Chapter Seventeen: Disorders Common Among Children and Adolescents

Childhood and Adolescence

• Close to half of all children in the US have multiple fears
• Bullying is a major problem
  • Over 20% of students report being bullied frequently kids who’ve been bullied react with feelings of humiliation, anxiety, or dislike for school
  • May attempt suicide
  • Psychological effects of being bullied can carry on far into adulthood
  • Cyberbullying: Bullying and humiliating by email, texts, and social media
• ⅕ of all children and adolescents in North America experience a diagnosable psychological disorder
  • Boys with disorder outnumber girls

Childhood Anxiety Disorders

• Anxiety is a normal part of childhood
• Children may be strongly affected by parental problems or inadequacies
• Anxiety Disorder: When one’s everyday anxieties become long-lasting and debilitating, interfering with their daily lives and their ability to function appropriately
• 14-25% of all children and adolescents experience an anxiety disorder
• Some patterns of anxiety can’t fully unfold until children have more cognitive, physical, and emotional growth
• Anxiety disorders of young children are dominated by behavioral and somatic symptoms
  • Clinging
  • Sleep difficulties
  • Avoidance
  • Irritability
  • Stomach pains
• Anxiety symptoms are more often triggered by thoughts about events that could happen in the future

Separation Anxiety Disorder and Selective Mutism

• Separation Anxiety Disorder: When children have enormous difficulty being away from their parents or other major attachment figures and are often reluctant to go anywhere where they might be separated from their parents
  • Most common anxiety disorder among children
  • Often begins as early as the preschool years
  • School Refusal: Children fear going to school and often stay home for a long period
• Selective Mutism: Children consistently fail to speak in certain social situations, but show no difficulty at all speaking in others
  • 1% of all children display this disorder
  • Believed to be an early version of social anxiety disorder
  • Some children with this disorder have significant delays in their development of communication and language skills
  • May be misclassified as having an intellectual disability

Treatments for Childhood Anxiety Disorders

• ⅔ of anxious children go untreated
• Cognitive-behavioral therapy works the best
• Antidepressant drugs are particularly helpful for severely anxious children
• Combining cognitive-behavioral therapy and antidepressant drug therapy led to the most favorable outcome
• Play Therapy: Children express their conflicts and feelings indirectly by drawing, playing with toys, and making up stories
• Child-centered Therapy: Clinician listens carefully to the child, reflects on what the child is saying, shows empathy, and gives unconditional positive regard

Depressive and Bipolar Disorders During Childhood

• 2% of children and 8% of adolescents currently experience a major depressive disorder
• Children can experience a bipolar disorder

Major Depressive Disorder

• Children
  • Very young children lack some of the cognitive skills that help produce clinical depression
  • If life situations or biological predispositions are significant enough, even very young children sometimes have severe downturns of mood
  • May be triggered by negative life events, major changes, rejection, or ongoing abuse
  • Symptoms: Irritability, headaches, stomach pain, disinterest in toys and games
• Adolescents
  • Much more common in teens than among young children
  • 1 in 8 teens persistently thinks about suicide each year
  • Girls are twice as likely as boys to be depressed by age 16
  • Hormonal changes
  • Teenage girls’ growing body dissatisfaction
  • Family-focused approaches
  • Antidepressants alone are more helpful than cognitive-behavioral therapy alone
  • CBT and antidepressants more helpful together than either alone
  • Antidepressants may be dangerous for some depressed children and teens
  • May produce an increase in the risk of suicidal behavior for certain children and adolescents
    • That show where they go to a retreat and the lady drugs them
  • Overall risk of suicide is reduced for the vast majority of children who take the drugs

Bipolar Disorder and Disruptive Mood Dysregulation Disorder

• Diagnosis of bipolar disorder may have been overapplied to children and adolescents and been assigned to the majority of extremely explosive, aggressive children
  • Rage, aggression, and depression were dominating the clinical picture of most children who were receiving a bipolar diagnosis
  • Many children weren’t even displaying the symptoms of mania or mood swings
  • ⅔ receiving diagnosis were boys, but adult men and women have bipolar in equal numbers
• Disruptive Mood Dysregulation Disorder: A childhood disorder marked by severe recurrent temper outbursts along with a persistent irritable or angry mood

