Child psychopathology

Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood.[1] Mental health providers who work with children and adolescents are informed by research in developmental psychology, clinical child psychology, and family systems. Lists of child and adult mental disorders can be found in the International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10), published by the World Health Organization (WHO) and in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association (APA). In addition, the Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC: 0-3R) is used in assessing mental health and developmental disorders in children up to age five.[2]

## Contents

* 1 Causes
* 2 Stress
* 3 Temperament
* 4 Neurology and etiology
* 5 Agenesis of the corpus callosum and etiology
* 6 Treatment
* 7 Psychotherapy Treatments for Common Psychological Disorders in Children
* 8 Future of Child Psychopathology
* 9 Theory and Research
* 10 References
* 11 External links

## Causes

The etiology of child psychopathology has many explanations which differ from case to case. Many psychopathological disorders in children involve genetic and physiological mechanisms, though there are still many without any physical grounds. It is absolutely imperative that multiple sources of data be gathered. Diagnosing the psychopathology of children is daunting. It is influenced by development and contest, in addition to the traditional sources. Interviews with parents about school, etc., are inadequate. Either reports from teachers or direct observation by the professional are critical. (author, Robert B. Bloom, Ph.D.) The disorders with physical or biological mechanisms are easier to diagnose in children and are often diagnosed earlier in childhood. However, there are some disorders, no matter the mechanisms, that are not identified until adulthood. There is also reason to believe that there is co-morbidity of disorders, in that if one disorder is present, there is often another.[3]

## Stress

Emotional stress or trauma in the parent-child relationship tends to be a cause of child psychopathology. First seen in infants, separation anxiety in root of parental-child stress may lay the foundations for future disorders in children. There is a direct correlation between maternal stress and child stress that is factored in both throughout adolescent development.[4] In a situation where the mother is absent, any primary caregiver to the child could be seen as the "maternal" relationship. Essentially, the child would bond with the primary caregiver, and may exude some personality traits of the caregiver.[5]

In studies of child in two age groups of pregnancy to five years, and fifteen years and twenty years, Raposa and colleagues (2011) studied the impact of psychopathology in the child-maternal relationship and how not only the mothers stress affected the child, but the child's stress affected the mother. Historically, it was believed that mothers who suffered from post partum depression might be the reason their child suffers from mental disorders both earlier and later in development. However this correlation was found to not only reflect maternal depression on child psychopathology, but also child psychopathology could reflect on maternal depression.[6]

Children with a predisposition to psychopathology may cause higher stress in the relationship with their mother, and mothers who suffer from psychopathology may also cause higher stress in the relationship with their child. Child psychopathology creates stress in parenting which may increase the severity of the psychopathology within the child.[7] Together, these factors push and pull the relationship thus causing higher levels of depression, ADHD, defiant disorder, learning disabilities, and pervasive developmental disorder in both the mother and the child. The outline and summary of this study is found below: ""In looking at child-related stress, the number of past child mental health diagnoses significantly predicted a higher number of acute stressors for mothers as well as more chronic stress in the mother-child relationship at age 15. These increased levels of maternal stress and mother-child relationship stress at age 15 then predicted higher levels of maternal depression when the youth were 20 years old.[6]

Looking more closely at the data, the authors found that it was the chronic stress in the mother-child relationship and the child-related acute stressors that were the linchpins between child psychopathology and maternal depression. The stress is what fueled the fires between mother and child mental health. Going one step further, the researchers found that youth with a history of more than one diagnosis as well as youth that had externalizing disorders (e.g., conduct disorder) had the highest number of child-related stressors and the highest levels of mother-child stress. Again, all of the findings held up when other potentially stressful variables, such as economic worries and past maternal depression, were controlled for.[7]

Additionally, siblings- both older and younger and of both genders, can be factored into the etiology and development of child psychopathology. In a longitudinal study of maternal depression and older male child depression and antisocial behaviors on younger siblings adolescent mental health outcome. The study factored in ineffective parenting and sibling conflicts such as sibling rivalry. Younger female siblings were more directly affected by maternal depression and older brother depression and anti social behaviors when the indirect effects were not place, in comparison to younger male siblings who showed no such comparison. However, if an older brother were anti-social, the younger child- female or male would exude higher anti-social behaviors. In the presence of a sibling conflict, anti social behavior was more influential on younger male children than younger female children. Female children were more sensitive to pathological familial environments, thus showing that in a high- stress environment with both maternal depression and older- male sibling depression and anti social behavior, there is a higher risk of female children developing psychopathological disorders.[8] This was a small study, and more research needs to be done especially with older female children, paternal relationships, maternal-paternal-child stress relationships, and/or caregiver-child stress relationships if the child is orphaned or not being raised by the biological child to reach a conclusive child-parent stress model on the effects of familial and environmental pathology on the child's development.[citation needed]

