chapter 14 Nuerodevelopmental

Neurological disorders

Disorders  that show themselves early in life often persist as the person grows older, so the term childhood disorder may be misleading. Because the developmental disorders in this group are all believed to be neurologically based, DSM-5 categorizes  them as  neurodevelopmental disorders. Neurologically based disorders that are revealed in a clinically significant way during a child’s developing years.

• Diagnosed first in infancy, childhood, or adolescence

types of nuerological disorders 

• Attention deficit hyperactivity disorder (ADHD)

• Specific learning disorder

• Autism spectrum disorder

• Intellectual Disability

• Communication and Motor Disorders

Normal vs abnormal development

• Consider age and environment of child

• Developmental psychopathology

  • Study of how disorders arise and change with time

  • Disruption of early skills can affect later development 

  • Caution: do not excessively pathologize childhood behavior that is part of normal development

Internalizing disorders:

Anxiety Disorders, selective mutism, depression,Enuresis, encopresis, sleepwalking,Tourette’s, Autism Spectrum Disorders

Externalizing Disorders

Rule violations, Negativity, anger, aggression, Impulsivity, Hyperactivity, Attention Deficits

• More problematic when part of a cluster of problems

1. .Child’s age and rule violations

2. Adolescent limited or life course persistent

3. .Negativity, anger & aggression

4. Impulsivity, jumping from cliffs

5. Hyperactivity, some kids are very active, constantly moving 

6. Attention deficits

7. Frustration tolerance, do not tolerate frustration well

Attention deficit/ hyperactivity disorder (adhd)

Developmental disorder featuring maladaptive levels of inattention, excessive activity, and impulsiveness, sense of entitlement, inattention, overactivity, and impulsivity. One of the most common reasons children are referred for mental health services in the United States. The primary characteristics of such people include a pattern of inattention (such as being disorganized or forgetful about school or work-related tasks)or of hyperactivity and impulsivity. These characteristics can significantly disrupt academic efforts, as well as social relationships

DSM-5 adhd

 on a continuum from non severe to severe, DSM-5 differentiates two categories of symptoms. The first includes problems of  inattention.  People may appear not to listen to others; they may lose necessary school assignments, books, or tools; and they may not pay  enough attention to details, making careless mistakes. The second category of symptoms includes  hyperactivity and impulsivity.Hyperactivity includes fidgeting, having trouble sitting for any length of time, and always being on the go. Impulsivity includes blurting out answers before questions have been completed and having trouble waiting turns. Either the first (inattention)or the second and third (hyperactivity and impulsivity) set of symptoms must be present for someone to be diagnosed with ADHD

▪Predominantly inattentive presentation

▪Predominantly hyperactive/impulsive presentation

▪Combined presentation

subtypes

they include the inattentive subtype (what some may call ADD, noting the absence of hyperactivity, although this is not

  an official diagnostic label) and the hyperactive/impulsive subtype. Other individuals meet criteria for both inattention  and hyperactivity/impulsivity, and these individuals are labeled with the combined  subtype

• ▪Inattentive

• ▪Hyperactive/impulsive 

• ▪Combined

Prevalence 

• Occurs in approximately 5% of school-aged children throughout the world

• ADHD most commonly diagnosed in the United States, although prevalence appears fairly constant worldwide

  • One study: 11% of children labeled with ADHD in 2011-2012

• In general population (including adults), 5 to 9% meet criteria

Adhd features

people with this disorder have a great deal of difficulty sustaining their attention on a task or activity (Barkley, 2015c). As a result, their tasks are often unfinished, and they often seem not to be listening when someone else is speaking. In addition to this serious disruption in attention, some people with ADHD display motor hyperactivity. Children with this disorder  are often described as fidgety in school, unable to sit still for more than a few minutes.  In addition to hyperactivity and problems sustaining attention, impulsivity—acting apparently without thinking

• Symptoms usually appear around age 3 to 4

• Half of children with ADHD continue to have difficulties as adults

  • Divorce, lower education, substance use

• Impulsivity decreases, but inattention remains

• Brain development progresses in a more typical fashion in children receiving medication for ADHD versus those who do not

• Gender differences: Boys outnumber girls 3:1

  • Some suggest girls’ symptoms less likely to be disruptive, thus less likely to be diagnosed

Genetic contributions

Genetic research on both ADHD and learning disabilities suggests that they may share a common biological cause (DuPaul, Gormley, & Laracy, 2013). Children with ADHD are likely to be unpopular and rejected by their peers (McQuade & Hoza, 2015). This, too, may be the result of genetic factors as well as environmental influences such as a hostile home environment  and gene–environment interactions. For example, some research shows that having a specific genotype (that is, a dopamine transporter—DAT1; and a serotonin transporter) and psychosocial distress can predict ADHD in children (Lambacher et al., 2020).

