Disorders First Apparent in Childhood

Why “first apparent”?

Childhood disorders may continue into adulthood

Childhood disorders may lead to other adult disorders

Childhood disorders may impact development

Disorders

1. Attention Deficit Hyperactivity Disorder2. Learning Disorders/Communication Disorders3. Autism & Asperger’s Disorder4. Mental Retardation (Axis II)5. Conduct Disorder & Oppositional Defiant

Disorder6. Selective Mutism

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

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

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)

ADHD

Significant social impairments Academic problems Comorbid with: mood disorders, learning

disorders, substance use, APD, neurological problems, physical accidents and injury

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

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)

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)

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

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

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

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

Learning Disorders

Deficits in reading, math, or written expression

Child’s 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

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

Consequences of Learning Disorders

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

Causes of Learning Disorders

Genetic basis Almost 100% concordance between identical

twins Neurological differences

E.g., in sound recognition

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

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

Disruptions in social interaction & communication skills

Presence of stereotyped behaviors, interests, and/or activities

Pervasive Developmental Disorders

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

Symptoms of Autism

Unable to form friendships - shared interests

Social/emotional reciprocity

Stereotypic behavior Self-destructive

behavior*

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

Symptoms of Autism

Restricted, repetitive, stereotyped behavior, interests, activities

Abnormal in intensity/focusE.g. dates, phone numbersLining up objects

Inflexible patterns, routines, rituals Preoccupation with parts of interest

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

Asperger’s 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

Prevalence & Course

1 in every 166 births 4:1 boys to girls Deficits sometimes noticed early Some improve at school Some improve during adolescence, but

others deteriorate IQ & functional language predictors

Causes of Autism: Genetic Contributions

Strongest genetic component Early studies thought not genetic But, hard to study:

1. 1 in 240,000 possible twin studies (1000 in US)

2. Autistic adults unlikely to have children

3. Autistic children have less siblings

Twin Studies Solve the Mystery:

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

pregnancy

Causes of Autism: Biological Abnormalities

75% = neurological abnormalities Abnormal reflexes/muscle tone Perceptual/motor coordination Movement/posture problems

Increase of seizures Reduced brain size

Behavioral Treatments for Autism

Decrease undesirable behavior & shape desirable

Positive reinforcement & extinction Social punishment Families are important Language + social skills

Alternative Treatments for Autism

Vitamins Other medications Diet Auditory Integration Training Facilitated Communication

What are “Alternative” Treatments?

Scientifically unverified Randomized

control studies Replication Large samples

What’s 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

Facilitated Communication

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

Claims:

Produces (“frees”) unexpected literacy

Shows normal/superior intelligence

Provides a means to communicate (for those who have no means, but otherwise would)

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

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

Auditory Integration Training

Berard, France, 1960s (US in 1991) 1991 -> published book “cured” 10 hours

Autistic children (and other patients) are hypersensitive to certain frequencies

Claims: 76.2% of 1850 children “very positive results”

Claims:

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

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

The Best Type of Treatment…

Structured educational programs geared to the person’s 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

Mental Retardation

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

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

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

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

What Causes Mental Retardation?

Chromosomal abnormalities (e.g., Down’s syndrome & Fragile-X syndrome) Down’s syndrome leading cause of organic MR Moderate to severe Females with fragile x = mild to moderate; males

= moderate to severe

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

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

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

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

Conduct Disorder Deliberately sets fires w/ intention of doing

damage or destroys property in other ways Broken into someone’s 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, >2 times Is truant from school prior to age 13

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 another’s perspective Interpret ambiguous gestures as hostile Prevalence = 3-6% (boys 2:1)

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

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

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

The Coercive Process Jimmy’s 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. You’re 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

The Coercive Process

What happens as a result of this process?1. Jimmy is rewarded for screaming2. Reward for screaming = increased

probability of screaming in future3. Parent is rewarded for giving in4. Parents likelihood of giving in is increased* If this pattern is typical, it is a risk factor. It

also tends to escalate over time

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!

Treating CD and ODD

1. Problem-Solving Skills

2. Parent Management Training

3. Family Therapy

4. School & Community Based Treatments

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

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

Parent Training and Family Therapy

Outcomes look good (reduce arrest, increase school performance, family relationships)

Most families may be unwilling/able to participate

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

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