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Chapter 31: Child Psychiatry
accompany school failures—damage self-esteem emotionally
and cognitively, disabling future performance and clouding
expectations for success. Generally, children with academic
problems require either school-based intervention or individual
attention.
Tutoring on an individual and frequent basis is an effective
technique for increasing academic production and is typically
included in a comprehensive educational program. Tutoring has
proved of value in preparing for standardized multiple choice
examinations, such as the
Scholastic Aptitude Test
(SAT), as
well as for increasing academic achievement in daily school
subjects. Taking examinations, either school-based or standard-
ized exams repetitively and using relaxation skills are tech-
niques of great value in diminishing interference of test anxiety.
R
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learning, nutritional status and brain development. Head, IQ, learning, nutrition
and brain.
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culties and subsequent problem behaviors.
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31.17c Identity Problem
The normative developmental process for an adolescent was
conceptualized by the developmentalist Erik Erikson as an ado-
lescent “crisis of identity.” The transition between a childhood
identity and the process of accepting a more mature sense of
self is the resolution of the “crisis.” Consolidation of identity
encompasses cognitive, psychodynamic, psychosexual, neuro-
biological, and cultural development. As identity is confirmed
in adolescence, a sense of self-sameness and continuity over
time unfolds. The notion of an
identity crisis
in adolescence
gained widespread attention by clinicians and the popular
media during the late 1960s and early 1970s, when many ado-
lescents displayed rejection of mainstream cultural values and
ideas and demonstrated alternative lifestyles. The concept of
identity disorder
as a psychiatric diagnosis was embraced in the
1980s when the DMS-III was devised, as a disorder usually first
evident in childhood. It was meant to include adolescents who
presented with “severe subjective distress regarding uncertainty
about a variety of issues relating to identity” to the point where
they became impaired.
Identity problem is not currently conceptualized as a psychi-
atric disorder, rather it refers to uncertainty about issues, such as
goals, career choice, friendships, sexual behavior, moral values,
and group loyalties. An identity problem can cause severe dis-
tress for a young person and can lead a person to seek psycho-
therapy or guidance; however, it is not included in the DSM-5.
It sometimes occurs in the context of such mental disorders as
mood disorders, psychotic disorders, and borderline personal-
ity disorder. A study examining Intolerance of Uncertainty (IU),
that is, the tendency to react negatively to uncertain situations,
in 191 adolescents found that IU is correlated with adolescent
social anxiety, worry, and to a lesser extent, depression.
Epidemiology
No reliable information is available regarding overall prevalence;
however, factors increasing risk for identity problems include
psychiatric disorders, psychosocial difficulties, and the pressures
of assimilation as an ethnic minority into mainstream society.
Etiology
The causes of identity problems often are multifactorial and
include the pressures of a dysfunctional families, the influ-
ences of coexisting mental disorders, and the degree to which
adolescents feel integrated into their school and family envi-
ronments. In general, adolescents with social skills deficits,
major depressive disorder, psychotic disorders, and other men-
tal disorders report feeling alienated from their peer group and
family members, and experience some turmoil. Children who
have had difficulty mastering expected developmental tasks all
along are likely to have difficulty with the pressure to establish a
well-defined identity during adolescence. Erikson used the term
identity versus role diffusion
to describe the developmental and
psychosocial tasks challenging adolescents to incorporate past
experiences and present goals into a coherent sense of self.
Clinical Features
The essential features of identity problem seem to revolve
around the question, “Who am I?” Conflicts are experienced
as irreconcilable aspects of the self that the adolescent cannot
integrate into a coherent identity. As Erikson described iden-
tity problem, youth manifests severe doubting and an inabil-
ity to make decisions, a sense of isolation, inner emptiness, a
growing inability to relate to others, disturbed sexual function-
ing, a distorted time perspective, a sense of urgency, and the
assumption of a negative identity. The associated features fre-
quently include marked discrepancy between the adolescent’s
self-perception and the views that others have of the adolescent;
moderate anxiety and depression that are usually related to inner
preoccupation, rather than external realities; and self-doubt
and uncertainty about the future, with either difficulty making
choices or impulsive experiments in an attempt to establish an
independent identity. Adolescents with identity problem may
join “outcast” cult-like groups. A study examining relationships
of social context and identity of high-risk Hispanic adolescents
