By Amy R. Williams

Abstract

This manuscript details some of the emotional, mental, and psychological effects of a terminally ill diagnosis. While the individual that is ill must suffer the greatest consequences of such a diagnosis (including death), the family dynamic is also greatly troubled upon diagnosis of a terminal illness. The wave effect of such a grave diagnosis reaches every facet of life including work, family, the will to live (or die), and one’s coping mechanisms. These topics are explored within this manuscript; the author then challenges the direction for future research on each topic followed by drawing relevance to the Boston Counseling profession relating to terminal illness.

Introduction

At first glance, an individual diagnosed with a terminal illness has one major battle to fight, a physical one. Immediately upon hearing of an individual diagnosed with a terminal illness most people envision frail bodies with no hair fighting for physical strength day in and day out. While this is often an accurate picture of terminal illness, it is not a complete assessment of the many facets a terminal illness effects in an individual and family life.

The physical challenges of a terminal illness are undeniable and clearly seen, but the psychological, emotional, and mental disturbances are not. Individuals diagnosed with incurable diseases that are aware of impending death deal with greater questions than ‘will this treatment/medicine make me sick?’ An individual diagnosed with terminal illness also begins to consider such topics as advance directives, financial concerns, anxiety about death, and emotional welfare of family members. Some individuals choose to continue working as long as physical conditions allow, others choose to live out remaining days at home with family, and still others consider hastening death. The mental, emotional, and psychological processes that arise from a terminal diagnoses are complex. While these processes are not prominent in the minds of objective points of view, they are acutely present for individuals diagnosed with a terminal illness.

In addition to a personal battle physically, mentally, emotionally, and psychologically, one must also consider the social and familial challenges of a terminal illness. Whether an individual is highly or minimally involved in a social network, the diagnosis of a terminal illness limits interaction to one degree or another. One such example is demonstrated by an individual receiving chemotherapy for cancer. While an individual is treated with chemotherapy, his or her immune system is not capable of fighting the least of harmful diseases. Therefore, one cannot interact with others to the same degree as before his or her diagnosis. This type of limitation affects family interactions as well. It is also important to note that in some cases those diagnosed as terminally ill are children or have small children. Clearly, the diagnosis of a child or young parent poses significant challenges for the family unit.

The challenges faced by a terminally ill individual prove to be great in all areas of life. Families change, social networks change, mental and emotional attitudes about life change, and death becomes a reality. The following headings detail empirical findings on the subject of the terminally ill and a few of the many facets affected by a terminal diagnosis.

Employment

One of the first considerations by individuals receiving a terminal diagnosis is whether to continue working or not. In some cases, the choice is easy because of physical disabilities that will result from diseases such as Lou Gehrig’s, AIDS, or advanced stages of cancer. These individuals are often unable to return to work upon diagnosis. For others, the choice to work is not apparent upon diagnosis of a terminal illness. Some individuals choose to work normal hours while others choose to stay home indefinitely.

It is logical to question why one would continue working when he or she is facing impending death. However, if one is able to work, it is beneficial to the psychological and emotional health of the individual; “pursuing professional goals may promote psychological well-being, quality of life, and overall adjustment to disease progression” (Westaby & Versenyi, 2005).

A study conducted by Westaby and Versenyi (2005) explored several reasons individuals with terminal illnesses chose the intention to work or not to work. When intrinsic and extrinsic motivations were considered, individuals continued to work for intrinsic reasons more than extrinsic reasons (Westaby et al., 2005). Intrinsic reasons reflect emotions and feelings of fulfillment while extrinsic reasons reflect material benefits of continued work such as wages and health benefits (Westaby et al., 2005). This supports the idea that individuals diagnosed with a terminal illness feel a sense of urgency to contribute to society in an impressionable way.

Familial Challenges

Perhaps the most difficult strain placed on a young family in present society is the diagnosis of a terminal illness. When a child or a parent with a young child is diagnosed with a life-threatening disease, the entire family dynamic is scrambled. Children diagnosed with a terminal illness face significant challenges in dealing with daily life. Acceptance is hard among peers throughout childhood, but harder still if one is facing the obvious differences a terminal illness is certain to bring. Likewise, while the differences vary from that of personal diagnosis, children living with the daily burden of a dying parent also face significant challenges. Parents and children alike must redefine life to revolve around the challenges introduced by such a diagnosis.

The Healthy Parent

Upon the diagnosis of a terminal illness in a family unit, the healthy parent immediately receives several unexpected burdens. The first and most obvious new responsibility is that of helping a sick spouse through physically difficult times. Other responsibilities that present themselves include housekeeping, maintenance of finances, open communication with medical personnel, and daily interaction with well-intended friends, family, neighbors, and community. While all previously mentioned tasks are of importance, perhaps one of the most significant responsibilities of the healthy parent is remaining attentive and available for his or her children during such a difficult trial. Clinical experience shows that parenting taking place during a terminal illness can influence a child’s overall adjustment to loss after the death of a spouse (Bettes, Christ, Mesagno, Raveis, Siegel, & Weinstein, 1990). During the terminal illness of a parent, children’s needs are accelerated beyond normal levels, “children experience a sense of vulnerability and an associated heightened need for emotional support and physical care” (Bettes, et al., 1990, p. 568). Often, while it is the desire to remain attentive to the child, the healthy parent becomes overwhelmed with the responsibilities of caring for an ill spouse and has difficulty gathering enough physical, emotional, and psychological strength to support and discipline children adequately. Lack of strength to provide parental discipline and needed emotional support for children leaves a parent questioning his or her competence as a parent during the terminal illness of a spouse.

Using the Global Parenting Confidence Measure (GPCM), Bettes, Christ, Mesagno, Raveis, Siegel, and Weinstein (1990) examined the perceived competence levels of well parents facing the death of spouse while also trying to remain attentive to the needs of children in the family unit. The GPCM allowed well parents to self-report perceptions of competence in relation to raising a child, or children, while also supporting a terminally ill spouse. Bettes et al. (1990) explored several parent/child relational areas through well parents’ competence perception including, Comfort/Openness, Sensitivity/Reassurance, Promoting Self-Esteem/Independence, Support/Trust, and Setting Standards/Discipline. While confidence levels dropped in most areas, the most obvious decline in parent’s confidence levels came in the areas of Sensitivity/Reassurance and Setting Standards/Discipline (Bettes, et al., 1990). This finding supports logical thought in the case of a parent facing the death of a spouse and trying to raise a child simultaneously.

It is not hard to imagine the small amount of reassurance one parent could offer a child when the other parent is facing imminent death. It is also quite logical to assume it would be harder to establish rules and apply discipline when one’s main concern is whether one’s family unit will remain intact throughout another day or not. The physical, emotional and psychological demands on that of a well parent facing the death of a spouse are inconceivable to others without the same experience. Because well parents are not able to interact with other individuals experiencing the same type of situation, often the well parent struggles with depression and feelings of inadequacy while trying to raise socially adjusted children despite the challenge of caring for a dying spouse (Bettes, et al., 1990).

Child Understanding and Bereavement

As previously mentioned, children also face significant challenges upon a parent’s diagnosis of a terminal illness. Depending upon the age of a child, a terminal diagnosis may or may not be understood completely. According to Feldman (2008), children do not begin to understand the concept of death until around the age of five. Before the age of five, most children do not understand the finality of death, furthermore the universality of death is not usually comprehended until around the age of nine (Feldman, 2008). With this in mind, one must consider whether advance knowledge of the impending death of a parent is beneficial for children in the grieving process. While it is important children are aware of such a diagnosis as terminal illness, it must also be understood that knowledge of coming death does not necessarily better prepare children for the death of a parent.

In a study conducted by Cain, Kalter, Lohnes, and Saldinger (1999) it was concluded that the advance knowledge of the impending death of a parent is no more beneficial to the bereavement process of a child with a terminal parent than that of child experiencing the sudden death of a parent. There are several reasons this conclusion holds truth. One obvious reason for this result is the mental capacity of young children to cognitively comprehend death as a future result of a terminal diagnosis (Cain, et al., 1999). As previously stated, most children do not fully comprehend death and the finality of death until around the age of five (Feldman, 2008). Another reason is that children often do not receive the same opportunity as adults to say goodbye to a dying parent because of both parents’ wish to avoid the subject of impending death in the presence of the child (Cain, et al., 1999). Thirdly, a child has no need to prepare for a new role in society upon death of parent (Cain, et al., 1999). This is unlike the surviving parent that will immediately take on the role of widow or widower upon death of the spouse (Cain, et al., 1999). This conclusion suggests the importance of being attentive to the emotional and psychological needs as well as the social adjustment of a child affected by a terminal illness before and after a death.

Euthanasia and Physician Assisted Suicide

A critical debate alive and well in the United States and around the world among members of society is that of euthanasia and physician assisted suicide. With the exception of the state of Oregon, no state has legalized either option for individuals wishing to hasten death due to terminal illness or other inflictions. Euthanasia involves a physician administering a lethal amount of medication to an individual wishing to die whereas physician assisted suicide allows a patient to administer his or her own lethal dosage of medication. The underlying assumption driving much of the political debate involving these topics is that terminally ill patients, whom are going to die anyway, should have the right to end suffering before it becomes unbearable. However, research suggests that individuals faced with the decision to hasten death often consider it as a later option, but rarely would choose it immediately if given the opportunity (Allard, Chary, Chochinov, Clinch, De Luca, Fainsinger, Gagnon, Karam, Kuhl, Macmillan, McPherson, O’Shea, Skirko, and Wilson, 2007). Through conducting interviews with open-ended questions, Allard et al. (2007) found that individuals facing a terminal illness were more likely to endorse euthanasia or physician assisted suicide if they, “had lower religiosity and….had no fundamental moral objections…that were grounded in religious tenets” (2007, p. 321). This supports the idea that fundamental Christians, holding the Bible as ultimate truth, have a difficult time supporting hastening one’s own death. However, it is difficult, even in Christian circles, to justify prolonged suffering facing the certainty of death.

Complicating the moral questions of euthanasia and physician assisted suicide are the emotional and psychological uncertainties one is sure to face in the later stages of life. While an individual may be certain of the decision for or against euthanasia and physician assisted suicide in the early stages of a terminal illness, opinions are likely to change with additional physical, emotional and psychological stressors related to impending death.

It is also important to note that while many people support the idea of euthanasia and physician assisted suicide, opinions tend to change when the question is considered on a personal level. Some research has shown that up to 62% of individuals support such actions when considering the general moral principle, while only 4% of individuals facing impending death would actually choose euthanasia or physician assisted suicide if it were made available to them (Cicirelli, 1997). Furthermore, in the state of Oregon only 0.1% of individual’s faced with hastening certain death have chosen to do so (Allard et al., 2007).

While it is true that the underlying assumption that drives the political debate on euthanasia and physician assisted suicide is to alleviate the physical suffering terminally ill patients endure, there is research to suggest that patients are likely to choose hastening death for emotional and psychological reasons more so than physical reasons (Rosenfeld, 2000). A survey of patients in pain because of terminal illness resulted in little difference of opinion than the general public on the legalization of euthanasia whereas, a survey administered to terminal patients experiencing depression reported discussing euthanasia as an option with a physician (Rosenfeld, 2000). The emotional and psychological processes accompanying terminal illness can be described as complicated, at best. It is difficult to assess the emotional and psychological strain placed on individuals facing imminent death. However, it is not hard to understand that one sometimes becomes emotionally and psychologically distressed by a terminal diagnosis to the point of wanting to hasten coming death. Rosenfeld (2000) asserts that the psychology profession and the consideration of the mental, emotional and psychological state of many individuals facing the decision for euthanasia or physician assisted suicide has been largely insignificant in the political debate for legalization of such acts. In other words, it seems the actual mental, emotional and psychological states of individuals in such a position are being overlooked for the sake of political argument and expression.

Advance Directives

Similar to the decision of euthanasia or physician assisted suicide is the decision to extend life using medical technologies or not, this decision is often legalized through documents referred to as advance directives. Ditto and Hawkins (2005) document ambivalence toward end of life decisions previously stated when actually faced with looming death. The importance of advance directives such as living wills is great, but Ditto et al. (2005) also suggests one must follow certain steps in order to ensure his or her wishes are met when faced with end of life decisions.

First, an advance directive must be stated in writing, then it must be deemed authentic, does the document authentically represent the individual’s right to choose end of life medical treatment (Ditto et al., 2005)? Thirdly, if a person is designated to make end of life decisions for the individual once incapacitated (deemed a surrogate), the surrogate must be made aware of the advance directive or it is useless (Ditto et al., 2005). Once these barriers are hurtled, the surrogate’s emotional capacity to fulfill an individual’s desire or a doctor’s personal moral obligations could still stand in the way of an advance directive (Ditto, et al., 2005). Thus, even if an individual takes the necessary steps to create advance directives there are still several barriers that may complicate the patient’s wishes (Ditto et al., 2005). Because terminally ill patients are often not coherent enough to make important decisions toward the end of life, it is vitally important for advance directives to be clearly stated and readily available for medical personnel and those responsible for surrogate decision-making.

It is wise to have advance directives in place even for a healthy individual, but why are advance directives more relevant to terminally ill patients than the general public? The answer lies in shortened life expectancy and rapid physical decline among individuals faced with a terminal illness. Often the physical and mental capabilities of a terminally ill individual rapidly decline upon diagnosis. For this reason, it is vitally important for terminally ill individuals to discuss living wills and other advance directives with family and medical personnel as soon as possible upon diagnosis. Despite obvious reasons previously discussed that one should have advance directives in place, less than 25% of Americans have a living will or other type of advance directive in writing (Ditto et al., 2005).

Various Relief Tactics

Terminal illness cuts a difficult path that one must travel despite any wishes to follow another. No one wishes such diseases as Parkinson’s, Lou Gehrig’s, AIDS, or cancer to befall anyone. The truth remains that many individuals are affected day in and day out by the infection of such diseases. What can be done to aid individuals faced with the grave consequences of a terminal illness? How can the quality of life for such individuals improve while awaiting impending death? There are many therapies, support groups, and community agencies to help support individuals with terminal illnesses. Detailed here are three supportive tactics: expressive writing, filial therapy, and hospice care.

Expressive Writing

Terminally ill patients often have trouble sleeping, “Comparisons with the general population indicate that sleep difficulties are approximately two to three time more prevalent in cancer patients than in healthy controls” (Amato, Cohen, Gilani, Hall, Moor, Sterner & Warneke, 2002, p. 618). This is sometimes due to medicines or treatments that must be taken for chronic illness and it is sometimes due to anxiety about one’s impending death (Amato, et al., 2002). Regardless of the reasons one is unable to sleep during terminal illness, a study conducted by Amato, Cohen, Gilani, Hall, Moor, Sterner and Warneke (2002), concludes that the use of Expressive Writing (EW) aids healthy sleep patterns in the terminally ill. In EW, a terminally ill patient writes about his or her experience with cancer including emotions related to the illness (Amato, et al., 2002). These individuals were compared to a control group of terminally ill patients that practiced Neutral Writing (NW) about general health behaviors regarding terminal illness (Amato, et al., 2002). The results concluded individuals in the EW group showed a significant difference in four measures of sleep; total sleep disturbance, Sleep Duration, Sleep Quality, and Daytime Dysfunction (Amato, et al., 2002).