## Temperament

The child-parent stress and development is only one hypothesis for the etiology of child psychopathology. Other experts believe that child temperament is a large factor in the development of child psychopathology. High susceptibility to child psychopathology is marked by low levels of effortful control and high levels of emotionality and neuroticism. Parental divorce is often a large factor in childhood depression and other psychopathological disorders.[9] This is more so when the divorce involves a long-drawn separation and one parent bad-mouthing the other.[10] That is not to say that divorce will lead to psychopathological disorders, there are also other factors such as temperament, trauma, and other negative life events (e.g. death, sudden moving of home, physical or sexual abuse), genetics, environment, and nurture that correlate to the onset of a disorder. Research has also shown that child maltreatment may increase risk for various forms of psychopathology as it increases threat sensitivity, decreases responsivity to reward, and causes deficits in emotion recognition and understanding.[11]

Found in "The Role of Temperament in the Etiology of Child Psychopathology", a model for the etiology of child psychopathology by Vasey and Dadds (2001) proposed that the four things that are important to the development of psychopathological disorders is: 1) biological factors: hormones, genetics, neurotransmitters 2) psychological: self-esteem, coping skills, cognitive issues 3) social factors: family rearing, negative learning experiences, and stress 4) child's temperament. Using an array of neurological scans and exams, psychological evaluations, family medical history, and observing the child in daily factors can help the physician find the etiology of the psychopathological disorder to help release the child of the symptoms through therapy, medication use, social skills training, and life style changes.[9]

Child psychopathology can cause separation anxiety from parents, attention deficit disorders in children, sleep disorders in children, aggression with both peers and adults, night terrors, extreme anxiety, anti social behavior, depression symptoms, aloof attitude, sensitive emotions, and rebellious behavior that are not in line of typical childhood development. Aggression is found to manifest in children before five years of age, and early stress and aggression in the parental-child relationship correlates with the manifestation of aggression. Aggression in children causes problematic peer relationships, difficulty adjusting, and coping problems. Children who fail to overcome acceptable ways of coping and emotion expression are put on tract for psychopathological disorders and violent and anti social behaviors into adolescence and adulthood. There is a higher rate of substance abuse in these children with coping and aggression issues, and causes a cycle of emotional instability and manifestation psychopathological disorders.[citation needed]

## Neurology and etiology

Borderline personality disorder (BPD) is one of many psychopathology disorders a child can suffer from. In the neurobiological scheme, borderline personality disorder may have effects on the left amygdala. In a 2003 study of BPD patients versus control patients, when faced with expressions that were happy, sad, or fearful BPD patients showed significantly more activation versus control patients. In neutral faces, BPD patients attributed negative qualities to these faces.[12] As stated by Gabbard, an experimenter in this study: "A hyperactive amygdala may be involved in the predisposition to be hyper vigilant and over reactive to relatively benign emotional expressions. Misreading neutral faces is clearly related to transference misreadings that occur in psychotherapy and the creation of bad object experiences linked with projective identification."[12]

Also linked to BPD, is the presence of serotonin transporter (5-HTT) in a short allele demonstrated larger amygdala neuronal activity when presented with fearful stimuli as in comparison to individuals with a long allele of 5-HTT. As found in the Dunedin Longitudinal Study a short allele of 5-HTT predisposes the person to have hyperactivity in the amygdala in response to trauma, and thus moderated the impact of stressful life events leading to a higher risk of depression and suicidal idealities. These same qualities were not observed in individuals with long alleles of 5-HTT. However, the environment the child is in can change in impact of this gene, proving that correct treatment, intensive social support, and a healthy and nurturing environment can modify genetic vulnerability.[12]

