Developmental

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Developmental Disruptive Disorders of Childhood
and Adolescence

• January 18, 2012
• Will Beyer, LSPE-HSP, LPC-MHSP
• The ADHD/LD Clinic of Tennessee
• 731-660-2850
• willbeyerlpe_at_gmail.com

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There is nothing new under the sun. (Solomon-
Book of Ecclesiasties)
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You will never accomplish greatness without
loving what you do. Steve Jobs- CEO- Apple
Computers.Stay Hungry, Stay Foolish
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Where is happiness not found?

• Alcohol or drugs
• Sex, food, or money
• Education or knowledge
• Power or position
• Any Thing
• In the past or in the future
• In Control

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Where do we find happiness?

• Healthy Relationships
• Special Moments
• Practicing Forgiveness
• Regularly engaging in acts of kindness
• In Healthy Living
• In our Spiritual Lives

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The Words and Wisdom of Forrest Gump

• I may not be a smart man, but I know what love
  is.
• Sometimes there just arent enough rocks.
• I could run like the wind blows!
• I gave Bubbas mother his share. I had to keep
  my promise.
• You can sit here. Jenny
• I love to beat up on Notre Dame! (I dont
  recall where this is in the movie, but Im kinda
  sure it is in there somewhere.)

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Keymakers

• Some people see a closed door and turn away.
  Some people see a closed door, try the knob and
  if the door doesnt open, turn away. Some people
  see a closed door, try the knob, and if the door
  doesnt open, they find a key, and if the key
  doesnt fit they turn away. A rare few see a
  closed door, try the knob and if it doesnt open,
  find a key, and if the key doesnt fit they make
  one!

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What Have I Learned About Kids?

• All children need and desire love and approval.
  Tell them you care and want to help. Be real,
  and dont fake it.
• Most children with anger problems have been
  deeply hurt and are grieving. Acknowledge their
  losses and comfort them.
• Children with anger problems have difficulty
  seeing a future. They often feel helpless and
  hopeless. Give them hope and help them regain a
  vision for the future.
• Human behavior is complicated. Do not
  oversimplify behavior. Think like a scientist,
  use methodology, study hard and ask lots of
  questions.
• All children need safety in times of storm and
  stress. Provide a safe haven. Programs do not
  change people-Relationships do!
• Self-control begins with self-talk. When what
  they say to you and what they say to themselves
  is the same, trust has been established.
• If we punish or scare children into compliance,
  we increase the need for supervision and decrease
  their self-control and individual initiative.

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What I have learned about kids, cont.,

• Treat the child with fairness, consistency and
  respect while clearly communicating expected
  behavior, reasonable consequences and reward for
  success. Take them from where they are, not where
  they should be.
• Parents generally love their children, but they
  may not understand why their child is having
  problems, nor how to help. Therefore, treat the
  parent with respect and seek to form a
  collaborative relationship.
• Children themselves may not understand why they
  are are struggling with self-control.
• Tantrums represent a signal of helplessness and a
  test to assert ones own independence.
• Violence demands that people listen. It empowers
  the person.

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Sequence of Topics for this Program

• Brain Development and etiological factors
• Observing and interviewing for developmental
  problems/Biological mechanisms in psychopathology
• ADHD
• Oppositional Defiant Disorder
• The Angry/Aggressive Child
• Effects of Divorce
• Abuse/ Maltreatment/Trauma/R.A.D.
• Mental Retardation/Developmental Delay
• Learning Disabilities
• Tic Disorders/Tourettes/Impulse Control
  Disorders
• Autism/Pervasive Developmental Disorders
• Fear and Anxiety/PTSD
• Childhood Depression
• Neurogenetic Disorders

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DSM-IV Disorders of Infancy, Childhood or
Adolescent
Mental Retardation Learning Disorders (Reading, Math, Written Language Motor Skills Disorders, Developmental coordination Communication Disorders (expressive language-mixed recep-expres, phonological disorders) Pervasive Developmental Disorders (Autistic, Retts Aspergers)
ADHD and Disruptive Behavior Disorders (ODD, C.D.) Feeding and Eating Disorders (Pica, etc.) Tic Disorders (Tourettes, Chronic vocal or Motor Tic, Transient Tic) Elimination Disorders (Encopresis, Enuresis Other Selective Mutism, RAD, etc.
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DSM-V Revisions

• Intellectual Developmental Disorder/ IDD or
  Global Developmental Delay-NOS (not M.R.)
• Bi-Polar Disorder- More stringent criteria for
  children
• Gender Dysphoria (Moved out of sexual disorders)
• Hypersexual Disorder
• Oppositional Defiant Disorder- (Angry/Irritable
  Mood/Headstrong Behavior, and Vindictiveness)
• Behavioral Addictions-gambling
• New Suicidal Scales to determine risk.
• Temper dysregulation with Dysphoria (TDD)
• Communication Disorders (Language, Speech, Social
  Communication)
• Autism Spectrum Disorder (inclusive of PDD
  Aspergers)
• Deleting specific categories of Schizophrenia
• Attention Deficit Hyperactivity Disorder-Age
  change and number of criteria required.
• Specific Learning Disability

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Case Study

• 13 year old female, African-American/Professional
  parents recently relocated/private school.
• Not paying attention in class/ Acted like she had
  a hearing problem. Previously diagnosed ADD and
  prescribed meds. Not much help.
• Headaches, impaired appetite/obese, Ringing in
  ears
• Flattened affect- looked depressed/spacing out
• Speech and language had diminished/slow talking.
  Expressive language was impaired.
• Slow writing and weak motor movement.
• Not athletic/poor balance.

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Case Study Cont.,

• Elevated scores on ADHD checklist consistent with
  ADD-I.T.
• Clinically significant scores on Child Depression
  Inventory
• Underachieving in school.
• Complained of body aches/Didnt feel good.
• Daydreamed/lost in her own thoughts/slept
  excessively/Schizoid features/Poor Socialization
• WISC-IV VCI 78, PRI 84, WMI 72, PSI 68
• WIAT-III- Reading Comp- 78
• Adaptive 88
• Emotionality P-MACI Elevated -Somatization,
  ADD, GAD. OCD

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Differential Diagnosis?

• ADHD-Inattentive Type
• Borderline Intellectual functioning
• Learning Disability/Language Disorder
• Adjustment Disorder
• Dysthymia or Mood Disorder
• Selective Mutism
• Early somatization symptoms
• Early onset schizophrenia or psychosis

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Then I noticed.

• A few café au lait splotches on her legs and
  arms.
• Small subcutaneous bumps starting under her
  skin, swollen joints.
• I remembered Tinnitis symptoms, headache, balance
  problems, flattened affect in face (paralysis).
• Hypotonicity in arm and leg strength
• Then I had a House moment what if she has.?