Oppositional Defiant Disorder and Conduct Disorder

• Oppositional Defiant Disorder: A disorder in which children are repeatedly argumentative, defiant, angry, irritable, and perhaps vindictive
  • 10% of children qualify for a diagnosis of oppositional defiant disorder
  • More common in boys than in girls before puberty
  • Equal in both genders after puberty
• Conduct Disorder: A disorder in which children repeatedly violate the basic rights of others and display significant aggression
  • Usually begins between 7 and 15 years
  • ¾ boys
  • Those with a relatively mild conduct disorder often improve over time
  • Those with a severe case may continue into adulthood and develop into antisocial personality disorder and/or a criminal lifestyle
  • The earlier the onset of the conduct disorder, the poorer the eventual outcome
  • 80% of those who develop this disorder first display a pattern of oppositional defiant disorder
  • More than ⅓ of children with conduct disorder also display ADHD
  • A number experience depression and anxiety
  • Several kinds of conduct disorder
  • Overt-destructive Pattern: Individuals display openly aggressive and confrontational behaviors
  • Overt-nondestructive Pattern: Pattern dominated by openly offensive but non-confrontational behaviors
  • Covert-destructive Pattern: Characterized by secretive destructive behaviors
  • Covert-nondestructive Pattern: Individuals secretly commit nonaggressive behaviors different patterns may have different causes
  • Relational Aggression: The individual is socially isolated and primarily performs social misdeeds
  • More common in girls than boys
  • Many children with conduct disorder are suspended from school, placed in foster homes, or incarcerated
  • Juvenile Delinquents: Children between the ages of 8 and 18 who break the law
  • Recidivists: When criminals and delinquents have a history of being arrested

What Are the Causes of Conduct Disorder?

• Drug abuse, poverty, traumatic events, and exposure to violence
• Genetic and biological factors
  • MAOA gene
• Troubled family life

How Do Clinicians Treat Conduct Disorder?

• Generally most effective with children younger than 13
• Parent Management Training: A treatment approach for conduct disorder in which therapists combine family and cognitive-behavioral interventions to help improve family functioning and help parents deal with their children more effectively
  • Parent-child Interaction Therapy: Therapists teach parents to work with their child positively and establish appropriate expectations regarding the child
  • Video Modeling: Family intervention tool for preschoolers that uses video tools to help achieve the same goals as parent-child interaction therapy
  • Videoconferencing: Using webcams, a therapist coaches parents through their family interactions
  • Multisystemic Therapy: Approach that aims to make changes across multiple contexts of children’s lives - family dynamics, schools, social lives, community
• Child-Focused Treatments
  • Problem-solving Skills Training: Therapists combine modeling, practice, role-playing, and systematic rewards to help teach children constructive thinking and positive social behaviors
  • Coping Power Program: Child-focused approach in which children with conduct problems participate in group sessions that teach them to manage their anger more effectively
  • Stimulant drugs may help reduce children’s aggressive behaviors at home and school
• Residential Treatment
  • Treatment foster care: Delinquent children with conduct disorders are assigned to a foster home in the community by the juvenile justice system
  • Shildren, foster parents, and birth parents all receive training and treatment interventions
  • Children and their parents continue to receive treatment and support after the children leave foster care
  • Juvenile training centers
  • Not much success
  • Strengthen delinquent behavior
• Prevention
  • Change unfavorable social conditions before a conduct disorder is able to develop
  • Seek to ease the stress of poverty
  • Promote more positive school environments
  • Improve parents’ child-rearing skills

Elimination Disorders

• Children repeatedly urinate or pass feces in their clothes, in bed, or on the floor, and these symptoms aren’t caused by physical illness

Enuresis

• A childhood disorder marked by repeated bed-wetting or wetting of one’s clothes

• Typically occurs at night during sleep but may also occur during the day

• Children may be at least 5 yrs to receive this diagnosis

• May be triggered by stressful events

• Prevalence decreases with age

• Those with this disorder typically have a close relative who has had or will have the same disorder

• Theories

  • Psychodynamic theory: This is a symptom of broader anxiety and underlying conflicts
  • Family theory: This is the result of disturbed family interactions
  • Cognitive-behavioral theory: This is the result of improper, unrealistic, or coercive toilet training
  • Biological theory: Children with this disorder often have a small bladder capacity, weak bladder muscles, and/or disturbed sleep patterns

• Most cases correct themselves even without treatment

• Bell-and-Battery Technique: Common cognitive-behavioral treatment where a bell wakes the child as they start to wet

