavior in children is concerned with negative learning experiences. Obviously, children who experience aversive life events run greater risk for devel- oping psychopathology (Cuffe, McKeown, Addy, & Garrison, 2005; Tiet et al.,
2001). Maltreatment, abuse, parental divorce, being teased at school, or the death of a significant person are all negative life events that may give rise to abnor- mal behavior in children, and especially in those characterized by a vulnerable temperament. However, there are also more subtle forms of learning experiences that may promote the development of psychopathology. For example, research has demonstrated that negative information promotes children?s fear (Field, Argyrus, & Knowles, 2001). Seven- to 9-year-old children received either negative or pos- itive information about an unknown monster doll. Results showed that negative information significantly increased children?s fear ratings, whereas after positive information fear ratings slightly decreased. These results were replicated by Muris, Bodden, Merckelbach, Ollendick, and King (2003) who provided children with either negative or positive information about an unknown, doglike animal, called ?the beast.? This study demonstrated that information-induced fear effects endured over a 1-week follow-up period and generalized to other stimuli; that is, children who became more fearful of the beast after receiving negative information also became more apprehensive of other dogs and predators.
It is good to keep in mind that children are confronted with negative infor- mation in various ways: they may hear things from adults or other children, but they may also see things on television or come across certain information while surfing on the internet. These learning experiences not only play a role in anxiety phenomena, but also seem to contribute to other forms of abnormal behavior in youths. For instance, Greenfield (2004) studied the effects of inadvertent exposure to pornographic material on the internet, and noted that children who regularly come across such information are more likely to develop different sexual attitudes, and even engage in age-inappropriate sexual activity and sexual violent behaviors.
Society and Culture
The fourth and final group of factors that is involved in the etiology of abnormal behavior in youths is operating at a societal and cultural level. For example, research on the prevalence of anxiety symptoms in South African chil- dren has consistently demonstrated that black and colored youths in this country display higher anxiety levels than their white counterparts (Burkhardt, Loxton, & Muris, 2003; Muris, Schmidt, Engelbrecht, & Perold, 2002). This difference was almost completely explained by the socio-economic background of the chil- dren (Muris, Loxton, Neumann, & Du Plessis, in press). That is, in the after- math of the Apartheid regime black and colored children still live in poor and threatening neighborhoods, whereas white children are raised under rich and safe living conditions. While such marked differences in socio-economic background are seldom seen in Western countries, this example illustrates that a societal factor can make a significant contribution to the psychological (dys)functioning of children.
About the Origins of Abnormal Behavior 7
Further evidence for a link between society and anxiety comes from a meta- analytic study by Twenge (2000) who compared children?s scores on a commonly employed anxiety questionnaire for various birth cohorts between 1952 and 1993. Results indicated that youths in the 1990s displayed considerably higher anxiety levels as compared to youths in the 1950s. To put it even stronger, the mean score of the normal children in the 1990s was even higher than the mean score of clinically referred children in the 1950s. Interestingly, this increase in anxiety across various age cohorts was significantly related to a variety of social parameters (e.g., divorce rate, number of violent crimes), which made Twenge (2000) conclude that a decrease in social connectedness and an increase in environmental danger may be responsible for the rise in anxiety among youths.
Another example illustrating the role of society in the etiology of child psy- chopathology is concerned with culturally determined body ideals. In Western countries, children and adolescents are attracted by good-looking idols of whom women look slim and men look slender and muscular. It has been demonstrated that early adolescent youths frequently engage in body change strategies, with girls engaging in dieting in order to lose weight and boys doing exercises in or- der to develop their muscles (Ricciardelli & McGabe, 2001). Further research indicates that culturally determined body ideals have a substantial impact on the development of abnormal manifestations of body change strategies, and this influ- ence remains statistically significant when controlling for various biological (e.g., Body Mass Index) and psychological factors (e.g., self-esteem; Muris, Meesters, Van de Blom, & Mayer, 2005).