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NF-1 Neurofibromatosis-Type 1

• Long arm q of chromosome 17
• Encodes for the protein (neurofibromin) which is
  a tumor suppressor (usually benign).
  Subcutaneous tumors begin to grow and café au
  lait clusters with neurological symptoms
  emerging. (headache, lethargy, depression,
  attention deficits, facial paralysis, learning
  disabilities, etc.)
• NF-2 is chromosome 22q-

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Case Study Timmy Tornado

• Development Born 10 weeks premature, mother used
  methamphetamine in utero and heavy smoker.
  Emergency C-Section/fetal distress
• Age 9 Hasnt spoken, Makes sounds, extremely
  hyperactive, PICA,
• Lives in old house, self-injurious-bites, hits,
  head butts, younger sibling in the home.

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Timmy Cont.,

• 2-3 simple gestures
• Meds Seroquel, Trileptal, Ambien, Risperdal,
  Melatonin, (Has been on Haldol, Ritalin,
  Neurontin, and Depakote in the past) Only seen
  Physician Assistant.
• Severe PICA Feces, balloons, pins, glass,
  buttons, teeth, toys, insects, rocks, etc. etc.
• Impaired Social Interaction, Motor Movement,
  impaired communication, restricted or repetitive
  patterns of behavior.

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Discuss Assessments and Treatment Plan

1. Initial diagnostic Impression?
2. What assessments may prove useful?
3. Where do you start?
4. To whom do you refer and why?
5. Complication Indigent family/TN Care only.

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To get it right we may need..

• Direct Observations
• Rating Scales
• Hearing, Vision, Speech and Language
• Play Based Assessments
• Functional Assessments
• Occupational Therapy
• Physical Therapy
• Intellect and Achievement
• Developmental Inventories
• Adaptive Behavior

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Brain Development

• Begins in week three with neuroectoderm and forms
  the neural plate
• Cell Proliferation-Neural plate-neural tube-brain
  and spinal cord
• Cell Migration-neurons move to specific regions
  to their final positions
• Cell Differentiation- segmenting
• Cell Death (apoptosis) (Pruning)
• (Stress, nutrition, drugs, chemical contaminants,
  hypoxia, gene expression, etc.)

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Neurodevelopmental Disorders-Etiology

• Deprivation
• Genetic
• Immune Dysfunction
• Infectious Disease
• Metabolic Disorders
• Nutrition
• Trauma
• Toxic and Environmental Factors

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Common Neurotoxins to the Fetal Brain

• Affect the transmission of chemical signals
  between the neurons
• Lead, Mercury, Toluene, Dioxins, PCBs, Arsenic,
  Alcohol
• There are both presynaptic and postsynaptic
  effects such as interfering with production of
  transmitters, to conduction of action potentials,
  transmitter storage, transporter molecules and
  transmitter metabolism

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Biological Mechanisms involved in Psychopathology

• Severe Maltreatment-(3 million cases per
  year/one-third between ages 3 and 7.)
• Disease (CNS infections (cytomegalovirus,
  toxoplamosis, rubella, herpes simplex, HIV, HIB
  meningitis)
• Nutrition
• Accidental Injury
• Genetics (ADHD, Fragile X, PKU, etc.)
• Exposure to Toxins Lead, ETOH, cocaine, etc.
• In utero Stroke, hemorrhage, anoxia, etc.

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Most Common Causes of Neurological Insult

• Prenatal (includes genetic), 80-85
• Perinatal (most often asphyxia), 5-10
• Postnatal- 5-10
• Testing for hypothyroidism (1 in 4000) and
  Phenylketonuria (1 in 12,000) has reduced M.R.
• Most common chromosomal-Downs-1 in 700, Fragile
  X, 1 in 800 males, Trisomy 18-1 in 4000.
  (Prader-Willi syndrome, Wilsons Disease)

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Medical Assessments

• Genetic Studies
• Brain Image Studies ( MRI, FMRI, CT, EEG, SPECT,
  PET, etc.)
• Metabolic Screens (blood and urine- for how the
  child metabolizes food.
• Lead Chelation (Pica)

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Drugs that affect the fetus
Tobacco Vaccines Vitamins Alcohol Narcotics
Anti Cancer Agents Anti-biotics Aspirin Sex hormones Barbituates
Anti Seizure Anti Coagulants Anti Psychotics Stimulants Designer Drugs
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The Mental Health of the Child begins in Utero

• Low Birth Weight
• Precipitous Birth
• Exposure to Toxins/drugs
• Tobacco
• STDs
• Poor Nutrition
• Absence of Prenatal Care

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The Relationship between AOD Use and Psychiatric
Symptoms and Disorders

• AOD can mask psychiatric symptoms and disorders.
• AOD can worsen the symptoms of psychiatric
  disorders.
• AOD withdrawal can cause psychiatric symptoms and
  mimic psychiatric disorders.
• Psychiatric disorders and AOD disorders can
  co-exist.
• Psychiatric disorders can mimic behaviors
  associated with AOD abuse.
• AOD can cause psychiatric symptoms and mimic
  psychiatric disorders.

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Environmental Factors

• Pre or postnatal
• Acute or Chronic
• Single or Additive or multiplicative
• Biochemical or Social
• (Parenting style, family interaction, peer
  interaction, education, culture, community)

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Prevention of Childhood Disorders

• Good prenatal care.
• Targeting low income teenage mothers linking to
  community services.
• Character Development in early years
• Protect against abuse and neglect.
• Targeting caregivers/Increase Training
  Opportunities.

• Environmental change.
• Enhance educational opportunity.
• Target 5th-7th grade males at risk for
  delinquency.
• Protect against accidental head injury or
  Neurological Insult

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Educating Parents About Risks

• Drowning- Pools, 5 gallon buckets, bathtub, etc.
• Suffocation-dry cleaner bags, coins, toys,
  refrigerators, ropes, hanging, chemical,
  age-appropriate foods
• Burns- matches, gasoline, etc.

• Bicycle helmets/ car seats
• Toxic chemicals
• Child Safety gates
• Bars on upstairs windows.
• Child resistant containers
• Safety walk-through/checklist

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Birth Psychology- What have we learned?

• The placenta doesnt always protect the prenate.
  (Pollution-solvents, metals, radiation,
  pesticides)
• Ubiquitous exposure to adults-nicotine, caffeine,
  aspirin affect growth and development.
• Prenates are learning voices, music, stories
• Brain growth spurt-Beginning of third trimester
  to age 2. R.H. maturation- once and for all
  opportunity.
• The effects of nutrients folic acid, taurine,
  etc.
• The importance of attachment.