• Dry-Bed Training: Children receive training in cleanliness and retention control, are awakened periodically during the night, practice going to the bathroom, and are appropriately rewarded

Encopresis

• A childhood disorder characterized by repeated defecating in inappropriate places, such as one’s clothing

• Less common than enuresis

• Seldom occurs at night during sleep

• Usually involuntary, starts at the age of 4+, and affects 1.5-4% of all children much

• More common in boys than in girls

• Causes intense social problems, shame, and embarrassment

• Biological factors: Constipation, stress, improper toilet training

• Physical factors are very often linked to this disorder

• Treatments

  • Interventions to eliminate the child’s constipation
  • Biofeedback training to help the children better detect when their bowels are full
  • Stimulation of regular bowel functioning family
  • Therapy

Neurodevelopmental Disorders

• A group of disabilities in the functioning of the brain that emerge at birth or during very early childhood and affect a person’s behavior, memory, concentration, and/or ability to learn

Attention-Deficit/Hyperactivity Disorder

• A disorder marked by the inability to focus attention, or overactive and impulsive behavior, or both

• Often appears before the child starts school

• ½ also have learning or communication problems

• 7% of all children display ADHD at any given time

• As many as 70% of them are boys

• Those whose parents have had ADHD are more likely than others to develop it

• Usually persists throughout childhood, and 60% continue to have it as adults

• Symptoms of restlessness and overactivity are not usually as pronounced in adult cases

• Symptoms of hyperactivity and inattentiveness must be present across multiple settings in order for ADHD to be diagnosed

• Causes

  • Certain children have a predisposition to display inattention, impulsivity, and overactivity
  • Symptoms of poor attention are understood as a breakdown in the balance between Type 1 and Type 2 attention processes
  • ADHD has been linked to high levels of stress and to family dysfunction
  • These factors interfere with the development of effective Type 2 attention processes
  • ADHD symptoms and a diagnosis of ADHD may themselves create interpersonal problems and produce further symptoms in the child

• Treatment

  • 80% of all children and adolescents with ADHD receive treatment
  • Drug Therapy
  • Methylphenidate: A stimulant drug commonly used to treat ADHD
  • Most common treatment
  • ADHD is overdiagnosed in the US
  • Stimulant medication can improve children’s attention and behavioral control in the short term, but doesn’t necessarily lead to meaningful long-term improvements
  • Stimulant medications are safe for the majority of ppl with ADHD
  • In a small number of cases, the medications may increase the risk of developing mild tremors or tics, developing psychotic symptoms, or having a heart attack
  • Can affect the growth of some children
  • Children must take periodic breaks from the medications (drug holidays)
  • Cognitive-Behavioral Therapy and Combination Therapies
  • Parents and teachers are taught how to apply the principles of operant conditioning
  • Token Economy Program: Children receive tokens whenever they attend and respond appropriately, and the tokens can later be exchanged for rewards of various kinds
  • Parent Management Training: Cognitive-behavioral techniques are combined with family interventions to help them deal with their children more effectively
  • School interventions
  • Summer treatment programs
  • Children with ADHD may improve most when they receive a combination of stimulant drug therapy and the cognitive-behavioral treatments we have been discussing

• Multicultural Factors and ADHD

  • African American and Hispanic American children with significant attention and activity problems are less likely to be assessed for, receive a diagnosis of, or undergo treatment for ADHD
  • Children from racial/ethnic minorities are less likely to be treated with stimulant drugs or a combination of stimulants and cognitive-behavioral therapy
  • Economic factors: Poorer children are less likely to be identified as having ADHD
  • Social bias and stereotyping
  • Children from minority backgrounds may be underdiagnosed and undertreated

Autism Spectrum Disorder

• A developmental disorder marked by extreme unresponsiveness to others, severe communication deficits, and highly repetitive and rigid behaviors, interests, and activities

• Symptoms usually appear before 3 years of age

• Steady increase in the number of children diagnosed with ASD

• 80% boys

• As many as 90% of children with the disorder remain significantly disabled into adulthood

• Have enormous difficulty maintaining employment, performing household tasks, and leading independent lives

• Lack of responsiveness and social reciprocity

  • Extreme aloofness
  • Lack of interest in other people
  • Low empathy
  • Inability to share attention with others
  • Central feature of autism

• Communication problems

  • Great difficulty understanding speech or using language for conversational purposes
  • Rigid and repetitive speech patterns
  • Echolalia: The exact echoing of phrases spoken by others
  • Pronominal Reversal: Confusion of pronouns