This study is just one proof that humans are emotive creatures that require balance between overly expressing emotions and holding emotions back to an unhealthy level effecting important aspects of life such as sleep patterns. The idea of Expressive Writing supports the biblical principle of expressing one’s self through prayer in an honest and forthright manner. God desires for humans to relay thoughts and emotions about current life experiences to Him through prayer as evidenced in Jesus’ prayer to His Father before His crucifixion. This same principle is also expressed in the psalms that contain the ebb and flow of positive and negative emotional prayers to the Lord. As exemplified in many of the Psalms, burdens were lifted after expressing emotions to the Lord. One such example is when David cried out to the Lord for relief in Psalm 69, “but I am afflicted in pain; may Your salvation, O God, set me securely on high” (New American Standard Bible, 2000). David then continues a few verses after that to call for all the earth to praise the Lord. This example supports expressing one’s emotions to aid in the lifting of life’s burdens and improving psychological health just as in the case of Expressive Writing aiding in healthy sleep patterns.

Filial Therapy

While Expressive Writing can improve the quality of life for many adults facing an impending death due to terminal illness, there are also techniques in helping the parents of seriously ill children learn to cope with life despite illness. Having a terminal ill child places great stress on the life of parents. In addition to the emotional stress that results from knowing a child is facing death, one must also consider a parent’s strong desire to help a child adjust to society despite an illness. Children diagnosed with a serious illness have more difficulties adapting to the world around them, “chronically ill children have an increased risk for developing anxiety and depressive symptoms, as well as general behavioral and adjustment difficulties” (Joiner, Landreth, Solt, & Tew 2002, p. 81).

One technique designed to help parents deal with the emotional stress of an ill children that of filial therapy. Filial therapy allows parents to engage in different types of play therapy with his or her child (Joiner et al., 2002). In a study conducted by Joiner, Landreth, Solt and Tew (2002), filial therapy was examined to be an effective tool in helping parents manage overall emotional stress levels in relation to the illness of a child. It is logical to conclude that as a result of lowered emotional stress levels through filial therapy, a parent is likely to be more attentive to the needs of the ill child. Because of outlets such as that of filial therapy, a parent is able to contribute higher levels of emotional strength to the social adjustment of an ill child.

Hospice Care and Volunteers

Many therapies and techniques require great emotional and physical strength from those inflicted with terminal illness and the families affected by an individual’s diagnosis. However, entities such as hospice medical care and hospice volunteers offer support beyond that of the immediate family. Hospice care not only provides practical support for terminally ill patients, but also emotional, psychological, and often spiritual support as well. While some hospice care is provided in facilities designed for inpatient hospice care, there is also a facet of hospice care that provides support in the homes of the terminally ill. Hospices and hospice agencies are staffed with doctors, nurses and other medical personnel to provide physical comfort to patients during a terminal illness. These agencies also employee social workers, chaplains, and provide volunteers as well.

Volunteers play an important role in the functioning of hospice care. Volunteers are available to families facing the death of a loved one for various relief tasks such as household chores, reading to the terminally ill and sitting with a terminal patient while the primary caretaker attends to duties not otherwise manageable. Some hospice volunteers are also trained to provide additional emotional support to individuals and families facing imminent death. According to a study conducted by Herbst-Damm and Kulik (2005), the involvement of hospice volunteers play a role in the survival times of individuals diagnosed with a terminal illness. Herbst-Damm et al. (2005) studied the effects of volunteer support on individuals with a prognosis of six months or less to live. Hospice volunteers present in the homes of dying patients proved to be a factor in the longevity of terminal patients. Individuals and families that accepted hospice volunteers extended survival times of the terminal patient by an average of 80 days (Herbst-Damm et al., 2005). This is a remarkable conclusion that should encourage many more individuals towards involvement in agencies providing hospice care in communities around the country.

Conclusion

Future Directions

The diagnosis of a terminal illness affects the lives of many individuals day in and day out. The physical restraints of such an illness are undeniable, but the emotional, mental and psychological changes that take place upon a diagnosis of terminal illness loom as well. No area of one’s life is untouched by the effects of a terminal diagnosis. Employment must be reconsidered, the family structure is shaken, individuals must consider end of life decisions (perhaps for the first time), and techniques to help cope with a new way of life must be introduced. Realizing these topics are just a few of the many areas touched by the new of a terminal illness, it is important to challenge further research in each of these areas.

In the area of work, it is interesting to note the benefits of working despite the infliction of a terminal illness. The intrinsic motivations noted that urge people to continue working pose further research questions. If given the opportunity to invest in future generations in ways other than career, would terminally ill individuals choose to do so? Perhaps community organizations should offer activities for terminally ill patients to give back to the local community through investing time in other’s lives.

As if the family structure were not complicated enough in today’s society, the diagnosis of a terminal illness complicates this delicate structure even more. The strain placed on every member of a family involved with a terminal illness is draining in all areas of life: physically, emotionally, mentally and psychologically. Determining the next course of research involving the family structure and terminal illness should involve family therapy revolving around the terminal illness and its many effects. Expressive Writing and filial therapy seem to have benefits for improving the quality of life for those affected by a terminal illness. It is important to acknowledge the benefits of the therapies previously discussed while also researching new ways to help individuals and families cope with a terminal diagnosis. Research is slim in the area of whole-family support during such difficult times. Suffering family members are often overlooked when the physical pain of the diagnosed individual is evident. Further research on the dynamics of family life during a terminal illness would help establish coping strategies. It would then be beneficial to implement the identified coping strategies. The available training for these coping strategies could then be publicized through oncologists’ offices and terminal illness organizations.

While research regarding euthanasia and physicians assisted suicide is not lacking, it is an interesting fact that much of the debate centers on physical pain. As noted earlier, psychological and emotional factors seem to be greater determinates as to whether either of these methods are actually used. It stands to question whether proponents of legalizing such acts are advocating for the reduction of pain for loved ones or the reduction of the length of time one must see a loved one suffering. Perhaps, it is the psychological and emotional factors of those advocating for legalization of euthanasia that fuel the passion. Physical deterioration is clear in those suffering from a terminal illness, but one must also consider the emotional and psychological processes involved before advocating for euthanasia or physician assisted suicide. It would be beneficial to see more research reflecting the emotional and psychological processes supporting or rejecting euthanasia and physician assisted suicide in terminally ill individuals.

Another aspect gaining consideration is that of advance directives as discussed previously. Advance directives have obvious benefits in the life of an individual facing a terminal illness, but more individuals must begin using them. With the benefit of advances directives, families carry less of a burden in end of life decisions. To prevent advance directives from being ignored, it may be helpful for health care professionals to advocate for a clear definition and process to place advance directives in writing. Family members should be informed of the location of such advance directives as living wills and have access to them.

Boston Counseling Implications

It is important that counselors gain knowledge in the area of dealing with terminally ill patients. While not all clients are affected by a terminal illness, there is a great possibility that one of its many facets touches some. Counselors must look beyond the physical effects of a terminal disease and consider the emotional, mental, psychological and spiritual effects of such a diagnosis on an individual and the family involved.

The aspects of a terminal illness detailed here can be practically applied to the Boston Counseling office in several ways. What if a client asked whether or not to continue working in the face of impending death? What if a client had a spouse, child or loved one with a terminal illness complicating his or her existing severe emotional problems? What is a client posed the idea of hastening impending death? These are all relevant questions likely to occur in the Boston Counseling office upon the terminal diagnosis of one’s self or a family member. One must be well informed of the looming emotional, mental, psychological and spiritual effects of terminal illness in order to provide adequate counsel to individuals faced with a terminal illness.

References

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Amato, R., Cohen, L., Gilani, Z., Hall, M., Moor, C., Sterner, J., & Warneke, C. (2002). A pilot study of the effects of expressive writing on psychological and behavioral adjustment in patients enrolled in a phase II trial of vaccine therapy for metastatic renal cell carcinoma. Health Psychology, 21(6), 615-619. Retrieved May 5, 2008, from PsychINFO database.

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Summary and Abstract

An estimated 26.2 % of Americans suffer from a diagnosable mental disorder in a given year. Approximately 30% of adults and 17% of the children and adolescents in the United States display serious emotional psychological disturbance. The field of behavioral genetics studies the effects of genetics on behavior and psychological characteristics. This paper examines research that supports the author’s contention that the etiology of most mental disabilities is genetically influenced. The author researches forms of psychopathology of various disabilities and their etiology that supports her contention. Disabilities examined occur across the developmental stages of the life span. The author seeks to answer the question, “Nature or nurture?” Findings reveal that nature predisposes and nurture determines manifestation and severity of the disability.

Introduction

The author chose to research mental disability as it occurs throughout life stages because of the prevalence of mental illness in her family, and her life’s dedication to the vocation of mental health. The author’s great-grandfather suffered depression and committed suicide; grandfather endured depression and developed an addiction to alcohol; mother endured depression and developed dementia; the author (great-granddaughter) has a diagnosis of situational depression, and her children have been diagnosed with depression. This generational history spans more than 120 years and five generations. The author precludes that a causal factor for depression and other mental disabilities is genetics.

The author received certification as a cross-categorical special education teacher and taught children with various mental and developmental disabilities. She specialized in teaching children with autistic disorder; and worked as the primary therapist and case manager with persons dually diagnosed with mental illness and developmental disabilities. Society stigmatizes individuals who carry a mental disability label. The author supported the students and clients in their right for self -direction of their lives.

A mental illness is any disease or condition affecting the brain that influences the way one thinks, feels, behaves and/or relates to others and to the environment. A person with an untreated mental illness often is unable to cope with life’s daily routines and demands.

It is estimated that of 100 adults: 13 have a significant anxiety disorder, six suffer from serious depression, five display a personality disorder involving maladaptive tendencies that cause distress or impaired functioning, one is schizophrenic, one suffers from Alzheimer’s disease, and 10 abuse drugs or alcohol (Chiu, Demler, Kessler & Walters, 2005). This data suggests that psychological and behavioral disorders are a major problem in our society. Individuals with mental illness are a part of the norm due to its prevalence.

This paper discusses the disorders that significantly affect a given life stage. Those examined are: anxiety, cognitive, communication, disruptive behavior, eating, mood and psychosis. It gives a general description of several of the most prevalent mental disabilities; organizes the disabilities by onset as it relates to stages of development over the life span; and examines research that discusses causal factors for each disability. The author attempts to answer the question, “nature or nurture?” The field of behavioral genetics revealed surprising answers.

Mental Disability across the Life Span

Prenatal/ infancy/ toddlerhood (conception to three years)

Psychosis

Schizophrenia. Schizophrenia is categorized as psychosis. A chronic neurological disorder, it affects 1% of the general population. The onset of behavioral characteristics occurs in early adulthood around age 25. The author chose to discuss in the prenatal stage of development due to studies indicating etiology. Epidemiological studies indicate that viral infections during the second trimester of gestation increase the likelihood that the offspring will go on to develop schizophrenia in adulthood (Wolff & Bilkey, 2008).

It appears likely that multiple genes are involved in creating a predisposition to develop the disorder. In addition, factors such as prenatal difficulties like intrauterine starvation or viral infections, perinatal complications, and various nonspecific stressors, seem to influence the development of schizophrenia. However, it is not yet understood how the genetic predisposition is transmitted, and it cannot yet be accurately predicted whether a given person will or will not develop the disorder (Wolff & Bilkey, 2008).

Several regions of the human genome were investigated to identify genes that may confer susceptibility for schizophrenia. The strongest evidence to date leads to chromosomes 13 and 6 but remains unconfirmed. Identification of specific genes involved in the development of schizophrenia will provide important clues into what goes wrong in the brain to produce and sustain the illness and will guide the development of new and better treatments. Neurotransmitters, substances that allow communication between nerve cells, have long been thought to be involved in the development of schizophrenia. It is likely, although not yet certain, that the disorder is associated with some imbalance of the complex, interrelated chemical systems of the brain, perhaps involving the neurotransmitters dopamine and glutamate ( Wolff & Bilkey, 2008) .

Many studies of people with schizophrenia have found abnormalities in brain structure, enlargement of the fluid-filled cavities, called the ventricles, in the interior of the brain, and decreased size of certain brain regions for example, or function, decreased metabolic activity in certain brain regions. These abnormalities are quite subtle and are not characteristic of all people with schizophrenia, nor do they occur only in individuals with this illness (Wolff & Bilkey, 2008).

Microscopic studies of brain tissue after death have also shown small changes in distribution or number of brain cells in people with schizophrenia. It showed that many of these changes are present before an individual becomes ill, and schizophrenia may be, in part, a disorder in development of the brain. Developmental neurobiologists funded by the National Institute of Mental Health (NIMH) have found that schizophrenia may be a developmental disorder resulting when neurons form inappropriate connections during fetal development. These errors may lie dormant until puberty, when changes in the brain that occur normally during this critical stage of maturation interact adversely with the faulty connections (Wolff & Bilkey, 2008).

This research has spurred efforts to identify prenatal factors that may have some bearing on the apparent developmental abnormality. In other studies, investigators using brain-imaging techniques have found evidence of early biochemical changes that may precede the onset of disease symptoms, prompting examination of the neural circuits that are most likely to be involved in producing those symptoms. Meanwhile, scientists working at the molecular level are exploring the genetic basis for abnormalities in brain development and in the neurotransmitter systems regulating brain function (Wolff & Bilkey, 2008).

Wolff and Bilkey (2008) hypothesized that an increase in proinflammatory cytokines in response to infection alters fetal neurodevelopment in a way that increases vulnerability to the disease. They used an animal model to induce maternal immune activation (MIA) during mid gestation. Offspring of the animals showed normal behavior as juveniles and behavioral features of schizophrenia in adulthood.

Communication

Autism. Autism is a developmental disorder characterized by impairments in language and social interaction and by excessively repetitive and ritualistic behaviors. Onset is before the age of three, and though severity of symptoms may change over time, they typically persist in some form throughout life. A recent study reported the prevalence of autism in 3-10 year-olds to be about 3.4 cases per 1000 children. Autism is part of a group of disorders called autism spectrum disorders (ASDs), also known as pervasive developmental disorders. ASDs range in severity, with autism being the most debilitating form while other disorders, such as Asperger syndrome, produce milder symptoms (Boyle, Doernberg, Karapurkar, Murphy, Rice & Yeargin-Allsopp, 2003).

Estimating the prevalence of Autism is difficult and controversial due to differences in the ways cases are identified and defined, differences in study methods, and changes in diagnostic criteria. Autism is about four times more common in boys than girls. Girls with the disorder, however, tend to have more severe symptoms and greater cognitive impairment. (Boyle et al, 2003).

Abraham and Geshwind (2008) examined autism for genetic linkage, genotyping 350 markers in 75 autism affected sibling pair families. They found strengthened evidence for linkage of autism to chromosomes 1q, 13p, 16q, and Xq, and diminished evidence for linkage to 7q and 13q. Family and twin studies suggest that autism arises from interactions of multiple genetic variants, and that different combinations of variants may be causative in different groups of people. This study suggests genetics as a causal factor for Autism disorder.

