Welcome to Abnormal Child Psychology

1
Welcome to Abnormal Child Psychology

• Jill M. Norvilitis, Ph.D.

2
Issues that research in this field addresses

• What constitutes normal/abnormal behavior for
  kids of different ages and both genders.
• Identifying causes and correlates of abnormal
  child behavior
• Making predictions about long term outcomes
• Developing and evaluating methods for treatment
  and prevention

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Unique to disorders of childhood

• Often not clear whose problem it is
• Problems often involve failure to show expected
  developmental progress
• Many problems are not entirely abnormal
• Interventions are often intended to promote
  further development

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Developmental Psychopathology

• Multiply influencedpsychological, sociocultural,
  biological
• Patterns of behavior, emotions, cognitions that
  are abnormal, disruptive, distressing
• Either to person or to others around the person

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Defining Psychological Disorders

• Person shows some degree of distress
• Behavior indicates some degree of disability
• Distress or disability increases risk of further
  suffering or harm

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Keys to Remember

• Importance of relationships
• Labels and stigma
• Competence
• Frequency/intensity of problems
• Multifinality
• Equifinality
• Accurate views of what is normal

7
Risk Factors

• Characteristics, events, or processes that
  increase risk for the development of psych
  problems
• Categories
• Some risk factors are more predictive of problems
  than others
• Vulnerability varies
• Risk accumulates
• Some connection between risk factors and specific
  disorders
• Number of risk factors is important

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Resiliency/Protective Factors

• Characteristics, events, or processes that
  protect an individual from the dev of
  psychological problems
• Personal attributesintelligences,
  self-confidence, etc
• Family strengths
• Support from outside the family

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How common are problems?

• Epidemiology
• Prevalencetotal of cases at a given time
• Incidence-- of new cases in a given period
• Between 1/8 and 1/5 have clinical problem that
  impairs functioning
• 10-20 meet diagnostic criteria
• 10 of those with problems receive tx
• Youngest ¼ of population receives 1/9 tx dollars

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Theories and Causes

• Theorysystematic set of statements designed to
  help organize, analyze, explain, and predict
• Purpose
• A good theory should
• Account for the majority of existing research
  data
• Give relevant explanations/logical reasons
• Be able to be tested for accuracy
• Predict new events, incorporate new info
• Be parsimonious
• Be logically consistent

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Etiology

• Underlying assumptions
• Behavior is multiply determined
• Child and environment are interdependentthis
  dynamic interaction is called a transaction
• Abnormal development involves continuity and
  discontinuity
• Adaptational failurefailure to master or
  progress in accomplishing developmental
  milestones
• Developmental psychopathology is a macroparadigm
  that draws on multiple perspectives

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Freud

• Deterministic
• Mental processes are often unconscious
• Conflict modelid/ego/superego
• Stages
• Oral
• Anal
• Phallic
• Latency
• Genital
• Advantages to this theory
• Helped establish field of psychology
• Emphasized importance of childhood

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Updates to Psychoanalytic Theory

• Object relations theoryimportance of
  relationship with caregiver is key.
• Melanie Kleinhealthy relationships as infants
  lead to healthy relationships as adults
• Attachment theoryBowlby 1969, Ainsworth, 1978
• Secure, ambivalent, avoidant, disorganized

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Biological Model

• Hippocratessomatogenesis
• Late 1800s, bio causes for everything
• Varies by genetic and constitutional factors,
  neuroanatomy, rates of maturation
• Neural plasticitymalleability
• It is rare to find a disorder that is completely
  bio in origin
• Diathesis-stress model

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Genetic Contributions

• ADHDmultiple genes, Huntingtons Choreasingle
  gene
• Heritabilityproportion of variation in a given
  trait that is genetic/inherited
• Concordance ratesMZ, DZ, adoption

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Neurobiological Contributions

• Brain structure function
• Many locations, particularly frontal lobes
• Damage to brain pre or post-natally
• Accident
• Illness
• Malnutrition
• Toxic substances
• Neurotransmitters
• Implicated in many disorders
• Not as well understood in kids

