Chapter Fifteen

1
Chapter Fifteen

• Disorders of Childhood and Adolescence

2
Disorders of Childhood and Adolescence

• Child psychology
• Emotional and behavioral manifestation of
  psychological disorders in children and
  adolescents
• Prevalence of childhood disorders
• One in five has serious emotional or behavioral
  problem
• Two-thirds of those with mental illness received
  no treatment

3
Disorders of Childhood and Adolescence (contd.)
4
Disorders of Childhood and Adolescence (contd.)

• Diagnosis requires that symptoms cause
  significant impairment in daily functioning over
  extended period of time
• Include
• Internalizing disorders
• Externalizing disorders
• Neurodevelopmental disorders
• Conditions involving impaired neurological
  development

5
Internalizing Disorders of Childhood

• Conditions involving emotional symptoms directed
  inward
• Heightened reactions to trauma, stressors or
  negative events and difficulty regulating
  emotions
• Prevalent in early life and often lead to
  substance use and suicide

6
Anxiety, Trauma, and Stressor-Related Disorders
in Early Life

• Most common mental health disorder in childhood
  and adolescence (32)
• Can significantly affect academic, social, and
  interpersonal functioning and can lead to adult
  anxiety disorders
• Include
• Social phobia
• Separation anxiety disorder
• Selective mutism

7
Anxiety, Trauma, and Stressor-Related Disorders
in Early Life (contd.)

• Post-traumatic stress disorder in early life
• Recurrent, distressing memories of a shocking
  experience, such as experience with death,
  serious injury, or sexual violation
• Memories may entail
• Distressing dreams
• Intense physiological or psychological reactions
  to thoughts or cues associated with event and
  avoidance of those cues
• Episodes of playacting the event
• Dissociative reactions

8
Anxiety, Trauma, and Stressor-Related Disorders
in Early Life (contd.)

• Post-traumatic stress disorder in early life
• Children often display social withdrawal,
  diminished positive affect, and disinterest in
  previously-enjoyed activities
• Lifetime prevalence
• 8 for girls and 2.3 for boys
• Effective treatments include
• Trauma-focused cognitive-behavioral therapies

9
Depressive Disorders in Early Life

• Youth with depressive disorders have more
  negative self-concepts and are more likely to
  engage in self-blame and self-criticism
• Early-onset depressive symptoms tends to predict
  a more chronic and severe course
• Evidence-based treatment for depression
• Individual, group, or school-based
  cognitive-behavioral therapy
• SSRIs increase suicidality but benefits may
  outweigh risk

10
Nonsuicidal Self Injury

• Involves induction of bleeding, bruising, or pain
  by means of intentional, self-inflicted injury,
  without suicidal intent
• Intense negative affect or cognitions and a
  preoccupation with engaging in self-harm
  typically precede episodes of NSSI
• Expectation that mood will improve after episode

11
Nonsuicidal Self Injury (contd.)

• Prevalence
• 14-17 of adolescents and young adults have
  engaged in self-injury at least once
• Increased risk of attempted suicide
• Treatment includes
• Teaching problem-solving, coping and
  emotional-regulation skills
• Focus on emotional expression and improving
  interpersonal relationship skills

12
Pediatric Bipolar Disorder

• Debilitating disorder that parallels mood
  variability, depressive episodes, and significant
  departure from individuals typical functioning
  seen in adult bipolar disorder
• Episodes of recurring depression, rapid mood
  changes, and distinct periods of
  abnormally-elevated mood involving diminished
  need for sleep, increased activity,
  distractibility, talkativeness, and inflated
  self-esteem
• Lifetime prevalence estimated 3

13
Pediatric Bipolar Disorder (contd.)

• Rapid cycling of moods combined with
  neurocognitively based difficulties processing
  emotional stimuli and regulating behavior and
  social-emotional functioning
• Elevated responsiveness to emotional stimuli,
  reduced volume in amygdala, and other brain
  abnormalities
• Medications are often combined with psychosocial
  treatment

14
Attachment Disorders

• Exposure to early environments devoid of
  predictable caretaking and nurturing can cause
  significant difficulties with emotional
  attachment and social relationships
• Includes
• Reactive attachment disorder (RAD)
• Disinhibited social engagement disorder (DSED)

15
Attachment Disorders (contd.)

• Reactive attachment disorder
• Inhibited, avoidant social behaviors and
  reluctance to seek or respond to attention or
  nurturing
• Show little trust that needs will be attended to
  and do not readily seek nor respond to comfort,
  attention, or nurturing
• Use avoidance or ambivalence as psychological
  defense
• Limited positive emotion and may demonstrate
  irritability, sadness, or fearfulness when
  interacting with adults

16
Attachment Disorders (contd.)

• Disinhibited social engagement disorder
• Indiscriminate, superficial attachments and
  desperation for interpersonal contact
• Socialize effortlessly, but indiscriminately, and
  become superficially attached to strangers or
  acquaintances
• History of harsh punishment or inconsistent
  parenting, as well as emotional neglect and
  limited attachment opportunities
• Exposure to maltreatment or maternal psychiatric
  hospitalizations are particularly vulnerable

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Attachment Disorders (contd.)