Possibly the most studied or documented of the child psychopathologies is attention deficit hyperactivity disorder (ADHD) which is marked with learning disabilities, mood disorders, and/or aggression. Though believed to be over diagnosed, ADHD is highly comorbid for other disorders such as depression and obsessive compulsive disorder. In studies of the prefrontal cortex in ADHD children, which is responsible for the regulation of behavior, cognition, and attention; and in the dopamine system there has been identified a hidden genetic polymorphisms. More specific, the 7-repeat allele of the dopamine D4 receptor gene, responsible for inhibited prefrontal cortex cognition and less efficient receptors, causes more externalized behaviors such as aggression since the child has trouble "thinking through" seemingly ordinary and at level childhood tasks.[13]

## Agenesis of the corpus callosum and etiology

Agenesis of the corpus callosum (ACC) is used to determine the frequency of social and behavioral problems in children with a prevalence rate of about 2-3%. ACC is described as a defect in the brain where the 200 million axons that make the corpus collosum are either completely absent, or partially gone. In many cases, the anterior commissure is still present to allow for the passing of information from one cerebral hemisphere to the other. The children are of normal intelligence level. For younger children, ages two to five, Agenesis of the corpus callosum causes problems in sleep. Sleep is critical for development in children, and lack of sleep can set the grounds for a manifestation of psychopathological disorders.[14] In children ages six to eleven, ACC showed manifestation in problems with social function, thought, attention, and somatic grievances. In comparison, of children with autism, children with ACC showed less impairment on almost all scales such as anxiety and depression, attention, abnormal thoughts, and social function versus autistic children. However, a small percentage of children with ACC showed traits that may lead to the diagnosis of autism in the areas of social communications and social interactions but do not show the same symptoms of autism in the repetitive and restricted behaviors category.[15] The difficulties from ACC may lead to the etiology of child psychopathological disorders, such as depression or ADHD and manifest many autistic-like disorders that can cause future psychological disorders in later adolescence. The etiology of child psychopathology is a multi-factor path. A slew of factors must be taken into account before diagnosis of a disorder.[citation needed]

The child's genetics, environment, temperament, past medical history, family medical history, prevalence of symptoms and neuro-anatomical structures are all factors that should be considered when diagnosing a child with a psychopathological disorder.[15] Thousands of children each year are misdiagnosed and put on the wrong treatment, which may result in the manifestation of other disorders the child would have not have gotten else wise. There are hundreds of causes of psychopathological disorders, and each one manifests at different ages and stages in child development and can come out due to trauma and stress. Some disorders may "disappear" and reappear in the presence of a trauma, depression, or stress similar to the one that brought the disorder out in the child in the beginning.[citation needed]

## Treatment

It is estimated that 5% of children under the age of eight suffer from a psychopathology disorder. Girls more frequently manifested disorders than boys in similar situations. By age sixteen about thirty percent of children will have fit the criteria for at least one psychopathology disorder. Only a small number of these children receive treatment for their disorder. Anxiety and depression disorders in children- whether noted or unnoted, are found to be a precursor for similar episodes in adulthood. Usually a large stressor similar to the one the person experienced in childhood brings out the anxiety or depression in adulthood.[citation needed]

Multifinality refers to the idea that two children can react to same stressful event quite differently, and may display divergent types of problem behavior. Psychopathological disorders are extremely situational- having to take into account the child, the genetics, the environment, the stressor, and many other factors to tailor the best type of treatment to relieve the child of the psychopathology symptoms.[citation needed][16]

Many child psychopathology disorders are treated with control medications prescribed by a pediatrician or psychiatrist. After extensive evaluation of the child through school visits, by psychologists and physicians, a medication can be prescribed. A patient may need to go through several trials of medicines to find the best fit, as many cause uncomfortable and undesired side effects- such as dry mouth or suicidal thoughts can occur. There are many classes of drugs a physician can choose from and they are: psychostimulants, beta blockerss, atypical antipsychotics, lithium, alpha-2 agonists, traditional antipsychotics, SSRIs, and anticonvulsant mood- stabilizers. Given the multifinality of psychopathological disorders, two children may be on the same medication for two completely different disorders, or have the same disorder and be taking two completely different medications.

ADHD is the most successfully treated disorder of child psychopathology, and the medications used have a high- abuse rate especially among college-aged students. Psycho stimulants such as Ritalin, amphetamine- related stimulant drugs: e.g., Adderall, and antidepressants such as Wellbutrin have been successfully used to treat ADHD with a 78% success rate. Many of these drug treatment options are paired with behavioral treatment such as therapy or social skills lessons.