• Nonverbal behaviors are often at odds with their efforts at verbal communication

  • Not using a proper tone when talking
  • Displaying few or no facial expressions or body gestures
  • Incapable of maintaining proper eye contact during interactions

• Highly rigid and repetitive behaviors, interests, and activities

  • Become very upset at minor changes in objects, persons, or routines and resist any efforts to change their own repetitive behaviors
  • Preservation of sameness
  • Strongly attached to particular objects

• Motor movements - unusual, rigid, and repetitive

  • Self-stimulatory behaviors
  • Self-injurious behaviors

• Hyperreactivity: When individuals seem overstimulated by sights and sounds and appear to be trying to block them out

• Hyporeactivity: When individuals seem understimulated and appear to be performing self-stimulatory actions

• Causes

  • Sociocultural Causes
  • Primary cause was first thought to be family dysfunction
  • Refrigerator Parents: Parents who are very intelligent yet cold
  • Psychological Causes
  • People with ASD have a central cognitive disturbance that makes normal communication and interactions impossible
  • Theory of Mind: An awareness that other people base their behaviors on their own beliefs, intentions, and other mental states, not on information that they have no way of knowing
    • By 3-5 ys, most neurotypical children can take the perspective of another person into account and use it to anticipate what the person will do
    • Children with autism have an impaired theory of mind
  • Deficiencies in joint attention
    • Difficulty sharing focus with other people on items and events in their immediate surroundings
  • Biological Causes
  • Genetic factor
    • Prevalence of autism among their siblings is 10-20%, a rate much higher than the general populations
    • Prevalence of autism among the identical twins of people with the disorder is 60%
    • Specific genes can increase the likelihood of developing ASD
  • Prenatal difficulties or birth complications
    • Rubella during pregnancy
    • Exposure to toxic chemicals before or during pregnancy
    • Complications during labor or delivery
  • Biological Factors
    • Cerebellum develops and functions abnormally beginning very early in life
    • Flawed communication among brain structures
    • Two or more circuits in the brain are dysfunctional in ppl with this disorder
  • MMR vaccine theory: The vaccine for measles, mumps, and rubella might produce autistic symptoms in some children
    • Unfounded in science
    • Research has argued against this theory

• Treatment

  • Cognitive-Behavioral Therapy
  • Communication Training
  • ⅓ of ppl with ASD remain speechless, so they are taught other forms of communication
  • Sign Language
  • Simultaneous Communication: A method combining sign language and speech
  • Augmentative Communication Systems / Communication Boards: Computers that use pictures, symbols, or written words to represent objects or needs
  • Child-initiated interactions
  • Improve joint attention
  • Parent Training
  • Cognitive-behavioral programs: Train parents so that they can apply conditioning and skill-building techniques at home
  • Individual therapy and support groups are becoming more available to help the parents of children with autism deal with their own emotions and needs
  • Community Integration
  • Self-help, self-management, and living, social, and work skills to help the individuals function better in their communities
  • Group jokes and sheltered workshops

Intellectual Disability

• A disorder marked by intellectual functioning and adaptive behavior that are well below average

• Low IQ (a score of 70 or below) and great difficulty in areas like communication, home living, self-direction, work, or safety

• Symptoms must appear before the age of 18

• Assessing Intelligence

  • Intelligence Quotient: A score derived from intelligence tests that theoretically represents a person’s overall intellectual capacity
  • Accuracy of IQ tests at measuring extremely low intelligence has not been evaluated adequately

• Assessing Adaptive Functioning

  • Some people with a low IQ are quite capable of managing their lives and functioning independently, while others aren’t
  • Clinicians should observe the adaptive functioning of each individual in their everyday environment

• Person learns very slowly

• Difficulty in attention, short-term memory, planning, and language

• Mild ID

  • IQ 50-70
  • Individuals can benefit from schooling and can support themselves as adults
  • Not usually recognized until children enter school and are assessed there
  • Demonstrate rather typical language, social, and play skills
  • Need assistance when under stress
  • Intellectual performance seems to improve with age
  • Linked to sociocultural and psychological causes
  • Poor and unstimulating environments during a child’s early years
  • Inadequate parent-child interactions
  • Insufficient learning experiences
  • Biological Factors
  • Mother’s moderate drinking, drug use, or malnutrition during pregnancy
  • Malnourishment during a child’s early years

