Chapter 15 - childhood disorder

what % and what disorder is most prevalent in children

• anxiety disorders are most prevalent

Disorder of uncontrolled behaviour

• also known as externalizing problems

• DSM-5 classification - disruptive, impulse-control and conduct disorder

  1. oppositional defiant disorder

  2. conduct disorder

  3. attention deficit hyperactivity disorder

Disruptive mood dysregulation disorder

• Referred to as ‘temper tantrum disorder’

• persistent irritability

• Episodes of temper outbursts, three or more times per week

• In DSM-IV-R called childhood bipolar disorder

Attention - Deficit/Hyperactivity Disorder

• Not recognized until research by Virginia Douglas

• Difficulty concentrating on tasks

• Difficulty sustaining attention over time

• Trouble following through on instructions

• Forgetful in daily activities

• Boys with ADHD are more likely than girls with ADHD to be aggressive. In girls, hyperactivity is more likely to be manifested in talkativeness.

Types of ADHD

• ADHD predominantly attention deficit – problems with executive functions

• ADHD predominantly hyperactive

• ADHD combined

Hyperactivity

• constantly in motion

• trouble sitting still

• unable to stop moving or talking when asked to be quiet

• activities and movements may seem haphazard

Thomas Brown’s model of executive functions impaired in ADHD

1. Activation: Organizing, prioritizing, and activating to work

2. Focus: focusing, sustaining focus, and shifting focus to tasks

3. Effort: Regulating alertness, sustaining effort, and processing speed

4. Emotion: Managing frustration & modulating emotions

5. Memory: Utilizing working memory & accessing recall

6. Action: Monitoring & self-regulating action

children with ADHD have

• Peer-relations difficulty since their behaviour can be annoying to others

• Learning disabilities in 15- 30%

• Comorbidity with many disorders

Genetic predisposition - biological theories and ADHD

• ADHD is considered to be one of the most heritable phenotypes

• Estimates of heritability: 75%

Differences in brain structure and function - biological theories and ADHD

• reductions in volume in the cerebrum and cerebellum

• delays in cortical maturation

• smaller basal ganglia volumes

• dysfunction in dopaminergic and noradrenergic systems

Possible environmental risk factors in ADHD

pre and perinatal factors

• maternal smoking, alcohol and substance abuse

• maternal stress

• low birth weight and prematurity

environmental toxins

dietary factors and nutritional deficiencies

psychosocial adversity

• family adversity and low income

• conflict parents and children hostility

• early deprivation

Psychological Theories of ADHD

Diathesis -stress theory of ADHD

• Hyperactivity develops when predisposition to disorder is coupled with an authoritarian upbringing (Bettelheim)

• Attention -seeking and hyperactivity

Treatment of ADHD

Stimulant Drugs

• Drugs such as Methylphenidate (Ritalin) used to reduce attention deficit

• Side effects: sleep problems, loss of appetite

• higher prescriptions in recent years

Psychological Treatment of ADHD

• Parent training and changes in classroom management based on operant conditioning principles

• Reinforcement for behaving appropriately

Oppositional Defiant Disorder

Three main themes:

• Pattern of disobedient, hostile, and defiant behaviour towards authority figures

• angry irritable mood

• vindictiveness

  Children with ODD do NOT demonstrate serious violations of societal norms

Conduct Disorder

• More severe than ODD

• Marked by callousness, viciousness, lack of remorse \

  Repetitive pattern of behaviour that includes: 3 or more

• Aggression to people and animals

• bullying, threatening, cruel

• Destruction of property

• Deceitfulness or theft

• Serious violations of rules, rights of others

• CD is a criteria for antisocial personality disorder

• comorbidity with ODC and ADHD

Etiology of CD - Biological Factors in Conduct Disorder

Genetic influences

• Aggressive behaviour clearly heritable

• Delinquent behaviour seems not to be heritable

Neuropsychological deficits

• Poor verbal skills, difficulty w/ executive functioning, problems w/ memory

Neurological correlates (brain imaging studies)

