Psych 360 Chapter 13
- DSM-5 childhood disorders
o Developmental psychopathology
§ The study of disorders of childhood within the context of life-span development
o Two broad domains
§ Internalizing disorders
· Characterized by inward-focused experiences and behaviors
o Depression, social withdrawal, and anxiety
· Includes childhood anxiety and mood disorders
§ Externalizing disorders
· Characterized by outward-directed behaviors
· Aggressiveness, noncompliance, overactivity, impulsiveness
· Includes attention-deficit/hyperactivity disorder, conduct disorder, and oppositional defiant disorder
o Attention-deficit/hyperactivity disorder (ADHD)
§ Symptoms of inattention and/or hyperactivity-impulsivity that interfere with school, work, or relationships
§ Hyperactive behaviors are
· Extreme for a particular developmental period
· Persistent across different situations
· Linked to significant impairments in functioning
§ These symptoms and behaviors don’t fit with what is expected at a particular age or developmental level
§ May have particular difficulty controlling their activity in situations that call for sitting still (e.g., classrooms)
§ May experience difficulty getting along with peers
· Aggressive and intrusive behaviors
· Difficulty noticing subtle social cues
· Singled out very quickly and rejected or neglected by peers
§ DSM-5 criteria
· Inattention
o Manifestations of inattention can include:
§ Making careless mistakes
§ Not listening well
§ Not following instructions
§ Being easily distracted
§ Being forgetful in daily activities
· Hyperactivity
o Manifestations of hyperactivity-impulsivity can include:
§ Fidgeting
§ Running about inappropriately (or restlessness in adults)
§ Acting as if “driven by a motor”
§ Interrupting or intruding
§ Nonstop talking
§ ADHD and comorbidities
· Symptoms present before age 12
· Present in two or more settings, e.g., at home, school, or work
· Significant impairment in social, academic, or occupational functioning
· For children 6 symptoms of inattention and/or hyperactivity-impulsivity are required
· Only 5 symptoms required for ages 17 and above
· Three specifiers to indicate which symptoms predominate:
o Predominantly inattentive presentation
o Predominantly hyperactive-impulsive presentation
o Combined presentation
· Often co-occurs with
o Conduct disorder
o Anxiety and depression
§ 30% of kids with ADHD have a comorbid internalizing disorder
o Learning disorders
o Substance use disorders
§ ADHD prevalence
· Prevalence estimates 8 to 11%
o Risen dramatically in past decade
· Public policy can affect diagnosis rates
o Access to comprehensive diagnostic testing
o Education policies
· 3x more common in boys than girls
o May be because boys’ behavior more likely to be aggressive, leading to evaluation and diagnosis
· Symptoms persist beyond childhood
o 60-74% still exhibit symptoms into at least early adulthood
§ Etiology of ADHD
· Adoption and twin studies
o Heritability estimates as high as 70 to 80%
· Several candidate genes implicated
o DRD4, DRD5, DAT1
§ Dopamine genes
§ Associated with increased risk only when prenatal nicotine or alcohol use is present
o SNAP-25
§ Codes for protein that promotes plasticity
· However, GWAS studies have not always found the same genes and many genes identified are not specific to ADHD
· Neurobiological influences
o Individuals with ADHD show differences in brain structure, function, and connectivity
o Dopaminergic areas smaller in children with ADHD
§ E.g., amygdala, hippocampus, caudate nucleus, nucleus accumbens, putamen
§ Poor performance on tests of frontal lobe function
o Perinatal and prenatal complications
§ Low birth weight
· Can be mitigated by later maternal warmth
o Environmental toxins
§ Food additives may influence ADHD symptoms
§ No evidence that refined sugar causes ADHD
§ Maternal smoking
· Family influences
o Parent-child relationship interacts with neurobiological influences to maintain or exacerbate symptoms, but family dynamics do not cause the initial onset of ADHD
o Parents give more commands and have more negative interactions
§ Children are less compliant and more negative in interactions with their parents
o Many parents of children with ADHD have ADHD themselves
o Contribute to maintaining or exacerbating ADHD symptoms
§ Treatment of ADHD
· Medications
o Stimulants (Ritalin, Adderall, Concerta, Strattera)
§ Reduce disruptive behavior, aggression, and impulsivity
§ Improve ability to focus attention
§ Improve concentration, goal-directed activity, classroom behavior
§ Improve social interactions with parents, teachers, peers
§ Effective in about 75% of children with ADHD
· Medication plus behavioral treatment
o Combined treatment slightly better than medications alone and yielded improved functioning (e.g., social skills)
o Additive benefits of medications did not persist beyond the study, suggesting both treatments performed similarly in the longer term