Preschool/Middle childhood (3-12 years)

Disruptive Behaviors Disorder

Attention Deficit Hyperactivity Disorder. Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common mental disorders in children and adolescents. ADHD usually becomes evident in preschool or early elementary years. The median age of onset of ADHD is seven years, although the disorder can persist into adolescence and occasionally into adulthood. It is hard for these children to control their behavior and/or pay attention. It is estimated that between 3 and 5 percent of children have ADHD, or approximately 2 million children in the United States. This means that in a classroom of 25 to 30 children, it is likely that at least one will have ADHD (Chiu et al, 2005).

The principal characteristics of ADHD are inattention, hyperactivity, and impulsivity. These symptoms appear early in a child’s life. Because many normal children may have these symptoms, but at a low level, or the symptoms may be caused by another disorder, it is important that the child receive a thorough examination and appropriate diagnosis by a well-qualified professional. A child who “can’t sit still” or is otherwise disruptive will be noticeable in school, but the inattentive daydreamer may be overlooked. The impulsive child who acts before thinking may be considered a “discipline problem,” while the passive child may be viewed as unmotivated. Yet both may have attention deficit disorders (Chiu et al, 2005).

Hay, Martin, and Piek (2006) researched the role that genes play in the susceptibility to ADHD. Family, twin, and adoption studies provide compelling evidence that genes play a strong role in one’s susceptibility to ADHD. Many gene studies of ADHD have produced evidence implicating several genes in the etiology of the disorder. These studies are also consistent with the idea that the genetic vulnerability to ADHD is mediated by many genes of small effects. Results of Behavioral genetic and molecular genetic studies have converged to suggest that both genetic and nongenetic factors contribute to the development of attention deficit hyperactivity disorder.

McGiffen, Plomin, Riley (2001) say ADHD is among the most recognized genetic-based disorders in psychiatry. In their studies families, they found that relatives of ADHD children are at high risk for ADHD, comorbid psychiatric disorders, school failure, learning disability, and impairments in intellectual functioning. In later life stages, ADHD may comorbid with depression, bipolar, and substance use.

Additional lines of evidence from twin, adoption, and segregation analysis studies suggest that the familial aggregation of ADHD has a substantial genetic component. Their results suggest that the heritability of ADHD ranges from 0.88 to 1.0, suggesting a substantial role for genetic factors in its etiology (Hay et al, 2006).

Adolescence/young adulthood (12-20 years)

Eating disorders.

Eating Disorders are also a type of mental illness. Females are much more likely than males to develop an eating disorder. Only an estimated 5-15% of people with anorexia or bulimia and an estimated 35% of those with binge-eating disorder are male. The three main types of eating disorders are anorexia nervosa (AN), bulimia nervosa, and binge-eating disorder (BED). In their lifetime, an estimated 0.5 to 3.7% of females suffer from anorexia, and an estimated 1.1 to 4.2% suffers from bulimia. Individuals with ED have a complex of puzzling symptoms, for which there has been no neurobiological explanation (Walter, 2008).

BED. Community surveys have estimated that between 2 percent and 5 percent of Americans experience binge-eating disorder in a 6-month period. A family history study design (Lilenarchian, Ringham, Kalarchian & Marcus, 2008) was used to examine patterns of comorbidity and family psychopathology in women with and without BED and to assess whether any other forms of psychopathology may share a common etiology with BED. Elevated lifetime rates of major depressive disorder, dysthymic disorder, any depressive disorder, social phobia, and any anxiety disorder were found among women with BED compared with control women without BED.

Upon examination of psychopathology among first-degree relatives based upon reports by study participants serving as informants. Lienarchian et al found elevated lifetime rates of mood disorders (bipolar disorder, any depressive disorder), nearly all anxiety disorders (social phobia, specific phobia, obsessive-compulsive disorder, panic disorder, agoraphobia, any anxiety disorder), and eating disorders (any eating disorder) among the relatives of women with BED compared with the relatives of control women. All disorders that occurred at elevated rates in relatives followed a pattern of independent transmission from BED. The elevated lifetime rates of BED and any eating disorder reported among the first-degree relatives of women with BED compared with the first-degree relatives of women without BED are in accord with findings from other researchers.

Berry, Bulik, Crow & Hudson (2006) in a similar study of obese individuals, found that BED aggregated strongly in families, independent of obesity. The findings of these studies suggest that BED is familial. Although biological and other factors may be related, genetics may be a causal factor for BED.

Anorexia and Bulimia Nervosa. Anorexia nervosa (AN) and bulimia nervosa (BN) are related disorders of unknown etiology that most commonly begin during adolescence in women. The mortality rate among people with anorexia estimated at 0.56 % per year, or approximately 5.6 % per decade, which is about 12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population (US Census, 2005).

AN and BN have unique and puzzling symptoms, such as restricted eating or binge-purge behaviors, body image distortions, denial of emaciation (extreme loss of flesh), and resistance to treatment. These are often chronic and relapsing disorders. AN has the highest death rate of any psychiatric disorder. The lack of understanding of the pathogenesis of this illness has hindered the development of effective interventions, particularly for AN (Walter, 2008).

Symptoms are frequently chronic and often disabling conditions that are characterized by

aberrant patterns of feeding behavior and weight regulation, and deviant attitudes and perceptions toward body weight and shape. AN, fear of weight gain and unrelenting obsession with fatness, even in the face of increasing cachexia (loss of weight, muscle, and appetite), accounts for extreme medical and psychological morbidity, and standardized mortality rates exceeding those of all other psychiatric disorders. BN usually emerges after a period of food restriction, which may or may not have been associated with weight loss. Binge eating is followed by either self-induced vomiting, or by some other means of compensation for the excess of food ingested (Walter, 2008).

Walter (2008) reviewed findings in brain chemistry and neuroimaging that shed new light on understanding the psychopathology of these disorders. The relationship of insular disturbance and interoceptive awareness in individuals with AN was examined. The insular is thought to play an important role in processing interoceptive information, which can be defined as the sense of the physiological condition of the entire body.

Aside from taste, interoceptive information includes sensations such as temperature, touch, muscular sensations, and hunger. The role of the insular is focused on how stimuli might affect the body state. Interoception is critical for self-awareness because it provides the link between cognitive and affective processes and the current body state. Many of the symptoms commonly found in AN, such as distorted body image, lack of recognition of the symptoms of malnutrition, could be related to disturbed interoceptive awareness. In support of this possibility, only the controls showed positive relationship between self-ratings of pleasantness and the intensity of the signal for sugar in the insular (Walter, 2008).

In addition, studies have consistently found that AN and BN individuals have elevated pain thresholds and is potentially a marker of altered interoceptive awareness. Those with AN fail to accurately recognize and incorporate affective and social stimuli in the environment. Individuals with AN have enhanced ability to pay attention to detail or use a logical/analytic approach, but exhibit worse performance with global strategies (Walter, 2008).

Brain imaging studies show that disturbances of 5-HT function occur when people are ill, and persist after recovery from AN and BN. It is possible that a trait related disturbance of 5-HT neuronal modulation predates the onset of AN and contributes to premorbid symptoms of anxiety, obsessions, and inhibition. This dysphoric temperament may involve dysregulation of emotional and reward pathways, which also mediate aspects of feeding, thus making these individuals vulnerable to disturbed appetitive behaviors (Walter, 2008).

In the treatment of AN, restricting food intake may become powerfully reinforcing because it provides a temporary respite from dysphoric mood. Several factors may act on these vulnerabilities to cause AN to start in adolescence. First, puberty-related female gonadal steroids ( age-related changes) may exacerbate 5-HT dysregulation. Second, stress and/or cultural and societal pressures may contribute by increasing anxious and obsessional temperament. Individuals with AN may discover that reduced

dietary intake, by reducing plasma tryptophan availability, is a means by which they can modulate brain 5-HT functional activity and anxious mood. People with AN enter a vicious cycle which accounts for the chronicity of this disorder because caloric restriction results in a brief respite from dysphoric mood. However, malnutrition and weight loss, in turn, produce alterations in many neuropeptides and monoamine function, perhaps in the service of conserving energy, but which also exaggerates dysphoric mood (Walter, 2008).

Anxiety Disorders

The etiology of child and adolescent anxiety may be of a biological and/or learned nature. Indeed, researchers propose that anxiety arises from a complex interaction of specific characteristics related to the child (e.g., biological, psychological, and genetic factors) and his or her environment (e.g., conditioning, observational learning, family relations, traumatic events (Stickle & Weems, 2005).

Within a biological model of etiology, researchers have investigated genetic influences as well as neurobiological structures and circuits. A recent meta-analysis of the genetic epidemiology of anxiety disorders demonstrated that PD, phobias, OCD, and GAD aggregate in families and concluded that genetic factors have a moderate influence on the

development of anxiety disorders. Research suggests that genetic factors may help us understand why certain individuals exposed to similar experiences have different responses and outcomes concerning the development of pathological anxiety (Stickle & Weems, 2005).

Research aimed at identifying specific brain areas and circuits underlying anxiety disorders has provided support for neurobiological influences in anxiety. The most support for neuroanatomical influences has come from research investigating the amygdala’s role in fear conditioning. Research in this area has implicated the amygdala in the pathophysiology of anxiety disorders (Rauch, Shin, & Wright, 2003).

Neurochemical factors have also been implicated in the development of anxiety symptoms. Abnormal function of serotonin, norepinephrine, dopamine, and γ-aminobutyric acid systems as well as abnormal chemoreceptor reactivity have all been implicated in anxiety ( Rauch et al, 2003).

Obsessive-Compulsive Disorder. Obsessive-Compulsive Disorder, also known as, OCD, is another type of anxiety disorder. Approximately 2.2 million American adults, 18 and older, have OCD (Chiu, 2005). The first symptoms of OCD often begin during childhood or adolescence, however, the median age of onset is 19.5. Obsessive-Compulsive Disorder (OCD) is an anxiety disorder where a person has recurrent and unwanted ideas or impulses (called obsessions) and an urge or compulsion to do something to relieve the discomfort caused by the obsession.

The obsessive thoughts range from the idea of losing control, to themes surrounding religion or keeping things or parts of one’s body clean all the time. Repetitive behaviors such as hand washing, counting, checking, or cleaning are often performed with the hope of preventing obsessive thoughts or making them go away. Performing these so-called “rituals,” however, provides only temporary relief, and not performing them markedly increases anxiety. They may be obsessed with germs or dirt, and wash their hands repeatedly. They may be filled with doubt and feel the need to check things repeatedly (Chiu et al, 2005).

Compulsions are behaviors that help reduce the anxiety surrounding the obsessions. Most people (90%) who have OCD have both obsessions and compulsions. The thoughts and behaviors a person with OCD has are senseless, repetitive, distressing, and sometimes harmful, but they are also difficult to overcome. OCD is more common than schizophrenia, bipolar disorder, or panic disorder. Yet, it is still commonly overlooked by mental health professionals, mental health advocacy groups, and people who themselves have the problem. Many people still carry the misperception that they somehow caused themselves to have these compulsive behaviors and obsessive thoughts. (National Institute of Mental Health (NIMH), 2001).

OCD is likely the cause of a number of intertwined and complex factors which include genetics, biology, personality development, and how a person learns to react to the environment around them. What scientists today do know is that it is not a sign of a character flaw or a personal weakness. OCD is a serious mental disorder, which is more treatable than ever. Without the appropriate treatment, it affects a person’s ability to function in everyday activities, one’s work, one’s family, and one’s social life (NIMH, 2001).

Other compulsive behaviors include counting (often while performing another compulsive action such as hand washing), repeating, hoarding, and endlessly rearranging objects in an effort to keep them in precise alignment with each other. Cognitive problems, such as mentally repeating phrases, list making, or checking, are also common (NIMH, 2001).

An epidemiological study of OCD (Reiger, Robins, 1991) revealed that 84% of youth diagnosed with OCD had comorbid disorders, including major depression (62%), social phobia (38%), alcohol dependence (24%), and dysthymia, (22%), The most common comorbid diagnoses include other anxiety disorders and depressive disorders. Additionally, children with anxiety disorders frequently experience other psychiatric conditions, including attention-deficit/hyperactivity disorder and disruptive disorders. etiology of child and adolescent anxiety may be of a biological and/or learned nature.

Researchers (Stickle and Weems, 2005) have investigated genetic influences as well as neurobiological structures and circuits. A recent meta-analysis of the genetic epidemiology of anxiety disorders demonstrated that PD, phobias, OCD, and GAD aggregate in families and concluded that genetic factors have a moderate influence on the development of anxiety disorders. Researchers have suggested that, although clearly not the only contributing influences, genetic factors may help us understand why certain individuals exposed to similar experiences have different responses and outcomes concerning the development of pathological anxiety.

Young adulthood/middle adulthood (20-65 years)

Anxiety disorders

Post traumatic stress disorder. Post-Traumatic Stress Disorder (PTSD) is an anxiety disorder that affects approximately 3.6% of U.S. adults aged 18 to 54 (5.2 million people) each year. An estimated 7.8 percent of Americans will experience PTSD at some point in their lives, with women (10.4%) twice as likely as men (5%) to develop PTSD (Chui et al, 2005).

Posttraumatic Stress Disorder, or PTSD, is a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. Fairbank, Hough, Jordan, Kulka, Marmar, Schlemager & Weiss ( 2005) report that the traumatic events most often associated with PTSD for men are rape, combat exposure, childhood neglect, and childhood physical abuse. The most traumatic events for women are rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse. PTSD can develop at any age. It can develop in childhood but research shows that the median age of onset is 23 years of age.

About 30% of Vietnam veterans experience PTSD at some point after the war. This disorder also frequently occurs after violent personal assaults such as rape, mugging, or domestic violence; terrorism; natural or human-caused disasters; and accidents. Most survivors of trauma return to normal given a little time. However, some people will have stress reactions that do not go away on their own, or may even get worse over time. These individuals may develop PTSD. People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged, and these symptoms can be severe enough and last long enough to significantly impair the person’s daily life (Fairbank et al, 2005).

PTSD is marked by clear biological changes as well as psychological symptoms. PTSD is complicated by the fact that it frequently occurs in conjunction with related disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health. The disorder is also associated with impairment of the person’s ability to function in social or family life, including occupational instability, marital problems and divorces, family discord, and difficulties in parenting (Fairbank et al, 2005).

About 30 percent of the men and women who have spent time in war zones experience PTSD. An additional 20 to 25 percent have had partial PTSD at some point in their lives. More than half of all male Vietnam veterans and almost half of all female Vietnam veterans have experienced “clinically serious stress reaction symptoms. PTSD has also been detected among veterans of the Gulf War, with some estimates running as high as 8 percent. Careful research and documentation of PTSD began in earnest after the Vietnam War. The National Vietnam Veterans Readjustment Study estimated in 1988 that the prevalence of PTSD in that group was 15.2% at that time and that 30% had experienced the disorder at some point since returning from Vietnam (Fairbank et al, 2005).

