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online publication of undergraduate studies

DEPARTMENT OF APPLIED PSYCHOLOGY

S P R IN G 2 0 1 2


EDITORS

Alyssa Deitchman Javanna Obregon

EDITORS IN TRAINING Kara Duca

Caila Gordon-Koster Coralie Nemhe

         

STAFF WRITERS

Kara Duca

Brit Lippman

Sammy Ahmed

Chloe Mullarkey Josephine Palmeri

FACULTY MENTORS Dr. Diane Hughes

Dr. Catherine Tamis-LeMonda

CONTRIBUTORS Lana Denysyk

Annabelle Moore Coralie Nehme Andrea Paloian Lauren Scarola Jess Trane

GRAPHIC DESIGN & LAYOUT Justin Conway

COVER PHOTO Jess Trane

SPECIAL THANKS NYUSteinhardt Department of Applied Psychology

Applied Psychology OPUS was initiated in 2010 by a group of undergraduate students in NYU Steinhardt’s Department of Applied Psychology. The ideas and opinions contained in this publication solely reflect those of the authors and not New York University. All work is licensed under the Creative Commons Attribution Noncommercial No Derivative Works License. To view a copy of this license, visit http://creativecommons.org


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Contents LETTER FROM THE EDITORS

Alyssa Deitchman & Javanna Obregon | 4

STAFF ARTICLES

Epigenetic effects of Maternal Behavior…Sounds a lot like Attachment Theory | Sammy Ahmed | 6 Mean Kids, Mean Moms? Exploring the maternal relationship to children’s relational aggression | Kara Duca | 8 Problematizing Perfectionism: A Closer Look at the Perfectionism Construct | Brit Lippman | 11 Food Allergy and Bullying: The Implications for Parents of Children with Food Allergies | Chloe Mullarkey| 14 Child Maltreatment and Resilience in the Academic Environment | Josephine Palmeri | 17

SUBMISSIONS

The Role of Consumer Satisfaction in Psychiatric Care | Lana Denysyk | 21 The Many Treatment Methodologies for Phobias: Finding the Best Fit | Annabelle Moore | 26 The Effect of Post Traumatic Stress Disorder on the Ability to Recognize Facial Expressions Coralie Nehme | 29 The Female/Athlete Paradox: Managing Traditional Views of Masculinity and Femininity | Andrea Paloian | 32 Socio-emotional Interventions: The Efficacy of Socio-Emotional Interventions in Head Start Classrooms | Lauren Scarola | 38 PSTD and type of trauma: Comparing the type of trauma and the severity of PTSD symptoms in children and adolescents | Jess Trane | 43

ABSTRACTS

The Role of Community Connection for Immigrant Youth’s School Engagement | Sammy F. Ahmed | 48 Household Economic Shock and the Academic Experiences of College Women | Alyssa Deitchman | 48 Sexual Minority Identity Development, Onset of Same-Sex Sexual Behavior, and HIV Risk Outcomes | Elizabeth Glaeser | 49 Parent-Child Interactions in Behavioral Treatment of Selective Mutism: A Case Study | Christina M. Mele | 49 Children’s Fictional Narratives: Gender Differences in Storytelling | Javanna Obregon | 50 Risk-Taking Behaviors in First Generation Immigrant Adolescents: The Role of Acculturative Stress and Social Support | Josephine M. Palmeri | 50 Promoting the Mathematics Achievement of Economically Disadvantaged Latino and African American Students: Understanding the Roles of Parental Involvement and Expectations | Steven Roberts | 51 Caregiver and Teacher Use of Evaluation and the Development of Latino Preschoolers’ Socio-Emotional Skills | Lauren Scarola | 51

STAFF & CONTRIBUTOR BIOS | 53


Letter from the Editors

Â

Letter from the Editors

To Our Readers,

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Reflecting back on our last four years as students of Applied Psychology in Steinhardt, as  well as our last two years of reading, writing and editing for OPUS, it is difficult to believe this part of our lives is concluding. Our commitment to providing Applied Psychology students with a platform for their inspired research has driven us to work tirelessly for our fellow students, esteemed faculty, and for ourselves. Since its conception, OPUS has always strived to highlight the passion for social justice and behavioral research of the Applied Psychology community, as well as the high caliber of student work. The current issue features various topics including but not limited to the relationship between neurons and attachment theory, interventions for the generally overlooked population of children with food allergies, and types and outcomes of Post Traumatic Stress Disorder. Through the work of our dedicated staff and contributors, we at OPUS hope to both provide our readers with a diverse range of literature as well as reflect the interests of the NYU Applied Psychology community at large. Though the current editorial staff and many of our staff writers are graduating, we have faith that the new editors, Kara Duca, Caila Gordon Koster and Coralie Nehme, will continue to maintain the same level of excellence that OPUS has always upheld. We hope that the breadth of issues this publication draws attention to challenges your own assumptions and current knowledge. It has been an honor for us to provide undergraduate students with a platform to voice their opinions and interests, a tradition that we hope will continue for years to come. With gratitude,

Alyssa Deitchman Editor

Javanna Obregon Editor

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Staff Writer articles                  


Ahmed

| Epigenetic effects of Maternal Behavior…| 6

Epigenetic effects of Maternal Behavior… Sounds a lot like Attachment Theory

Sammy Ahmed In the realm of human development, there is large debate as to whether “nature” or “nurture” is more influential to various aspects of human development. The field of developmental psychology recognizes both nature and nurture as deterministic forces, however, places a large emphasis on the influences associated with “nurture”, providing evidence that the postnatal family environment is the primary force in the development of individual differences in personality (Zhang & Meaney, 2010). On the other hand, developmental biologists tend to view human development with a “nature” lens. For example, biological or evolutionary approaches understand the brain and its development as being subject to evolutionary forces outside of immediate environmental factors. Additionally, geneticists provide evidence that variation in behavior is merely variation in DNA sequence (Zhang & Meaney, 2010). Although these two opposing perspectives make the umbrella field of human development very dynamic and comprehensive, the emerging field of epigenetics has the potential to unite these two disciplines and provide a unified understanding of human development. Epigenetics is a field of evolutionary biology that focuses on non-heritable modifications in genetic material and the various factors that can alter gene expression (Lillycrop et al., 2007), such as DNA methylation. When regions of genes are methylated, the factors necessary for expression are inhibited. Conversely, the de-methylation of gene regions enhances gene expression (Henckel, Toth, & Arnaud, 2007). In other words, DNA methylation causes certain genes to be “turned on or off” without changing the actual DNA sequence (Moalem & Prince, 2007). To get a better understanding of how epigenetics works, consider the famous ‘skinny brown mouse study’ at Duke University. During this study, a team of scientists utilized fat yellow mice to test their epigenetic hypothesis (Moalem & Prince, 2007). These fat yellow mice typically gave birth to fat yellow mice because of a gene called agouti, which gave them the chubby/yellow characteristics (Moalem & Prince, 2007). However, when the treatment group was fed a different diet, they gave birth to skinny brown mice. Interestingly, when analyzing the skinny brown mice’s genetic code, the researchers found that the agouti gene was still present but the characteristics the gene provided were no longer apparent (Moalem & Prince, 2007). The researchers deduced that altering the

maternal mouse’s diet caused the gene to be turned off. In other words, the new diet, which included “methyl donors” triggered the methylation of the agouti genes and suppressed the gene, which led to skinny brown mice (Moalem & Prince, 2007). Shortly after the ‘skinny brown mouse experiment’, the field of epigenetics exploded. It was evident that genetic sequence is not set in stone and environmental factors can alter the expression of certain genes. Just a brief overview about genetic coding and expression, the genetic make-up/code is called genotype, this determines the genes that are acquired but not necessarily the genes that are expressed; the expression of genes is called phenotype (Mustard, 2010). For instance, identical twins have the same DNA (genotype) but oftentimes will have different experiences, which leads to differences in gene expression (phenotype). Studies reveal that identical twins can have a 30% difference in behavior as adults. According to the epigenetic theory, this difference is likely to be related with the epigenetic affects in early development (Mustard, 2010). There have been numerous studies examining epigenetic effects on various psychological outcomes. For example, studies have revealed that epigenetics could be a factor in schizophrenia, bi-polar disorders and Attention Deficit Hyperactivity Disorder (Mustard, 2010). Whereas the ‘skinny brown mouse experiment’ showed how factors before birth could affect the offspring’s characteristics, studies have also shown that epigenetic modifications can occur after birth. In fact, a study at McGill University set out to examine whether there could there be epigenetic changes after birth. According to Meaney & Szyf (2005), the interaction between mothers and their offspring could provoke epigenetic changes in their offspring’s phenotypes. The results of their experiment reveal that when baby rats received different levels of attention from their mothers, they grew up with relatively different temperaments. Rats who received more attention from their mothers shortly after being born grew up to be relaxed, sociable and handled stress better than their attention deprived counterparts, who grew up to be nervous and more susceptible to stress (Meaney & Szyf, 2005; Moalem & Prince, 2007). To rule out genetic effects, the researchers switched the baby rats; they gave the baby rats from mothers that tended to be less attentive to more attentive mothers. Regardless of the biological mother, the babies who received more maternal care, grew up to be well-adjusted and

A Different Kind of Bully


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had ‘better social skills’ (Moalem & Prince, 2007). Furthermore, the follow-up gene analysis revealed that the rats that received more maternal attention had a decrease in methyl makers of the genes associated with brain development, so the researchers concluded that the maternal care removed the methyl markers that would have otherwise caused their nervous temperament (Moalem & Prince, 2007). Interestingly the results of Meany’s experiment appear very similar to John Bowlby’s ethological theory of attachment. The ecological theory of attachment was established in 1969 and has been a prominent theory in developmental psychology, as it attempts to understand how the infantcaregiver bond is related to the child’s feelings of security, emotional development and future relationships. The notion of establishing a secure attachment to the primary caregiver is paramount to this theory and is linked to various social and emotional outcomes. During the pre-attachment phase (birth-6 weeks), having an attentive caregiver is crucial to the establishment of this attachment, as it helps newborns feel connected and comforted (Berk, 2009). According to Sroufe (2005), children who had secure attachments to their caregivers displayed higher levels of selfesteem, social competence and empathy than children with insecure attachments during preschool. When tested again at age 11, the children who had secure attachment to their primary caregiver, displayed better social skills and closer relationships with peers; these children continued to benefit from their secure attachments as children throughout their adolescent and adult years (Sroufe, 2005). Although epigenetic principles have revealed some important findings as they relate to psychological development, the challenge lies in integrating genetic and biological principles into a very environmentally based discipline, such as developmental psychology. The findings do not necessarily contract the fundamentals of environmental influences on psychological processes and development; however, reveal how genetics and the environment interact with each other and, together, play a large role in human development. To adopt a holistic approach, is to better understand the dynamics of human development and is crucial in moving forward in both biologically and environmentally based disciplines. References Berk, L. E. (2009). Child development (8th ed.). Boston, MA: Pearson Publishers. Henckel, A., Toth, S., & Arnaud, P. (2007). Early mouse embryo development: Could epigenetics influence cell fate determination? Bioessays, 29(6), 520-524. Lillycrop, K. A., Slater-Jefferies, J. L., Hanson, M. A., Godfrey, K. M., Jackson, A. A., & Burdge, G. C. (2007). Induction of altered epigenetic regulation of the hepatic glucocorticoid receptor in the offspring of rats fed a proteinrestricted diet during pregnancy suggests that reduced DNA methyltransferase-1 expression is involved in impaired DNA methylation and changes in histone modifications. Br Journal of Nutrition, 97(6), 1064-1073.

Meaney, M. J., & Szyf, M. (2005). Maternal care as a model for experience-dependent chromatin plasticity? Trends in Neuroscience, 28(9), 456463. Moalem, S., & Prince, J. (2007). Survival of the sickest: The surprising connections between disease and longevity. New York: HarperCollins Publishers. Mustard, J. F. (2010). Early brain development and human development. Encyclopedia on Early Childhood Development. (Published online February 17, 2010) Sroufe, L. A. (2005). Attachment and development: A prospective, longitudinal study from birth to adulthood. Attachment and Human Development, 7, 349-367 Zhang, T., & Meaney, M. J. (2010). Epigenetics and the environmental regulation of the genome and its function. Annual Review of Psychology, 61, 439–66. doi: 10.1146/annurev.psych.60.110707.163625

Author’s Biography

Sammy Ahmed is a senior in the Applied Psychology honors program. He works with Dr. Selcuk R. Sirin on The Meta-Analysis of the Immigrant Paradox Project (MAP) and The New York City Academic and Social Engagement Study (NYCASES). Sammy has recently been awarded the Outstanding Research Contribution Award for his honors thesis and his work with Dr. Sirin, as well as the Founder’s Day Award. He will also be Applied Psychology’s Banner Barer at this year’s Baccalaureate Ceremony. His research interests lie at the intersection of psychology and medicine, with an emphasis on the psychological and sociocultural triggers for disease. He will be attending Harvard University next fall to continue his premedical studies, with the ultimate goal of attaining an MD/Ph.D.


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Mean Kids, Mean Moms?

Exploring the maternal relationship to children’s relational aggression

By Kara Duca

| Mean Kids, Mean Moms? | 8

Increases in popular media depictions of adolescent “Mean Girls” in the last decade highlight the destructive and all too common pattern of relational aggression among young girls. Generally, relational aggression encompasses behaviors that attempt to harm others through the manipulation of relationships (Crick & Grotpeter, 1995). Behaviors associated with relational aggression include threats of social exclusion, actual social exclusion or ostracization, and spreading rumors or gossip within a peer group (Crick & Grotpeter, 1995; Young et al., 2006). In contrast to physical aggression, which is more overt, most relational aggression is concealed behind a façade of kindness and even friendship (Reed et al., 2008; Tackett et al., 2009). Research has shown relational aggression to relate to a host of detrimental outcomes for victims, including negative internalizing and externalizing symptoms, isolation, and peer rejection (e.g., Card, Stucky, Sawalani, & Little, 2008; Crick et al., 2001). This research underscores the idea that relational aggression can be just as serious and harmful as physical aggression, as it can negatively affect a child’s development in many ways. Because of the longstanding belief that parent-child interactions profoundly affect a child’s beliefs surrounding proper behavior, research suggests that parents should be vigilant in identifying and preventing signs of relational aggression in their children (Kawabata et al., 2011; Maccoby & Martin, 1983). Yet, what if some parenting behaviors unintentionally bring about the opposite result, and end up increasing relational aggression in children? In particular, research suggests that mothers’ beliefs about the seriousness and harmfulness of relational aggression, their use of emotional discourse, and patterns of psychological control all contribute to relational aggression in children (Garner, Dunsmore, & Southam-Gerrow, 2008; McNamara, Selig, & Hawley, 2010; Werner, Senich, & Przepyszny, 2006). One particular way that mothers may influence children’s perception of relational aggression is through their diverse reactions to different types of aggressive behavior. In a study examining variations in mothers’ responses to children’s physical and relational aggression, Werner and her colleagues (2006) found a large discrepancy in beliefs concerning various types of aggression. Whereas only 1.3% of mothers said they would not intervene in the physical aggression conflicts, 13.5% of mothers claimed they would not intervene in their child’s relational aggression conflicts (Werner et al., 2006). Furthermore, when mothers were asked how they would react to various hypothetical situations that depicted their child engaging in either physical or relational aggression, mothers overwhelmingly reported that they would be less disturbed by instances of relational aggression (Werner et al., 2006). These results support prior evidence suggesting that adults view physical aggression as more serious and harmful than relational aggression (Colwell et al., 2002; Young, Boye, & Nelson, 2006). Although physical aggression is also worrisome, adults’ views on relational aggression could perpetuate a harmful and dangerous pattern of relationally aggressive behavior in a child. When mothers downplay the seriousness of


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relational aggression, their lack of interventions in child-peer conflicts may act as a mechanism through which mothers may unintentionally socialize relationally aggressive behavior in their children (Werner et al., 2006). In other words, seeing their mothers respond negatively to physical aggression but not relational aggression, young children adopt the belief that relational aggression is an acceptable alternative method of social manipulation. By placing their primary concern on addressing and minimizing children’s physical aggression, mothers minimize the harmfulness of relational aggression, providing a kind of negative reinforcement to their children to continue engaging in these behaviors. Though young children may not yet understand the concept of “social manipulation,” such reinforcement perpetuates the belief that relational aggression is an acceptable means for a child to get what he/she wants. Thus, the practice of discriminating between physical and relational aggression and placing more emphasis on minimizing the former is one means through which mothers may unintentionally socialize relationally aggressive behavior in their children. In addition to maternal beliefs about the need to respond to various forms of child aggression, specific mother-child communication patterns may be linked to the development of relationally aggressive behavior in children. In one study, mothers who frequently explained emotions during story-telling with their children were more likely to have children who engaged in prosocial behavior (Garner et al., 2008). Ironically, these emotional explanations (i.e., statements meant to identify the cause or effect of an emotion) were also positively correlated with children’s relational aggression. These results suggest a two-step process that leaves considerable room for outside factors and other components of the mother-child relationship to exert an effect. It seems that maternal explanations of the dynamics of emotion facilitate interpersonal sensitivity in the child; the ability to recognize various emotions, surmise their causes, and predict the consequences of different behaviors on emotions in storybook characters then transfers over to a child’s realworld contexts. Thus, during encounters with others, the child has the choice to use this newfound social knowledge either “to benefit and co-operate with others (prosocial behavior) or to acquire resources for themselves (relational aggression)” (Garner et al., 2008, p.269). However, there is a great need for further research into this relationship that controls for various demographic variables and child’s baseline emotional competence, as these variables have somewhat clouded the analysis of the interaction between maternal emotional discourse and child relational aggression. Though it seems apparent that mothers’ emotional explanations play a role in the socialization of children’s relational aggression, is not yet clear how the child decides whether to invest his/her emotional knowledge in prosocial or relationally aggressive behavior. This gap in the literature leaves ample room for further research into potential parental practices and styles that foster relational aggression in children. Along with maternal beliefs and communication patterns, mothers’ use of psychological control plays a multifaceted role in the likelihood that children will engage in

relationally aggressive behavior (McNamara et al., 2010; Reed et al., 2008). Psychological control, a parenting style often studied in the context of relational aggression, includes devices such as guilt induction, conditional love, and repeated expression of disappointment with the child in order to manipulate the parent-child relationship and control the child’s behavior (Kawabata et al., 2011; Nelson & Crick, 2002). Parental psychological control, which is itself a kind of relational aggression, can hinder the development of a child’s psychological autonomy and social competence. Furthermore, this type of parenting can even affect the child’s own patterns of relational aggression (Kawabata et al., 2011; Nelson et al., 2006). For instance, research indicates that children whose mothers engaged in high levels of psychological control displayed significantly higher levels of relational aggression than children whose mothers ranked low in psychological control (McNamara et al., 2010). However, these differences leveled out when mothers displayed high amounts of autonomy support (i.e., encouraging independence and active problem-solving; McNamara et al., 2010). The fact that autonomy support can potentially mitigate the negative effects of maternal psychological control suggests that efforts to increase maternal autonomy support may be more beneficial than interventions to decrease psychological control (McNamara et al., 2010). Interestingly, no empirical study to date has shown maternal relational aggression to independently predict child relational aggression, though maternal psychological control provides a link between these two constructs (Reed et al., 2008). Mothers who engage in relational aggression in their own social relationships are more likely to use psychological control with their children, suggesting that mothers transfer emotionally manipulative behavioral patterns across contexts (Reed et al., 2008). Research has speculated that social reinforcement, in the form of increased social status or successful manipulation of others in order to achieve some desired result, leads adults to perceive relationally aggressive behavior as having an valid purpose, a speculation that is in line with Werner et al.’s (2006) research about the subtle reinforcement of relational aggression in children (Reed et al., 2008). Given that maternal psychological control correlates positively with child’s relational aggression, psychological control may act as an indirect connection between maternal relational aggression and child relational aggression. When children see their mothers receiving social benefits from behaving in relationally aggressive ways and do not encounter resistance or objection for engaging in these behaviors themselves, they begin to think that social manipulation is a valid and acceptable strategy for getting what they want. Furthermore, when parents passively reinforce such behavior, children cannot understand the harm that their actions inflict upon their victims. Relational aggression is a serious form of mental and emotional injury that is related to a plethora of negative internalizing and externalizing outcomes in victims (Young et al., 2006). Despite the fact that physical aggression has traditionally received more research attention, relational aggression can inflict just as much harm


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on its victims. Research suggests that mothers play an integral role in the development of children’s relationally aggressive behavior through minimizing the seriousness of such behavior in comparison to physical aggression, using psychological control while inhibiting autonomy development, and employing specific patterns of emotional discourse. Because maternal relationships are a rich source of socialization for young children, it is essential to gear them towards the production of beneficial, prosocial behavior rather than self-seeking, interpersonally damaging behavior. However, interventions to instill prosocial behaviors in children will only be beneficial when relational aggression and other forms of emotional abuse achieve parity with their physical counterparts in the minds of researchers and laypersons alike. It is only at this point that society may be able to realize that the experience of social exclusion, ostracization, and manipulation day in and day out can and will hurt a child just as much as a kick in the stomach. References Archer, J. & Coyne, S. M. (2005). An integrated review of indirect, relational, and social aggression. Personality and Social Psychology Review, 9, 212-230. doi: 10.1207/s15327957pspr0903_2 Card, N. A., Stucky, B. D., Sawalani, G. M., & Little, T. D. (2008). Direct and indirect aggression during childhood and adolescence: a metaanalytic review of gender differences, intercorrelations, and relations to maladjustment. Child Development, 79, 11851229. doi:10.1111/j.1467-8624.2008.01184.x Colwell, M. J. Mize, J. Pettit, G. S. & Laird, R. G. (2002). Contextual determinants of mothers' interventions in young children's peer interactions. Developmental Psychology, 38(4), 492-502. doi: 10.1037/00121649.38.4.492 Crick, N. R., & Grotpeter, J. K. (1995). Relational aggression, gender, and social-psychological adjustment. Child Development, 66, 710-722. Crick, N. R., Nelson, D. A., Morales, J. R., CullertonSen, C., Casas, J. F., & Hickman, S. E. (2001). Relational victimization in childhood and adolescence: I hurt you through the grapevine. In J. Juvonen & S. Graham (Eds.), Peer Harassment in School: The Plight of the Vulnerable and Victimized (pp. 196-214). New York: Guilford Press. Garner, P. W., Dunsmore, J. C., and SouthamGerrow, M. (2008). Mother-child conversations about emotions: linkages to child aggression and prosocial behavior. Social Development, 17(2), 260-277. doi: 10.1111/j.14679507.2007.00424.x Kawabata, Y., Alink, L. R. A., Tseng, W., van IJzendoorn, M. H., & Crick, N. R. (2011). Maternal and paternal parenting styles associated with relational aggression in children and adolescents: A conceptual analysis and meta-analytic review. Developmental Review, 31, 240-78. Maccoby, E. E. (1992). The role of parents in the socialization of children: an historical overview. Developmental Psychology, 28(6), 1006, 1017. doi: 0012-I649/92/

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Mahoney, A., Donnelly, W. O., Boxer, P., & Lewis, T. (2003). Marital and severe parent-toadolescence physical aggression in clinic referred families: mother and adolescent reports on co-occurrence and links to child behavior problems. Journal of Family Psychology, 17, 3-19. doi: 10.1037/08933200.17.1.3 McNamara, K. A., Selig, J. P., and Hawley, P. H. (2010). A typological approach to the study of parenting: associations between maternal parenting patterns and child behaviour and social reception. Early Child Development and Care, 180(9), 1185-1202. doi: 10.1080/03004430902907574 Reed, T. J., Goldstein, S. E., Sheffield Morris, A., and Keyes, A. W. (2008). Relational aggression in mothers and children: links with psychological control and child adjustment. Sex Roles, 59, 39-48. doi: 10.1007/s11199-0089423-5 Tackett, J. L., Waldman, I. D., and Lahey, B. B. (2009). Etiology and measurement of relational aggression: a multi-informant behavior genetic investigation. Journal of Abnormal Psychology, 118(4), 722-733. doi: 10.1037/a0016949 Werner, N. E., Senich, S., and Przepyszny, K. A. (2006). Mothers’ responses to preschoolers’ relational and physical aggression. Applied Developmental Psychology, 27, 193-208. doi: 10.1016/j.appdev.2006.02.002 Young, E. L., Boye, A. E., and Nelson, D. A. (2006). Relational aggression: understanding, identifying, and responding in schools. Psychology in the Schools, 43(3), 297-312. doi: 10.1002/pits.20148

Author’s Biography Kara Duca is a junior in the Applied Psychology program. Her main research interests include the development of ethnic identity and self-esteem among urban adolescents, as well as the influence of acculturation-related stressors on mental health outcomes. Currently, Kara is an OPUS editor-intraining. After graduating, she plans to pursue a doctoral degree in counseling psychology.