· Psychological treatments
o Parental training and changes in classroom management
§ Behavior monitoring
· Daily report cards
§ Reinforcement of appropriate behavior
· Children earn points or stars for behaving in certain ways
· They can then spend their earnings for rewards
o focus of these programs:
§ improving academic work
§ completing household tasks
§ learning specific social skills
§ do not specifically focus on reducing ADHD symptoms
o conduct and related disorders
§ intermittent explosive disorder (IED)
· recurrent verbal or physical aggressive outbursts that are out of proportion to the circumstances
· aggression is impulsive and not preplanned
§ oppositional defiant disorder (ODD)
· loses temper, argumentative, lack of compliance, deliberately aggravates others, vindicative, spiteful, touchy
· often comorbid with ADHD
o disruptive behavior of ODD more deliberate than ADHD
§ DSM-5 criteria: conduct disorder
· Defined by the impact of child’s behavior on people and surrounding
· Pattern of repeated destructive and harmful behavior that can take different forms, including
o Aggressive behavior
o Destroying property
o Lying or stealing
o Breaking rules
§ Conduct disorder
· Diagnostic specifier: “limited prosocial emotions”
o Children who have callous and unemotional traits
§ Lack of remorse, empathy, and guilt, and shallow emotions
o Associated with a more severe course, cognitive deficits, antisocial behavior, and poorer response to treatment
· One common pathway to antisocial personality disorder in adulthood
o ODDàconduct disorder + limited prosocial emotionsà APD
§ Comorbidities and longitudinal course
· Significant impairment in social, academic, or occupational functioning
· Substance abuse is common
o Unclear whether it precedes or is concomitant with disorder
· Comorbid with anxiety and depression
o Comorbidity rates vary from 15 to 45%
o CD precedes depression and most anxiety disorders
· 7% of preschool children exhibit the symptoms of conduct disorder
o Assessing conduct disorder early is important
§ Two courses of CD (Moffit, 1993)
· Life-course-persistent pattern of antisocial behavior
o Beginning to show conduct problems by age 3 and continuing into adulthood
· Adolescence-limited
o Typical childhoods, engagement in high levels of antisocial behavior during adolescence, and typical, nonproblematic adulthoods
o Maturity gap between the adolescent’s physical maturation and the opportunity to receive rewards for assuming adult responsibilities (society considers them still too young to work, have sex, etc., so they seek rewards in other ways that are harmful)
o Continue to have troubles with substance use, impulsivity, crime, and overall mental health in their mid-20s
§ Prevalence and diagnosis
· Fairly common: prevalence rates between 5 and 6%
· More common in boys than girls
· Life-course-persistent type of conduct disorder will likely continue to have problems in adulthood, including violent and antisocial behavior
· Conduct disorder in childhood does not inevitably lead to antisocial behavior in adulthood
o About half of boys with CD did not fully meet diagnostic criteria at a later assessment (1 to 4 years later)
o Almost all continued to demonstrate some conduct problems
§ Etiology
· Genetic influences
o Heritability likely plays a part
§ Some genetic influences are shared with other disorders and some are specific
§ Importance of gene X environment interactions
o Aggressive behavior is more heritable than other rule breaking behavior
o Combination of conduct problems and callous/unemotional traits is more highly heritable than conduct problems alone
o Aggressive and antisocial behaviors that begin in childhood are more heritable than similar behaviors that begin in adolescence
· Neurobiological influences
o Deficits in regions of the brain that support emotion and empathetic responses
§ Reduced activation of amygdala, ventral striatum, and prefrontal cortex
o Autonomic nervous system
§ Lower levels of resting skin conductance and heart rate
§ Lower arousal levels
§ May not fear punishment
o Poor verbal skills, difficulty with executive functioning, and problems with memory
o Children who develop conduct disorder at an earlier age:
§ IQ score 1 standard deviation below peers without conduct disorder
§ Not attributable to lower socioeconomic status or school failure
· Psychological influences
o Deficient moral awareness, especially lack of remorse
o Dodge’s cognitive theory of aggression
§ Deficits in social information processing
§ Interpretation of ambiguous acts (e.g., being bumped) as evidence of hostile intent
§ Leads to aggressive retaliation
· Peer influences
o Acceptance or rejection by peers
§ Rejection by peers is casually related to aggressive behavior
§ Rejection by peers predicts later aggressive behavior
