Chapter Fifteen Disorders of Childhood and Adolescence.

Chapter Fifteen

Disorders of Childhood and Adolescence

Disorders of Childhood and Adolescence

• Child psychology:– Emotional and behavioral manifestation of

psychological disorders in children and adolescents

• Prevalence of childhood disorders:– One in five has serious emotional or behavioral

problem – Two-thirds of those with mental illness received

no treatment

Disorders of Childhood and Adolescence (cont’d.)

Disorders of Childhood and Adolescence (cont’d.)

• Diagnosis requires that symptoms cause significant impairment in daily functioning over extended period of time

• Include:– Internalizing disorders– Externalizing disorders– Neurodevelopmental disorders

• Conditions involving impaired neurological development

Internalizing Disorders of Childhood

• Conditions involving emotional symptoms directed inward

• Heightened reactions to trauma, stressors or negative events and difficulty regulating emotions– Prevalent in early life and often lead to substance

use and suicide

Anxiety, Trauma, and Stressor-Related Disorders in Early Life

• Most common mental health disorder in childhood and adolescence (32%)

• Can significantly affect academic, social, and interpersonal functioning and can lead to adult anxiety disorders

• Include: – Social phobia– Separation anxiety disorder– Selective mutism

Anxiety, Trauma, and Stressor-Related Disorders in Early Life (cont’d.)

• Post-traumatic stress disorder in early life:– Recurrent, distressing memories of a shocking

experience, such as experience with death, serious injury, or sexual violation

– Memories may entail: • Distressing dreams• Intense physiological or psychological reactions to

thoughts or cues associated with event and avoidance of those cues

• Episodes of playacting the event • Dissociative reactions

Anxiety, Trauma, and Stressor-Related Disorders in Early Life (cont’d.)

• Post-traumatic stress disorder in early life:– Children often display social withdrawal,

diminished positive affect, and disinterest in previously-enjoyed activities

– Lifetime prevalence:• 8% for girls and 2.3% for boys

– Effective treatments include:• Trauma-focused cognitive-behavioral therapies

Depressive Disorders in Early Life

• Youth with depressive disorders have more negative self-concepts and are more likely to engage in self-blame and self-criticism

• Early-onset depressive symptoms tends to predict a more chronic and severe course

• Evidence-based treatment for depression:– Individual, group, or school-based cognitive-

behavioral therapy– SSRIs increase suicidality but benefits may

outweigh risk

Nonsuicidal Self Injury

• Involves induction of bleeding, bruising, or pain by means of intentional, self-inflicted injury, without suicidal intent

• Intense negative affect or cognitions and a preoccupation with engaging in self-harm typically precede episodes of NSSI

• Expectation that mood will improve after episode

Nonsuicidal Self Injury (cont’d.)

• Prevalence:– 14-17% of adolescents and young adults have

engaged in self-injury at least once

• Increased risk of attempted suicide• Treatment includes:

– Teaching problem-solving, coping and emotional-regulation skills

– Focus on emotional expression and improving interpersonal relationship skills

Pediatric Bipolar Disorder

• Debilitating disorder that parallels mood variability, depressive episodes, and significant departure from individual’s typical functioning seen in adult bipolar disorder– Episodes of recurring depression, rapid mood

changes, and distinct periods of abnormally-elevated mood involving diminished need for sleep, increased activity, distractibility, talkativeness, and inflated self-esteem

• Lifetime prevalence: estimated 3%

Pediatric Bipolar Disorder (cont’d.)

• Rapid cycling of moods combined with neurocognitively based difficulties processing emotional stimuli and regulating behavior and social-emotional functioning

• Elevated responsiveness to emotional stimuli, reduced volume in amygdala, and other brain abnormalities

• Medications are often combined with psychosocial treatment

Attachment Disorders

• Exposure to early environments devoid of predictable caretaking and nurturing can cause significant difficulties with emotional attachment and social relationships

• Includes:– Reactive attachment disorder (RAD)– Disinhibited social engagement disorder (DSED)

Attachment Disorders (cont’d.)