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Chromosomes

• Humans normally have 46 chromosomes in each cell,
  divided into 23 pairs. Each parent contributes
  23. Changes in genomic imprinting disrupt the
  regulations of genes resulting in inaccurate
  copying from either the paternal or maternal
  copy. A missing piece of the chromosome is called
  a deletion
• (p) Is the short arm for petit.
• (q) Is the long arm (next letter in the alphabet)

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Behavioral Genetics

• 100,000 genes in human genome.
• Tens of thousands of genes contribute to
  neuroanatomical and neurophysiological substrates
  in the CNS.
• The expression of a gene depends on the genetic
  milieu in which it is placed and the interaction
  with the environment.

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Chromosome 11

• Chromosome 11 contains 134 million DNA building
  blocks (base pairs) and represent 4 percent of
  the total DNA in cells.
• Chromosome 11 Disorders include
• Beckwith-Widemann (p) short arm
• JacobsenSyndrome (q) long arm
• Neuroblastoma/Leukemias/lymphomas
• Ewing Sarcoma ( (t) fuses Chromosome 11 and 22)

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Genetically Determined Disorders of Cognition

• Chromosome 11 q-syndrome
• Downs Syndrome- 1/1000
• Fragile X Syndrome- 1/1250 males and 1/
• Kleinfelter Syndrome 1/1000 males
• Turner Syndrome-1/2500 females
• Prader-Willi Syndrome
• Phenylketonuria- 1/10,000

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Classification of Neurogenetic Disorders

• Autosomal Recessive Disorders- (Ex. PKU,
  Tay-Sachs)
• Autosomal Dominant Disorders-(Ex. Huntingdons
  Disease)
• Sex-Linked Disorders (Ex. Fragile X, Turners
  Syndrome)
• Genetic Deletion Disorders- (Ex. Prader-Willi
  Syndrome, Monosomy 21)
• Multifactorial Chromosomal Abnormalities
  (Dyslexia, Schizophrenia, Parkinsons,
  Tourettes, Alzheimers, Depression)
• Extra Genetic Material Disorders- Klinefelters
  Syndrome XXY, Jacob Syndrome XYY

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Developmental Delay

• D.D. is more appropriate when cognitive ability
  and adaptive behavior are significantly below
  average.
• Used when clear-cut data is not available to
  diagnose mental retardation.
• Parent or pediatrician may first raise concerns
  that the child seems behind.
• Motor skills, speech, language, cognition,
  social, emotional delays

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Human Behavior is defined asVtVg VeVgVe

• Phenotype The observable physical or biochemical
  characteristics of an organism, as determined by
  both genetic and environmental influence.
  Genotype is the genetic makeup of a cell (the
  combnation of allele makeup of the individual)
• Vt, the total phenotype variance, equals Vg, the
  component of variance due to genetic factors plus
  Ve, the component of phenotypic variance due to
  environmental factors, plus a component of
  variance which reflects specific
  gene-environmental interactions.

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Restriction Fragmentation Length Polymorphism
(RFLP)
DNA is cut by a restriction enzyme The DNA
fragments are separated by electrophoresis The
fragments are transferred to a membrane by the
Southern blot procedure Hybridization of the
membrane to a labeled DNA probe Each fragment is
considered an allele
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Genotyping is the process of elucidating the
genotype of an individual with a biological assay.

• Restriction fragment length polymorphism (RFLP)
• Terminal restriction fragment length polymorphism
  (t-RFLP)
• Amplified fragment length polymorphism (AFLP)
• Multiplex ligation dependent probe amplification
  (MLPA)

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Chromosome 18q-Syndrome

• Deletion of long arm of (q) of chromosome.
• Symptoms short stature, hypotonia, abnormalities
  of skull, face, deeply seated eyes, prominent
  ears, visual/hearing abnormalities, heart
  defects, malformations of hand and feet. Carp
  shaped mouth, Lots of variability in severity
  of symptoms. Not always low functioning.

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Rett Syndrome

• Normal pre-perinatal development through first 5
  months (boys), first 28 months (girls).
• Decelerated head growth from age 5 to 48 months
  (neurodegenerative disorder) MECP2 gene
  (Seizures, gastrointestinal problems, No verbal
  skills,
• Progressive loss of motor, then cognitive skills.
  Hand movements, stereotypic hand movements such
  as hand wringing and poorly coordinated gait.
• Mental retardation. Severe to Profound.

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Downs Syndrome

• Downs Syndrome-Trisomy 21. Increasing risk with
  maternal age. Mean IQ 47-50.
• 10 are institutionalized.
• Physical characteristics-high cheek bones,
  microcephaly, large tongue, small round ears,
  hypertonic muscles.
• Prone to congenital heart defects, infections,
  and injury. Temperament is typically friendly and
  love music.

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Huntingtons Disease (Chorea)

• Chromosome 4 (CAG Repeat) Huntingtin gene (HTT)
  codes for protein Huntingtin
• Trinucleotide repeat (CAGCAGCAG)
  Cytosin-adenine-guanine)
• Symptoms Behavioral disturbance, hallucinations,
  irritability, restlessness, psychosis, facial
  movements, unsteady gait, anxiety, speech
  impairment, prancing walk, etc. (basal ganglia
  in striatum) 250,000 Americans have H.D.
• Symptoms can begin anytime but usually begin
  between 35-44 years of age. Search youtube (The
  Real Huntingtons Disease The Sequel)
• Dopamine blockers may slow progression, possible
  co-enzyme Q10, Amantadine may help.

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Sydenhams chorea

• Etiology Infection with Group A beta-hemolytic
  streptococcus. (basal ganglia and corpus
  striatum)
• Occurs in 20-30 with acute rheumatic fever.
  (youtube Syndenhams chorea Rebekah Everest
• May occur 6 months after infection.
• Symptoms chorea, slowed cognition, facial
  grimacing, hypotonia, hand milking, (Not PANDAS)
• 50 recover in 6 months.

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What are the needs of the children I serve?

• Self-Control (Impulse, aggression, etc.)
• Mood Stability
• Cognitive (Reasoning, Problem Solving)
• Self-care skills (hygiene, cleanliness)
• Social skills (Conflict Resolution)
• Academic (Reading, Writing, Arithmetic)
• Motor skills (fine gross motor)
• Language/Communication skills
• Virtues and Character Development

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Intelligence

• Fluid-strong heritability, independent of
  education and experience. Matrices, figural
  relations, abstract, non-verbal.
• Crystallized-increases with experience and
  education. Verbal Comprehension, Arithmetic,
  Vocabulary, Knowledge of facts, Deductive
  Reasoning, Associative memory

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Substance Abuse in those with Intellectual
Deficiency

• 2.6 with I.D. have S.A. (Slater, 2010)
• Start drinking a couple years later than peers.
• Less likely to be Caucasian.
• Less likely to seek help and less likely to
  receive it when sought.
• More likely to be prescribed medication.
• Greater risk of accidental overdose.
• More likely to have legal issues.
• More likely to have another co-morbid mental
  illness.
• Poor reading skills limit access to materials and
  programming.

