Childhood Disorders

impulse control disorders

• examples

  • Two disorders that usually present in childhood:

    • Oppositional defiant disorder

    • Conduct disorder

  • Intermittent explosive disorder

  • Kleptomania

  • Pyromania

• Develop stress reduction skills (relaxation)

• Challenge distressing thoughts (thoughts related to the need to perform the behaviour)

• Prevent damaging behaviours (observe and change behaviours that consistently lead to the problem behaviour)

• Develop emotion regulation and distress tolerance skills

• Develop problem-specific coping skills (scripted response to an anger producing situation)

oppositional defiant disorder

• A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

  • Often loses temper

  • Often touchy or easily annoyed by others

  • Often angry and resentful

  • Often argues with authority figures

  • Often actively defies or refuses to comply with adults' requests or rules

  • Often deliberately annoys people'

  • Often blames others for his or her mistakes or misbehavior

  • Has been spiteful or vindictive twice in the last six months

• Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level

• Prevalence between 1 and 11 percent, slightly more common in males

conduct disorder

• A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:

  • Aggression to people and animals

  • Destruction of property

  • Deceitfulness or theft

  • Serious violations of rules

• If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder

• Specifiers:

  • Onset (Childhood or Adolescent)

  • Severity (mild, moderate or severe)

  • With limited prosocial emotions, including at least two of:

    • lack of remorse/guilt,

    • callous lack of empathy,

    • unconcerned about performance,

    • shallow of deficient affect

• Prevalence of about 3%, and more common in males

• Adolescent onset has the best outcome; it is more likely to represent a “rebellious phase” or a reaction to the stressors of adolescence than core personality traits

• Associated with lower than average IQ, ADHD, learning disabilities, anxiety disorders, mood disorders, and substance disorders

• Care must be taken to avoid making a diagnosis when the behaviour is protective (high-crime environment, impoverishment)

intermittent explosive disorder

• Recurrent behavioural outbursts representing a failure to control aggressive impulses, by at least one of:

  • Verbal or physical aggression twice per week for 3 months

  • At least three serious outbursts that cause damage to physical property or assault against a person or animal within a 12-month period

  • The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors

  • Not premeditated

  • At least 6 years old

  • Onset usually in childhood to early 20s

  • Sometimes experience “sub-threshold” episodes of anger or rage

  • One year prevalence is around 2.5%, and decreases with age

  • Tends to be chronic and persisting

  • Maybe slightly more common in males than females, but the research is not clear

kleptomania

• Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value

• Increasing sense of tension immediately before committing the theft

• Pleasure, gratification, or relief at the time of committing the theft

• The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination

• Twice as common in women than men

• About 5% of identified shoplifters

• Individuals with kleptomania often feel extreme guilt afterwards and return the stolen item!

• Although theft is not planned, individuals are often able to resist stealing when there is a high chance of being caught

• Differential diagnosis with Malingering!

pyromania

• Deliberate and purposeful fire setting on more than one occasion

• Tension or affective arousal before the act

• Fascination with, interest in, curiosity about, or attraction to fire and its situational contexts (e.g., paraphernalia, uses, consequences)

• Pleasure, gratification, or relief when setting fires, or when witnessing or participating in their aftermath

• The fire setting is not done for monetary gain, as an expression of sociopolitical ideology, to conceal criminal activity, to express anger or vengeance, to improve one's living circumstances, in response to a delusion or a hallucination, or as a result of impaired judgment (e.g., in Dementia, Mental Retardation, Substance
  Intoxication)

• Often involves substantial advance planning (then is that really an
  “impulse”?)

• Indifferent to property damage, or satisfaction in destruction

• Over 40% of people arrested for arson are under 18, but few of these individuals would qualify for a diagnosis of pyromania
  

intellectual disability

• A disorder with onset during the developmental period that includes
  both intellectual and adaptive functioning deficits in conceptual, social, and practical domains.

• diagnostic criteria

  • A. 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

  • B. 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.

  • C. Onset of intellectual and adaptive deficits during the developmental period.

