Disorders First Apparent in Childhood

Why “first apparent”?

May continue into adulthood

May lead to other adult disorders

May impact development

Disorders

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

Disorder

Symptoms of Inattention

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

Symptoms of Hyperactivity 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

Require more than one setting

6% of school-age children (drops with age)

Associated Problems

Significant social impairments

Academic problems

Comorbidities with ADHD

mood disorders learning disorders substance use APD neurological problems physical accidents and injury

What Happens When they Grow Up?

Impulsivity decreases, inattention does not Accidents, etc

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

What Causes ADHD?

Higher rates of family general psychopathology

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

Multiple Approach to ADHD

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

Sample Changes

Home Reward plans Shorter lists of tasks Timers Reorganization of living

space

School Seating plans Folders for parents Reduced distractions for

exams Shortened HW

assignments

Learning Disorders

Deficits in reading, math, or written expression

Child’s achievement level is below what would be predicted based upon their ability level

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 (32%) 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

1. Remediate processing of problems Visual and auditory perception skills

2. Improve cognitive skills Listening, comprehension, memory

3. Target behavioral skills to compensate Extended time for tasks

Early diagnosis = better prognosis

Disruptions in social interaction

Impaired communication skills

Restricted behavior, interests and activities

Pervasive Developmental Disorders: Autism

Disruptions in social interaction

Lack of joint attention Lack of interaction with

parents or other children

Lack of attention to social cues

Supported by eye tracking research

Impaired communication skills

50% of patients do not acquire useful speech Unusual communication Echolalia (repeating of words/phrases) Inability to understand irony, sarcasm,

pretend play

Restricted behavior, interests and activities

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

Symptoms of Autism

Apparent by age 3

20% report normal 1-2 years of development, followed by regression or lack of milestones

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 of Autism

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

others deteriorate IQ & functional language predictors of

prognosis

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

Few think psychological or social influences play a role in the onset

Psychologists (and other professionals) can assist with management of disorder

Behavioral Treatments for Autism

Decrease undesirable behavior & shape desirable

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

prognosis

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

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

Behavioral DisordersConduct Disorder General pattern of

disrespect for others Violation of norms Includes criminal

activity

Oppositional Defiant Disorder

Pattern of negative, hostile, defiant behaviors

Symptoms of Conduct Disorder

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

Symptoms of 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

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

1. Jimmy is rewarded for screaming

2. Reward for screaming = increased probability of screaming in future

3. Parent is rewarded for giving in

4. Parents likelihood of giving in is increased

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 positive (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

Cognitive Disorders - Dementia

Dementia

Gradual deterioration of brain function

Affects judgment, memory, language, other executive functions Some are reversible Others are degenerative and eventually fatal

Emotional changes are common

Kinds of Dementia (DSM)

1. Alzheimer’s Disease

2. Vascular Dementia

3. Dementia due to HIV, Head Trauma, Parkinson’s, Huntington’s

4. Pick’s Disease

5. Creutzfeldt-Jakob Disease

6. Substance Abuse

Other Causes of Dementia

Drugs & alcohol Nutritional deficits Brain tumors Thyroid Problems Neurosyphilis Korsakoff’s Disease

Alzheimer’s Disease

Most develop during old age

Prevalence for < 65 = 1%, 90+ = 22%

Higher rates, as people are living longer

Annual Cost = $112 billion US

Associated Symptoms of Alzheimer’s

Impaired memory, orientation, judgement, reasoning

Inability to integrate/learn new information Forget events, lose objects Decreased interest in nonroutine activities Increasing depression, agitation, aggression

with disease progession

Symptoms & Course

Increased Speed of Disease Progression

Global Deterioration Scale(Reisberg et al., 1982)

1. No cognitive/functional impairment2. Mild forgetfulness, some work problems3. Mild concentration problems, some problems

working/travelling alone4. Increased problems in planning, finances, denial of

symptoms & withdrawal5. Poor recall of recent events. Reminders needed6. Daily Living Assistance, Personality Changes7. Loss of verbal abilities, incontinence, walking,

coma

Normal Aging vs. Possible AD(Hooyma & Kiyak, 2002)

Forgetting to set alarm clock

Forgetting a name & remembering later

Having to search for keys b/c forgot location

Forgetting where your car is

Forgetting how to set alarm clock

Forgetting a name & never remembering it even when told

Forgetting places you might find keys

Forgetting how you arrived at a location

Intellectual Functioning and Alzheimer’s

Less formal education = increased risk “mental reserve” Cognitive reserve hypothesis

More synapses an individual requires, the more neuronal death required before dementia is obvious

Causes of Dementia

Proximal causes Distal Causes

Biological Causes Psychological & Social Influences

Neurofibrillary Tangles & Amyloid Plaques

Normal, but excessive

Proximal Causes - Senile Plaques

Protein deposits Also normal, but excessive

Unclear why, or how this impacts Both overrepresented in hippocampus &

parts of cerebral cortex = thought process

What are Distal Causes?

Genes (esp. early onset) Estrogen can be protective Down syndrome = virtually guaranteed

Alzheimer’s by 40 Education & Cognitive Ability

Protecting with Cognitive Ability

2x more likely in people with < 8th gr. Education

Friedland et al. 2000 - 193 AD vs. 358 Control Control elderly more likely intellectual & physical

noneducational past-times in middle years Greatest effect for intellectual past-times Regardless of education, gender, current age

Assessment of Alzheimer’s

Medical evaluation Neuropsychological Tests Observations Interviews Self-reports

How do we definitively diagnose Alzheimer’s?

Rule out other possible diagnoses Autopsy following patient death

Tangles Plaques

Dementia is a very heterogeneous disorder

Dementia & Pseudodementia

Depression most common psychopathology in old age Est. 20% for elderly community sample (Hooyman &

Kiyak)

10-15% for institutionalized elderly sample Older adults often have “masked depression”

Does not express/denies mood changes Reports somatic complaints Complains of problem solving/memory problems

Medical Treatment for Dementia

Medication enhancing cognitive ability Initial effect (to 6 months earlier) No long-term improvement over placebo Prevent breakdown of acetylcholine

Decline continues Loss of gain if medication is quit $250/month

Psychosocial Treatments for Dementia

Compensation for lost abilities Memory wallets Cues and reminders