Introduction

The first three years of life have lifelong consequences, affecting our neurological and psychological make-up. Transitional growth is concentrated during this period, with the brain reaching 85% of its size and structure (as cited in Dulcan, 2020). The impact of changes on the developmental trajectory can be life altering. For example, when I began working with Shawna at age four, she had already gone through an intense period of neurological, social, and emotional growth in the first two years of her life, as a result of serious child maltreatment and deprivation. Her resilience (even prior to therapy) and receptiveness to consistent nurturant and appropriately responsive caregiving reflects the potential impact of intervention and environmental change. Conversely, Shawna’s re-experiencing of the effects of the abuse and signs of a serious emotional disorder also reflect the nature of change, adaptation, and growth.

The Developmental Systems Approach

The developmental systems approach explicitly focuses our attention on 1) the complex interactions of the child or adolescent developmental needs, capacities, and challenges with 2) the micro, mezzo, and macro systems that create and sustain resources and barriers (Hayden & Mash, 2014). Assessment, diagnosis, and intervention that incorporate a developmental systems approach allow clinicians to work with the understanding that children and adolescents are experiencing developmental challenges, tasks, and capacities that intersect with risk and protective factors of the environment. When working with children and adolescents, it’s critical to understand the development within a child’s neurological and physiological systems, as well as the immediate physical and social environment and interactions among all systems relevant to the child’s life. Simply put, this approach combines the work of developmental psychology and ecological systems to recognize what Hayden and Mash (2014) describe as a framework that emphasizes “the role of developmental processes, the importance of context, and the influence of multiple and interacting events and processes in shaping adaptive and maladaptive development” (p. 3). A well-established body of theory and empirical research guides us in applying this framework.

Aspects of Ecological Systems

The developmental systems approach is grounded in Bronfenbrenner’s (1977) bioecological model. This classic paradigm conceptualizes the ecosystems that are part of each human’s life, and this conceptualization serves as an excellent starting point for understanding the developmental systems approach. Bronfenbrenner (1977) conceptualized systems that interact with each child as the micro, mezzo, and macro systems. The micro system consists of the child as an individual system of biological and psychological subsystems which interact with the primary family, neighborhood, childcare, and school systems. Macro systems include institutional influences like the school system, government, and culture. The mezzo system is an intermediary step between the micro and the macro system, representing the transactions between the micro and macro systems. More precisely, this is where these systems intersect and affect the child, family, neighborhood, or school. The mezzo system also involves systems that the child is not directly part of, for instance the employer of the child’s caregiver. It is the reciprocal product of these interactions that are critical to understand during assessment, intervention, and evaluation. For example, to what extent does the labor market provide employment opportunities or barriers to for the caregiver? In turn, how do the products of these transactions shape the caregiver’s access to basic needs, adequate housing, security, and socioemotional health that is available to the child? It is the interactions between and among systems that are the focus of the ecological framework.

Many have pointed out that Bronfenbrenner’s theory is often oversimplified to focus only on the micro, mezzo and macro systems with the child standing only in the micro system (Asiabi & O’Neil, 2015). A focus on the transactional nature of the bioecological model highlights important contributions that this model makes, including the idea that the child and all transactional systems are reciprocal partners over time. These dynamics create patterns of healthy or unhealthy behaviors and proclivities that have enormous potential for future outcomes.

Bronfenbrenner focuses on the context of the environment interacting with the individual resulting in mutual reciprocity. The child not only reacts to but shapes the environment; this changed environment further shapes the child and so on. Darling (2007) suggests that a critical part of Bronfenbrenner’s model focuses on interactions between the two. This interactional focus brings the clinician’s attention to the importance of the individual uniqueness of each child, the changing environment, and the transactions that occur between them. Ashiabi and O’Neil (2015) describe the bioecological model as consisting of nested systems that allow us to focus on how interactions within each system influence all systems, including the development of the child.

This can be especially useful when studying mental health disorders in children and adolescents. For example, consideration of the interactions within these systems can elucidate tendencies that may reinforce behaviors and emotions associated with depression, anxiety, and disruptive actions. These transactions may be the critical precipitators of disordered behavior, and focusing on them can strengthen assessment and intervention.

Human interaction with the environment occurs on different planes, with localized interactions in the home, neighborhood, and school environments, and globalized interactions within culture and societal expectations or social determinants (Hayden & Mash, 2014). It must also be acknowledged that larger structural forces of our society are also often impinging on the child’s immediate micro system. For instance, poverty, community violence, insecure housing, and overcrowded/under-resourced schools are large scale risk factors that must be addressed systemically. Macro level interventions such as guaranteed median level family income, affordable and available housing, and equity in our public education system can create new environmental conditions that influence the available transactions for the child and their immediate environment. For the social worker (or other clinician), advocating for these large-scale changes alongside working with individual clients and their families to obtain resources is a critical part of the clinical work. If we are to address the causal factors which create the conditions of vulnerability for all children, we must work to meet individual needs in the existing inadequate system that presents multiple risk factors and then advocate for changes on a larger scale. The vulnerability posed by exposure to multiple risk factors is especially of concern for families and communities subject to health disparities caused by poverty, racism, and the lack of safe, affordable, and available housing.

