Lecture 7- childhood disorders

Overview of Childhood Disorders

• Conceptual Framework:

  • Externalising Disorders: These create problems for the external world. They are characterized by breaking age-appropriate social rules, disobeying authority figures (parents and teachers), anger, aggression, and impulsivity.

  • Internalising Disorders: These create problems for the individual's internal world. They are primarily characterized by anxiety and sadness.

• Broad Categories of Childhood Disorders:

  • Neurodevelopmental Disorders: Intellectual disabilities, communication disorders, Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), specific learning disorders, and motor disorders.

  • Depressive Disorders: Includes Disruptive Mood Dysregulation Disorder.

  • Anxiety Disorders: Separation Anxiety Disorder and Selective Mutism.

  • Obsessive-Compulsive and Related Disorders.

  • Trauma and Stressor-Related Disorders: Reactive Attachment Disorder and Disinhibited Social Engagement Disorder.

  • Feeding and Eating Disorders: Pica, Rumination Disorder, Anorexia Nervosa (typically adolescence), and Bulimia Nervosa (typically adolescence).

  • Elimination Disorders: Enuresis and Encopresis.

  • Disruptive, Impulse-Control, and Conduct Disorders: Oppositional Defiant Disorder (ODD), Intermittent Explosive Disorder, and Conduct Disorder (CD).

Attention-Deficit/Hyperactivity Disorder (ADHD)

• DSM-5-TR Diagnostic Criteria:

  • Criterion A: A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development.

    • A1 (Inattention): $6$ or more symptoms for at least $6$ months.

    • A2 (Hyperactivity and Impulsivity): $6$ or more symptoms for at least $6$ months.

    • Note for Adolescents/Adults: For individuals aged >=17 years, only $5+$ symptoms are required for a period of $6$ months.

  • Criterion B: Several symptoms must have been present before the age of $12$ years.

  • Criterion C: Symptoms must be present in two or more settings (e.g., home, school, work, with friends/relatives, or other activities).

  • Criterion D: Clear evidence that symptoms interfere with or reduce the quality of social, academic, or occupational functioning.

  • Criterion E: Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (mood, anxiety, dissociative, personality, or substance-use disorders).

• Inattentive Symptoms (Criterion A1):

  • Fails to give close attention to details or makes careless mistakes.

  • Difficulty sustaining attention in tasks or play.

  • Does not seem to listen when spoken to directly.

  • Does not follow through on instructions; fails to finish chores or workplace duties (not due to opposition or failure to understand).

  • Difficulty organizing tasks and activities.

  • Avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort (e.g., schoolwork).

  • Loses things necessary for tasks (toys, pencils, books, tools).

  • Easily distracted by extraneous stimuli.

  • Forgetful in daily activities.

• Hyperactivity/Impulsivity Symptoms (Criterion A2):

  • Fidgets with hands/feet or squirms in seat.

  • Leaves seat when remaining seated is expected.

  • Runs about or climbs excessively in inappropriate situations (in adults, may be limited to subjective restlessness).

  • Difficulty playing or engaging in leisure activities quietly.

  • Often "on the go" or acts as if "driven by a motor."

  • Talks excessively.

  • Blurts out answers before questions are completed.

  • Difficulty waiting turn.

  • Interrupts or intrudes on others (e.g., butts into conversations or games).

• Presentation Specifiers:

  • Combined Presentation (ADHD-C): Both Criterion A1 and A2 are met for the past $6$ months.

  • Predominantly Inattentive Presentation (ADHD-PI): Criterion A1 is met, but Criterion A2 is not met for the past $6$ months.

  • Predominantly Hyperactive-Impulsive Presentation (ADHD-HI): Criterion A2 is met, but Criterion A1 is not met for the past $6$ months.

Oppositional Defiant Disorder (ODD)

• DSM-5-TR Diagnostic Criteria:

  • Criterion A: A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least $6$ months, involving at least four symptoms from the following categories, exhibited with at least one individual who is not a sibling.