Role of toxins in adhd:

• Food additives (e.g., dyes, pesticides) may play very small role in hyperactive/impulsive behavior among children

• Maternal smoking increases risk

Psychosocial factors of adhd:

• ADHD children are often viewed negatively by others > Frequent negative feedback from peers and adults

  • Peer rejection and resulting social isolation

  • Such factors foster low self-esteem

Goal of biological treatments of adhd

reduce impulsivity and hyperactivity, improve attention

• Stimulant medications

  • Currently prescribed for approximately 3.5% of American children

  • Examples include Ritalin, Dexedrine, Adderall, conedine 

  • Problem: May increase risk for later substance abuse

• Guanfacine - treats high blood pressure by decreasing heart rate and relaxing the blood vessels so that blood can flow more easily through the body. Guanfacine extended-release tablets may treat ADHD by affecting the part of the brain that controls attention and impulsivity.

• Stratera - Atomoxetine is used to treat attention-deficit hyperactivity disorder as part of a total treatment plan, including psychological, social, and other treatments.

• Other medications with more limited efficacy

  • Imipramine and clonidine (antihypertensive)

• Genes affect individuals’ response to meds

  • Some trial and error is necessary

• Effects of medications

  • Improve compliance, decrease negative behaviors

  • Do not affect learning/academics directly

  • Benefits are not lasting following discontinuation

Behavioral treatment for adhd

• Behavioral treatment for children

  • Reinforcement programs increase appropriate behaviors, decrease inappropriate behaviors

  • May also involve parent training

• Adults: Cognitive behavioral therapy to increase attention and organization, help parents understand the ways in which the child can be helped so outside of the therapy center the child can receive the help and coping skills needed. 

• Combined bio-psycho-social treatments

  • May be superior to medication or behavioral treatments alone, but more research is needed, as the kid learns the skills they back off the medication gradually, not possible for all children

Conduct Disorder

Precursor to Conduct disorder is Oppositional Defiant Disorder (ODD)., kids that are defiant, over time these evolve into a conduct disorder. Much more serious types of behavioral problems, features may be seen early, injuring animals at an early age, as they move through school have fewer and fewer friends, increasingly getting themselves into trouble, persist - adolescent persistent conduct disorder 

• Developmental sequence: ODD > conduct disorder 

• All conduct disorders preceded by ODD

• Not all children with ODD develop conduct disorder.

Scope of learning disorders

 which is characterized by performance that is substantially below what would be expected given the person’s age, intelligence quotient (IQ) score, and education (Black & Andreasen, 2021). We also look briefly at disorders that involve how we communicate. Academic problems in reading, mathematics, and/or writing, Performance substantially below expected levels based on age and/or demonstrated capacity, Problems persist for 6+ months despite targeted intervention

Specific learning disorder:

• With impairment in reading, may include:

  • Word reading accuracy

  • Reading rate or fluency

  • Reading comprehension

• With impairment in written expression, may include:

  • Spelling accuracy

  • Grammar punctuation and accuracy

  • Clarity/organization of written expression

  • With impairment in mathematics, may include:

    • Number sense

    • Memorization of arithmetic facts

    • Accurate or fluent calculation

    • Accurate math reasoning

Prevalence of specific learning disorder

 Students with learning disorders are more likely to:

• Drop out of school

• Be unemployed

• Have suicidal thoughts

• Have negative school experiences

• May be related to communication disorders

• 5 to 15% prevalence across youth of various age and cultures

• Highest rate of diagnosis in wealthier regions, but children with low SES more likely to have difficulties

• Reading difficulties most common, affect 7% of the general population

Genetic and neurobiological contributors:

