abnormal PSYCHOLOGY

Fourth Canadian Edition

Chapter 15Chapter 15Disorders of Childhood

Prepared by: Tracy Vaillancourt, Ph.D.

Modified by: Réjeanne Dupuis, M.A.

Chapter Outline

• Classification of Childhood Disorders

• Disorders of Uncontrolled Behaviours

• Learning Disabilities

• Autistic Disorder

• Disorders of Overcontrolled Behaviours

• Mood Disorders in Childhood and Adolescence

Scope of the Problem

• Most adults w/ a first psychiatric diagnosis also met criteria for a disorder in childhood

• 14% of Canadian children have clinical disorders that cause significant distress and impairment – Anxiety disorders most prevalent – Mental health problems are leading cause of health

problems after infancy in Canada – < 25% of children receive specialized treatment– > 50% of children with 1 disorder have 2+ concurrent

disorders

ADHD• Attention-deficit/hyperactivity disorder (ADHD)

– Deficits in attention– Hyperactivity– Impulsivity

• Three subcategories of ADHD:−Primarily poor attention

• ADHD primarily inattentive−Primarily hyperactive-impulsive behaviour

• ADHD primarily hyperactive−Both sets of problems

• ADHD combined type• Majority of all children

ADHD (cont.)

• Children with ADHD have– Peer-relations difficulty– Learning disabilities in 15-30%– 50% placed in special education programs

because of their difficulties– Comorbidity with anxiety disorders– Considerable overlap with conduct problems

• Combined sub-type

ADHD (cont.)

• Prevalence: 5.29% worldwide

• More common in boys than in girls

severity of symptoms in adolescence– 65-80% still meet criteria for disorder in

adolescence and adulthood

Biological Theories of ADHD

• Genetic component supported by adoption and twin studies– 75% is heritable – Family environment does not make a significant

contribution

• Differences in brain structure and function– Implication of frontal striatal circuitry – Reductions in volume in cerebrum and cerebellum – Delays in cortical maturation – Smaller basal ganglia volumes – Dysfunctions in dopaminergic and noreadrenerbic

systems

Theories (cont.)

• Environmental toxins– 22% of mothers of children with ADHD

reported smoking pack of cigarettes/day during pregnancy, compared with 8% of mothers whose children were normal

Psychological Theories of ADHD

• Diathesis-stress theory of ADHD– Hyperactivity develops when predisposition to

disorder is coupled with an authoritarian upbringing

– Learning may play a role in hyperactivity • Reinforced by the attention it elicits thus increasing

in frequency or intensity

Note. These theories are not sustained by research

Treatment of ADHD• Typically treated with drugs and behavioural

methods based on operant conditioning• Stimulant Drugs

– Methylphenidate (MPH) or Ritalin– Supported by double-blind studies comparing

stimulants with placebos in concentration, goal-directed activity, classroom

behaviour, and social interactions and in aggressiveness and impulsivity in about 75%

• Psychological Treatment – Parent training and changes in classroom

management based on operant conditioning principles

Conduct Disorder and ODD

• Conduct Disorder – Behaviours that violate basic rights of others and major societal

norms

• Oppositional Defiant Disorder (ODD)– Diagnosed if child does not meet the criteria for conduct disorder– Physical aggression, losing temper, arguing with adults, lack of

compliance with requests from adults, deliberately annoying others, being angry, spiteful, touchy, or vindictive.

• Comorbidity is the norm rather than the exception – ODD, conduct disorder, and ADHD – Anxiety and depression are also common among children with

conduct disorder

• Prevalence– 8% of boys and about 3% of girls aged 4 to 16

Etiology of Conduct Disorders

• Biological Factors– Genetic influence

• Aggressive behaviour clearly heritable• Delinquent behaviour seems not to be

– Neuropsychological deficits • Poor verbal skills, difficulty w/ executive

functioning, problems w/ memory– Neurochemical correlates

Etiology of Conduct Disorders

• Psychological Factors – Hostile/ineffective parenting practices – Lax parental discipline and parental adjustment

difficulties – Learning theories

• Modelling and operant conditioning– Cognitive Biases

• Social-information processing theory– Socio-cultural context factors

• Neighbourhood and classroom environments

Biopsychosocial Model of CD

Treatment of Conduct Disorder

• Fairer distribution of income

• Alleviate material deprivation in lower SES groups

• Jailing juvenile delinquents does not reduce crime.– In fact, harsh discipline (imposed by government or