PTSD has subsequently been observed in all veteran populations that have been studied, including World War II, Korean conflict, and Persian Gulf populations, and in United Nations peacekeeping forces deployed to other war zones around the world. There are substantially similar findings of PTSD in military veterans in other countries. PTSD is not only a problem for veterans, however. Although there are unique cultural- and gender-based aspects of the disorder, it occurs in men and women, adults and children, Western and non-Western cultural groups, and all socioeconomic strata. A national study of American civilians conducted in 1995 estimated that the lifetime prevalence of PTSD was 5% in men and 10% in women. A revision of this study done in 2005, reports that PTSD occurs in about 8% of all Americans (Fairbank et al, 2005).

PTSD is associated with a number of distinctive neurobiological and physiological changes. PTSD may be associated with stable neurobiological alterations in both the central and autonomic nervous systems, such as altered brainwave activity, decreased volume of the hippocampus, and abnormal activation of the amygdala. Both the hippocampus and the amygdala are involved in the processing and integration of memory. The amygdala has also been found to be involved in coordinating the body’s fear response. Psycho-physiological alterations associated with PTSD include hyper-arousal of the sympathetic nervous system, increased sensitivity of the startle reflex, and sleep abnormalities (Bonomo, Cella, Gagliano, Galimberti, Giunta, Guaita, Muller, and Rigamonti, 2005).

People with PTSD tend to have abnormal levels of key hormones involved in the body’s response to stress. Thyroid function also seems to be enhanced in people with PTSD. Some studies have shown that cortisol levels in those with PTSD are lower than normal and epinephrine and norepinephrine levels are higher than normal. People with PTSD also continue to produce higher than normal levels of natural opiates after the trauma has passed. An important finding is that the neuro-hormonal changes seen in PTSD are distinct from, and actually opposite to, those seen in major depression. The distinctive profile associated with PTSD is also seen in individuals who have both PTSD and depression (Bonomo et al, 2005).

Mood disorders

There is wide array of mental illnesses. Depression, bipolar disorder, schizophrenia and obsessive-compulsive disorder are all mood disorders. They are among the U.S.’s top 10 leading causes of disability. Approximately 20.9 million American adults, or about 9.5 % of the U.S. population age 18 and older, in a given year, have a mood disorder. The median age of onset is 30 years. Mood disorders include major depressive disorder, dysthymic disorder, and bipolar disorder (Chiu et al, 2005). Depression. Major Depressive Disorder is a type of mood disorder. It is the leading cause of disability in the U.S. for ages 15-44. Depressive disorders often co-occur with anxiety disorders and substance abuse. Major depressive disorder affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year. While major depressive disorder can develop at any age, the median age at onset is 32 and is more prevalent in women than in men. More than twice as many women (6.7 million) as men (3.2 million) suffer from major depressive disorder each year. All ethnic, racial and socioeconomic groups suffer from depression. About three-fourths of those who experience a first episode of depression will have at least one other episode in their lives. Some individuals may have several episodes in the course of a year (Kessler, Berglund, Demler, Jin, Koretz, Merikangas, Rush, Walters, & Wang, 2005).

The symptoms of major depression characteristically represent a significant change from how a person functioned before the illness.. Social, occupational, educational or other important functioning must also be negatively impaired by the change in mood. A person who has missed work or school because of their depression for instance, or has stopped attending classes or usual social engagements altogether may suffer from major depressive disorder. A depressed mood caused by substances, such as drugs, alcohol, or medications, is not considered a major depressive disorder, nor is one which is caused by a general medical conditioner (Kessler et al, 2005).

Typically the diagnosis of major depression is also not made if the person is grieving over a significant loss in their lives. Symptoms also include pronounced changes in sleep, appetite, and energy, difficulty thinking, concentrating, and remembering, physical slowing or agitation, lack of interest in or pleasure from activities that were once enjoyed, feelings of guilt, worthlessness, hopelessness, and emptiness, and persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain (Kessler et al, 2005).  There is no single cause of major depression. Psychological, biological, and environmental factors may all contribute to its development. Whatever the specific causes of depression, scientific research has firmly established that major depression is a biological brain disorder. Norepinephrine, serotonin, and dopamine are three neurotransmitters (chemical messengers that transmit electrical signals between brain cells) thought to be involved with major depression. Scientists believe that if there is a chemical imbalance in these neurotransmitters, then clinical states of depression result. Antidepressant medications work by increasing the availability of neurotransmitters or by changing the sensitivity of the receptors for these chemical messengers (Kessler et al, 2005).

Scientists have also found evidence of a genetic predisposition to major depression. There is an increased risk for developing depression when there is a family history of the illness. Not everyone with a genetic predisposition develops depression, but some people probably have a biological make-up that leaves them particularly vulnerable to developing depression. Life events, such as the death of a loved one, a major loss or change, chronic stress, and alcohol and drug abuse, may trigger episodes of depression (Kessler et al, 2005).

Bipolar disorder. Bipolar disorder causes dramatic mood swings, from overly “high” and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression (Berglun, Demler, Jin, Kessler & Walters, 2005).

Signs and symptoms of mania, or a manic episode, include increased energy, activity, and restlessness, Excessively “high,” overly good, euphoric mood, Extreme irritability, Racing thoughts and talking very fast, jumping from one idea to another, Distractibility, can’t concentrate well, Little sleep needed, Unrealistic beliefs in one’s abilities and powers, Poor judgment, Spending sprees, A lasting period of behavior that is different from usual, Increased sexual drive, Abuse of drugs, particularly cocaine, alcohol, and sleeping medications, Provocative, intrusive, or aggressive behavior, and/or Denial that there is anything wrong (Berglun, et al, 2005).

Scientists are learning about the possible causes of bipolar disorder through several kinds of studies. Most scientists now agree that there is no single cause for bipolar disorder, rather, many factors act together to produce the illness. Because bipolar disorder tends to run in families, researchers have been searching for specific genes passed down through generations that may increase a person’s chance of developing the illness (Berglun et al, 2005).

Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. However, if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling (Berglun et al, 2005).

In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene. It appears likely that many different genes act together, and in combination with other factors of the person or the person’s environment, to cause bipolar disorder. Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder and other mental illnesses. New brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine its structure and activity, without the need for surgery or other invasive procedures (Berglum et al, 2005).

These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (MRI). There is evidence from imaging studies that the brains of people with bipolar disorder may differ from the brains of healthy individuals (Berglum et al, 2005).

Late adulthood (65 years to death)

Anxiety

PTSD. PTSD can have its onset in late adulthood. Some older veterans, who report a lifetime of only mild symptoms, experience significant increases in symptoms following retirement, severe medical illness in themselves or their spouses, or reminders of their military service such as reunions or media broadcasts of the anniversaries of war events. Those who experience greater stressor magnitude and intensity. Those with prior vulnerability factors such as genetics, early age of onset and longer-lasting childhood trauma, lack of functional social support, and concurrent stressful life events, and those with a social environment that produces shame, guilt, stigmatization, or self-hatred are most likely to develop posttraumatic stress disorder (Fairbank et al, 2005).

Cognitive disorder

Alzheimer’s disease. Alzheimer’s (AD) disease affects an estimated 4.5 million Americans. The number of Americans with AD has more than doubled since 1980. AD is the most common cause of dementia among people age 65 and older. Increasing age is the greatest risk factor for Alzheimer’s. In most people with AD, symptoms first appear after age 65. One in 10 individuals over 65 and nearly half of those over 85 are affected. Rare, inherited forms of Alzheimer’s disease can strike individuals as early as their 30s and 40s. From the time of diagnosis, people with AD survive about half as long as those of similar age without dementia (National Institute on Aging, 2005).

Incidence and prevalence of AD is higher in postmenopausal women than in age-matched men. Since at menopause the endocrine system and other biological paradigms undergo substantial changes. Studies show that the balance between some biological parameters related to estrogen and others related to glucocorticoid (naturally produced steroid hormones) vary during lifespan in either sex in either normalcy or neurodegenerative disorders (National Institute on Aging, 2005).

Conclusion

The field of behavioral genetics has made great strides in cracking the genetic code as it pertains to psychological disorders. Behavioral genetics is the study of the effects of heredity on behavior and psychological characteristics. The role of genetics serves to produce a tendency towards the potential to develop a specific disorder. Three other factors increase the likelihood for the development of the disability. They are structural abnormalities in the brain, biochemical imbalance, and environmental influences of parenting and other socializing factors.

There are inherent barriers to the research efforts of behavioral genetics. Often, persons with mental disabilities are nonadherent to medications. Outcomes of samples are affected by frequent non-compliant medication behavior. Secondly, disabilities tend to comorbid with other disabilities, complicating research outcomes for a specific disability. Finally, the impact of all etiological factors vary significantly on a continuum from weak to severe and change over the developmental life span. As the child ages, the environmental influence of the parent lessens and genetic traits manifest.

Epidemiological studies of mental health problems in the first years of life are few. More studies are needed to examine infancy predictors of psychopathology in the first years of life.

The mental health of young children is affected by parents’ negative expectations of the child because of an unwanted pregnancy. This behavior toward the child as recorded in the first months of the child’s life becomes significant predictors of relationship disturbances at 1(1/2) years.

The lack of understanding of the pathogenesis of many disabilities has hindered the development of effective interventions. Particularly amongst illnesses that need effective interventions are AN and Bipolar disorder. AN has the highest death rate of any psychiatric disorder. Bipolar has a high rate of suicide. Ongoing research is needed to develop these interventions.

Dementia is a cognitive neurodegenerative disorder that most fear as they approach late adulthood. Menopausal transition is a critical phase of women’s life where the occurrence of an unfavorable biological milieu would predispose to an increased risk of neurodegeneration, making the incidence of Alzheimer’s disorder much higher in women than women. Research should continue to lessen the incidence and onset of this disorder.

As technological advances continue, researches will continue to identify the biological differences in the brain of individuals with specific mental disability and a “normal” brain. When the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness, and eventually may be able to predict which types of treatment will work most effectively. The author’s belief is that scientist will be able to identify genes and prevent the occurrence of disabilities.

In summary, this paper examined the disorders that significantly affect a given life stage: anxiety, cognitive, communication, disruptive behavior, eating, mood and psychosis. The author gave a general description of several of the most prevalent mental disabilities that occur throughout the life span; organized the disabilities by onset as it relates to stages of development over the life span; and examined research that discussed causes for each disability. The author attempted to answer the question for each disability, “nature or nurture?”

How much of a behavior is due to nature and how much is due to nurture is a challenging question. Nature refers to traits inherited from one’s parents and any factor produced by predetermined genetic information. Nurture refers to the environmental influences that shape behavior. They include biological factors such as a mother’s drug use. Other environmental factors are social such as a parent’s parenting style or socioeconomic circumstances. Although one’s genetic disposition orients toward particular behaviors, those behaviors will not occur without an appropriate environment. The two sides of the nature versus nurture issue are at opposite ends of the continuum. There are no absolutes. The behaviors will always fall somewhere along the continuum based on the circumstantial influences of genetics, biology, brain chemistry, and social environment.

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by Dinah Stacy

Abstract and Summary

Conduct Disorder:
Definition, Statistics, Parental Role and Intervention
Introduction

When asked what developmental stage is diagnosed with conduct disorder the primary answer would be adolescent. However, based on research the greatest damage to society is the result of actions by delinquent adolescents but conduct disorder begins below the age of 7 (Scott, 2007). The researcher hypothesis suggests conduct disorder has a multi-factorial causation which includes biologic, psychosocial and numerous facets of the family unit. The research reveals a negative combination of these factors may predispose young children to exhibit symptoms of conduct disorder. The following questions will hopefully be answered: (1) What causes conduct disorder? (2) Can conduct disorder be prevented or predicted? (3) Does parenting style promote symptoms of conduct disorder? and (4) What are the interventions?

Definition

Conduct disorder is differentiated from other psychiatric disorders diagnosed in children by the following criteria: “persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated” American Psychiatric Association (as cited from Tehama, 2007). According to Sea right et al., (2001) conduct disorder is a psychiatric syndrome occurring in childhood and adolescence which characterized by a longstanding pattern of violations of rules and antisocial behaviors. They interpret conduct disorder as:

Conduct disorder is a common childhood psychiatric problem that has increased incidence in adolescence. The primary diagnostic features of conduct disorder include aggression, theft, vandalism, violation of rules and/or lying. For a diagnosis these behaviors must occur for a least a six-month period.

According to Evans (2003) conduct disorder is a steady pattern of harming others or their property, lying, stealing, or breaking societal rules of behavior. Remote instances of acute behavior, running away, or vandalism is not enough to merit a diagnosis of conduct disorder. Most children exhibit instances of poor judgment and bad behavior at least one time in their childhood. The distinction is children with conduct disorder break the rules over and over again, exhibit aggressive behavior, and show no regard for others. The behavior is not considered conduct disorder until the symptoms are displayed for one year or more. The disturbances in behavior result in significant clinical impairment with social skills, academics and occupational functioning (American Psychiatric Association, 1994).

Clinical Symptoms/Diagnosis

The clinical features of Conduct Disorder are:

· aggression or serious threats of harm to people or animals;

· deliberate property damage or destruction (i.e. fire setting);

· repeated violation of household or school rules, laws or both; and

· persistent lying to avoid consequences or to obtain tangible goods or privileges (Searight et al., 2001).

The American Psychiatric Association (1994) provides further symptoms which support the clinician in diagnosis of conduct disorder. The child will often bully, threaten or intimidate others. They may intentionally set fires with the objective of harming others. The violation of rules would include: (1) often staying out late at night regardless of parental prohibitions which can begin before the age of 13; (2) has run away from home more than two times; and (3) the child is often truant from school which usually begins before the age of 13.

Additional features of conduct disorder include an indifference to the welfare of others and little if any remorse about harming others. Adolescents often verbalize outward remorse to avoid punishment but do not exhibit any guilt. They do not require an objective basis to conclude others are a threat to them. Because of this demeanor they may lash out aggressively without being provoked (Searight et al., 2001).

During normal child development aggression and fighting is pertinent for defensive issues which do not escalate into anti-social behaviors; but, persistent anti-social behavior collectively handicaps during childhood and leads to deprived adjustment during adulthood. The child often endures negative responses by their peers and high levels of disapproval from their parents (Scott et al., 2001).

Worldview

Children who are diagnosed with conduct disorder judge the world as an antagonistic and intimidating place. They may tattle on friends or blame others for the harm they have caused. They have few if any friends because of their limited interpersonal skills. Peers and family members may view them as irritating because of their indifference to their actions. They often have low self-esteem internally but externally they appear tough, cocky or self-assured (Evans, 2003).

Statistics

Conduct disorder has become a major health and social problem; it is the most common psychiatric problem diagnosed among children. Around the world the prevalence of conduct disorder is 5% (Scott, 2007). A study conducted by Sujit et al., (2006) reveals 4.58% of boys and 4.5% of girls are diagnosed with conduct disorder worldwide. In their study of 240 students in four schools in Kanke childhood conduct disorder was found in 73% and in adolescent 27%. Mild conduct disorder was found in 36%, moderate in 64% and severe conduct disorder in none. Lying, bullying and cruelty to animals were the primary symptoms (Sujit, 2006).

