DISORDERS OF CHILDHOOD

1

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

2

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

3

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

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

5

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

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

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

8

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

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

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

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

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

13

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

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

15

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

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

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

18

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

19

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

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

21
DISORDERS OF CHILDHOOD Treatment of ODD
CDParents impact on child
Brother and sister at play Children play cooperatively Parent ignores children Extinction of cooperative play
Brother and sister at play Children fight Parent criticizes or scolds children Positive reinforcement for fighting
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DISORDERS OF CHILDHOOD Treatment of ODD
CDChilds impact on parent
Children fight Parent criticizes or scolds Children stop fighting (temporarily) Negative reinforcement for criticism or scolding
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• DISORDERS OF CHILDHOOD
• Pattersons parent training for ODD CD
• Defining and pinpointing behaviour
• I want Johnny to be a good student
• I want Johnny to stop being aggressive
• I want Johnny to stop hitting his peers

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

25

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

26

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

27

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

28

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

29

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

30

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

31

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

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

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

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