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Psychological Factors

• Emotional influences
• Reactivitydifferences in threshold and intensity
  of expression of emotion regulation
• Temperament
• Easypositive affect and approach
• Difficultnegative affect or irritability
• Slow to warmfearful or inhibited

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Behavioral Theories

• The connection with developmental psychopath
  really began with Watson
• Operant conditioning
• Some disorders are more linked to behavioral
  contingencies than others. For example, phobias,
  enuresis, oppositional problems
• We will talk about this theory more when we
  discuss tx
• Social learning theory

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Cognitive Behavioral Theories

• Observable behavior can be influenced by mental
  processes
• Particularly useful as a theory for depression
  (but others as well)
• Automatic thoughtsimmediate, unquestioned
  thoughts when faced with a new or recurrent
  situation
• Cognitive distortions-help develop and maintain
  symptoms

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Family Systems Theory

• The child is only the identified
• Childs problems are a reflection of family
  problems or problems in marital relationship
• Families want to maintain homeostasis
• Family structures and alliances are often
  disrupted
• Communication is also often disrupted
• Can be enmeshed or disengaged

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Bronfenbrenners Ecological Systems Theory

• There are many systems and settings to be
  considered when trying to understand the etiology
  of problems
• Macrosystembeliefs and values of the culture
• Exosystem-social structures
• Mesosystem-interconnections between various
  community systems
• Microsystem-childs immediate environment
• Ontogenic developmentthe childs own internal
  development and adaptation

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Ethics in Working with Children and Families

• Competencecant just deem yourself competent
• Multiple relationshipsalso known as dual
  relationships
• Informed consent and assentmust inform about the
  kind of therapy or assessment
• Alsomust clarify who is the client and what role
  each person plays

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Confidentiality and Limits to Confidentiality

• Suicide, homicide, and abuse of a dependent
  person
• Tarasoffduty to warn
• Involuntary commitment
• Childrens legal rights in treatment decisions
• Children cant be forced to participate, but can
  be forced to sit there

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Research Ethics

• IRBs
• Non-harmful procedures
• Incentives
• Deception
• Anonymity
• Mutual responsibilities
• Jeopardy
• Informed consent and assent
• Confidentiality
• Informing participants of results

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Research in Abnormal Child Psychology

• Time frame of the study
• Cross-sectionalpossible cohort effects
• Longitudinal designstime consuming, expensive,
  drop outs, historical factors
• Accelerated longitudinal designs aka sequential
  designs
• Where do we get participantsschools, clinics,
  hospitals, community, laboratory

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Just a Bit on Freud Himself

• Born 5/6/1856 in Freiburg, Moravia (now Pribor,
  Czech) to a 40 yo wool merchant father on his 2nd
  marriageremote and authoritarian.
• MotherAmaliemore nurturing
• Had 2 older ½ brothers, but had nephew 1 yr older
• 1859 moved to Leipzig for economic reasons
• 1860to Vienna where Freud stayed until 1938 when
  Nazis came
• Had brother Juliusone year younger, died in 1858
• Sister Anna
• Age 17moved by curiosity about human concerns
• Became physician in his 20s
• Trained as a neurologist under Charcot and then
  under Breuer.
• With Breur treated Anna O in 1895, began to
  develop own ideas after that

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Dora

• Dora began to suffer from a hysterical cough and
  loss of voice
• Threatened to kill herself
• Freud found multiple sexual conflicts
• Doras father was having an affair with Frau K,
  whom Dora had adored
• Dora envied both of the lovers and felt betrayed
  by both
• Frau Ks husband was attracted to Dora and Herr K
  made advances to Dora
• Doras father didnt believe her, but Dora was
  also attracted to Herr K and had fantasized
  marrying him but Dora learned hed been having an
  affair with the governess and she was mad.
• But Dora quit tx abruptly

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Doras Outcome

• Freud had had high hopes for the tx. Wrote it up
  in only 3 wks
• Book was written as a follow up to Freuds dream
  book. Not intended to convey every treatment
  utterance.
• In April 1902, 15 mos after termination, Dora
  reappeared. She had improved. Had visited Ksgot
  Frau K to admit affair and Herr K to admit
  advances.
• In Oct. 19011 yr after beginning therapy, Dora
  lost her voice again after she bumped into Herr K
  on the street. He stopped and was run over by a
  carriage. He survived and her voice got better.
• Later Dora married and Freud wrote that she was
  reclaimed by the realities of life

