Disorders First Apparent in Childhood

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Disorders First Apparent in Childhood
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Why first apparent?

• Childhood disorders may continue into adulthood
• Childhood disorders may lead to other adult
  disorders
• Childhood disorders may impact development

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Disorders

• Attention Deficit Hyperactivity Disorder
• Learning Disorders/Communication Disorders
• Autism Aspergers Disorder
• Mental Retardation (Axis II)
• Conduct Disorder Oppositional Defiant Disorder
• Selective Mutism

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Attention Deficit Hyperactivity Disorder (ADHD)

• Inattention
• lack of focus on detail careless mistakes
• difficulty with sustained attn
• not listening when spoken to
• fails to follow through on tasks

• organizational problems
• dislikes sustained effort
• easily distracted
• forgetful in daily activities

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Attention-Deficit Hyperactivity Disorder

• Hyperactivity/Impulsivity
• Fidgets or squirms in seat
• Leaves seat when it is inappropriate
• Runs or climbs excessively
• Difficulty playing quietly
• Is often on the go or acts as if driven by a
  motor

• Talks excessively
• Blurts out answers before questions are finished
• Difficulty waiting for his/her turn
• Disrupts or interrupts others

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ADHD

• Symptoms are usually evident before school-age,
  but more relevant in that setting
• Symptoms must be present in more than one setting
• 5 of school-age children have ADHD (drops with
  age)

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ADHD

• Significant social impairments
• Academic problems
• Comorbid with mood disorders, learning
  disorders, substance use, APD, neurological
  problems, physical accidents and injury

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What Happens When they Grow Up?

• Adults may self-select environments that result
  in less noticeable symptoms
• 68 have attention problems in adulthood
• Only 30 of children retain the diagnosis in
  adolescence, and 10 in young adulthood
• 25 do not finish school
• 1/5 develop APD w/ high levels of crime

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What Causes ADHD?

• Large genetic component
• Subtle brain differences
• Smaller brain volume
• Association with maternal smoking
• 2-3 times more likely
• Inability to inhibit behavior
• Executive functioning deficit (goals, planning)

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What Causes ADHD?

• Is the real problem our regimented modern
  classrooms?
• Decreased time for active play
• Change in environment penalizes students who
  would be normal under different circumstances
• Little evidence of brain abnormalities
• ADHD looks like extreme playfulness
• Function well outside the classroom (no control)

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Does Diet Affect ADHD?

• Some argue that dietary additives affect/cause
  ADHD (e.g., food coloring)
• Parents place children on special diets
• Evidence indicates that NO, diet is not
  responsible for ADHD

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How do we treat ADHD?

• Stimulant medications
• Increase arousal and help focus attention
• Short half-life
• Stimulants do affect growth hormones and can
  suppress appetite
• Many children take only during school hours
• Drug holidays are recommended
• Use the lowest therapeutic dose

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How do we treat ADHD?

• Behavioral Therapy for Children
• Improve socialization skills
• Reinforce and reward improved behavior until the
  environment is rewarding alone
• Main techniques
• Progressive muscle relaxation
• Contingency plans
• Cognitive therapy to increase awareness

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How do we treat ADHD?

• Behavioral Therapy for Parents
• Parents are trained in behavior management,
  contingency management
• Reduce family stress
• Psychoeducation can reduce family blame
• Best treatment is meds therapy
• Meds are often necessary for severe cases

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Learning Disorders

• Deficits in reading, math, or written expression
• Childs achievement level is below what would be
  predicted based upon their ability level
• In DE, this difference must be present in less
  than 4 of children of the same age to qualify
  for services

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Learning Disorders

• Diagnosis based on comparison of those tests, in
  those specific domains only
• 5 of American students have a learning disorder
• Reading is most common

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Consequences of Learning Disorders

• Many drop out of school
• Low employment rates (60-70)
• Self-esteem problems

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Causes of Learning Disorders