• Course depends on severity of social deprivation,
  abuse, neglect or disruptions in caregiving, and
  subsequent events in the childs life
• Symptoms of RAD can disappear whereas symptoms of
  DSED are more persistent
• Effective intervention
• Providing stable, nurturing environment, and
  opportunities to develop interpersonal trust and
  social skills

18
Externalizing Disorders of Childhood

• Also known as disruptive behavior disorders
  conditions associated with socially disturbing
  symptoms and distressing others
• Include
• Disruptive mood dysregulation disorder
• Oppositional defiant disorder
• Conduct disorder
• Early intervention is necessary

19
Externalizing Disorders of Childhood (contd.)

• Diagnosis is controversial, and requires a
  pattern of behavior that is
• Atypical for the childs gender, age, and
  developmental level
• Persistent
• Severe enough to cause significant impairment in
  social, academic, or vocational functioning

20
Disruptive Mood Dysregulation Disorder

• Characterized by chronic irritability and
  significantly exaggerated anger reactions
• Patterns begin in early childhood
• Diagnosis requires that symptoms persist beyond
  age six
• Predictive of later depressive and anxiety
  disorders
• Clinicians need to rule out PBD due to symptom
  overlap

21
Oppositional Defiant Disorder

• Pattern of negativistic, argumentative, and
  hostile behavior in which children often
• Lose their temper
• Argue and defy adult requests
• Primarily directed toward parents, teachers, and
  others in authority
• No serious violation of societal norms
• Two components
• Negative affect
• Oppositional behavior

22
Conduct Disorders

• Persistent pattern of behavior that violates
  rights of others
• Reflect dysfunctions in individual and include
• Serious violations of rules and social norms
• Cruelty and deliberate aggression towards people
  or animals
• Theft, deceit, and vandalism
• Callous and unemotional subtype
• Often exhibit antisocial personality disorder in
  adulthood

23
Conduct Disorders (contd.)

• Prevalence
• Approximately 2-9 of youth meet criteria
• 50 display inattention and hyperactivity
• Gender differences
• Males display confrontational aggression
• Females display truancy, substance abuse, or
  chronic lying
• More persistent than other childhood disorders

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Etiology of Externalizing Disorders

• Figure 15-1 Multipath Model of Conduct Disorder
  The dimensions interact with one another and
  combine in different ways to result in a conduct
  disorder

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Etiology of Externalizing Disorders (contd.)

• Biological factors
• Appear to exert greatest influence
• Aggressive behavior linked to brain abnormalities
  and reduced activity in amygdala
• Low MAOA and childhood maltreatment
• Reduced autonomic nervous system activity
• Cortisol (stress levels)

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Etiology of Externalizing Disorders (contd.)

• Social and sociocultural
• Family and social context play large role
• Large families and marital breakdown
• Economic stress
• Crowded living conditions
• Harsh or inconsistent discipline
• Maternal or peer rejection
• Parent-child conflict and power struggles
• Limited parental supervision

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Etiology of Externalizing Disorders (contd.)

• Psychological factors
• Difficult child temperament (irritable,
  resistant, impulsive tendencies)
• Underlying emotional issues
• Depression frequently coexists with ODD and DMDD

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Treatment of Externalizing Disorders

• Must consider family and social context of
  behaviors and psychosocial skills deficits
• CD is particularly difficult to treat
• Effective when implemented before patterns of
  disruptive behavior are established
• Parent-focused interventions regarding child
  management techniques

29
Treatment of Externalizing Disorders (contd.)

• Psychosocial interventions that focus on
• Assertiveness-training
• Anger management techniques
• Building skills in empathy, communication, social
  relationships and problem-solving
• Mobilizing adult mentors

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Neurodevelopmental Disorders

• Involve impaired development of the brain and
  central nervous system
• Symptoms become increasingly evident as child
  grows and develops
• Include
• Tic disorders
• Attention-deficit hyperactivity disorder
• Autism spectrum disorders
• Intellectual and learning disorders