• Reactive attachment disorder:– Inhibited, avoidant social behaviors and

reluctance to seek or respond to attention or nurturing

• Show little trust that needs will be attended to and do not readily seek nor respond to comfort, attention, or nurturing

• Use avoidance or ambivalence as psychological defense• Limited positive emotion and may demonstrate

irritability, sadness, or fearfulness when interacting with adults


• Disinhibited social engagement disorder:– Indiscriminate, superficial attachments and

desperation for interpersonal contact• Socialize effortlessly, but indiscriminately, and become

superficially “attached” to strangers or acquaintances• History of harsh punishment or inconsistent parenting,

as well as emotional neglect and limited attachment opportunities

• Exposure to maltreatment or maternal psychiatric hospitalizations are particularly vulnerable


• Course depends on severity of social deprivation, abuse, neglect or disruptions in caregiving, and subsequent events in the child’s life

• Symptoms of RAD can disappear whereas symptoms of DSED are more persistent

• Effective intervention:– Providing stable, nurturing environment, and

opportunities to develop interpersonal trust and social skills

Externalizing Disorders of Childhood

• Also known as disruptive behavior disorders: conditions associated with socially disturbing symptoms and distressing others

• Include:– Disruptive mood dysregulation disorder– Oppositional defiant disorder– Conduct disorder

• Early intervention is necessary

Externalizing Disorders of Childhood (cont’d.)

• Diagnosis is controversial, and requires a pattern of behavior that is:– Atypical for the child’s gender, age, and

developmental level– Persistent– Severe enough to cause significant impairment in

social, academic, or vocational functioning

Disruptive Mood Dysregulation Disorder

• Characterized by chronic irritability and significantly exaggerated anger reactions

• Patterns begin in early childhood• Diagnosis requires that symptoms persist

beyond age six• Predictive of later depressive and anxiety

disorders• Clinicians need to rule out PBD due to

symptom overlap

Oppositional Defiant Disorder

• Pattern of negativistic, argumentative, and hostile behavior in which children often:– Lose their temper– Argue and defy adult requests– Primarily directed toward parents, teachers, and

others in authority – No serious violation of societal norms

• Two components:– Negative affect– Oppositional behavior

Conduct Disorders

• Persistent pattern of behavior that violates rights of others

• Reflect dysfunctions in individual and include:– Serious violations of rules and social norms– Cruelty and deliberate aggression towards people

or animals– Theft, deceit, and vandalism

• Callous and unemotional subtype– Often exhibit antisocial personality disorder in

adulthood

Conduct Disorders (cont’d.)

• Prevalence:– Approximately 2-9% of youth meet criteria– 50% display inattention and hyperactivity

• Gender differences:– Males display confrontational aggression– Females display truancy, substance abuse, or

chronic lying

• More persistent than other childhood disorders

Etiology of Externalizing Disorders

Figure 15-1 Multipath Model of Conduct Disorder The dimensions interact with one another and combine in different ways to result in a conduct disorder

Etiology of Externalizing Disorders (cont’d.)

• Biological factors:– Appear to exert greatest influence – Aggressive behavior linked to brain abnormalities

and reduced activity in amygdala – “Low MAOA” and childhood maltreatment – Reduced autonomic nervous system activity– Cortisol (stress levels)


• Social and sociocultural:– Family and social context play large role– Large families and marital breakdown– Economic stress– Crowded living conditions– Harsh or inconsistent discipline– Maternal or peer rejection– Parent-child conflict and power struggles– Limited parental supervision


• Psychological factors:– Difficult child temperament (irritable, resistant,

impulsive tendencies)– Underlying emotional issues – Depression frequently coexists with ODD and

DMDD

Treatment of Externalizing Disorders

• Must consider family and social context of behaviors and psychosocial skills deficits

• CD is particularly difficult to treat• Effective when implemented before patterns

of disruptive behavior are established• Parent-focused interventions regarding child

management techniques

Treatment of Externalizing Disorders (cont’d.)