• Genetic basis
• Almost 100 concordance between identical twins
• Neurological differences
• E.g., in sound recognition

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Treating Learning Disorders

• Treatment such as distinguishing sounds
• Children usually require educational
  interventions
• Extra time
• Additional practice and assistance
• Special education
• Earlier diagnosis better prognosis

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Communication Disorders

• Deficits in the ability to express or comprehend
  verbal language
• Expressive Language Disorder
• Phonological Disorder
• Stuttering
• Many are new categories to DSM-IV
• Usually the realm of Speech Language Pathologists

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Pervasive Developmental Disorders

• Disruptions in social interaction communication
  skills
• Presence of stereotyped behaviors, interests,
  and/or activities

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Symptoms of Autism

• Abnormal/delayed development
• Socially
• Communication
• Apparent by age 3 (20 report normal 1-2 years)
• Failure to engage (e.g., reciprocal interactions)
• Inappropriate facial expressions, body postures,
  gestures, eye contact

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Symptoms of Autism

• Unable to form friendships - shared interests
• Social/emotional reciprocity
• Stereotypic behavior
• Self-destructive behavior

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Symptoms of Autism

• Functional language deficits
• No language at all
• Repeat others
• Pragmatic language deficits
• Integrate words with gestures
• Inability to understand irony, sarcasm, pretend
  play

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Symptoms of Autism

• Restricted, repetitive, stereotyped behavior,
  interests, activities
• Abnormal in intensity/focus
• E.g. dates, phone numbers
• Lining up objects
• Inflexible patterns, routines, rituals
• Preoccupation with parts of interest

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Associated Features and Disorders

• Hyperactivity, short attention span, impulsivity,
  aggressiveness
• Self-injurious behavior temper tantrums
• Odd responses to sensory stimuli (e.g. high
  threshold for pain, sensitive to sound, touch,
  light)
• Abnormal affect or fear reaction

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Aspergers Disorder

• Mild autism
• No significant delays in early language
• Other language may be odd and preoccupied with
  certain topics
• No delay in cognition or self-help skills,
  adaptive behavior, curiosity about environment
• Little concern in infancy, may seem precocious
• Usually noticed after entrance to school

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Prevalence Course

• 1 in every 166 births
• 41 boys to girls
• Deficits sometimes noticed early
• Some improve at school
• Some improve during adolescence, but others
  deteriorate
• IQ functional language predictors

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Causes of Autism Genetic Contributions

• Strongest genetic component
• Early studies thought not genetic
• But, hard to study
• 1 in 240,000 possible twin studies (1000 in US)
• Autistic adults unlikely to have children
• Autistic children have less siblings

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Twin Studies Solve the Mystery

• Heritability index .90 (risk)
• Genetically heterogeneous
• Unable to isolate genes
• Some evidence for viral infections during
  pregnancy

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Causes of Autism Biological Abnormalities

• 75 neurological abnormalities
• Abnormal reflexes/muscle tone
• Perceptual/motor coordination
• Movement/posture problems
• Increase of seizures
• Reduced brain size

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Behavioral Treatments for Autism

• Decrease undesirable behavior shape desirable
• Positive reinforcement extinction
• Social punishment
• Families are important
• Language social skills

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Alternative Treatments for Autism

• Vitamins
• Other medications
• Diet
• Auditory Integration Training
• Facilitated Communication

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What are Alternative Treatments?

• Scientifically unverified
• Randomized control studies
• Replication
• Large samples

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Whats so bad about alternative treatments?

• They give parents false hope
• They can violate patient rights
• Can allow others to control decisions made by
  patients
• In some cases, have led to abuse allegations

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Facilitated Communication

• Provide assistance for communicating
• Alphabet board, computer, typewriter, etc
• Support hand/arm
• May isolate fingers
• Requires extensive training

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Claims

• Produces (frees) unexpected literacy
• Shows normal/superior intelligence
• Provides a means to communicate (for those who
  have no means, but otherwise would)

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What does the research say?