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Functional Delay

• A continuous, significant delay in intellectual
  functioning and achievement which adversely
  affects the students ability to function in the
  general school program, but adaptive behavior in
  the home or community is not significantly
  impaired.
• Significantly impaired intellectual functioning
  two or more standard deviations from the mean.
• Deficient academic achievement below the 4th
  percentile in two areas basic reading, reading
  fluency, reading comprehension, math problem
  solving, math calculation, written expression.
• Home or school adaptive behavior above that for
  intellectual deficiency.

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Diagnosis of Mental Retardation

• Intelligence 70 or below (SEM 3)
• Adaptive Behavior- In at least two areas
  Communication, self-care, etc.
• Not a single disease, syndrome or symptom, but
  rather a state of cognitive impairment that is
  identified by the behavior of the individual.
• Not always readily identifiable. They can look,
  act, and talk normally.

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Diagnosis of M.R. cont.

• May be classified as M.R. at one time during
  their lives and not at another.
• Etiology is varied and complex. May include both
  genetic and environmental factors.
• IQs of 70 to 84 are considered borderline
  intelligence.

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Category of Mental Retardation

• Mild 50-55 to 69
• Moderate 35-40 to 50-55
• Severe 20-25 to 35-40
• Profound below 20

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Adaptive Deficits

• Self-care
• Communication
• Safety
• Self-direction
• Social Interpersonal
• Use of Community Resources

• Leisure
• Health
• Academic Skills
• Home living
• Tests Vineland Adaptive Behavior Scales and
  Adaptive Behavior Evaluation Scales

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Social Skills

• The ability to communicate and interact with
  peers and adults in an appropriate manner.
• The ability to adapt to new environments.
• The ability to interact in groups and conform to
  expected social behaviors.
• Basic knowledge of facts and social judgment.
• The ability to solve conflicts.

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Teaching Strategies to promote skill acquisition

• Check frequently for understanding.
• Teach students to use self-talk.
• Use the skill in several different learning
  environments to promote generalization.
• Prompt to focus attention.
• Prompts-Natural, Visual, Verbal, Modeling,
  Physical Guidance

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Methods for teaching students with low cognitive
functioning

• Break task down into small steps.
• Demonstrate/model
• Positive reinforcement of desired behavior
• Shaping-Operant Conditioning
• Community Based instruction
• Individualized instruction
• Self-contained classrooms/LRE

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Curriculum for Students with MR

• Basic academics- reading, math, writing.
• Math- counting, telling time, measurement.
• Reading- functional vocabulary
• Social Skills
• Life Skills
• Making choices, decisions

• Accepting responsibility
• Safety Issues
• Self-determination
• Legal issues
• Conflict Resolution
• Health issues
• Vocational

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Assessing Motor Skills

• Eye Tracking
• Palm Rotation
• Finger to thumb
• Balance on one foot
• Heel to toe- Front and back.
• Draw a circle, line, square, triangle

• Balance in seat with feet and arms extended
• Number Recognition (1,3,9)
• Skipping
• Touch finger with arm extended.
• Resistance
• Hand grip

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Coordination Disorder

• Delays in achieving motor milestones, e.g.
  walking, crawling, sitting) dropping things,
  clumsiness, poor performance in sports,
  handwriting, etc.
• Additional problems may include cerebral palsy,
  hemiplegia, muscular dystrophy.

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To Improve Disorganization

• Reinforce organization efforts.
• Use a peer model.
• Provide time for organization.
• Provide storage space
• Evaluate Is the length of time to complete the
  task appropriate?

• Is the task too difficult?
• Increase prompting and cueing.
• Demonstrate and rehearse procedure.
• Establish routine.
• Use color coded organizational system.
• Minimize needed materials.

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Autism/PDD

• Impairment in Communication- Receptive skills
  tend to be better than expressive.Loudness,
  intonation, rhythm, stress. Echolalia
• Social impairments- eye contact, facial
  expressions, gestures, (how skillful does the
  child relate to peers) Difficulty in imitation,
  affective expression.
• Stereotypic Motor Movements.
• Lower intellectual ability
• Significant heterogeneity
• Six symptoms across two categories, with at
  least two symptoms in the social category and one
  in the restrictive/repetitive behavior category.

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Interesting Facts about Autism

• 20-33 have seizures
• Frequent complications in pregnancy
• Occurs more often with viral infections.
• Difficulty with autonomic arousal

• Elevated Serotonin levels (also in first degree
  relatives)
• Fragile X is present in 8 of individuals with
  autism.
• Higher rate in monozygotic than dizygotic twins

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Aspergers Syndrome

• May be high functioning autism.
• Higher cognitive and language ability.
• Clear social impairments Social awkwardness,
  motor clumsiness, idiosyncratic or engrossing
  interest.
• Absence of deficits in intellect, adaptive, or
  language abilities.

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Communication Disorders

• Expressive Language
• Receptive Language
• Mixed Expressive-Receptive Language
• Phonological (articulation)
• Stuttering
• Dyslexia, Dysgraphia

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Sex Errors of the Body

• Triple X Syndrome XXX- Increased M.R.
• Turner Syndrome X (Short stature, missing
  ovaries or testicles, low IQ,
• Klinefelter Syndrome XXY- male, insuffient
  masculination, sterility, low sex drive, learning
  problems
• Androgen Insensitivity Syndrome- Male
  hermaphroditism, defective gene on x chromosome
  (Sex assignment is female) Remove testicles and
  female hormone replacement)
• Congenital adrenal hyperplasia- female
  hermaphrodistism- female internal organs, male
  external organs

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Gender Identity Disorder

• (1) Strong and persistent cross-gender
  identification, as manifested in a desire to be
  or belief that one is the opposite sex,
  preferences for stereotypical cross-gender
  clothing, etc.
• (2) Persistent discomfort with ones own sex in
  aversion to ones own genitalia or sex typed
  behavior, activities or clothing.

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Homosexuality

• Not a mental disorder.
• Possible genetic basis Twin studies concordance
  rate is 52 for MZ and 22 for DZ, 11 for
  adopted brothers, and 9 for sons of homosexual
  fathers.
• Possible prenatal hormonal influence
• Possible Maternal immune response
• Differential socialization
• Identification with opposite-sex parent

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Intrauterine Causes

• Fetal Alcohol Syndrome- 1 in 600, flat cheeks,
  short nose, thin upper lip, flat filtrum, growth
  retardation, weak cognitive abilities,
  hyperactivity, attention deficits
• Fetal Alcohol Effected- 1 in 200-300, ADHD, lower
  IQ, math deficits,
• Asphyxia- maternal hypertension, toxemia,
  placenta previa, etc.

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Learning Disabilities
Learning disabilities is a generic term that
refers to a heterogeneous group of disorders
manifested by significant difficulty in the
mastery of one or more of the following
Listening, speaking, writing, reasoning,
mathematical, reading, etc. Even though it may
occur concomitantly with emotional disturbance,
cultural differences, environmental influences,
sensory impairment, etc. it is not the direct
result of the conditions of influences.
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Subtypes of L.D.