§ Children prone to react negatively to situations:
· More likely to be rejected by peers
· More likely to engage in antisocial behavior
o Affiliation with deviant peers
§ Increases the likelihood of delinquent behavior
· Modeling or coercion
§ Genetic influences encourage children with conduct disorder to select more deviant peers to associate with
§ Environmental influences (e.g., socioeconomic disadvantage, exposure to violence) play a role in whether children associate with deviant peers
§ Treatment of CD
· Most effective when it addresses the multiple systems involved in the life of a child
o Family, peers, school, neighborhood
o Multisystemic treatment (MST)
· Family interventions
o Family checkups (FCU)
§ 3 meetings to assess and provide feedback to parents regarding their children and parenting practices
§ Associated with less disruptive behavior
o Parental management training (PMT)
§ Teach parents to use positive reinforcement for positive behaviors and time-out and loss of privileges for aggressive or antisocial behaviors
§ Most efficacious for children with CD and oppositional defiant disorder
§ CD prevention programs
· Fast track
o Designed to help children academically, socially, and behaviorally
o Focuses on areas that are problematic in conduct disorder:
§ Peer relationships, aggressive and disruptive behavior, social information processing, and parent-child relationships
o Treatment delivered over the course of 10 years
§ Groups and at individual families’ homes
§ More intensive treatment years 1-5 and less intensive years 6-10
o Children who received fast track
§ Reduced behavior problems and delinquent behaviors
§ Better social information processing skills
§ Decrease in the hostile attribution bias
§ Less likely to have externalizing or internalizing psychopathology, substance use problems, or antisocial personality disorder
- Internalizing disorders
o Depression
§ Common symptoms in children and adolescents ages 7 to 17 and adults show:
· Depressed mood, inability to experience pleasure, fatigue, concentration problems, and suicidal ideation
§ Children and adolescents differ from adults in:
· More guilt but lower rates of early-morning wakefulness, early-morning depression, loss of appetite, and weight loss
§ Depression in children often is recurrent
§ Prevalence among adolescent girls (15.9%) almost twice that among adolescent boys (7.7%)
· Few differences in the types of symptoms they experience
§ Comorbid with anxiety
§ Etiology
· Genetic influences
o Similar to factors identified in studies with adults
o A child with a depressed parent has 4x greater risk than a child without a depressed parent
o Gene-environment interactions
§ Short allele of the serotonin transporter gene AND significant interpersonal stressful life
· Early adversity and negative life events
o E.g., financial hardship, maternal depression, chronic illness as a child
· Cognitive distortions and negative attributional style
o Stable attributional style
§ Develops by early adolescence
§ By middle school, attributional style serves as a cognitive diathesis for depression
o Rumination
§ Treatment
· Antidepressants
o Side effects including diarrhea, nausea, sleep problems, and agitation
o Possibility of increased risk of suicide attempts
§ Children taking medication were at risk for suicidal ideation
· CBT
o In school settings more effective and associated with more rapid reduction of symptoms than family or supportive therapy
o Immediate benefits of CBT may not last long for young people
§ Prevention of depression
· Selective prevention programs:
o Target youth based on family, environmental, or personal risk factors
· Universal programs:
o Targeted large groups, typically in schools, and provide education about depression
· Selective prevention more effective than universal programs
o Those in selective prevention program had fewer depression episodes than those in the usual care group
o Anxiety in children and adolescents
§ Fears and worries common in childhood
§ More common in girls than boys
§ For fears and worries to be classified as disorders, child’s functioning must be impaired
· Unlike adults, do not need to regard fear as excessive or unreasonable
§ Prevalence
· 3-5% of children and adolescents
· Higher in minority youth but may be due to bias in assessment measures
§ Social anxiety may prevent acquisition of skills and participation in activities enjoyed by peers
§ Separation anxiety disorder
· Constant worry that some harm will befall their parents or themselves when they are away from their parents
o At home, children shadow one or both of their parents
· Often first observed when children begin school
· Associated with the development of other internalizing and externalizing disorders at later ages
· DSM-5 criteria
o Experiencing a great deal of distress when separated from a parent or caregiver