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The Real Dora

• Ida Bauer, born 1882 in Vienna of Bohemian Jewish
  ancestry
• Dora's father, Philip Bauer, was a wealthy
  textile manufacturer.
• Dora's brother, Otto Bauer, became a leading
  figure in the Austrian Social Democratic Party, a
  Marxist theorist who specialized in the question
  of nationality and nationalism.
• Dora married in 1903 at the age of twenty-one.
• She continued to suffer from a variety of
  psychosomatic ailments throughout her life.
• One of her few satisfactions, a later analyst
  reported, was that she knew herself to be the
  subject of one of Freud's most famous case
  histories.

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Hysteria

• Originally wandering uterustherefore only
  women
• Multiple somatic complaints without any obvious
  medical cause
• Overtime took on connotation of exaggerated or
  overly dramatic
• Take overpowering anxiety and convert it into sx
  (conversion hysteria)

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Assessment

• Developmental considerations age, gender,
  cultures
• Many purposes of assessment
• Determine levels of problematic emotions and
  behaviors
• Determine range of problematic emotions and
  behaviors
• Help identify any appropriate diagnoses
• Identify strengths and competencies
• Evaluate efficacy of treatment by assessing
  before, during, and after tx
• Determine etiological factors of problem
• Identify children at risk for dev problems in the
  future
• Establish prognosis and tx planning

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Effective Assessment (Prevatt, 1999)

• Prereferral usedmay be able to intervene before
  an assessment
• Ecologically based assessment
• Multimodal
• Emphasis on family/school environment
• Avoidance of label/pathology based approach
• Emphasis on why things occur
• Outcome-based
• Adherence to legal and ethical guidelines
• Uses tests with good psychometric
  propertiesreliable, valid, adequate normative
  data, cost effective
• Intervention focused
• Strengths and weaknesses
• Learning-based strategies, school, family and
  community strategies
• ? need for consultations

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• Must choose between depth and breadth in
  assessment
• Should be multimethodusing several types of
  techniques and should use multiple informants

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Interviews

• The most common technique
• Unstructured, semi-structured, structured
• Rapport
• Weaknesses of unstructured interviewsnot very
  reliable, may go off on tangents as they come up
• Structured and semi-structured are more reliable.
• May be used in combination.

• Should cover
• Parent and child
• History of current difficulties
• Childs educational hx
• Home environment
• Expectations for child
• Childs strengths and competencies
• Parent only
• Details of pregnancy and birth
• Developmental hx
• Medical hx
• Family characteristics and hx
• Childs interpersonal skills
• Child only
• Job hx and goals
• Sexual involvements
• Friendships
• Illicit substances

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Behavioral Assessment

• Behavioral observation
• structured or unstructured
• look for antecedents and consequences
• most often done in schools
• A-Antecedent, B-Behavior, C-Consequences
• Functional assessment
• evaluation of actual behaviors and childs
  ability to perform these
• Self-monitoring
• allows child to keep track of a specific behavior
  by recording its occurrence
• Concern with all of these techniques reactivity

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Checklists and Rating Scales

• Not very expensive, widely used
• Most take 5-15 minutes
• Broad measures CBCL, TRF, YSR
• Specific measures CDI, Conners, STAI-kiddie
• Concernparents pathology may increase ratings
  of kids problems. Kids may downplay problems.
• When looking at CBCL, TRF, YSR
• Those in similar roles (parent-parent) corr about
  .6, adults in different roles (parent-teacher)
  corr about .3, children with adults corr about .2
  
• All corrs are higher for externalizing.
• Why?

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Personality Assessment

• Ask about functioning without asking about
  specific behaviors
• Personality inventoriesMMPI-A
• Projective measures
• Ambiguous stimuli onto which individuals project
  ideas and feelings.
• Many types-Rorschach, TAT/CAT/RAT, DAP.