• BASIC PHONOLOGICAL PROCESSING DISORDER
• Neuropsychological Deficits auditory
  attention/auditory perception/verbal memory/word
  decoding/spelling/R.C.

• NONVERBAL LEARNING DISABILITY
• Neuropsychological Deficits visual/tactile
  perception/visual memory/concept formation
• Early graphomotor deficits

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Tests commonly utilized when testing for learning
disabilities

• Intellectual (WISC-IV, WAIS-IV,SBIV, WJ)
• Achievement (WIAT-III, WJ)
• Rating Scales (Vanderbilt, Conners, etc.)
• Teacher Observations (Auditory, Visual,
  Behavior)
• Language Functioning

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Recognizing Tics
Simple Motor Eye Blinking Neck Jerking Shoulder Shrugging Facial Grimacing Complex Motor Facial Gestures Jumping Hitting Biting Stamping Smelling objects Simple Vocal Barking Coughing Grunting Throat Clearing Sniffing Snorting Complex Vocal Echolalia Coprolalia Palilalia
77
Tourettes Syndrome

• A tic is defined (DSM-IV-TR) as a sudden, rapid,
  recurrent, nonrhythmic, stereotyped motor
  movement or vocalization.
• Three times more males than females.
• Co-morbid with OCD, ADHD, and LD
• TS requires at least two motor tics and one vocal
  tic. Must occur several times a day and be
  present for one year or longer.
• Coprolalia occurs in about 60- clicks, grunts,
  yelps, barks, sniffs, snorts, coughs.

78
Stereotypic Movement Disorders

• Head banging, body rocking, self-biting, self
  picking at skin, self-hitting, mouthing of
  objects.
• 3.5 times more often in boys than girls.
• In a study of 60 children under 10 years of age
  referred for EEG testing, 40 had pseudoseizures
  consisting of rhythmic movements or staring
  episodes.
• May be related to avoidance of aversive
  consequences. Higher rates in abused children.

79
Teeth Grinding/Bruxism

• Habitual gnashing, grinding, clicking, or
  clenching of the teeth. (male to female 31)
• May occur nocturnally or diurnally.
• Etiology Learned behavior related to response to
  stress./ Malocclusion, rough teeth, oral
  infections
• Treatment Bite block, psychotherapy,
  biofeedback, anxiety reduction

80
Thumb Sucking

• Sucking of one or both thumbs, but may also
  include finger or fist sucking.
• Incidence 45 of 2 year olds, 42 of 3 year
  olds, 36 of 4 year olds, 20 of 5 year olds, 5
  of 11 year olds.
• Tends to occur when hungry, sleepy, frustrated,
  fatigue. May suck a blanket, rub a cheek with a
  pillow or blanket.
• Etiology Tension Reduction
• Treatment Aversion-nagging, gloves, splints,
  bandages, palital crib, pacifiers, foul tasting
  liquids

81
PICA (307.52)

• Commonly associated M.R.
• Potential risk of lead, toxoplasmosis, hair
  balls, intestinal perforation.
• For at least one month of eating non-nutritive
  substances inappropriate to developmental level.

82
Obsessive-Compulsive Disorder

• Incidence 0.2
• Obsessions Irrational thoughts (fear, anxiety,
  need to avert perceived danger) It doesnt feel
  right.
• Compulsions Irrational behaviors (counting,
  checking, cleaning, etc.)
• Frequently co-morbid with ODD, ADHD, Anxiety
  disorders, phobias, learning disabilities
  (reading or language delays)
• Etiology Unknown (PANDAS)
• Treatment Psychodynamic, behavioral, family,
  pharmacotherapy

83
Posttraumatic Stress Disorder

• Constellation of symptoms associated with trauma
• A. Reexperiencing symptoms
• B. Avoidance
• C. Hyperarousal
• Intrusive thoughts, images, distressing dreams,
  detachment,

84
Stressors associated with PTSD

• Parental Conflict, Separation or Divorce
• Witnessing or learning of a traumatic event
• Child Physical or Sexual Abuse
• Serious Accident

• Family Deaths or Serious Illness
• Natural Disaster- Tornado, Hurricane, Flooding,
  Earthquake, etc.
• Frequent Moves-changes in schools
• Victim of Assault

85
Symptoms of PTSD

• Hypervigilance
• Restricted Emotions
• Exaggerated Startle Response
• Nightmares
• Intrusive, distressing thoughts
• Flashbacks

• Difficulty sleeping
• Irritability or Anger
• Avoidance of activities associated with the
  trauma Im not going back to school.
• Disruption of routine
• Detachment

86
PTSD Continued

• Prevalence 5-13 following exposure to
  hurricanes, burns, physical abuse, cancer
  treatment. 43-70 following sexual abuse,
  schoolyard sniper attack, war trauma.
• Etiology Cognitive,Behavioral, Neurobiological
• Treat 7-14 days after exposure. Individual and
  family therapy medication, co-morbid problems.

87
Trauma and the Brain

• Activation of higher cortisol levels.
• Chronic pain, digestive problems, weakened immune
  response.
• Hyper-vigilance (higher adrenal output)
• Changes in brain arousal level (dopamine,
  norepinephrine)
• Problems in shifting (serotonergic) controlling
  thoughts.
• Brain atrophy in multiple areas amygdala,
  hippocampus, prefrontal, striatal, etc.

88
When working with trauma victims

• Men do not disclose their histories of sexual and
  physical abuse easily.
• Victims fear being judged, feelings minimized,
  labels, being medicated, disbelief of others.
• Understand the power of threat.. If you tell I
  will kill your sister.
• If you go there you better have the skills to
  help! Do no harm!

89
Differential Response to Threat (Matthew Perry,
Ph.D. www.childtraumaacademy.com)

• DISSOCIATION
• Detached
• Numb
• Compliant
• Suspension of Time
• Brief Psychosis
• Fainting

• HYPERAROUSAL
• Alarm Response
• Flight-Panic
• Fight-Terror
• Anxious
• Reactive
• Hypervigilance
• Freeze-Fear

90
Brain Plasticity

• Brain Plasticity means the brain changes because
  of experience.
• Neural connections occur because of learning.
• The brain becomes thicker and denser with
  learning.
• Depression may result in brain atrophy.
• Drug use results in neurochemical dysfunction.

91
Mental Health Goals

• Reduce self-injurious behaviors
• Reduce agitation and aggression/Improve
  Self-control.
• Reduce anxiety/phobic behavior
• Reduce defiance/Improve Compliance
• Reduce psychotropic use.
• Reduce distractibility/Improve Attention to Task
• Reduce impulsivity/Improve Executive Functioning

92
Symptoms of Depression in Children

• Depressed mood
• Diminished interest in activities
• Sleep disturbance
• Weight loss or gain
• Inability to concentrate (attention problems)

• Irritability or oppositionality
• Decreased energy or motivation
• Psychomotor retardation or agitation
• 2 weeks duration-5 or more symptoms.