Which transaction, proximal (between child and caregiver) or distal (between caregiver and labor market) has the most influence on the child’s wellbeing or vulnerability to mental health disorders? The notions of proximal and distal transactions refer to the relational distance of the child to the stimulus within the bioecological  model. Proximal processes can be defined as consistent, close, and complex interactions within an ongoing primary relationship such as parent-child, siblings, caregiver-child, or teacher-child. These processes are essential mechanisms for development. The combination of distal and proximal processes creates the social, emotional, and physical conditions of the environment for every child. Ashiabi and O’Neal’s (2015) analysis of over 2000 children showed that the initial influence on outcomes for children comes from the child’s socioeconomic status and the amount of neighborhood social capital. They further showed that childhood outcomes are then mediated by the closer proximal interactions with the amount of parental and family stress. Recognition of the larger influence of proximal processes is not to diminish the impact of large structural inequities in our society that create and sustain enormous risk factors that make some families more at risk for hardship, stress, and deprivation. Furthermore, such effects of structural inequalities can increase the odds that proximal processes will be less than ideal for each child.

These structural inequities, in turn, create stress and insecurities that trickle down to the microsystem of the child, placing her in harm’s way. Rather than overstate the entire family, neighborhood, or school system as being overwhelmingly influential and deterministic, it is often the close interactions that the child has or does not have that shape her proclivities for healthy or unhealthy, disordered behaviors. That is, it is the abusive or nurturing parent, the supportive or punitive teacher, the kind or cruel sibling, or the positive or ill-intentioned neighbor who make the biggest difference in the child’s developmental outcomes. This consideration directs our assessment differently, in a way that may, in the end, be more fruitful; that is, our assessment should ask, where are the intense, consistent, and close interactions of the child, and what is the tenor, tone, or message of those interactions?

Adler-Tapia (2012) observes that child therapists are situated in a complicated matrix. This matrix can be conceptualized as an array of a child’s everchanging neurobiologic, physiologic, and socioemotional capacities and needs, which are intertwined with societal policies, inequities, and prejudices, as well as the more immediate and direct family and community systems interactions. Our focus as we attempt to understand, assess, and intervene with children and adolescents needs a framework that takes into account all of the moving parts. We have found that a developmental systems approach is this framework.

Aspects of Developmental Psychopathology

A developmental systems framework has also been heavily influenced by the developmental psychopathology approach conceptualized by Sroufe and Rutter (1984) and Cichetti (1993). In 2005, Cichetti and Cohen edited the first of three volumes of Developmental Psychopathology. In these volumes, they focus on bio-psycho-social interactions that set the context for normal and abnormal development across the lifespan, a focus that aligns with a developmental systems approach. Like the ecological perspective, developmental psychopathology framework studies human behavior as transactional relationships between each individual child or adolescent and his or her environment at multiple levels.

This suggests that when a child demonstrates the symptoms of a mental health disorder, the dysfunction is a product of interactions between the child and her environment, not a pathology inside of the child. Cichetti and Cohen (2005) propose that an exclusive focus on symptoms and DSM criteria may be misleading and instead, “adaptive functioning, the nature of the surrounding environment, and the relationship between organism and environment become critical areas for assessment, perhaps even central for understanding of a given disorder” (p. 31). Pathology is marked by the variance in degree from what is considered normative behavior in the context of culture, opposed to having distinct sets of behaviors that are pathological in kind/quality (Coghill & Burke, 2012). For instance, oppositionality is a common behavior in children; it becomes pathological not because it becomes a different kind of behavior but because of its increased quantity in duration, frequency, or magnitude. Child and adolescent disorders occur in a context in which multiple factors interact over time. The person and the environment mutually shape and adapt to each other.

The major premise of developmental psychopathology is that psychopathology develops and is governed by developmental principles which play out in multiple developmental domains (Cicchetti, 2005; Sroufe & Rutter, 1984; Sroufe, 2013). Clinicians need to understand normative ranges and identify the range of normative behaviors and feelings as continua and not as hard and fast thresholds. With the ideas of transactional processes and normative ranges, a developmental systems approach to understanding mental health disorders among children and adolescents focuses our attention on three processes:

1. Developmental processes that contribute to physical, social, emotional, cognitive, and behavioral outcomes.

2. Systemic influences (highlighting risks and protective factors) on the child, including the child herself (genetic predispositions and other biological factors), parents, caregivers, neighborhood, extended family, school, peers, and society.