• Learning disorders run in families, but specific difficulties are not inherited

• Evidence for subtle neurological difficulties is mounting (e.g., decreased functioning of areas responsible for word recognition)

• Overall, contributions are unclear

Causes of Specific learning disorders:

​​Psychosocial contributions are likely important

• Some languages more difficult to read > higher rates of reading impairment

• Performance also influenced by:

  • Motivational factors

  • Socioeconomic status

  • Cultural expectations

  • Parental interactions

  • Child management practices

Treatment of specific learning disorder: 

• Requires intense educational interventions

  • Remediation of basic processing problems, cognitive skills, and compensatory skills

  • Examples:

    • Vocabulary, discerning meaning, fact finding, decision making, critical thinking

• Data support behavioral educational interventions

• Biological interventions (e.g., Ritalin) usually used only for those individuals who also have ADHD

Internalizing disorders

1. Anxiety Disorders of childhood

A. Separation Anxiety

B. Selective Mutism

2. Childhood Depression

3. Other Disordes

A. Enuresis

B. Encopresis

C. Tics – Tourette’s syndrome

Autism Disorder

a neurodevelopmental disorder that, at its core, affects how one perceives and socializes with others (Durand, 2014).   DSM-5 combined most of the disorders previously included under the umbrella term “pervasive developmental disorders” 

Three levels of severity

• Level 1— “Requiring support”

• Level 2— “Requiring substantial support”

• Level 3— “Requiring very substantial support”

• Described qualitatively and, as yet, has no quantitative equivalent

Characteristics of autism

One of the defining characteristics of people with ASD is that they do not develop age-appropriate social relationships (Davis & Carter, 2014). Amy never made friends among her peers and often limited her contact with adults to using them as tools—for example, taking the adult’s hand to reach for something she wanted. Research on the symptoms of ASD including communication difficulties and social difficulties (which were listed independently as part of DSM-IV-TR) revealed the considerable overlap of these symptoms (Frazier et al., 2012; Skuse, 2012).

DSM-5 Autism Spectrum Disorder

Two major characteristics of ASD are expressed in DSM-5:  impairments in social communication and social interaction and restricted, repetitive patterns of behavior, interests, or activities In addition, DSM-5 recognizes that the impairments are present in early childhood and that they limit daily functioning. It  is the degree of impairment in each of these characteristics that presumably distinguish individuals previously diagnosed  with the separate disorders of autistic disorder, Asperger’s disorder, and   pervasive developmental disorder—not otherwise specified pervasive developmental disorder—not otherwise specifiedWide-ranging, significant, and long-lasting dysfunctions that appear before the age of 18.

Autism on a spectrum

One of the defining characteristics of people with ASD is that they do not develop age-appropriate social relationships (Davis & Carter, 2014). Amy never made friends among her peers and often limited her contact with adults to using them as tools—for example, taking the adult’s hand to reach for something she wanted. Research on the symptoms of ASD including communication difficulties and social difficulties (which were listed independently as part of DSM-IV-TR) revealed the considerable overlap of these symptoms, DSM-5 combines these two areas into one general symptom cluster (social communication and social interaction). Difficulties with social communication and interaction are further defined by the inclusion of three aspects—problems with social reciprocity (a failure to engage in back-and-forth social interactions), nonverbal communication, and  initiating and maintaining social relationships—all three of which must be present to be diagnosed with ASD.

More severe autism on a spectrum

Social reciprocity for individuals with more severe symptoms of ASD (previously diagnosed with autistic disorder) involves the inability to engage in Joint attention, Attention shared by two persons toward an object after one person has indicated interest in the object to the other person; this social interaction is limited or absent in people with  autism spectrum disorder . If a toddler without ASD sees a toy she likes, she might look at her mother, smile, look at the toy, and look at her mother   again. This social act communicates not only interest in the toy but also the desire to share this interest with another person.  This action is limited in persons with ASD (Ambrose et al., 2020). Among persons with milder symptoms of ASD (previously diagnosed with Asperger’s disorder), this lack of social reciprocity  might present itself as appearing self-focused and not showing interest in things other people care about.