93
Assessment of Depression

• Self-Report Questionnaires Child Depression
  Inventory, Reynolds Child Depression Scale, Beck
  Depression Inventory-II, Child Behavior
  Checklist, K-SADS
• (Co-morbid learning disabilities, PTSD, ODD,
  ADHD, etc.)
• Rule-out PDD, Anemia, PCS, Disease, Substance
  Abuse

94
Meds for Adolescent Depression

• Avoid Tricyclic (cardiac/lethality)
• Avoid MAOIs
• Avoid St. Johns Wort
• SSRIs and SSNI are most commonly used.
• Some use of heterocyclics such as wellbutrin
  (bupropion)
• Consider- fish oils, melatonin, Vitamin D, B-12,
  B-6

95
Dysthymic Disorder

• Depressed Mood, most of the day, more days than
  not, for at least one year.
• Two or more of the following
• Poor appetite or overeating
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

96
The Delineation of Causation

• Predisposition
• Initiation
• Perpetuation
• Exacerbation

97
DSM-IV-TR Disorders of Childhood
ADHD/ADD Autism PDD, Retts Childhood Disintegrative Disorder Aspergers Oppositional Defiant Disorder Mental Retardation
Reactive Attachment Disorder Tourettes Syndrome/ Tic Disorders Learning Disabilities Post- Traumatic Stress Disorder
Disorders of Communication Depression Mood Dis. Motor Skills Disorder Elimination Disorders
Separation Anxiety Selective Mutism, Conduct Disorder Feeding and Eating Disorders Adjustment Disorders
98
Interviewing Children

• Use Age-Appropriate language Children are are
  not likely to point out words they dont
  understand. Avoid words such as, guilty,
  depressed, anxious, disappointed. They do
  understand mad, sad, glad, and scared.

• Sharing a snack or drink may build rapport.
• Be observant activity level, physical
  appearance, mood/affect, parent-child
  interaction, coordination, etc.

99
The Role of Attachment

• Children rely on a parents availability to
  provide comfort, safety and support.
• Insecurely attached children ignore their
  caretakers when distressed and have difficulty
  being soothed.
• RAD develops out of a pattern of parental
  psychopathology, abuse, neglect, etc.
• RAD tends to predict increased rates of
  aggression and mood lability.

100
Social Learning

• Exposure to aggression results in vicarious
  learning experiences. (Television, video games,
  role-models)
• Delinquent behavior can be learned through direct
  observation.
• Delinquent behavior can be reinforced and
  maintained by operant conditioning (affiliation,
  acceptance, reward)

101
Assessing Minority Children

• Guard against Inappropriate Generalizations
  There is no monolithic black, Hispanic-American,
  Native American, or Asian-American subculture.
  This can include lower-socioeconomic children.
  We must check for our own bias and prejudices as
  we assess.

102
The Disruption of Community

• Abandonment
• Hostility/Fear
• Hopelessness
• Degradation
• Abuse/Neglect
• Poverty

103
Endocrinatic Influences
Pituitary Produces growth hormone Regulates Endocrine system Thyroid Produces thyroxin- growth/brain development metabolism Adrenal Gland Stimulates growth Pubescence
Testes Testosterone- Differentiation of male reproductive system and male sexual maturation Ovaries Estrogen Progesterone Regulates menstrual cycle metabolism
104
Observing for Visual Impairments

• Rubs eyes constantly
• Shuts or covers one eye, tilts head, or thrusts
  head forward.
• Squints eyelids together or frowns
• Crossed eyes, inflamed or watery eyes
• Eyes itch, burn or feel scratchy
• Blurred vision, dizziness, headaches

105
Observing for Hearing Impairments

• Frequent earaches/Sinus congestion
• Seasonal allergies
• Problems understanding spoken language.
• Inattention or lost in daydreaming.
• Often appears distracted or confused.
• Speech is loud.
• Turning head to hear.
• Frequent misunderstanding instructions.

106
Observing for Language Impairments

• Articulation problems
• Fluency problems- abnormal rate and rhythm
  (stuttering cluttering)
• Phonology problems-construction of word forms.
• Problems listening, speaking, writing, reading.
• Loudness/Quality/Pitch (disorders of
  phonation/resonance

107
Observing for Social/Emotional Impairments

• Externalizing- Aggressive, acting out
• Internalizing-Immature, Withdrawn Behavior
• Encopresis/Enuresis
• Self-stimulation rocking, twirling, hand
  flapping, staring
• Language Deviations echolalia
• Cognitive Impairments
• Lacks of Daily Living Skills
• Self-Injurious Behaviors

108
Observing for Giftedness

• Exceptional Academic Achievement
• Exceptional Creativity
• Existence of Special Talents
• Insight-A qualitative difference in reasoning and
  thinking.
• Abstract thought
• High task commitment

109
Alcoholism Giftedness

• Higher childhood mental ability was related to
  alcohol problems and higher alcohol intake in
  adult life. 2008 American Journal of Public
  Health
• For every 15 point increase in IQ there was a
  1.27 times increase for alcohol abuse.
• Gifted teens tend to be more adapt at hiding
  their alcohol or drug abuse.
• Alcoholism in professional women is growing at
  exponential rates.

110
A Primer on Regional Brain Functioning and
Behavior

• NEURONS Cell body- Axon, Synaptic bulb, Synapse,
  Reuptake, Dendrite
• PREFRONTAL CORTEX Executive functioning, neural
  braking, inhibition, gating, linking,
  (Dopaminergic)
• LIMBIC SYSTEM Cingulate- shifting,
  Hippocampus- memory, Amygdala- recognition of
  emotional affect. (Serotonergic)
• BASAL GANGLIA "idle speed", (Noradrenergic)
• TEMPORAL Memory, temper

111
Dopamine Effects

• Working Memory
• Shifting
• Cognitive Set
• Movement
• Motivation
• Too high dopamine may produce tics (basal ganglia
  pushed too far)

112
Serotonin Effects

• Response Inhibition- (Holding back the action)
• Mediates Mood Stabilization
• Reduce obsessive/intrusive thoughts (Ventromedial
  Cortex)
• Reduce binges of (eating, sex, drugs, etc.)
  Assigning value to stimulus. Orbitofrontal
  Cortex
• Integrates smell, touch, sight, texture

113
What is ADHD?
ADHD is a common neurobiological disorder
affecting 5-7 of the school age population. 80
will persist into adolescence and 50 into
adulthood. It is characterized by deficits in
executive functioning including inhibition
failure, working memory, sense of time,
self-regulation of affect/motivation/arousal
resulting in impaired rule-governed behavior.
114
The Problem of Attention

• Old as Mankind- Attention is the heart of
  self-control. It bridges time.
• Inattention and Impulsivity of childhood connects
  excessive impropriety of adulthood and feeds
  addictions.
• Attention rides on a genetic and environmental
  substrate.
• To understand human weakness and strength we must
  understand Attention.