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Problematizing Perfectionism: A Closer Look at the Perfectionism Construct BRIT LIZABETH LIPPMAN

Growing up, most of us have heard that practice makes perfect, a common idiom that elicits a dual interpretation. On the one hand, the phrase may serve as an incentive for perseverance—if we simply work hard enough, we can eventually achieve our goals and reach success. However, it also implies that perfect is an attainable way of being, and there must be something wrong with us if our performance remains flawed after excessive practice. The scholarly literature reflects this dichotomous view of perfectionism by addressing both the benefits and risks that are associated with the desire to be perfect. Most scholars contend that while being a perfectionist may contribute to success, it can also serve as a detriment to psychological wellbeing. In fact, the discussion continues among scholars as to whether perfectionism can ever be classified in a positive light or whether it is strictly a negative quality. Interestingly, studies have found links between perfectionism and certain psychopathology that shed light on the importance of studying the construct. Although research has come a long way in identifying these links and understanding the thought processes of perfectionists, it has done little to acknowledge the broader social context that play into perfectionist thinking and behavior. The current article reviews the evolution of perfectionism as a psychological construct while acknowledging the gaps in the research that warrant further consideration, particularly with regard to the social context of perfectionism. Over the past few decades, researchers have adopted an increasingly dimensional perspective on perfectionism that has resulted in various classifications of the construct. The multidimensional measure of perfectionism, established by Frost et al. (1990), acknowledged five different dimensions of the construct, including Personal Standards, Concern Over Mistakes, Parental Expectations, Doubting of Actions, and Organization. According to Frost’s model, perfectionists are individuals who set high and often unrealistic standards for themselves and evaluate themselves harshly if they do not meet those standards. They believe that their parents will judge them stringently for mistakes and they tend to equate these mistakes with failure. Perfectionists may also feel unconditionally dissatisfied with tasks they complete, and can be preoccupied with order and organization (Frost et al., 1990). Frost et al.’s (1990) breakdown of these different components of perfectionist thinking served as an important initial step to understanding the cognition underlying perfectionism. In addition to its individual components, perfectionism is also discussed in terms of its origin and directionality. The literature cites three main types: self-oriented perfectionism, other-oriented perfectionism, and socially prescribed perfectionism (Hewitt & Flett, 1991). Self-oriented perfectionism, as its name suggests, focuses entirely on the self; perfectionists who are self-oriented set specific personal standards and evaluate themselves based on these high standards. If and when their expectations are not met, self-blame ensues. In contrast, other-oriented perfectionism is a display of perfectionist standards directed towards another individual. The other-oriented perfectionist holds others to unrealistically high


Lippman

standards, and harshly evaluates the person to whom the perfectionist behavior is directed. Unlike the other types of perfectionism, socially prescribed perfectionism is externally derived; these perfectionists believe that the important people in their lives will judge them strictly, and consequently bear the burden of measuring up to the expectations of others (Hewitt & Flett, 1991). Thus, the pressure that perfectionists feel to succeed differs for each individual and can manifest in many different ways. However, it is important to consider that labeling the dimensions and types of perfectionists serves to further pathologize perfectionism rather than addressing the larger societal pressures that might be linked to the prevalence of such behavior. In other words, it merely describes the problem without addressing its source. Interestingly, perfectionism is not always considered problematic, and it has been conceptualized in both a positive and a negative light in the literature. One of the first scholars to acknowledge a difference between healthy and unhealthy forms of perfectionism was Hamachek (1978), who differentiated between “normal” and “neurotic” perfectionists. In his seminal work, Hamachek (1978) asserted that all perfectionists are individuals who hold high standards for themselves, but that neurotic perfectionists are unique in that they never feel satisfied despite their successes. According to Hamachek (1978), these normal perfectionists were considered to be adaptive, while neurotic perfectionists displayed a maladaptive form of perfectionism. Later, Slade and Owens (1998) proposed a dual process model that followed a similar ideology to that of Hamachek and other previous theorists, coining the terms positive and negative perfectionism. They asserted that the former was driven by a desire for success and achievement of goals, while the latter was driven by negative reinforcement and the avoidance of failure. In Slade and Owens’ (1998) theory, the concept of possible selves (Markus & Nurius, 1986) seemed to play an integral role in gauging the detrimental nature of perfectionism: positive perfectionists are motivated by the future possible selves that they hope to become, while negative perfectionists strive to avoid the possible selves they fear becoming. Along the same vein, Turner and Turner (2011) contended that higher levels of shame and guilt, and lower levels of pride mark an important difference between healthy and unhealthy perfectionists. Their findings align with those of many fellow researchers who believe that the desire to be perfect should not necessarily be pathologized in all cases. Nonetheless, the dichotomization of perfectionism begs the question: what are the larger external factors that serve to differentiate between healthy and unhealthy perfectionists? The notion that perfectionism carries any potential to be positive has not remained entirely free from criticism. Some theorists express skepticism toward Slade and Owen’s dual model— or any model that suggests a positive side to perfectionism—with concern that it reinforces the image of perfection as a socially acceptable and desirable ideal (Flett & Hewitt, 2006). In fact, researchers raise the controversial question as to whether perfectionism is ever truly a positive quality, emphasizing the danger of “equating

| Problematizing Perfectionism | 12

perfectionism with high levels of conscientiousness” (Flett & Hewitt, 2006, p. 476). Flett and Hewitt (2002; 2006) argue that it is both possible and preferable to be achievementoriented and conscientious without necessarily being a perfectionist. Interestingly, this controversy demonstrates the ways in which Western cultural values of high standards and excellence convolute the dialogue surrounding perfectionism and serve as a mechanism to promote perfectionist behavior by encouraging people to strive for the best (Bieling et al., 2004). Thus, it is possible that the idea of a beneficial perfectionism is actually linked to Western values that foster not only independence, but also a desire to surpass others in achievement. The concern that perfectionism may be harmful stems from links that were found between perfectionism and psychopathology. For instance, Bieling et al. (2004) found that both adaptive and maladaptive forms of perfectionisms are correlated with higher levels of depression, anxiety, stress, and test-taking anxiety, although maladaptive perfectionism alone was found to be a predictor of psychopathology. In particular, the literature has linked perfectionism to both depression and eating disorders such as anorexia nervosa and bulimia (Blatt, 1995; Shafran & Mansell, 2001). In fact, Blatt (1995) referred to the “destructiveness of perfectionism” and addressed the troubling link between perfectionism and suicidal depression. Some scholars suggest that the relationship between these constructs is closely related to locus of control (Blatt, 1995; Periasamy & Ashby, 2002). For instance, one study showed that adaptive perfectionists were found to have a greater external locus of control when compared to adaptive perfectionists, meaning that their motivation for achievement is externally derived and their sense of self-worth is thus dependent on the evaluation of others (Periasamy & Ashby, 2002). Since perfectionists are likely to avoid failure and criticism at all costs, they are also more likely to be depressed when they do not have the control to escape criticism from others (Blatt, 1995). Additionally, with the upcoming DSM-V currently underway, there is a recent push for perfectionism to be emphasized in terms of its relation to several Axis II personality disorders, beyond its current link to Obsessive Compulsive Personality Disorder (Ayearst, Flett, & Hewitt, 2012). Links between mental health problems and perfectionism raise the question: what marks the difference between those who develop this pathology and those who do not? Further, considering the prevalence of perfectionist thinking in cases of depression and eating disorders, why do some scholars continue to assert that perfectionism can be healthy? Overall, the literature surrounding perfectionism provides us with mixed ideas as to whether perfectionism is psychologically healthy or solely harmful. Researchers continue to divide the construct into multiple categories of good and bad, of healthy and unhealthy. In making these classifications, researchers tend to focus on the specific character traits associated with perfectionists. However, they fail to consider the cultural and societal context from which perfectionist traits are born. In doing so, they perpetuate the cycle of pathologizing individuals rather than seeking out the societal ills that


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sparked the problem in the first place. Furthermore, the literature demonstrates the contradictory nature of Western cultural views of perfectionism. On the one hand, striving for perfection is encouraged, but when it results in a psychiatric disorder, the individual receives diagnosis and is classified as an “unhealthy perfectionist.” Future researchers must consider looking beyond individual pathology in order to identify the larger social factors that breed perfectionism.

Slade, P. D. & Owens, R. G. (1998). A dual process model of perfectionism based on reinforcement theory. Behavior Modification, 22, 372-390. Turner, L. A. & Turner, P. E. (2011). The reaction of behavioral inhibition and perceived parenting to maladaptive perfectionism in college students. Personality and Individual Differences, 50, 840-844.

References Ayearst, L. E., Flett, G. L., & Hewitt, P. L. (2012). Where is multidimensional perfectionism in DSM-5? A question posed to the DSM-5 personality and personality disorders work group. Personality Disorders: Theory, Research, and Treatment. Advance online publication. Bieling, P. J., Israeli, A. L, & Antony, M. M. (2004). Is perfectionism good, bad, or both? Examining models of the perfectionism construct. Personality and Individual Differences, 36, 1373-1385. Blatt, S. J. (1995). The destructiveness of perfectionism: Implications for the treatment of depression. American Psychologist, 50(12), 1003-1020. Flett, G. L. & Hewitt, P. L. (2002). Perfectionism and maladjustment: An overview of theoretical, definitional, and treatment issues. In G. Flett & P. Hewitt (Eds.), Perfectionism: Theory, Research, & Treatment (pp. 5-31). Washington, DC: American Psychological Association. Flett, G. L. & Hewitt, P. L. (2006). Positive versus negative perfectionism in psychopathology: A comment on Slade and Owens’s dual process model. Behavior Modification, 30, 472-495. Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R. (1990). The dimensions of perfectionism. Cognitive Therapy and Research, 14(5), 449468. Hamachek, D.E. (1978). Psychodynamics of normal and neurotic perfectionism. Psychology, 15, 27-33. Hewitt, P. L. & Flett, G. L. (1991). Perfectionism in the self and social contexts: Conceptualization, assessment, and association with psychopathology. Journal of Personality and Social Psychology, 60(3), 456-470. Hewitt, P. L. & Flett, G. L. (1993). Dimensions of perfectionism, daily stress and depression: A test of the specific vulnerability hypothesis. Journal of Abnormal Psychology, 102(1), 58-65. Hewitt, P. L., Mittelstaedt, W. M., & Flett, G. L. (1990). Self-oriented perfectionism and generalized performance importance in depression. Individual Psychology, 46(1), 6773. Markus, H. & Nurius, P. (1986). Possible selves. American Psychologist, 41(9), 954-969. Periasamy, S. & Ashby, J. S. Multidimensional perfectionism and locus of control: Adaptive vs. maladaptive perfectionism. Journal of College Student Psychotherapy, 17(2), 75-86. Shafran, R. & Mansell, W. (2001). Perfectionism and psychopathology: A review of research and treatment. Clinical Psychology Review, 21(6), 879-906.

Author’s Biography Brit Lizabeth Lippman is a senior in the Applied Psychology Undergraduate Program . Currently, she works with Dr. Niobe W ay studying the experience of adolescents in Delhi, India. She is also a research assistant to Drs. Alisha Ali and Randy Mowry, exploring m eans of empowerm ent for victims of domestic violence. Brit's research interests include mental health of people with disabilities, therapeutic interventions for people with psychotic disorders, and the phenomenon of gender socialization among adolescents. She looks forward to beginning a doctoral program in Clinical Psychology at Hofstra University this fall.


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| Food Allergy and Bullying | 14

Food Allergy and Bullying: The Implications for Parents of Children with Food Allergies

By Chloe Mullarkey While many regard allergies as a simple or seasonal nuisance, food allergies can have an entirely different impact on children regardless of severity. The ubiquitous nature of food allergies has significant effects on young children’s social and mental development. Similarly, food allergies create a host of implications for parenting children with food allergies. Food Allergy (FA) related bullying is becoming a popular topic for discussion with the recent phenomenon of increases in diagnoses for both children and adults (Ravid et al., 2012). Amongst children, the prevalence of FA is currently estimated to be 4% to 8% (Ravid et al., 2012). A wide variety of foods produce allergic reactions, making food choice a serious daily concern. The most common food allergies for adults and children include peanuts, tree nuts, milk, egg, wheat, soy, finfish, and shellfish (Ravid et al., 2012). Many children are also allergic to different types of seeds, beans, fruits, and grains that make it extremely difficult to control diet. Wang and Sicherer (2009) report that reactions to allergens may be fatal in some cases, with 80% of fatalities accounted for by peanut and tree nuts. Possible exposure to FA in schools, camps, and other social settings represents one of the most significant threats to children with FA (Klinnert & Robinson, 2008). While young children may unintentionally expose themselves to an allergen, exposure can also be due to bullying, as when a classmate exploits the child’s weakness by threatening him or her with an allergen. There has been a surge in the prevalence of bullying due to food allergies, with an increase of 18% in children from 1997-2007 (Ravid et al., 2012). Bullies target children with food allergies in school because the child manages diet and medicine, which is a daily visible struggle. The special treatment children with FA receive can alienate them in school settings, allowing bullies the opportunity to tease and harass a child with FA in numerous ways. Bullying is a serious issue in cases of food allergies because a bully can not only cause psychological damage, but can also use the allergen as a weapon to cause physical harm. In serious cases, this type of bullying can be fatal. Bullying can include waving the allergen in the child’s face or touching the child with the allergen (Lieberman et al., 2010). Thus, the “inherent imbalance of power,” as Lieberman et al. (2010) coin it, sets children with FA at a disadvantage from the start. This is not the typical form of bullying that focuses on a child’s appearance, personality traits, or hobbies, yet it

can have similar effects: feelings of embarrassment, humiliation, sadness and even depression (Lieberman et al., 2010). Children with FA, much like children with diabetes, must learn to manage and accept responsibility of FA, and bullying adds unnecessary stress to this lifestyle. Parents share the child’s struggle when meticulously planning the child’s diet and responding to skeptical parents or family without food allergies. It is, therefore a constant concern for parents who expect schools to protect their children, especially from bullying. Parenting Concerns Although the quality of life of a child with FA can be compromised, parents also experience stress managing their child’s diet and daily routine (Lieberman et al., 2010; Ravid et al., 2012). Findings suggest that parents experience much distress and are often protective, sheltering their children from some of the stress and anxiety that may be a result of managing a life with FA (Valentine & Knibb, 2011). Overprotective parenting in families with FA is a common coping method that can delay children’s selfmanagement and lead to emotional distress when dealing with their FA (Valentine & Knibb, 2011). Such behavior can be expressed by extreme concern for the child’s diet and insistence on allergen-free options in community or school bake sales. On the contrary, parents that do not have children with FA may complain about the allergen-free rule for bake sales and snack time. The negative feedback a child with FA receives from non-FA families can induce negative feelings and shame. Both the stress of maintaining an allergen-free diet and protecting the child from harm can create overprotective or hypersensitive parenting, which shelters a child from the realities of his or her condition (Valentine & Knibb, 2011). Valentine and Knibb’s (2011) study did provide hope, in that older children began to detect the increased meaning of FA in their lives as a consequence of the parents’ diminished micromanaging of diet and medication. There is still much to learn about the transition parents make when handing over responsibility to a child that could help new families struggling with FA. Future research should look more closely at this relationship and perhaps what style of parenting complements FA management best. It would also be beneficial to redefine the term management in FA to take into account mental health (stress and anxiety) and bullying, in addition to risk and avoidance. Determining parenting style is not always intuitive or inherent because parenting operates


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on a trial-and-error method. Parenting is difficult to navigate without support, and for families dealing with FA, there are often more issues to tackle and less available support. Klinnert and Robinson (2008) note that “both overresponding and underresponding patterns of adaptation to children’s food allergies can place families at risk for poor outcome” and that some “struggle to achieve a positive adaptation with a balance between ensuring the child’s safety while achieving normative developmental and family functions” (Klinnert & Robinson, 2008, p. 195). In other words, children with FA often struggle to adjust to different social environments and situations properly. The way in which families raise a child with FA—particularly whether they are overprotective or neglectful—is harmful because the child does not learn how to effectively manage his or her FA and contend with possible bullying (Klinnert & Robinston, 2008). This is problematic because when children are not knowledgeable about their FA, they may not fully understand why they are being bullied and may, in turn, deal with this bullying in an unhealthy way. Alternatively, if children are raised to worry and overstress, the child may grow to resent their condition and may not be equipped to properly handle bullying. While finding a balance between overresponding and underresponding may seem impossible, there are steps parents can take to move towards a middle ground. Parents can take a more holistic approach to management of bullying by keeping an open dialogue with a child and his or her siblings about FA. In these open dialogues, it is important to discuss management of FA: the risks in exposure to allergens, the methods by which to handle an allergic reaction, and the possibility of bullying (Ravid et al., 2012). Parents can also discuss the way in which a child approaches their FA in social settings and how and when they are disclosing to teachers, friends and classmates. Education, voice, and expression are key components to empowerment, and through empowerment, a child can find confidence, resilience and acceptance. Interventions for Parents Shifting away from practices parents can employ in the home, there are other mediums that may inform the parenting of children with FA that are bullied: interventions for parents new to FA. An intervention for families with FA should focus on educating parents about management, the dangers of bullying and how to help the child deal with bullying, perhaps similar to some of the ideas suggested above. Lebovidge et al. (2008) examined the effects of an intervention to increase competence, testing parents prior to the intervention and after the intervention. The Lebovidge study was successful in increasing parents’ level of awareness and understanding of coping strategies, while simultaneously decreasing “perceived burden” (Lebovidge et al., 2008, p. 163). While this study was effective in improving competence of coping and reducing perceived burden, it has yet to be replicated with more families with FA to show reliability and validity across groups. Awareness and understanding of food allergies are essential in creating a discussion and agreement with a child with FA, yet it does not specifically address the concept of bullying.

Mainstream Medical Approach Perhaps researchers would create more interventions for parents and children with FA if practitioner detection of bullying and social and emotional problems was more streamlined. A typical visit to an allergy clinic for a child with food allergies or a child waiting to be diagnosed will show that allergists are primarily concerned with diagnosing and treating the food allergy, but little else. Clinical visits do not, however, always address mental health issues unless a patient or parent is open in bringing up any bullying, which children may not disclose to their parents (Ravid et al., 2012). The break in communication keeps the practitioner from diagnosing mental health issues in children with FA, and prevents families from receiving access to valuable mental health resources. Practitioners can overlook cases of anxiety and bullying because these experiences are not a part of the regimented checkup. Education is necessary for practitioners and specialists alike in regards to the harmful bullying that can occur in patients with FA to correctly diagnose mental health issues and inform parenting (Lieberman et al., 2010; Ravid et al., 2012). If practitioners were more aware and regularly evaluated for symptoms of bullying, the issues would be reported more frequently and perhaps addressed more efficiently. Researchers are, however, beginning to notice the need for more awareness for FA bullying in the medical community. Klinnert and Robinson (2008) suggest regular medical evaluation as a powerful psychological intervention making parents and children aware of the risks and responsibilities while allowing the health care provider to assess for anxiety and emotional distress. Yet, these interventions may not be enough for children with FA if a parent is not proactive in voicing concerns implicating bullying and mental health repercussions. Health care providers should supply patients with information regarding support groups and access to psychiatrists or psychotherapy. Psychotherapy or other forms of therapy/counseling may help a child open up about his struggles with FA and the bullying he may experience on a regular basis. Therapy can also help a child put these thoughts into perspective and develop methods of coping with bullies and the difficulty of managing FA. Support groups are also a good way for children and families to feel like they are not alone. Children may find empowerment simply by talking to others with FA and discussing ways to handle bullying and methods of management. Parents will not receive access to these forums for support if they are not open with their children and encouraging of disclosure of bullying, which ultimately brings us back to the importance of the holistic approach: open dialogue. Discussion It is difficult to adopt a comprehensive perspective regarding the varying severity of FA and consequent bullying. Lieberman et al. (2010) admit that sampling is sometimes biased towards children with more severe cases of food allergies that express concerns about management. If researchers overlook the less severe cases of FA and parents/children who do not express concern about management, they may neglect important trends that speak to why children remain silent about bullying. Parenting can only be informed by


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a child’s disclosure and behavior, which has not yet been a topic of research in terms of FA. Finally, there remains a lack of research addressing food allergy bullying and possible interventions or improvements. Many studies examine bullying prevention and intervention programs in schools, yet few directly address the issue of FA, which should be taken into special consideration. New treatment for FA may lead to better attitudes and decreased anxiety for children with FA, yet it remains unclear whether bullying would decrease as a result of a child’s treatment. Still, there remains a stigma for children with FA that is, in part, due to children receiving special treatment for FA within schools: sitting at a designated table, carrying and selfadministering medicine during the day, and increased attention from teachers or faculty. We must determine if this is a result of overresponsive/underresponsive parenting of FA children, or a characteristic that remains despite parent’s effort to normalize FA (Klinnert & Robinson, 2008). In the future, researchers should observe interventions and therapeutic measures to determine changes that need to be made to school cafeterias, teacher awareness and sensitivity, and the prevention of bullying within schools. There should be a better understanding among non-FA cohorts of the dangers of allergic reactions in children and the damaging effects of bullying on these children. Family therapy is another option for families with FA, and can help the entire family understand the severity and seriousness of the FA while easing some of the negative feelings towards the child’s medical issues within his home (Klinnert & Robinson, 2008). In many ways, FA has become the new ADD in that non-FA parents make claims about the extent to which FA is “over diagnosed” and criticize parents that are struggling to deal with their child’s FA. Fortunately, the increase of awareness in schools and the medical community has driven the development of new forums for food allergy. FAAN (Food Allergy and Anaphylaxis Network) created Camp TAG, a summer camp specifically designed for children with FA who cannot attend camps due to the severity of their FA. Food Allergy clinics, like Mount Sinai’s Jaffe Food Allergy Clinic, are opening at major hospitals around the United States as the need for research into food allergies and the detrimental social and developmental effects on children grow. It is becoming evident that the most important aspect in maintaining the mental health of a child with FA is openness and awareness: if the parent is aware of the child’s bullying, the parent will more than likely react in ways to help support his or her child and effectively manage the problem. If the parent can normalize a child’s FA within the home, the child will more than likely feel comfortable in other social settings and handle bullying more effectively. References Klinnert, M. D. & Robinson, J. L. (2008). Addressing the psychological needs of families of food-allergic children. Current Allergy and Asthma Reports, 8(3), 195-200. LeBovidge J. S., Timmons, K., & Rich, C. et al.

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(2008). Evaluation of a group intervention for children with food allergy and their parents. Annals of Allergy Asthma Immunology, 101(2): 160–5. Lieberman, J., Weiss, C., Furlong, T., Sicherer, M., & Sicherer, S. (2010). Bullying among pediatric patients with food allergy. Annals of Allergy, Asthma, Immunology, 105(4), 282-6. Ravid N., Annunziato R. A., Ambrose M. A., Chuang, K., Mullarkey, C., Sicherer, S. H., Shemesh, E., & Cox, A. L. (2012). Mental health and quality of life concerns related to the burden of food allergy. Immunology and Allergy Clinics of North America, 32(1): 98-95. Valentine, A. Z., & Knibb, R. C. (2011). Exploring quality of life in families of children living with and without a severe food allergy. Appetite (Print), 57(2), 467-474. Wang, J. & Sicherer, S. H. (2009). Immunologic therapeutic approaches in the management of food allergy. Expert Review of Clinical Immunology, 5(3), 301-310.