• Facilitators unintentionally influence
• May even actively influence
• Many well-designed studies
• Single- and double-blind
• Repeated measures
• Participant as control

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Auditory Integration Training

1. Conduct detailed audiogram, determining which
   frequencies sensitive to
2. Modify music by computer to remove those
   frequencies
3. Listen to music 10 hours/day, at least twice a
   day, for 10-12 days

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Auditory Integration Training

• Berard, France, 1960s (US in 1991)
• 1991 -gt published book cured 10 hours
• Autistic children (and other patients) are
  hypersensitive to certain frequencies
• Claims 76.2 of 1850 children very positive
  results

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Claims

• Improved attention
• Improved auditory processing
• Decreased irritability
• Reduced lethargy
• Improved expressive language
• Improved auditory comprehension

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The Critics

• No scientific evidence for hearing impairments in
  autism
• Inconsistent with medical knowledge re structure
  mechanism of ear
• No measurement is valid enough to discriminate
  peaks of hypersensitivity
• Weak, irrelevant, insignificant evidence
• Sound levels are unsafe

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The Best Type of Treatment

• Structured educational programs geared to the
  persons developmental level of functioning
• It is, however, important to be open-minded
• Majority of other treatments not scientifically
  proven
• Be educated
• Consider the individual child
• Do a thorough assessment and reevaluate

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Mental Retardation

• Sufficiently low cognitive ability (IQ)
• Significant social/functional impairment

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Assessing Cognitive Ability

• Intelligence - a collection of adaptive skills
• You can be good at one, but not another
• Intelligence effects our functioning
• IQ is normally distributed. Mean 100, SD 10
• Scores below 70 diagnostic of retardation
• 2-3 of the population falls below this cut-off

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Assessing Social/Functional Deficits

• Deficits must be present in 2 areas
• Communication
• Self-care
• Home living
• Interpersonal Skills
• Use of Community Resources
• Self-direction
• Functional academic skills
• Work
• Leisure
• Health Safety

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Levels of Mental Retardation

• Mild (IQ 50-55)
• Benefit from education (intense)
• Learn to read/write and do basic math
• Difficulties usually apparent after begin
  schooling
• May need supervision/guidance, but can live alone
  with support
• Profound (IQ below 20-25)
• Usually physical disorder accounts for problems
• Inability to manage even basic self-care tasks

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What Causes Mental Retardation?

• Chromosomal abnormalities (e.g., Downs syndrome
  Fragile-X syndrome)
• Downs syndrome leading cause of organic MR
• Moderate to severe
• Females with fragile x mild to moderate males
  moderate to severe

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What Causes Mental Retardation?

• Genetic Problems
• PKU - lack of enzyme to break down phenylalanine
  build-up causes brain damage
• Normal at birth - diagnosis results in food
  changes

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What Causes Mental Retardation?

• Pregnancy and Birth Complications
• Fetal alcohol syndrome (detectable only in
  infants exposed to large amounts)
• Exposure to other drugs
• Therapeutic drugs (e.g., for seizures, bipolar,
  Accutane for acne)
• Radiation (e.g., for cancer)
• Infections, such as rubella
• Physical damage to head, blood supply during birth

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What Causes Mental Retardation?

• Cultural-Familial MR
• Low end of IQ due to development or environment
• Heritability index for IQ .60-.80
• Genes predominantly cause MR, environment has
  less of an impact (But is important!)
• Appropriate stimulation during certain periods is
  necessary
• E.g. child requires stimulation of certain brain
  areas as they develop

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Behavior Disorders - Conduct Disorder

• A pervasive pattern of disrespect for rights of
  others violation of rules/norms
• Bullies, threatens, intimidates others
• Initiates physical fights, uses weapons
• Physically cruel to people and/or animals
• Stolen while confronting a victim
• Forced sexual activity

