PSYCHOPATHOLOGIES

January 21: Lecture 2

Definitions 

• Psychopathology 

• The scientific study of mental illness, along with the factors which may contribute or be relevant to such disorders

• Relates to etiology (cause) or risk factors, when cause is unknown 

• Causes of mental disorders may relate to biological and genetic, psychological, and social factors

• Greek words: psyche (soul) and pathos (suffering)

• Within psychiatry, pathology refers to disease 

• Focus is drawn from theories about child development, behavior, cognition, emotion, motivation, identity, relationship and context

• Psychodiagnostics

  • Process of arriving at a clinical diagnosis 

    • Articulated through descriptive criteria (what this looks like) based on agreed-on symptoms of pathology for each disorder through the DSM-5TR

      • There is some disagreement and pushback on diagnoses sometimes 

      • The rest of the world uses the ICD 

Developmental Psychopathology 

• Historic language is “normal” vs. “abnormal” 

  • This is difficult because we do not have a norm/the norm can vary 

• New language is “atypical” vs. “typical” or “normative”

• A term used to describe what is going wrong (maladaptive)

• Refers to intense, frequent and or persistent maladaptive patterns of emotion, cognition, and behavior indicating the child is on a different path than what is typical

• Developmental psychopathology emphasizes that these maladaptive patterns occur in the context of typical development and result in the current and potential impairment of infants, children, and adolescents 

• We must understand children’s disorders in the context of typical development

  • Looking at social, emotional, cognitive, moral, and behavioral development

  • Consider typical age-specific behaviors, but also disorder-specific development too 

    • Ex: what is typical for a 5-year-old child with autism, not just what is typical for a 5-year-old

  • Development unfolds over time, is affected by transitions and risk and resilience factors

• Atypical development 

  • We use different approaches to address the differences

    • Statistical difference: too much or too little of any age-expected behavior

      • Bell curve 

        • Middle is a range of behaviors 

        • Then there is too much and too little 

    • Sociocultural norm perspective

      • Children who fail to conform to age-related, location-specific gender-specific, or culturally-relevant expectations

        • Ex: a middle schooler cussing a teacher out is not okay based on norms 

    • Psychological well-being is also a key consideration (poor, adequate, optimal)

Models of Psychopathology 

• Dimensional models 

  • Ways in which typical thoughts/feelings/behaviors become atypical 

  • Emphasizes the ways in which typical feelings, thoughts, and behaviors gradually become more serious problems
    No sharp distinctions between adjustment and maladjustment
    Example: Adolescent who has increasing apathy and loss of interest in life in adolescence, following her parents’ difficult divorce 

• Categorical models 

  • Emphasize discrete and qualitative differences in individual patterns of emotion, cognition, and behavior

  • There are clear distinctions

  • Example: Child with Autism who has difficulty with social reciprocity

• Behaviors to evaluate 

  • Deviation from age-appropriate norms

    • Child behaves differently from other children their age—autism 

  • Exaggeration or diminishment of normal development expressions

    • A child with ADHD has too much of some behaviors and too little of others

  • Interference in normal developmental progress

    • Trauma

  • Failure to master age-salient developmental tasks

    • Speech, motor,  or social milestones

  • Failure to develop a specific function or regulatory mechanism

Development as a transactional process

• Development is the outcome of transactions between the child and their environment 

• The child comes in to the world with certain genetics and prenatal experience, but as the child experiences the world and faces parents/siblings/caregivers etc. we have to look at behavior as a process

• The child is an active participant in their development 

• Organizing their experience emotionally, cognitively, as they grow they have increasing capacity to do this

  • Trauma interferes, parenting interferes, illness interferes 

• As children grow they develop new capacities

• Children have an ability to “self-right” and grow

• At a young age they have more flexibility and it requires less effort to correct

• We need to work with children as children so we can interrupt maladaptive paths to help redirect them on to a normative path 

• “The more a child has experienced maladaptive “paths”, the more difficult it is to shift to a more adaptive one” (Sroufe, Carlson, Levy and Egeland, 1999)