• Possible amygdala dysfunction

Etiology of CD - Psychological, learning and cognitive Factors in Conduct Disorder

• Hostile/ineffective parenting practices

• inconsistent parental discipline and parental adjustment difficulties

Learning theories

• Modelling and operant conditioning

Cognitive Biases

• Social-information processing theory

• Mistaken views of neutral peer behaviour

Etiology of CD -Chaotic social environment

Noise levels, crowding, unpredictability in home and neighbourhood

• higher in communities with more chaos and low-socio economic places

Course of treatment of CD

• Some improvements seen when issues addressed at younger age

• Severe cases typically persist and develop into APD in adulthood

• Family Interventions - Parental Management Training

• Multi-systemic Treatment

• Cognitive Approaches - Anger management - Moral reasoning skills training

Prevention of CD

• Beginning treatment before age 3

• Identifying families and mothers at risk

• Prenatal and postnatal risks in mother:

  • Maternal antisocial behaviour

  • Young age of pregnancy

  • Smoking during pregnancy

  • Maternal depression soon after birth

  • Partner cruelty

  • Harsh parenting

Neurodevelopmental Disorders DSM-5

• Attention-Deficit/Hyperactivity Disorder (ADHD)

• Specific Learning Disorders

• Communication Disorders

• Motor Disorders

• Intellectual Disability Disorder

• Autism Spectrum Disorders (ASD)

Specific Learning Disorders

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

• Not due to intellectual disability autism, a demonstrable physical disorder, or deficient educational opportunities

• Usually have average or aboveaverage intellect

Specific Learning Disorders - Reading disorder

• • Difficulty with word recognition and reading comprehension

• Also known as dyslexia

Specific Learning Disorders - Mathematics disorder -Dyscalculia

Difficulties rapidly and accurately recalling arithmetic facts, counting objects correctly and quickly, or aligning numbers in columns

Specific Learning Disorders - Dysgraphia - disorder of written expression

• difficulties in composing written work

• spelling errors, errors in grammar or very poor handwriting

Etiology of Learning Disorders - Biological Factors

• Heritable component

  • Chromosome 13 is implicated in dyslexia

• Brain Structure Differences

  • Left temporo-parietal cortex ↓ activation in LD

  • Brain area responsible for ‘phonological awareness’

Treatment of Learning Disorders

• 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

Communication disorder - Language Disorder, Communication disorder

Language disorder

• Child sees a car but has trouble communicating the word for it

Communication disorder - Speech Sound Disorder (Phonology Disorder)

• says Wabbit not rabbit

Childhood Onset Fluency Disorder (Stuttering)

• most recover

Motor disorders

Developmental Coordination Disorder

• Marked impairment in motor coordination, such as troubles tying shoelaces, buttoning shirts

• Diagnosis only made if significant impairment

Tourette’s disorder

multiple motor tics and one or more vocal tics

Tics

involuntary, repetitive movements or vocalizations

Intellectual Disability Disorder

• Previously termed Mental Retardation

• Significant limitations in intellectual functioning and adaptive behaviour Diagnostic Criteria

• Intelligence-Test Scores (IQ = 70 or lower)

• Adaptive Functioning (deficits in conceptual skills, social skills and practical skills

Classification Intellectual Disability Disorder

• Four levels of intellectual disability disorder (DSM-5):

• Mild (most common), moderate, severe, profound •

• Use both IQ scores and adaptive functioning to determine severity levels

• Previous DSM-IV-TR classifications (IQ score based):

  • Mild • 50–55 to 70 IQ; 85% of people with Intellectual Disability

  • Moderate • 35-40 to 50-55 IQ; 10%

  • Severe • 20-25 to 35-40 IQ; 3 to 4%

  • Profound • below 20 to 25 IQ; 1-2%

Etiology Intellectual Disability Disorder

No Identifiable Etiology

Accidents and physical abuse. Illnesses such as measles, whooping cough, chicken pox, Hib disease, Reye’s syndrome, exposure to the Zika virus

