part 4

Etiology of ADHD

• Genetic factors

  • Adoption and twin studies

    • Heritability estimates as high as 70 to 80%

  • Two dopamine genes implicated

    • DRD4

      • Dopamine receptor gene

    • DAT1

      • Dopamine transporter gene

        • Mixed support for this gene

  • Either gene associated with increased risk only when prenatal maternal nicotine or alcohol use is present

• Neurobiological factors

  • Dopaminergic areas smaller in children with ADHD

    • Frontal lobes, caudate nucleus, globus pallidus

  • Poor performance on tests of frontal lobe function

Etiology of ADHD

• Perinatal and prenatal factors

  • Low birth weight

    • Can be mitigated by later maternal warmth

  • Maternal tobacco and alcohol use

• Environmental toxins

  • Limited evidence that food additives or food coloring can have a small impact on hyperactive behavior

  • No evidence that refined sugar causes ADHD

  • Nicotine from maternal smoking

    • Exposure to tobacco in utero associated with ADHD symptoms

    • May damage dopaminergic system, resulting in behavioral disinhibition

Etiology of ADHD

• Parent-child relationship

  • Parents give more commands and have more negative interactions

  • Family factors 

    • Interact with genetic and neurobiological factors

    • Contribute to or maintain ADHD behaviors but do not cause them

Treatment of ADHD

• Stimulant medications (Ritalin, Adderall, Concerta, Strattera)

  • Reduce disruptive behavior

  • Improve interactions with parents, teachers, peers

  • Improve goal-directed behavior and concentration

  • Reduce aggression

  • Effective in about 75 percent of children with ADHD but there are side effects

    • Loss of appetite, weight, sleep problems

• Medication plus behavioral treatment (MTA study)

  • Slightly better than meds alone

  • Improved social skills whereas meds alone did not

  • Three-year follow-up found superior benefits of meds did not persist

• Psychological treatment

  • Parental training

  • Change in classroom management

  • Behavior monitoring and reinforcement of appropriate behavior

• Supportive classroom structure

  • Brief assignments

  • Immediate feedback

  • Task-focused style

  • Breaks for exercise

Conduct Disorder (CD)

• Pattern of engaging in behaviors that violate social norms and the rights of others, and are often illegal

  • Aggression

  • Cruelty towards other people or animals

  • Damaging property

  • Lying

  • Stealing

  • Vandalism

  • Often accompanied by viciousness, callousness, and lack of remorse

Disorders Related to Conduct Disorder

• Intermittent explosive disorder: recurrent verbal or physical aggressive outbursts that are out of proportion to the circumstances.

  • Aggression is impulsive and not preplanned

• Oppositional Defiant Disorder (ODD) behaviors do not meet criteria for CD (especially extreme physical aggressiveness) but child displays pattern of defiant behavior

  • Argumentative, loses temper, lack of compliance, deliberately aggravates others, hostile, vindictive, spiteful, or touchy, blames others for own problems

• Comorbid with ADHD, learning and communication disorders

  • Disruptive behavior of ODD more deliberate than ADHD

• Most often diagnosed in boys but may be as prevalent in girls

Conduct Disorder

• Substance abuse common

  • Unclear whether it precedes or is concomitant with disorder

• Comorbid with anxiety and depression

  • Comorbidity rates vary from 15 to 45%

  • CD precedes anxiety and depression

• Prevalence

  • Boys

    • 4 to 16%

  • Girls

    • 1.2 to 9%

Figure 13.2: Arrest Rates Across Ages for Homicide, Forcible Rape, Robbery, Aggravated Assault, and Auto Theft

Conduct Disorder (CD)

• Two distinct CD types (Moffitt, 1993)

  1. Life-course-persistent pattern of antisocial behavior

     • 10 – 15x more common in boys than girls

  2. Adolescence-limited

     • Maturity gap between physical maturation and rewarding adult behaviors

• Follow-up longitudinal studies of life-course-persistent type show more severe problems into early adulthood, including:

• Academic underachievement

• Neuropsychological deficits

• ADHD

• Family psychopathology

• Poorer physical health

• Lower SES

• Violent behaviors

Figure 13.3: Etiology of Conduct Disorder

Etiology of Conduct Disorder (CD)

• Genetic factors

  • Heritability likely plays a part 

  • Twin study data show mixed results

  • Adoption studies focused on criminal behavior, not conduct disorder

• Meta-analysis of twin and adoption studies suggest 40 – 50% of antisocial behavior is heritable

