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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