• Moderate ID

  • IQ 35-49
  • Typically receive their diagnosis earlier in life
  • Demonstrate clear deficits in language development and play during their preschool years
  • Manage to develop a fair degree of communication skill, learn to care from themselves, benefit from vocational training, and can work in unskilled or semiskilled jobs

• Severe ID

  • IQ 20-34
  • 3-4% of people with intellectual disabilities
  • Demonstrate basic motor and communication deficits during infancy
  • Many also show signs of neurological dysfunction and have an increased risk for brain seizure disorder
  • Require careful supervision, profit somewhat from vocational training, and can perform only basic work tasks
  • Understanding of communication is usually better than speech
  • Often appear as part of larger syndromes that include severe physical handicaps

• Profound ID

  • IQ below 20
  • 1-2% percent of all people with intellectual disability
  • Very noticeable at birth or early infancy
  • Need a very structured environment with close supervision and considerable help
  • Often appear as part of larger syndromes that include severe physical handicaps

• Biological Causes

  • Chromosomal Causes
  • Down Syndrome
    • Trisomy 21 - A person has three free-floating 21st chromosomes instead of two
    • Range in IQ from 35-55
  • Fragile X syndrome
    • Born with an X chromosome with a genetic abnormality that leaves it prone to breakage
    • Displays mild to moderate degrees of intellectual dysfunction, language impairments, and behavioral problems
  • Metabolic Causes
  • The body’s breakdown or production of chemicals is disturbed
  • Typically caused by the pairing of two defective recessive genes
  • Phenylketonuria: When a person can’t break down the amino acid phenylalanine, and the chemical builds up and is converted into substances that poison the system
    • Causes severe intellectual dysfunction and several other symptoms
    • If started on a special diet before 3 months of age, they may develop normal intelligence
  • Tay-Sachs
    • Children progressively lose their mental functioning, vision, and motor ability over the course of 2-4 years
    • Will eventually die
    • 1 of every 900 Jewish couples is at risk for having a child with Tay-Sachs
  • Prenatal and Birth-Related Causes
  • Severe congenital hypothyroidism
    • Caused when a pregnant woman has too little iodine in her diet
    • Abnormal thyroid gland, slow development, intellectual disability, dwarflike appearance
    • May quickly be given thyroid extract to bring about normal development
  • Fetal Alcohol Syndrome: A group of problems in a child that result from excessive alcohol intake by the mother during pregnancy
  • Certain maternal infections during pregnancy (ex: rubella, syphilis)
  • Anoxia: Prolonged period without oxygen during or after delivery
  • Some babies with a premature birth weight of less than 3.5 pounds display low intelligence
  • Childhood Problems
  • Lead poisoning
  • Meningitis and Encephalitis can lead to intellectual disability if not diagnosed and treated in time

• Interventions

  • Proper Residence
  • Small institutions and other community residences that teach self-sufficiency, devote more staff time to patient care, and offer educational and medical services
  • Normalization: The principle that institutions and community residences for people with intellectual disability should provide living conditions and opportunities similar to those enjoyed by the rest of society
  • Vast majority of children with ID live at home
  • Educational Programs
  • Special Education: Children with ID are grouped together in a separate, specially designed educational program
  • Mainstreaming / Inclusion: The placement of children with intellectual disability in regular school classes
  • Teacher preparedness
    • Brief training courses
    • Operant conditioning principles
    • Spacing: Operant conditioning principle in which one breaks down learning tasks into small steps, giving positive reinforcement for each increment of progress
    • Token economy programs
    • Individualized Education Program: An education program that details the support services, therapies, and special accommodations to be afforded the child in order for them to achieve proper educational goals
  • When is Therapy Needed?
  • 30% or more have a psychological disorder other than intellectual disability
  • Some suffer from low self-esteem, interpersonal problems, and difficulties adjusting to community life
  • Large numbers also take psychotropic medications
  • Increasing Opportunities for Personal, Social, and Occupational Growth
  • Youth clubs - encourage those with ID to take risks and function independently
  • Special Olympics
  • Dating skills programs
  • Some states restrict marriage for people with ID
  • Sheltered Workshops: Protected and supervised workplaces that train adults with ID to work at a pace and level tailored to their abilities

Clinicians Discover Childhood and Adolescence

• Treatments typically fall short unless clinicians educate and work with the family as well
• A narrow focus on any one model can lead to problems

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