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Intellectual and Educational Assessment

• Intelligence tests
• Most commonly employed assessment device beyond
  interviews
• WISC-IV10 mandatory, 5 supplementary scales.
• Stanford-Binet
• Both M 100 sd15 or 16.
• Criticisms
• Cultural loading and school based quality of some
  tests
• Focus on speed of responses to detriment of
  methodical kids
• View of IQ as rigid and inflexible
• Using IQ tests makes IQ real and not a construct.
• Educational testsWoodcock-Johnson, WIAT, WRAT

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Neuropsychological Testing

• Primary purpose
• Find the implications of brain-related deficits
  and lesions
• Much more specific than broader measures
• Areas
• Perceptual/sensory
• Motor functions
• Verbal functions/language/communication
• Attention/learning/processing
• Non-verbal functions

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Strengths and Weaknesses of Testing

• Strengths of standardized testing
• Many testsfinding a good one in your area
  shouldnt be hard
• Identifies strengths and weaknesses from a
  variety of perspectives
• Weaknesses of testing
• Assumes that everyone is motivated and honest
• Some techniques may be biased

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Classification and Diagnosis

• In dx, we use either categories or dimensions
• Keys to a classification system
• Must be clearly defined
• Groups or dimensions must exist (go together
  regularly)
• Reliableget same dx across observers
• Validprovide us with useful info, not overlap
  with other dx
• Clinical utility

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Clinically Derived Systems

• From a consensus of clinicians about which sx
  usually go together
• DSM-American (ICD-10-other countries)
• Grew out of Kraepelins initial classification in
  1883
• 1952-DSM-I had 2 categories for
  children-Adjustment reaction and childhood
  schizophrenia
• Adultomorphism
• 1968DSM-IInew section Behavior Disorders of
  Child and Adolescence
• 1980DSM-IIImultiaxial
• Now DSM-IV-TR
• 5 axes
• IClinical disorders
• IIDevelopmental disorders, personality disorders
• III-General medical conditions
• IVPsychosocial stressors
• V-Global assessment of functioning 0-100

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Strengths and Weaknesses of the DSM

• Reliabilitytest-retests is fair for dx such as
  ADHD, CD, ODD--.51. to .64
• Inter-rater is better for some than othersautism
  .85, ODD .55
• Strengthscommon diagnostic language
• Wide acceptance and use
• Multiaxial
• Weaknessesusually used for classification (not
  for understanding or tx)
• Medical model
• Reliability for kids and adolescents behind
  adults
• Very complex
• Labeling
• Self-fulfilling prophecies

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Empirically-based Taxonomies

• Collect info in a standardized manner from a
  large N of kids
• Analyze data through statistical means
• Explore associations between sx
• Develop scales based on these behavioral items
• CBCL by Thomas Achenbach

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Therapeutic Interventions

• Settings for interventions
• Inpatient settings
• Residential tx facilities
• Group homes/therapeutic foster care homes
• Day hospitals
• Outpt settings
• School based mental health services

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Involvement in Treatment

• Flisher et al 1997at least 17 of kids and
  adolescents with severe psychopathology never
  receive tx
• Goodman et al 1997compared with those who do not
  receive services, those who do
• Experienced higher levels of psychopathology
• Showed lower levels of competence
• More likely to have comorbid disorders
• More likely to be non-Hispanic Caucasians
• Less likely to be prepubertal girls
• Tended to have parents who were
• More educated
• More dissatisfied with their family functioning
• Less involved in monitoring childrens behavior
• More likely to have received tx themselves

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Who drops out?