o Experiencing intense worry that something will happen to a parent or caregiver
o Refusing to go to school or show a great bit of trepidation about going to school (i.e., school refusal)
o Refusing sleep away from home or trepidation about doing so
o Having bad dreams or nightmares about being separated
o Experiencing a great deal of physical problems when separated
§ Posttraumatic stress disorder
· Exposure to trauma (e.g., abuse, community violence, natural disorders)
· Symptoms (similar to adults)
o Intrusively reexperiencing (e.g., flashbacks, nightmares, intrusive thoughts; reenactment play)
o Avoidance
o Negative cognitions and moods
o Increased arousal and reactivity (e.g., extreme temper tantrums)
o Distinct symptoms for children ages 6 and younger that capture developmental differences
· Negative beliefs about oneself do not apply to very young children
§ Obsessive compulsive disorder
· Prevalence 1 to 4%
· Symptoms similar to those in adults
· Most common obsessions
o Dirt or contamination
o Aggression
o Sex or religion become more common in adolescence
· OCD more common in boys than girls
§ Etiology of anxiety disorders
· Genetic influences
o Heritability estimates from 29-50%
o Stronger role in separation anxiety with more negative life events
· Parental control and overprotectiveness play a small role
· Emotion regulation and attachment problems
· Social influences:
o Experienced bullying, overestimation of danger in social situations and underestimation of ability to cope in social situations
· PTSD environmental influences:
o Level of family stress, coping styles of the family, and past experiences with trauma
§ Treatment of anxiety disorders
· CBT: Kendall’s coping cat program
o Confrontation of fears
o Development of new ways to think about fears
o Exposure to feared situations
o Relapse prevention
o Parents are also included in a couple of sessions
· Social anxiety disorder
o Behavior therapy and group cognitive behavior therapy
· OCD
o CBT recommended first line treatment for mild to moderate OCD
o Medication plus CBT for severe OCD
· PTSD
o Available research suggests CBT, whether individual or group, is effective
- Learning, communication, and motor disorders
o Problems in a specific area of academic, language, speech, or motor skills
§ Not due to intellectual disability or deficient educational opportunities
§ Progress in school is impeded
§ Discrepancy between achievement observed, vs. what is expected based on developmental stage and IQ
§ Often of average or above-average intelligence but have difficulty learning specific skills in the affected areas
o Often identified and treated in the school system
o Specific learning disorder
§ Difficulties learning and using academic skills
§ 1+ symptoms for 6+ months:
· Inaccurate or slow and effortful word reading
· Difficulty understanding meaning of what is read
· Difficulties with spelling
· Difficulties with written expression
· difficulties with mastering number sense, number facts, or calculation
· difficulties with math reasoning
§ specific learning disorder specifiers
· impairment in reading (includes dyslexia)
· impairment in written expression (dysgraphia)
· impairment in math (dyscalculia)
o communication disorders
§ speech sound disorder
· correct comprehension and sufficient vocabulary use, but unclear speech and improper articulation
· e.g., blue comes out bu, and rabbit sounds like wabbit
· with speech therapy, complete recovery occurs in almost all cases, and milder cases may recover spontaneously by age 8
§ language disorder
· problems in developing and using language
§ social (pragmatic) communication disorder
· difficulties in using verbal and nonverbal language in social communication
§ childhood onset fluency disorder (stuttering)
· difficulty with verbal fluency that is characterized by one or more of the following speech patterns:
o frequent repetitions or prolongations of sounds
o long pauses between words, substituting easy words for those that are difficult to articulate (e.g., words beginning with certain consonants)
o repeating whole words (e.g., saying “go-go-go-go” instead of just “go”)
· up to 80% of people with stuttering recover, most of them without professional intervention, before the age of 16
o motor disorders
§ Tourette’s disorder
· One or more vocal and multiple motor tics (sudden, rapid movement or vocalization) that start before age 18
§ Developmental coordination disorder
· Difficulties in the development of motor coordination not explainable by intellectual disability or a disorder such as cerebral palsy
§ Stereotypic movement disorder
· Repetition of purposeless movements over and over that interferes with functioning and could even cause self-injury
- Intellectual disability
o Intellectual deficits (e.g., in solving problems, reasoning, abstract thinking) determined by intelligence testing and broader clinical assessment
