Developmental and Cognitive Disorders

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Developmental and Cognitive Disorders

• Chapter 13

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What are developmental disorders?

• Disorders that usually first appear in childhood
  or adolescence (onset)
• Note most of these conditions persist into
  adulthood

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ICA D/O

• As you answer the questions below, you will be
  better able to choose between the four categories
  introduced earlier.
• 1. Is the predominant sx an impairment of
  learning or intellectual function?
• 2. Is the predominant sx abnormal motor activity?
• 3. Is the predominant sx socially inappropriate
  or self injurious behavior?
• 4. Is the predominant sx an impairment in the
  ability to communicate or exchange meaningful
  information?

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Perspectives on Developmental Disorders

• Normal vs. Abnormal Development
• Developmental Psychopathology
• Study of how disorders arise and change with time
• Childhood is associated with significant
  developmental changes
• Disruption of early skills will likely disrupt
  development of later skills

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Outline

• Common developmental disorders (ADHD Learning
  Disorders)
• Pervasive Developmental disorders (autism)
• Mental Retardation
• Cognitive Disorders (dementia)

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Attention Deficit Hyperactivity Disorder (ADHD)
An Overview

• Nature of ADHD
• Central features Inattention, overactivity, and
  impulsivity
• Difficulty w sustained attn (cant finish games,
  watch TV)
• Constant motion, fidgeting
• Blurt out answers, act without thinking
• Associated with behavioral, cognitive, social,
  and academic problems

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Attention Deficit Hyperactivity Disorder (ADHD)
An Overview

• DSM-IV and DSM-IV-TR Symptom Clusters
• Cluster 1 Symptoms of inattention
• Cluster 2 Symptoms of hyperactivity and
  impulsivity cluster
• Either cluster 1 or 2 must be present for a
  diagnosis

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ADHD Facts and Statistics

• Prevalence
• Occurs in 4-12 of children who are 6 to 12
  years of age
• Symptoms are usually present around age 3 or 4
• 68 of children with ADHD have problems as adults
• Impulsive component decreases over time
• Gender Differences
• Boys outnumber girls 4 to 1

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ADHD Overdiagnosis?

• Cultural Factors
• Probability of ADHD diagnosis is greatest in the
  United States
• Studies show more school-aged kids on stimulants
  than prevalence of Dx
• College-aged people often present for assessment
  when academic problems emerge

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ADHD Biological Contributions

• Genetic Contributions
• ADHD runs in families
• Some studies suggest High heritability
• Familial ADHD may involve deficits on chromosome
  20
• The D4 receptor gene is more common in ADHD
  children (dopamine dysregulation?)

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ADHD Biological Contributions

• Neurobiological Contributions Brain Dysfunction
  and Damage
• Used to be called minimal brain dysfunction
• Inactivity of the frontal cortex and basal
  ganglia
• Right hemisphere malfunction
• Abnormal frontal lobe development and functioning
• Yet to identify a precise neurobiological
  mechanism for ADHD

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ADHD Biological Contributions

• The Role of Toxins
• Allergens and food additives do not appear to
  cause ADHD
• Maternal smoking increases risk of having a child
  with ADHD

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ADHD Psychosocial Contributions

• Psychosocial Factors appear to Influence (not
  cause) the Disorder
• Constant negative feedback from teachers,
  parents, and peers
• Peer rejection and resulting social isolation
• Such factors foster low self-image

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Biological Treatment of ADHD

• Goal of Biological Treatments
• To reduce impulsivity/hyperactivity and to
  improve attention
• Stimulant Medications
• Reduce the core symptoms of ADHD in 70 of cases
• Examples include Ritalin, Dexedrine, Cylert
• Other Medications
• Imipramine and Clonidine (antihypertensive) have
  some efficacy

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Biological Treatment of ADHD

• Effects of Medications
• Improve compliance and decrease negative
  behaviors in many children
• Not clear that academic performance or social
  skills are improved in the long-term
• Beneficial effects are not lasting following drug
  discontinuation
• Negative side effects include insomnia,
  drowsiness, and irritability

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Behavioral and Combined Treatment of ADHD

• Behavioral Treatment
• Involve reinforcement programs
• Aim to increase appropriate behaviors and
  decrease inappropriate behaviors
• May also involve parent training
• Combined Bio-Psycho-Social Treatments
• Are highly recommended - it appears however that
  long-term psychosocial Tx is necessary to
  maintain gains