• High SES less likely to drop out
• Attrition is lower when the whole family is
  involved
• Most parent factors are not significant
• Congruence between parental expectations and
  treatment recommendations is related to lower
  attrition
• More coercive referral sources are more likely to
  drop out

48
Does therapy work?

• Consumer Reports surveys say pts are satisfied,
  but does it work?
• Outcome studieswaitlist controls, no treatment
  controls, attention-placebo control, standard
  tx/routine care control
• Casey and Berman 1985first large scale
  meta-analysis
• Tx outcome for those 12 and younger64
  studiessingle ES for each study
• Mean ES .71 -across studies the avg treated child
  functioned better after tx than 76 of control
  kids
• Most tx (other than dynamic) were more effective
  than no tx
• Behavioral somewhat better than non-behavioral
• Worked whether play or no-play and parents and
  kids vs kids only
• Tx is somewhat more effective for specific
  problems than for social adjustment problems
• Tx effective across observers
• Other meta-analyses have found very similar
  things

49
The Next Step in Efficacy

• Goal now is to establish empirically supported tx
  for specific problems
• Two categories
• Well-established tx
• Probably efficacious tx (new tx that appears
  effective from 1 or 2 high-quality studies)
• Problemclinic vs. research txgenerally clinic
  is less effective

50
Play Therapy

• One technique to discuss across tx
• Problem young kids are less verbal, so play tx
  uses play to concretize communications
• 2 primary perspectives
• Dynamickids cant do verbal free association
• Now dynamic people view play as a mode of
  expression
• Client-Centered
• Axlinebasic principles of CCTunconditional
  regard, accurate empathy, genuiness
• Non-directive

• Not a great deal of support for play therapy as a
  stand-alone technique
• Typical play therapy room contents
• Tactile materials
• Drawing materials
• Dolls and dollhouses
• Hand puppets
• Nerf balls
• Blocks
• Communication facilitators

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Psychodynamic Therapy

• Very little support with children
• Historical importance
• Interpretation of unconscious conflicts

52
Behavior Therapy

• 2 main typeschild oriented and parent oriented
• Generally based on research principles
• Child-focused
• Applied Behavior Analysisfocus on antecedents
  and consequences of behavior
• Reinforcement, prompting, modeling, shaping, time
  out, punish.
• Token economies
• Systematic desensitization

53
Parent-Oriented Behavior Therapy

• Behavioral Parent Training-Barkley
• Pay attention to and reward positive behavior
• Ignore bad behavior
• Allow natural consequences
• Model appropriate behavior
• Provide consistent and known consequences
• Anticipate and plan for problem behavior
• No idle threats
• Limit the use of punishments
• One 25 year follow up (Strain et al) showed
  positive results

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Evaluating Behavior Therapy

• Achieves results in a short period of timeless
  distress, lower cost
• Methods are clearly delineated results easily
  measured
• Works better with some problems than
  othersrarely used for complex personality
  disorders

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Cognitive-Behavioral Therapy

• EllisRational Emotive Therapy
• Sustained emotional reactions are caused by
  internal sentences that people repeat to
  themselvesirrational beliefs
• Eliminate self-defeatingness by rational
  examination
• Must decide together what to do
• BeckCognitive therapy
• Negative beliefs that people have about self,
  world and future cause disorders.
• Both behavioral and cognitive.
• Ellisdeductiveknows there are irrational
  beliefs
• Beckinductiveseeks negative beliefs
• Social problem solving skills training,
  assertion trainingpart of this
• Efficacy
• Less research on Ellis modelwhat is there says
  that it does not work as well as Becks approach.
  

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Family Systems Therapy

• Family tx
• All members all the time
• Structural interventions
• Change familys organizational patterns

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Psychopharmacology

• Medications are widely used, even if not widely
  studied in kids
• Zito et al 2000studied kids aged 2-4 between at
  three sites/three payees
• Stimulants 12.3, 8.9, 5.1 per 1000
• Antidepressants3.2, 1.6, .7
• Antidepressantslimited support, not studied
  until recently
• Fairly equivocal results
• Only two are approved (Prozac and Zoloft)
• Suicide concern
• Anxiolyticslimited evidence, limited research
• Antipsychoticsolder kids with later onset of
  schizophrenia, higher intellectual functioning
  respond better
• Psychostimulantsabout 75 of kids with ADHD
  respond well. Help attention and impulsivity but
  not social skills or academics
• Drawbacks to medsside effects message that med
  use sends

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Prevention

• 20 of kids have disorders, even 10 would be a
  huge need if more than 5 of those in need got
  help
• Primaryentire community
• Secondary-children at risk
• Tertiaryprevent recurrence
• DARE
• Head Start

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Attention Deficit Hyperactivity Disorder