parents), contributes to further delinquency and criminal activity in adulthood

• Family Interventions– Parental Management Training

• Multi-systemic Treatment

• Cognitive Approaches

Prevention of CD

• Beginning treatment as early as age 4 – Symptoms appear w/in first 2 years

• Identifying families and mothers at risk – Prenatal and postnatal risks in mother – Maternal antisocial behaviour and smoking

during pregnancy

• Early interventions – The Family Check-up– The Nurse-Family Partnership

Learning Disabilities

• Inadequate development in specific area of academic, language, speech, or motor skills

• Not due to mental retardation, autism, a demonstrable physical disorder, or deficient educational opportunities

Learning Disabilities

• Usually of average or above-average intelligence

• Term LD not used in DSM-IV-TR– Learning disorders, communication disorders,

and motor skills disorder

• Usually identified and treated in school system

• More common in males than in females

Learning Disorders

• Three categories renamed in DSM-V:– Reading disorder Dyslexia – Mathematics disorder Dyscalculia – Disorder of written expression May be

eliminated

Learning Disorders• Reading Disorder (dyslexia)

– Significant difficulty with word recognition and reading comprehension

– Written spelling as may also be a problem– Prevalence 2 to 8% of school-age children

• Mathematics Disorder – Difficulty rapidly and accurately recalling arithmetic facts,

counting objects correctly and quickly, or aligning numbers in columns

• Disorder of Written Expression– Impairment in ability to compose written word

• Spelling errors, errors in grammar, or very poor handwriting

Communication Disorders

• Expressive Language Disorder– Difficulty expressing in speech– Trouble finding words

• Phonological Disorder– Speech is not clear– Articulation poor for r, sh, th, f, z, l, and ch

• Stuttering– Disturbance in verbal fluency characterized by one or more

of the following speech patterns• Frequent repetitions• Prolongations of sounds• Long pauses between words• Substituting easy words for those that are difficult to articulate

Etiology of Learning Disabilities

• Biological Factors – Heritable component – Chromosome 13 (13q21) directly implicated as a

dyslexia phenotype – Generalist Genes Hypothesis – Brain Structure Differences

• Left temporoparietal cortex less activated – Problems with perception of speech and analysis of

the sounds of spoken language and their relation to printed words

• Family environment

Treatment of LD

• Most often occurs within special-education programs in the public schools

• Individualized programs should be implemented

• Duration of treatment should match the severity of the LD

• Parental involvement is essential

Mental Retardation• Mental retardation

– Sub-average intellectual functioning along

– Deficits in adaptive behaviour

– Occurring before age 18

• Traditional Criteria for Mental Retardation1. Intelligence-Test Scores

2. Adaptive Functioning

3. Age of Onset

• Prevalence in general population is 3%– Boys to girls ration is 1.6:1

Classification of Mental Retardation

• Four levels of MR – Mild mental retardation

• 50–55 to 70 IQ• 85% of people with MR

– Moderate mental retardation• 35-40 to 50-55 IQ• 10% of people with MR

– Severe mental retardation • 20-25 to 35-40 IQ• 3 to 4% of people with MR

– Profound mental retardation • below 20 to 25 IQ• 1-2% of people with MR

Etiology of Mental Retardation

• No Identifiable Etiology– 30-40% of people with MR have no identifiable etiology

• Known Biological Etiology– 25% of people with MR have a known biological cause

• Heredity Disorders (5%)– Genetic or Chromosomal Anomalies

• Phenylketonuria (PKU); Fragile X syndrome

• Early alterations of embryonic development (~30%) • Down syndrome, or trisomy 21; maternal alcohol consumption

• Late pregnancy and perinatal problems (10%) • Fetal malnutrition, placental insufficiency, prematurity, low birth

weight, viral and other infections (e.g., HIV infection)

• Medical conditions in childhood + accidents (5%)• Environment Influences (15-20%)