31
Tics and Tourettes Disorder

• Tics
• Involuntary, repetitive movements or
  vocalizations
• Motor tic
• Eye-blinking, facial-grimacing, head-jerking,
  foot tapping, flaring of nostrils, and
  contractions of the shoulders or abdominal
  muscles
• Vocal tics
• Coughing, grunting, throat clearing, sniffling,
  or sudden repetitive and stereotyped outburst of
  words

32
Tics and Tourettes Disorder (contd.)

• Tics
• Short-term suppression of a tic is possible, but
  results in subsequent increases in the tic
• Some report feeling tension build prior to tic,
  followed by a sense of relief after tic occurs
• Stress can increase frequency and intensity
• Provisional tic disorders (2.6 of children)
• Chronic motor or vocal tic disorders (3.7 of
  children)

33
Tics and Tourettes Disorder (contd.)

• Tourettes disorder (TD)
• Characterized by multiple motor tics and one or
  more vocal tic, present for at least one year
• Onset is prior to age 18
• About 8 show complete remission
• Symptoms can be severe or mild
• Coprolalia and motor movements involving
  self-harm
• Comorbid conditions

34
Tics and Tourettes Disorder (contd.)

• Etiology
• Both chronic tic disorder and TD appear to be
  genetically transmitted
• Involvement of basil ganglia and orbital frontal
  cortex
• Possible involvement of neurotransmitters
• Treatment
• Psychotherapy can help with distress
• Habit reversal technique
• Antipsychotic medication used for severe tics

35
Tics and Tourettes Disorder (contd.)

• Tourette's Syndrome Introduction Meet Isabella,
  Devon, Nikki, Amanda as they attend Camp
  Tic-a-Palooza, a camp designed for children with
  Tourette's Syndrome. Explore the many
  difficulties they encountered when integrating
  with other children in school, and even with
  their families.

36
Attention-Deficit/Hyperactivity Disorder

• Characterized by persistent inattention and/or
  impulsive, hyperactive behaviors
• Symptoms must interfere with social, academic, or
  occupational activities
• Diagnosis requires that symptoms begin before age
  12 and persist for at least six months
• Poor regulation of attentional processes

37
Attention-Deficit/Hyperactivity Disorder (contd.)

• Prevalence rates vary between studies
• One study 8.7
• More than twice as likely in boys than in girls
• Symptoms tend to improve in late adolescence
• Associated with behavioral and academic problems
• Risk of coexisting conditions is four times
  greater among children living in poverty

38
Attention-Deficit/Hyperactivity Disorder Etiology

• Biological dimension
• Highly heritable with up to 80 of symptoms
  explainable by genetic factors
• Rare inherited gene mutations
• Chromosomal DNA deletions and duplications
• Genes affecting regulation of dopamine and
  glutamate
• Hypotheses about neurological mechanisms
• Reduced activity in prefrontal cortex
• Differences in brain structure and circuitry in
  frontal cortex, cerebellum, and parietal lobes
• Low dopamine levels

39
Attention-Deficit/Hyperactivity Disorder
Etiology (contd.)

• ABC Video Brain Activity and ADHD See an
  in-depth look at the brain and how the brains of
  people with ADHC differ and are similar to those
  who do not have ADHD using brain imaging
  techniques

40
Attention-Deficit/Hyperactivity Disorder
Etiology (contd.)

• Biological dimension
• Prematurity
• Oxygen deprivation during birth
• Low-birth weight
• Lead and PCB exposure
• Viral infections, meningitis, and encephalitis
• Maternal smoking, drug, and alcohol abuse during
  pregnancy
• Possible involvement of food additives

41
Attention-Deficit/Hyperactivity Disorder
Etiology (contd.)

• Social and sociocultural dimensions
• Sociocultural and social adversity including
• Stressors in family
• Low social class
• Foster care placement
• Cultural and regional expectations
• Psychological dimension
• Interpersonal conflict

42
Attention-Deficit/Hyperactivity Disorder
Etiology (contd.)

• Figure 15-3 Prevalence of ADHD Among Youth (Ages
  4-17) by State, 2007-2008 The prevalence of
  parent-reported attention-deficit/hyperactivity
  disorder varied significantly from state to
  state, ranging from a low of 5.6 in Nevada to a
  high or 15.6 in North Carolina. What might
  account for the variability in ADHD diagnoses
  from state to state?
• Source Centers for Disease Control and
  Prevention (2010b)

43
Attention-Deficit/Hyperactivity Disorder
Treatment

• Stimulants such as methylphenidate (Ritalin)
  receive most evidence-based support
• Normalize neurotransmitter functioning and
  increased neurological activation in frontal
  cortex
• Increased rates of stimulant medication use in
  U.S.