115
Etiology Of ADHD

• Genetics DRD2, D4RD, DAT-1 These gene patterns
  are overrepresented. Twin studies-The
  concordance rate for ADHD is 81 for MZ twins and
  29 for DZ twins.
• Diminished arousal in the prefrontal cortex as
  demonstrated through SPECT and PET scans.
• FMRI's have smaller right hemisphere plana
  temporal than control group children.
• Environmental Toxins (alcohol, drugs, tobacco)
• Pre/perinatal history (intraventricular bleeding,
  eclampsia, toxemia, precipitous birth/low birth
  weight etc.)
• Diet, child-rearing, and common environmental
  toxins have been effectively ruled out as
  providing credible explanations for the etiology
  of ADHD.

116
DSM-IV CRITERIA

• INATTENTION Six or more (for six months) must be
  maladaptive and inconsistent with the childs
  developmental level.
• Often fails to give close attention to details or
  makes careless mistakes
• Often has difficulty sustaining attention in
  tasks
• Often doesnt listen when spoken to directly
• Often has difficulty organizing tasks and
  activities
• Often avoids, dislikes, or is reluctant to engage
  in tasks that require sustained mental effort
• Often doesnt follow through on instructions
• Often loses things
• Is often easily distracted
• Is often forgetful

117
DSM-IV Criteria, cont.,

• Hyperactivity Six or more for six months to a
  degree that is maladaptive and inconsistent with
  the childs developmental level.
• Often fidgets with hands or feet or squirms in
  seat.
• Often leaves seat in which remaining seated is
  expected.
• Often runs about or climbs excessively in
  situations where inappropriate.
• Often has difficulty playing or engaging in
  leisure activities quietly.
• Is often on the go or acts as if driven by a
  motor.
• Often talks excessively.

118
DSM-IV- Criteria, cont.,

• IMPULSIVITY
• (G) Often blurts out answers before the questions
  have been completed.
• (H) Often has difficulty awaiting turn.
• Often interrupts or intrudes on others.
• B. Some hyperactive-impulsive or inattentive
  symptoms that caused impairment were present
  before age 7 years.
• C. Some impairment from the symptoms is present
  in two or more settings.
• D. There must be clear evidence of clinically
  significant impairment in social, academic or
  occupational functioning.
• E. Not better explained by PDD, or other
  disorders.

119
The stimulant/abuse controversy
It is certainly true, for example, that some
children with ADHD-many of whom are taking
stimulant medication or have taken it some time
in the past-become involved with substance abuse.
It is even probable that a higher percentage of
children with ADHD experiment with illegal
substances than children who do not have ADHD.
After all people with this disorder are among the
most impulsive in our society, and many have been
extremely unsuccessful in school and life in
general. These are the factors that can lead to
drug abuse. In fact, the evidence indicates that
effective treatment of ADHD, which includes the
use of stimulants in many cases, improves
self-esteem and makes substance use less
likely. Likewise a sizable proportion of the
inmates of juvenile detention centers and prisons
have a history of ADHD, and many of them have, at
one time or another, been treated with Ritalin.
However, the probability is that early treatment
of these patients is more likely to prevent
criminal activity than lead to it.
120
We now have the first statistical evidence that
the treatment of ADHD in childhood Is protective
against substance abuse in adolescence.Joseph
Biederman, Professor of Psychiatry at Harvard
Medical School and Chief of Pediatric
Psychopharmacology at Massachusetts General
Hospital
121
International Consensus Statement January, 2002

1. ADHD is recognized as a valid disorder by The
   U.S. Surgeon General, The American Medical
   Association, The American Academy of Child and
   Adolescent Psychiatry, The American Psychological
   Association, The American Academy of Pediatrics,
   among others.
2. ADHD is not a benign disorder. It can cause
   devastating problems including interfering with
   educational attainment, family functioning,
   social impairment, contributing to antisocial
   activities, increased use of tobacco and drugs,
   increased teen pregnancy, increased accident
   history, increased depression and personality
   disorders.
3. Neuro-imaging studies find metabolic differences.
   Twin studies indicated genetic contribution. It
   is not the result of poor parenting.
4. The media has misled the public by distorting
   scientific evidence about the disorder suggesting
   the disorder is not real or consists of trivial
   affliction.

122
The debate continues
Do children become addicted to stimulant
medication? The truth is that when stimulant
medications are used to treat ADHD, there is no
evidence that patients develop any addictive
syndrome. Stimulant medication is a replacement
that normalizes brain chemistry based upon PET
scans. They do not get high, nor do they need
ever increasing doses to achieve the same effect.
Rather, the dose very often remains the same or
may even diminish as the child gets older.
Children on medications frequently skip the
medication over the weekend or holidays. These
children are not pilfering medication or whining
for extra pills. Some children may rebound
when the medication is wearing off with some
increased irritability, but this is a minor side
effect. Stimulant medications have remained a
first line treatment of ADHD since the 1940s
with no evidence of serious side effects. Why
then does the controversy continue? ADHD
children have long-lasting and profound problems.
To blame stimulant medication for the problems
of ADHD children is like blaming insulin for the
long-term sequelae of diabetes. (Thomas Spencer,
M.D., Harvard Medical School)
123
COMORBIDITY AND ADHD
TIC D.
C.D.
ADHD
O.D.D.
Aggres.
124
Behavioral Inhibition

• Stop, Delay, Think, Analysis, Synthesis, Act.
  Hindsight/Forethought/ Time Awareness/
  Self-awareness Reasoning/Create Rules/
  (Inhibiting a Prepotent Response)
• Stop an ongoing response. Interrupt
• Interference Control

125
A New Theory of ADHD

• DEFICITS IN
• INTERNALIZED SPEECH
• EMOTIONAL CONTROL
• WORKING MEMORY
• CREATIVE PROBLEM-SOLVING

126
COMORBIDITY AND ADD
OCD
Depress
ADD
Anxiety
L.D.
127
WORKING MEMORY

• Holding events in mind.
• Retrospective functioning (hindsight)
• Prospective functioning (forethought)
• Sense of time
• Imitation of complex behavioral sequences
• Self-awareness

128
Identified Deficits by Research

• Poor Persistence of Effort
• Perseveration of Responding- (Inflexibility)
• Impaired Behavioral Inhibition
• Deficits in Performance, not in knowledge or
  skill
• Planning, Sequencing, time conceptualization
• Greater Variability in work performance
• Less mature self-directed speech
• Less efficient mental calculation
• Reading comprehension