o Three components (AAIDD definition):
§ Significant problems in intellectual functioning
§ Significant problems in adaptive behavior across contexts
§ Problems begin before age 18
o The severity assessed in three domains:
§ Conceptual (intellectual and other cognitive functioning)
§ Social
§ Practical
o Individualized educational program (IEP)
§ School based intervention
§ Based on the person’s strengths and weaknesses and on the amount of instruction needed
o Etiology
§ Genetic/chromosomal influences
· Down syndrome (trisomy 21)
· Fragile-X syndrome
· Phenylketonuria (PKU) – amino acid buildup
§ Environmental influences:
· Maternal infectious disease (e.g., rubella, cytomegalovirus, toxoplasmosis, herpes simplex)
· Consequences most serious during 1st trimester of pregnancy
· Lead or mercury poisoning
§ Encephalitis and meningococcal meningitis in infancy or early childhood
o Treatment
§ Residential treatment
· Small to medium-sized community residences
§ Behavioral treatments
· Divide target behavior into small components
· Applied behavioral analysis
o Operant conditioning to increase target behaviors and reduce inappropriate or harmful behaviors
§ Cognitive treatments
· Problem-solving strategies
§ Computer-assisted instruction
- Autism spectrum disorder
o Social and emotional deficits
§ Problems with the social world
· Rarely approach others, may look through people
· Problems in joint attention
o E.g., two people paying attention to each other while speaking
· Pay less attention to speaking faces
o Particularly the eyes and mouth regions
§ Theory of mind
· Understanding that other people have different desires, beliefs, intentions, and emotions
· Crucial for successfully engaging in social interactions
· Typically develops between 2.5 and 5 years of age
· Children with ASD seem not to achieve this developmental milestone
§ May recognize emotions without understanding them
o Communication deficits
§ children with ASD evidence early language disturbances
§ echolalia: immediate or delayed repeating of what was heard
§ pronoun reversal: refer to themselves as “he” or “she”
§ literal use of words
o repetitive behaviors
§ repetitive and ritualistic acts
· become extremely upset when routine is altered
· focused and preoccupied on specific things
· engage stereotypical behavior, peculiar ritualistic hand movements, and other rhythmic movements
· become attached to inanimate objects
o DSM-5 criteria
§ Significant problems in social communication and social interactions, such as:
· Problems in understanding other people’s emotions, reluctance to approach others, trouble with back-and-forth conversations
· Problems maintaining eye contact, showing facial expressions, or using gestures to communicate with other people
· Problems in forming and keeping peer relationships
§ Repeated and ritualistic behavior patterns, interests, or activities, such as
· Repeating the same speech, movements, or use of objects over and over again in a fairly fixed and stable manner
· Extreme desire to maintain routines or behavior rituals; can become very upset if required to change
· Preoccupation with just a small number of interests or objects
· Very sensitive to sensory input or unusually interested in the sensory environment, such as being enchanted by lights or spinning objects
o Prevalence and comorbidity
§ Onset in early childhood and evidence in the first months of life
§ Affects 1 out of 54 children
§ Four times higher rates in boys than girls
§ Comorbidity
· Intellectual disability
· Specific learning disorder
· Separation anxiety, social anxiety, general anxiety, and specific phobias
o Prognosis
§ Diagnosis is stable over time
§ Children with higher IQs who learn to speak before age six have the best outcomes
§ Many independently functioning adults with ASD continue to show impairment in social relationships
o Etiology
§ Genetic influences
· Heritability estimates of between .5 and .8
· Linked genetically to a broader spectrum of deficits in communication and social interaction
· Shared environmental factors accounts for over half of risk for developing ASD
· GWAS studies show 5 unique loci and 7 that overlap with genetic risk for schizophrenia and depression
§ Neurobiological influences
· Brain size
o Although normal at birth, brains of autistic adults and children are larger than normal
o Normative pruning of neurons may not be occurring
· Enlarged cerebellum, caudate nucleus
o Treatment
§ Intensive operant conditioning
· 40 hours a week over more than 2 years
· Parents are trained
· Dramatic and encouraging results
o Larger increase in IQ scores
o Advanced to next grade
§ Joint attention intervention and symbolic play used to approve attention and expressive skills
§ Medication (antipsychotics)
· Less effective than behavioral treatment
· Used to treat problem behaviors
· Side effects include weight gain, fatigue, and tremors