44
Attention-Deficit/Hyperactivity Disorder
Treatment (contd.)

• Evidence that behavioral and psychological
  treatments are highly effective
• Modifying environment and social context can
  enhance feelings of competence, motivation, and
  self-efficacy
• Coordination of all services result in most
  successful interventions

45
Autism Spectrum Disorders

• Characterized by impairment in social
  communication and restricted, stereotyped
  interests and activities
• Symptoms range from mild to severe
• Prevalence
• Affects one out of 100-110 children
• Four times as common in boys

46
Autism Spectrum Disorders (contd.)

• ABC Video Underdiagnosed Autism in Girls
  Discover the ways in which autism is more often
  diagnosed, and often easier to diagnose, in boys,
  and the problems this can lead to for young girls
  with autism spectrum disorders

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Autism Spectrum Disorders (contd.)

• Symptoms of autism spectrum disorder
• Deficits in social communication and social
  interaction
• Atypical social-emotional reciprocity
• Atypical nonverbal communication
• Difficulties developing and maintaining
  relationships

48
Autism Spectrum Disorders (contd.)

• Symptoms of autism spectrum disorder
• Repetitive behavior or restricted interests or
  activities involving at least two of following
• Repetitive speech, movement, or use of objects
• Intense focus on rituals or routines and strong
  resistance to change
• Intense fixations or restricted interests
• Atypical sensory reactivity
• Autistic savants
• Individual with ASD who performs exceptionally
  well on certain tasks

49
Autism Spectrum Disorders (contd.)

• Problems diagnosing autism
• Typical procedures include clinical observation,
  parent interviews, developmental histories,
  autism screening inventories, communication
  assessment, and psychological testing
• Autism is usually diagnosed at age three or later
• Symptoms may appear following a period of normal
  social and intellectual development

50
Autism Spectrum Disorders Etiology

• Biological dimension
• Unique patterns of metabolic brain activity
• Abnormally high levels or serotonin
• Differences in brain anatomy and connectivity in
  brain regions associated with autistic traits
• Accelerated growth or amygdala
• Accelerated head growth
• Genetic mutations implicated in familial autism

51
Autism Spectrum Disorders Etiology (contd.)

• Biological dimension
• Genetic factors
• Heritability estimated to be around .73 percent
  for males and .87 for females
• Autistic traits have high heritability
• Clear evidence for genetic susceptibility
• Innate vulnerability triggered by environment
• Nutritional deficits, changes in immune system,
  low birth weight

52
Autism Spectrum Disorders Etiology (contd.)

• Figure 15-5 Changes in the Prevalence of Autism
  Spectrum Disorder Among 8 Year-Old Children in 10
  U.S. States 2002 to 2006 The prevalence of autism
  spectrum disorder among 8-year-old children
  increased between 2002 and 2006 in all 10 state
  sites monitored. What might account for these
  increases and the state-to-state variations in
  prevalence of the disorder?
• Source Center for Disease Control and Prevention
  (2009b)

53
Autism Spectrum Disorders Etiology (contd.)

• Psychological dimension
• Children with ASD seldom make eye contact, seek
  social connectedness, or bid for attention
• Prefer to be alone and ignore parental efforts at
  connection
• High stress levels among family due to ASD
• Psychological and social factors play a role in
  manifestation of symptoms, but ASD is primarily
  influenced by biological factors

54
Autism Spectrum Disorders Intervention and
Treatment

• Prognosis is mixed most children retain
  diagnosis and require support for life
• Individuals with higher levels of
  cognitive-adaptive functioning fare better than
  those with intellectual disabilities and severe
  autistic symptoms
• Significant recovery linked with intense early
  intervention

55
Autism Spectrum Disorders Intervention and
Treatment (contd.)

• ABC Video Autism Diagnosis Early intervention
  can help Autistic children lead more normal
  lives. Find out what parents can do to help
  identify this disorder early-on.

56
Autism Spectrum Disorders Intervention and
Treatment (contd.)

• Medications are used to decrease anxiety,
  repetitive behaviors, and hyperactivity
• Minimally effective and may be harmful
• Risperidone alone received FDA approval
• Preliminary research on effects of oxytocin
• Comprehensive treatment programs have enabled
  children with ASD to develop more functional
  skills

57
Autism Spectrum Disorders Intervention and
Treatment (contd.)

• Interventions with most significant gains
• Social communication
• Environmental enrichment
• Reinforcing appropriate attention and response to
  social stimuli
• Preventing repetitive behaviors
• Sustained practice of weaker skills
• Reducing environmental stress
• Improving sleep and nutrition