Author’s Biography Chloe Mullarkey is a senior in the Applied Psychology program. She is a member of Dr. Alisha Ali's research team and a clinical research assistant for Dr. Eyal Shemesh at the Mount Sinai School of Medicine. Her main research interests lie in food allergy and bullying, empowerment interventions and mental health in global public health. Upon graduating, she plans to continue working for Dr. Ali and Dr. Shemesh and pursue a Master in Public Health and Doctorate in Social Intervention Psychology or Clinical Psychology.


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Child Maltreatment and Resilience in the Academic Environment

By Josephine Palmeri

Success within the academic environment is an important value instilled during childhood. Children who are able to gain academic success within their school years are more likely to have an overall sense of well-being throughout childhood and into adulthood (CDC, 2011a). Although it may be ideal for all children to perform well within the school environment, there are many outside factors that can hinder a child’s potential for academic success. Particularly, negative health outcomes related to child maltreatment such as neglect, hunger, and all forms of abuse (i.e., sexual, physical, and emotional) are strong indicators of poor academic performance (CDC, 2011a). Children who are maltreated are less attentive and engaged in school, have higher absenteeism, lower grades, lower test scores, and are more likely to drop out of school than children who are not maltreated (Langsford et al., 2007; Leiter, 2007; Shonk & Cicchetti, 2001; Vig & Kaminer, 2002). Unfortunately, over three million children across the United States are reported as experiencing maltreatment per year (U.S. Department of Health and Human Services, 2010), which suggests that a significant portion of the American student population is subject to performing poorly in school. While a substantial amount of research claims that child maltreatment leads to academic failure, a growing body of literature conversely claims that said relationship differs depending on the personal experience of the individual and the specific type of maltreatment encountered (Coohey, Renner, Hua, Zhang, & Whitney, 2011; Jaffee & Gallop, 2010). The shift in perspective of the literature stems from the gap between the ways in which the construct of child maltreatment was formerly measured and is currently defined. Specifically, child maltreatment is defined as any act or series of acts of child abuse or neglect performed by a parent or other caregiver (e.g., religious leader, coach, or teacher) that result in harm to a child (CDC, 2011b). Because there are many different components that make up child maltreatment, researchers deconstructed this definition by type (i.e., abuse vs. neglect), length of time, and severity when examining how it relates to academic success (Coohey et al., 2011). As a result, recent literature shows that certain factors may compensate for the negative impact that maltreatment has on children’s academic achievement by allowing them to positively adjust to their negative situation (Coohey et al., 2011; Jaffee & Gallop, 2010). Thus, contrary to a formerly held and popular belief, maltreated children have the potential to succeed academically despite experiences of abuse or neglect. Formerly maltreated individuals who are able to overcome the negative affects of their abuse are regarded as “resilient”. Resiliency is defined as a process in which individuals display positive adaption despite experiences of adversity (Luthar & Cicchetti, 2000). Luthar and Cicchetti (2000) developed a two-dimensional risk-resilience framework that includes being exposed to an adversity (i.e., risk) followed by the manifestation of a positive adjustment outcome (i.e., resilience). The positive adjustment outcome acts as a protective factor in the context of high-risk adversities, which may lessen their ability to


Palmeri | Child Maltreatment and Resilience in the Academic Environment

negatively affect the individual. In the context of child maltreatment, protective factors can manifest through a variety of different venues. In particular, the maltreated child’s innate personal traits or attributes serve as significant protective factors against academic failure (Punamaki, Qouta, El Sarraj, & Montgomery, 2006). For example, Coohey et al. (2011) found that children with high levels of intelligence retained high reading and math scores despite encountering maltreatment. Children of high intelligence are also able to overcome the hardships associated with their maltreatment and adapt to the classroom environment by utilizing the resources available to them. In addition, Coohey et al. (2011) also found that those who were maltreated and were diagnosed with behavior problems had higher reading and math scores than those who were not diagnosed with behavior problems. The researchers suggest that this finding may be due to the extra attention that is often given to both students of high intelligence and students with behavior problems. Therefore, a child’s maltreatment is not masked by innate personality traits (e.g., high intelligence or misbehavior) and may serve as a protective factor for this population in that some trains direct school personnel to uncover the child’s abuse or neglect. While the findings of Coohey et al. (2011) show the diversity of personal sources of resilience, it may also suggest that maltreated children of average intelligence or behavior can go unnoticed within the classroom setting. Children who are maltreated, but not attention grabbing or seeking, may not be given the same opportunities or access to resources if they do not display a need for help, which can be especially difficult if the abuse has yet to be an invasive problem. In order to ensure that all children are given the opportunity to positively adjust and succeed academically, future interventions may find it useful to examine the behavioral patterns of maltreated children with high intelligence or behavior problems. Both groups of children are able to develop resiliency towards their adversities by gaining attention and using their support seeking skills. Therefore, interventions can incorporate these attention and support seeking skills into the classroom environment in hopes that all children (i.e., not just children with high intelligence or behavior problems) will seek help when needed, which in turn may manifest resiliency towards the onset of academic failure. Along with personal traits and attributes, research suggests that certain demographic factors of children who encounter maltreatment, such as gender and race, can be a protective factor against academic problems. Research shows that females are twice more likely to develop resiliency than males (DuMont, Spatz Widom, & Czaja, 2007). Females are less impacted by the stigmatization related to being abused or neglected, which enables them to seek help and grow from their experiences…Jaffee and Gallop (2010) found that race can also be a protective factor. More specifically, the researchers used a national survey to examine academic achievement in 2,065 children who were placed into child protective services. The results indicated that although approximately 40 percent of the participants were functioning normatively within the school environment, children who identified as

Black were less likely to achieve or maintain resilience than the children who identified as White. The researchers imply that these findings are related to the widespread achievement test gap between the Black and White populations (e.g., Aronson, 2010; Jaffee & Gallop, 2010), which shows that demographical attributes can impair resiliency as well. Overall, these findings suggest that certain populations (e.g., males, blacks) should be targeted when developing interventions on promoting academic achievement in children who were maltreated. Resiliency is not only an effect of certain demographic factors, but environmental influences have the power to foster or squelch resilience. For example, social supports, secure attachment to primary caregivers, positive relationships with adults, and communication/emotional sharing with others are all protective factors against adversities (Luthar & Cicchetti, 2000). In cases where child maltreatment is not occurring within the home, a supportive family environment that provides nurturance, stable family relationships, child monitoring, parental employment, and access to health care are all useful coping mechanism in that they allow the child to positively adjust within a safe space. However, limited literature examines how these protective factors may influence the academic achievement of maltreated children. One reason that this paucity exists is because roughly 80% of child maltreatment occurs within the child’s home, specifically by the child’s parents (CDC, 2010; Gilbert et al., 2009). Thus, children who are maltreated within their homes may not develop resiliency through secure attachment and positive relationships with their parents, yet may be able create positive relationships in a supportive environment outside of the home. Children who are maltreated often seek support from community members such as teachers or other adults in school (CDC, 2011c), as well as from their peers. Essentially, social support systems play a crucial role in promoting resilience among maltreated children. Within the literature on children maltreatment there is a trend suggesting that the school environment plays a substantially important role in promoting resiliency against academic failure (CDC, 2011c; Coohey et al., 2011; Jaffee & Gallop, 2010). Those children who had social support and resources to cope with their maltreatment typically gained these means through academic connections. This may suggest that older maltreated children are less likely to receive academic support due to their increased likelihood of academic failure. Therefore, future interventions should stress the importance of social support within the school environment of young children who follows into middle childhood and adolescence. Both maltreated and non-maltreated children will realize at a young age that they have access to resources that will help in times of adversities if they have a community and strong social support. While research on the role of resiliency in the relation between child maltreatment and academic achievement has grown over the years, there is still an extensive amount of research to be conducted. More specifically, the experiences of maltreated children can vary based on many different factors—whether it is their experiences of maltreatment, their personality traits, or factors

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outside of their home (e.g., socioeconomic status and neighborhood). Since the manifestation of resiliency can vary based on all of these factors, it may be difficult for interventions to promote resiliency in all maltreated children because different protective factors may only work for certain populations. However, researchers should continue to examine the role of resiliency across populations and different cases of maltreatment. By researchers taking into consideration that child maltreatment is not a uniform experience, future interventions may be able to develop preventive measures that work within and across populations. References Centers for Disease Control and Prevention (2010). Child maltreatment: Facts at a glance. Retrieved from http://www.cdc.gov/ViolencePrevention/pdf/ CM-DataSheet-a.pdf Centers for Disease Control and Prevention (2011a). Adolescent and school health: Health & academics. Retrieved from http://www.cdc.gov/healthyyouth/health_and _academics/ Centers for Disease Control and Prevention (2011b). Child maltreatment: Definitions. Retrieved from http://www.cdc.gov/ViolencePrevention/child maltreatment/definitions.html Centers for Disease Control and Prevention (2011c). Child maltreatment: Risk and protective factors. Retrieved from http://www.cdc.gov/ViolencePrevention/child maltreatment /riskprotectivefactors.html Coohey, C., Renner, L. M., Hua, L., Zhang, Y. J., & Whitney, S. D. (2011). Academic achievement despite child maltreatment: A longitudinal study. Child Abuse and Neglect, 35(9), 688699. doi:10.1016/j.chiabu.2011.05.009 DuMont, K. A., Spatz Widom, C., & Czaja, S. J. (2007). Predictors of resilience in abused and neglected children grown-up: The role of individual and neighborhood characteristics. Child Abuse & Neglect, 31, 255-274. doi: 10.1016/j.chiabu.2005.11.015 Gilbert, R., Spatz Widom, C., Browne, K., Fergusson, D., Webb, E., & Janson, S. (2009). Burden and consequences of child maltreatment in high-income countries. The Lancet, 373(9657), 68-81. doi:10.1016/S01406736(08)61706-7 Jaffee, S. R., & Gallop, R. (2010). Social, emotional, and academic competence among children who have had contact with child protective services: Prevalence and stability estimates. Journal of the American Academy of Child & Adolescent Psychiatry, 46(6), 757-765. doi:10.1097/chi.0b013e318040b247 Langsford, J. E., Miller-Johnson, S., Berlin, L. J., Dodge, K. A., Bates, J. E., & Pettit, G. S. (2007). Early physical abuse and later violent delinquency: A prospective longitudinal study. Child Maltreatment, 12(3), 233–245. doi:10.1177/1077559507301841 Leiter, J. (2007). School performance trajectories after the advent of reported maltreatment. Child and Youth Services Review, 29, 363-382. doi: 10.1016/j.childyouth.2006.09.002 Luthar, S. S., & Cicchetti, D. (2000). The construct of resilience: Implications for interventions and

social policies. Developmental Psychopathology, 12(4), 857-885. Punamaki, R-L., Qouta, S., El Sarraj, E., & Montgomery, E. (2006). Psychological distress and resources among siblings and parents exposed to traumatic events. International Journal of Behavioral Development, 30(5), 385-397. doi:10.1177/0165025406066743 Shonk, S. M., & Cicchetti, D. (2001). Maltreatment, competency deficits, and risk for academic and behavioral maladjustment. Developmental Psychology, 37(1), 3-17. doi:10.1037//00121649.37.1.3 U.S. Department of Health and Human Services (2010). Administration on children, youth, and families: Child maltreatment. Retrieved from http://www.acf.hhs.gov/programs/cb/pubs/ cm08/summary.htm Vig, S., & Kaminer, R. (2002). Maltreatment and developmental disabilities in children. Journal of Developmental and Physical Disabilities, 14(4), 371−386. doi:10.1023/A:1020334903216

Author’s Biography Josephine M. Palmeri is a senior in the Applied Psychology Honors program. She is currently a member of Dr. Selcuk Sirin's Meta-Analysis of the Paradox (MAP) research team. Her honors research project examined the relation between acculturative stress and risk-taking behaviors in first generation immigrant adolescents within an urban context. Her main research interest lies in adolescent development. After graduating, she plans to continue her studies in a counseling psychology graduate program.


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The Role of Consumer Satisfaction in Psychiatric Care Lana Denysyk Abstract This literature review uses past studies from PsycInfo and other medical and psychiatric peerreviewed journals to examine the importance of patient perceptions in a psychiatric inpatient unit, as well as ways to improve these perceptions. More specifically, it looks at the role of customer service in psychiatric inpatient units and how customer service relates to quality of care, patient education, and general atmosphere on the psychiatric ward. Research has shown that personalizing treatment for the patient and utilizing their feedback can create better treatment adherence and improve treatment outcomes. Studies on patient perceptions are lacking, and further research regarding patients with different mental health illnesses in psychiatric inpatient wards is recommended. Keywords: patient perceptions, inpatient, consumer satisfaction

psychiatric,

At the Patient Centered Care Department at New York University’s Langone Medical Center, patient advocates record and respond to patient concerns. Most hospitals employ patient advocates for the sole purpose of improving patient care and perceptions of hospital treatment. Patient perceptions are vital to health care work, as positive perceptions of psychiatric inpatient units can improve patients’ cooperation with their treatment, and ultimately their outcomes. Advocates play a crucial role in treatment by encouraging improved perceptions among patients. At Langone Medical Center, the patient advocates do rounds among many of the hospital departments. While psychiatric patients are able to meet with patient advocates, many times they are not able to discuss their issues on a daily basis. This practice, which is a common occurrence at many hospitals, leaves psychiatric patients without a consistent opportunity to air their grievances and request better treatment. One of the primary responsibilities of a patient advocate is to provide patients with an opportunity to discuss concerns regarding their treatment with a third party outside of their direct care team. Rather than giving preferential care to certain types of patients based on their own personal opinions and perceptions, patient advocates should make it a priority to treat all patients with the utmost care and concern. The practice of ignoring psychiatric patients ultimately affects their perceptions of the hospital and their treatment, which in turn affects their treatment outcomes.

It may be that encouraging patient advocates to do daily rounds with psychiatric patients will increase patient perceptions of the hospital ward, and research suggests that these perceptions may actually improve patient outcomes. Patients’ perceptions of their illness can predict their treatment course, and changing negative illness perceptions can aid in recovery and coping in mental health care by increasing adherence to treatment (Witteman, Bolks, & Hutschemaekers, 2011). It is important to study patient perceptions in psychiatric inpatient care so that the patient is more willing to cooperate with his or her treatment team, which will, in turn, hopefully improve recovery outcomes and achieve a higher level of treatment success. This literature review will examine the importance of consumer satisfaction and patient perceptions in mental health care. More specifically, it will discuss how patient reports on quality of care, patient education, and the atmosphere on psychiatric wards influence their perceptions of hospital care. Finally, it will investigate the ways in which these perceptions may affect patient health outcomes. Consumer Satisfaction The idea of consumer satisfaction as an important factor of care is a relatively new concept for America’s healthcare system. Consumer satisfaction measures the quality of service that consumers receive (Cleary, Horsfall, & Hunt, 2003). Patients’ perceptions of their treatment play a large role in their levels of satisfaction. One of the earliest definitions of mental health consumer satisfaction is the extent to which the treatment fulfills the client’s desires, wants, and wishes (Lebow, 1982). It is important to measure the quality of a healthcare service because a patient’s perspective and experiences are essential to his/her achieved outcomes, which are the criteria for overall treatment success (Howard, El-Mallakh, Rayens, & Clark, 2003; Rosen & Proctor, 1981). Rosen and Proctor (1981) define an outcome as a state that is directly caused by clinician intervention or factors of the intervention itself. Symptom reduction, social and work functioning, satisfaction of services, and perceptions of well-being are all measures of treatment outcomes (Docherty & Streeter, 1996). However, researchers continue to face the issue of determining how to measure consumer satisfaction. The World Health Organization has determined as many as eight aspects of consumer satisfaction pertaining to healthcare: autonomy, choice, communication, confidentiality, dignity, quality of basic amenities, prompt attention, and access to family and community support


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(Brunero, Lamont, & Fairbrother, 2009). In contrast, Brunero, Lamont, & Fairbrother (2009) found only three aspects of patient perception in psychiatric units that predicted overall satisfaction. These aspects were: happiness with the service that workers provided, confidence with the support received after discharge, and feeling safe while on the ward (Brunero et al., 2009). In addition to the challenge of determining which aspects of the healthcare system to assess, researchers must contend with an over-reporting of positive satisfaction among patients using existing consumer satisfaction surveys. Research suggests that, in general, it is characteristic for consumers to report high quality satisfaction on surveys regardless of the quality of the services that they actually received. Kaplan, Busner, Chibnall, & Kang (2001) exposed overreporting of positive satisfaction in hospital settings, showing that both children and parents were likely to report high satisfaction with the child’s stay in the psychiatric unit even after having conflicts with some of the clinicians. Through exaggerating their satisfaction, patients may be attempting to minimize their cognitive dissonance; customers would like to believe that they chose the right service, and to admit that they received inadequate service is dissonant with their perception of themselves as wise consumers (Kaplan, Busner, Chibnall, & Kang, 2001). Thus, in their efforts to believe that they made the right choice in terms of healthcare, they rate the hospital more favorably (Kaplan et al., 2001). Kaplan et al. (2001) also found that in terms of reporting problems on the unit, those children and parents who complained of staff abuse reported levels of problem improvement similar to those who did not report abuse, suggesting that overall satisfaction is not dependent on perception of problem improvement. Research should explore the implications of these findings for various populations in order to determine exactly how problems on the ward interact with levels of satisfaction. The discrepancies that occasionally occur between problems with treatment and levels of patient satisfaction highlight the importance of accounting for all aspects of care, such as problems with staff or first time admission. Researchers found that patients for whom it was their first admission into a psychiatric inpatient unit had much lower overall satisfaction than long-term or repeat patients (Berghofer et al., 2001; Brunero et al., 2009). First time patients may feel shocked upon encountering other patients with severe mental disorders (e.g., psychosis or schizophrenia), and may wonder if their illness is ‘as bad’ as that of the other patients (Berghofer et al., 2001). First admission is also associated with negative perceptions of the unit’s comfort and cleanliness (Brunero et al., 2009). The unit may be comfortable and clean for a hospital, but patients for whom it is their first time staying in a hospital, it may be relatively worse than their own homes. This association suggests a role for expectations in predicting satisfaction levels, as first time patients will have markedly different expectations for their experience on the ward than repeat patients, who understand what the experience will entail. Clinicians and hospital staff can use this data to determine ways to increase patient satisfaction levels.

| The Role of Consumer Satisfaction in Psychiatric Care | 22

Hospitals can dramatically raise patient satisfaction levels with small changes to their psychiatric units. Something as simple as providing a magazine and a bottle of water for patients at intake could reverse their negative perception and render them more open to treatment (Brunero et al., 2009). First time patients may also rate their satisfaction lower if they did not receive an explanation of their rights and responsibilities upon admission to the unit (Brunero et al., 2009). Psychiatric inpatient units should have written information readily available to the patients due to some patients’ inability to retain spoken information based on their mental health status (Brunero et al., 2009). However, these policy improvements may not be enough to improve overall patient perceptions. One study found that even when hospitals provided patients with a comprehensive booklet, patients often felt that the clinicians did not fully explain their reason for admission (Brunero et al., 2009). This again illustrates a discrepancy between consumer expectation and the clinical service delivery, which can have negative effects upon the patients such as misunderstanding one’s diagnosis or lacking confidence in their potential for positive mental health outcomes (Brunero et al., 2009). Small changes on the part of clinicians and hospital staff can greatly affect patient satisfaction levels. For example, education regarding their mental illnesses and reason for admission can increase a patient’s adherence to his or her treatment plan and lead to better outcomes. Hospitals should focus on these kinds of structural improvements in their psychiatric wards in order to encourage better patient outcomes. Patient Reports on Quality of Care Quality of care is one factor affecting patient perceptions. Quality of care in a psychiatric setting is a multidimensional concept, and is therefore difficult to define (Hansson, 1989). One method of operationalizing quality of care is to separate it into an empirical component (i.e., the reality of the care) and a normative one (i.e., the ideal of the care) (Donabedian, 1980). However, one should be wary of such generalizations due to the distinctive characteristics of psychiatric care, namely, the use of the patient and professional relationship as a therapeutic tool (Schroder, Ahlstrom, & Larsson, 2006). While quality of care in psychology can have specific dimensions that are necessary for positive treatment, it is important to remember that certain aspects of this care (i.e., the patient-therapist relationship) are not always conducive to easy and reliable measurement. The care setting plays a role in patient perceptions as well. In other words, patients in a psychiatric setting can have different perceptions of what is important in their care as compared to patients in somatic care settings. Specifically, patients in a psychiatric setting considered the cognitive aspect of their care most important, while somatic patients ranked task-oriented aspects such as technical and medical care as the most important (Schroder et al., 2006). Clinicians should account for and attend to differences between what psychiatric and somatic patients deem most important in their treatment. In order to determine how these patient care perceptions differ, Schroder, Ahlstrom, & Larsson


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(2006) conducted a qualitative interview study with twenty psychiatric patients regarding their perception of the quality of care they received in an inpatient psychiatric setting. The researchers discovered five categories of good quality of care: clinicians respect the patient’s dignity, the patient feels secure with regard to care, the patient was able to participate in the care, the patient recovered, and the quality of the care environment itself (Schroder et al., 2006). The authors concluded that the planning and evaluation of care should include patients’ perceptions of the quality of psychiatric care. Another interesting finding of Schroder et al. (2006) was that most of the psychiatric patients wanted help in reducing the sense of shame that resulted from their diagnosis. Surprisingly, no other study on quality of care shared this finding. Shame can affect patient care by hindering a patient’s willingness to seek help. Today’s society stigmatizes mental illnesses to such a degree that patients often see asking for help as a sign of weakness. By addressing the shame that patients can feel while receiving treatment for a mental illness, clinicians can improve the patient’s perception of the quality of care. One patient describes his/her experience with patient care in a psychiatric inpatient unit: Depression and psychosis are so powerful, you feel so weak and defenseless – so it’s extra important that the staff treat you right, you’re so easily hurt. All it needs is a brusque tone of voice, or that you see they haven’t been listening to what you’ve been saying – and there you are, feeling even more guilty, putting the blame on yourself, more desperate and unhappy than ever. So especially in psychiatric care it’s very important that you’re seen and listened to, I think (Schroder et al., 2006, p.97). Like the patient quoted above, many of the other participants in this study agreed that it is especially important in a psychiatric unit to have highly trained staff that are easy to talk to (Schroder et al., 2006). In addition to having highly trained staff who know how to deal with psychiatric problems, patients wanted continuity in their doctors so that they would not have to “tell their story all over again,” which can add to insecurity in psychiatric care, more so than in other types of care (Schroder et al., 2006, p.97). The experience of having to re-explain their mental health history to each new doctor may make patients feel ashamed, overwhelmed, and insecure about how the doctor will react. This does not occur often with somatic care. The patient–clinician relationship is an incredibly important aspect of treatment, and having multiple doctors compromises and complicates those relationships. Patients also agreed that they would like doctors to include them in the development of their treatment plan and comprehensively explain their condition and treatment process: I mean, I didn’t know a thing, I’d never heard of compulsive thoughts or actions. I thought: ‘What’s happening? I’m going mad.’ But when I got the chance to talk to the psychologist and he described it and explained it, I had some understanding of it and could work on it. It didn’t

frighten me any more once I’d got proper answers to my questions (Schroder et al., 2006, p.98). Explaining the patient’s condition, possible care plan, and potential outcomes can put the patient at ease and potentially allow the patient to become more active in his or her treatment (Schroder et al., 2006). Just as patients would like doctors to include them in the development of their care plan and keep them informed about their treatment process, family members often want these same privileges. Here lies the potential for conflict, as family members tend to hold conflicting values, priorities, and goals from their ill relatives (Lasalvia et al., 2011). These differences typically stem from patients placing more emphasis on daytime activities and independence, whereas family members prioritize symptom reduction and intensive medical support (Lasalvia et al., 2011). Research suggests that family members and staff do share views on how to solve patients’ problems, which is a promising finding that provides encouragement to involve family members more often with treatment (Lasalvia et al., 2011). Therefore, family can help staff with supervising medication, encouraging their relatives to participate in rehabilitation programs, and providing a nurturing environment for recovery (Lasalvia et al., 2011). While the combination of clinician, patient, and family perspectives regarding patient care can often lead to conflict, research supports the extra effort required to surmount these obstacles. The amalgamation of all three perspectives offers a more comprehensive view of how staff and patient interactions operate within real-world mental health services (Lasalvia et al., 2011). This benefits the patient by taking their perspectives regarding day-to-day activities into account, while also focusing on the symptom reduction that is so important to clinicians and family members. Patient Education Patient education, along with other psychosocial interventions, is a crucially important approach to help patients manage their illness (Hatonen, Suhonen, Warro, Pitkanen, & Valimaki, 2010). Patient education involves teaching patients about components of their mental illnesses such as prevalence, risk factors, and prognosis. The general public has a poor level of knowledge regarding mental illnesses such as depression, and when a member of the general public becomes a psychiatric patient, this ignorance translates into negative beliefs about his/her diagnosis (Petrie, Broadbent & Kydd, 2008). These negative beliefs can in turn negatively affect a patient’s knowledge of his/her illness and adoption of active coping skills (Petrie et al., 2008). However, patient education programs must take into consideration the individual needs of patients (Hatonen et al., 2010). One patient described what he would like in his treatment: You want the dialogue to work, you want to take in what’s said to you and really think about it and try to live that way, which may mean changing. When you feel it’s really working, you think what a good thing it is. You want an open dialogue where the staff understand your problem, understand how you feel, and keep the conversation going