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Conduct Disorder

• Deliberately sets fires w/ intention of doing
  damage or destroys property in other ways
• Broken into someones house/building/car
• Lies to obtain goods or avoid responsibility
• Stolen costly items without confronting victim
• Stays out at night before age 13
• Has run away, overnight, gt2 times
• Is truant from school prior to age 13

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Conduct Disorder

• Children also have poor interpersonal skills
• Often experience peer rejection
• Seem to have problem-solving deficits
• Do not generate as many options as non-CD
  children
• Inability to take anothers perspective
• Interpret ambiguous gestures as hostile
• Prevalence 3-6 (boys 21)

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Oppositional Defiant Disorder

• Pattern of negative, hostile, defiant behaviors
• Arguing for the sake of arguing, hostility toward
  parents/teachers
• Usually begins at home (which can impede
  diagnosis)
• May develop into later conduct disorder
• Typically emerge by age 8, est. 5-10 prevalence

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What Causes Conduct Disorders?

• Neurological differences
• Poor coordination, fine motor skills
• Usually have significantly lower IQ than peers
• Temperament
• Easily distressed, reactive to change, react to
  intense stimuli (more likely behavior problems)
• Family Links
• Parent with APD increases chances of CD
• Criminal and/or alcoholic parents
• Family history of aggression

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What Causes Conduct Disorders?

• Family Links cont..
• Poor maternal mental health, prenatal health
• Poor supervision
• Spousal aggression
• Lax, erratic and inconsistent parenting/discipline
  
• Less acceptance, warmth, affection, support
• Reinforce CD behavior, ignore/reward other
  (coercive process)
• Child-parent interactions are also bidirectional

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The Coercive Process

• Jimmys parents tell him to go to bed
• Jimmy refuses I want to play 1 more video
  game!
• Parent says No! Its late and you have school.
• Jimmy gets upset, hitting table, screaming Just
  one more game. Youre mean - you never let me
  have fun!
• Parent feels guilty at having spent little time
  together, and is too tired after work to argue -
  says Okay, 1 more game
• Jimmy stops screaming and plays his game
• Parent, relieved fight is over, goes to kitchen.
  Does not monitor or play with child

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The Coercive Process

• What happens as a result of this process?
• Jimmy is rewarded for screaming
• Reward for screaming increased probability of
  screaming in future
• Parent is rewarded for giving in
• Parents likelihood of giving in is increased
• If this pattern is typical, it is a risk
  factor. It also tends to escalate over time

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Conduct Disorder APD

• A minority of CD children develop Antisocial
  Personality Disorder
• Treatment for conduct disorder is of interest, as
  preventing APD would reduce associated financial
  and criminal costs to society
• Remember, APD is untreatable!

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Treating CD and ODD

1. Problem-Solving Skills
2. Parent Management Training
3. Family Therapy
4. School Community Based Treatments

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Problem-Solving Skills

• Children tend to have poor problem-solving
  interpret intentions/actions as hostile
• Combines modeling, role-playing, and
  reinforcement contingencies to increase
  problem-solving and prosocial behavior

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Parent Training Family Therapy

• Break cycle of coercive process
• Promote prosocial behavior in child
• Apply proper discipline techniques by parent
• Increase reciprocity positive reinforcement
  between family members

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Parent Training and Family Therapy

• Outcomes look good (reduce arrest, increase
  school performance, family relationships)
• Most families may be unwilling/able to participate

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School Community Based Treatments

• Target children at school (easier)
• Often has more attendance than individual therapy
• Available to all children (universal
  intervention)
• Increased likelihood of reaching those who need
  it
• Minimizes stigma
• Offers opportunity to interact with other children

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Selective Mutism

• Selective Mutism
• Consistent failure to speak in specific social
  situations (where these is an expectation for
  speaking) despite speaking in other situations
• Not due to a lack of knowledge or comfort with
  spoken language
• An anxiety disorder
• Is not merely a child refusing to speak in a
  situation