Restricted or repetitive behaviors of autism

The more striking characteristics of ASD include restricted, repetitive patterns of behavior, interests,  or activities. Amy appeared to like things to stay the same: She became extremely upset if even a small change was introduced (such as moving  her toys in her room). This intense preference for the status quo has been called maintenance of sameness. Often, people with ASD spend countless hours in stereotyped and  ritualistic behaviors,  making such stereotyped movements as spinning around in circles, waving their hands in front of their eyes with their heads cocked to one side, or biting their hands (Durand, 2014). For individuals with less severe ASD, these behaviors can take the form of an almost obsessive interest in certain, very specific subjects (such as following airline schedules or memorizing ZIP codes). This tendency to be much more interested  in esoteric facts than in people further helps to interfere with social relationships.

Autism Prevalence

Previously thought to be very rare, but this is not the case

Gender differences are apparent in ASD, with the average reported male to female estimate being 4.5 to 1 (Centers for Disease  Control and Prevention, 2014). ASD appears to be a universal phenomenon, identified in every part of the world, including Sweden

• 1 in 50 school-aged children meet criteria

• More commonly diagnosed in males

  • Gender ratio: 4 to 5:1

• IQ interaction

  • 38% show intellectual disabilities

• Occurs worldwide

Psychological Dimensions of asd

: origins of ASD were based on the unusual speech patterns of some individuals—namely, their tendency  to avoid first-person pronouns such as I and  me  and to use he  And she instead. For example, if you ask a child with ASD, “Do you want something to drink?” he might say, “He wants something to drink” (meaning “I want something to drink”). This observation led some theorists to wonder whether ASD involves a lack of self-awareness (Goldfarb, 1963;Mahler, 1952). Imagine, if you can, not understanding that your existence is distinct. There is no “you,” only “them.” Such a debilitating  view of the world was used to explain the unusual ways people with ASD behaved. Theorists suggested that the withdrawal seen among people with ASD reflected a lack of awareness of their own existence. 

• Some people with ASD do seem to have self-awareness (Lind & Bowler, 2009) and that it follows a developmental progression. Just like children without a disability, those with cognitive abilities  below the level expected for a child of 18 to 24 months show little or no self-recognition, but people with more advanced  abilities do demonstrate self-awareness. Self-concept may be lacking when people with ASD also have cognitive disabilities or delays, not because of the disorder itself.

Biological dimensions of asd

Deficits in such skills as social communication and the characteristic restricted and repetitive behaviors and interests appear to be biological in origin (Lord et al., 2018). The role of biological influences on the origins of ASD, examined next, has received much empirical support.

Genetic influences of asd

It is now clear that ASD has a significant genetic component. What is also evident is that the genetics of ASD are highly complex (Wang et al., 2015) with a moderate genetic heritability (Hallmayer et al., 2011; Rutter, 2011a). Numerous genes on a number of our chromosomes have already been implicated in some way in the presentation of ASD (Li, Zou, & Brown, 2012). And as with other psychological disorders such as schizophrenia, many genes are involved, but each one has only a relatively  small effect.

• Families that have one child with ASD have about a 20% chance of having another child with the disorder (Ozonoff et al., 2011). This rate is more than 100 times the risk in the general population, providing strong evidence of a genetic component in  the disorder. The exact genes involved in the development of ASD remain elusive. One area that is receiving attention involves  the genes responsible for the brain chemical oxytocin. Because oxytocin is shown to have a role in how we bond with others and in our social memory, researchers are looking at whether genes responsible for this neurochemical are involved with the disorder.

Neurobiological influences of asd

amygdala—the area of the brain that is involved in emotions such as anxiety and fear. Researchers studying the brains of people with ASD after they died note  that adults with and without the disorder have an amygdala of about the same size but that those with ASD have fewer neurons  in this structure (Schumann & Amaral, 2006). Earlier research showed that young children with ASD actually have a larger amygdala. The theory being proposed is that the amygdala in children with ASD is enlarged early in life—causing excessive anxiety and fear (perhaps contributing to their  social withdrawal). With continued stress, the release of the stress hormone cortisol damages the amygdala, causing the relative absence of these neurons in adulthood. The damaged amygdala may account for the different way people with ASD respond to social  situations

Treatment of Autism

Most treatment research has focused on children with the more severe form of ASD, so we primarily discuss treatment research for these individuals. There are a growing number of studies aimed at persons displaying less severe forms of ASD—typically focused on teaching social skills—and we describe this research as well. One generalization that can be made about ASD is that no completely effective treatment exists. Attempts to eliminate the social communication problems experienced by these  individuals have not been successful to date (Durand, 2014). Rather, most efforts at treating people with ASD focus on enhancing their communication and daily living skills and on reducing problem behaviors, such as tantrums and self-injury (Durand, 2014). We describe some of these approaches next, including important work on early intervention for young children with ASD.