Lithium has shown to be extremely effective in treating ADHD and bipolar disorder. Lithium treats both mania and depression and helps prevent relapse.[17] The mechanism of lithium include the inhibition of GSK-3, it is a glutamate antagonism at NMDA receptors that together make lithium a neuroprotective medicine. The drug relieves bipolar symptoms, aggressiveness and irritability. Lithium has many, many side effects and requires weekly blood tests to tests for toxicity of the drug. [citation needed][18]

Medications that act on cell membrane ion channels, are GABA inhibitory neurotransmission, and also inhibit excitatory glutamate transmission have shown to be extremely effective in treating an array of child psychopathological disorders. Pharmaceutical companies are in the process of creating new drugs and improving those on the market to help avoid negative and possibly life altering short term and long term side effects, making drugs more safe to use in younger children and over long periods of time during adolescent development.[citation needed]

## Psychotherapy Treatments for Common Psychological Disorders in Children

Some psychological disorders commonly found in children include depression, anxiety, and conduct disorder.[19][20] For adolescents with depression, a combination of antidepressants and cognitive-behavioral or interpersonal psychotherapy is recommended, in contrast there is not much evidence for the efficacy of antidepressants in children under 12 years of age, therefore a combination of parent training and cognitive-behavioral psychotherapy is recommended.[21][22] For children and adolescents suffering from anxiety disorders, cognitive-behavioral therapy in combination with exposure-based techniques is a highly recommended and evidence-based treatment.[23][24] Research suggests that children and adolescents with conduct disorder or disruptive behavior may benefit from psychotherapy that includes both a behavioral component and parental involvement.[25][26]

## Future of Child Psychopathology

The future of child psychopathology- etiology and treatment has a two-way path. While many professionals agree that many children who suffer from a disorder do not receive proper treatment, at the rate of 5-15% that receive treatment leaving many children in the dark. In the same boat are the physicians who also say that not only do more of these disorders need to be recognized in children and treated properly, but also even those children who show some qualifying symptoms of a disorder but not to the degree of diagnosis should also receive treatment and therapy to avoid the manifestation of the disorder. By treating children even with slight degrees of a psychopathological disorder, children can show improvements in their relationships with peers, family, and teachers and also improvements in school, mental health, and personal development.[27] Many physicians believe the best prevention and help starts in the home and the school of the child, before physicians and psychologists are contacted.

So while there is more awareness of child psychopathological disorders and more research to prevent and effectively treat these disorders to maintain healthy emotional health in children, there is also a negative factor in that parents, schools, and psychologists may be more sensitive and therefore over-diagnose children with these disorders. Mental health professionals and pharmaceutical marketing companies need to be cautious of making disorders too readily diagnosed and treated with medications.

Child psychopathology is a real thing that thousands of children suffer from. While hundreds of children are diagnosed with a new disorder daily, researchers are developing new strategies to beat these disorders in children to allow all children the right to a happy and healthy childhood. With further education on the symptoms and implications of child psychopathology, psychologists and physicians will improve their accuracy in diagnosing children- giving the right diagnosis and discovering the most helpful treatment and therapies for children.[citation needed]

## Theory and Research

The current trend in the U.S. is to understand child psychopathology from a systems based perspective called developmental psychopathology. Recent emphasis has also been on understanding psychological disorders from a relational perspective with attention also given to neurobiology. Practitioners who follow attachment theory believe that early attachment experiences of children can promote adaptive strategies or lay the groundwork for maladaptive ways of coping which can later lead to mental health disorders.[28][29]

Research and clinical work on child psychopathology tends to fall under several main areas: etiology, epidemiology, diagnosis, assessment, and treatment.