• Psychosocial interventions that focus on:– Assertiveness-training – Anger management techniques– Building skills in empathy, communication, social

relationships and problem-solving

• Mobilizing adult mentors

Neurodevelopmental Disorders

• Involve impaired development of the brain and central nervous system

• Symptoms become increasingly evident as child grows and develops

• Include:– Tic disorders– Attention-deficit hyperactivity disorder– Autism spectrum disorders– Intellectual and learning disorders

Tics and Tourette’s Disorder

• Tics:– Involuntary, repetitive movements or

vocalizations– Motor tic:

• Eye-blinking, facial-grimacing, head-jerking, foot tapping, flaring of nostrils, and contractions of the shoulders or abdominal muscles

– Vocal tics:• Coughing, grunting, throat clearing, sniffling, or sudden

repetitive and stereotyped outburst of words

Tics and Tourette’s Disorder (cont’d.)

• Tics:– Short-term suppression of a tic is possible, but

results in subsequent increases in the tic– Some report feeling tension build prior to tic,

followed by a sense of relief after tic occurs– Stress can increase frequency and intensity – Provisional tic disorders (2.6% of children)– Chronic motor or vocal tic disorders (3.7% of

children)


• Tourette’s disorder (TD):– Characterized by multiple motor tics and one or

more vocal tic, present for at least one year– Onset is prior to age 18– About 8% show complete remission– Symptoms can be severe or mild– Coprolalia and motor movements involving self-

harm– Comorbid conditions


• Etiology:– Both chronic tic disorder and TD appear to be

genetically transmitted– Involvement of basil ganglia and orbital frontal

cortex– Possible involvement of neurotransmitters

• Treatment:– Psychotherapy can help with distress

• Habit reversal technique

– Antipsychotic medication used for severe tics


Tourette's Syndrome: Introduction Meet Isabella, Devon, Nikki, Amanda as they attend “Camp Tic-a-Palooza,” a camp designed for children with Tourette's Syndrome. Explore

the many difficulties they encountered when integrating with other children in school, and even with their families.

Attention-Deficit/Hyperactivity Disorder

• Characterized by persistent inattention and/or impulsive, hyperactive behaviors

• Symptoms must interfere with social, academic, or occupational activities

• Diagnosis requires that symptoms begin before age 12 and persist for at least six months

• Poor regulation of attentional processes

Attention-Deficit/Hyperactivity Disorder (cont’d.)

• Prevalence rates vary between studies– One study: 8.7% – More than twice as likely in boys than in girls

• Symptoms tend to improve in late adolescence

• Associated with behavioral and academic problems

• Risk of coexisting conditions is four times greater among children living in poverty

Attention-Deficit/Hyperactivity Disorder: Etiology

• Biological dimension:– Highly heritable with up to 80% of symptoms

explainable by genetic factors• Rare inherited gene mutations• Chromosomal DNA deletions and duplications• Genes affecting regulation of dopamine and glutamate

– Hypotheses about neurological mechanisms• Reduced activity in prefrontal cortex• Differences in brain structure and circuitry in frontal

cortex, cerebellum, and parietal lobes• Low dopamine levels

Attention-Deficit/Hyperactivity Disorder: Etiology (cont’d.)

ABC Video: Brain Activity and ADHD See an in-depth look at the brain and how the brains of people with ADHC differ and are similar to those who do not have ADHD using

brain imaging techniques


• Biological dimension:– Prematurity– Oxygen deprivation during birth – Low-birth weight– Lead and PCB exposure– Viral infections, meningitis, and encephalitis– Maternal smoking, drug, and alcohol abuse during

pregnancy– Possible involvement of food additives


• Social and sociocultural dimensions:– Sociocultural and social adversity including:

• Stressors in family• Low social class• Foster care placement

– Cultural and regional expectations

• Psychological dimension:– Interpersonal conflict


Figure 15-3 Prevalence of ADHD Among Youth (Ages 4-17) by State, 2007-2008 The prevalence of parent-reported attention-deficit/hyperactivity disorder varied significantly from state to state, ranging from a low of 5.6% in Nevada to a high or 15.6% in North

Carolina. What might account for the variability in ADHD diagnoses from state to state?Source: Centers for Disease Control and Prevention (2010b)

Attention-Deficit/Hyperactivity Disorder: Treatment

• Stimulants such as methylphenidate (Ritalin) receive most evidence-based support– Normalize neurotransmitter functioning and

increased neurological activation in frontal cortex– Increased rates of stimulant medication use in

U.S.

