DISORDERS OF CHILDHOOD

1

• DISORDERS OF CHILDHOOD
• LECTURE OUTLINE
• Overview
• Externalizing disorders - Attention-deficit/Hyper
  activity disorder (ADHD), oppositional defiant
  disorder (ODD), and conduct disorder (CD)
• Internalizing disorders Separation anxiety
  disorder (SAD)
• Other disorders tic disorders, elimination
  disorders
• Pervasive developmental disorder including
  autism

2

• DISORDERS OF CHILDHOOD
• OVERVIEW
• The DSM and childhood disorders
• Developmental psychopathology
• Risk and protective factors
• Special considerations in treating children
• Prevalence of childhood disorders

3

• DISORDERS OF CHILDHOOD
• OVERVIEW
• Ontario Child Health Study (Offord et al., 1987)
• studied rates of 4 disorders (conduct disorder,
  hyperactivity, emotional disorders, somatization)
  for children 4-16 years of age
• 6-month prevalence rate for any disorder was 18
• boys have higher rates of conduct disorders (8)
  and hyperactivity (9) than girls (3 for both)

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• DISORDERS OF CHILDHOOD
• OVERVIEW
• Ontario Child Health Study (Offord et al., 1987)
• girls have higher rates of emotional (14) and
  somatization (11) disorders than boys (8 5)
• for boys, rates of conduct disorder increase
  with age, while rates of hyperactivity and
  emotional problems decrease
• for girls, rates of emotional problems increase
  with age

5

• DISORDERS OF CHILDHOOD
• ADHD History and background
• originally called MBD (minimal brain
  dysfunction), then Hyperkinetic Reaction of
  Childhood
• most common presenting problem in mental health
  clinics for children
• more common for boys than girls (31 to 51)

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• DISORDERS OF CHILDHOOD
• ADHD Core features
• age-inappropriate levels of inattention (e.g.,
  difficulty sustaining attention with school work,
  easily distracted)
• impulsivity (e.g., not waiting turn, blurting
  out answers)
• hyperactivity (fidgets, squirms, talks
  excessively)

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• DISORDERS OF CHILDHOOD
• ADHD - Subtypes
• Children can be diagnosed as ADHD combined type,
  predominantly inattentive, or predominantly
  impulsive-hyperactive
• Research by Virginia Douglas at McGill
  demonstrated that inability to sustain attention
  and control impulses, not higher activity levels,
  were key features of this disorder

8

• DISORDERS OF CHILDHOOD
• ADHD and other disorders
• high rates of comorbidity with oppositional
  defiant disorder (80), conduct disorder (40),
  and antisocial personality disorder (25) in
  adolescence
• also, high rates of comorbidity with learning
  disabilities
• assessed primarily with rating scales (e.g.,
  Connors)

9

• DISORDERS OF CHILDHOOD
• ADHD Long-term prognosis
• Follow-up studies of children with ADHD show
  elevated rates of school problems, conduct
  disorders or antisocial personality, substance
  abuse, criminal behaviour
• But this long-term trend is observed mostly with
  aggression associated with ADHD

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• DISORDERS OF CHILDHOOD
• ADHD Long-term prognosis
• Moreover, some children seem to outgrow ADHD
  (see figure 5.1 in text)
• at age 10, 250 cases per 1000 for ADHD in boys
  drops to lt 50 cases per 1000 by age 20
• girls remain at low rates (75 cases per 1000)
  from ages 10 to 20

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• DISORDERS OF CHILDHOOD
• ADHD - Etiology
• likely some biological predisposition
• 30-50 heritability component
• food additives and sugar no evidence that
  these are causal factors
• PET and MRI research suggests some brain
  abnormalities, such as reduced glucose metabolism

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• DISORDERS OF CHILDHOOD
• ADHD - Treatment
• stimulant medications Ritalin, Dexedrine,
  Cylert
• reduced impulsiveness and hyperactivity and
  improved attention, but little evidence of
  improvement in academic achievement

13

• DISORDERS OF CHILDHOOD
• ADHD - Treatment
• proliferation of medications for treatment of
  ADHD
• rates of use quadrupled in Canada from 1990 to
  1995, then increased by 85 per year from 1996-98
  (McCubbin Cohen, 1999)
• concerns about side effects about use of
  stimulant medication

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• DISORDERS OF CHILDHOOD
• ADHD - Treatment
• behavioural management at home and school
• these strategies can also help, but appear less
  powerful and are more demanding of adults than
  medications
• combination of medication and behavioural
  treatment may be most beneficial