Developmental pathways 

• Equifinality

  • Equi (equal) finality (outcome)

  • Different circumstance can lead to the same outcome

  • Multiple processes can lead to the same diagnosis

  • Example: depression in adolescence

    • Could happen because they had an accident a year ago, or because they were depressed before, or because they have a biological predispositions, or were sexually assaulted

• Multifinality

  • Similar circumstances can lead to different outcomes

  • Example: three people get SAed - one develops PTSD, one gets anxiety, one gets nothing

• Do not make assumptions - because of these circumstances, this is going to happen

  • Adjustment and maladjustment are points in time

  • There are multiple pathways, and pathways can change; 

  • Change is constrained or enabled by previous adaptations

Risk and resilience factors 

• Risk factors have to do with any influences that increase the chances for harm

• What causes harm, what maintains it, what makes it better or worse 

• Cumulative risk 

• Typically not one risk factor, instead it is a “pile up” 

  • The risk factor itself did not matter, it is the number of them

  • Rutter constructed a “family adversity index,” related to the number of risk factors identified in that child’s life

    • As he studied the cumulation of risk factors, he found that the chance of being diagnosed was only about 2% with 0 or 1 risk factor, but over 20% with 4 or more

• Risk factors in the child 

  • Temperament 

    • Goodness of fit

  • Exposure to chemicals or drugs 

  • Exposure to toxins in the environment 

  • Prematurity and low birth weight 

  • In utero stress

  • Neurodevelopmental processes 

  • Genetics 

    • All psychological traits show significant and substantial genetic influence

    • No traits are 100% heritable

    • Genetic impact is cause by many genes with small effects

    • Environments matter - epigenetics 

• Risk factors in the parent/family 

  • Substance abuse

  • Domestic violence

  • Maltreatment

  • Harsh parenting

  • Parental conflict, separation, divorce

  • Disrupted attachment and foster care

  • Parental psychopathology, such as mental illness or intellectual disability

• Risk factors in the community

  • Poverty

    • American children are more likely to remain in poverty than in other rich, industrialized countries

    • Chronic poverty is dehumanizing

    • It typically involves multiple risk factors including overcrowded and substandard housing, unsafe neighborhoods, including physical risks such as crime, food insecurity and hunger, food deserts, lack of access to resources

  • Poor quality of schools

  • Social disadvantage, racism, and minority status

    • Historical and intergenerational trauma as backdrop for children and families of color

  • Exposure to community violence

  • Exposure to media violence

Culture and developmental psychopathology 

• Some of our judgments about what is typical or atypical, and what is psychopathology, are based in judgments about sociocultural values

  • Deviance from ‘normative’

  • What is acceptable or not?

  • How does that differ across cultures, socioeconomic status, racial group, and other factors?

• Culture 

  • Resilience is promoted by the client’s values and beliefs, family ties, and social network resources

  • Cultural context = individual client’s perceptions and meanings about their own life, embedded in larger cultural meanings

  • We need to pay attention to the roles of social power, discrimination, racism, and the effects of social marginalization (e.g., invisibility, devaluation) 

    • Overlap between these experiences and mental disorders

  • Culture is crucial to what is normative and psychopathological

    • “When we transform persons into cases, we often see only them in terms of how well they fit in a category. In this way, we miss important elements of a person’s life—cultural, social, political, ethnic, spiritual, and economic—and how they contribute to, sustain, and shape a person’s misery or struggles or mistakes. The irony here is that in making a case, we really do not individualize. Information about context not considered relevant to an assessment scheme, might indicate important resources for help and transformation as well as problem-solving.” 

      • What might this mean for our work?