3. Transactions within and between the child and systems and the mutual reciprocity that affects child outcomes.

The clinician must bring their attention to the many tensions in these concepts, especially when considering psychopathology versus normality, what is considered to be health functioning, and what is known as developmental continuities and discontinuities (Hayden & Mash, 2014).

Developmental Processes. As child and adolescent clinicians, we need to know children and appreciate their developmental processes that secure each developmental task. This does not mean that we need to memorize every developmental milestone at each stage, but we do need to be attuned to what children are likely to be doing within their developmental period and alert to indicators of possible developmental delay. We also need to know how this process unfolds. The developmental pathway helps us understand the process of continuities and discontinuities of development through repeated assessments and clinical judgments over time. The synthesis of these assessments and judgments can come from effective strategies of intervention, including referral for developmental or medical assessment, investigation of antecedents and consequences of both normative and developmentally out-of-step behavior or emotion and consultation to more directly assess concerns In addition, accurate diagnosis of mental health disorders among youth require knowledge of emotional and social maturity for a given age range in order to distinguish disordered behavior from normative behavior.

A developmental systems approach explains impairment in terms of an outcome of interactions between the genetic susceptibilities of the individual, her developmental needs and capacities of the moment transacting according to the goodness-of-fit with the environment (Cicchetti, 2005; Sroufe, 2013). There are mutual reciprocal changes in this ever-evolving relationship between the person and the environment. The idea of successful adaption to the environmental adversity is known as resilience, and often resilience may be related to protective factors, or those conditions that serve to buffer vulnerabilities to dysfunction and unsuccessful adaptation to environmental adversity (Hayden & Mash, 2014).

A developmental systems perspective incorporated into this approach brings our attention to concepts of equifinality and multifinality. When similar environments transact with different individuals to produce different outcomes, multifinality is observed (Cicchetti & Rogosch, 1996). For example, identical twins raised in the same environment are unique individuals with their own personalities and social emotional make-ups. With equifinality,different combinations of biological and psychological predispositions of different children combine with different environments yet produce a similar outcome (Cicchetti & Rogosch, 1996). As we work with children and families, we will encounter children with varying predisposing factors who demonstrate similar diagnostic syndromes and children with similar predisposing factors who demonstrate varying diagnostic syndromes. We need to remain open to all information and the potential of each child and adolescent we meet.

The developmental trajectory and outcome of each child throughout her lifetime is also one of vast potential. Rutter (2012) refers to earlier research which demonstrates that the same experience of risk can release multiple trajectories. For some, the individual might show a traumatic reactivity with negative consequences, while others might show what Rutter calls a “steeling” effect. Developmental trajectories can be stable or show dramatic changes over time, and there is not a singular cause for pathology. It is important to determine factors across many levels of the child’s life as part of our understanding of their developmental trajectory and the potential for positive influences to improve developmental outcomes.

Normative Developmental Ranges and Domains. Child pathology can be defined through recognizing its presence as an adaptational difficulty or incongruence with generally held social standards, i.e., through the social judgments of collective adults in the child’s life. There are various theories highlighted in child psychopathology literature, ranging from psychodynamic and attachment models to social learning, behavior, and cognitive models, to constitutional/neurobiological models, to interpersonal or family systems models. These theories will be surveyed in the intervention section of this book. For our purposes here, we will focus on normative developmental ranges and domains, which are a more concrete guide of child psychopathology for practitioners. Four central developmental domains have often been cited in the literature: 1) Cognitive Development; 2) Language Development; 3) Sensory-Motor Development, and 4) Social and Emotional Development (Drabick, 2009; Kendall & Comer, 2010; Pollak, 2015; Sroufe, 2013).

History of developmental issues can be informative to the presenting issue (Thapar & Riglin, 2020). In addition to these indirect effects of developmental difficulties, it is critical to know of developmental delays or challenges associated with specific disorders. Language and cognitive developmental delays as well as social skill deficits can each be associated with either criteria or specifiers for Autism Spectrum Disorder (ASD), Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), and Intellectual Disability (ID) (Sroufe, 2013; Thapar & Riglin, 2020). Clinicians must work out whether developmental differences are attributable to a specific mental health disorder or a developmental variation for a child that exists outside of a diagnosis.

Developmental, Systemic Influences

A developmental systems perspective provides a framework to assess systemic and transactional influences in conjunction with developmental processes and normative expectations as each separately or in combination relate to developmental differences and criteria or symptoms of specific mental health disorders (Hayden & Mash, 2014). It is also through a developmental systems lens that we can not only assess and diagnose but also intervene with strategies that are designed to improve functioning both within and between systems. As we consider the factors about gene-environment and development as well as transactional processes, consider various epidemiological considerations that weave throughout, such as age differences, socioeconomic status, sex differences, rural versus urban differences, ethnicity, and culture.