Conduct disorder affects 1 to 4 percent of 9- to 17-year olds in the United States. The disorder is more predominate in boys than girls and more common in cities than in rural areas (U.S. Department of Health and Human Services, 1999). Between 6 to 16 percent of boys and 2 to 9 percent of girls meet the criteria to be diagnosed with conduct disorder. It is estimated 40 percent of these children will grow up to be adults with antisocial personality disorder (Searight, 2001).

Epidemiological studies state approximately 2% of girls and 9% of boys are afflicted with this disorder. Adolescents with more external signs and symptoms would amplify the percentage to one third or one half of all children and adolescent clinic referrals Kazdin et al., 1992 (as cited by McCabe et at., 2005).

Heredity, Prenatal Care & Other Aspects of Causation

The etiology of conduct disorder consists of the correlation of genetic, family and social factors. The child may inherit limited baseline autonomic nervous system activity, resulting in a need for greater stimulation to attain optimal arousal. This hereditary aspect may explain the high level of sensation-seeking activity associated with the disorder (Johnson et al., 2002). Several studies have revealed the role of autonomic under-arousal in conduct-disordered adolescents (Crowell et al., 2006). According to McBurnett & Lahey, 1994 & Scrapa & Raine, 1997 (as cited in Crowell et al., 2006) conduct disorder and antisocial behavior in adulthood are marked by autonomic under-arousal which included reduced electro-dermal responding (EDR) and heart rate. Beauchaine, 2003 & Beuchaine et al., 2001 (as cited in Crowell et al., 2006) revealed both elementary children and adolescents have reduced sympathetic and parasympathetic linked cardiac activity when diagnosed with conduct disorder.

The importance of this research is evident when considering the critical period of preschool when noradrenergic, serotonergic, and dopaminergic systems which administer behavioral control are susceptible to long-term changes in functioning Bremner & Vermetten, 2001 (as cited in Crowell et al., 2006). Parasympathetic nervous system (PNS)-linked cardiac activity has been associated with emotional regulation capabilities Porges, 1995 (as cited in Crowell et al., 2006) in contrast to deficiencies in sympathetic nervous system (SNS)-linked cardiac activity have been linked with reward inconsiderateness Beauchaine et al., 2001 (as cited in Crowell et al., 2006).

During gestation the brain is vulnerable to the effects of environmental stressors; this statement applies to both prenatal and postnatal development Dawson et al., 2000 & Hulzink et al., 2004 (as cited in Van Goozen et al., 2007). Environmental factors which can affect brain development are:

· Poor nutrition

· Maternal psychopathology

· Atypical child interaction from a depressed mother (Van Goozen et al., 2007)

Baumrind (as cited in Marsiglia et al., 2007) classified three parenting styles: authoritarian, authoritative, and permissive. For the purpose of this research authoritarian parenting styles will be discussed. The characteristics of an authoritarian parent are extremely restrictive and demanding rules. Parents who utilize this style tend to hamper children’s autonomy and force them to follow stringent rules by threatening harsh punishment (Marsiglia et al., 2007). This type of parenting may lead children to believe they are not responsible for their actions; by contrast, when actions are questions they assume it is not their fault. According to numerous psychological theories parent-child relationship can generate psychological disorders such as anxiety, identity confusion and conduct disorder (Dwairy, et al., 2006). Hoeve et al., (2008) concluded from their study a strong link between parenting styles and delinquency trajectories; therefore, they recommended future research include parenting styles in measuring serious behaviors which are classified as conduct disorders.

The link between exposure to violence in the home and community is a crucial risk factor for conduct disorder according to research by Elze et al., 1999; Fergusson & Horwood, 1998; Jouriles et al., 1989; Kaplan et al., 1998 (as cited in McCabe et al., 2005). Violence exposure can take place in many places within the child’s environment including: (1) victimization and witnessing child abuse; (2) community violence; (3) parental abuse (McCabe et al., 2005).

Culture and societal norms make up the macro-system which is seen as the most distant factors; the exo-system is seen as a midlevel factor; and the micro-system is seen as the most proximal position to the child. Lynch & Cicchetti, 1998 (as cited in McCabe, et al., 2005) stress risk factors which have the most impact are the factors which are more proximal to the child.

Family stresses: (1) substance abuse; (2) violence; and (3) social isolation etc increase a child’s risk of conduct disorder or other mental health disorders. Garrison et al., 1992 (as cited in Baker et al., 2007) reveals several studies have documented the relationship between childhood psychosocial issues and primary care visits. Pediatricians consistently under identify mental health problems in children. Behavioral problems have been linked to an increase in family stressors: (1) divorce; (2) relocation; and (3) financial issues Lavigne et al., 1998 (as cited in Baker et al., 2007). Pediatrician should be aware of these factors when addressing repetitive visits to the office or the emergency room for treatment (Baker et al., 2007).

Parental psychopathology and parenting behavior may be potentially important risk or protective factors in developmental outcomes for these children with concurrent conduct problems. Parental stress and maladaptive parenting may foster the development of conduct disorder Johnson & Mash, 2001 (as cited by Chronis et al., 2007).

The researchers propose maternal smoking is a significant factor in conduct disorder because nicotine may interrupt fetal brain development. Dr. Wakschalg stated, “Our study suggests that cigarette smoking may be one of the first prenatal risk factors for this very serious disorder” (University of Chicago Medical Center, 1997).

According to the ecological-transactional model child abuse has the greatest impact on child functioning. Kaplan et al., 1998 states several studies have correlated child maltreatment to an increase risk of conduct disorder (as cited in McCabe et al., 2005). A study at University of Chicago Medical Center (1997) reveals a link between smoking during pregnancy and the likelihood of having a son with conduct disorder. The researchers analyzed records of 177, 7-12 year-old boys who were referred for outpatient treatment for behavioral problems. The study indicated 24 percent of the mothers who reported smoking more than a half-pack of cigarettes per day during pregnancy, 80% of their sons had conduct disorder. This was in contrast to conduct disorder in 50% of the boys whose mothers did not smoke (University of Chicago Medical Center, 1997). Dr. Lauren Wakschlag stated “Our study indicates that regardless of other factors, smoking during pregnancy can have serious behavioral outcomes in children” (University of Chicago Medical Center, 1997).

The longitudinal and experimental studies on children who are raised in orphanages, children’s homes, and foster homes have established the adverse effects of long-term institutional care on children’s personality development according to the American Academy of Child and Adolescent Psychiatry, 2005 (as cited in Chronis et al., 2007). Consistent research has shown a correlation between institutional child rearing and hyperactivity and inattention. Both of these symptoms are precursors of conduct disorder Roy et al., 2000 (as cited in Chronis et al., 2007).

The research repeatedly exposes children who are diagnosed with ADHD and conduct disorder are predisposed for (1) risky sexual behavior; (2) substance abuse; (3) delinquency; and (4) driving risks Barkley et al., 1993 (as cited in Chronis et al., 2007). The most disturbing fact is children who are diagnosed with ADHD and conduct disorder are at a greater risk of chronic criminal offenses Lyman, 1998 (as cited in Chronis et al., 2007). Lynam 1996 (as cited in Chronis et al., 2007) identified children with conduct disorder at a greater jeopardy for continual offending and explained their perseverance by the correlation of their behavior, neuropsychological and physiological deficits are comparable to adult psychopaths.

Childhood conduct disorder is a major risk factor for adult disorders especially anti-social behavior. The key to diagnosing these children is to identify the origin of antisocial behavior which is found in (1) difficult temperament and (2) ineffective socialization (Van Goozen et al., 2007).

Conduct disorder in childhood which persists through adolescence is associated with co-morbidity, recurrence and resistance to treatment Moffit, 2005 (as cited in Jaffee et al., 2006). The study shows children and adolescence who struggle with signs and symptoms of conduct disorder continue to struggle throughout adulthood with psychosocial problems. The trajectories of antisocial behavior influence these children throughout adulthood and influence the childrearing environment (Jafee et al., 2006).

The influences of individual factors are multifaceted and confusion. Family dysfunction is repetitively identified as one of the crucial factor for conduct disorder in adolescence. Poor parental supervision is the preeminent predictor of violence and vandalism committed by boys. Psychosocial disturbances in children and adolescence bring together a comprehensive range of research to shed light on these young people who become parents of tomorrow; these parents who were diagnosed with conduct disorder predispose their child to the same disorder (Pearce, 1996).

The public debate concerning the relationship between family characteristics and children with conduct disorder continues to raise questions which researchers hope to answer. A longitudinal survey of children suggests ineffective parenting style is the strongest predictor of delinquent behavior in children between the ages of 8 and 11 years. In addition, aversion tactics, low socioeconomic status and the number of siblings in the home are associated with higher probability of children exhibiting conduct disorder (Stevenson, 1999). Somerstein (2007) reveals the common family dynamic in many individuals’ histories of male terrorist is authoritarian parents.

Intervention

There are several factors noted by the research which can help with children who are exhibiting signs and symptoms of conduct disorder. Parents need to monitor their child’s activities on a daily basis. Compliance with (1) curfew; (2) being a responsible parent; (3) monitoring your child’s activities; and (4) quality time with your child are important aspects of parenting (Searight et al., 2001). Most of the parents are diagnosed with some type of psychological disorder and do not have the skills to implement this tips.

A productive intervention for parents is learning good communication skills. Parents should be able to communicate clear, direct and specific rules, request or expectations. Parents should expect the child to react in a concise manner. There should be respect from each party and rules need to be enforceable. Parents of children with conduct disorder rely on inconsistent coercion which increases the negative climate of the home (Searight et al., 2001).

School based intervention has begun to be implemented because of the increase in children who are diagnosed with conduct disorder. Ray (2007) compared the impact of child-centered play therapy, teacher interaction only and a combination of teacher-child relationship. The results were statistically significant for each treatment group, the indication was school based play therapy intervention was more effective in facilitating a positive rapport between the teacher and child.

Hoagwood et al. (2007) reported school-based mental health interventions have a positive effect on academic and mental health progress for children. The interventions were more productive when received long-term and addressed multiple needs in the child’s lives. Community based agencies that provided services for children with conduct disorder in Great Britain were rated effective if they include:

· Socialization skills

· Improvement in family dynamics

· Role play

· Professionally trained personnel (National Institute for Health & Clinical Excellence, 2007).

Functional Family therapy is an empirically grounded, successful family intervention for kids with conduct order and other risk factors which hinder them from living a healthy life in society. The concept of FFT is to develop family member’s strengths which can improve the environment. The characteristics of the program give the family a foundation for change which includes direct support from the therapist. The family is included in each phase of treatment: (1) goals i.e. reduce negativity and improve communication; and (2) risk and protective factors i.e. blaming (risk) and alliance (protective) (FFT, 2007).

The effectiveness of the intervention is based on the following factors: (1) engagement with the child and the family; (2) motivation; (3) clear/concise/understandable assessment; (4) teaching the family skills to change behaviors; and (5) being available for individualized needs from each member of the family.

The program’s protocol suggests if the program is implemented successfully the child and family will show the following benefits:

1. noticeable changes in Conduct Disorder, Oppositional Defiant Disorder, Disruptive Behavior Disorder and substance abuse

2. reducing the need for other social service program which increase costs for the state and federal government

3. generate positive outcomes

4. preventive measures which are learned enhance the future outlook for the families

5. provide role models for the younger children in the family

6. prevent the adolescent offender from becoming an adult offender (Barton, 2007).

7. effective treatment touches beyond the family into the micro, macro, and other phases of the youths life.

According to the U.S. Department of Justice (U.S. Department of Justice, 2000):

Thirty years of clinical research indicate that FFT can prevent the onset of delinquency and reduce recidivism at a financial and human cost well below that exacted by the punitive approaches noted earlier.

If there is no change in the child’s behavior pharmacotherapy may be added to the treatment. There are no formally approved medications for conduct disorder there are medication which can help with specific symptoms. Stimulants i.e. Dexedrine, Ritalin, are the most promising medication for the treatment of conduct disorder. There is limited research for the long-term effects of these medications on conduct disorder.

There is some controversy when administering antidepressants to children with ADHD and conduct disorder. There have been reports of improvement by parents but more studies are needed. Lithium has shown to reduce aggression but lithium requires regular blood level monitoring for toxicity. The use of lithium and anticonvulsants provides limitations in treatment. Several studies have shown significant improvement with Clonidine but the side effects interrupt the child’s normal day i.e. drowsiness (Searight et al., 2001).

The parent may choose an outpatient mental health provider such as a community service board. The child would be assigned a case manager to assist with programs and concerns in the home and school. The case manager with the assistance of the parent would complete a treatment plan to notate long-term and short-term goals. Therapeutic interventions would include but not limited to: (1 psychological evaluation; (2) psycho-educational testing; (3) provide feedback to the parents and the teachers; (4) assist the parent and the child with establishing rule, boundaries and consequences; and (6) build a therapeutic rapport with the child (Jongsma et al., 1996).

Conclusion

Clearly the research reveals the correlation of diverse factors which promote conduct disorder. Parenting styles play a key role in promoting an environment which is conductive of this disorder. We (I) as new therapist need to education our clients, public, parents, families etc on the negative effects authoritarian parenting styles have on our children.

The research suggest children with conduct disorder become adults with anti-social behavior and others psychological problems. The disorder is more than a fussy child it is a serious issue which parents, teachers and the mental health profession needs to address.

The researcher has provided a brief look into the world of conduct disorder. Parents, caregivers, and clinicians need to be aware of the warning signs of conduct disorder. All three entity need to form a coalition to improve the environment these children endure everyday. Parents need to learn resources, interventions and build rapports with faculty at the schools.

Another aspect to consider is the link between nicotine and conduct disorder. Pregnant women need to be warned against smoking during and after pregnancy. There are significant risks with cigarette smoking during pregnancy but the research adds another aspect to the issue.

The statistics are staggering but the realization of what these children and their parents are enduring is more staggering. As a clinician at a community service board I witness daily these children who can not sit in a chair for five minutes. They need constant re-direction; as the research stated parents resort to coercion and threats instead of implementing good parental skills. Another aspect of the research is lack of communication; this is noticeable immediately.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual

of mental disorders (4^th ed. Text Revision). Washington D.C.: Author.

Barton, A. et al. (2007). Functional Family Therapy: blueprint for violence

Prevention. Institute of Behavioral Science. Retrieved June 19, 2007 from

http:www.colorado.edu/cspv/blueprints/model/programs/FFT.html

Functional Family Therapy Website. (2007). http://www.fftinc.om

Hoeve et al. (2008). Trajectories of delinquency and parenting styles. Journal

of Abnormal Child Psychology, 36 (2), 223-235. Retrieved April 28,

2008 from http://www.pubmedcentral.nih.gov/

Hoagwood, K., et al. (2007). Empirically-based school interventions targeted

at academic and mental health functioning. Journal of emotional

and behavioral disorders, 15(2), 66-92.

Marsiglia et al. (2007). Impact of parenting styles and locus of control on emerging

psychosocial success. Journal of Education and Human Development, 1.

Retrieved April 29, 2008 from:

http://www.scientificjournals.org

National Institute for Health & Clinical Excellence. (2007). Conduct disorder

programs {Electronic Version}. Community Care, Issue 1672, 32-33.