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forward (Schroder et al., 2006, p.98). This patient, as well as many others, would like a more personalized treatment approach. One method of personalizing treatment is using information technology (IT), a technique that many patient education intervention programs currently utilize. In the IT patient education modules, patients learn about mental illnesses and available treatments. Patients see this technology as useful because it offers self-paced learning as well as a shorter time commitment than traditional patient education programs. One patient described the benefit of shorter education sessions, highlighting the fact that long, drawn out education programs often tire out the patients whereas shorter sessions allow them an opportunity to rest (Hatonen et al., 2010, p.338). The IT approach to patient education provides individualized learning at the patients’ convenience. Unfortunately, some of the patients believed that while the information they receive in patient education sessions was important, it did not help them with everyday coping (Hatonen et al., 2010). Though IT use for patient education shows great promise, some changes are necessary in order for it to fully help patients and improve outcomes. Patients suggested that the education modules include interactive features and utilize more pictures and videos (Hatonen et al., 2010). Such improvements would address patient concerns concerning the individualization of standardized IT modules. One method of individualizing patient education is to utilize illness perception interventions. These programs have grown out of Howard Leventhal’s theory that in order to understand and cope with health threats, individuals form common-sense beliefs about their illness (Petrie et al., 2008). The process of understanding their symptoms and illness drives the patient’s emotional and coping responses and may lead to more help seeking and improvement in perception of their illness (Petrie et al., 2008). Illness perception interventions are an important aspect of patient education and treatment because patients who believe that their treatment is effective tend to better keep to treatment and rehabilitation programs (Petrie et al., 2008). Initial studies have shown that illness perception interventions are applicable to many different common mental health disorders including schizophrenia, non-affective psychotic disorder, bipolar disorder, anorexia nervosa, psychotic or personality disorders, depression, and anxiety (Petrie et al., 2008). Further research should attempt to determine how illness perception interventions differ among various diagnoses. When researchers utilized illness perception interventions among hospitalized bipolar and schizophrenic patients, they discovered that patients with different diagnoses wanted to learn how to come to terms with their diagnosis and deal with the medical model as it applies to symptomology and treatment. Additionally, they expressed a desire to separate their illness from their identity, understand the social dimensions of their new label, and differentiate the current self from past experiences (Petrie et al., 2008). However, illness perception interventions are most effective when the patient is in remission from psychosis, and can make better sense of his or her

| The Role of Consumer Satisfaction in Psychiatric Care | 24

illness (Petrie et al., 2008). In order to apply illness perception interventions to improve mental health outcomes, clinicians should focus on increasing adherence to therapy, reducing inappropriate service use (repeat patients), and improving family and other significant relationships (Petrie et al., 2008). By focusing on these areas, clinicians can improve mental health outcomes for patients through education. With this improved knowledge, patients develop a greater understanding of what they can do in order to improve their mental illnesses. Treatment Climate Inpatient psychiatric units act as intensive care areas that mainly treat patients with psychotic disorders in cases of acting out, relapse, or suicidality (Middelboe, Schjodt, Byrsting, & Gjerris, 2001). These units also serve as an early rehabilitation to prepare patients to resume daily living activities after they are discharged (Middelboe et al., 2001). It is especially important to listen to the patients and their perceptions of the treatment climate as these perceptions can influence many aspects of the recovery process, including drop out rates, involvement within the community on the ward, and satisfaction with treatment (Timko & Moos, 1998). Patients perceive an ideal ward as one containing support, order, organization, and allowing for autonomy (Middelboe et al., 2001). When patients judged the staff and program as providing support and encouraging involvement and spontaneity, patients engaged in group discussions more often during treatment (Timko & Moos, 1998). Patient engagement in treatment can be beneficial to mental health outcomes as well as social outcomes. From this framework, Timko & Moos (1998) suggest that programs should encourage patients to make gains in practical skills while relating those gains to treatment and recreational activities. Patients who participated in such programs were better functioning, more active in the ward community, and used recreational services more often (Timko & Moos, 1998). However, no matter how ideal a program may be, patients with severe psychiatric impairment will have poorer outcomes, functioning, and activity (Timko & Moos, 1998). Clinicians may actually harm these patients by assertively trying to get them to participate. Such assertive attempts may be over-stimulating for patients with severe psychiatric impairment and may lead to further psychopathology or hospital readmission (Timko & Moos, 1998). Therefore, clinicians should encourage patients to participate in activities on the psychiatric unit, but only up to a certain point, as some severely impaired patients will not respond well to that much pressure or overstimulation. Conclusion By increasing quality of care based on patient perception, psychiatric patients may be more receptive to treatment and outcomes may improve. Focusing on consumer satisfaction in the mental health field can yield many positive results, as patient satisfaction predicts treatment compliance, which ultimately leads to improved outcomes (Middelboe et al., 2001). Patient advocates should make it a priority to treat psychiatric patients just as they would treat their patients with physical illnesses. By giving


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psychiatric patients the opportunity to discuss concerns with their treatment, clinicians can make changes and treatment outcomes can improve. Current research on patient perceptions provides many implications for the improvement of hospital procedures. First, it is important that doctors include patients in the development of their treatment plan. Professional education should include knowledge about patient’s shame and stigma regarding treatment (Schroder et al., 2006). Staff in psychiatric inpatient units should actively work to foster agreement with patients, as this relationship may encourage feelings of responsibility within patients (Lasalvia et al., 2011) Such responsibility may lead to better adherence to treatment and reciprocally strengthen the therapeutic alliance, ultimately leading to greater effectiveness of the intervention. Understanding the negative perceptions that the patient holds towards treatment can help clinicians be more sensitive to the patient’s difficulties during recovery. Clinicians should also be aware of setting too high expectations for patients, such as expecting them to make significant progress in a short amount of time or to actively participate in activities on the ward before they feel ready. Researchers found that clinicians can foster better results for their patients if they focus on achievable goals and ways to reach them rather than simply setting high expectations (Strating, Broer, Van Rooijen, Bal, & Nieboer, 2011). Unfortunately, research on patient perceptions is lacking. Future studies should examine whether perceptions vary by each particular mental illness, and which techniques are most effective for each diagnosis. By creating a more nuanced picture of how different patients respond to different treatments, healthcare professionals can not only improve patient perceptions of hospital care, but ultimately their overall treatment outcomes. References Berghofer, G., Lang, A., Henkel, H., Schmidl, F., Rudas, S., & Schmitz, M. (2001). Satisfaction of inpatients and outpatients with staff, environment, and other patients. Psychiatric Services, 52(1), 104-106. Brunero, S., Lamont, S., & Fairbrother, G. (2009). Using and understanding consumer satisfaction to effect an improvement in mental health service delivery. Journal of Psychiatric and Mental Health Nursing, 16, 272-278. Cleary, M., Horsfall, J., & Hunt, G. (2003). Consumer feedback on nursing care and discharge planning. Journal of Advanced Nursing, 42, 269-277. Docherty, J. P., & Streeter, M. J. (1996). Measuring outcomes. In L. I. Sederer & B. Dickey (Eds.), Outcomes Assessment in Clinical Practice (pp.8-18). Baltimore, MD: Williams & Wilkins. Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press. Hansson, L. (1989). The quality of outpatient psychiatric care. Scandinavian Journal of Caring Sciences, 3, 71-82. Hatonen, H., Suhonen, R., Warro, H., Pitkanen, A., & Valimaki, M. (2010). Patients' perceptions of patient education on psychiatric inpatient wards: A qualitative study. Journal of Psychiatric and Mental Health Nursing, 17, 335-

341. Howard, P. B., El-Mallakh, P., Rayens, M. K., & Clark, J. J. (2003). Consumer perspectives on quality of inpatient mental health services. Archives of Psychiatric Nursing, 17(5), 205-217. doi: 10.1016/S0883-9417(03)00096-7 Kaplan, S., Busner, J., Chibnall, J., & Kang, G. (2001). Consumer satisfaction at a child and adolescent state psychiatric hospital. Psychiatric Services, 52(2), 202-206. Lasalvia, A., Boggian, I., Bonetto, C., Saggioro, V., Piccione, G., Zanoni, C., . . . & Lamonaca, D. (2011). Multiple perspectives on mental health outcome: Needs for care and service satisfaction assessed by staff, patients and family members. Social Psychiatry and Psychiatric Epidemiology. doi: 10.1007/s00127011-0418-0 Lebow J. (1982). Consumer satisfaction with mental health treatment. Psychological Bulletin, 91, 224-259. Middelboe, T., Schjodt, T., Byrsting, K., & Gjerris, A. (2001). Ward atmosphere in acute psychiatric in-patient care: Patients' perceptions, ideals and satisfaction. Acta Psychiatrica Scandinavica, 103, 212-219. Petrie, K. J., Broadbent, E., & Kydd, R. (2008). Illness perceptions in mental health: Issues and potential applications. Journal of Mental Health, 17(6), 559-564. Rosen, A., & Proctor, E. K. (1981). Distinctions between treatment outcomes and their implications for treatment evaluation. Journal of Consulting and Clinical Psychology, 49(3), 418-425. Schroder, A., Ahlstrom, G., & Larsson, B. W. (2006). Patients' perceptions of the concept of the quality of care in the psychiatric setting: A phenomenographic study. Journal of Clinical Nursing, 15, 93-102. Strating, M. M. H., Broer, T., Van Rooijen, S., Bal, R. A., & Nieboer, A. P. (2011). Quality improvement in long-term mental health: Results from four collaboratives. Journal of Psychiatric and Mental Health Nursing. doi: 10.1111/j.1365-2850.2011.01802.x Timko, C., & Moos, R. H. (1998). Outcomes of the treatment climate in psychiatric and substance abuse programs. Journal of Clinical Psychology, 54(8), 1137-1150. Witteman, C., Bolks, L., & Hutschemaekers, G. (2011). Development of the illness perception questionnaire mental health. Journal of Mental Health, 20(2), 115-125. doi:10.3109/09638237.2010.507685

Author’s Biography Lana Denysyk is a senior in the Applied Psychology program . Her m ain professional interests include finding effective mental health interventions and increasing access to mental health care. After graduating, Lana will be attending Columbia University's Mailman School of Public Health to pursue her Master's of Public Health degree.


Moore

| The Many Treatment Methodologies for Phobias | 26

The Many Treatment Methodologies for Phobias: Finding the Best Fit By Annabelle Moore People often casually refer to their aversion to snakes as a “phobia”, however, phobias are a serious mental illness, affecting 10-12% of people in the United States (Adler, 2010). A phobic response is overwhelming anxiety and significant disruption to a person’s activities of daily living due to a specific a stimulus. Phobias are listed in the DSM IV-R as “Specific Phobia”, an anxiety disorder known to be unreasonable, marked by an intense anxiety response (often a panic attack) to a feared stimulus that is either avoided or endured with intense distress. There are a variety of types, including animal type, situational type, and natural environment type (APA, 2000); for example common phobias might include fears of spiders, cockroaches, elevators, and airplanes. Phobic people exhibit two common cognitive distortions: a belief that an encounter with the feared stimulus will result in catastrophe and an overestimation of the likelihood of such an encounter. Elizabeth is diagnosed with a phobia of elevators. She is terrified of elevators; she believes that she will get stuck in one, run out of oxygen and die. Elizabeth’s thinking is disordered because she believes that getting stuck in an elevator will result in death and that elevators get stuck frequently. If she is expected to use the elevator or put in a situation where it is only logical to use an elevator, she will experience severe distress and agitation. In order to manage their anxiety, phobic people will go to great lengths to avoid the stimulus, which ultimately impedes their normal functioning. Though the etiology of phobias is hotly debated, they are considered to be the most easily treated mental disorder (Adler, 2010). Unlike most mental health issues, the first line of treatment is not psychotropic medication. In order to develop the most beneficial intervention many methods have been created and tested. “The Many Treatment Methodologies for Phobias” will discuss popular treatments, such as psychoanalysis and cognitive behavioral techniques, as well as more recent approaches. All of these treatments have shown different rates of efficacy depending on the population and the phobia. Clinicians should be well versed in all of these methods in order to select the most appropriate treatment for the phobic client. Psychoanalysis Freud, the father of psychoanalysis, believed that a phobic stimulus is rooted in a traumatic childhood experience. The memory may be repressed, but the associated stimulus still

produces fear and anxiety (Willemsen, 2002). In Elizabeth’s case, her elevator phobia may have stemmed from an experience when she was very young and was trapped in an elevator for hours, eventually wetting. While she may not consciously remember the experience, a psychoanalyst would explore the client’s past to discover and expose these repressed processes. By talking about the experience, the client gains insight and is then able to work towards separating the stimulus from the painful memory. However, in order for psychoanalysis to be affective the patient must be psychologically minded and committed to intense introspection (Jemmer, 2005). In addition to the commitment of the patient, the psychoanalytic process can take years and therefore may not be financially feasible. Other treatment methods developed to provide an alternative for psychotherapy and supplement these shortcomings. Exposure Therapy Although Psychoanalysis was the first treatment methodology, the most popular and reliable treatment for phobias is Exposure Therapy (ET), a method created by CognitiveBehaviorists. These clinicians believe that phobias are evolutionary instincts which, in the modern world, are maladaptive (Willemsen, 2002). The principle behind ET is that avoidance of a feared stimulus reinforces the fear while exposure diminishes it. By slowly exposing the client to the stimulus in a safe and controlled environment, their cognitive distortions are challenged and eventually diminish (Scharfstein, 2011). The therapist and client first work together to understand where exactly the fear lies, identifying “key barriers.” Next, they construct a list from the least to the most anxiety-producing stimuli and work in phases to conquer the list, a process known as hierarchical systematic desensitization (Beutler, 1991). Returning to Elizabeth’s case, if she were engaging in ET she would start with some CBT visualization and verbal discussion about elevators. While some of the therapy session would be devoted to the desensitization process, a CBT therapist would also address behavioral and cognitive anxiety-management techniques. For example, a CBT therapist would teach Elizabeth deep breathing exercises to perform while riding an elevator. The sessions would also be devoted to cognitive restructuring: challenging the misconceptions driving the phobia. Elizabeth would be assigned homework, a hallmark of CBT. An assignment might be to research how frequently elevators get stuck and


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the basic mechanics of an elevator. She would use her breathing exercises during the research if her anxiety started to feel overwhelming. The key feature of the Cognitive-Behavioral approach is the exposure element. During exposure, Elizabeth and her therapist may progress to entering and later taking a short ride on a relatively nonfrightening elevator (maybe a brightly lit, modern) and slowly working on the more intense stimuli (perhaps an older elevator that makes a lot of noise) as time progresses. Psychoeducation, much like anxietymanagement techniques and cognitive restructuring, is a quintessential element of CBT. Elizabeth can restructure her thinking and decrease her fear by realizing how she overestimates the frequency by which elevators get stuck, thereby decreasing her fear. During their sessions, Elizabeth would be taught that her elevator phobia stems from an evolutionarily adaptive aversion to both heights and small spaces. The inclusion of systematic hierarchical desensitization is a phobia treatment first used in ET and later was adopted by other methodologies due to its impressive response rate of 80-90% (Adler, 2010). Despite these robust findings, Exposure Therapy presents some limitations. For some phobias (such as flying), traditional ET would be unfeasible (Tortella, 2011). Furthermore, CBT addresses the phobia and behavior, but not necessarily any underlying psychological issues (Barber, 1991). Like any treatment besides psychoanalysis, if a client has a co-occurring mental illness, it may be impossible to engage them in ET before first addressing these issues using another form of therapy. ET is typically the first line of treatment for phobias because it has shown such impressive response rates and is easy to administer. Still, no one treatment fits all clients or phobias, and so alternative approaches emerged. Hypnotherapy Hypnotherapy employs the principles of systematic desensitization much like Exposure Therapy, but without ever leaving the couch. The hypnotherapist leads the client through a guided visualization exercise, during which the client imagines encountering the stimulus while maintaining a relaxed state (Jemmer, 2005). It is the hypnotherapist’s responsibility to both lead the visualization exercise and remind the client to use relaxation techniques (such as deep breathing,) to self-soothe (Willemsen, 2002). One drawback of hypnotherapy is that imagination does not fully prepare the client for the real experience, and while a client may complete systematic desensitization in hypnotherapy, he may not be able yet to fully expose himself to the stimulus in vivo. Still, hypnotherapy provides an opportunity for clients for whom traditional Exposure Therapy would not be possible. For example, if a client were afraid of airplanes, hypnotherapy would be a practical method of exposure. Other alternative approaches to Exposure Therapy that are currently undergoing trial include virtual reality exposure therapy, which uses computer programming to virtually experience the stimulus. Virtual Reality Exposure Therapy Virtual reality exposure therapy (VRET) employs modern technology to simulate ET, and is only used in the treatment of phobias. In VRET, a

virtual scene is designed to portray a realistic encounter with the stimuli using auditory and visual sensory channels (Tortella-Feliu, 2011). VRET is created from the perspective of the person sitting before the computer, so the interaction is as similar as possible to true ET. Some studies found that VRET shows effect sizes similar to those of traditional in vivo exposure (Tortella-Feliu, 2011). VRET is especially useful in treating flying phobias, and realistic flying experiences have been simulated and are stored for clients to use. Since it can be conducted over the Internet in the client’s home, it may be more appealing to people with social phobias, or other phobias limiting travel. If Elizabeth worked with a VRET clinician, she would meet with them once to learn some basic coping skills, such as breathing techniques, before gaining access to the simulation program. The program would present a realistic-looking elevator from her perspective, and would include the sounds of a normal elevator. Elizabeth would use her computer to “enter” the elevator, select a floor, and ride the elevator. She would maintain contact with her clinician over the phone and over the Internet, and the clinician can monitor her progress through the program. While VRET is very new and requires further research and design, it allows for innovation to enter the therapeutic process by introducing technology (Tortella-Feliu, 2011). Neuro-Linguistic Programming Neuro-Linguistic Programming (NLP) is a form of exposure therapy that typically only requires one session to treat phobias (Jemmer, 2005). NLP is used to neutralize troubling memories and situations, and is unique in that the client is not required to disclose anything about the phobia to the practitioner. The process employs ‘dissociated visualization’, and is commonly encorporated in the treatment of post-traumatic stress disorder. If Elizabeth seeks treatment with an NLP practitioner, she would imagine that in the projection booth of a movie theater. Looking down into the theater, she would “see” herself sitting in the seats below. Elizabeth would then “turn on” the projector. A grainy, black and white film is displayed, depicting herself riding an elevator. Throughout the viewing, Elizabeth must try to remain composed and dissociated while watching herself having a phobic response, and the visualization of herself seeing herself watch a film can help her feel removed, and disconnected. Though the encounter is only imagined, a client with a severe phobia may still experience intense fear and anxiety, and the practitioner must constantly remind her that she is safe, she is in the projector booth, and she is in control of the film. The exercise is done multiple times with the client experiencing less and less anxiety each time. Then the NLP practitioner asks the client to “reassociate” with the film, imagining herself in the scene, which is now pictured in 3-dimensions and in vivid color. She is asked to imagine the sounds, smells, and sensations of the scene. The final stage of the process involves “erasing the phobic memory trace” by imagining the film rewinding very quickly, over and over again (Jemmer, 2005). If NLP is successful, clients report feeling secure, calm, and detached from the stimulus. The treatment method is limited in that it does not explore subconscious processes like psychoanalysis or teach important coping skills


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and behavioral techniques like CBT, which may limit the long-term efficacy. Still, NLP is effective in the short term that can be beneficial for some clients. Eye Movem ent Desensitization and Reprocessing Eye Movement Desensitization and Reprocessing (EMDR) therapy is used to treat anxiety caused by a specific memory and is recommended for clients who can readily identify the experience that lead to the phobia. The first three phases work to desensitize the memories surrounding the trauma, much like psychotherapy. In Elizabeth’s case she would work through her memory of the initial elevator memory that led to her phobia, then address the most painful memory associated with the phobia, and lastly of the most recent memory of an encounter with the feared stimulus (De Roos, 2008). For Elizabeth, these first two steps could all involve that first, traumatic experience. The fourth step is the creation of a ‘future template,’ or a mental image of the client interacting with the stimulus paired with a ‘positive cognition’, such as the thought, “I can handle this,” (De Roos, 2008). The fifth step involves visualizing the future encounter and identifying the fear provoking aspects, much like the ‘key barriers’ discussed by cognitivebehaviorists. When anxiety starts to emerge, eye movements are introduced, along with positive cognition, to reduce the fear response. The sixth and final step involves in vivo exposure to explore any remaining dysfunctional thinking. EMDR has been proven to be effective for those with specific trauma-related phobias, providing a cost-efficient and time-sensitive alternative to psychoanalysis. Conclusion When deciding which phobia treatment best fits a client, several important factors must be considered. First, the root of the phobia must be identified. If the client does not know when or how the phobia originated, cognitive-behavioral Exposure Therapy would be recommended as it has been shown to be the most effective, wellresearched treatment. If the phobia were difficult to encounter with the therapist, such as a fear of flying, then hypnosis, NLP, and virtual reality exposure therapy would be worth exploring. NLP also requires very little time and money, and might be ideal if a person must overcome a phobia in a limited amount of time. NLP does not require the client discuss any aspect of the phobia and is recommended for clients who do not know how the phobia began. If the client does connect the phobia to a particular traumatic event, EMDR might be a more appropriate recommendation. However, if the client is contemplative, selfanalyzing, and able to afford an analyst’s fees, psychoanalysis could also relieve these symptoms. Because ET is so successful, these alternative treatments have hardly been researched and more investigation of their effectiveness is necessary. Though each treatment is limited in its own way, all are viable options when confronted with a phobic patient. It is up to the clinician to weigh the costs and benefits of each in order to determine which methodology would be most appropriate, and to employ their intuition and creativity to blend these tools into a treatment approach as unique as the individual before them.

| The Many Treatment Methodologies for Phobias | 28 References

Adler, J., Cook-Nobles, R. (2011). The successful treatment of specific phobia in a college counseling center. Journal of College Student Psychotherapy, 25, 56-66. American Psychological Association. (2000). Specific Phobias. Diagnostic and Statistical Manual of Mental Disorders IV-R. Barber, J. P., Luborsky, L. (1991). A psychodynamic view of simple phobias and prescriptive matching: a commentary. Psychotherapy: Theory, Research, Practice, Training, 28(3), 469-472. Beutler, L. (1991). Selective treatment matching: systematic eclectic psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 28(3), 457-462. De Roos, C., de Jongh, A. (2008). EMDR treatment of children and adolescents with a choking phobia. Journal of EMDR Practice and Research, 2(3), 201-211. Jemmer, P. (2005). Phobia: fear and loathing in mental spaces. European Journal of Clinical Hypnosis, 6(3), 24-32. Scharfstein, L., Beidel, D. C., Finnell, L. R., Distler, A., Carter, A. (2011). Do pharmacological and behavioral interventions differentially affect treatment outcome for children with social phobia? Behavior Modification, 35(5), 451-467. Tortella-Feliu, M., Botella, C., Llabres, J., BretonLopez, J. M., del Amo, A. R., Banos, R. M., Gelabert, J. M. (2011). Virtual reality versus computer-aided exposure treatments for fear of flying. Behavior Modification, 35(1), 3-30. Willemsen, H. (2002). Needle phobia in children: a discussion of aetiology and treatment options. Clinical Child Psychology and Psychiatry, 7, 609-619.