  • Genetics a stronger influence when behaviors begin in childhood rather than adolescence

• Genetics and environment interact 

  • Abuse as a child PLUS low MAOA activity most likely to develop CD 

Etiology of Conduct Disorder (CD)

• Neurobiological factors

  • Poor verbal skills

  • Difficulty with executive functioning

  • Low IQ

  • Lower levels of resting skin conductance and heart rate suggest lower arousal levels

• Psychological factors

  • Deficient moral development, especially lack of remorse

  • Modeling and reinforcement of aggressive behavior

  • Harsh and inconsistent parenting

  • Lack of parental monitoring

  • Cognitive bias: Neutral acts by others perceived as hostile

Figure 13.4:
Dodge’s Cognitive Theory of Aggression

Etiology of Conduct Disorder (CD)

• Peer influences associated with CD 

  • Rejection by peers

  • Affiliation with deviant peers

• Sociocultural factors

  • Poverty

  • Urban environment

• Higher rates of delinquent acts among African American males linked to living in poorer neighborhoods rather than race

Treatment of Conduct Disorder

• Family interventions

  • Family check-ups (FCU) associated with less disruptive behavior

  • Parental management train (PMT)

    • Teach parents to reward prosocial behavior

• Multisystemic therapy

  • Deliver intensive community-based services

  • Figure 13.5: Multisystemic Treatment of CD

Depression and Anxiety in Children and Adolescents

• Commonly co-occur with ADHD and CD

• Also co-occur with each other

• Early research suggested that depression and anxiety could be distinguished from each other in the same way they are in adults: 

  • Depression – high negative affect, low positive affect

  • Anxiety – high negative affect but not low levels of positive affect 

  • More recent research calls this finding into question

Depression in Children and Adolescents

• Symptoms common to children, adolescents, and adults

  • Depressed mood

  • Inability to experience pleasure

  • Fatigue

  • Problems concentrating

  • Suicidal ideation

• Symptoms specific to children and adolescents

  • Higher rates of suicide attempts and guilt

  • Lower rates of 

    • Early morning awakening

    • Early morning depression

    • Loss of appetite

    • Weight loss

• Prevalence

  • 1% of preschoolers

  • 2 – 3% of school-age children

  • 6% of girls and 4% of boys during adolescence

Etiology of Depression in
Children and Adolescents

• Genetic factors

• Early adversity and negative life events

• Family and relationship factors

  • A parent who is depressed

  • Parental rejection only modestly associated with depression

  • Children with depression and their parents interact in negative ways

    • Less warmth

    • More hostility

• Cognitive distortions and negative attributional style

• Stable attributional style  

  • Develops by early adolescence

  • By middle school, attributional style serves as a cognitive diathesis for depression

Treatment of Depression in
Children and Adolescents

• Medications

• SSRIs more effective than tricyclics

• Meta-analysis showed medications most effective for anxiety other than OCD

  • Less effective for depression and OCD

• Concerns about medications

  • Side effects including diarrhea, nausea, sleep problems, and agitation

  • Possibility of increased risk of suicide attempts

• Interpersonal psychotherapy (IPT)

  • Focuses on peer pressures, transition to adulthood, and issues related to independence

• CBT

  • More effective for Caucasian adolescents and those with pretreatment, good coping skills, and recurrent depression

• Psychotherapy generally only modestly effective with children and adolescents

  • CBT no better than non-CBT therapies

Anxiety in Children and Adolescents

• Fears and worries common in childhood

• Anxiety disorder

  • More severe and persistent worry

  • Must interfere with functioning

• Most childhood fears disappear but adults with anxiety disorders report feeling anxious as children

  • “I’ve always been this way”

• Prevalence

  • 3-5% of children and adolescents are diagnosed with anxiety disorder

Anxiety Disorders in Children

• Separation anxiety disorder

• Worry about parental or personal safety when away from parents

• Typically first observed when child begins school

• Social anxiety disorder

• Extremely shy and quiet

• May exhibit selective mutism

• Refusal to speak in unfamiliar social setting

• Prevalence

  • 1% of children and adolescents

• Etiology

  • Overestimation of threat

  • Underestimation of coping ability

  • Poor social skills

PTSD

• Exposure to trauma

  • Chronic physical or sexual abuse

  • Community violence

  • Natural disasters

• Symptom categories

  • Flashbacks, nightmares, intrusive thoughts

  • Avoidance 

  • Negative cognitions and moods

  • Hyperarousal and vigilance

• Some symptoms may differ from adults

  • May exhibit agitation instead of fear or hopelessness

PTSD

• Exposure to trauma

  • Chronic physical or sexual abuse

  • Community violence

  • Natural disasters

• Symptom categories

  • Flashbacks, nightmares, intrusive thoughts

  • Avoidance 

  • Negative cognitions and moods

  • Hyperarousal and vigilance

• Some symptoms may differ from adults

  • May exhibit agitation instead of fear or hopelessness

OCD

• Prevalence 1 to 4%

• Symptoms similar to those in adults

• Most common obsessions:

  • Contamination from dirt and germs

  • Aggression

  • Thoughts about sex and religion more common in adolescence

• OCD more common in boys than girls

Etiology of Anxiety Disorders

• Genetics

  • Heritability estimates from  29 – 50%

  • Genetics plays a stronger role in separation anxiety in context of more negative life events

• Parenting plays a small role in anxiety disorders

  • Only 4% of variance 

• Emotion regulation and attachment problems also play a role

• Perception of lack of acceptance by peers a factor in social phobia

• Risk factors for PTSD include:

  • Family stress and coping style

  • Past experience with trauma

Treatment of Anxiety Disorders in
Childhood and Adolescence

• Exposure to feared object 

  • Reward approach behavior

• CBT Kendall’s Coping Cat program

  • Shows to be effective in two randomized clinical trials

  • For children between 7 and 13 years old

  • Cognitive restructuring

    • Develop new ways to think about fears

  • Psychoeducation

  • Modeling and exposure

  • Skills training and practice

  • Relapse prevention

  • Family involved in treatment

Learning Disability

• Evidence of inadequate development in a specific area of academic, language, speech or motor skills

  • e.g., arithmetic or reading

• Not due to mental retardation, autism, physical disorder, or lack of educational opportunity

• Individual usually of average or above average intelligence

• Often identified and treated in school 

• Reading disorders more common in boys

Specific Learning Disorder

• DSM-5 Criteria for Specific Learning Disorder:

  • Difficulties in learning basic academic skills (reading, mathematics, or writing) inconsistent with person’s age, schooling, and intelligence

  • Significant interference with academic achievement or activities of daily living

• Dyscalculia and dyslexia no longer distinct diagnoses

• Specifiers include impairments in reading, written expression, and mathematics

Etiology of Learning Disabilities:
Impairment in Reading (Formerly Dyslexia)

• Genetic factors

  • Evidence from family and twin studies

  • Genes are those associated with typical reading abilities (generalist genes)

• Problems in language processing

  • Speech perception

  • Analysis of sounds and their relationship to printed words

  • Difficulty recognizing rhyme and alliteration

  • Problems naming familiar objects rapidly

  • Delays learning syntactic rules

  • Deficient phonological awareness 

    • Inadequate left temporal, parietal, occipital activation

Figure 13.6: Areas of the Brain Implicated in Dyslexia: Frontal, Parietal, and Temporal Lobes

Etiology of Learning Disabilities: Impairment in Mathematics (Formerly Dyscalculia)

• Genetic and biological factors

  • Evidence from twin studies suggest common genetic factors underlie both reading and math deficits

  • Intraparietal sulcus implicated

  • Has different cognitive deficits from dyslexia

  • Children with only dyscalculia do not have deficits in phonological awareness

Treatment of Learning Disabilities

• Reading and writing specifiers

  • Multisensory instruction in listening, speaking, and writing skills

  • Readiness skills in younger children as preparation for learning to read

  • Phonics instruction

• Communication disorders

  • Fast ForWord

    • Involves computer games and audiotapes that slow speech sounds

Intellectual Disability
(Intellectual Developmental Disorder)

• Formerly called mental retardation in DSM-IV-TR

  • Not preferred due to stigma

  • Followed the guidelines of the American Association on Intellectual and Developmental Disabilities (AAIDD)

• The AAIDD Definition of Intellectual Disability:

  • Intellectual disability is characterized by significant limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills

  • This disability begins before age 18

  • Five Assumptions Essential to the Application of the Definition

    1. Limitations in present functioning must be considered within the context of community environments typical of the individual’s age, peers, and culture

    2. Valid assessment considers cultural and linguistic diversity as well as differences in communication, sensory, motor, and behavioral factors

    3. Within an individual, limitations often coexist with strengths

    4. An important purpose of describing limitations is to develop profile of needed supports

    5. With appropriate personalized supports over a sustained period, the life functioning of the person with intellectual disability generally will improve