        • Individualized services

        • Goodness of fit of the clinical approach to the client’s needs”

        • Movement toward cultural humility, sensitivity, and competence in work with diverse children, adolescents and their families

  • Strengths and cultural contexts 

    • Our aim is to:

      • Balance the assessment of pathology with an appreciation of internal/external strengths and resources 

        • To better understand the interaction of stressors and resources in the client’s life

    • Identify domains that highlight the client’s cultural, familial, and  socioeconomic contexts and enhance diagnostic information 

    • Cultural context + sources of resiliency = diagnoses and treatment plans that consider the client’s complex contextual world

January 28 - Lecture 3

Agenda 

1. Case study - Julia and Jon

2. DSM 5 and 5TR

3. Social work perspective on the DSM 

4. Implications for assessment of children and adolescents 

Case study - Julia 

• There is in fact enough information to diagnose 

  • Atypical behaviors 

  • Period of time exceeds what is standard for a child in kindergarten 

• More information is needed to understand the whole picture, when diagnosing 

• Consider if a diagnosis is helpful

  • In some environments you can only treat/intervene if there is a diagnosis 

  • Diagnosis often means psychiatric care and medication 

  • Can bring label, stigma, and treatment that may be prejudicial 

Case study - Jon 

• Do the math - figure out when something occurred → he is 15, parents divorced for 15 years = happened when he was 5 which is a pivotal time 

DSM

• Very focused on science/research as the basis for diagnosis 

• Wants to create strong, consistent and objective validators for mental disorders 

• Purpose: 

  • A bridge between problem assessment and treatment 

  • Identifies prevalence rates and documents trends

• History: 

  • DSM I (1950s): to highlight the mental health difficulties of veterans

  • DSM III (1980): shift from psychoanalytic ideas to a medical basis

    • aided by Beck

    • More specific descriptions of diagnostic entities 

  • DSM IV and IV-R (1994 & 2000): feminism pushed back on over-diagnosing women

    • Added a lot more specificity and categorization 

  • DSM 5 and 5-TR (2013 & 2022): concerns with psychologists’ agendas influencing the DSM, movement toward neurobiology - loss of multiaxial diagnosis 

• Comparing to ICD 11

• Organizational structure 

  • Organized according to internalizing and externalizing factors in diagnosis 

    • Internalizing = symptoms that are within, more hidden, not always visible, tend to be acted out internally, ex: anxiety and depression

    • Externalizing = acted out, prominent impulsive, disruptive conduct

  • Also organized on developmental and lifespan consideration 

  • No longers stars with a chapter on disorders in infants and children → within each diagnosis there is a section on kids 

• V/Z code 

  • Important addition since axis IV was eliminated 

  • Enable us to address psychosocial and environmental problems that social workers highlight 

  • Z codes come from the ICD-10

  • Vi codes come from ICD-9 and DSM 5 

  • Examples of V codes:

    • Relationship problems 

    • Abuse and neglect 

    • Educational and occupational problems 

    • Housing and economic problems 

    • Other problems related to the social environment 

  • Help kids without diagnosable disorders to get support 

  • Alert other professionals to important issues for current and future care 

• Severity 

  • Replaced the global assessment of functioning 

  • Dimensional assessment: mild, moderate, severe 

    • Rated by number of symptoms or clinical judgement, as outlined 

• DSM 5-TR changes 

  • Mostly clarity in the text → 70 disorders 

  • New diagnosis: prolonged grief disorder 

  • New symptom code: suicidal and non-suicidal self0injury behaviors 

  • Including a focus on social-determinants of health - culture, racism and discrimination 

Social work focus on the DSM

• Assumptions of the DSM

  • Mental disorders are defined by clusters of “symptoms” (behaviors, thoughts, emotional states) that can be classified categorically and have discrete meaning

  • Diagnostic terms promote common understanding

  • DSM diagnosis leads to correct treatment methods

  • Diagnosed illnesses need treatment, often pharmacologic treatment (meds)

  • Mental disorders emerge due to problems in the brain

  • Mental disorders are considered medical conditions

  • Mental disorders result in “significant distress or disability in social, occupational, or other important activities” 

• Assumptions of social work 

  • Empowerment is healing

  • Building on strengths rather than focusing on diagnoses promotes resilience and recovery

  • Need to work beyond symptoms — or dig deeper than symptoms

  • Clients are experts on their own lives and can define their own problems

  • Best interest of clients is always first

  • Human suffering occurs due to complex, multi-level forces in systems around individuals

  • Language is powerful, and can help or harm

  • Labels can affect identity and behavior

• The DSM in not a bible

  • DSM works from a disease model that often contradicts SW values 

  • The DSM tells us WHAT not WHY

  • DSM does not focus on etiology 

  • Alan Francis (DSM IV chair) “Be skeptical and don’t follow DSM 5 blindly down a road likely to lead to massive over diagnosis and harmful over-medication.”