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Learning Disorders

• Scope of Learning Disorders
• Problems related to academic performance in
  reading, mathematics, and writing
• Performance is substantially below what would be
  expected (IQ - Ach discrepancy)
• DSM-IV and DSM-IV-TR Reading, Mathematics,
  Written Expression Disorders
• Performance is at a level significantly below
  that of a typical person of the same age
• Problem cannot be caused by sensory deficits
  (e.g., poor vision)

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Learning Disorders Some Facts and Statistics

• Incidence and Prevalence of Learning Disorders
• 1 to 3 incidence of learning disorders in the
  United States
• Prevalence is highest in wealthier regions of the
  United States
• Prevalence rate is 10 to 15 among school age
  children
• Reading difficulties are the most common of the
  learning disorders
• School experience for such persons tends to be
  quite negative
• About 32 of students with learning disabilities
  drop out of school

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Figure 13.1

• Half of school children classified as disabled
  have learning disabilities. Twenty years ago the
  proportion was 50 lower

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Biological and Psychosocial Causes of Learning
Disorders

• Genetic and Neurobiological Contributions
• Reading disorder runs in families, with 100
  concordance rate for identical twins
• Evidence for subtle forms of brain damage is
  inconclusive
• Overall, genetic and neurobiological
  contributions are unclear
• Psychological and motivational factors seem to
  affect eventual outcome

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Treatment of Learning Disorders

• Medications not typically used
• Requires Intense Educational Interventions
• Remediation of basic processing problems (e.g.,
  teaching visual skills)
• Efforts to improve of cognitive skills (e.g.,
  instruction in listening)
• Targeting behavioral skills to compensate for
  problem areas
• Data Support Behavioral Educational Interventions
  for Learning Disorders

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Pervasive Developmental Disorders

• PDD is an umbrella term
• severe and pervasive impairments in several areas
  of development reciprocal social interaction
  skills, communication skills, presence of
  stereotyped behavior, interests, and activities
• Symptoms are on a continuum
• 5 PDDs autistic disorder, Aspergers disorder,
  Retts disorder, Childhood Disintegrative
  Disorder, PDD/NOS (distinctions among these not
  particularly clear)

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Autistic Disorder

• Approximately 10 cases per 10,000 individuals
• More common in males (4-51)
• Impairment in Social Interactions
• Impairment in Communication
• Restricted, Repetitive and Stereotyped Behaviors,
  Interests, and Activities
• Onset of delays prior to age 3 years

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Autistic Disorder (cont.)

• Qualitative Impairment in Social Interaction
  (needs at least 2)
• marked impairment in the use of nonverbal
  behaviors
• Failure to develop peer relationships appropriate
  to developmental level
• A lack of spontaneous seeking to share enjoyment,
  interests, or achievements
• lack of social or emotional reciprocity

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Autistic Disorder (cont.)

• Qualitative impairment in Communication (needs a
  lest one)
• delay or total lack of development of spoken
  language (no compensation)
• marked impairment in the ability to initiate or
  sustain a conversation with others in individuals
  that can speak
• stereotyped and repetitive use of language or
  idiosyncratic language
• lack of carried , spontaneous make-believe play
  or social imitative play appropriate to
  developmental level.

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Autistic Disorder (cont.)

• Restricted, Repetitive and Stereotyped
  Behaviors, Interests, and Activities (needs at
  least one)
• encompassing preoccupation with one or more
  stereotyped and restricted patterns of interest
  that is abnormal either in intensity or focus
• apparently inflexible adherence to specific,
  nonfunctional routines or rituals
• stereotyped mannerisms
• persistent preoccupation with parts of objects

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Other issues related to autism

• Sensory issues (e.g., high threshold for pain,
  oversensitivity to sounds, fascination with touch
  or smell)
• Abnormalities in mood and affect
• Feeding issues (limited diet, pica)
• Behavior difficulties (SIB, Tantrums, short
  attention span, hyperactivity, sleep problems)

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Phenomenology of Autism

• 20/20 Video
• What is it like to be autistic?