Gene-Environment and Development. Present and past environmental resources and genetic and biological predisposition of the child interact to create individual outcomes for each child. Hayden and Mash (2014) assert that “most forms of child psychopathology are likely to have an oligo- or polygenic basis, involving susceptibility genes that interact with one another and with environmental influences to result in observed levels of impairment”(p. 5). Genetic influences on mental health disorders are rarely reduced to a direct impact of one specific gene. Rather, our genetic make-up results in genetic predispositions to certain disorders and these predispositions are modified by other genetic factors and our interactions with the environment. Environmental stressors, in particular, appear to have the most impact on the extent to which a genetic predisposition will result in a specific disorder (Thapar & Riglin, 2020). Social adversities are multifactorial but that we can make efforts to identify key elements that may be amenable to change as we work with the child and family (Thapar & Riglin, 2020).

Childhood development is adaptive to prevailing responses and conditions in the immediate environment (Rutter, 2012). Research on early stressors and maltreatment in particular shows what Rutter calls “experience-adaptive programming effects” in which long after the conditions of maltreatment exist, the changed neural pathways of the brain and the reactivity of the HPA axis remain. Cichetti and Cohen (2005) point out that disordered behavior could have been adaptive at one point. However, if it continues when no longer adaptive to the environment, this may create delayed or reduced achievement of social and emotional developmental tasks. The clinician can be instrumental in partnering with the child or adolescent to develop transactions that are adaptive to the current environment.

Transactions and Mutual Reciprocity. This example illustrates both the ways in which the child’s social and emotional development and behaviors are shaped by the early environment and the potential for her to respond in a new adaptation to a healthier environment. But it also demonstrates that when the environment changes, it takes a great deal of time and effort to revise the body’s and brain’s adaptive response. However, when the caregiver is consistent, and there is a persistent new environment, eventually the child’s emotional and behavioral response will adapt once again.

These transactions cannot, however, be one-sided. The caregiving environment can change, but until these changes are internalized, and the consistency of the change is strong enough, the child’s responses to the previous adaptation will remain. It is with time and consistent presentation of healthy transactions that the child can be expected to show positive change. This mutual dance between child or adolescent and adult reflect the reciprocal nature of interactions that shape both the child and the environment. In turn, the environment shifts slightly upon each transaction. For example, Shawna has created an adaptive function based on a past abusive environment. Now that she is in a safe and secure environment, she no longer needs the behavior, but she must repeatedly and consistently experience these new environmental conditions before her neurological and behavioral activation system reorganizes into a more healthy and functional response.

Transactions in a healthy environment must mirror the consistency and duration of the dysfunctional environment which contributed to the maladaptive unhealthy and sometimes disordered behaviors and emotional reactivity. This is challenging for families, the child, and the clinician. Assessment of small changes and encouragement for these changes to continue and build on each other are essential. The mezzo system in which the individual child interacts with the family, school, and peers can allow the child to integrate reinforcement of healthy functional behavior and extinction of previously learned maladaptive responses. The child’s adaptive responses in turn create healthier families, peers, and school environments. This is often the arduous process of developmental systems that clinicians who work with children and adolescents must orchestrate for healing and recovery to occur.

Final Thoughts and Looking Forward

As we have seen, a developmental systems approach combines aspects of the ecological model and the developmental psychopathology framework. These together have a synergism in their joint explanation of the manifestation of childhood emotional and behavioral disorders. While each can stand on its own, both parts of a developmental system assist clinicians in their quest for precision care and help them understand the particular influences and potential palliatives for an individual child. Developmental psychopathology and ecological systems inform the other. A developmental systems theory will allow a systematic approach to each of the clusters of childhood emotional behavioral disorders.

The chapters immediately following this introduction will cover assessment, formulation, and treatment planning, then move to special treatment considerations with psychopharmacology. The first section of the book includes considerations of race, racial trauma, and multicultural counseling to discuss these critical aspects of psychosocial therapy more pointedly. The second section of the book will walk through the most common diagnoses and clinical areas in child mental health, with learnings focused on engagement, assessment, and intervention. Each one of these chapters is prefaced by an interview with a clinical voice in the field, so that readers may understand how this work is done on the ground. The chapters will end with links to open-access resources to provide clinicians with assessment tools and intervention materials that are ready at-hand. The last section of the book will cover organizational factors related to doing behavioral healthcare. Thank you for taking the time to read our book; it is the effort of clinicians trying to give back to other clinicians. When clinicians collaborate, not compete, children and communities can heal.

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