Attention-Deficit/Hyperactivity Disorder: Treatment (cont’d.)

• Evidence that behavioral and psychological treatments are highly effective

• Modifying environment and social context can enhance feelings of competence, motivation, and self-efficacy

• Coordination of all services result in most successful interventions

Autism Spectrum Disorders

• Characterized by impairment in social communication and restricted, stereotyped interests and activities

• Symptoms range from mild to severe• Prevalence:

– Affects one out of 100-110 children – Four times as common in boys

Autism Spectrum Disorders (cont’d.)

ABC Video: Underdiagnosed Autism in Girls Discover the ways in which autism is more often diagnosed, and often easier to diagnose, in boys, and the problems this can

lead to for young girls with autism spectrum disorders


• Symptoms of autism spectrum disorder:– Deficits in social communication and social

interaction• Atypical social-emotional reciprocity• Atypical nonverbal communication• Difficulties developing and maintaining relationships


• Symptoms of autism spectrum disorder:– Repetitive behavior or restricted interests or

activities involving at least two of following:• Repetitive speech, movement, or use of objects• Intense focus on rituals or routines and strong

resistance to change• Intense fixations or restricted interests • Atypical sensory reactivity

– Autistic savants• Individual with ASD who performs exceptionally well on

certain tasks


• Problems diagnosing autism:– Typical procedures include clinical observation,

parent interviews, developmental histories, autism screening inventories, communication assessment, and psychological testing

– Autism is usually diagnosed at age three or later– Symptoms may appear following a period of

normal social and intellectual development

Autism Spectrum Disorders: Etiology

• Biological dimension:– Unique patterns of metabolic brain activity– Abnormally high levels or serotonin– Differences in brain anatomy and connectivity in

brain regions associated with autistic traits– Accelerated growth or amygdala – Accelerated head growth – Genetic mutations implicated in familial autism

Autism Spectrum Disorders: Etiology (cont’d.)

• Biological dimension:– Genetic factors

• Heritability estimated to be around .73 percent for males and .87 for females

• Autistic traits have high heritability• Clear evidence for genetic susceptibility

– Innate vulnerability triggered by environment– Nutritional deficits, changes in immune system,

low birth weight


Figure 15-5 Changes in the Prevalence of Autism Spectrum Disorder Among 8 Year-Old Children in 10 U.S. States 2002 to 2006 The prevalence of autism spectrum

disorder among 8-year-old children increased between 2002 and 2006 in all 10 state sites monitored. What might account for these increases and the state-to-state variations in

prevalence of the disorder?Source: Center for Disease Control and Prevention (2009b)


• Psychological dimension:– Children with ASD seldom make eye contact, seek

social connectedness, or bid for attention– Prefer to be alone and ignore parental efforts at

connection– High stress levels among family due to ASD– Psychological and social factors play a role in

manifestation of symptoms, but ASD is primarily influenced by biological factors

Autism Spectrum Disorders: Intervention and Treatment

• Prognosis is mixed; most children retain diagnosis and require support for life

• Individuals with higher levels of cognitive-adaptive functioning fare better than those with intellectual disabilities and severe autistic symptoms

• Significant recovery linked with intense early intervention

Autism Spectrum Disorders: Intervention and Treatment (cont’d.)

ABC Video: Autism Diagnosis Early intervention can help Autistic children lead more normal lives. Find out what parents can do to help identify this disorder early-on.


• Medications are used to decrease anxiety, repetitive behaviors, and hyperactivity– Minimally effective and may be harmful– Risperidone alone received FDA approval:– Preliminary research on effects of oxytocin

• Comprehensive treatment programs have enabled children with ASD to develop more functional skills


• Interventions with most significant gains:– Social communication– Environmental enrichment– Reinforcing appropriate attention and response to

social stimuli– Preventing repetitive behaviors – Sustained practice of weaker skills– Reducing environmental stress– Improving sleep and nutrition

Intellectual Developmental Disorder

• Limitations in intellectual functioning and adaptive behaviors including:– Significantly below average general intellectual

functioning (generally IQ of 70 or less)– Deficiencies in adaptive behavior that are lower

than would be expected based on age or cultural background

• Only diagnosed when low intelligence is accompanied by impaired adaptive functioning

Intellectual Developmental Disorder (cont’d.)