• Mercury, lead

Prevention and Treatment of MR

• Environmental Interventions and Enrichment Programs

• Residential Treatment

• Behavioural Interventions Based on Operant Conditioning– Applied Behaviour

Analysis

• Cognitive Interventions– Self-instructional training

Pervasive Developmental Disorders

Autism• Impairments in social

interaction, social communication and imagination– Triad of impairments

• More boys than girls• Onset— infancy or very

early childhood• Often co-occurs with MR

and epileptic seizures

Asperger’s Syndrome• Often regarded as a mild

form of autism• Poor social relationships• Stereotyped behaviour• Language and

intelligence are intact

PDD (cont.) Rett’s Disorder

• Very rare; found only in girls• Development normal until

1st-2nd year of life• Head growth decelerates• Loses ability to use hands

purposefully• Stereotyped movements

such as handwringing or handwashing

• Walks in an uncoordinated manner

• Poor speech

Childhood Disintegrative Disorder

• Very rare• Normal development in the

first 2 years of life then significant loss of – Social, play, language, and

motor skills

Characteristics of Autism

• Autism and MR– 80% score below 70 on standardized IQ tests

• Extreme Autistic Aloneness

• Communication Deficits– Echolalia– Pronoun reversal

• Obsessive-Compulsive and Ritualistic Acts

Etiology of Autistic Disorder

• Psychological bases – Psychoanalytic and behavioural perspectives believed

that parents play a crucial role in ASD

• Biological bases– Genetic Factors

• Risk of autism in siblings of people with the disorder is about 75 times greater

– Fragile X syndrome; Chromosomal abnormalities

• Linked genetically to broader spectrum of deficits in communicative and social areas

Etiology of Autistic Disorder

• Neurological Factors and Environmental Risks– Epileptic seizures (30% of adolescents with ASD) – Abnormal brainwave patterns – Larger brains but reduced brain volume– Abnormalities in the cerebellum

• See also Focus on Discovery 15.1

Treatment of Autistic Disorder

• Most effective treatments use modelling and operant conditioning techniques– Example ABA

• Most commonly used medication for treating problem behaviours in autistic children is haloperidol (Haldol)

Childhood Fears and Anxiety Disorders

• 1/3rd of Canadian children (ages 4 -11) rated by parents as too fearful or anxious

• Fears and phobias reported more often for girls than for boys

• 10 to 15% of children and adolescents have an anxiety disorder– Most common disorders of childhood

Separation Anxiety Disorder

• Unrealistic concern about separation from major attachment figures

• Symptoms associated with SAD must be experienced for at least eight weeks– Unrealistic and persistent worries about harm to major

attachment figures – Fears of abandonment– Refusal to attend school – Avoidance of being alone– Experience of nightmares involving separation themes– Experience of physical complaints in anticipation of being

separated from attachment figures

School Phobia• Related to separation anxiety

– But not all children with SAD refuse to go to school

• Two types identified1.More common type is associated with SAD

• Children worry constantly that some harm will befall parents or themselves when they are away from parents

2.Second type associated with true phobia of school• Either a fear specifically related to school or a more general

social phobia• Generally begin refusing to go to school later in life• Have more severe and pervasive avoidance of school

Social Phobia

• Selective Mutism– Refusal to speak when it is expected of a

person• Example: refusing to speak to a teacher

• Social Phobia– Prevalence 1% of children and adolescents– Processes and mechanisms

• Social learning

• Genetic factors

Treatment of Fears and Phobias

• Similar to that employed with adults– Exposure to feared object while performing

some action to inhibit their anxiety– CBT shows great promise in treating

childhood anxiety

Depression in Childhood and Adolescence

• Resemble adult depression in terms of depressed mood, inability to experience pleasure, fatigue, concentration problems, and suicidal ideation – But higher rates of suicide attempts and guilt in children and

adolescents

• Masked depression– Acting aggressively or misbehaving at school or at home

• Prevalence– < 1% of preschoolers – 2 to 3% of school-age children – Adolescents similar to adult rates

• 9% in females and 3 -5% in males• Lifetime prevalence is 21.4% for females and 10.7% for males

Etiology of Depression• Genetic factors • Family and other relationships as sources of stress

– Might interact with a biological diathesis

• Serious emotional problem in a parent

• Poor social skills and impaired relationships with siblings and friends

• Likely stems from a complex interplay of – Biological vulnerability factors– Parental factors– Psychosocial factors – “Social capital” resources

Treatment of Depression

• Controversy regarding effectiveness of drug therapies

• Interpersonal therapy (IPT)

• CBT

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