• Symptoms
• Inattention
• Losing things
• Disorganized
• Cant follow through on steps
• Easily distracted
• Hyperactivity
• Talkative
• Driven by a motor
• Run in situations when it is inappropriate

• Keys
• Before age 7 (but some studies find little diff
  between before or after 7)
• 6 mos duration (may be too brief for young kids)
• 2 or more settings
• Evidence of significant impairment
• 3 typesprimarily inattentive, primarily
  hyperactive, combined

60
Prevalence

• Lots of controversy, lots of research
• In 200925 of articles in Journal of Abnormal
  Child Psychology were about ADHD
• Some controversy about whether it is all one
  disorder or two
• Prevalence3-5 of kids (2-10)
• 50-60 when clinical or special education samples
  are used
• Kids tend to be referred for help between ages
  7-9
• 50-80 will continue to have problems into
  adulthood
• Boys outnumber girls by 21, some reports as high
  as 91

61
Gender Differences

• Compared with boys with ADHD, girls with ADHD
  tend to
• have lower intellectual functioning
• have lower levels of hyperactivity
• fewer comorbid externalizing problems
• inattentive types
• No gender differences in
• fine motor skills
• social functioning
• academic performance
• impulsivity
• family relationship variables like parental
  depression or parental education

62
Inattention

• May be able to pay attention in some situations
• Not deficient in selective attention
• Instead a basic deficit in the ability to sustain
  attentionCPT, reaction time
• Deficit is context-dependent and task-dependent
• All of this suggests, perhaps, a motivational
  deficit

63
Hyperactivity and Impulsivity

• Hyperactivity
• Far less robust dimension than inattention
• Some evidence that they are more active on a 24
  hr basis (including sleep)
• Greater restlessness
• Differences most marked in younger kidsdecrease.
  with age
• Situation dependent
• Impulsivitycognitive vs. behavioral impulsivity
• Act before they think
• Complex tasksaccept 1st solution that comes to
  mind
• Make very rapid responses, as well as irrelevant
  and inappropriate ones
• Do not lack search strategies, but they are
  deficient

64
IQ and Academic Achievement

• 7-15 pts below avgnot clear if IQ is low or poor
  test-taking skills
• Do poorly in school
• Repeat more grades, lower marks on standardized
  measures of reading, spelling, vocabulary, and
  math
• Academic performance decreases with time
• 40 receive some form of special education by
  adolescence
• Cognitive etiologycore cognitive problems
  prevent development of problem-solving
• Motivational factorsschool failures lower
  self-esteem and undermine desire to achieve as
  child grows older

65
ADHD and Memory

• Intact as long as the list of stimuli is
  relatively short
• Deteriorates as of stimuli to be remembered
  increases
• Appears that, instead of increasing in effort as
  task becomes more difficult, actually expend less
  effort and use less efficient memory strategies

66
Higher Order Processes

• Adequate on simple, but performance decreases as
  task complexity increases
• Word knowledge2 vs. 5 choices
• When asked to scan an array, they skip around and
  focus on novel or striking stimuli instead of
  processing all relevant info
• Performance increases with interest in task
• When told about more effective strategies, dont
  always use them
• Poor metacognition

67
Response to Reinforcement

• Performance will increase if every correct
  response is reinforced
• Withdrawal of expected rewards can interfere with
  performance, even on simple tasks
• Performance deteriorates when reward is given
  after every 2nd correct response or at regular
  intervals
• Exceptionally strong need for immediate
  gratification
• Tend to invest more energy and interest in
  obtaining the reward than solving the problem
  (not task-oriented)

68
Other Characteristics

• Accident proneness1/2 described this way
• 15 have had 4 or more serious injuries
• 3x more likely to have accidental poisoning
• Distorted self-perceptionspositive illusory bias

