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