  • Angry/Irritable Mood:

    1. Often loses temper.

    2. Often touchy or easily annoyed.

    3. Often angry and resentful.

  • Argumentative/Defiant Behavior:

    4. Argues with authority figures/adults.

    5. Actively defies or refuses to comply with requests or rules.

    6. Deliberately annoys others.

    7. Blames others for mistakes or misbehavior.

  • Vindictiveness:

    8. Spiteful or vindictive at least twice within the past $6$ months.

  • Criterion B: Disturbance is associated with distress in the individual or others, or impacts negatively on social, educational, or occupational functioning.

  • Criterion C: Behavior does not occur exclusively during psychotic, substance use, depressive, or bipolar disorders, and does not meet criteria for Disruptive Mood Dysregulation Disorder.

• Severity Specifiers:

  • Mild: Symptoms confined to only one setting (e.g., just at home).

  • Moderate: Some symptoms present in at least two settings.

  • Severe: Some symptoms present in three or more settings.

Conduct Disorder (CD)

• DSM-5-TR Diagnostic Criteria:

  • Criterion A: A repetitive and persistent pattern of behavior violating the basic rights of others or major age-appropriate societal norms. Requires $3$ or more of the following $15$ criteria in the past $12$ months, with at least one present in the past $6$ months.

  • Aggression to People and Animals:

    1. Bullies, threatens, or intimidates others.

    2. Initiates physical fights.

    3. Used a weapon capable of serious physical harm.

    4. Physically cruel to people.

    5. Physically cruel to animals.

    6. Stolen while confronting a victim (e.g., mugging).

    7. Forced someone into sexual activity.

  • Destruction of Property:

    8. Deliberate fire setting with intention of serious damage.

    9. Deliberate destruction of others' property (not by fire).

  • Deceitfulness or Theft:

    10. Broken into someone's house, building, or car.

    11. Often lies to obtain goods/favors or avoid obligations ("cons" others).

    12. Stolen items of nontrivial value without confronting a victim (e.g., shoplifting, forgery).

  • Serious Violations of Rules:

    13. Stays out at night despite prohibitions, beginning before age $13$ years.

    14. Run away from home overnight at least twice (or once for a long period).

    15. Truant from school, beginning before age $13$ years.

• Specifiers:

  • With Limited Prosocial Emotions: Requires lack of remorse/guilt, callousness (lack of empathy), unconcern about performance, or shallow/deficient affect.

  • Functional Significance: If the individual is $18$ or older, the criteria for Antisocial Personality Disorder must not be met.

Prevalence, Course, and Aetiology of Externalising Disorders

• Prevalence in Australia:

  • ADHD: $7.4\%$ of all children and adolescents.

  • ADHD Sex Ratio: More common in boys ($12.9\%$) than girls ($5.6\%$). Ratio is approximately $4:1$ in children and $1.6:1$ in adults. The disparity may be due to different symptom presentations in girls.

  • ODD: $5.1\%$.

  • Conduct Disorder: $2.1\%$.

• Course:

  • ADHD: Hyperactivity typically declines in adolescence. However, ADHD persists into adulthood in approximately $50-65\%$ of individuals.

  • ODD/CD: ODD onset is usually at $2-3$ years. CD onset is late childhood or early adolescence. Half of those with ODD/CD continue to face difficulties in adulthood regarding education, employment, and relationships.

• Aetiology:

  • Genetic Risk: Strong heritability for ADHD. Genetic contribution is lower for ODD but present for CD.

  • Temperamental Risk: Difficult temperament involving high reactivity and poor frustration tolerance.

  • Neurobiological Risk:

    • ADHD: Delayed brain maturation and reduced activity in areas like the prefrontal cortex. Deficiencies in neurotransmitters (dopamine, serotonin).

    • CD: Structural/functional differences in areas associated with affect regulation/processing.