• Specifiers: mild, moderate, severe, profound

• The DSM5 lists descriptions of each level of severity for three areas of adaptive functioning

  • Conceptual, Social, Practical

  • Ongoing support must be needed in at least one of these domains for ID to be diagnosed

• Adaptive behaviour (social, motor, self-care, communication) often measured by collateral report, direct observation

• Scores on IQ tests are approximately 2 SD below the population mean, but the specific numerical cutoff has been removed from the diagnostic criteria

• Equally prevalent in males and females

• Usually diagnosed by the time of elementary school

  • Later diagnosis usually occurs in families in which the parents are themselves lower functioning

intellectual disability - etiology

• ID is defined by level of impairment regardless of etiology – Equifinality

• Numerous biological and environmental causes have been identified

  • Prenatal (chromosomal, metabolic, environmental)

  • Perinatal (intrauterine, neonatal)

  • Postnatal (brain injury, infection, seizures, toxins, malnutrition, abuse/neglect)

• Trisomy 21 (Down's syndrome)

  • Mild to severe intellectual impairment

  • Health problems (gastrointestinal, heart disease)

  • Increased risk of Alzheimer's dementia

• Fetal alcohol syndrome

  • Distinctive facial features, smaller head circumference, mild to severe cognitive problems, executive functioning impairments, characteristic behavioural problems (impulse
    control, ADHD, etc)

  • “Fetal alcohol effects” used to described individuals with more mild symptoms who do not meet diagnostic criteria

intellectual disability - treatment

• Prevention

  • Nutrition, toxic exposure, environmental impoverishment, maternal health

• Normalization

  • Move towards community settings, started in 1980s

  • Contrasts with the segregation/institutionalization movement in the past

  • There is a difficult balance to maintain between autonomy and protection

Autism Spectrum Disorder (ASD)

• Impairment in social communication and social interaction:

  • Deficits in social-emotional reciprocity

  • Deficits in nonverbal communicative behaviours

  • Deficits in developing, maintaining, and understanding relationships

• Restricted or stereotyped patterns of behaviour, interests, or activities, manifested by at least 2 of:

  • Stereotyped or repetitive motor movements

  • Insistent on sameness, inflexible adherence to routines

  • Highly restricted, fixed interests that are abnormal in intensity/focus

  • Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of the environment

• Symptoms present from an early age, and cause clinically significant impairment

• For each of the two main features (social communication and restricted repetitive behaviours), the clinician rates the severity: requires support, requires substantial support, requires very substantial support

• Other specifiers: with or without language impairment, with or without intellectual disability, associated with known medical/genetic/environmental factor, with catatonia

• 3-5x greater prevalence in boys than girls

• Prevalence appears to have changed over time (DSM-5: around 1 in 100)

autism - etiology

• Mostly genetic: Heritability of 70-80%

  • Family members often express a “broader phenotype”
    or similar cognitive/behavioural features that are more
    mild

• Can occur in the context of some rare neurological/medical conditions

• Regardless of the root cause, converging causal pathways affect brain structure and function

  • Frontal disconnection syndrome?

• The “Extreme Male Brain” hypothesis

  • Thinking styles can be roughly organized in terms of
    “systematizing” and “empathizing,” and these styles of thinking are not equally distributed across genders

  • Autism represents an extreme example of the “normal” style of thinking for boys and men, and relates to prenatal testosterone exposure

  • There may be a higher prevalence of autism among transgender people

  • The theory is limited by the fact that “systematizing and
    “empathizing” have not been shown to be innate or biological,
    and could be related to early socialization

other autism spectrum disorders

• Asperger's Disorder (removed from DSM5 as a separate disorder)

  • Restricted interests and poor social communication, in the context of normal intellectual and adaptive functioning

  • Social language is impaired, but vocabulary and other language abilities are generally normal (unlike high functioning autism)

ASD - treatment

• Intensive behavioural intervention is one of the best supported approaches, although access to treatment is quite limited

• Perhaps because autism is so distressing to parents, quackery is
  more prevalent in autism treatment than most other psychological
  disorder

  • “Facilitated communication”

  • Use of most pharmaceuticals has little empirical support, though antipsychotic medications may provide short term control of behaviour

  • Vitamins, nutrition, and exercise may help manage some symptoms slightly (usually much less than is claimed)

Attention Deficit/Hyperactivity Disorder (ADHD) diagnostic criteria

• A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2):

• 1) Inattention: 6 or more (5 in adults) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

• 2) Hyperactivity and impulsivity: 6 or more (5 in adults) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

• Several symptoms were present prior to age 12 years.

• Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (home, school, or work; in other activities).

• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

• The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal)

ADHD impulsivity

• 6 or more (5 in adults) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

  • Often fails to give close attention to details, careless mistakes

  • Often has difficulty sustaining attention in tasks or play activities

  • Often does not seem to listen when spoken to directly

  • Often does not follow through on instructions and fails to finish tasks at work or school

  • Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

  • Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort

  • Often loses things necessary for tasks or activities

  • Is often easily distracted by extraneous stimuli

  • Is often forgetful in daily activities

ADHD hyperactivity and impulsivity

• 6 or more (5 in adults) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

  • Often fidgets with or taps hands or feet or squirms in seat.

  • Often leaves seat in situations when remaining seated is expected

  • Often runs about or climbs in situations where it is inappropriate

  • Often unable to play or engage in leisure activities quietly

  • Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with)

  • Often talks excessively

  • Often blurts out an answer before a question has been completed

  • Often has difficulty waiting his or her turn

  • Often interrupts or intrudes on others

ADHD

• Specifiers:

  • Combined presentation: If both Criterion A1 (inattention) and
    Criterion A2 (hyperactivity-impulsivity) are met for the past 6
    months

  • Predominantly inattentive presentation: If Criterion A1
    (inattention) is met but Criterion A2 (hyperactivity-impulsivity)
    is not met for the past 6 months

  • Predominantly hyperactive/impulsive presentation: If Criterion
    A2 (hyperactivity-impulsivity) is met and Criterion A1
    (inattention) is not met for the past 6 months

• Prevalence of about 5% of children and 2.5% of adults

• Hyperactive type more common in boys and men (esp among kids), and inattentive type more common in girls and women

• ADHD can be under-diagnosed and/or over-diagnosed

• Heritability up to 75%, and prenatal environmental factors
  also implicated

• The prefrontal and frontostriatal dysfunction appears to
  underlie neuropsychological deficits in ADHD, resulting in
  problems with executive functioning (planning, inhibition, sequencing, time estimation, hypo/hyper-focus)

  • Dysfunction of initiation and termination may underlie the
    relationships between ADHD and OCD, and ADHD and
    Tourette’s

  • In neuropsychological assessment, we usually see deficits
    in academic performance, IQ (esp: processing speed), and
    sustained attention

• Please ignore anyone who connects the etiology of ADHD with TV, video games, or sugar

ADHD - treatment

• Untreated (and especially undiagnosed) ADHD can have significant implications into adulthood, in terms of personality, substance use, other mental illness, academic and vocational achievement

  • 25% with anxiety disorders and major depression

  • Up to 50% with behavioural disorders in childhood (CD, ODD)

  • 20% with sleep disorders

  • Rejection-sensitivity dysphoria and justice-sensitivity dysphoria

• Treatment is usually stimulant medication (Adderall, Ritalin)

• Non-pharmacological approaches to management:

  • ADHD Coaching

  • Management of other conditions

  • Academic and vocational accommodations

  • Auditory beat stimulation (binaural beat)

Tic Disorders

• Tourette's disorder

  • Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently

  • The tics may wax and wane in frequency but have persisted for more than 1 year since first tic onset

  • Onset is before age 18 years

• Persistent (Chronic) Motor or Vocal Tic Disorder

  • Limited to motor or vocal tics, but not both

• Provisional Tic Disorder

  • Less than one year duration

• Coprolalia (involuntary swearing) is actually uncommon (less then 10% of individuals with Tourette's)

• Onset usually before age 7, and 2-4x more common in boys than girls

• Most tics are transient, which is why there are duration criteria for the two diagnoses

• Course is variable, but most tics decrease in frequency and intensity in adolescence and early adulthood

• Frequency of tics is often related to level of stress Tourette's, ADHD, and Obsessive- compulsive disorder constitute a triad of disorders that often occur together

externalizing disorders - treatment

• these disorders are a group of mental health conditions characterized by outward behaviors that reflect the individual's negative emotions and actions directed at the environment

• treatment

  • Stimulant medication

  • Environmental and educational adaptations/accommodations

  • Much of the therapy for these disorders takes place with the parents only

other mental disorders in children

• Specific Learning Disorder

  • With impairment in reading/written expression/mathematics

• Communication disorders

  • Social (Pragmatic) Communication Disorder

  • Stuttering (Childhood onset fluency disorder)

• Eating disorders

  • Pica

  • Rumination disorder

• Children can be diagnosed with almost any mental illness that
  an adult can be diagnosed with

• The manifestations of the disorders can differ significantly from what is seen in adults

  • Depression – irritability instead of sadness

  • Anorexia – failure to make expected gains

  • Schizophrenia – failure to make developmental gains

  • Time criteria often reduced

  • Need for insight is often not required for diagnosis (anxiety, psychotic disorders)