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Autism and Intellectual Functioning

• 75 of individuals have mental retardation
• 50 have IQs in the severe-to-profound range of
  mental retardation
• 25 test in the mild-to-moderate IQ range (i.e.,
  IQ of 50 to 70)
• Remaining people display abilities in the
  borderline-to-average IQ range
• Better language skills and IQ test performance
  predicts better lifetime prognosis

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Etiology of Autism

• Psychosocial Contributions Are Unclear
• Autism has a genetic component that is largely
  unclear
• Neurobiological evidence for brain damage Link
  with mental retardation
• Cerebellum size Substantially reduced in
  persons with autism

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Aspergers Disorder

• Qualitative impairment in social interaction
• Restrictive Repetitive and stereotyped patterns
  of behavior, interest, and activities
• Disturbance causes clinically significant
  impairment
• no clinically significant general delay in
  language
• no clinically significant delay in cognitive or
  adaptive functioning

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Retts Disorder

• Only reported in females
• Apparent normal pre and perinatal development
• Normal head circumference at birth
• Deceleration of head growth between 5 and 48
  months
• Loss of hand skills between 5 and 30 months with
  development of stereotyped hand movement, loss of
  social engagement, poorly coordinated gait or
  trunk movements, severely impaired expressive and
  receptive language development with severe
  psychomotor retardation
• Severe or Profound MR

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Applied Behavior Analysis

• Breaks down autism into separate behavioral
  problems and attempts to treat as many of these
  problems as possible.
• By far the most well documented treatment
  approach with hundreds of studies on behavioral
  treatment for children with autism.
• Goal is remediation (recovery) from the disorder
  to the point that children are indistinguishable
  from their peers.

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UCLA Young Autism Project (Lovaas)

• Intensive one-on-one training for app. 40 hours a
  week.
• Training prg carried out in homes, school,
  community
• commences at age no older than 46 months
• 1st phase, focuses on teaching compliance, simple
  imitation, appropriate play, suppress
  self-stimulation and non-compliant behavior
• 2nd phase teaching expressive skills, early
  abstract language, social play with peers
• Third phase teaching expression of emotions,
  functional academics and more complex cognitive
  abilities (e.g., cause-to-effect relationships)

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• UCLA Young Autism Project - study design
• Initial 2 year treatment
• N 59 children
• 3 groups
• (a) Experimental group (N19) - 40 hours a week
  of treatment for 2 years
• Control group 1 (N19) - 10 hours of treatment
  for 2 years on average
• Control group 2 (N21) - No treatment provided
  by UCLA
• Blind Evaluations pre post treatment

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UCLA Young Autism Project pre-treatment

• Exp Group Control Group 1
• Treatment 40 hrs/week 10 hrs/week
• Pre Treatment Measures
• Age at Dx 32 months 34 months
• Age _at_ Beg. trt 35 months 40 months
• IQ 53 46

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UCLA Young Autism Project pre-treatment

• Exp Gr Control Group 1
• (N19) (N19)
• Mute 58 47
• Reject Adults 63 42
• Not Toilet Trained 68 63
• Gross Inattention 89 74
• Tantrums 89 79
• Absent Toy Play 53 63
• Self Stimulation 95 89
• Absent Peer Play 100 100

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UCLA Young Autism Project- Results

• Blind evaluation pre treatment 2 years later
  (Age 6-7)
• Experimental Group Results
• Average IQ Gain 20 points
• 9/19 (47) Completed first grade in regular
  class
• IQ Gain for these 9 subjects 37 points
• 8/19 (42) Continued in a learning disabled class
• 2/19 (11) Severe MR / autistic classroom
• Control Group Results Group
  1 Group 2
• IQ no significant changes
• Completed first grade in regular class 0/19 (
  0) 1/21 (5)
• Continued in a learning disabled class 8/19
  (42) 10/21 (48)
• Continued in a Severe MR Class 11/19
  (58) 10/21 (48)

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UCLA Young Autism Project- Results 1993 Follow
Up Study Results

• Blind Evaluations of the 9 children in the Best
  Outcome Group
• Age at follow up evaluation - 13 years old.
• IQ gains remained.
• Normal functioning on tests of
• emotional functioning
• social functioning
• intellectual functioning.
• 8/9 (88) Remained in typical classrooms.
• 1/9 was in an LD classroom.