Retrieved June 22, 2007

http://www.nice.org.uk/page.aspx?0=529846

Ray, D. (2007). Two counseling interventions to reduce teacher-child relationship

Stress {Electronic version}. Professional School Counseling, 10(4), 428-440.

http://www.goliath.ecnext.com/coms2

Scott, S. Conduct disorder in children. BMJ 2007. Retrieved July 13, 2007 from

http://www.bmj.com/cgi/content/full/334/7595/646

Somerstein, L. (2007). I came with a sword on judgment day: a psychoanalytic look

at terrorist enactments. Psychoanalytic Review, 94 (5).

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A report of the Surgeon General {Electronic Version}. Rockville, MD.

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antisocial behavior. Psychological Bulletin, Vol 1333(1), pp.149-182.

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Abstract
Depression is very common in adolescence and if not treated properly it can produce long-term negative consequences, such as alcohol and drug abuse, criminal behavior, and even suicide.  It is imperative that parents, educators, mental health workers, and the entire society better understand the signs, symptoms, risk factors, and behavior problems associated with depression in adolescence.  This paper attempts to provide society with a better understanding of adolescent depression by reviewing the current literature on adolescent depression. This paper defines depression and reviews its symptoms, as well as the genetic, environmental, and social influences of adolescent depression. It also examines gender and racial differences among adolescents with depression and examines treatment options available to depressed adolescents.

Introduction
Everyone has most likely experienced a sad mood at one time or another in their lives.  A short period of sadness is not uncommon as humans struggle with the pressures of every day life, such as financial, marital, and job difficulties.  Raising children and taking care of aging parents add to the increase in people’s sometimes sad moods.  However, it is depression that is of significant concern in our society, today.  Many adults experience depression which can result in significant health consequences and even death from suicide.  Furthermore, depression is one of the most common disorders that occur among adolescents. Depression affects 5 to 8 percent of adolescents (Son, 2000).  Depression can have devastating effects on adolescents.  Research indicates that depressed adolescents are at risk for increased illness, low academic performance, difficult family and peer relations, substance abuse, and delinquent behavior (Allen-Meares, Colarossi, Oyserman, & DeRoos, 2003).  Also, depression is often associated with suicide among adolescents and suicide is the third leading cause of death for youth ages 15-24 (McCarthy, Downes, & Sherman, 2008).  The dangers associated with adolescent depression are evidence that recognizing, understanding, and treating adolescent depression are extremely important.  However, while adolescent depression is common it is difficult to recognize.  It is imperative that society, especially parents, educators, and mental health professionals understand what adolescent depression is, recognize its symptoms and its causes, as well as recognize the effects depression has on adolescents and the options available in treating adolescent depression.

What is Adolescent Depression?
Depression is an emotional state that involves feelings of great sadness, worthlessness, and guilt. The Diagnostic and Statistical Manual of Mental Health Disorders (4th ed., text revised) (DSM-IV-TR) requires that five out of nine symptoms must be present for at least two
weeks for a diagnosis of depression to be given.  These nine symptoms include a sad, depressed mood most of the day, for most days, loss of interest and pleasure in regular activities, difficulties sleeping, lethargy or agitation, loss or increase in weight and appetite, loss of energy, negative self-concept and feelings of worthless and guilt, difficulty concentrating, and recurrent thoughts of death or suicide.  The symptoms of either depressed mood, or loss of interest and pleasure must be one of the five symptoms for a depression diagnosis to be made.  Other symptoms include low self-esteem, and somatic complaints.  Depression is a recurrent disorder and has increased steadily over the last fifty years, especially among adolescents (Davison & Neale, 2001).  Within two years, 40% of individuals will experience another depressive episode and within five years 72% will have a recurrent episode. While the DSM-IV-TR diagnosis does not differentiate between adolescents and adults, the symptoms are the same for adolescents for the most part.  The requirement of depressed mood most of the day does specifically mention that this mood can appear as an irritable mood among the adolescent population.  Adolescents experience more symptoms of somatic complaints, social withdrawal, and irritability rather than a sad mood.  Symptoms of depression can also be different for adolescents of different ages.  Younger adolescents may have symptoms of anxiety manifested in clinging behaviors, fearfulness, and physical complaints.  Furthermore, research indicates that 89% of depressed
adolescents usually show signs of sleep difficulty while 79.5% show appetite and weight disturbances (McCarthy, Downes, & Sherman, 2008).

Risk Factors of Adolescent Depression
It is just as important to understand the risk factors of adolescent depression as it is to recognize the symptoms of it.  Young people can become depressed for many reasons.  Biomedical risk factors are associated with adolescent depression.  This includes a genetic
predisposition to depression.  Parental depression or a family history of depression increases the risk that adolescents will also develop depression.  Adolescents with chronic illnesses such as diabetes, asthma, or heart disease are also at risk for depression.  Another biomedical risk factor is puberty.  The hormonal changes during puberty can bring about a depressive episode.  Furthermore, girls are twice as likely to experience depression as boys.  Using certain drugs such as birth control pills and Acutane for acne has been found to cause adolescent depression, also (Bhatia & Bhatia, 2007).
There are also psychosocial factors that put adolescents at risk for getting depression.  Childhood neglect or abuse is one such psychosocial factor.  Adolescents who experience physical, emotional, or sexual abuse are at a higher risk for developing depression (Bhatia & Bhatia, 2007).  For example, one study by Buzi, Wienman, and Smith reveals that sexual abuse is a significant factor is predicting depression.  In this study, adolescents were recruited from teen clinics in the Southwest part of the United States that provide free family planning and reproductive health services to adolescents. Each participant was given a questionnaire that combined several measures from other adolescent risk-behavior surveys.  The Reynolds Adolescent Depression Scale (RADS) was used to measure depression symptoms. Two hundred seventy-nine females participated in the study.  Forty of the adolescents reported a history of sexual abuse.  Forty of the participants scored at or above a raw score of 77 on the RADS which indicates that these adolescents should be evaluated further for depression. This study suggests that sexual abuse is a significant factor is predicting depression (Busi, Weinman, & Smith, 2007).  Other psychosocial factors that influence adolescent depression include stressors such as peer pressure, low academic performance, and poverty.  Adolescents who experience the loss of a loved one, or have difficult parental or romantic relationships are also at greater risk for depression (Bhatia & Bhatia, 2007).  In addition, depressed parents can influence depression in adolescents.  Furthermore, adolescents with parents who abuse alcohol or controlled substances are at a higher risk for developing depression (Feldman, 2008).  Parental attachment during childhood and adolescence may also play a role in adolescent depression.  A study by Maria Cristina Richaud De Minzi examines this notion.  Richaud De Minzi examined whether there are differences in the influence of attachment and parent-child relationships on depression, along with other areas.   The study examined 1,019 children in elementary schools in Buenos Aires.  Each child was tested using the Argentine Scale of Perception of the Relationships with Parents, the Kern’s Security Scale, the Self-Perception Profile for Children, the Dimensions of Depression Profile for Children and Adolescents, and the Louvian Loneliness Scale for Children and Adolescents.  Results indicated that parents’ acceptance promotes secure attachment and positive outcomes in children and helps protect them from depression (Richaud De Minzi, 2006). Other psychosocial factors that influence adolescent depression include adolescents who feel unpopular, have few close friends, experience rejection, have to move to another place to live, and change to a new school.(Son, 2000).

Cognitive factors also influence adolescent depression.  Negative thinking and low self-esteem can contribute to depression in adolescents.  Depressed individuals see themselves as worthless, and undesirable.  They also tend to view all of their experiences in negative ways.  Adolescents who view themselves, others, and their future negatively tend to be depressed. Charoensuk conducted a study of 812 Thailand students.  Charoesnuk administered several questionnaires to test parental bonding, everyday stressors, depressive symptoms, negative thinking, and self-esteem.  Negative thinking was assessed using the Crandell Cognitions Inventory and self-esteem was measured using the Rosenburg Self-Esteem Scale. 

The results
concluded that among all factors tested, negative thinking was the strongest predictor of depressive symptoms.  Self-esteem was also a predictor of depressive symptoms, but this was only the case when negative thinking was a strong factor.  Thus, without negative thinking, self-esteem would not be much of an issue in influencing depression (Charoensuk, 2007).
Other factors have been shown to increase the risk of depression.  Adolescents who have a history of depression, or smoke are more likely to experience depressive symptoms.  In addition, some psychological disorders such as Anxiety Disorder and Attention-Deficit Hyperactivity Disorder, or conduct and learning disorders influence adolescent depression as well (Bhatia & Bhatia, 2007).
Effects of Depression on Adolescents
It is difficult if not impossible to prevent adolescent depression resulting from heredity, or environmental influences like physical or sexual abuse.  However, knowledge of the harmful behaviors that result from adolescent behavior may allow parents, educators, and mental health professionals to find preventions for these behaviors among depressed adolescents.  Depression has been found to occur along side harmful disorders, such as eating disorders which include obesity, anorexia, and bulimia.  Obsessive-compulsive behaviors, anxiety disorders, and conduct, and oppositional-defiant disorders also have been found to be present along with depression.  Further, adolescents tend to engage in harmful behaviors, such as smoking cigarettes, alcohol and drug abuse, criminal behavior, and even suicide (Allen-Meares, Colarossi, Oyserman, & DeRoos, 2003).  However, it is not clear which comes first, the depression or the harmful behaviors, or vice versa.  Many mental health professionals counsel depressed adolescents assuming that depression occurs first followed by harmful behaviors because there is much research indicating this.  However, some studies suggest otherwise.  For example, a study by Silberg, Rutter, D’Onofrio, and Eaves on the genetic and environmental factors in adolescent substance use revealed that harmful behaviors occurred first, then depression.  Their study revealed that their was a greater effect of substance abuse leading to depression than the other way around (Silberg, Rutter, D’Onofrio, & Eaves, 2003).  Another study conducted by Teresa Otsuki revealed a different picture.  Otsuki studied a sample of Asian Pacific Islander and Non-API American high school students in California. The sample included 13,374 ninth – and twelfth-grade students among 34 high schools in California. Questionnaires were administered in the classrooms of these students.  The questionnaire used was the Multiethnic Drug and Alcohol Survey.  Self-esteem and depression were measured.  Results indicated that both self-esteem and depression were significantly related to substance use (Otsuki, 2003).
Depression has been closely associated with delinquent behavior among adolescents.  Many adolescents engage in illegal use of illicit drugs, petty theft, group assault, and truancy.  Adolescents who are depressed engage in violent and non-violent crimes, as well as promiscuous

sexual behavior.  One study conducted by Ritakallio, Kaltiala-Heino, Kivivouri, Luukaala, and Rimpela investigated patterns of criminal behavior according to depression among repeatedly delinquent adolescents.  This study was conducted on 53,524 students aged 14 to 16 years who took part in the Finnish School Health Promotion Study.  The study investigated several issues among adolescent depression and delinquent behavior.  Specifically, the study examined whether any differences existed in criminal activities between depressed and non-depressed delinquent adolescents.  These differences were assessed by comparing the frequency of self-reported delinquent behavior among both groups.  Results indicated that depression was associated with repeated delinquency, and both depressed boys and girls repeated delinquent behaviors more frequently than non-depressed boys and girls.  Depression was also associated with a variety of delinquent behaviors.  Depressed adolescents tended to engage in more types of delinquent behaviors as well as more violent crimes than did non-depressed adolescents (Ritakallio, Kaltiala-Heino, Kivivuori, Luukkaala, & Rimpela, 2006).
Probably the most serious consequence of adolescent depression is suicide.  Suicide is the leading cause of death in adolescents ages 15 to 19 and the third leading cause of death among all adolescents, just falling behind accidents and homicides.  White males are at the highest risk of suicide, but African Americans are not following far behind.  While suicide occurs at higher rates for boys, girls attempt suicide more often.  Suicide attempts by boys usually cause automatic death because of the methods used to commit suicide, such as using guns.  Girls usually attempt suicide using less violent methods, such as a drug overdose.  While there are many reasons for such a high rate of suicide among adolescents, such as peer pressures, and stress, depression is a major factor as well.  With such a high risk of suicide among adolescents it is important that society recognizes the risk factors and warning signs of suicide, as well as depression.  Risk factors for suicide include having attempted suicide before, depression that includes strong feelings of helplessness and hopelessness, additional psychiatric problems such as conduct disorder, alcohol and substance abuse, stressful life events such as family difficulty or divorce, and access to firearms.   There are several warning signs that are important to recognize regarding adolescent suicide.  These warning signs include adolescents who talk about suicide, or dying, difficulty with school such as poor academic performance, or low attendance, making arrangements such as giving away personal belongings, writing a will, loss of appetite or over eating, depression, sleep difficulties that include not being able to sleep, or sleeping all the time, extreme changes in behavior, and a preoccupation with death in music, art, and literature (Feldman, 2008).

The prevention of suicide is of great importance.  Parents, educators, doctors, and mental health professionals can do a lot in preventing adolescent suicide.  Feldman offers several suggestions.  One important suggestion is to talk and listen to the person that is contemplating suicide.  Just listening in a non-judgmental way can help adolescents talk through their issues.  Also, it can be helpful to talk specifically about suicide with a suicidal person.  Getting specific information such as how the person plans to commit suicide, whether they have a gun or pills, and where they keep them can be important information in keeping the adolescent from committing suicide. Evaluating the seriousness of the adolescent’s claims and behaviors is important as well.  If the person is in serious danger, do not leave them alone.  Being supportive also helps.  Just letting the person know you are there for them and care about them, and attempting to break down that person’s isolation feelings is important. Seek professional help for this person.  Remove all dangerous objects out of reach of this person, such as guns, razors, scissors, and medication.  Call for help immediately, do not keep it secret.  Do not try to call the suicidal person’s bluff by daring them to attempt suicide to make them aware of the wrong thinking because this sometimes can cause the person to actually do it.  Contracting with the suicidal personal that he or she promises not to attempt suicide until talking with someone can help. It is important to not be fooled by a suicidal person’s sudden improvement.  It is still imperative to seek professional help for them because the issues are probably still there (Feldman, 2008).
Gender, Ethnic, and Racial Differences
There are many gender, ethnic, and racial differences among adolescents with depression.  On average, more girls than boys are depressed.  African Americans, and Native Americans  have been found to have higher rates of depression than whites.  However, whites and Asians are more likely to be depressed when under stress than African Americans or Hispanics.  Factors that lead to higher depression in girls may be the drop in their self-esteem during middle school due to peer and media pressure to be more attractive, thin, and to value relationships over academic or career achievements.  Ethnic and racial differences in adolescent depression may occur due to the fact that minorities experience significant stressors such as poverty and discrimination.  Furthermore, due to lack of financial and social resources, African Americans, Hispanics, and Native Americans have difficulty keeping healthy.  They may have more illness such as colds, and are at more risk for developing chronic illnesses, such as diabetes and heart disease.  These illnesses contribute to depression (Feldman, 2008). Brown, Elder, and Meadows conducted a study on race-ethnic inequality and psychological distress in adolescents.  The study examined