15

• DISORDERS OF CHILDHOOD
• OPPOSITIONAL DEFIANT DISORDER (ODD)
• diagnosed when children behave in a negative,
  hostile, or defiant manner related to problems
  in relationships and at school
• symptoms emerge before age 8
• 1 in 4 boys will go on to develop CD

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• DISORDERS OF CHILDHOOD
• CONDUCT DISORDER (CD)
• repetitive and persistent pattern of conduct in
  which the basic rights of others and major
  age-appropriate societal norms or rules are
  violated
• aggression is a major concern also property
  destruction, lying, theft, rule violation
• poor interpersonal skills and peer rejection

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• DISORDERS OF CHILDHOOD
• Diagnostic issues in ODD CD
• more common in boys (21)
• many boys with ODD do not develop CD
• minority of those with CD dont develop
  antisocial personality disorder
• CD linked with ADHD and substance abuse

18

• DISORDERS OF CHILDHOOD
• Etiology of ODD CD
• subclinical neurological signs
• temperament
• inter-generational patterns
• marital conflict, divorce, abuse
• attachment problems
• parenting

19

• DISORDERS OF CHILDHOOD
• Long-term development of ODD CD
• form of behaviour changes over time from overt
  to covert
• severity and frequency of problems best
  predictors of who will continue to have problems
  in the future
• many children do improve over time

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• DISORDERS OF CHILDHOOD
• Treatment of ODD CD
• Coercive process Gerry Patterson
• parents behaviour impacts on child childs
  behaviour impacts on adult
• in families of children with ODD or CD, parents
  lack child management skills and often end up in
  coercive interactions that sprial out of control
  and are self-perpetuating

21
DISORDERS OF CHILDHOOD Treatment of ODD
CDParents impact on child
22
DISORDERS OF CHILDHOOD Treatment of ODD
CDChilds impact on parent
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• DISORDERS OF CHILDHOOD
• Pattersons parent training for ODD CD
• Defining and pinpointing behaviour
• I want Johnny to be a good student
• I want Johnny to stop being aggressive
• I want Johnny to stop hitting his peers

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• DISORDERS OF CHILDHOOD
• Pattersons parent training for ODD CD
• Focusing on the positive alternative,
  incompatible behaviours
• yelling
• whining
• interrupting
• non-compliance

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• DISORDERS OF CHILDHOOD
• Pattersons parent training key focus is on
  obtaining compliance from child
• commands vs. requests
• positive reinforcement (praise)
• extinction (ignoring)
• punishment (timeout)

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• DISORDERS OF CHILDHOOD
• Community Parent Education Program (COPE) for ODD
  CD Cunningham et al. (1993)
• parent training in schools and community centres
• school-based intervention

27

• DISORDERS OF CHILDHOOD
• Other treatments for ODD CD
• Problem-solving skills training
• Family therapy multisystemic therapy
• the earlier the treatment, the better long-term
  prognosis

28

• DISORDERS OF CHILDHOOD
• Separation Anxiety Disorder
• only SAD remains in DSM-IV as an anxiety
  disorder unique to childhood
• distress upon being separated from a parent or
  fears that parent will be harmed
• average age of onset is 9
• typically occurs after a major stressor

29

• DISORDERS OF CHILDHOOD
• SAD Diagnosis and assessment
• severe and excessive anxiety when faced with
  separation from a parent
• also related to mood problems, school refusal,
  somatic complaints
• need for multi-dimensional assessment

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• DISORDERS OF CHILDHOOD
• SAD Long-term development
• social withdrawal, poor school performance
• not much known about long-term course if left
  untreated, possibly related to adult anxiety
  disorders such as agoraphobia and panic disorder

31

• DISORDERS OF CHILDHOOD
• SAD Etiology
• strong heritability component, concordance for
  anxiety disorders is 3 times higher in MZ than DZ
  twins
• temperament behavioural inhibition (shyness,
  vigilance, avoidance)
• insecure attachment

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• DISORDERS OF CHILDHOOD
• SAD Treatment
• cognitive-behaviour therapy
• play therapy
• medication
• overall, shy and anxious children respond well
  to treatment, again early treatment is needed
• SAD is far less researched than the
  externalizing disorders

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• DISORDERS OF CHILDHOOD
• Other disorders
• tic disorders Tourette syndrome, responds well
  to anti-psychotic medication Haldol
• elimination disorders enuresis and encopresis,
  Mowrer bell and pad treatment based on classical
  conditioning

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• DISORDERS OF CHILDHOOD
• SUMMARY
• childhood disorders have high prevalence (OCHS)
• externalizing disorders (ADHD, ODD, CD) have
  received the most attention because of negative
  impacts on others and their damaging long-term
  impacts
• less well understood are internalizing
  disorders, such as SAD