Author’s Biography Annabelle Moore is a senior in the Applied Psychology program, with a minor in American Sign Language. She is a research assistant for Dr. Alisha Ali on the PhotoCLUB project, as well as a Case Worker at New York Foundling: Family Services for Deaf and Hard of Hearing Children and Adults. Her research interests include severe and persistent mental illness, trauma and addiction. After graduation she plans to pursue a PhD in Clinical Psychology.


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The Effect of Post Traumatic Stress Disorder on the Ability to Recognize Facial Expressions

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BY CORALIE NEHME

More than 13 million Americans will suffer from posttraumatic stress disorder (PTSD) at some point in their lives (Frueh, 2000). The DSM-IV-TR (2000) 4th ed., text rev. criterion for PTSD includes a history of exposure to a traumatic event which must meet two criteria and symptoms from each of the following symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms. The duration of symptoms and the functional significance (acute vs. chronic) is also a part of the diagnostic criteria. Symptoms some people with PTSD may experience include: re-living the trauma through flashbacks, nightmares, memories or escalating physical manifestations of trauma through increased anger, stress and sleeplessness (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 200). There is no determined time lapse following a traumatic event during which one typically begins experiencing an onset of PTSD symptoms. Symptoms may appear directly after the traumatic event or may be delayed, taking place months or years later. PTSD symptoms are typically so severe that they interfere in the individual’s ability to live daily life as they normally would (Akhter, Nordine & Levinson, 2009). PTSD affects a person’s emotions, and recent research indicates that PTSD affects the ability to recognize facial expressions (Poljac, Montagne, & Haan, 2010; Ross and Monnot, 2010; Akhter, Nordine & Levinson, 2009; Masten, Guyer, Hodgdon, McClue, Charney et al., 2008; Kirsch and Brunnhuber, 2006). The inability to recognize facial expressions is significant because factual knowledge that is associated with certain types of facial expressions is lost when the ability to recognize these expressions is diminished (Adolphs, Damasion, Tranel & Damasio, 1996). Studies show differences in the ability of individuals with diagnosed PTSD and their ability to recognize different facial expressions, specifically expressions of fear and sadness (Poljac, Montagne, & Haan, 2010; Ross and Monnot, 2010; Akhter, Nordine & Levinson, 2009; Masten, Guyer, Hodgdon, McClue, Charney et al., 2008; Kirsch and Brunnhuber, 2006). Current research also seems to indicate a difference in PTSD in adults and children and its effects on their ability to recognize facial expressions of emotions (Masten, Guyer, Hodgdon, McClue, Charney et al., 2008; Kirsch and Brunnhuber, 2006). Research is conflicted, however, as to the nature of the relationship between PTSD and the ability to recognize facial expressions. Some studies have found that having PTSD inhibits the ability to recognize facial expressions, whereas others have concluded that PTSD increases an individual’s ability to recognize certain emotions in facial expressions, such as sadness and fear. There appears, however, to be a link between PTSD and emotional numbing, but research does not explore this relationship. PTSD has been linked with decreased ability to express emotions, a part of emotional numbing (Poljac, Montagne, & Haan, 2010; Ross and Monnot, 2010; Akhter, Nordine & Levinson, 2009; Masten, Guyer, Hodgdon, McClue, Charney et al., 2008; Kirsch and Brunnhuber, 2006). Emotional numbing is a form of detachment or dissociation that is part of the avoidance cluster of symptoms that is typical in trauma survivors (Litz et al., 1997).This paper will


Nehme

examine the studies conducted examining the relationship between PTSD and emotional numbing. It will attempt to make connections between these (PTSD and emotional numbing) and the ability to recognize facial expressions. The paper will explore the relationship between having PTSD and the ability to recognize facial expressions, as well as the effect of this phenomenon on the daily lives and interactions of individuals with PTSD. Despite disparities in the literature, this paper will analyze the differential effects of PTSD on the ability to recognize facial expressions in adults and children. Connections to Post Traumatic Stress Disorder According to the DSM-IV-TR (2000), individuals with PTSD suffer three types of symptoms: avoidance/numbing, increased anxiety/emotional arousal, and intrusive memories. PTSD affects one’s emotional wellbeing, perhaps due to the emotional impairment prevalent in those who have experienced trauma (Frueh, 2000). Emotional impairment has been suggested as the pivotal connection, responsible for the difference between the ability or lack of ability to recognize emotions in facial expressions. How does the inability to express emotions lead to inability to recognize those same emotions in the facial expressions of others? Poljac, Montagne and Hann (2010) suggest, “Facial expressions represent strong cues for emotional states and their perception and interpretation is a human ability crucial for establishing normal interpersonal relationships” (Poljac, Montagne, & Haan, 2010, p. 977). This means that facial expressions play a vital role in social networking and relationshipbuilding. Further support for this claim comes from the emotion-type hypothesis proposed by Ross and Monnot’s research on emotions in the right and left hemispheres of the brain, suggesting that these emotional facial expressions allow for cross-cultural communication. Emotion-Type Hypothesis that combines the two main hypotheses about the lateralization of emotions, which states: “primary emotions and related displays are processed preferentially by the right hemisphere whereas social emotions and related ‘display rules’ are processed preferentially by the left hemisphere” (Ross and Monnot, 2010, p. 872). The study conducted by Ross and Monnot supports this third hypothesis. This is significant because primary emotions, such as anger, fear, sadness, and happiness are believed to be “genetically hard-wired” and are thus recognized across all cultures. Aging plays a role in this, however, and as one ages, the ability to recognize multiple facial expressions at once (different in the upper and lower halves of the face) diminishes, specifically with sadness and fear (Ross and Monnot, 2010). Similarly, studies have shown that PTSD mainly affects the ability to recognize emotions of fear, sadness and anger. Further research aims to better examine the relationship between PTSD the ability to recognize facial expressions, most notably the study by Poljac, Montagne, & Haan (2010). In the research study conducted in 2010 by Poljac, Montagne, & Haan, the researchers selected 20 male war veterans who were diagnosed with PTSD and 20 males matched in age and education level who had no history of mental illness (control group). Results showed

| The Effect of PTSD on the Ability to Recognize Facial Expressions | 30 that PTSD participants had slightly higher depression scores than the control group. The Benton Facial Recognition Test did not reveal significant differences between the groups. Results of the experiment showed that that group differences existed between the control and experimental group. The PTSD group could only recognize expressions of fear and sadness in more expressive faces, but there were no differences for the emotions of anger, disgust, happiness and surprise (Poljac, Montagne, & Haan, 2010). This finding suggests the negative impact of PTSD on the ability to recognize emotional facial expressions. Kirsch and Brunnhuber, (2006) found that individuals with PTSD report diminished restrictions in their capacity to feel (Kirsch & Brunnhuber, 2006). Women with PTSD exhibited higher levels of negative stimulation and expressed more negative emotion words in response to both positive and negative stimuli, whereas no group differences emerged in facial expressivity, suggesting that PTSD affects the type of response across varied stimuli (Kirsch and Brunnhuber, 2006). The data found that there was a difference between the control and experimental groups’ abilities to distinguish and convey facial expressions, but this difference is not enough to be statistically significant. Results of this study, however, found that there were significant differences in anger. Participants with PTSD recognize and experience anger more often than the control group (Kirsch and Brunnhuber, 2006). No significant differences were found between having PTSD and the ability to recognize sadness and fear, directly opposing previous research. In an attempt to further understand the relationship between PTSD and the ability to recognize facial expressions, another study compared the severity of PTSD on the ability to recognize masked and unmasked facial expressions of happiness and fear. Researchers monitored activity in the amygdala, which is a key neurological component of emotional processing. Researchers then showed participants with acute and long-standing chronic PTSD images of masked and unmasked facial expressions of fear and happiness (Armony, Corbo, Clement & Brunet, 2005). Amygdala activation increased in masked facial expressions with increased scores of PTSD severity (Armony et al., 2005). This indicates that severity of PTSD has some effect on the ability to recognize expressions of both happiness and fear (Armony et al., 2005). Children with PTSD Studies have shown that PTSD affects a child’s ability to recognize facial expressions differently than it affects an adult’s. Understanding why this difference exists will allow us to further comprehend the effect of PTSD on the ability to recognize facial expressions. Participants were shown “morphed facial emotion identification tasks.” Participants included a mix of maltreated and homeless children (Masten, Guyer, Hodgdon, McClue, Charney et al., 2008). The researchers looked at the patterns of emotional processing in children with PTSD. They tested whether atypical processing of emotions after trauma was related to a PTSD diagnosis. The study focused on fear as the negative emotion of interest because fear suggests the presence of danger in the immediate


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environment, which is the negative emotion often exhibited by an abuse victim. Though there was no difference between the control and experimental groups in the accuracy of recognizing fear, the rate at which this task was executed differed between groups. Specifically, children with PTSD were able to recognize facial expressions of fear much faster than the control children who did not meet diagnostic criteria for PTSD. There were not, however, any differences between the control and PTSD groups in the ability to recognize neutral and happy expressions. Children with PTSD recognize facial expressions of fear better than those without PTSD, whereas studies have shown that adults with PTSD are less able to recognize facial expressions of fear and anger. PTSD, therefore, differentially affects the ability to recognize facial expressions in children than it does in adults. The occurrence of such is an interesting phenomenon that merits further research to indicate why such a disparity exists. Limitations There is little research about the link between PTSD and the ability to recognize facial expressions. This is, however, an important topic to research, because the ability to recognize emotional expressions is vital to successful social interactions and effective communication (Masten et al., 2008). Better understanding of the effects of PTSD on the ability to recognize facial expressions and more research on the possible link to emotional numbing will help us develop a better understanding of the brain and the role that recognizing emotions plays in social interactions. Further research should also be done on the severity of PTSD and the ability to recognize emotional expressions. More research on this could allow better motivation for individuals suffering from PTSD to get help immediately, to prevent the effects that long-term chronic PTSD has on emotional processing. The difference between the effect of PTSD in children and adults should also be explored to teach us more about the effects of trauma on brain and emotional development from childhood to adulthood. Discussion The ability to recognize facial expressions is vital to the formation of social and inter-personal relationships. The cross-cultural homogeneity of facial expressions indicates the significance of this ability. Understanding the relationship between PTSD and the ability to recognize facial expressions is also essential to the development of better techniques for treating PTSD. PTSD affects the emotional processing of all those afflicted with it, but the field lacks understanding of how emotional processing is effected, and how to rehabilitate individuals with damaged emotional processing capabilities. References Adolphs, R., Damasio, H., Tranel, D., & Damasio, A. R. (1996). Cortical systems for the recognition of emotion in facial expressions. Journal of Neuroscience, 16(23), 7678-7687. Akhter, M.N., Nordine, G., & Levinson, R.A. (2009). Technology-assisted management of posttraumatic stress disorder in nonmilitary personnel returning from the war zone by

family practitioners. Journal of National Medical Association, 101(8) American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. Armony, J. L., Corbo, V., Clement, M. H., & Brunet, A. (2005). Amygdala response in patients with acute PTSD to masked and unmasked emotional facial expressions. The American Journal of Psychiatry, 162(10), 1961-1963. Bernsten, D., Rubin, D. C., & Siegler, I. C. (2011). Two versions of life: Emotionally negative and positive life events have different roles in the organization of life story and identity. Emotion, 11(5), 1190-1201. doi: 10.1037/a0024940 Frueh, B.C. (2000). Posttraumatic Stress Disorder. (2000). Encyclopedia of psychology. USA: Oxford University Press. Kirsch, A., & Brunnhuber, S. (2007). Facial expression and experience of emotions in psychodynamic interviews with patients with PTSD in comparison to healthy subjects. Psychopathology, 40, 296-302. doi: 10.1159/000104779 Lewis, S. F., & Garver, D. L. (1995). Treatment and diagnostic subtype in facial affect recognition in schizophrenia. J. Psychiat, 29(1), 5-11. Litz, B. T., Schlenger, W. E., Weathers, F. W., Caddell, J. M., Fairbank, J. A., & LaVange, L. M. (1997). Predictors of emotional numbing in posttraumatic stress disorder. Journal of Traumatic Stress, 10(4), 607-618. Masten, C. L., Guyer, A. E., Hodgdon, H. B., McClure, E. B., Charney, D. S., Ernst, M., et. al. (2007). Recognition of facial emotions among maltreated children with high rates of posttraumatic stress disorder. Child abuse and neglect, 32, 139-153. doi: 10.1016/j.chiabu.2007.09.006 Poljac, E., Montagne, B., & Haan, E. H. F. (2010). Reduced recognition of fear and sadness in post-traumatic stress disorder. Cortex, 47, 974-980. doi: 10.1016/j.cortex.2010.10.002 Ross, E. D., & Monnot, M. (2010). Affective prosody: What do comprehension errors tell us about hemispheric lateralization of emotions, sex, and aging effects, and the role of cognitive appraisal . Neuropsychologia, 49, 866-877. doi: 10.1016/j.neuropsychologia.2010.12.024

Author’s Biography Coralie Nehm e is a first-semester senior in Applied Psychology. She is currently the OPUS publicity chair and an editor-in-training. Her research interests include trauma, anxiety disorders, and the influences of immigration and culture. She is exploring her interest of the influence of immigration and culture on parenting on Dr. Erin Godfrey's research team looking at the customs that immigrant mothers want their children to adapt. She is also exploring her interest in trauma and anxiety disorders at the Bellevue/NYU Langone Program for Survivors of Torture. After graduation in December, she plans to take a gap year to work before applying to PhD programs in Counseling Psychology.


Paloian

The Female/Athlete Paradox: Managing Traditional Views of Masculinity and Femininity

By Andrea Paloian How can you win if you’re female? Can you just do it? No. You have to play the femininity game. Femininity by definition is not large, not imposing, not competitive. Feminine women are not ruthless, not aggressive, not victorious. It’s not feminine to have a killer instinct, to want to win with all your heart and soul to win…Femininity is about appearing beautiful and vulnerable and small. It’s about winning male approval (Nelson 1998, p. 145). The concept of gender is one that is instilled in us at birth and attempts to define, evaluate, and classify males and females (Blinde & Taub, 1992; Koivula, 1995, 2001; Kolnes, 1995; Ross & Shinew, 2008). The qualities associated with gender are socially constructed according to cultural standards, and consist of stereotypes that lead to the creation of gender roles and gender typing (Berk, 2009). The global concept of gender is subdivided into two bipolar constructs: masculinity and femininity, although occasionally androgyny is also included. Interpretations of these concepts may vary according to an individual’s ethnicity, culture, sexual orientation, or socioeconomic status, but in the Western world, there is a privileged, or “hegemonic” conceptualization when considering masculinity and femininity (Anderson, 2005; Krane, 2001; Krane, Choi, Baird, Aimar, & Kauer, 2004; Ross & Shinew, 2008). Hegemonic masculinity and femininity are generally structured in our culture by the “dominant” group, which refers to those who are White, heterosexual, and middle-class with an ideal physique that differs according to one’s gender. The standard body type for females is one that is thin, yet toned and lean, while males are expected to have large muscles that are toned and well defined (Dworkin, 2001; Krane et al., 2004). Male athletes who participate in “masculine sports” (i.e. competitive sports that require power, speed, and strength) such as Tom Brady, Derek Jeter, and David Beckham are idolized not only for their athletic achievements, but also for their physical appearances and representations of hegemonic masculinity (Alley & Hicks, 2005; Dworkin, 2001; Wiley, Shaw, & Havitz,

A Different Kind of Bully

| The Female/Athlete Paradox | 32

2000). However, female athletes who do not necessarily represent the hegemonic feminine ideal, such as Venus and Serena Williams, Mia Hamm, and mixed martial arts fighter Gina Carano, encounter more difficulties in their careers as they attempt to balance a feminine image with the masculine qualities associated with their sports (Dworkin, 2001). While female athletes are more likely to encounter this conflict, males who participate in more “feminine” sports, such as figure skating, dancing, and cheerleading are also subject to this dilemma (Anderson, 2005). Although research regarding this conflict exists for both males and females, this review will focus predominantly on female athletes. Females’ participation in sports is often thought to be less appreciated by Western cultures since athletics are primarily maledominated and characterized by masculine qualities, such as strength, aggression, and competition (Krane et al., 2004). Contrary to this belief, others insist that a significant change has occurred due to the implementation of Title IX in 1972, which mandates nondiscrimination in admission, access, and treatment in all educational institutions receiving government funding (Lopiano, 2000). Since the passage of Title IX, women’s sport participation is constantly on the rise, leading to a variety of psychological and physiological benefits (Lopiano, 2000). Despite these positive strides, women still face multiple challenges when pursuing their athletic desires, which are largely due to long-standing gender norms established long ago. As women continue to contradict these traditional beliefs, perhaps our society will continue to become more accepting of female athletic participation, and more specifically when considering those engaging in the more male-dominated sports. One of the prevailing arguments presented by multiple researchers states that athletic women face a dilemma; they are expected to succeed in their sport while maintaining hegemonic femininity, which can be a difficult balance to establish and maintain (Dworkin, 2001; Halbert, 1997; Kolnes, 1995; Krane, 2001, Krane et al., 2004; Mennesson, 2000; Ross & Shinew, 2008). This conflict describes what is referred to as the “female/athlete paradox” (Krane et al., 2004; Kolnes, 1995; Meân & Kassing, 2008; Ross & Shinew, 2008). As Krane (2001) explains, “Sportswomen tread a fine line of acceptable femininity…engaging in athletic activities is empowering, yet maintaining an acceptable feminine demeanor is disempowering” (116). Krane’s statement reflects the results of various research studies, which found that traditional expectations focusing on appearance and exhibiting femininity are maintained by society’s attitudes towards athletic women (Halbert, 1997; Hardin, Chance, Dodd, & Hardin, 2002; Krane, 2001; Ross & Shinew, 2008). Therefore, female athletes are faced with the task of learning to balance hegemonic femininity and athleticism both on and off the field, ring, or court in order to be accepted in Western culture. Although social boundaries appear to dissuade women from engaging in masculine-labeled sports, they are actually becoming more popular among female athletes as time progresses and traditional gender norms are gradually restructured. Despite modified conceptualizations


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of gender ideals and an increase in female participation, it has been argued that these changes are still not enough to eradicate the “deviant” label often associated with female athletes who do not conform to traditional Western beliefs (Halbert, 1997). A question that arises from this conflict is, “How can these ‘deviant’ female athletes become more accepted by our society?” One potential answer is to simply begin by understanding the female/athlete paradox, which may have the potential to facilitate changes in our society’s gender stereotypes. Females’ integration in sport “forces society to re-define masculinity and femininity, and this throws into turmoil beliefs regarding gender roles” (as cited by Ross & Shinew, 2008, p. 53). While athletic women understand the beliefs associated with traditional gender roles, they are beginning to challenge these views by reframing what it means to be feminine in society (Ross & Shinew, 2008). As a result of this contention, the well-established boundary dividing gender between masculinity and femininity begins to fade, allowing individuals to freely exhibit qualities associated with both categories simultaneously. Femininity and Masculinity as Bipolar Constructs Masculinity and femininity have traditionally been perceived as two distinct and opposing concepts, causing individuals to be categorized as either entirely masculine or entirely feminine. Understanding gender in this manner led to a unidimensional research approach that measured people based on levels of either masculinity or femininity, but not both simultaneously (Alley & Hicks, 2005). Recently, a more modern view is developing that aims to understand masculinity and femininity on a spectrum such that an individual, regardless of his or her gender, can exhibit varying degrees of both gender categories. This new approach allows athletic women to “retain their femininity even if they are ‘masculinized’ by participation in competitive sports” (Alley & Hicks, 2005, p. 275). In order to fully understand the conflict athletic women face and the findings from present research, it is essential to operationalize the terms “masculine” and “feminine.” The definition of femininity may not necessarily be the same across cultures, but in conventional Western communities, being feminine is often characterized by having dainty, polite, and girly qualities (Krane, 2001; Krane et al., 2004). One of the most definitive representations of feminine perfection in North American culture is exhibited by the best-selling Barbie doll. After converting the doll’s proportions to those of a human, Barbie would equate to a 5 foot 10 inch tall female weighing just over one hundred pounds with a 20-inch waist (as cited in Neverson & White, 2002). According to the National Health Statistics Reports from 2003-2006, the average woman in the United States was 5 foot 3 inches, weighed 155 pounds, and had a waist measurement of 36 inches (McDowell, Fryar, Ogden, & Flegal, 2008). Even though there are now variations of Barbie that include her wearing outfits from several different sports, such as basketball, soccer, and rollerblading, they still emphasize her femininity by using clothing that is predominantly pink or purple and emphasizes her

exaggerated physique. Several studies examining the ways Barbie affects girls in late childhood and early adolescence found that those exposed to the doll at an earlier age reported a greater desire for thinness, poorer body image, and were more likely to develop eating disorders (Dittmar, Halliwell, & Ive, 2006; Norton, Olds, Olive, & Dank, 1996). The differences between Barbie’s ideal feminine image and the reality of the NHSR’s sample of women seem quite obvious, but Western cultures continue to focus on the necessity of a flawless and delicate body to correspond with the weak and passive qualities associated with women (Neverson & White, 2002). This view is further amplified by the basic biological assumption that women are weaker than men, which can possibly constrain both genders and place limitations on females who wish to pursue sports (Lopiano, 2000; Ross & Shinew, 2008). Women who find ways to see beyond these societal pressures and learn to integrate their desired levels of femininity within their chosen sport may have the ability to develop effective coping methods when facing insecurities surrounding body image and/or when approaching the female/athlete paradox. In a study by Ross and Shinew (2008), semistructured interviews were given to elite college female athletes involved in either gymnastics or softball to understand how they perceived and experienced the female/athlete paradox. When asked about their definitions of femininity, the participants focused mainly on beauty, fashion, body-type, and make-up. More than half of the participants specifically referred to cheerleaders, models, or sorority girls when providing examples of feminine women, and explained that their choices were based on women who often place significant value on their daily appearances, regardless of the context. The athletes also commonly described feminine qualities as “slender,” “weaker and slower,” “passive,” and “more unsure of themselves” (p. 47), which contrasted with perceptions of masculine traits (more muscular, aggressive, strong, and confident). These women acknowledged and discussed the dualistic notion between masculinity and femininity in their interviews; they found that this gender differentiation placed limitations not only on their athletic competence, but also on the ways in which they were publically perceived when compared to females who followed traditional feminine norms. However, the participants also expressed a sense of pride and appreciation for their athletic skill and physical power, along with enjoyment in portraying a feminine appearance when they chose to do so. These results suggest that athletic women may have the ability to challenge and even redefine what it means to be a sportswoman, which includes understanding that they do not have to sacrifice their femininity to participate in “masculine” sports or to be a successful athlete. While much of the research surrounding female athletes and gender stereotypes focuses predominantly on the bipolarity between masculinity and femininity, there is a large gap in the literature when considering a third, less extreme gender construct: androgyny. Relatively little research exists on androgyny and athletics, particularly beyond the 1980s, but it is an