adolescents in grades 7 through 12 from across the United States.  The sample included 10, 718 females (52% White, 24% African American, 17% Hispanic, 7% Asian) and 9,948 males (52% White, 22% African American, 18% Hispanic, 8% Asian).  Depression was measured in these adolescents using a variation of the Center for Epidemiological Studies Depression Scale.  Stressful life events, coping and problem solving skills, mother’s social support, and age was also measured. Results indicated that depressive symptoms varied dramatically across race and ethnic groups.  Whites scored the lowest depressive symptoms while Hispanics and Asians scored the highest levels.  African Americans scored levels in between whites, Hispanics and Asians.  In addition, this study revealed higher scores of depressive symptoms in females than males (Brown, Elder, & Meadows, 2007).
Prevention and Treatment for Adolescent Depression
There are three factors that provide protection and help adolescents cope with depression and the struggle of the transition period of adolescence itself.  First, positive relationships with parents and friends provide adolescents with a good support system to help them cope with stress.  As stated earlier, parents are significant in producing positive outcomes and high self-esteem in their children.  In addition, adolescents who have close friends tend to not be depressed like those who have few close friends.  Second, adolescents who find a particular area of competence or expertise cope with stress and depression better.  Participating in sports, music, art, and other activities provide adolescents with friends and boost their self-confidence if they do well, and can create a sense of belonging if the identify with a team or group. Participating in these positive activities and others, such as shopping, going out with friends, watching television, or taking up a hobby such as collecting coins, or scrap booking can relieve stress and keep
adolescents from participating in harmful behaviors, such as smoking, drinking, or stealing.  Lastly, adolescents who feel needed and take on a responsibility role for others such as responsibility to a younger sibling or to a team cope better with stress which may prevent depression (Craig & Baucum, 2002). McCarthy, Downs, and Sherman conducted a study to identify many factors, specifically persons’ sources of assistance, and helpful and unhelpful factors of treatment. The study included a sample of students ages 20 to 23 that had been diagnosed with adolescent depression at ages 15 to 18.  These students were administered a questionnaire that reflected the DSM-IV-TR criteria for major depression.  They also were administered the Beck Depression Inventory-II which assessed the level of depression of the students. The data was analyzed mostly through a five step analytic process outlined by McLeod.  Other guidance came from the work of Strauss, Polkinghouse, and suggestions form the Journal of Counseling and Development.   McCarthy, Downs, and Sherman reported that five themes emerged from their data. They found that the participants found talking to someone to be helpful, such as talking to a counselor.  The participants felt that just being able to sit down and discuss their depression without having to have a reason for the depression was helpful.  A second theme was the relief and respect that occurred.  The participants attributed their decrease in depressive symptoms to the therapy with the counselor rather than just the medication.  Another theme that emerged had to do with parental an adult partnerships.  Most of the participants depended on the parents to help them rather than rejecting them.  Participants said the parental support of their parents being involved with therapy just by driving them to an appointment, for example was helpful.  Helpful friends were important to the participants as well.  Finally, participants seemed to possess a realistic optimism.  The participants knew that the depression would reoccur, but
they were not negative about it.  They were realistic about the return of the depression being a real possibility, but were optimistic about how to handle it (McCarthy, Downes, & Sherman, 2008).
However, the above factors will not always protect adolescents from depression.  Therefore, one must look to all the treatment options available to adolescents once they have become depressed. Psychotherapy, pharmocycotherapy, and education for the parents and family are significant.
Cognitive-Behavioral Therapy, and interpersonal therapy can help adolescents cope with depression.  Cognitive-Behavioral therapy is considered first before using drugs to treat depression in adolescents.  Cognitive-Behavioral Therapy helps patients recognize distortions in thoughts about themselves and the way others see them.  Cognitive-Behavioral Therapy is seen as better than other methods in the treatment of adolescent depression.  However, interpersonal psychotherapy is used in the treatment of adolescent depression as well.  It involves helping adolescents focus on areas of difficulty in their lives, such as grief, arguments with others, and transitions.  Children and adolescents ages 10 to 14 with mild depressive symptoms responded well to therapeutic intervention.  Other studies reveal that adolescents ages 13 to 17 do well with Cognitive Behavioral Therapy, but children younger than 9 years of age may not benefit from this therapy due to their verbal and cognitive limitations.  Other therapies are helpful in treating adolescent depression including play therapy, family therapy, and group therapy (Dopheide, 2006).
Treatment of adolescent depression with antidepressant medications is another option.  Selective serotonin reuptake inhibitors (SSRIs) have been approved by the Food and Drug
Administration (FDA) for treating adolescent depression.  Fluoxetine is one antidepressant approved by the FDA in treating depression in children 8 years or older. In the study, Treatment of Adolescents with Depression Study, the combination of Cognitive-Behavioral Therapy and fluoxetine was shown to be better at reducing depressive symptoms among adolescents ages 12 to 17 during a 12 week study than Cognitive-Behavioral Therapy or fluoxetine alone. Sertaline is another antidepressant medication commonly used to treat adolescent depression.  However, it is used less commonly since the FDA issued warnings about increased suicidal risks associated with antidepressants.  The FDA approved its use for the treatment of obsessive-compulsive disorder in children ages six years and older.  Sertaline has lower risks of drug interactions than fluoxetine, but its effectiveness in treating depression lags behind fluoxetine.  Paroxetine was the drug most commonly used to treat adolescent depression in 2002.  However, the FDA found that adolescents taking paroxetine were at a higher risk of developing suicidal behavior, so the FDA issued a warning in June 2003 that paroxetine should not be used to treat pediatric depression. Citalopram is being studied as an option for treating adolescent depression because it has a low risk of drug interactions compared with the other drugs, but its use is still being investigated.  Fluvoxamine has been approved by the FDA for treatment of obsessive-compulsive disorder in children 8 years of age and older.  It has been effective in decreasing depressive symptoms as well as binging, purging, and anxiety (Dopheide, 2006).  However, parents and pediatricians may be somewhat reluctant to use antidepressants in adolescents due to adverse reactions and side effects.  SSRI side effects include mild stomach upset, or adolescents may become sedated.  Frontal lobe symptoms such as disinhibition, apathy, and indifference can occur if too much medication is given.  Serotonin Syndrome which can be deadly is of concern as well. There are
many other drugs that have been studied for their effectiveness in treating adolescent depression and some are and are not approved by the FDA (Son, 2000).
Trycyclic drugs were the first drugs available in treating adolescent depression. These drugs have been effective in treating attention-deficit hyperactivity disorder and obsessive-compulsive disorder.  However, clinical trials showed no significant difference in using these drugs versus using a placebo in the treatment of depression. The potential cardio toxicity side effects and anticholingeric concern has led to trycyclic drugs being used second to SSRIs in treating depression. Another harmful side effect of trycyclic drugs is weight gain. Sudden death has occurred in some children as well (Son, 2000).
Due to the numerous side effects and dangers in using psychotropic drugs, it is important that families and caregivers exercise caution and are aware of warning signs of the dangers in persons taking these drugs.  A medication guide should come with all medications and should provide danger signs to look.  These include looking for suicidal thoughts or behaviors, behavioral changes or increase in suicidal thoughts, depression, anxiety, panic attacks, or agitation.  It is also important to be aware of signs of restlessness, aggression, anger, violence, impulsive behavior, and moodiness.  Furthermore, careful monitoring from a clinician is beneficial in preventing suicidal behavior in adolescents on antidepressants (Dopheide, 2006).
Patient and family education is another important treatment option for adolescents with depression. Education providing a better understanding of depression and its risks provides several benefits.  For example, patients may be more willing to comply with therapy if they know all the facts and seriousness of their disorder.  Also, it may relieve guilt in parents who feel that their child’s depression is their fault and it may also help parents be more aware of
depressive and suicidal symptoms.  This education would benefit the adolescent’s entire social support network, including teachers, pediatricians, pastors, coaches, and the like (Son, 2000).
Conclusion
A majority of adolescents have and cope with depression every day.  Adolescent depression can be difficult to recognize and treat, but it does not have to be a death sentence for them.  Suicide rates are high among adolescents and depression is a major factor that increases the risk of suicide.  However, parents, educators, coaches, mental health professional as well as all of an adolescent’s support system who is armed with the knowledge and understanding of depression, its symptoms, causes, risks, and treatment options can help defend adolescents against this serious disorder.

References
Allen-Meares, P., Oyserman, D., & DeRoos, Y. (2003). Assessing depression in childhood and Adolescence: A guide for social work practice. Child and Adolescent Social Work Journal,          20(1), 5-20.  Retrieved May 6, 2008, from Academic Search Premier.
Bhatia, S., & Bhatia, S. (2007). Childhood and adolescent depression. American Family Physician, 75(1), 73-80. Retrieved May 6, 2008, from Academic Search Premier.
Brown, J. S., Elder, G., Jr., & Meadows, S. (2007). Race-ethnic inequality and psychological distress: Depressive symptoms from adolescence to young adulthood. Developmental Psychology, 43(6), 1295-1311. Retrieved May 6, 2008, from Academic Search Premier.
Buzi, R., Weinman, M., & Smith, P. (2007). The relationship between adolescent depression and a history of sexual abuse. Adolescence, 42(168), 680-688. Retrieved May 6, 2008, from Academic Search Premier.
Charoensuk, S. (2007). Negative thinking: A key factor in depressive symptoms in Thai adolescents. Issues in Mental Health Nursing, 28, 55-74. Retrieved May 6, 2008, from Academic Search Premier.
Craig, G. J, & Baucum, D. (2002). Human Development (9th ed., pp. 429-433). Upper Saddle River:NJ: Prentice Hall.
Davison, G. C., & Neale, J. M. (2001). Abnormal Psychology (8th ed., pp. 241-243). New York: John Wiley & Sons.
Dopheide, J. (2006). Recognizing and treating depression in children and adolescents. American Journal of Health-System Pharmacists, 63, 233-243). Retrieved May 6, 2008, from Academic Search Premier.
Depression    19
Feldman, Robert S. (2008). Development Across the Life Span (5th ed.,  pp. 71-72). Upper Saddle                       River, NJ: Pearson Prentice Hall.
McCarthy, J., Downes, E., & Sherman, C. (2008). Looking back at adolescent depression: A qualitative study. Journal of Mental Health Counseling, 30(1), 49-68. Retrieved May 6, 2008, from Academic Search Premier.
Otsuki, T. (2003). Substance abuse, self-esteem, and depression among asian American adolescents. Journal of Drug Education, 33(4), 369-390. Retrieved May 6, 2008, from Academic Search Premier.
Richaud De Minzi, M. C. (2006). Loneliness and depression in middle and late childhood: The relationship to attachment and parental styles. The Journal of Genetic Psychology, 167(2), 189-210. Retrieved May 6, 2008, from Academic Search Premier.
Ritakallio, M., Kaltiala-Heino, R., Kivivuori, J., Luukkaala, T., & Rimpela, M. (2006). Delinquency and the profile of offences among depressed and non-depressed adolescents. Criminal Behavior and Mental Health, 16, 100-110. Retrieved May 6, 2008, from Academic Search Premier.
Silberg, J., Rutter, M., D’Onofrio, B., & Eaves, L. (2003). Genetic and environmental risk factors in adolescent substance use. Journal of Child Psychology and Psychiatry, 44(5), 664-676. Retrieved May 6, 2008, from Academic Search Premier.
Son, S. E. (2000). Depression in children and adolescents. American Family Physician, 62(10), 2297-2310. Retrieved May 6, 2008, from Academic Search Premier.

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Abstract
Culture, was once “thought of as a whole, internally consistent system of symbols and values held in common by members of bounded social groups, including whole society” (Erickson, 2002 p. 229). Culture shapes the nature of many features of every developmental environment. Nearly every aspect of development is influenced by its environment which affects survival and provide protective as well as risk factors for health and success throughout the entire course of human life. Social context is, at an assortment of levels, inherent to the developmental process. This paper examines how individual influence of culture has shaped and changed views of the primary origins and meaning of culture as a holistic construct and the impact autonomous views has upon creating a cultural crisis society.

Autonomous Influencing Views Creating a Culturally Crisis Society
The word culture alone is deemed “one of the most complex words in the English language. Lonner (1984) noted, the “culture concept has been examined, poked at, pushed, rolled over, killed, revived, and reified ad infinitum” (p.108). Nevertheless, the apparent importance of culture as a precursor to behavior is currently thought to be on the upswing (Erez & Earley, 1993) and is seen as the missing link (Schein, 1996) to advancing our understanding of the dynamics of organizational behavior.

British anthropologist, Edward Tylor (1970) notes culture or civilization “as that complex whole which includes knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by man as a member of society (Erickson, 2002 p.300). In this defining, culture is treated as a whole entity with various aspects of culture included as both behavior and symbol systems. Throughout time, there became as shift in this concept of culture from having to do with behaviors of social action to placing more emphasis upon symbol systems and ideology.

Culture was once considered as the development of nature within the context of human environment. Culture (from the Latin coler) meant to tend, cultivate, inhabit. Soon, this simple view of culture became more complex, thus losing its original meaning. “The complication of the idea of culture followed the diversification and distended specialization of society’s political, industrial and educational forms” (Cooper 2001 p. 163).

Claude Levi-Strauss defines culture as “any ethnography unit which, from the point of view of the researcher and in comparison with other units, presents significant differences” (Touraine, 1998). From this perspective of culture, at first appears confounding, as nothing assures the differences observed between the two cultures are interdependent or universal, but rather based upon what society deems as its unifying principle. However, this definition takes into account the shift in view from culture as a make up of inherited patterns of behavior which we acquire as members of a given society that convey its values to the “voluntaristic” construction of a set of norms and practices.

Autonomous Influencing Views Creating a Culturally Crisis Society
This paper will begin with a discussion of significant theoretical approaches relative to the cultural development perspective and how these models impact human growth and ideology. Next, this paper will take at look back in time to examine the origins of culture, its initial contributing influence and the present controlling forces that have altered its original unifying construct. Throughout this paper, this writer will relate Biblical perspective that emphasizes how culture relates, both past and present.  This paper will conclude by exploring the consequences of what this writer deems “a culture in crisis” resulting from autonomous views of culture.

Culture, according to (Feldman, 2007) defines culture as “a set of behaviors, beliefs, values and expectations shared by members of a particular culture…consisting of subculture groups” (p. 313). The influence of culture must be considered in order to begin to understand human development. The contextual perspective acknowledges the “relationship between individuals and their physical, cognitive, personality, and social worlds” (p. 23).

Two major theories guide the process of such developmental relationship, the first of which is known as the bioecological approach. Psychologist Urie Bronfenbrenner identifies five, of which the following four levels in his approach that are deemed influential in understanding human development known as microsystem, mesosystem, exosystem, macrosystem and chronosystem. The microsystem is a child’s everyday exposure to their influential environment within the home, with cargivers, friends and teachers. The mesosystem associates with various aspects on the microsystem, linking child to parent, students to teachers, employees to bosses, friends to friends. The exosystem and macrosystem represents a broader more encompassing societal and cultural influence such as government and politics, communities, schools, religions and places of worship and the media, all of which have immediate and major impact on personal development.