  • Parenting Factors: ADHD is associated with neurotoxin/alcohol exposure in utero and low birthweight. ODD is associated with harsh, inconsistent, or neglectful parenting. CD is associated with rejection, maltreatment, and lack of supervision.

  • Psychological Factors: Lack of self-control and inability to delay gratification.

Treatment of Externalising Disorders

• ADHD Treatment by Age:

  • Preschool (4-5 years): Behavioural interventions are the first line. Stimulants only if impairment is moderate-to-severe and behavioral changes fail.

  • Primary School (6-11 years): Medication and/or behavioral interventions (preferably both).

  • Adolescence (12-18 years): Medication as the first line; behavioral interventions may be included.

• Pharmacotherapy:

  • Psychostimulants (e.g., Ritalin): Increase norepinephrine and dopamine to improve alertness. Side effects include decreased appetite, increased heart rate, and sleep difficulties.

  • Non-stimulants: Include SSRIs, SNRIs, and alpha-agonists to increase serotonin and regulate other systems.

• Behavioural and Coping Strategies:

  • Evidence-based Support: Triple P (Positive Parenting Program), PCIT, and Incredible Years.

  • Classroom Accommodations: Organizational supports and scaffolding with immediate consequences.

  • Personal Coping Skills for Executive Function Deficits:

    • Externalize information (use to-do lists, charts, reminders).

    • Externalize time (use clocks, alarms, timers).

    • Break tasks into small increments (using tools like Goblin AI).

    • Make motivation external (immediate rewards/tokens).

    • Refill the "self-regulation fuel tank" via regular breaks ($10$ mins work, $3$ mins break), exercise, and blood glucose management.

Evidence-Based Support with First Nations Communities

• Triple P for First Nations Families:

  • Tailoring Approach: statewide consultation asked "What is positive parenting?" to create culturally appropriate resources.

  • Dar’in Djanum (Strong Together): A partnership in Cherbourg (collaboration with CRAICCHS, Council, and UQ). Focuses on cultural wisdom, traditional ways, and family/kin connection.

  • Program Features: Flexible delivery (e.g., $8$ sessions over $3$ days), co-facilitation by male and female practitioners, and localized imagery.

  • Evaluation Outcomes:

    • Significant decrease in disruptive behaviors (p < 0.01) at follow-up.

    • Significant decrease in inconsistent parenting (p < 0.05) and coercive parenting (p < 0.001).

    • Significant increase in parent self-efficacy at post-test (p < 0.001).

Internalising Disorders in Childhood

• Depressive Disorders:

  • Symptoms: Five of nine symptoms over a two-week period. Mood in children may manifest as irritability rather than sadness.

  • Symptom List: Depressed/irritable mood, diminished interest (anhedonia), weight changes, sleep disturbance (insomnia/hypersomnia), psychomotor changes, fatigue, worthlessness/guilt, cognitive slowing/indecisiveness, and recurrent thoughts of death.

• Anxiety Disorders:

  • Separation Anxiety Disorder: Developmentally inappropriate fear regarding separation from attachment figures lasting $4+$ weeks. Symptoms include nightmares, refusal to sleep alone, and worry about harm to figures.

  • Selective Mutism: Consistent failure to speak in specific social situations where there is an expectation to speak, despite speaking in other situations.

• Prevalence (Internalising):

  • Major Depressive Disorder: $3.2\%$ ($5\%$ in ages $12-17$).

  • Anxiety Disorders: $6.9\%$ (Separation Anxiety is most common at $4.3\%$).

  • Childhood depression increases the risk of young adult suicide by six-fold.

• Aetiology and Treatment:

  • Biological: Heritability is noted, such as $73\%$ in twins for Separation Anxiety Disorder (SAD).

  • Psychological: Rumination predicts future depression.

  • Treatment (Anxiety): Child-focused CBT is the gold standard, involving psychoeducation, emotion regulation (breathing, positive self-talk), and in vivo exposure.