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important concept that departures from dichotomous gender theories. It suggests the possibility for a medium between the opposing masculine and feminine labels, allowing androgynous individuals to be simultaneously gentle and strong, dependent and independent, and/or competitive and passive (Hoferek & Hanick, 1985). Since this gender category allows one to exhibit masculine and feminine qualities concurrently, it seems as if androgyny would be an appropriate solution for the conflicts female athletes experience. However, since women who convey androgynous traits inevitably embody some characteristics associated with masculinity, such as self-confidence, assertiveness, and determination, it seems that the mere presence of these qualities has the ability to overpower the existence of their feminine traits. The focus then returns to the belief that these individuals are not feminine, and they frequently become associated with negative stereotypes including “man-hating,” “pushy,” or homosexual (Lenskyj, 1987, p. 382). Androgyny may seem to be the perfect and logical solution to the female/athlete paradox, but research shows the reality of this concept is clearly quite different than its theoretical implications. Since nearly all of the studies involving androgyny were conducted during the 1980s, this gap in the literature is one that needs to be further explored to have a more comprehensive understanding of gender categorizations, and more specifically in relation to the female/athlete paradox. Classifying Sports Through Gender Stereotypical gender roles created a boundary that delineated which sports were socially acceptable for male and female participation according to perceived degrees of masculinity, femininity, or gender-neutrality i.e., androgyny (Koivula, 1995, 2001). Participation in sports traditionally regarded as masculine, including boxing (Halbert, 1997), ice hockey (Krane, 2001), weight lifting, and motor sports (Koivula, 2001), are deemed inappropriate for women. Instead, females are often encouraged to engage in activities such as figure skating, gymnastics, and tennis (Ross & Shinew, 2008) since these are considered more feminine and are therefore met with less criticism and fewer encounters with negative consequences. When athletic women do not appear to be feminine enough or choose to engage in male-dominated sports, they are bound to face a variety of repercussions including: maltreatment from administrators and coaches, verbal harassment by fans, fewer endorsements, decreased media attention, and/or unfair decisions by judges or officials during competitions (Krane, 2001). These challenges clearly impact sport participation choices, often leading women to conform to the more feminine options (as cited by Wiley, Shaw, & Havitz, 2000). Various studies have been conducted to understand how individuals rate sports as being more or less appropriate for a particular gender. Nathalie Koivula (1995) examined this theory to explore the ways in which college men and women categorize a variety of sports. The participants rated the options as either female appropriate, male appropriate, or neutral, based on how they believed society would classify the activities. Results showed that most sports were regarded as gender-neutral, which included

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examples such as cycling, jogging, and tennis. About 30% of the sports were thought to be more masculine, including football, weightlifting, and boxing, and the fewest amount (about 10%) were considered feminine sports with examples such as dance, figure skating, and synchronized swimming. Koivula’s findings led to the conclusion that classifying sports in this manner greatly influences males’ and females’ choices in regard to sport type, as well as their levels of commitment. A possible explanation for this finding could be that individuals often avoid activities deemed sexinappropriate because of the negative thoughts, feelings, and stigmatizations they experience, such as body image insecurities, homophobic harassment, and anxiety about not conforming to societal norms (Blinde & Taub, 1992; Dworkin, 2001; Krane et al., 2004). Therefore, women who do not participate in gender-appropriate sports are at greater risk for quitting or choosing a “feminine” sport from the start (Halbert, 1997; Koivula, 1995). Studies examining the classification of sports through gender try to understand how society’s sex-role expectations impact the categorization of athletic activities as being masculine, feminine, or gender neutral, while attempting to identify the characteristics used to differentiate between these three constructs (Alley & Hicks, 2005; Koivula, 1995, 2001; Krane, 2001). Researchers found that sports considered beautiful, graceful, nonaggressive, and aesthetically pleasing are typically considered most appropriate for women, and unsuitable for male involvement. The existence of beauty seems especially significant in feminine sports, most likely because of its importance to the general idea of femininity. Common examples of sports appropriate for female participation are gymnastics, dance, and figure skating, which is probably due to their expressive qualities and graceful movements that are meant to visually please the audience by emphasizing the athletes’ feminine physiques (Koivula, 2001). This category of sports is also usually individualistic rather than team oriented, and frequently involves a separation of opponents from one another (e.g. swimmers compete in the same pool but have individual lanes to divide participants). Organizing athletes in this manner excludes almost all contact sports, which are deemed more male-appropriate. Sports categorized as “masculine” tend to focus less on aesthetics and more on competition, strength, and aggression. Examples of these characteristics can be observed in wrestling, ice hockey, and bodybuilding, which require efforts to physically subdue an opponent, lift or overpower heavy objects, and/or use bodily contact to succeed (Alley & Hicks, 2005; Dworkin, 2001; Ross & Shinew, 2007). Sport qualities that include winning and a “war-like structure” (Ross & Shinew, 2007, p. 44) are socially limited to males, while females are expected to participate in those based on cooperation and grace; these activities are deemed sex-appropriate since they allow both genders to maintain traditional gender norms (Koivula, 2001). While almost all sports are categorized by gender to some degree, certain types are more gender-differentiated, or significantly more appropriate for one gender than another. Individuals who participate in highly differentiated


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sports that are “gender-inappropriate” will most likely experience negative consequences, such as being labeled “deviant:” one who departs from or violates traditional social norms (Blinde & Taub, 1992; Halbert, 1997; Kolnes, 1995). Women who threaten these standards, such as those who participate in highly differentiated “masculine” sports (e.g., boxing or football) are sometimes considered a challenge to the “boundaries of femininity” (as cited by Halbert, 1997, p. 11). Since boxing is often considered the most masculine of any other sport and is characterized by aggression, brutality, violence, and bloodshed, female boxers are thought to be exceptionally gender deviant (Halbert, 1997). Joyce Carol Oates describes the mainstream view of female boxers and writes, “Raw aggression is thought to be the peculiar province of men, as nurturing is the peculiar province of women. The female boxer violates this stereotype and cannot be taken seriously – she is parody, she is cartoon, she is monstrous” (p. 73). Female boxers’ engagement in a sport representing pure masculinity in Western culture causes their femininity to be distorted until it is unrecognizable. Since people are often less familiar with observing women display such stereotypical masculine qualities, including strength, destruction, and vehemence, these athletes are more likely to be labeled as deviant, unnatural, and/or manly (Dworkin, 2001; Krane, 2001; Krane et al., 2004). Females who participate in gender-inappropriate sports do not fulfill the characteristics of hegemonic femininity and are therefore met with harsh criticisms and negative consequences they must learn to manage. Women who participate in “gender deviant” sports often use identity-controlling strategies to cope with negative feedback from the public. Some examples of these defensive techniques may include: deemphasizing their athletic achievements and what their sport means to them, choosing to participate in a less stigmatized sport, or dropping out of their sport when they can no longer manage being associated with the negative stereotypes (Halbert, 1997). The issue that causes one to use these identity controlling strategies or stigma management methods (Blinde & Taub, 1992) ultimately leads back to the larger cultural attitudes surrounding athletic women. Negative societal views directed towards female athletes are perhaps the strongest prohibiting factors for women who have the desire to enter and commit to the maledominated sports world. Females who participate in boxing and other “masculine” sports challenge the traditional cultural stereotypes associated with athletics, as these women prove that they can play any sport, no matter how masculine it is considered. The ability to confront our society’s traditional gender roles demonstrates how “nothing remains off limits to women” (Halbert, 1997, p. 32). Female boxers are often used to represent the experiences women encounter when involved in a “masculine” sport, while gymnasts are a common example used when referring to those engaged in “feminine” sports. In the study previously mentioned by Ross and Shinew (2008), female gymnasts and softball players were asked various questions regarding their beliefs about female athletes and whether or not participating in their

chosen sports created conflicts in their lives. Almost all of the gymnasts considered their sport more feminine than others, especially when compared to those such as basketball, soccer, and softball, which they felt were almost always associated with masculinity. They also expressed that sports such as rugby, wrestling, hockey, and bodybuilding were strongly associated with male characteristics and were “weird” and “odd” for female participation. When the athletes were asked what sports they felt were more associated with female participation, some of them mentioned cheerleading as being exceptionally feminine, although others questioned whether or not this was actually a sport. The overall findings of this study showed that the participating athletes were aware of traditional gender definitions and stereotypes, but were able to balance being successful in their sport with representing the ideal feminine image when they chose to do so. Perhaps understanding the significance of being a female athlete and revising the negative assumptions associated with being one will eventually lead to changes in traditional representations of femininity, especially when considering physical appearance and body type expectations. Muscularity and Physical Build While the ideal body size and shape varies across cultures, the feminine standard for Western societies emphasizes a thin physique with toned, lean muscle (Lenskyj, 1987). Attempts to fulfill these demands can create difficulties for female athletes, since they must develop more muscle mass to successfully perform in their sport. These women cannot develop “oversized muscles” (Krane et al., 2004), because exhibiting this feature violates gender norms and contributes to the connection between athleticism and lesbianism (Halbert, 1997). Associating female athletes with lesbianism has been a common theme in the United States and “follows a belief in the myth of the masculinization and mannishness of athletic women” (as cited in Halbert, 1997, p. 11). Females’ sexual orientations are often judged according to their physical build; those who exhibit a more muscular body type are more likely to be labeled “dyke,” “butch,” or “lesbian” (Blinde & Taub, 1992, p. 529). Sportswomen attempt to avoid these negative stereotypes by trying to prevent an increase in muscle mass, or for some women, ceasing participation altogether. Dworkin’s (2001) study examined how women from a variety of ethnicities and SES’s perceived and managed cultural body ideals through their exercise routines. Many women stated the importance of cardiovascular exercises, since these burned fat, helped them stay lean while maintaining curves, and did not make them “bigger.” The most common theme throughout the study was the fear of an increase in size, whether it was due to muscle or fat. Most women expressed increased muscle mass and weight lifting as masculine, which they tried to avoid. Dworkin describes: “[the women] focused on weight work and bulk as ‘masculine’ bodily villains and cardiovascular work as a ‘feminine’ bodily savior” (p. 338). Through this statement, one can observe the immense amount of pressure and emphasis women place on physical size in relation to gender. The extreme way in which weight work and cardiovascular work are contrasted provides


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a telling depiction of how gender is perceived in our culture; despite more recent efforts that attempt to reframe it so masculinity and femininity exist on a spectrum, it is still often viewed as a divided concept where men and women must adhere to their respective norms in order to be accepted by society. Complications can inevitably arise from the pressures and expectations that female athletes feel they must present through the “appropriate” female body. In a study by Krane, Waldron, Michaelenok, and Stiles-Shipley (2001), women who had to wear revealing uniforms, such as bathing suits or leotards, were apprehensive about their appearance. They feared that others would view them as being “fat” or “too big” (p. 320), which led to unhealthy dieting, disordered eating, or excessive exercise in some cases (Krane et al., 2001). Other women were concerned about their amount of muscle mass, which led to negative associations in regards to their weight, despite their low percentage of body fat. The athletes explained feeling traumatized by their initial increase in body weight and were upset by their increased muscle mass because it contradicted cultural perceptions of the ideal body and discredited their femininity (Krane et al., 2001). Since sportswomen must have an athletic body in order to meet the demands required by their sport while simultaneously trying to maintain society’s ideal feminine body-image standards, it is not uncommon for them to feel forced to face a lose-lose situation (Krane, 2001). This is yet another example of the struggle sportswomen experience when trying to navigate their way through the female/athlete paradox. In order to manage the difficulties associated with this complex dilemma, women attempt to develop positive coping mechanisms (e.g., finding a sense of appreciation for their athletic achievements), which may foster greater feelings of selfacceptance, pride, and empowerment that may not be obtainable elsewhere (Ross & Shinew, 2008). Discussion Understanding the female/athlete paradox and the difficulties sportswomen experience may be the first step towards confronting socially constructed gender norms and dichotomous views of masculinity and femininity in Western culture. Female involvement in athletics provides an opportunity to reassess the implications of masculinity and femininity in society by constructing new definitions of what genderappropriate behaviors may look like (Ross & Shinew, 2008). As Ross and Shinew (2008) state, “While dualistic notions of gender have been shown to constrain sport participation for girls and women, they are developing ways to persist and succeed within sport” (p. 53). When women participate in athletic activities, they are given the opportunity to feel more powerful and in control over their lives, leading to a sense of selfacceptance, pride, and appreciation for their athletic competence (as cited by Ross & Shinew, 2008). A study assessing adolescent girls found that those involved in physical activity were less likely to take part in high-risk health behaviors such as cigarette smoking, were more likely to graduate from high school and experience academic success, and reported higher levels of self-esteem and fewer cases of depression

| The Female/Athlete Paradox | 36

(Lopiano, 2000). While some researchers examining disordered eating and body image reported that these negative behaviors and perceptions were more likely to exist in female athletes, especially for those in certain “high-risk” sports such as gymnastics, swimming, and running (Krane et al., 2004; as cited by Smolak, Murnen, & Ruble, 2000), others found contradictory results. Research conducted by Smolak et al. (2000) compared female athletes with a non-athlete control group and determined that the experimental athlete group managed considerably better in regards to body dissatisfaction. Therefore, perhaps sport participation has the ability to provide a preventative intervention to protect females from experiencing body image discontentment and potential disordered eating behaviors. One area of research that needs to be covered more extensively is the affect of culture on gender norms and how perceptions of female athletes may vary cross-culturally. Most of the studies conducted in this area of research have focused on “generic sporting women” (as cited in Krane et al., 2004, p. 327), or women in Western cultures who can identify with the ways in which hegemonic femininity is structured. Although many of the participating athletes in these studies described similar ideal body types, which mirrored those most frequently portrayed by the media, it is important to recognize that these responses were all from an analogous sample type (i.e. mostly generic sporting women). Athletes of various ethnicities and sexual orientations may not desire the same image that consumes the media, and are often ignored in comparison to the “dominant” group of women who represent hegemonic femininity (Krane et al., 2004). It is essential for researchers to examine and explore this gap in order to resolve the conflicts female athletes experience, regardless of their racial/ethnic background, SES, or sexual orientation. Despite dualistic gender notions, which are believed to inhibit females’ participation in sports, more women are challenging these traditional Western beliefs by competing and succeeding in a variety of sports. Females’ involvement in athletics provides opportunities for women to challenge themselves by exploring a domain where they may feel excluded, leading to a previously undiscovered sense of security and confidence (Ross & Shinew, 2008). As more women try to determine their roles in the athletic realm, they may actually encounter a sense of liberation, not oppression, by experiencing their bodies and selves as strong and free from male domination (Theberge, 1985). As this review has indicated, navigating one’s way through the female/athlete paradox is a complicated and challenging task that often requires women to confront a variety of internal and external struggles. As female athletes continue to persevere and work through various gender constraints, they also begin to redefine what it means to be a sportswoman in Western culture, which is an initial step towards redefining hegemonic femininity.


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References Alley, T. R., & Hicks, C. M. (2005). Peer attitudes towards adolescent participants in male- and female-orientated sports. Adolescence, 40(158), 273-280. Anderson, E. (2005). Orthodox and inclusive masculinity: Competing masculinities among heterosexual men in a feminized terrain. Sociological Perspectives, 48(3), 337-355. Berk, L.E. (2008). Child development (8th ed.). Boston: Bacon & Allyn. Blinde, E. M., & Taub, D. E. (1992). Women athletes as falsely accused deviants: Managing the lesbian stigma. The Sociological Quarterly, 33(4), 521-533. Dittmar, H., Halliwell, E., & Ive, S. (2006). Does Barbie make girls want to be thin? The experimental exposure to images of dolls on the body image of 5- to 8-year-old girls. Developmental Psychology, 42(2), 283-292. Dworkin, S. L. (2001). “Holding back”: Negotiating a glass ceiling on women’s muscular strength. Sociological Perspectives, 44(3), 333-350. Halbert, C. (1997). Tough enough and woman enough: Stereotypes, discrimination, and impression management among women professional boxers. Journal of Sport and Social Issues, 21(7), 7-36. Hardin, M., Chance, J., Dodd, J. E., & Hardin, B. (2002). Olympic photo coverage fair to female athletes. Newspaper Research Journal, 23, 6478. Hoferek, M. J., & Hanick, P. L. (1985). Woman and athlete: toward role consistency. Sex Roles, 7(8), 687-695. Koivula, N. (1995). Ratings of gender appropriateness of sports participation: Effects of gender-based schematic processing. Sex Roles, 33, 543-557. Koivula, N. (2001). Perceived characteristics of sports categorized as gender-neutral, feminine and masculine. Journal of Sport Behavior, 24(4), 377-393. Kolnes, L. (1995). Heterosexuality as an organizing principle in women’s sport. International Review for the Sociology of Sport, 30(1), 61-77. Krane, V. (2001). We can be athletic and feminine, but do we want to? Challenging hegemonic femininity in women’s sport. Quest, 53, 115-133. Krane, V., Choi, P. Y. L., Baird, S. M., Aimar, C. M., & Kauer, K. J. (2004). Living the paradox: Female athletes negotiate femininity and muscularity. Sex Roles, 50, 315-329. Krane, V., Waldron, J., Michalenok, J., & StilesShipley, J. (2001). Body image, and eating and exercise behaviors: A feminist cultural studies perspective. Women in Sport and Physical Activity Journal, 10(1), 17-54. Lenskyj, H. (1987). Female sexuality and women’s sport. Women’s Studies International Forum, 10(4), 381-386. Lopiano, D. A., (2000). Modern history of women in sports: Twenty-five years of Title IX. Cinics in Sports Medicine, 19(2), 1-8. McDowell, M. A., Fryar, C. D., Ogden, C. L., & Flegal, K. M. (2008). Anthropometric reference data for children and adults: United States, 2003-2006. National Health Statistics Reports, 10, 1-45. Meân, L. J., & Kassing, J. W. (2008). “I would just like to be known as an athlete”: Managing

hegemony, femininity, and heterosexuality in female sport. Western Journal of Communication, 72(2), 126-144. Mennesson, C. (2000). ‘Hard’ women and ‘soft’ women: The social construction of identities among female boxers. International Review for the Sociology of Sport, 35(1), 21-33. Nelson, M. B. (1998). I won, I’m sorry. Self Magazine, 145-147, March. Neverson, N., & White, P. (2002). Muscular, bruise, and sweaty bodies…That is not Barbie territory. Canadian Woman Studies, 21(3), 4449. Norton, K. I., Olds, T. S., Olive, S., & Dank, S. (1996). Ken and Barbie at life size. Sex Roles, 34, 287294. Oates, J. C. (2006). On boxing. Garden City, NY: Harper Perennial Modern Classics. Ross, S. R., & Shinew, K.J. (2008). Perspectives of women college athletes on sport and gender. Sex Roles, 58, 40-57. Smolak, L., Murnen, S. K., & Ruble, A. E. (2000). Female athletes and eating problems: A metaanalysis. International Journal of Eating Disorders, 27, 371-380. Theberge, N. (1985). Toward a feminist alternative to sport as a male preserve. Quest, 37, 193202. Wiley, C. G. E., Shaw, S. M., & Havitz, M. E. (2000). Men’s and women’s involvement in sports: An examination of the gendered aspects of leisure involvement. Leisure Sciences, 22, 19-31.

Author’s Biography Andrea Paloian is a senior in the Applied Psychology program. Her main research interests include gender studies and attachment theory. After graduating, she hopes to pursue a degree in clinical psychology.


Scarola

Socioemotional Interventions:

The Efficacy of Socio-Emotional Interventions in Head Start Classrooms

By Lauren Scarola

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Due to current economic hardship, rates of poverty are continuously expanding, forcing families and individuals to live in less than ideal conditions. For children, the effects of these circumstances can be particularly detrimental. Specifically, growing up in poverty coincides with an environment that is harmful to children’s mental, emotional, and physical development. Currently in the United States, one in every five preschool aged children lives in poverty, revealing a significant area of concern (Bierman, Nix, Greenberg, Blair, & Domitrovich, 2008). Children who experience poverty have less accessibility to certain resources that are fundamental for their healthy development, such as nutritious meals and healthcare programs. Additionally, children who live in poverty lack accessibility to quality educational programs, which affects children’s opportunities for superior education and achievement. One resource that is profoundly affected by poverty is a child’s access to quality educational programs. Currently, available programs are generally short staffed, lacking monetary resources, skilled instructors, and do not provide children with adequate skills, impeding children’s achievement in the classroom environment (Shields et al., 2001). A child’s successful integration into formal schooling is dependent on their acquisition of school readiness skills. Although educational research often focuses on the development of numeracy and literacy, strong development of positive learning behaviors is crucial. Positive learning behaviors include patience, following directions, motivation, as well as regulation of behaviors and emotions. Learning behaviors aid children in their adaptation to the kindergarten environment, in which children are expected to accomplish more sophisticated goals than those of the preschool years (Blair, 2003). As learning goals must be achieved in an environment with decreased supervision and more emphasis on autonomy, positive learning behaviors are essential for children’s continued success in the classroom environment (Graziano, Reavis, Keane, & Calkins, 2007). Unfortunately 35 % of children entering kindergarten have not attained these skills, often creating a pattern of school failure throughout formal schooling (Kober, 2010). As a result of the documented detrimental affects of poverty on children’s academic success, federally funded programs like Head Start have been implemented in hopes to close the achievement gap between low-income children and their more affluent peers. Head Start is the nation’s largest federally sponsored early education program that serves at risk, underprivileged children by fostering the development of strong school readiness skills (Fantuzzo et al., 2007). Head Start operates on the belief that successful integration into formal schooling is achieved through the proper development of eight learning domains: language, literacy, math, science, creative arts, health, approaches to learning, and socio-emotional skills (Fantuzzo et al., 2007). Thus, classroom activities focus on the development of learning domains to enhance children’s abilities to ensure success during the integration into formal schooling. Despite their goals, recent research indicates that children enrolled in Head Start programs still have unmet school readiness needs, particularly in


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the domain of socio-emotional development (Domitrovich, Cortes, & Greenberg, 2007). Insufficient development of socio-emotional skills leads to children lagging behind their peers in communication skills, behavior regulation, and successful classroom behaviors. Without the proper fostering of these socio-emotional skills, children enter formal schooling with maladaptive learning skills, which contribute to disparities in school performance, high school graduation rates and consequently, employment potential (Bierman, Domitrovich et al., 2008). Furthermore, the effects of these maladaptive behaviors are not only limited to the child. An interruption in class disturbs other children’s learning abilities and distracts the focus of educators, as they must disrupt their lesson to address the behavior. In fact, Head Start teachers report feeling overwhelmed and poorly equipped to handle behavior challenges such as interruptions, and implementations of socio-emotional interventions to aid in development. Interview data from a study by Quesenberry, Hemmeter, and Ostrosky (2011) denotes that educators who are not properly trained in clear programs or policies are less likely to employ classroom activities that support children’s socio-emotional development and promote advanced learning behaviors. Therefore, the literature seems to present a need for educational interventions that not only develop children’s socio-emotional skills, but also instill knowledge and confidence in teachers to implement these programs. Weekly volunteering in Head Start centers allows me to experience firsthand the behavioral issues that exist within the classroom. Time and time again, I watch children in the classroom struggle with skills such as behavioral regulation, following directions, and having patience. Head Start instructors use the tools they have been given to correct these behaviors and shape positive development, but if they prove unsuccessful they often do not know where to turn next. It has become apparent the degree of impact these skills have on children’s academic achievement. For example, it is impossible for a child who cannot regulate his or her behaviors to focus on a task that is designed to help him or her learn letter recognition. Without the ability to regulate behaviors and emotions, children are unprepared for learning, delaying their development not only in socio-emotional skills, but also in other domains. Noting the difficulties and frustration faced by classroom teachers, I have wondered if socio-emotional interventions designed for Head Start centers have proven effective in educating teachers on fostering preschoolers’ positive socio-emotional skills, and the results of these interventions on children’s development. To answer this question, this review article will first provide a clearer picture of the necessity and benefits of the development of strong socio-emotional skills, and will then focus on the implementation and efficacy of two Head Start interventions: The Emotion Course and The Head Start REDI (Research Based Developmentally Informed) program. Socio-emotional Development The preschool years serve as a crucial time for the development of socio-emotional skills such as regulation, pro-social behavior, and positive learning behaviors (Fantuzzo et al., 2007; Izard,