Intellectual Disability
(Intellectual Developmental Disorder)

• DSM-5 criteria:

  • Intellectual deficits (e.g., in solving problems, reasoning, abstract thinking) determined by intelligence testing and broader clinical assessment  

  • Significant deficits in adaptive functioning relative to the person’s age and cultural group in one or more of the following areas: communication, social participation, work or school, independence at home or in the community, requiring the need for support at school, work, or independent life

  • Onset before age 18

• DSM-5 changes:

  • There is explicit recognition that an IQ score must be considered within the cultural context of a person

  • Adaptive functioning must also be assessed and considered within the person’s age and cultural group

  • No longer distinguish among mild, moderate, and severe ID based on IQ scores alone 

Etiology of Intellectual Disability:  Neurological Factors

• Down syndrome

  • Chromosomal trisomy 21: an extra copy of chromosome 21

  • 47 instead of 46 chromosomes

• Fragile-X syndrome

  • Mutation in the fMRI gene on the X chromosome

• Recessive-gene disease

  • Phenylketonuria (PKU)

• Maternal infectious disease, especially during first trimester

  • Cytomegalovirus, toxoplasmosis, rubella, herpes simplex, HIV, and syphilis

• Lead or mercury poisoning

Treatment of
Intellectual Disability

• Residential treatment

  • Small to medium-sized community residences

• Behavioral treatments

  • Language, social, and motor skills training

  • Method of successive approximation to teach basic self-care skills in severely retarded

    • e.g., holding a spoon, toileting

  • Applied behavioral analysis

• Cognitive treatments

  • Problem-solving strategies

• Computer-assisted instruction

Autism Spectrum Disorder

• DSM-5 combines multiple diagnoses into one: Autism Spectrum Disorder

  • Autistic disorder, Asperger’s disorder, pervasive developmental disorder not otherwise specified, and childhood disintegrative disorder

  • Research did not support distinctive categories

  • Share similar clinical features; vary only in severity

  • Specifiers include with or without accompanying intellectual impairment, language impairment, or catatonia

• Profound problems with the social world

  • Rarely approach others, may look through people

  • Problems in joint attention

  • Pay attention to different parts of faces than do people without autism; focus on mouth, neglect eye region 

  • This neglect likely contributes to difficulties in perceiving emotion in other people

• Theory of mind

  • Understanding that other people have different desires, beliefs, intentions, and emotions

  • Crucial for understanding and successfully engaging in social interactions 

  • Typically develops between 2½ and 5 years of age

  • Children with ASD seem not to achieve this developmental milestone

• 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

• Repetitive and ritualistic acts

  • Become extremely upset when routine is altered

  • Engage in obsessional play

  • Engage in ritualistic body movements

  • Become attached to inanimate objects (e.g., keys, rocks)

• Comorbidity

  • IQ < 70 is common

    • Children with intellectual developmental disorder score poorly on all parts of an IQ test; children with ASD score poorly on those subtests related to language, such as tasks requiring abstract thought, symbolism, or sequential logic 

• Prevalence 

  • 1 out of 110 children

  • Found in all SES, ethnic, and racial groups

  • Diagnosis of ASD is remarkably stable

• Prognosis

  • Children with higher IQs who learn to speak before age six have the best outcomes

Etiology of Autistic Spectrum Disorder

• Genetic factors

  • heritability estimates of around .80

  • Twin studies

    • 47 to 90% concordance rates for MZ twins; 0-20% for DZ twins

  • Genetic flaw

    • Deletion on chromosome 16

• Neurobiological factors

  • Brain size

    • Although normal size at birth, brains of autistic adults and children are larger than normal

    • Pruning of neurons may not be occurring

  • “Overgrown” areas include the frontal, temporal, and cerebellar, which have been linked with language, social, and emotional functions

  • Abnormally sized amygdalae predicted more difficulties in social behavior and communication 

Treatment of
Autistic Spectrum Disorder

• Psychological treatments more promising than drugs

• Earlier treatment associate with better outcomes

• Intensive operant conditioning (Lovaas, 1987)

  • Dramatic and encouraging results

• Parent training and education

• Pivotal response treatment (Koegel et al., 2003)

  • Focus on increasing child’s motivation and responsiveness rather than on discrete behaviors

• Joint attention intervention and symbolic play used to improve attention and expressive skills

• Medication used to treat problem behaviors

  • Haloperidol (Haldol)

    • Antipsychotic

    • Reduces aggression and stereotyped motor behavior

    • Does not improve language and interpersonal relationships