Etiology Intellectual Disability Disorder - Heredity Disorders (5%)

• Genetic or Chromosomal Anomalies

• Phenylketonuria (PKU); Fragile X syndrome

what is intellectual disability disorder

• Down syndrome, or trisomy 21; maternal alcohol consumption

Late pregnancy and perinatal problems (10%) - etiology of intellectual disability disorder

• Fetal malnutrition, placental insufficiency, prematurity, low birth weight, viral and other infections (e.g., HIV infection)

Environmental Influences (15-20%) - etiology of intellectual disability disorder

• Deprivation, lack of nurturance, reduced stimulation

• Effects of ↓ socio-economic conditions

Prevention and Treatment Intellectual Disability

Environmental Interventions and Enrichment Programs

• Behavioural Interventions Based on Operant Conditioning

• Applied Behaviour Analysis

• Cognitive Interventions

• Self-instructional training

Autism Spectrum Disorder (ASD)

• Consisted of several subcategories, including autistic disorder (autism), Asperger’s Disorder, Rett’s disorder, childhood disintegrative disorder , pervasive developmental disorder – not otherwise specified

• DSM-5 eliminated subcategories since distinctions found to be ‘inconsistent’, more related to:

• symptom severity levels, language levels, intellectual levels • Prevalence is increasing

• Onset: infancy and early developmental period

• Comorbidity: depression, anxiety, ADHD

Autism Spectrum Disorder (ASD) Characteristics

• Deficits in social communication and social interaction

• Troubles adjusting behaviour in changing social contexts

• Limited imaginative play

• Repetitive and rigid behaviour (insistence on sameness)

• Unusual motor movements

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

Extreme Autistic Aloneness, Communication Deficits, • Obsessive-Compulsive and Ritualistic Acts

Extreme Autistic Aloneness

• Rarely engage others in play

• Fail to offer spontaneous greetings

Communication Deficits

• Echolalia echo speech

• Pronoun reversal

Obsessive-Compulsive and Ritualistic Acts

• Upset easily over changes

• Prone to stereotypic behaviour

Etiology of ASD - Psychological bases

• Psychoanalytic and behavioural perspectives

• It was previously thought that parents play a crucial role in ASD

• This is not credible and it is cruel

Etiology of ASD - genetic factors

• risk of autism in siblings of people with the disorder is about 75% higher

• fragile X syndrome - chromosome abornmalities

  • linked genetically to broader spectrum of deficits in communications and social areas

  • autism reflects exceeding complex variation, more than 1000 genes

Etiology of ASD - neurological factors and environmental risks

• epileptic seizures

• abnormal brainwave patterns

• Possible brain regions implicated include:

• Cerebellum

• Amygdala and corpus callosum

• Medial frontal cortex and medial temporal cortex

• possible role of: maternal infections, drugs, and toxicants as well as metabolic and nutritional factors

Treatment of ASD

• early intervention is critical to providing a better chance of success in school and in living independently

• treatments that are most effective using modelling and operant conditioning

  • early intensive behavioural intervention

  • most effective if delivered early

  • children with higher initial cognitive levels and fewer early social interaction deficits show best response

Disorders of Overcontrolled Behaviour

• Separation Anxiety (now included among Anxiety Disorders)

• Social Phobia (also known as Social Anxiety)

• Selective Mutism

• Specific Phobia

• Generalized Anxiety Disorder

• Obsessive-Compulsive Disorder

• Post-Traumatic Stress

• Panic Disorder Depression

Childhood Fears and Anxiety Disorders

• most common disorder in childhood

• some anxious children report helicopter parents style

Separation Anxiety Disorder

Unrealistic concern about separation from major attachment figures

• 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

Social Phobia

• Extremely quiet, shy, avoid strangers

• May include selective mutism

Theories of social phobia in children

• individual differences in behavioural inhibition

• Higher risk when parent has social phobia

Treatment of Fears and Phobias in Children

• 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