Parents are considered a reliable source of information because they spend more time with children than any other adult. A child's psychopathology can be connected to parental behaviors. Clinicians and researchers have experienced problems with children's self-reports and rely on adults to provide the information.[30]

## References

1. ↑ Child Psychopathology \- 2nd Edition, Mash & Barkley
2. ↑ Early childhood mental health, archived from the original on 2012-10-13, https://web.archive.org/web/20121013184721/http://www.zerotothree.org/child-development/early-childhood-mental-health/dc-0-3-revisions.html
3. ↑ Mattison RE, Mayes SD (2012). "Relationships between learning disability, executive function, and psychopathology in children with ADHD". J Atten Disord 16 (2): 138–46. doi:10.1177/1087054710380188. PMID 20837980.
4. ↑ .Schimizzi A (August 2011). "Maternal Depression and child psychopathology: a two way street". child-psych.com. http://www.child-psych.org/2011/08/maternal-depression-and-child-psychopathology-a-two-way-street.html.
5. ↑ Richter, L. (2004). The importance of caregiver-child interactions for the survival and healthy development of young children: a review. World Health Organization. ISBN 978-92-4-159134-8. http://repository.hsrc.ac.za/handle/20.500.11910/8219.
6. ↑ 6.0 6.1 Raposa, Elizabeth B.; Hammen, Constance L.; Brennan, Patricia A. (November 2011). "Effects of Child Psychopathology on Maternal Depression: The Mediating Role of Child-Related Acute and Chronic Stressors" (in en). Journal of Abnormal Child Psychology 39 (8): 1177–1186. doi:10.1007/s10802-011-9536-0. ISSN 0091-0627. PMID 21735051.
7. ↑ 7.0 7.1 "Effects of Child Psychopathology on Maternal Depression: The Mediating Role of Child-Related Acute and Chronic Stessors". Journal of Abnormal Child Psychology 39 (8): 1177–1186. 2011. doi:10.1007/s10802-011-9536-0. PMID 21735051.
8. ↑ .Compton KL (2000). "A double jeopardy model of risk: The additive effects of maternal depression and sibling psychopathology in negative child outcome by gender.". Dissertation Abstracts International 61 (6–B): 3272. https://books.google.com/books?id=icxNOAAACAAJ.
9. ↑ 9.0 9.1 ."The role of temperament in the etiology of child psychopathology". Clinical Child and Family Psychology Review 8 (4): 271–289. 2005. doi:10.1007/s10567-005-8809-y. PMID 16362256.
10. ↑ Rose, Katherine (2017-09-08). "How to Deal With Your Partner's Cheating?". https://medium.com/@imkatherine23/how-to-deal-with-your-partners-cheating-2ef809c4df1e. Retrieved 12 September 2017.
11. ↑ Jaffee SR. Child maltreatment and risk for psychopathology in childhood and adulthood. Annual Review Clinical Psychology, 2017 May 8;13:525-551. doi: 10.1146/annurev-clinpsy-032816-045005
12. ↑ 12.0 12.1 12.2 .Knowlton L (July 2005). "Nature Versus Nurture: How Is Child Psychopathology Developed?". Psychiatric Times 22 (8): 184–201. http://www.psychiatrictimes.com/child-adolescent-psych/content/article/10168/52541?pageNumber=1.
13. ↑ ."Psychopharmacology of aggression in children and adolescents with primary neuropsychiatric disorders: A review of current and potentially promising treatment options". Experimental and Clinical Psychopharmacology 18 (2): 184–201. 2010. doi:10.1037/a0018059. PMID 20384430.
14. ↑ ."Concurrent associations among sleep problems, indicators of inadequate sleep, psychopathology, and shared risk factors in a population-based sample of healthy Ontario children". Journal of Pediatric Psychology 35 (7): 790–799. 2010. doi:10.1093/jpepsy/jsp097. PMID 19923203.
15. ↑ 15.0 15.1 ."Social and behavioral problems of children with agenesis of the corpus callosum". Child Psychiatry and Human Development 38 (4): 287–302. 2007. doi:10.1007/s10578-007-0065-6. PMID 17564831. https://digitalcommons.georgefox.edu/cgi/viewcontent.cgi?article=1098&context=gscp_fac.