• Four distinct categories:– Mild: IQ score 50-55 to 70– Moderate: IQ score 35-40 to 50-55– Severe: IQ score 20-25 to 35-40– Profound: IQ score below 20-25


• American Association on Intellectual and Developmental Disabilities:– IQ score may be used to approximate intellectual

functioning– More important to focus on adaptive functioning

and nature of psychosocial supports needed– Given ongoing, individualized support, overall

functioning of individual with ID will improve


• Prevalence:– Approximately 1% of students in public school– Increases in low and middle income countries– Coexisting conditions are common

• One-fourth have seizure disorders

Intellectual Developmental Disorder: Etiology

• Etiology differs depending on level of intellectual impairment– Mild IDD is often idiopathic (no known cause)– Pronounced IDD related to genetic factors, brain

abnormalities, or brain injury

Intellectual Developmental Disorder: Etiology (cont’d.)

• Genetic factors: – In up to 80 percent of cases of IDD, underlying

cause is unknown• Unidentified genetic factors

– Genetic variations • Normal distribution of traits (upper vs. lower range)

– Genetic abnormalities• Chromosomal abnormalities

– Down syndrome most common

• Inheritance of single gene– Fragile X syndrome most common (mild to severe ID)


• Down syndrome (DS):– Extra copy of chromosome 21 originates during

gamete development – Majority have mild to moderate IDD– With support many can have jobs and live semi-

independently – Medical interventions improve outcome, but

significant risks remain– Prenatal detection of DS through amniocentesis


Developmental Disabilities Children with developmental disabilities are said to have exceptionalities, which are diagnosed based on delays or differences in what we know of

typical development


• Nongenetic biological factors:– Influences during prenatal, perinatal, or postnatal

period• Fetus is susceptible to viruses and infections, drugs and

alcohol, radiation, and poor nutrition – Fetal alcohol spectrum effects and fetal alcohol syndrome

• Birth trauma, prematurity, and low birth weight• Head injuries, brain infections, tumors, and prolonged

malnutrition • Exposure to environmental toxins, including lead


• Psychological, social, sociocultural dimensions: – Genetic background interacts with environmental

factors • Effects of low SES• Parents with mild IDD • Long-term effects of prematurity

– Enriching and encouraging home environment, as well as ongoing education intervention

Learning Disorders

• Academic disability characterized by reading, writing, and math skills deficits

• Primarily interferes with academic achievement and activities of daily living in which reading, writing, or math skills are needed (e.g., dyscalculia, dyslexia)

• Prevalence:– Around 5% of students in public schools– Boys are almost twice as likely as girls

Learning Disorders (cont’d.)

• Etiology:– Little is known about precise causes of LD– Appear to have slower brain maturation– Lifelong differences in neurological processing of

information related to basic academic skills– May be similar to biological explanations for IDD

and ADHD– Runs in families, suggesting genetic component

Support for Individuals with Neurodevelopmental Disorders

• Produce lifelong disability, goal of intervention is to build skills and develop potential to the fullest extent possible

• Support should begin in infancy and extend across the life span

• Different levels of support

Support for Individuals (cont’d.)

• Support in childhood:– Individualized home-based or school-based

programs – Parent involvement is integral part of early

intervention programs– School services are individualized to meet child’s

needs and to maximize learning opportunities• Rates of improvement decrease once programs are

completed

Support for Individuals (cont’d.)

• Support in adulthood:– Programs focusing on specific job skills– Institutionalization is rare, but many live with

family members– “Least restrictive environment” possible

• As much independence and personal choice as is safe and practical

• Most normalized living arrangements vary from setting to setting

Chapter Fifteen Disorders of Childhood and Adolescence.

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Transcript of Chapter Fifteen Disorders of Childhood and Adolescence.