Psychosocial treatment of autism

they encouraged ego development (the creation of a self-image) (Bettelheim, 1967). Given our current understanding about the nature of the disorder, we should not be surprised to learn that treatments based solely on ego development have not had a positive impact on the lives of people with ASD (Kanner & Eisenberg, 1955). Greater success has been achieved with behavioral approaches that focus on skill building and behavioral treatment of problem behaviors. This approach is based on the early work of Charles Ferster (1961) and Ivar Lovaas. Although the work of Ferster and Lovaas has been greatly refined over the past few decades, the basic premise—that people with ASD can learn and  that they can be taught some skills they lack—remains central

Intellectual Disability Disorder

(down syndrome) a disorder evident in childhood as significantly below-average intellectual and adaptive functioning (Black & Andreasen, 2021). People with IDD experience difficulties with day-to-day activities to an extent that reflects both the severity of their cognitive deficits and the type and amount of assistance they receive. DSM-5 identifies difficulties in three domains: conceptual  (skill deficits in areas such as language, reasoning, knowledge, and memory), social (problems with social judgment and the ability to make and retain friendships), and practical (difficulties managing personal care or job responsibilities) (American Psychiatric Association, 2013). Perhaps more than any other group you have studied in this text, people with IDD have throughout history received treatment that can best be described as shameful (Scheerenberger, 1983).

Clinical description of Intellectual Disability Disorder

People with IDD display a broad range of abilities and personalities. Individuals like Ethan, who have mild or moderate impairments,can, with proper preparation, carry out most of the day-to-day activities expected of any of us. Many can learn to use mass transportation, purchase groceries, and hold a variety of jobs. Those with more severe impairments may need help to eat, bathe, and dress themselves, although with proper training and support, they can achieve a degree of independence 

• In contrast, people with more  severe forms of IDD may never learn to use speech as a form of communication, requiring alternatives such as sign language or special communication devices to express even their most basic needs. Because many cognitive processes are adversely affected, individuals with intellectual developmental disorder (intellectual disability) have difficulty learning, the level of challenge depending on how extensive the cognitive disability is.

Intellectual disabilities DSM-5

To be diagnosed with IDD, a person must have significant atypical intellectual functioning, a determination made with one of several IQ tests with a cutoff score set by DSM-5 of approximately 70. The American Association on Intellectual and Developmental Disabilities (AAIDD), which has its own, similar definition of intellectual  developmental disorder (intellectual disability), has a cutoff score of approximately 70 to 75 The second criterion calls for concurrent deficits or impairments in adaptive functioning. In other words, scoring “approximately 70 or below” on an IQ test is not sufficient for a diagnosis of IDD. A person must also have significant difficulty in areas such as communication, self-care, home living, social and interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety.   Intellectual developmental disorder (intellectual disability) is a disorder with onset during the developmental period that  includes both intellectual and adaptive functioning deficits in conceptual, social, and practical domains. The following three  criteria must be met: Deficits in intellectual functions, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience, confirmed by both clinical assessment and individualized, standardized intelligence testing. Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility. Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, across multiple environments such as home, school, work, and community. Onset of intellectual and adaptive deficits during the developmental period.