  • Treatment (Depression): CBT, family therapy, and SSRIs (preferred over tricyclics).

Practice Questions & Discussion

• Q1: Diagnostic Differences: Which symptom can differ between children and adults in Major Depression?

  • Answer: (b) Adults present with sad mood whereas children may present with irritable mood.

• Q2: Internalising Identification: Symptoms like refusal to sleep away from home and nightmares about separation relate to which disorder?

  • Answer: (d) Separation anxiety disorder.

• Q3: ADHD Coping Skills: Which was not included in the list of compensatory skills?

  • Answer: (a) Use humour when you can't remember an instruction (this was not listed as a formal coping strategy; aids such as reminders and breaking up tasks were).

Again, like the Foxe et al. paper, this is a book chapter rather than an empirical study, so it doesn't have a traditional research design — but here's a structured breakdown:

Turner et al. (2020) — Summary

Aim

The chapter aimed to review the cross-cultural evidence for the Triple P — Positive Parenting Program, and to discuss what factors support or hinder its effective delivery across culturally diverse and low-resource contexts globally. A broader goal was to make the case for evidence-based parenting support (EBPS) as a global public health priority.

What the researchers did

The authors, based at UQ's Parenting and Family Support Centre (the group that developed Triple P), drew on over 40 years of accumulated research to present a narrative review. The centrepiece is Table 19.1, which summarises 41 studies evaluating Triple P across First Nations communities, Asian countries, the Middle East, Latin America, Africa, and culturally and linguistically diverse (CALD) migrant/refugee populations. Studies varied in design from RCTs to service evaluations to qualitative focus groups. The authors also described two models they developed for culturally sensitive program delivery: the Collaborative Participation Adaptation Model (CPAM) and the Model of Engaging Communities Collaboratively (MECC).

Key findings

The overall picture from the 41 studies is broadly positive, with a few important nuances:

Effectiveness: Positive outcomes were reported across virtually all cultural contexts — improved parenting practices (less coercive, more confident), better child behaviour and emotional adjustment, and reduced parental stress and depression. This held across vastly different cultures including Indigenous Australian, Māori, Chinese, Japanese, Iranian, Turkish, Chilean, Kenyan, and refugee populations.

Acceptability: Program acceptability was consistently high across cultures, even where formal outcome data were limited.

Adaptation: Successful delivery ranged from minimal surface-level changes (language translation, locally relevant examples, adjusted session length) to deep structural adaptations (e.g., linking Triple P's five principles to Māori tikanga, or using Indigenous co-facilitators and oral/experiential rather than written formats for communities with literacy barriers). Crucially, core program content rarely needed to change — it was mainly the delivery that needed cultural tailoring.

Key program features supporting cross-cultural fit: The authors identified several features of Triple P that made it inherently transportable: its focus on parental self-regulation (rather than prescriptive advice), flexible tailoring to individual family goals, a collaborative therapeutic relationship, and accessible resources designed with diverse populations in mind (low literacy level, video-based, multiethnic representation).

Challenges in LMICs: Significant barriers include the treatment gap (too few trained practitioners), lack of epidemiological data, out-of-pocket healthcare costs, and mental health being deprioritised relative to infectious and non-communicable diseases.

What this means

For practice: Practitioners don't necessarily need to overhaul programs when working cross-culturally — flexible delivery within the existing framework is often sufficient. However, communities with a history of colonisation (e.g., First Nations groups) may require deeper structural adaptations and community-led engagement processes.

For policy: Governments should fund EBPS as a public health priority, including culturally adapted versions, and develop performance-based funding mechanisms. Parenting support connects to broader UN Sustainable Development Goals around reducing poverty, inequality, and child maltreatment.

For research: There is a need for greater transparency in documenting adaptation processes, more rigorous designs in LMIC contexts, and ideally a validated global parenting and family well-being survey to allow international comparisons.