129
Differential Diagnosis
Tourette Syndrome Learning Disability Fragile X TBI
OCD Low IQ PDD/Autism/Asp. Anxiety Social Anxiety Disorder/ADD
ICD-NOS Depression/ Dysthymia AD Abuse Physical Illness(Mono)
PTSD Conduct Disorder ODD Personality Disorders
130
Implications For Understanding ADHD
It is more commonly a trait, than a pathology. It
interferes with free-will. It is a disorder of
performance, not lack of skill. It requires long
spans of time to become fully evident to
others. It creates great stress on the family.
The family will look dysfunctional, but improves
when the child is absent. It is contextually
dependent. It becomes more complex over time due
to the development of co-morbid conditions such
as ODD, CD, SA, LD, etc. It may not be a
disadvantage in every situation.
131
Evaluating for ADHD

• Clinical history
• Genetic co-morbidity
• Screen for other neurological, psychological
  disorders
• Age of onset
• Severity of symptoms
• Setting
• DSM-IV criteria

• A brief measure of intellect- working memory,
• Rating scales.
• Achievement.
• Rule-outodd, PDD, Tourettes, adjustment, etc.
• TOVA, WCS, FD may give false positives or false
  negatives.

132
Effects on the Family

• Increased marital tension.
• More disagreements.
• More supervision is required.
• More criticism by family members.
• More difficult to get babysitters.

133
Negative Parental Feelings Associated with
Parenting the ADHD Child
Frustration Guilt Shame Fatigue
Anger Helpless Denial Grief
Fear Isolation Exhaustion Loneliness
Confusion Sadness Anxiety Worried
134
Parenting Principles for the ADHD Child

• Practice Forgiveness
• Keep a Disability Perspective
• Use Positive Reinforcement
• Make Rules External
• Vacation Away From Your Child
• Join a Support Group
• Increase the Immediacy of Consequences
• Stay Away from Unproven Treatments

135
Parenting Principles, Cont.,

• Choose your fights carefully
• Dont neglect your spouse and other children.
• Modify expectations
• Grieve your loss of normalcy.
• Use token systems
• Learn about medication
• Become an advocate for your child.

136
Educational Management

• Allow some restlessness.
• Be animated, theatrical.
• Create compliance opportunities.
• Increase prompting and cueing.
• Have access to rewards several times a day.
  Increase immediacy of consequences/Reward
  throughout the task.
• Increase frequency of consequences
• More frequent changes in consequences
• Maintain a disability perspective
• Dont use multiple commands

137
Educational Management

• Use token systems.
• 3 step command- Command-count 5, Warning-Count 5
  (Raise voice), Time-out
• After time-out reward next good behavior.
• Use occasional exercise periods.
• Teach Think-aloud approach
• Sit child close to teachers desk
• Act Dont Yak!
• Stop repeating your commands
• Avoid lengthy reasoning over misbehavior.
• Have child pre-state goals or rules.
• Turtle Technique

138
The evidence for drug efficacy and the side
effects are so benign, that to refuse medication
for the child with ADHD is tantamount to
malpractice. John Werry, M.D. Professor
Emeritus of Child Psychiatry
139

• REWARD DEFICIENCY SYNDROME
• 1954 James Olds discovered the ability to produce
  a reward sensation by activation of the
  mesolimibic dopamine pathways. (the medial
  hypothalamus)
• 2. Gerald McLearn produced an in-bred mouse (the
  C57) strain that bred true for a preference for
  alcohol, suggesting that alcoholism could have a
  genetic basis.
• 3. Dopaminergic and opiodergic reward pathways
  are critical for survival. They provide pleasure
  drives for eating, love and reproduction. These
  pathways can be reached by unnatural rewards
  such as alcohol, cocaine, nicotine, and other
  drugs, and by compulsive activities such as sex,
  gambling, and eating. Activation of these
  pathways produce an agents addictive properties.

140
4. The primary neurotransmitter for reward is
dopamine, however norepinephrine, serotonin,
GABA, Cannabinoid, and Opioid neurons modify
metabolism. 5. Dopamine influences mood and
affect along with inhibition and executive
functioning thus influencing motivation. 6.
Heroin increases the neuronal firing rate of
dopamine cells. Cocaine inhibits the reuptake of
dopamine. Combined these two drugs produce even
more intensive dopamine activation.
(speed-ball) 7. Repeated drug use produces
neuroadaptive changes causing normal rewards to
lose their motivational significance.
(motivational toxicity)/ Sensitization occurs.
141
The effects of a dopamine agonist on recovery for
the A2/A2 as compared to the A1/A1
142
Types Of Medications
STIMULANTS- Ritalin, Dexedrine, Adderall,
Metadate, Concerta, Focalin, Vyvanse, Daytrana,
Methylyn, etc. (Enhance dopamine release and
concentration in the synapse.) Improves
inhibition, attention, memory storage and
retrieval, time management, self-regulation of
affect, improved internalization of speech,
fine-motor control, improved reasoning. ANTIHYPERT
ENSIVES- Clonidine, Tenex (reduces arousal,
improves sleep, improves frustration tolerance,
decreases aggression) ANTICONVULSANTS-Tegretol,
Depakote (may reduce aggression) ANTIDEPRESSANTS
(Tricyclics)- Tofranil, Norpramine (may improve
self-regulation of affect) (SSRIs)- Prozac,
Celexa, Paxil, Zoloft, Effexor (May improve
inhibition and control of affect) NEUROLEPTICS
Risperdal, Zyprexa, (may improve reality
orientation, decrease aggression)
143
Medication In Special Populations
SUBSTANCE ABUSE Stimulant mediation use
decreases rather than increases the risk for drug
abuse in adolescence and adulthood. Stimulant
medication may even reduce the risk of relapse of
substance abusers after treatment. CONDUCT
DISORDER Symptom severity appeared reduced in
the short-term. MINORITIES African-Americans are
2.5 times less likely to receive methylphenidate
than Caucasian youths. HEAD INJURY MPH appears
to be an effective treatment for post TBI
cognitive and behavioral sequelae in the brain
injured child. Speed of mental processing appears
improved while motor speed is unaffected. TOURETTE
S Both anti-hypertensive and stimulants have
been used successfully in the treatment of
Tourettes.
144
Diagnostic Criteria for Oppositional Defiant
Disorder

• A pattern of negativistic, hostile, and defiant
  behavior lasting at least six months, during
  which four (or more) of the following are
  present.
• 1. Often loses temper
• 2. Often argues with adults
• 3.often actively defies or refuses to comply
  with adults requests or rules.
• 4.Often deliberately annoys people.
• 5. Often blames others for his or her mistakes
  or misbehavior.
• 6. Is often touchy or easily annoyed by others
• 7. Is often angry and resentful
• 8. Is often spiteful or vindictive.

145
Diag. Criteria for