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Autism - Pharmacotherapy

• No known effective medications

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Mental Retardation

• Nature of Mental Retardation
• Disorder of childhood
• Below-average intellectual and adaptive
  functioning
• Range of impairment varies greatly across persons
• Mental Retardation and the DSM-IV and DSM-IV-TR
• Significantly subaverage intellectual functioning
  (IQ below 70 - about 2-3 of the population)
• Concurrent deficits or impairments two or more
  areas of adaptive functioning
• MR must be evident before the person is 18 years
  of age

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Levels of MR

• Mild MR
• Includes persons with an IQ score between 50 or
  55 and 70 (often can lead independent lives)
• Moderate MR
• Includes persons in the IQ range of 35-40 to
  50-55
• Severe MR
• Includes people with IQs ranging from 20-25 up to
  35-40
• Profound MR
• Includes people with IQ scores below 20-25
  (typically require complete assistance)

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Other Classification Systems for Mental
Retardation (MR)

• American Association of Mental Retardation (AAMR)
• Defines MR based on levels of assistance required
• Examples of levels include intermittent, limited,
  extensive, or pervasive assistance
• Not that widely adopted
• Classification of MR in Educational Systems
• Based on whether person is Educable
• Stigmatizing system

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Mental Retardation (MR) Some Facts and
Statistics

• Prevalence
• About 1 to 3 of the general population
• 90 of MR persons are labeled with mild mental
  retardation
• Gender Differences
• MR occurs more often in males, male-to-female
  ratio of about 1.61
• Course of MR
• Tends to be chronic, but prognosis varies greatly
  from person to person

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Mental Retardation (MR) Psychosocial
Contributions

• Cultural-Familial Retardation
• Believed to cause about 75 of MR cases and is
  the least understood
• Believed to result from combination of biological
  (low IQ) and social factors
• Neglect, abuse, poor nutrition
• Associated with mild levels of retardation on IQ
  tests and good adaptive skills
• Lower end of distribution but probably distinct
  etiology from those w clear organic causes

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Mental Retardation (MR) Biological Contributions

• Genetic Research
• MR involves multiple genes, and at times single
  genes
• Chromosomal Abnormalities and Other Forms of MR
• Down syndrome Trisomy 21
• Fragile X syndrome Abnormality on X chromosome
• Maternal Age and Risk of Having a Downs Baby
• Nearly 75 of cases cannot be attributed to any
  known biological cause

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Specific genetic syndromes associated with MR

• Down Syndrome
• Fragile X syndrome

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Down Syndrome
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Down Syndrome

• Most common chromosomal form of MR
• Prevalence about 1 out of every 700 live births
• As many of 75 of trisomy 21 result in
  miscarriages or stillbirths.
• The older the mother, the higher the (p) of DS
  (e.g., Maternal age of 20 1 in 2000 35 1 in
  500 45 1 in 18)
• Theory - ova (eggs) produced in youth are exposed
  to toxins, radiation - damaged

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Down Syndrome (cont.)

• Health issues Congenital heart defects (50),
  hearing loss (66-89), ophthalmic conditions (60),
  endocrine conditions (e.g., hypothyroidism)
  (50-90), obesity (50-60), dental problems
  (60-100), seizure disorders (6-13), high risk of
  Alzheimer's disease.

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Down Syndrome (cont.)

• Adaptive behavior In general children with DS
  show higher AB levels than intelligence
• Personality Sociable and pleasant.
• Dual DX Less often and less severe maladaptive
  behavior and psychopathology

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Fragile X Syndrome
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Fragile X syndrome

• Most common known inherited form of MR
• Prevalence 1 in 4000 males and at least half
  that in females.
• The marker was an X chromosome with a small,
  pinched-off piece of genetic material
• Mothers often have learning disabilities

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Fragile X syndrome (cont.)

• Physical features 80 of post pubertal boys and
  men with this disorder have enlarged testicules
  (about twice the size).
• Other physical features long narrow face and
  prominent ears, flat feet, hyper extensible
  finger joints, soft skin
• Features become more pronounced with age and are
  subtle in childhood
• Few significant medical problems are associated
  with fragile X (seizures in about 20)

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Fragile X syndrome (cont.)

• IQ levels vary from moderate levels of MR to the
  average range of functioning (varies with genetic
  status, gender, and age)
• In general, females are less impaired than males
• Many males seem to show declines in their IQ
  scores over time.

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Treatment of MR

• For mild MR, tx is similar to that for learning
  disabilities
• For more severe MR, treatment is similar to that
  for PDD
• Goals include communication, social development,
  independent living and job skills
• People with MR often Benefit from Such
  Interventions