  • CBT therapists had most position attitudes about the DSM 

  • Psychodynamic, humanistic and constructivist were negatively inclined towards the DSM

  • May mean focusing on symptom relief rather than holisitc 

Assessment

• Writing diagnoses 

• Assessment of children and adolescents

February 4: Lecture 4 - Early Childhood Disorders

Agenda 

1. Early childhood disorders (ECD)

   1. Trauma 

   2. Feeding 

   3. Sleeping 

2. Cast studies: Luke and Lizze, Mark

Language

• Etiology = the cause, set of causes or manner of causation of a disease or condition 

  • Used in medicine 

  • Genetic contributions 

  • Gene-environment interactions 

  • Environment-environment interactions 

    • Environment now acting on environment in the past 

    • May create risk and vulnerability for psychopathology 

    • We don’t have brain basis for all diagnoses 

ECD

• Psychopathology perspectives focus on:

  • Neurodevelopment 

  • Temperament

    • Physiological/genetic basis 

    • Building blocks of personality

    • Thought to emerge in infancy 

    • All types are okay, just different strengths and weaknesses 

    • Thought to be enduring - but can change/be changed by intervention

    • Environmental factors too

      • “Goodness of fit” between parent temperament and child temperament 

    • Types:

      • Easy 

        • Flexible 

        • Adaptable 

        • Go with the flow 

        • Sunny/optimistic

        • Approachable 

        • About 40% of the population  

      • Difficult 

        • About 10% of children 

        • Not as easily engage

        • More pessimistic 

        • More challenges interacting with the environment 

      • Slow to warm up

        • About 15% 

        • Like a pond/lake defrosting after the winter - it takes to warm up as compared to the air 

      • Combination 

        • About 35% of kids 

    • Traits:

      • Activity level 

      • Distractibility 

      • Intensity 

      • Regularity 

        • Rhythms: sleep, eating, routines

      • Sensory threshold 

      • Approach/withdrawal 

      • Adaptability 

      • Persistence 

      • Mood 

    • Research 

      • Two groups of adolescents 

        • With behavioral inhibition 

        • Without behavioral inhibition 

      • Hypothesized that parenting styles would influence how kids with fearfulness would react 

      • Found that BI with warm and supportive parentings = less affected around fearfulness in new situations 

    • Sensitivity 

      • 20% of kids may seem to overreact to stimuli 

        • Born with a nervous system that is highly aware and quick to react 

      • Sensory processing disorder (not in the DSM 5)

        • Oversensitivity to certain stimuli 

        • Undersensitivity to certain stimuli 

        • Difficulty with fine motor skills 

        • Avoidant or seeking behaviors related to sensory input 

        • Challenges with attention and focus 

        • Social and emotional difficulties 

  • Attachment 

    • Two-way relationship 

    • Emotional and physical relationship between child and caregiver 

    • Sets stage for all future, intimate, trusting relationships 

    • Attachment system provides:

      • Proximity to the attachment figure 

      • Experience for separation distress 

      • An internal working model of a secure base 

      • Sense of safe haven 

    • Is it pathological or normative?