In sum, it can be concluded that psychopathology is highly prevalent among youths, and there are clear indications that a substantial proportion of these psy- chological problems will continue into adulthood. Various child, family, environ- mental, and societal factors have been discussed that are thought to be involved in the etiology of abnormal behavior in youths. Two additional remarks should be made with regard to the role of these factors. First, it should be kept in mind that in reality factors frequently interact with each other (Wenar & Kerig, 2000). For example, a child is particularly vulnerable if he/she is characterized by an emotional temperament and is raised by parents who are rejective and show little emotional warmth. Thus, it should be kept in mind that it is often the combination of vulnerability factors and/or the lack of protective variables that are responsible for the emergence of abnormal behavior. Second, when studying factors that are involved in the etiology of child psychopathology, one should adopt a developmen- tal perspective. For example, when raising a 2-year-old child it may be perfectly adequate for parents to rely on a controlling rearing style. However, this style
may be totally inappropriate for a 16-year-old who generally fares better with an autonomy-granting attitude of his parents.
The general impression is that contemporary youths run greater risk for developing psychopathology. Changes in society (increased individualization) and family (increased divorce rate) and increased confrontation with the negative and even dark sides of life (not only via television and internet, but also in the direct environment) put children under greater pressure and will result in an increase of psychopathology.
Fortunately, there is also good news. In the past decade, researchers in the field of clinical psychology have developed effective intervention methods for treating the most prevalent psychological problems among youths (Barrett & Ollendick, 2004). When detected in good time, disruptive behavior disorders can be treated effectively by training parental rearing skills (Barkley, 1997). Depres- sion can be successfully handled with cognitive-behavioral therapy (CBT) of the child (Lewinsohn, Clarke, Hops, & Andrews, 1990). Impressive progress has also been made with the treatment of childhood anxiety disorders (Kendall, 1994), which also respond well to CBT-based interventions. For example, in a study by our research group (Muris, Meesters, & Van Melick, 2002), children with anxi- ety disorders were randomly assigned to three conditions: CBT, a psychological placebo intervention (i.e., emotional disclosure), or a no-treatment control con- dition. Therapy outcome measures were obtained three months before treatment, at pretreatment, and at posttreatment. Results showed that levels of psychopatho- logical symptoms remained relatively stable during the three months preceding treatment. Most importantly, pretreatment-posttreatment comparisons indicated that CBT was superior to psychological placebo and no-treatment control. That is, only in the CBT condition significant reductions of anxiety symptoms were observed. Recently, research has demonstrated that these positive effects of CBT in anxious children are maintained over very long time periods (Barrett, Duffy, Dadds, & Rapee, 2001).
In spite of this positive news, there are also a number of problems. The first problem has to do with the dissemination and implementation of the intervention methods that have been developed by scientists (Weisz, Jensen, & McLeod, 2005). Effective programs frequently remain in the research institute and, as a result, they are not used by clinicians who actually work with disordered youths. A second problem pertains to the late detection of abnormal behavior in youths (Angold, Costello, Farmer, Burns, & Erkanli, 1999; Champion, Goodall, & Rutter, 1995). This is not only true for disruptive behavior problems which either elicit shame in parents or are not seen as a serious problem (because parents show antisocial behavior themselves) but also for emotional problems such as anxiety disorders
About the Origins of Abnormal Behavior 9
and depression that are less clearly visible to the outside world. As a result, many children already suffer from their problem for many years. When they are eventually referred to the clinic the problem has become so severe that effective treatment is difficult. A third and final problem concerns the organization and quality of the mental health service system. Even in such a civilized and well- organized country as the Netherlands, it is still surprising to note that not all clinicians are using empirically validated, effective treatment methods. Further, it is far from clear for children and their parents where they can get the most optimal treatment for psychological problems.
WAS FREUD RIGHT?
Was Freud right in his ideas on the origins of abnormal behavior? Formally, the answer to this question is of course negative, as Freud developed an almost unreal theory about the etiology of psychopathology in which constructs such as Id-Ego-Superego, repression, and Oedipus complex play a prominent role. It has become clear that such constructs are difficult to validate empirically and as such a firm scientific basis for Freud?s theory is still lacking. However, there is at least one important issue on which Freud was right: that is, human abnormal behavior frequently has its origins in childhood. Researchers and clinicians seem to have accepted this idea, but it is time that politicians and other policy makers also become convinced of this notion, so that they put more effort in tackling the problems that hinder the effective detection and intervention of disordered youths.
This paper is based on the academic lecture given by the author on February 18, 2005 when accepting his position as full professor in Clinical and Health Psychology at the Erasmus University Rotterdam, The Netherlands.
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Muris, P. (2006). Freud was right…about the origins of abnormal behavior. Journal of Child
and Family Studies, 15(1), pp.1-12. doi: 10.1007/s10826-005-9006-9.