The Origins of Culture as a Unitary Construct
From the defining of the exosystem and macrosytem levels, it is important to digress and note who and what influences society and culture and how influence has changed over time. This day and age, culture is shaped by a small number of gatekeepers. The unfortunate reality, with respect to culture, the majority do not rule. The majority has little influence upon cultural formation. Instead, Neuhaus (2007) notes elites dominate as he writes:
Even though these elites may be a minority of the population, they succeed in presenting themselves as mainstream through their control of powerful institutions in the media, in entertainment, in the arbitrations of literary tastes, in the great research universities and professional associations, and in the worlds of business and advertisement that seek the approval of those who control the commanding heights of culture. Increasingly, grassroots political efforts to reverse the current cultural direction are proving futile. (p.12).
The origins of culture were viewed as unitary and holistic with its controlling force based upon universal truths that no longer exists within the present view of culture.

The 20th century perspective of culture was based upon functionalism which conventionalized “culture as holistic and unified, with its various aspects mutually supportive and complementary” (Erickson 2002 p. 300). By the late 1950’s and 1960’s, there began a shift in conception of culture as having to do with symbol systems and ideology as opposed to behaviors of social action. The functionalist recognize socialization as the primary means by which culture and society were replicated from generation to generation and as such the primary basis for social order. This pattern formed the basis by which children adopted their value system, worldview and societal rule systems. This trend carried on throughout adulthood, conforming and adhering to the general societal rules.

The Origins of Culture as a Unitary Construct
The second major theory relative to cultural development which draws explicit similarities from the functionalist perspective regarding replication of culture and society is the sociocultural theory of Russian developmentalist Lev Semenovich Vygotsky. Vygotsky’s theory emphasizes how cognitive development is contingent upon social interactions between members of cultures. This theory emphasizes development as a reciprocal transaction between persons within a child’s environment and the child. This developmental pattern becomes a continuous cycle of learned behavior. Vygotsky is noted as a pioneer in emphasizing the importance of culture in human development.

An expressed example resulting from expected and implicit cultural identify can be found in the social clock theory. Social clocks are described as being culturally determined and a direct reflection of societal expectations. The unfortunate reality of social clocks is its “timing” is inherently wrong, as it is construed by human perception. In addition, social clocks are based upon cultural influences that are also flawed. Aspects of culture, irregardless of cultural background specified, are a cause of much dissention. Ones inherently held cultural connections and values has created division within the Body of Christ, which results in a multitude of religious beliefs. The controlling force behind the basis of culture is mans desire to have autonomy over what he or she deems right.

In defining culture in voluntaristic terms, “enables a central regulating power system to control, limit and even repress the diversity of interest, of opinions and of representatives” (Touraine 1998 p. 140). Thus culture and society are interdependent as defining culture in these terms is what allows the construction of a unified society, which without a cultural unity, would appear fragmented. The origins of culture were based upon empires and kingdoms uniting in a religious authority and political power. Culture was regarded as a means for producing order and linking together religious values and social hierarchies with technical and economic practices. Culture is thus indivisible from an absolute, traditional and monarchical power.

Autonomous Views of Culture
Political democracies soon became consumed by secularist views resulting from the rise of British and French style nation. This soon gave way to an increase of religious freedom resulting in social order rather than religious order in command. Culture became reflective of class thus united in the interest and represented by the dominant class with the legal and educational principles serving to maintain order. Another modern shift in view of culture is the development of moral individualism and an increased identification with “social sub-systems: religion, family, art, economy etc., which reduced the strength of central power and thus of culture as society’s unifying force” (Touraine, 1998 p. 141).

Moral and cultural principles have become eroded as society becomes increasing disconnected from a supernatural authority:
Society no longer recognizes any transcendental order-neither divine law, reason nor a philosophy…the only unifying, or at least mediating, principle between the world of instrumentality and the world of identity is each individual’s or each group’s desire to combine these two worlds within its own experience (Touraine, 1998 p. 146).

Touraine views this process as a desire to incorporate cultural identity into a project of “individuation”. Thus cultural principles of social integration become insolvent by the division of strategic action from individuals living within the world. The end result, Touraine implies is that priority is given to individual life on the basis of preserving individual personality.

The demand for cultural rights has fueled the need for reinterpretation of our personal and collective identity. This has led us on a quest to satisfy what Sigmund Freud deemed the “Id”, described as wanting whatever feels good at the time with no consideration for the reality of the situation. This search was pivotal in Freud’s work. This line of thinking is not subject to the common good and general interest, nor to a divine or natural law, rather to a moral claim.
This is representative of a complete fragmentation of socio-cultural entities; societies are not longer unified by cultural principles or logical systems of power.

Autonomous Views of Culture
Conflict theorist, Randal Collins notes “the divisions and dynamics of society are based on inevitable conflicts and ideas, resources and power. Society is less a unity than a composite of completing networks” (Schwartz 1999 p. 45). Collins believes that society has four basic networks: military, political, economical, and cultural, which, when one gains control -as the cultural has today- tends to result in domination of the other networks and determine society’s direction. Thus, the cultural network characterized by education, art media and entertainment is the cooperative governing source of existing social power.

Philip Rieff, in his book entitled Sacred Order/Social Order: My Life Among the Deathworks argues that identity, morality, and society itself are impossible to maintain unless they are premised on an existing sacred order. Thus, the development of culture is predicated upon the conversion of sacred order into social order. The unfortunate reality of today is society’s detachment from the vertical relationship with the sacred. Rieff identifies three historical eras or worlds: fate, faith and fictions, the first of which he deems as pagan in nature; the second described as theistic and lastly the postmodern third world, based upon fictions. Rieff identifies the third world as representative of the American culture, and participants as “transliterate no sacred order, only fictions and rhetoric of power and self-interest. Every world, until our third, has been a form of address to some ultimate authority” (Sackmann 1997 p.247).

The culture war, as we know it today, is unprecedented; historic conflicts were competing between scared and symbolic religious systems. Sociologist, James Davidson Hunter, writes “What makes the contemporary culture war distinctive is that it is a movement of enmity towards all sacred orders and directed, in its particulars, against the verticals in authority that meditate sacred order to social order” (Tajfel 1982 p. 30).

A Culture without Submission
The evolutionary view of culture are the results of ones adamant need for autonomy and unwillingness to adhere to authority, particularly, Gods authority expressed in His Law. While, this is not specifically a problem with adherence to Gods Law, the problems with mans submission can be found in the first created beings, that being Adam and Eve. To submit requires that one yield to the authority of another based upon hierarchy. Even Jesus submitted to Gods authority by both his obedience to Gods will and to his earthy parents.

Submission is a challenge, in part, to our desire to be free. The majority, however are not aware of what it means to be free. Galatians 5:13 asserts “therefore brothers, you are called to be free, but do not allow your freedom to indulge the sinful nature, rather serve one another in love”. The majority view freedom as being interchangeable and as such, aspects of freedom is not equally important to everyone. The end result is ones freedom is controlled by circumstances and emotions resulting in self righteous and self indulging attitudes and behavior, known as Freud’s “Id” notion. Peter expressed our redemption from such cultural conduct as he writes “knowing that you were not redeemed with corruptible things, like silver and gold, from your aimless conduct received by tradition from your fathers”.

Culture, once oriented around family-around mom and dad and all of the siblings and all of the cousins and all of the aunts and uncles, has become reoriented around individuals. Personal freedom and individual rights are paramount in reorientation. As such, the traditional authorities to which people once look to, have changed. The increase in perceived freedom from family and law, for example has its benefits that are found in artistic expression, economic entrepreneurship and self expression. This does not however, negate the fact that these new found freedoms has its downfalls that are expressed in increased crime for example, that is inextricably intertwined.

A Culture without Submission
“The denial of an absolute morality and an actual transcendent sacred order has real human and social consequences. We live in a culture where there are no acknowledged obligations to other people or institutions or God” (Schwarts & Bilsky 1987 p. 555). The position of all authority is directly fixed on the individual subjective self.  A Christian, however, should recognize God’s rule over everything. We are subject to authority because of God and as such our submission to authority is not relative to being inferior, rather an expression of faith in God’s governing of His creation. A Christian’s submission is an act of trust in God and our government.

Exodus 16:2 states “Then the whole congregation of the children of Israel complained against Moses and Aaron in the wilderness. Judges 21:25 says “In those days there was no king in Israel; everyone did what was right in his own eyes. These two verses are explicit examples of mans problems with submission and need to cling to there culture. While Moses, through God, brought the people out of Egypt, the people brought with them the culture of Egypt and were never converted. The people refused to adhere to God’s traditions given by Moses while in the wilderness and taught to them. The result was being in constant conflict with their leader.

Everyone doing what is right in their own site is the autonomous freedom toward which our American culture is headed. Having no central law, authority or absolute standards that are universally accepted results in situational ethics. It is God’s desire, however that we operate not in situational ethics, rather in “Aspirational Ethics”. In the Book of Matthew, Jesus tells his disciples, “Do not think that I have come to abolish the Law or the Prophets; I have not come to abolish them but to fulfill them”, making reference to fulfilling the Laws spiritual intent. Just as it not enough to fulfill the letter of God’s Law, the same is true with regards to ethical decisions. Aspirational ethics is described as the highest standards of thinking and conduct to seek (Corey, Corey & Callanan 2007 p.13).

A Culture without Submission
There are consequences of breaking the law, rather it be natural law of Gods’ law. Ignorance to a law does not repudiate this fact. Societies disregard for God’s authoritative law, found in His Holy Commandments has resulted in an ever increasing disregard for natural law, the results of which can be seen throughout the world. The Holy Spirit convicts believers to satisfy the foundational principles that determine the decisions he or she will make. In the Book of John, Jesus tells His disciples “when he comes, he will convict the world of guilt in regard to sin and righteousness and judgment: in regard to sin, because men do not believe in me. It was clear Jesus was referring to the Holy Spirits work to convict those who transgress in the law. The Psalmist writes “My tongue shall speak of thy word: for all thy commandments are righteousness”.
The first law ever broken by man has created a ripple effect upon the world in which we live in, thus creating an environment of conflict. Adam and Eve taking from the tree of knowledge of good and evil introduced to them and to the world, knowledge from many sources. This resulted in somewhat of a foretaste of multiculturalism-knowledge from a variety of sources without God’s spiritual direction. II Thessalonians warns us to “stand fast and hold the traditions which you were taught, whether by word or our epistle”.
God has traditions that He wants us to adhere to that are in conflict with the traditions the world has been subjected to. II Thessalonians argues “but we command you, brethren, in the name of our Lord Jesus Christ that you withdraw from every brother who walks disorderly and not according to the tradition which he received from us”. God holds traditions, culture and autonomy; the difference in His versus mans are His are always right, always true and always work.

The Origins of Church in a Cultural Crisis
The origins of culture can be traced back to the church, thus cultures dissension begins with the church. “The religion in general, and Christianity in particular, is a bull market because it is now evident that homo religious, man in search of transcendent meaning, is irrepressible” (Neuhaus, 2007 p.2). The secularization theories of the eighteenth century assumed the ever increasing Enlightenment rationalism-which fueled progress of modernity-would result in increased skepticism of religion, thus gradually withering away or confining religions cultural influence.

While religion is clearly not withering away, it has become fragmented into several denominations as it’s expansive cross cultural expansion appears to have tainted its original culture. Religion now appears “impotent and quite prosperously happy in its impotence…Christianity in America is not challenging the hearts and habits of the mind that dominate American culture (Neuhaus 2007 p 3). On the contrary, some of the more affluent forms of Christianity exploit these habits thus reinforcing such behavior. Preachers of the “gospel” have reduced their sermons to motivational speaking, self-esteem pep rally events that focus on prosperity and happy feel good sermons. Such teaching was forecasted in God word as Isaiah 30:10 read “Prophesy not unto us right things, speak unto us smooth things, prophesy deceits”. This leaves one to believe struggles and discontent with the trials of life is a sickness and self-examination that results in disheartening life discoveries is dangerous behavior.

The consumer spirit has developed a large assortment of Christian books, music and entertainment that has been misconstrued as worship, creating an illusion of living in an effervescent Christian subculture that is, in reality, a mirrored image of the “habits of heart and mind that its participants think they are challenging-or at least escaping. As everything goes better with Coke, so everything goes better with Jesus, and if that doesn’t work, there is always Prozac” (Neuhaus 2007 p 3).

Consequences of a Culturally Crisis Society
The breakdown of the American culture has resulted in erroneous tolerant behavior and moral views that have serious consequences. A number of social and cultural influences impact on the incidence of violence. The persistent exposure to popular media, such as television, movies, computer games and music has subjected youth to everyday violence. There has been a dramatic increase in the depiction of violence in video games. These images contribute to the desensitization of individuals to actual violence versus unrealistic possibilities of violence video games depict in having “extra lives”.

Role models approved by members of the community are often those seen in the media or promoted through popular culture. Many of these “role models” promote behaviors that are violent and rebellious. Frequently popular sports figures and celebrities receive negative media attention and publicity in relation to violent behavior and alcohol and drug use and abuse.

An example of the erroneous tolerance our culture has embraced can be described in a movie I recently viewed entitled “Juno”. This movie received much attention and tremendous reviews. The movie seems to poke fun at the seriousness of teen pregnancy as if it is socially acceptable. This is attributed to the fact that society sees it more important to look for the positives in teen pregnancy and accept the fact that teens will have sex and as such should “encourage” them to practice “safe sex” etc. the results of our tolerance of teen sexual activity is of major concern. Multimedia Apologetics report the following. An estimated 15 million STD infections occur each year, two-thirds of which are individuals under age twenty five. In 1960 only two major STD’s were of concern, those being syphilis and gonorrhea, both of which when treatable with penicillin. Today there are more than twenty five major STD’s, many of which are viral with no known cure.

Consequences of a Culturally Crisis Society
Our culture is progressively losing a strong sense of morality. The reestablishment of morality must begin at an early age. Moral development can be described as a progressive understanding of what one deems right or wrong. Developmentalists have concentrated their immediate attention upon moral development based upon children’s rationale of morality and the behaviors exhibited when faced with moral dilemma. The underlying influence that affects behavior is found in Ephesians 6:12 which states “For we do not wrestle against flesh and blood, but against principalities, against powers, against the rulers of the darkness of this age, against spiritual hosts of wickedness in the heavenly places”.

The Bible declares that “the imagination of man’s heart is evil from his youth”. This was evident in Adam and Eve’s disregard for Gods command not to take from the Tree of Knowledge of Good and Evil. This act was rooted and grounded in a sense of pride and selfishness, orchestrated by Satan (the father of pride) and continues to impact our children at some point, to this day. The Bible asserts that “wherein in time past ye walked according to the course of this world, according to the prince of the power of the air, the spirit that now worketh in the children of disobedience”. From this perspective I agree, in part, with Gilligan’s “stage one” which contends initial attention is given to what is convenient and most important for self. Gilligan goes on to describe that the transition from selfishness to responsibility is gradual. I believe, however that transition into this stage is dependent upon environmental factors and that, given the lack of positive environmental conditions, that regression is a possible scenario.

Borrowing from the social learning approaches of moral development is what I believe is the basis for determining progress in the previously mentioned transitional stage. It is at this point where a child’s sense of morality is impacted and/or shaped by positive reinforcement and environmental influences, which requires the aid of any and every person who has the child’s best interest in mind.

References
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