16. ↑ Raber, J. H., & Wienclaw, R. A. (2012). Lithium Carbonate. In K. Key (Ed.), The Gale Encyclopedia of Mental Health (3rd ed., Vol. 1, pp. 896-898). Detroit, MI: Gale.
17. ↑ Blader, Joseph C.; Kafantaris, Vivian (March 2007). "Pharmacological Treatment of Bipolar Disorder among Children and Adolescents". Expert Review of Neurotherapeutics 7 (3): 259–270. doi:10.1586/14737175.7.3.259. ISSN 1473-7175. PMID 17341174.
18. ↑ Raber, J. H., & Wienclaw, R. A. (2012). Lithium Carbonate. In K. Key (Ed.), The Gale Encyclopedia of Mental Health (3rd ed., Vol. 1, pp. 896-898). Detroit, MI: Gale. Retrieved from https://link.gale.com/apps/doc/CX4013200269/GVRL?sid=GVRL
19. ↑ Polanczyk, Guilherme V.; Salum, Giovanni A.; Sugaya, Luisa S.; Caye, Arthur; Rohde, Luis A. (2015-02-03). "Annual Research Review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents". Journal of Child Psychology and Psychiatry 56 (3): 345–365. doi:10.1111/jcpp.12381. ISSN 0021-9630. PMID 25649325. http://dx.doi.org/10.1111/jcpp.12381.
20. ↑ Zubrick, Stephen R.; Silburn, Sven R.; Burton, Paul; Blair, Eve (August 2000). "Mental Health Disorders in Children and Young People: Scope, Cause and Prevention" (in en). Australian & New Zealand Journal of Psychiatry 34 (4): 570–578. doi:10.1080/j.1440-1614.2000.00703.x. ISSN 0004-8674. PMID 10954387. http://journals.sagepub.com/doi/10.1080/j.1440-1614.2000.00703.x.
21. ↑ Dopheide, Julie A. (2006-02-01). "Recognizing and treating depression in children and adolescents". American Journal of Health-System Pharmacy 63 (3): 233–243. doi:10.2146/ajhp050264. ISSN 1079-2082. PMID 16434782. http://dx.doi.org/10.2146/ajhp050264.
22. ↑ Weersing, V. Robin; Jeffreys, Megan; Do, Minh-Chau T.; Schwartz, Karen T. G.; Bolano, Carl (2016-11-21). "Evidence Base Update of Psychosocial Treatments for Child and Adolescent Depression". Journal of Clinical Child & Adolescent Psychology 46 (1): 11–43. doi:10.1080/15374416.2016.1220310. ISSN 1537-4416. PMID 27870579.
23. ↑ Higa-McMillan, Charmaine K.; Francis, Sarah E.; Rith-Najarian, Leslie; Chorpita, Bruce F. (2015-06-18). "Evidence Base Update: 50 Years of Research on Treatment for Child and Adolescent Anxiety". Journal of Clinical Child & Adolescent Psychology 45 (2): 91–113. doi:10.1080/15374416.2015.1046177. ISSN 1537-4416. PMID 26087438.
24. ↑ Reynolds, Shirley; Wilson, Charlotte; Austin, Joanne; Hooper, Lee (June 2012). "Effects of psychotherapy for anxiety in children and adolescents: A meta-analytic review". Clinical Psychology Review 32 (4): 251–262. doi:10.1016/j.cpr.2012.01.005. ISSN 0272-7358. PMID 22459788. http://dx.doi.org/10.1016/j.cpr.2012.01.005.
25. ↑ Kaminski, Jennifer W.; Claussen, Angelika H. (2017-07-04). "Evidence Base Update for Psychosocial Treatments for Disruptive Behaviors in Children" (in en). Journal of Clinical Child & Adolescent Psychology 46 (4): 477–499. doi:10.1080/15374416.2017.1310044. ISSN 1537-4416. PMID 28459280.
26. ↑ McCart, Michael R.; Sheidow, Ashli J. (2016-09-02). "Evidence-Based Psychosocial Treatments for Adolescents With Disruptive Behavior" (in en). Journal of Clinical Child & Adolescent Psychology 45 (5): 529–563. doi:10.1080/15374416.2016.1146990. ISSN 1537-4416. PMID 27152911.
27. ↑ .Leadbeater B (2010). "The fickle fates of push and pull in the dissemination of mental health programs for children". Canadian Psychology 51 (4): 221–230. doi:10.1037/a0020486.
28. ↑ Perry, Bruce. The Boy who was raised as a dog. ISBN 978-0-465-05652-1.
29. ↑ Karr-Morse (1997). Ghosts from the Nursery. ISBN 978-0-87113-734-0. https://archive.org/details/ghostsfromnurse000karr.
30. ↑ Nolen-Hoeksema, S. (2013). (Ab)normal Psychology (6th edition). McGraw Hill.

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