58
Intellectual Developmental Disorder

• Limitations in intellectual functioning and
  adaptive behaviors including
• Significantly below average general intellectual
  functioning (generally IQ of 70 or less)
• Deficiencies in adaptive behavior that are lower
  than would be expected based on age or cultural
  background
• Only diagnosed when low intelligence is
  accompanied by impaired adaptive functioning

59
Intellectual Developmental Disorder (contd.)

• Four distinct categories
• Mild IQ score 50-55 to 70
• Moderate IQ score 35-40 to 50-55
• Severe IQ score 20-25 to 35-40
• Profound IQ score below 20-25

60
Intellectual Developmental Disorder (contd.)
61
Intellectual Developmental Disorder (contd.)

• American Association on Intellectual and
  Developmental Disabilities
• IQ score may be used to approximate intellectual
  functioning
• More important to focus on adaptive functioning
  and nature of psychosocial supports needed
• Given ongoing, individualized support, overall
  functioning of individual with ID will improve

62
Intellectual Developmental Disorder (contd.)

• Prevalence
• Approximately 1 of students in public school
• Increases in low and middle income countries
• Coexisting conditions are common
• One-fourth have seizure disorders

63
Intellectual Developmental Disorder Etiology

• Etiology differs depending on level of
  intellectual impairment
• Mild IDD is often idiopathic (no known cause)
• Pronounced IDD related to genetic factors, brain
  abnormalities, or brain injury

64
Intellectual Developmental Disorder Etiology
(contd.)

• Genetic factors
• In up to 80 percent of cases of IDD, underlying
  cause is unknown
• Unidentified genetic factors
• Genetic variations
• Normal distribution of traits (upper vs. lower
  range)
• Genetic abnormalities
• Chromosomal abnormalities
• Down syndrome most common
• Inheritance of single gene
• Fragile X syndrome most common (mild to severe
  ID)

65
Intellectual Developmental Disorder Etiology
(contd.)

• Down syndrome (DS)
• Extra copy of chromosome 21 originates during
  gamete development
• Majority have mild to moderate IDD
• With support many can have jobs and live
  semi-independently
• Medical interventions improve outcome, but
  significant risks remain
• Prenatal detection of DS through amniocentesis

66
Intellectual Developmental Disorder Etiology
(contd.)

• Developmental Disabilities Children with
  developmental disabilities are said to have
  exceptionalities, which are diagnosed based on
  delays or differences in what we know of typical
  development

67
Intellectual Developmental Disorder Etiology
(contd.)

• Nongenetic biological factors
• Influences during prenatal, perinatal, or
  postnatal period
• Fetus is susceptible to viruses and infections,
  drugs and alcohol, radiation, and poor nutrition
• Fetal alcohol spectrum effects and fetal alcohol
  syndrome
• Birth trauma, prematurity, and low birth weight
• Head injuries, brain infections, tumors, and
  prolonged malnutrition
• Exposure to environmental toxins, including lead

68
Intellectual Developmental Disorder Etiology
(contd.)

• Psychological, social, sociocultural dimensions
• Genetic background interacts with environmental
  factors
• Effects of low SES
• Parents with mild IDD
• Long-term effects of prematurity
• Enriching and encouraging home environment, as
  well as ongoing education intervention

69
Learning Disorders

• Academic disability characterized by reading,
  writing, and math skills deficits
• Primarily interferes with academic achievement
  and activities of daily living in which reading,
  writing, or math skills are needed (e.g.,
  dyscalculia, dyslexia)
• Prevalence
• Around 5 of students in public schools
• Boys are almost twice as likely as girls

70
Learning Disorders (contd.)

• Etiology
• Little is known about precise causes of LD
• Appear to have slower brain maturation
• Lifelong differences in neurological processing
  of information related to basic academic skills
• May be similar to biological explanations for IDD
  and ADHD
• Runs in families, suggesting genetic component

71
Support for Individuals with Neurodevelopmental
Disorders

• Produce lifelong disability, goal of intervention
  is to build skills and develop potential to the
  fullest extent possible
• Support should begin in infancy and extend across
  the life span
• Different levels of support

72
Support for Individuals (contd.)

• Support in childhood
• Individualized home-based or school-based
  programs
• Parent involvement is integral part of early
  intervention programs
• School services are individualized to meet
  childs needs and to maximize learning
  opportunities
• Rates of improvement decrease once programs are
  completed

73
Support for Individuals (contd.)

• Support in adulthood
• Programs focusing on specific job skills
• Institutionalization is rare, but many live with
  family members
• Least restrictive environment possible
• As much independence and personal choice as is
  safe and practical
• Most normalized living arrangements vary from
  setting to setting