Trentacosta, King & Mostow, 2004). Recent research identifies behavioral and emotional regulatory skills as especially fundamental for success in a kindergarten environment (Fantuzzo et al., 2007; Raver et al., 2011). Children who have high levels of regulatory skills develop advanced learning behaviors such as following directions, attentive listening, independently attempting to problem solve, and patience. Statistically, children who are able to apply regulatory skills to classroom learning goals perform better on tests of academic achievement (Denham, 2006). These regulatory skills allow children to modify their behaviors in a manner that is conducive to learning and ultimately results in higher levels of achievement. Therefore, the development of regulatory skills is essential during this time period, as numerous studies have indicated a relation between school readiness skills and future school success (Fantuzzo et al., 2007; Izard et al., 2004; Raver et al., 2011). On the other hand, preschoolers who do not develop emotional and behavioral competencies are at risk for disruptive classroom and learning behaviors throughout their formal schooling experience (Domitrovich et al., 2007). In fact, disruptive behaviors established in the preschool years have been identified to remain stable across childhood and adolescence (Domitrovich et al., 2007). Behaviors such as poor attention focus, acting out in class, inability to control emotional reactions, and impatience, negatively impacts children’s engagement and positivity within the classroom environment (Izard et al., 2004). Furthermore, children’s opportunities to learn from their peers and teachers are lessened when they enter schooling with disinterest and negativity. Without highly developed regulatory skills and successful classroom involvement, children enter formal schooling unprepared for the challenges and educational demands (Raver et al., 2011). Deficits in necessary regulatory and advanced learning behaviors have been shown to continue throughout schooling and often result in children falling behind their more skilled classmates. School failure is often recurrent and places children on a cyclical pattern of low levels of academic achievement throughout formal schooling (Pyle, Boves, Greif, & Furlong, 2005), furthering the need for early intervention practices within the preschool environment. Head Start programs were founded as means to address significant concerns regarding lowincome preschoolers transition into formal schooling environments, as early adjustment determines much of children’s subsequent success. However, research indicates that Head Start instructors struggle with fostering socioemotional development within the classroom. As these positive behaviors are crucial for children to excel within the challenging kindergarten environment, intervention initiatives have been implemented into numerous Head Start classrooms in hopes to instill programming that successfully fosters children’s socio-emotional development (Izard et al., 2004). Head Start Socio-emotional Interventions Within the past forty years, there has been an increase in the implementation of intervention programs for at risk populations, including children who experience poverty. Research strives to lesson risk factors that inhibit children’s


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development, while simultaneously seeking to enhance skills that foster positive growth (Domitrovich & Greenberg, 2004). Currently, much of the focus of these interventions exists within the area of education reform. However, developmental research acknowledges that there are new areas for educational improvement. Recently, research focuses on the quality of education as a means to guide the development of preventative interventions. Current directions of educational research state that providing early childhood teachers with appropriate tools and techniques is integral for continued success in fostering necessary growth (Spritz, Sanberg, Maher, & Zajdel, 2010). Head Start children’s underdeveloped levels of socio-emotional skills have inspired significant attention on the implementation of successful interventions to aid in socio-emotional education (Domitrovich & Greenberg, 2004). Various interventions have been established to assist in this target objective, including two of the most widely utilized Head Start socio-emotional interventions, Emotion Courses (Izard et al., 2004), and The Head Start REDI program (Bierman, Domitrovich et al., 2008). The emotions course. Carrolls Izard’s program, The Emotions Course, concentrates on the importance of teaching properties of emotions, emotional expressions, and emotional functionality. The program is guided by Izard’s theory, which explains that changing children’s understanding of emotions with regards to regulation and appropriate utilization of emotions leads to a transformation in positive socialization, communication, and social practices (Izard et al., 2004). Izard argues that the significant increase of children’s abilities to understand emotions and the substantial growth of the connections between emotions, cognition, and children’s actions during the preschool years makes the attainment of regulatory and pro-social skills feasible (Izard et al.,2008). The program operates through the teaching of 22 weekly lessons that apply to the four basic emotions: happiness, sadness, anger and fear (Izard et al., 2004). The learning process is tri-fold in that it requires the ability to label an emotional state, understand its causes and effects, and develop the skills necessary to regulate said emotion. Learning activities consist of puppet vignettes, talk about emotions, emotion expression posters, games, storybooks, and interactive reading. These hands-on lessons serve as a context for developmentally appropriate, real world applications of emotion-focused processes. After a two-hour training seminar, during which instructors are provided with necessary information and lesson agendas that they are expected to master on their own, Head Start classroom teachers lead the program’s lessons. Throughout the school year, program creators also visit Head Start classrooms twice to ensure proper implementation and to provide any necessary support. The Emotions Course seeks to educate instructors on proper implementation of emotion education in hopes to increase levels of socio-emotional skills in Head Start preschoolers. Before and after The Emotions Course programming, children’s levels of emotion knowledge, including the ability to label and recognize emotions as well as teacher ratings of children’s emotional expressions and behaviors,

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are assessed (Izard et al., 2004). Results of the intervention indicate positive development in certain domains. Specifically, children who participated in The Emotions Course developed an increased level of emotion knowledge, showing vast improvement in emotion vocabulary, labels, and recognition. However, despite the investigator’s theory that children’s emotion knowledge translates into regulated behaviors, children showed no improvement in teachers’ assessment of their emotional expression and behaviors (Izard et al., 2008; Izard et al., 2004). These findings indicate that while The Emotions Course is successful in fostering children’s development of emotion competence, this increased knowledge did not predict children’s abilities to regulate emotions and behaviors within the classroom environment, suggesting other impeding variables on children’s development exist. Due to the increase in children’s emotion knowledge, it is clear that the interactive lessons provide a stimulating environment that allows for the child’s comprehension of information. However, a disconnect exists between children’s level of emotion knowledge and their ability to apply learned information. Furthermore, as teachers’ satisfaction with the intervention was not assessed, it is possible that teachers felt unprepared to administer the intervention. In preparation for the implementation of the intervention, instructors were given written lesson plans; however, there was not much additional training or support from the program’s creators. Educators received two pre-training sessions and were then required to learn the lessons completely independently (Izard et al., 2004). As Head Start educators already have numerous educational mandates in place for their classroom activities, the lack of extra support may have hindered teachers’ abilities to successfully integrate The Emotions Course into their Head Start classrooms. Unfortunately, while emotion knowledge showed increased levels, the ultimate goal of improved levels of behavioral and emotional regulation were not achieved. These results seem to suggest that The Emotions Course intervention program is lacking elements that allow for children’s increased emotion knowledge to translate into regulatory functioning. Head Start REDI. Whereas The Emotions Course intervention does not provide the Head Start teachers with the necessary support they need, the Head Start REDI program believes that extra support for teachers is crucial to the success of intervention strategies. REDI takes into account that most Head Start teachers do not have the skills, financial resources, or assistance to integrate new learning strategies (Bierman, Nix et al., 2008). Therefore, the intervention was designed with the intention to fit seamlessly into the existing framework of the Head Start program. In addition to supplemental materials such as planning manuals and facilitator guides, educators received extensive outside training. Before implementing the program in their classrooms, teachers attended a three-day training conference, followed by a one-day refresher course halfway through the implementation of the program (Bierman, Domitrovich et al., 2008). Furthermore, mentors visited Head Start teachers weekly to provide further training and support in


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necessary domains. Investigators believed that this more hands-on approach would promote teacher’s abilities to apply intervention practices that support children’s socio-emotional competencies and literacy skills in the most successful manner. For the focus of this review article only the results of children’s socioemotional competencies will be addressed. Head Start REDI employs the Head Start PATHS (Promoting Alternate Thinking Strategies) social-emotion intervention to reduce children’s behavioral and emotional problems, while enhancing levels of socio-emotional competence (Bierman, Domitrovich et al., 2008). The program emphasizes the teaching of socio-emotional skills through real-life opportunities. Although the PATHS program has been used independently, creators of the Head Start REDI program wanted to examine the contribution of increased teacher training in conjunction with the goals of the PATHS program. The implementation of the program involved thirty weekly lessons focusing on basic and advanced feelings, as well as selfcontrol and problem solving, conducted during circle time in Head Start classrooms (Domitrovich et al., 2007). During these weekly lessons, educators were instructed to pair corresponding games and activities to the weekly lesson. For example, a lesson regarding fear might include a puppet vignette about classroom children’s own experiences with the emotion. The goal of the program was to foster positive socio-emotional development through five learning domains: (1) children’s awareness and communication regarding their own and others emotions, (2) teaching self control of behavior, (3) implementing problem solving skills, (4) promoting positive self-concept, and (5) creating a constructive classroom atmosphere, all of which provide children with the information, skills, and supportive environment necessary to excel (Domitrovich et al., 2007). The execution of the PATHS programs without the use of the Head Start REDI intervention have seen positive results in the development of emotion knowledge skills, much like the results of The Emotion Courses. However, there is little improvement seen in the areas of inhibitory control, attention, problem solving or behavioral regulation (Domoitrovich et al., 2007). While it is clear that PATHS is fostering children’s development of emotion knowledge skills, such as recognition and labeling, children’s application of these skills to regulation practices is lacking. Conversely, when the PATHS program is used in combination with Head Start REDI, children not only improve in emotion knowledge skills, but also within the domains of behavioral and emotional regulation (Bierman, Domitrovich et al., 2008; Bierman, Nix et al., 2008). It is this comparison that allows for interpretation of the conflicting results of socio-emotional interventions. Conclusion Trends in the literature clearly indicate strengths and weaknesses of socio-emotional interventions for Head Start children. Each of the reviewed intervention programs noted an apparent increase in children’s levels of emotion knowledge after the utilization of the intervention. Results denote that the interactive learning process used by all three interventions proved successful for Head Start children’s

comprehension of emotions. In other words, puppet shows, games, and emotions posters act as an outlet for children to interpret and act out their own and others’ emotions. Although positive results were found, each intervention reviewed also expected to discover an existent relation between the increase in emotion knowledge and high levels of socio-emotional skills. However, only the Head Start REDI program found this relation. As the relation between increased emotion competence and socio-emotional skills was not consistent across interventions, results indicate a need for the reevaluation of intervention practices. As a large component of the Head Start REDI program is teacher training, the argument can be made that the less extensive training provided by Emotion Courses (Izard et al., 2008) and PATHS (Domitrovich et al., 2007) are limitations of their programs. These findings are congruent with Head Start teachers’ own expressions of a greater need for training and assistance in the implementation of programming. Therefore, prevention research should focus on the development of interventions that not only foster emotion knowledge, but also teacher training and support. Future research might benefit from the addition of a teacher satisfaction measure for educators to indicate how successful they deem the intervention, the ease with which it was implemented, and their indicated level of support and understanding of the intervention. This lack of information for The Emotion Courses and Head Start REDI in the reviewed interventions made it impossible to assess whether or not teachers found techniques feasible and appropriate for the classroom. Additionally, further insight could be gained through studies conducted by individuals other than those researchers who developed the program. As this was the case with PATHS, REDI, and The Emotions Course, there is a possibility of investigator biases and a lacking variety of viewpoints. To ensure efficacy of future studies, researchers might consider embarking on a more in depth longitudinal study to determine longterm rates of success and satisfaction of teachers. At present time, intervention programs are predominately tested immediately after the completion of the program. Quick turnover eliminates the possibility of long-term deterioration of effects and lack of successful implementation of programming by teachers once investigators are removed from the Head Start classroom. Additional research should be conducted to assess the efficacy of teacher centered intervention programs in order to establish successful interventions for Head Start children. Identification of these programs might help to close the gap of school readiness between Head Start children and their more affluent peers. References Bierman, K. L., Domitrovich, C. E., Nix, R. L., Gest, S. D., Welsh, J. A., Greenberg, M. T., … Gill, S. (2008). Promoting academic and socioemotional school readiness: The head start REDI program. Child Development, 79(6), 1802-1817. Bierman, K. L., Nix, R. L., Greenberg, M. T., Blair, C., & Domitrovich, C. E. (2008). Executive


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functions and school readiness intervention: Impact, moderation, and mediation in the head start REDI program. Development and Psychopathology, 20(3), 821-843. Blair, C. (2003). Behavioral inhibition and behavioral activation in young children: Relations with self-regulation and adaptation to preschool in children attending head start. Developmental Psychobiology, 42(3), 301-311. Denham, S. A. (2006). Socio-emotional competence as support for school readiness: What is it and how do we assess it? Early Education and Development, 17(1), 57-89. Domitrovich, C. E., Cortes, R. C., & Greenberg, M. T. (2007). Improving young children's social and emotional competence: A randomized trial of the preschool "PATHS" curriculum. The Journal of Primary Prevention, 28(2), 67-91. Domitrovich, C. E., & Greenberg, M. T. (2004). Introduction to the special issue: Preventive interventions with young children: Building on the foundation of early intervention programs. Early Education and Development, 15(4), 365370. Fantuzzo, J., Bulotsky-Shearer, R., McDermott, P. A., McWayne, C., Frye, D., & Perlman, S. (2007). Investigation of dimensions of socioemotional classroom behavior and school readiness for low-income urban preschool children. School Psychology Review, 36(1), 4462. Graziano, P. A., Reavis, R. D., Keane, S. P., & Calkins, S. D. (2007). The role of emotion regulation in children's early academic success. Journal of School Psychology, 45(1), 3-19. Izard, C. E., King, K. A., Trentacosta, C. J., Morgan, J. K., Laurenceau, J., Krauthamer-Ewing, E. S., & Finlon, K. J. (2008). Accelerating the development of emotion competence in head start children: Effects on adaptive and maladaptive behavior. Development and Psychopathology, 20(1), 369-397. Izard, C. E., Trentacosta, C. J., King, K. A., & Mostow, A. J. (2004). An emotion-based prevention program for head start children. Early Education and Development, 15(4), 407422. Kober, N. (2010). Improving achievement for the growing Latino population is critical to the nation's future. Student achievement policy brief #3: Latino students Center on Education Policy. 1001 Connecticut Avenue NW Suite 522, Washington, DC 20036. Tel: 202-8228065; Fax: 202-822-6008; e-mail: cepdc@cep-dc.org; Web site: http://www.cepdc.org. Pyle, R. P., Bates, M. P., Greif, J. L., & Furlong, M. J. (2005). School readiness needs of Latino preschoolers: A focus on parents' comfort with home-school collaboration. California School Psychologist, 10, 105-116. Quesenberry, A. C., Hemmeter, M. L., & Ostrosky, M. M. (2011). Addressing challenging behaviors in head start: A closer look at program policies and procedures. Topics in Early Childhood Special Education, 30(4), 209-220. Raver, C. C., Jones, S. M., Li-Grining, C., Zhai, F., Bub, K., & Pressler, E. (2011). CSRP's impact on low-income preschoolers' preacademic skills: Self-regulation as a mediating mechanism. Child Development, 82(1), 362-378.

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Shields, A., Dickstein, S., Seifer, R., Giusti, L., Magee, K. D., & Spritz, B. (2001). Emotion competence and early school adjustment: A study of preschoolers at risk. Early Education and Development, 12(1), 73-96. Spritz, B. L., Sandberg, E. H., Maher, E., & Zajdel, R. T. (2010). Models of emotion skills and social competence in the head start classroom. Early Education and Development, 21(4), 495-516.

Author’s Biography Lauren Scarola is a senior in the Applied Psychology program. She is a member of Dr. Gigliana Melzi’s research team, the Latino Family Involvement Project, as well as a member of the Applied Psychology Honors program. After graduating, she plans to further her research experience and pursue a graduate degree in psychology.


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PSTD and type of trauma:

Comparing the type of trauma and the severity of PTSD symptoms in children and adolescents

By Jess Trane

Traumatic events are often far more powerful than the temporary terror and discomfort that they cause. The concerns that arise from natural disasters, maltreatment, and war do not simply end when the event does. They can result in serious long-term psychological impacts. One way that these impacts can manifest is Posttraumatic Stress Disorder (PTSD). Community-based studies found that there is a lifetime prevalence of PTSD or roughly 8% of the adult population in the United States (American Psychiatric Association, 2000). PTSD also affects a significant number of children and adolescents; community studies of high school students in the US have found that between 3 and 6 percent have PTSD (Kaminer, Seedat, & Stein, 2005) Exploring the relationship between the different types of trauma that can result in PTSD and the severity of PTSD symptoms in children and adolescents is important to creating the most developmentally appropriate and effective treatment of this disorder. Understanding what kinds of trauma are frequently linked with PTSD and how severe symptoms will help to ensure that children and adolescents receive the best possible treatment. Exposure to trauma is linked to higher prevalences of eating disorders, substance abuse, depression, anxiety, psychosis, and suicidality (Vizek-Vidovic, Kuterovac-Jagodic, & Arambasic, 2000). PTSD is also linked to declines in school performance, peer relational problems, and negative effects in cognition, behavior, and personality change (Vizek-Vidovic, KuterovacJagodic, & Arambasic, 2000). Developing a deeper understanding of this disorder will not only help treat these issues, but may also help treat or prevent the many comorbidities. Exposure to a natural disaster, maltreatment, and war are all types of trauma that may result in PTSD in children and adolescents. Further understanding of the relationship between these types of traumas and the severity of PTSD symptoms will help mental health practitioners to better treat this disorder. Diagnosing PTSD The DSMIV-TR contains specific diagnostic criteria for PTSD. The first aspect of these criteria is that the person was exposed to a traumatic event in which they experienced, witnessed, or were confronted by an event or series of events that involved the threat of or actual death, serious injury, or threat to the physical integrity of themselves or others and felt intense fear, helplessness, or horror in response. The DSMIV-TR is careful to note that these symptoms may express themselves somewhat differently in children. Children’s response may be more centered on disorganized or agitated behavior. The criteria also requires that there be symptoms of re-experiencing the trauma, persistent avoidance of stimuli associated with the trauma and a general numbing of responsiveness, and hyperarousal. To be diagnosed with PTSD it is also


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required that symptoms last for over a month and cause significant distress or impairment. Children may also experience symptoms not included in the DSMIV-TR criteria. Kaminer, Seedat, and Stein (2005) noted that children might also experience regression, new fears or the reactivation of old ones, accidents and reckless behavior, separation anxiety, and somatic issues. They also claimed that children exhibit symptoms of hyperactivity, distractibility, and increased impulsivity. There are some scales used to diagnose and assess severity in PTSD symptoms in youths based on both the DSMIV-TR criteria and the additional knowledge about the way PTSD is expressed in children. One of the most commonly used scales is the Child Post-Traumatic Stress Disorder Reaction Index (CPTSD-RI), which uses particular ranges of scores to indicate mild, moderate, severe, and very severe symptoms (Pynoos et al., 1987). Natural Disasters Exposure to a natural disaster, such as a hurricane, earthquake, tsunami, and other extreme force of nature, is one type of traumatic experience that can result in PTSD (Goenjian et al., 1995; Goenjian et al., 2001; Kolaitis et al., 2003; Shaw et al., 1994; Vernberg, La Greca, Silverman & Prinstein, 1996). PSTD caused by a disaster is often very complex because disasters often feature multiple traumatic aspects. During a disaster children and adolescents are exposed to the event itself, possible separation from a parent during the event or loss of a parent in light of the event, loss of another family member, possible injury to themselves or others, and possibly witnessing the death or suffering of others (Goenjian et al., 1995). Additionally, the aftermath of the event can be further traumatic. In particular, disasters in less developed countries are associated with serious public health issues (Goenjian et al., 1995). The many different issues associated with natural disasters mean that children and adolescents may experience multiple traumatic exposures. In the aftermath of these multiple exposures, some children and adolescents develop PTSD. Kolaitis et al., (2003) looked at children living near the epicenter of the 1999 earthquake in Athens and found that 40% of their sample had CPTSD-RI scores that suggested moderate to severe symptoms. Goenjian et al.’s (1995) study on the rates of PTSD and other disorders in the aftermath of the 1988 Armenian earthquake found that two of the three neighborhoods they looked at had mean CPTSD-RI scores that indicated severe PTSD symptoms. Studies examining children in Dade County, Florida after Hurricane Andrew and adolescents in Nicaragua following Hurricane Mitch found that a significant number of their subjects reported CPTSD-RI scores that suggested moderate to very severe symptoms. (Goenjian et al., 2001; Shaw et al., 1994; Vernberg, La Greca, Silverman, & Prinstein, 1996). In a study of adolescents in Aceh affected by the 2004 tsunami found that over 60% of their sample had CPTSD-RI scores that indicated moderate to very severe symptoms. While the numbers vary across studies, a consistent trend of having a large number of children and adolescents reporting symptoms that are moderate to severe emerges. Most studies found that over 30% of their sample had moderate to severe symptoms. The high rate

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of subjects reporting this level of symptoms suggests that disasters are a type of trauma closely linked with more severe PTSD symptoms. A similar link may also exist in other types of traumatic events, such as war. W ar War is another type of trauma that can result in PTSD. There are many horrors of war that a child or adolescent could be exposed to including witnessing violence, loss of a parent, being injured, being forced to join the fighting, and more (Thabet, Abed, Vostanis, 2004). There are other aspects of war that are less often considered but may also contribute to the trauma, such as stress from seeking refugee status of trying to migrate, separation from family, socioeconomic struggles, food and water shortages, and other issues (Thabet, Abed, Vostanis, 2004). Despite the many ways war can impact children and adolescents only a limited amount of studies have been done in this area. A study of children of Kuwait after the Gulf Crisis found that 70% of the sample reported CPTSD-RI scores that indicated moderate to severe symptoms (Nader, Pynoos, Fairbanks, & AlAjeel, 1993). Thabet, Abed, and Vostanis’ (2004) and Thabet & Vostanis’ (1999) studies of Palestinian refugees during conflict in the region found that a large portion of their sample had CPTSD-RI scores that indicated moderate to very severe PTSD symptoms. Bayer, Klasen, and Adam’s (2007) study of former Ugandan and Congolese child soldiers found that over 35% of their sample had CPTSD-RI scores that suggested moderate to very severe PTSD symptoms. These numbers suggest that there is a relationship between war-related trauma and severity of symptoms but more studies must be done before further conclusions can be drawn. The limited research that exists makes it difficult to identify any overarching themes and trends. More research on children and adolescents who have been exposed to war must be done to understand this relationship. In addition to war, maltreatment is another type of trauma that requires further research. Maltreatment Exposure to maltreatment can also result in PTSD but there is a very limited amount of research on the relationship between maltreatment and the severity of PTSD symptoms. Wechsler-Zimring and Kearny (2011) quoted the American Psychological Association Committee on Professional Practice Standards’ definition of maltreatment, “a physical harm inflicted nonaccidentally upon (a child) by his parents of caretaker” (p. 601). Several different issues fall under the category of maltreatment, including physical abuse, sexual abuse, and neglect, making it an incredibly broad category. Maltreatment is disturbingly common. In fact, in the United States alone in 2006, 3.6 million children were the subject of a child protective services investigation and 905,000 were found to be neglected or abused (Shipman & Taussig, 2006). Research exploring the relationship between childhood maltreatment and severity of PTSD symptoms is rare. Studies largely focus on prevalence. The studies that do explore severity generally only look at severity of symptoms as mediated by other factors or explore severity in adult survivors of maltreatment. Only a limited amount of