Causes of Intellectual Disability

Hundreds of known causes

• Environmental (e.g., neglect)

• Prenatal (e.g., exposures to toxins in the womb)

• Perinatal (e.g., problems with delivery)

• Postnatal (e.g., head injury)

Genetic influences

• Chromosomal influences

  • Down Syndrome 

    • Most common chromosomal cause of intellectual disability

    • Extra 21^st chromosome (Trisomy 21)

    • Distinctive physical symptoms

  • Chromosomal disorders (e.g., Down Syndrome)

  • Multiple genetic mutations

  • Single genes can be responsible

    • Dominant genes less often responsible for ID (because people with ID are less likely to have children)

    • Recessive genes more often responsible 

• As many as 30% cases of ID have no identified etiology

• Genetic influences

  • De novo disorders

  • Lesch-Nyham syndrome

    • Intellectual disability, symptoms of cerebral palsy, self-injurious behavior

    • Recessive allele on the X chromosome > only affects males (females have an additional X chromosome to balance)

Fragile X Syndrome

 Learning disabilities, Hyperactivity, Short attention span, Gaze avoidance, Perseverative speech a second common heritable cause of IDD (Black & Andreasen, 2021). As its name suggests, this disorder is caused by a change on the X chromosome, a mutation that makes the tip of the chromosome look as though it were hanging from a thread, giving it the appearance of fragility (Lubs, Stevenson, & Schwartz, 2012). As with Lesch-Nyhan syndrome, which also involves the X chromosome, fragile X primarily affects men because they do not have a second X chromosome with a typical gene to balance out the mutation. Primarily affects males, Women with Fragile X have mild symptoms

Cultural Familial Intellectual Disabilities

Refers to intellectual disability influenced by social environmental factors, such as: Abuse, Neglect, Social deprivation people with these characteristics are thought to have cognitive impairments that result from a combination of psychosocial and biological influences, although the specific mechanisms that lead to this type of intellectual developmental disorder (intellectual disability) are not yet understood. Fortunately, because of better child-care systems and early identification of potential family difficulties, these cases are rare today (Black & Andreasen, 2021).

These factors likely interact with existing biological factors

Treatment for intellectual disability

Biological treatment of IDD is currently not a viable option. Generally, the treatment of individuals with IDD parallels that of people with more severe forms of autism spectrum disorder, attempting to teach them the skills they need to become more productive and independent. For individuals with mild IDD, intervention is similar to that for people with learning disorders.  Specific learning deficits are identified and addressed to help the student improve such skills as reading and writing (Black & Andreasen, 2021). At the same time, these individuals often need additional support to live in the community

• Severe ID: Treatment similar to that for autism spectrum disorder

• Mild ID: Treatment similar to that for learning disorders

• Goals are similar across severity; level of assistance differs

• Behavioral interventions teach:

  • Basic skills (e.g., dressing, hygiene)

  • Social skills

  • Practical skills (e.g., paying bills)

Phenylketonuria

which affects 1 of every 10,000 newborns and is characterized by an inability to break down a chemical in our diets called  phenylalanine (Black & Andreasen, 2021;  Christ et al., 2020). Until the mid-1960s, the majority of people with this disorder had IDD, seizures, and behavior problems, resulting from high levels of this chemical. Researchers developed a screening technique, however, that identifies the existence of PKU; infants are now routinely tested at birth, and any individuals identified with PKU can be successfully treated with a special diet that avoids the chemical phenylalanine. This is a rare example of the successful prevention of one form of IDD.

• Cannot break down phenylalanine, which is found in some foods

• Results in ID when the individual eats phenylalanine

• Now, test at birth can detect PKU > diets without phenylalanine actually prevent development of intellectual disability and other problems

Prevention of Neurodevelopmental Disorders

• Efforts are still in early stages

• Early interventions for at-risk children

  • Head Start Program: Educational, medical (e.g., nutritional), and social support

• Future directions: Genetic screening

  • Detection and correction

  • Prenatal gene therapy

Down Syndrome

 the most common chromosomal form of IDD, was first identified by the British physician Langdon Down in 1866. Down had tried  to develop a classification system for people with IDD based on their resemblance to people of other races; he described individuals with this particular disorder as “mongoloid” because they resembled people from Mongolia (Scheerenberger, 1983). The term mongoloidism was used for some time but has been replaced with the term Down syndrome. The disorder is caused by the presence of an extra 21st chromosome and is therefore sometimes referred to as  trisomy 21.

• Higher risk with advanced maternal age

• Detectable with some prenatal tests

  • Amniocentesis

  • Chorionic villus sampling (CVS)

  • Mother’s blood tests

  • Tests do not indicate severity of impairment

  • 1 in 4 mothers elects to terminate the pregnancy