69
Comorbidity and Differential Diagnosis

• Comorbidityrule rather than exception for ADHD
• Between 42 93 for ext, 13-51 for
  internalizing
• Conduct disorder20-50
• CD alonemore antisocial parents, more family
  hostility
• ADHD alonemore frequently off-task in school and
  play
• Kids with both have worst features of both
• LD
• 10-92--Loose defs of LD. Rigorous defs -17-35
• Inattention leads to learning probs and vice
  versa
• Less task persistence in ADHD kids
• Speech or language30-60 have impairments
• Use fewer pronouns and conjunctions
• Also more formal speech problems
• Differential diagnosisbipolar, PTSD, FAS, lead
  poisoning

70
Course of the Disorder

• Preschool
• 6 mos required of DSM may be too short, at least
  1 yr is more predictive of future problems
• Preschoolers restless, driven by a motor,
  impulsive, incr. risk for accidents and
  poisoning, moody, demanding of attn., defiant,
  noncompliant
• 40 of 4 yo have problems with attention severe
  enough to be noted by teachers or parents but,
  for most of these kids, problems are gone in 6
  mos
• Of 4 yo. with ADHD, only 48 will still have dx
  in middle childhood or adolescence
• Those who develop it earlier have greater
  problems with cognitive functions, worse family
  functioning, increased comorbidity, increased
  likelihood of it lasting to adolescence

71
Course of the Disorder

• Middle childhood
• 50 experience peer rejection
• ADHD who arent comorbid are in the minority
• ½ will have individual or family tx
• 1/3 will receive some special education services
• Parents note failure to accept responsibility,
  having to supervise self-help activities such as
  dressing and bathing, temper tantrums, immaturity

72
Course of the Disorder

• 50-80 continue to show sx of ADHD
• 25 engage in antisocial behavior such as
  stealing or fire setting
• 50-70 repeat grades
• 8x as likely to be expelled or drop out of school

73
Course of the Disorder

• Adulthood
• Longitudinal studies show continuing problems
  with ADHD, antisocial PD, substance abuse (31 vs
  3 of controls)
• More car accidents/tickets
• Less job stability
• Academic achievement suffers
• No direct connection with criminalityonly if
  comorbid with CD

74
Etiology

• No one theory that everyone accepts
• Family-genetic risk factors
• Twin studies70-80
• Between 25-30 of first degree relatives of kids
  with ADHD also meet criteria
• Neurobiological factorsabnormalities in
  frontal-striatal region
• Limitations in self-control and behavioral
  inhibitions (Barkley)
• Family factors
• Negative controlling mother-child interactions
  begin when child is as young as 2 or 3
• Mothers report incr. stress, incr. social
  isolation, incr. distress
• Interactions improve on both sides when child is
  given Ritalin or when Valium is given to mother
• Hoover Milichgave kids placebomothers told it
  was sugar reported increased hyperactivity, were
  more critical
• Things that dont cause ADHDdiet, food
  additives, sugar

75
Treatment of ADHD

• No known cure
• Medication1937 math pills
• Effectiveness rates range from 50-95 (about 70)
• 20-30 show no effects or adverse effects
• When treatedless impulsive, more planful, fewer
  task-irrelevant behaviors, more goal-directed,
  more coordinatedmakes beh more appropriate
• Academic achievement and social skillsnot
  improvednever learned in the first place
• Can create kids who credit success to medication
  and failure to selves
• Other problemscan be addictive, can make kids
  jumpy or zombie-like, bland mood
• Overuse? About 3 of all school age kids
• 90 of scripts for methylphenidate are in USat
  least 5x higher than other places
• Girls and adolescents are less likely to receive
  stimulants
• 90 of visits to physician with complaints of
  hyperactivity result in script
• At least 50 of kids dxd with ADHD are not
  treated in a way consistent with recommendations
  of the American Academy of Child and Adolescent
  Psychiatry

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Treatment of ADHD

• Behavioral Parent Training
• Behavioral Interventions in the classroom
• Both are empirically supported
• Basically involve education into observing
  behavior, reinforcing behavior, token
  economies, appropriate discipline, empowering
  parents to work with schools, time out
• Works best for kids 2-11
• Intensive summer programs
• Combination of behavioral methods and medications
  works best
• Other interventions
• Cognitive-behavioral interventionsmay help with
  problem solving
• Social skills training
• Dietnot effective for majority of kids
• Funny glasses
• Sensory integration training
• Biofeedback?