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research is available that focuses on the severity of PTSD symptoms resulting from this type of trauma. Despite the limited research in this area, the studies that have been done offer some sense of the trends in this area. Ford, Wasser, and Connor (2011) looked at a sample of children in a psychiatric outpatient setting who had experienced polyvictimization, exposure to multiple types of maltreatment and domestic based traumas, and found that polyvictimization was associated with severe parent-reported externalizing issues and clinician reported psychosocial issues and that PSTD was the only psychiatric diagnosis associated with polyvictimization. Wechsler-Zimring and Kearney’s (2011) study of adolescents who experienced different types of maltreatment found that almost 90% of their sample fit criteria for PTSD and that adolescents who had experienced physical and or sexual abuse had higher mean scores for each of the symptoms observed by the Children’s PTSD Inventory (CPTSD-I). The next highest scores were found in adolescents who had experienced neglect and physical and/or sexual abuse and the lowest scores were found in adolescents who had only experienced neglect. The lack of research on maltreatment makes it difficult to draw conclusions about a relationship between this type of trauma and the severity of symptoms. The information that is available suggests that a relationship does indeed exist but there is not enough research available to draw any further conclusions (Ford, Wasser, & Connor, 2011; Zimring & Kearney, 2011). Limitations There are many different limitations that are important to consider when looking over this literature. The incredible complexity of trauma makes it very difficult to study accurately. Even when the basic type of trauma is the same, such as exposure to trauma vs. a natural disaster vs. maltreatment, there are differences in levels of exposure, aspects of exposure, aftermath, and other key details that affect how someone will experience the trauma. The lack of research for particular types of trauma also limits understanding. Maltreatment is already a vague category, including several different types of trauma that include physical abuse, sexual abuse, neglect, and more, yet even then there is only a small amount of research on the severity of PTSD symptoms related to this type of trauma. War is a serious type of trauma that can have major effects on the psychological health of children and adolescents but little research has been done in this area. The research that has been done is inconsistent in several different ways. The studies vary in many ways. First, there is a disparity in the amount of time that passed between the trauma and the study and the measurements used. Many of the measurements differ in what they focus on and how they define severe symptoms and many measurements fail to define severe at all. Culture is also a key factor to consider because trauma is understood and may be experienced differently across cultures. These studies were conducted in many different locations across many levels of development. Culture is important to the accuracy of the

measurements used as well. While the CPTSD-RI scale is very commonly used and often applied in samples outside of the United States, it was developed based on non-Hispanic White youth (Hawkins & Radcliffe, 2006). It is possible that differences in symptom expression across cultures and differences in the wording of questions in different languages affected results. The way traumatic events are viewed may also differ across cultures. This is particularly notable in the case of maltreatment; different cultures have different childrearing practices and different definitions of what constitutes maltreatment (Ferrari, 2002). Future studies should set out to address all these issues and explore the areas lacking in research. Conclusion Posttraumatic Stress Disorder is a serious issue that can have major effects on the well being on children and adolescents. There are a multitude of different types of trauma that can result in PTSD, including exposure to disasters, maltreatment, and war. Studies on natural disasters showed that significant portions of the children exposed to that type of trauma developed moderate to severe PTSD symptoms. The limited amount of studies on the severity of symptoms associated with maltreatment and war makes it harder to draw conclusions in these areas. The literature available on adolescents exposed to war is particularly sparse and well deserving of continued exploration. What little information is available suggests that there are trends in symptomatology for PTSD resulting from these types of trauma but further research must be done before themes can be accurately identified. Continuing to explore this area will further our understanding of PTSD in children and adolescents and help improve treatment. References Agustini, E. N., Asniar, I. and Matsuo, H. (2011), The prevalence of long-term post-traumatic stress symptoms among adolescents after the tsunami in Aceh, Journal of Psychiatric and Mental Health Nursing, 18: 543–549. doi: 10.1111/j.1365-2850.2011.01702.x American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.) Arlington, VA: author. Bayer, C. P., Klasen, F., & Adam, H. (2007). Association of trauma and PTSD symptoms with openness to reconciliation and feelings of revenge among former Ugandan and Congolese child soldiers, JAMA, 289(5), 555559. doi: 10.10001/jama.298.5.555 Ferrari, A. M. (2002). The impact of culture upon child rearing practices and definitions of treatment, Child Abuse & Neglect, 26(8), 789813. doi: 10.1016/S0145-2134(02)00345-9 Foa, E. B., Johnson, K. M., Feeny, N. C. & Treadwell, K. R. H. (2001) The Child PTSD Symptom Scale: A Preliminary Examination of its Psychometric Properties, Journal of Clinical Child & Adolescent Psychology, 30(3), 376-384. doi: 10.1207/s15374424JCCP3003_9 Ford, J. D., Wasser, T., & Connor, F.D., (2011). Identifying and determining symptom severity associated with polyvictimization among


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psychiatrically impaired children in the outpatient setting, Child Maltreatment, 16(3), 216-226. doi:10.1777/1077559511406109 Goenjian, A. K., et al. (1995). Psychiatric comorbidity in children after the 1988 earthquake in Armenia, Journal of the American Academy of Child & Adolescent Psychiatry, 34(9), 1174-1184. doi: 10.1097/0000483-199509000-00015 Goenjian, A. K., et al., (2001). Posttraumatic stress and depressive reactions among Nicaraguan adolescents after Hurricane Mitch, American Journal of Psychiatry, 158, 788-794. Hawkins, S. S. & Radcliffe, J. (2006). Current measures for PTSD for children and adolescents. Journal of Pediatric Psychology, 31(4), 420-430. doi: 10.1093/jpepsy/jsj039 Kaminer, D., Seedat, S., & Stein, D. J., (2005). Posttraumatic stress disorder in children, World Psychiatry, 4(2), 121-125. Kolaitis, G et al. (2003), Posttraumatic stress reactions among children following the Athens earthquake of September 1999, European Child & Adolescent Psychiatry, 12(6), 273-280. doi: 10.1007/s00787-003-0339-x La Greca, A. M., Silverman, W. K., Vernberg, E. M., Prinsteing, M. J. (1996). Symptoms of posttraumatic stress in children after Hurricane Andrew: A prospective study, Journal of Consulting and Clinical Psychology, 64(4), 712-723. doi: 10.1037/0022006X/64/4/712 Nader, K. O., Pynoos, R. S., Fairbanks, L. A., AlAjeel, M., (1993). A preliminary study of PTSD and grief among the children of Kuwait following the Gulf crisis. British Journal of Clinical Psychology, 32(4), 407-416. Pynoos, R. S., et al. (1987). Life threat and posttraumatic stress in school age children, Archives of General Psychiatry, 44(12), 10571063. Shaw, J. A., et al. (1995). Psychological effects of Hurricane Andrew on an elementary school population, Journal of the American Academy of Child & Adolescent Psychiatry, 34(9), 11851192. doi: 10.1097/00004583-19950900000016 Shipman, K & Taussig, H., (2006). Mental health treatment of child abuse and neglect: The promise of evidence-based practice, Pediatric Clinics of North America, 56(2), 417-428. Thabet, A. A. M., Vostanis, P., (1999). Posttraumatic stress reactions in children of war. Journal of Child Psychology and Psychiatry, 40(3), 385-391. Thabet, A. A. M., Abed, Y., & Vostanis, P. (2004). Comorbidity of PTSD and depression among refugee children during war conflict, Journal of Child Psychology and Psychiatry, 45(3), 533542. Doi: 10.111/j.1469-7610.2004.00243.x Vernberg, E. M., La Greca, A. M., Silverman, W. K., & Prinstein, M. J. (1996). Prediction of posttraumatic stress symptoms in children after Hurricane Andrew. Journal of Abnormal Psychology, 105(2), 237-248. doi:10.1037/0021843X.105.2.237 Vizek-Vidović, V., Kuterovac-Jagodić, G. and Aramba⌃ić, L. (2000), Posttraumatic symptomatology in children exposed to war. Scandinavian Journal of Psychology, 41, 297– 306. doi: 10.1111/1467-9450.00202

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Weschsler-Zimring, A., Kearney, C. A., (2011). Posttraumatic stress and related symptoms among neglected and physically and sexually maltreated adolescents, Journal of Traumatic Stress, 24(5), 601-604. DOI: 10.1002/jts.20683

Author’s Biography Jessica Trane is a senior in the Applied Psychology Program. She is currently a member of Dr. Ali and Dr. Mowry's research team. Her main research interests include empowerment, trauma, and children and adolescents. After graduating she plans to take the opportunity to gain work experience before continuing her education.


Volume I

Spring 2012

                 

Abstracts                      


Abstracts

The Role of Community Connection for Immigrant Youth’s School Engagement: Sammy F. Ahmed Acculturative stress has been found to put individuals at risk for poor psychological and physical health. However, its impact on school engagement has yet to be entirely understood. Furthermore, the ways that immigrant students cope with acculturative stress has not been fully recognized. Community connection, as a source of resilience during this transitional period, has the potential to be a buffer against acculturative stress. Hence, this study examined the relation between acculturative stress and school engagement among urban adolescent high school students using a cross-sectional design (N = 345), as well as exploring the potential moderating role of community connection. Measures of community connection included the extent of participants’ feelings about their immediate community. Measures of school engagement included cognitive, behavioral and relational school based engagement. The data used for this study were drawn from the first wave of the New York City Academic and Social Engagement Study (NYCASES, P.I. Selcuk R. Sirin) in the spring of 2008 (Mage=16.08 years, SD=1.29). Barron and Kenny’s (1986) moderation method revealed that when controlling for generation, socio-economic status and ethnicity/race of the participant, acculturative stress (β = -.2, t = -3.5, p = .001) and community connection (β = .07, t = 2.16, p = .03) significantly predicted relational school engagement. Additionally, community connection moderated the relation between acculturative stress and relational school engagement (β = .15, t = 2.87, p = .004), accounting for 10% of the variance (F(338, 6) = 5.8, p < .001).

Household Economic Shock and the Academic Experiences of College Women Alyssa Deitchman The economic crisis of 2008 rendered many families and individuals out of financial security. In light of this economic volatility in the United States, it is imperative to examine Socioeconomic status (SES) as a dynamic variable that is capable of fluctuating dramatically. Most research across disciplines uses SES as an independent variable to predict future outcomes. From this perspective, SES is conceptualized as a combination of three variables: income, occupation and education. As thousands of families have lost significant income due to the economic climate, using SES as a static variable becomes problematic. In fact, over 70 percent of parents of college students admitted to making significant changes in their economic habits as a result of lay-offs, salary-cuts and a fear of an inability to retire (Hogwharter, 2009). Literature addresses the propensity of a dramatic loss in economic resources through a concept known as Household Economic Shock. To address the potential for a household economic shock occurring in a college student’s life, this study will examine economic loss and academic experiences with the following research questions: 1. How does household economic shock relate to an individual’s self-concept, agency and identity? 2. How does a household economic shock relate to an individual’s confidence with which s/he can achieve both future and present academic goals? 3. How does a household economic shock affect a student’s social and family relationships? The current study used qualitative methods such as the in-depth interviewing technique, the Consensual Qualitative Research model (Hill, 1997) to code for individual experiences across three domains inherent in the research questions: intrapersonal, interpersonal and academic. In accordance with the literature, this study found all participants experienced anxiety, questioning the security of their future and methods of accommodative coping in their ability to adapt to their unforeseen economic loss. Household Economic Shock and Academic Experiences of College Women contributes to the lack of current literature on emerging adults who have underwent an economic loss in that it reveals the unique challenges of these individuals.

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Sexual Minority Identity Development, Onset of Same-Sex Sexual Behavior, and HIV Risk Outcomes Elizabeth Glaeser For young men who have sex with men (“YMSM”) same-sex sexual behavior often precedes sexual minority self-identification. The period prior to self-identification is a vulnerable time to high risktaking behaviors such as substance abuse and sexual risk-taking associated with HIV infection, as evidenced by the fact that YMSM are the population at highest risk for HIV infection. Previous research has focused on either sex behavior or sexual identity in understanding the experiences and risks of these young men. The present study sought to examine how first same-sex sexual behaviors are related to identity trajectories and how these two variables might influence risktaking behaviors among YMSM. Participants were 598 men who completed baseline assessments pertaining to first same-sex sexual experiences, Gay/Bisexual/Transgender identity development, sex behavior, and drug use at age 18-19 (part of a longitudinal NIMH-funded study called P-18, PI: Halkitis). Results indicated that lower age of first same-sex behavior and non-identification as gay were related to high levels of drug use. For gay-identifying youth, same-sex sexual behavior prior to self-identification was related to higher risk-taking behaviors, suggesting that there is a distinct relation between behavior and identity to risk outcomes possibly leading to HIV infection for this population. Identifying as gay does seem to serve as a protective factor against risk outcomes leading to HIV infection, yet it is the timing of the identity achievement that might hold the protective value, not identification itself.

Parent-Child Interactions in Behavioral Treatment of Selective Mutism: A Case Study Christina M. Mele Selective Mutism (SM) is a childhood anxiety disorder that affects children’s social functioning in a variety of settings. Individuals with Selective Mutism are often talkative with their parents at home, but experience a persistent failure to verbalize in other social environments, such as school. In order to address these impairments, the goal of treatment is for children to speak with various people and in multiple contexts (i.e., generalization). Interestingly, research has suggested that parents’ interaction styles play a role in the maintenance of anxiety symptoms and may interfere with the process of generalization. Recent intervention techniques have also shown that involving parents in treatment may afford them with the necessary skills to foster a positive way of interacting with their children. In order to shed light on the role of parental involvement in the treatment of SM, this case study examined the interactions of one mother-child dyad to determine the ways in which a parent verbally engaged with her child. The parent and her five-year-old daughter attended six therapeutic sessions over a five-week period in a clinical office. Over the course of these sessions, clinical therapists were introduced in the presence, then in the absence, of the parent with the child. Mother-child and therapist-child verbal interactions were analyzed in the context of developmentally appropriate, game-based play activities (e.g., cards, doll play) to determine four trends: (1) the child’s verbal response rate to questions (i.e., yes/no, forced-choice, and open-ended), (2) child’s verbal response rate to commands (i.e., direct and indirect), (3) parent and therapist’s verbal response rate contingent to child’s speech (e.g., verbal reinforcement of child’s talking), and (4) the child’s rate of spontaneous speech (i.e., unprompted verbalizations) over the course of treatment. Results show that the child’s response rate to questions and commands by the mother and therapist increased as a function of time and treatment. The mother and therapist also provided a high rate of contingent responses to the child’s verbalizations over the course of six sessions, suggesting that the mother and child shared verbal exchanges. The child’s rate of spontaneous verbalizations increased four-fold as a function of time and treatment. Results of this case study provide insight into the ways in which parents and therapists can promote, or hinder, the verbalizations of children diagnosed with Selective Mutism. Given these findings, future research should replicate this study with a larger sample and examine the nature of verbal interactions between multiple parent-child dyads.


Abstracts

Children’s Fictional Narratives: Gender Differences in Storytelling Javanna Obregon Children’s ideas about gender influence various aspects of their daily life such as the toys they play with, the clothes they wear, people they befriend, and interestingly the stories they tell, both personal and fictional. Despite the fact that middle childhood is a critical point in fictional narrative development, most research has explored children’s fictional narratives only during the early childhood years. This study seeks to address this gap in the current research by investigating the features, gender differences in the performance and content, and differences across narrative contexts in the fictional narratives told by eight- to eleven- year-old children. Twenty children, evenly divided by gender, were asked to recount the two best made up stories they have ever heard and produce a story using a wordless picture book. The stories were audio and videotaped and subsequently transcribed, the coded for: (1) narrative performance using Gilliam and Gilliam’s (2010) Tracking Narrative Language Progress schema and (2) theme using Propp’s Morphology of a Folktale (1968) and Quiller-Couch’s Narrative Conflicts (1929). Results indicate that during middle childhood, children are able to tell well-structured stories independently and make use of basic conflicts and characters. Girls and boys do not differ in terms of narrative performance. However, children use more complex language when they are provided with a wordless picture book. Interestingly, there were gender differences in narrative content. Results of the study will further our awareness of fictional narrative development and the gender differences during the critical period of middle childhood.

Risk-Taking Behaviors in First Generation Immigrant Adolescents: The Role of Acculturative Stress and Social Support Josephine M. Palmeri Acculturative stress arises when immigrants’ experience difficulty in reconciling differences between their home and host cultures. Research shows that acculturative stress can lead to negative outcomes, yet limited research examines its effect on risk-taking behaviors. Theory and research also suggests that social support may buffer acculturative stress by providing a space where immigrants’ identities are validated. The present study examined (1) whether acculturative stress predicts risk-taking behaviors in first generation immigrant 11th graders within an urban context (N = 189, female = 50.8%) and (2) whether social support moderates this relation. Acculturative stress was measured using Societal, Attitudinal, Familial, and EnvironmentalRevised-Short Form (Mena, Padilla, & Maldonado, 1987). Risk-taking behaviors were measured by Youth Risk Behavior Survey (Brener et al., 2002). Social support was measured by Support Networks Measure (Suárez-Orozco, Suárez-Orozco, & Todorova, unpublished). Pearson’s correlation analysis revealed that marijuana use was the only risk-taking behavior related to acculturative stress or social support. In addition, hierarchal regression analysis showed that academic support significantly moderated the relation between acculturative stress and marijuana use. The results suggest that in times of high acculturative stress, immigrants with low academic support experience less marijuana usage.

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Spring 2012

Promoting the Mathematics Achievement of Economically Disadvantaged Latino and African American Students: Understanding the Roles of Parental Involvement and Expectations Steven Roberts In the U.S., economically disadvantaged Latino and African American students are repeatedly found to have low mathematics proficiency rates, which often leave these students without the skills and knowledge needed to compete in our increasingly technological job market. Therefore, supporting the mathematics achievement of these students may increase their ability to become economically successful in later life. Research suggests that through parental involvement and expectations, parents play an important role in promoting their children’s mathematics achievement. However, how parental involvement and expectations relate to different types of mathematics achievement is not clear. This study examined how parental involvement and expectations related to both basic (i.e., arithmetic) and complex (e.g., algebra) types of mathematics in a sample of 29 economically disadvantaged Latino and African American parents and their early adolescent children. Bivariate correlations and regression analyses indicated that parental involvement was not related to any of the mathematics outcomes, whereas parental expectations were related to the more difficult mathematics outcomes. Implications for research, practice, and policies are discussed.

Caregiver and Teacher Use of Evaluation and the Development of Latino Preschoolers’ Socio-Emotional Skills Lauren Scarola National statistics show that the majority of Latino children enter kindergarten without the skills necessary for school success. Although these basic school readiness skills include literacy and numeracy, socio-emotional abilities, such as self-regulation and learning behaviors, are also necessary for a successful transition into kindergarten. Language interactions at home and school during the preschool years are critical contexts for the development of these skills. The present study examined the influence of caregivers’ and teachers’ language use on children’s socioemotional development. Forty Latino preschoolers, their caregivers, and Head Start teachers participated in this two-year longitudinal study. At the beginning of Year 1, caregiver-child and teacher-child naturalistic language interactions were recorded. At the end of Head Start years, children’s socio-emotional skills were assessed through teacher and investigator assessments. Language interactions were transcribed and verified using a standardized system, and coded for evaluative language (e.g., talk about emotions and intentions). Results show that mothers’ evaluative language was predictive of children’s positive learning behaviors only for the first year of Head Start, whereas teachers’ evaluation predicted levels of self-regulation during the first and second year. Results are discussed in relation to the independent and joint contributions of both home and school for children’s development of school readiness skills.


Staff & Contributor Bios

     

Staff & Contributor Bios                      

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VolumeI II Spring Spring2012 2011 Volume

Staff Bios Justin Conway is a senior in the Applied Psychology program. He is currently assisting Dr. Elise Cappella on the BRIDGE research team studying the effects of social interactions and child behaviors within the classroom. While studying at NYU Justin has provided counseling services to inmates at Rikers Island Correctional Facility and mentoring services to high-school students at Upward Bound. He was previously published for his literary works, and is a recipient of the QSA Presidential Service Award. Justin’s focus is primarily based in organizational development and management consulting and his main research interests include the supervisoremployee relationship, motivation, and decision making. After graduating he plans to work within a consulting firm while pursuing his MA degree in Industrial/Organizational Psychology. Alyssa Deitchman is a senior in the Applied Psychology department and is a co-editor of OPUS. Her research interests include adolescents and emerging adults who have experienced economic loss and its impact on academic contexts. She is a member of Dr. Elise Cappella's research team as well as an Intake Counselor at the door. Upon graduation, she plans to pursue research positions and apply to graduate programs in Clinical Psychology. Javanna Obregon is a senior in the Applied Psychology program and is a co-editor of OPUS. She is a member of Dr. Gigliana Melzi’s research team as well as a member of the Applied Psychology Honors program. Currently, she is working on an honors research project investigating the gender differences in children’s fictional narrative development during the middle childhood years. Upon graduation, she plans to continue her work with Dr. Melzi and obtain a position as a research coordinator. She will also be working for ROAED (Reaching Out Against Eating Disorders) as a group facilitator. Furthermore, she will be applying for doctoral programs in clinical psychology. Sammy Ahmed is a senior in the Applied Psychology honors program. He works with Dr. Selcuk R. Sirin on The Meta-Analysis of the Immigrant Paradox Project (MAP) and The New

York City Academic and Social Engagement Study (NYCASES). Sammy has recently been awarded the Outstanding Research Contribution Award for his honors thesis and his work with Dr. Sirin, as well as the Founder’s Day Award. He will also be Applied Psychology’s Banner Barer at this year’s Baccalaureate Ceremony. His research interests lie at the intersection of psychology and medicine, with an emphasis on the psychological and sociocultural triggers for disease. He will be attending Harvard University next fall to continue his premedical studies, with the ultimate goal of attaining an MD/Ph.D. Kara Duca is a junior in the Applied Psychology program. Her main research interests include the development of ethnic identity and self-esteem among urban adolescents, as well as the influence of acculturation-related stressors on mental health outcomes. Currently, Kara is an OPUS editor-intraining. After graduating, she plans to pursue a doctoral degree in counseling psychology. Caila Gordon-Koster is a junior in the Applied Psychology program. Her main research interests include political psychology and religiosity. Currently, Caila is an OPUS editor-in-training. After graduating she plans to work as a research analyst and obtain a Masters degree in Statistics Brit Lizabeth Lippman is a senior in the Applied Psychology Undergraduate Program. Currently, she works with Dr. Niobe Way studying the experience of adolescents in Delhi, India. She is also a research assistant to Drs. Alisha Ali and Randy Mowry, exploring means of empowerment for victims of domestic violence. Brit's research interests include mental health of people with disabilities, therapeutic interventions for people with psychotic disorders, and the phenomenon of gender socialization among adolescents. She looks forward to beginning a doctoral program in Clinical Psychology at Hofstra University this fall. Chloe Mullarkey is a senior in the Applied Psychology program. She is a member of Dr. Alisha Ali's research team and a clinical research assistant for Dr. Eyal Shemesh at the Mount Sinai School of Medicine. Her main research interests lie in food allergy and bullying, empowerment interventions and mental health in global public health. Upon graduating, she plans to continue working for Dr. Ali and Dr. Shemesh and pursue a Master in Public Health and Doctorate in Social Intervention Psychology or Clinical Psychology. Coralie Nehme is a first- semester senior in Applied Psychology. She is currently the OPUS publicity chair and an editor-in-training. Her research interests include trauma, anxiety disorders, and the influences of immigration and culture. She is exploring her interest of the


Staff & Contributor Bios

influence of immigration and culture on parenting on Dr. Erin Godfrey's research team looking at the customs that immigrant mothers want their children to adapt. She is also exploring her interest in trauma and anxiety disorders at the Bellevue/NYU Langone Program for Survivors of Torture. After graduation in December, she plans to take a gap year to work before applying to PhD programs in Counseling Psychology. Josephine M. Palmeri is a senior in the Applied Psychology Honors program. She is currently a member of Dr. Selcuk Sirin's Meta-Analysis of the Paradox (MAP) research team. Her honors research project examined the relation between acculturative stress and risk-taking behaviors in first generation immigrant adolescents within an urban context. Her main research interest lies in adolescent development. After graduating, she plans to continue her studies in a counseling psychology graduate program.

Contributor Bios Lana Denysyk is a senior in the Applied Psychology program. Her main professional interests include finding effective mental health interventions and increasing access to mental health care. After graduating, Lana will be attending Columbia University's Mailman School of Public Health to pursue her Master's of Public Health degree. Annabelle Moore is a senior in the Applied Psychology program, with a minor in American Sign Language. She is a research assistant for Dr. Alisha Ali on the PhotoCLUB project, as well as a

Case Worker at New York Foundling: Family Services for Deaf and Hard of Hearing Children and Adults. Her research interests include severe and persistent mental illness, trauma and addiction. After graduation she plans to pursue a PhD in Clinical Psychology. Coralie Nehme is a first-semester senior in Applied Psychology. She is currently the OPUS publicity chair and an editor-in-training. Her research interests include trauma, anxiety disorders, and the influences of immigration and culture. She is exploring her interest of the influence of immigration and culture on parenting on Dr. Erin Godfrey's research team looking at the customs that immigrant mothers want their children to adapt. She is also exploring her interest in trauma and anxiety disorders at the Bellevue/NYU Langone Program for Survivors of Torture. After graduation in December, she plans to take a gap year to work before applying to PhD programs in Counseling Psychology. Andrea Paloian is a senior in the Applied Psychology program. Her main research interests include gender studies and attachment theory. After graduating, she hopes to pursue a degree in clinical psychology. Lauren Scarola is a senior in the Applied Psychology program. She is a member of Dr. Gigliana Melziâ&#x20AC;&#x2122;s research team, the Latino Family Involvement Project, as well as a member of the Applied Psychology Honors program. After graduating, she plans to further her research experience and pursue a graduate degree in psychology Jess Trane a senior in the Applied Psychology Program. She is currently a member of Dr. Ali and Dr. Mowry's research team. Her main research interests include empowerment, trauma, and children and adolescents. After graduating she plans to take the opportunity to gain work experience before continuing her education.

OPUS is a student-run publication. To get involved or to submit content for the next issue, please visit

steinhardt.nyu.edu/opus

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OPUS Spring 2012  

OPUS Publication for Spring 2012