      • Duration 

      • Age - toddler clinging vs. 12 year old clinging 

    • Secure attachment is associated with a process of tuning in to the child’s physical and emotional needs 

    • Requires responding consistently → provides basis for emotional regulation, development of self, identity and optimal development 

    • “Serve and return”

    • Styles

      • Secure 

        • 65% 

        • More likely to explore 

        • Have a basis in security 

        • Dropped in recent years (more so 55%)

      • Avoidant 

        • 20%

        • Not very explorative 

        • Emotionally distant 

        • Often happens when parents are disengaged

        • Believes needs probably won’t be met 

        • Significant risk factors for psychopathologies: anx/dep

      • Ambivalent

        •  10-15%

        • Anxious

        • Insecure 

        • Angry

        • Try to get parents attention “mom, mom, mom, mom”

        • Tend to be more demanding 

        • Cannot rely on their needs being met

        • Often happens when parents are disengaged

        • Can be significant risk factors for psychopathologies 

      • Disorganized 

        • 10-15%

        • Depressed 

        • Angry 

        • Passive and non-responsive 

        • Confused with no strategy to have needs met 

        • Often associated with child abuse or neglect 

    • Attachment is enduring 

  • Experiences of the caregiving relationship, parenting styles and stability of the caregiver 

Trauma and stressor related disorders 

• Trauma typically relates to various forms of neglect and abuse 

  • Developmental or complex trauma (used synonymously) 

    • Developmental trauma = not a one off shock 

      • At the hands a caregiver 

      • Has significant impact on every aspect of that child’s development 

      • Impacts sense of self 

      • Impacts ability to form secure attachment 

        • Many aspects of a child’s healthy physical and mental development relies on this primary source of safety and stability 

      • Really serious diagnosis 

    • Complex trauma = children's exposure to multiple traumatic events 

      • Invasive, interpersonal nature 

      • Wide-ranging, long-term effects of exposure

      • Severe and pervasive 

        • Abuse and profound neglect 

        • Typically in early life 

  • Reactive Attachment Disorder 

    • Connected to our internalizing system

      • Depressive symptoms and withdrawal 

    • Etiology = abuse and neglect 

      • Failure of nurturing caregiving and secure attachment 

    • Associated with disorganized attachment 

      • However not in the DSM 5

    • Might be seen in early childhood, but observed in adolescence or early adulthood

    • Children show a pattern of markedly disturbed and developmentally inappropriate attachment behaviors 

  • Disinhibited Social Engagement Disorder

    • Connected to our internalizing system

      • Depressive symptoms and withdrawal 

    • Etiology = abuse and neglect 

      • Failure of nurturing caregiving and secure attachment 

    • Associated with disorganized attachment 

      • However not in the DSM 5

    • Might be seen in early childhood, but observed in adolescence or early adulthood

    • Children show a pattern of markedly disturbed and developmentally inappropriate attachment behaviors  

Reactive Attachment Disorder (RAD)

• Core features:

  • Does not seek comfort, support and nurturance from caregiving adult (A)

    • Also does not respond to comfort positively 

  • Persistent social and emotional disturbances (B)

    • Minimal emotion regulation 

    • Limited positive affect 

      • Affect = physical expression of mood

    • Episodes of unexplained irritability, sadness and fearfulness 

  • Children have experienced a pattern of extremes of insufficient care (C)

    • Social neglect or lack of basic emotional needs being met 

    • Repeated changes in primary caregivers that limit opportunities for stable attachments 

    • Rearing in unusual settings 

      • Institutions with high child to caregiver ratios = high risk 

        • Birth to 1 year in SC is 1:5

      • Romanian orphanages example

        • You see a lot of self-soothing behavior 

          • Rocking 

  • Symptoms begin before age 5, not ASD, reached a developmental age of at least 9 months (D, E, F, G)

  • Behavior to meet my needs: I'm on my own

Disinhibited Social Engagement Disorder (DSED)

• Central features:

  • Pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers 

    • Don’t check back with caregiver 

  • Child interacts with unfamiliar adults with 2 of the following: (A)

    • Behavior includes an inappropriate approach to unfamiliar adults - lack of wariness of strangers - willingness to wander off with strangers

    • Overly familiar verbal or physical behavior

    • Diminisher or absent checking back with adult caregiver

    • Willingness to go off with an unfamiliar adult with minimal or no hesitation

  • This behavior has to be differentiated from ADHD impulsivity (B)

  • Social neglect is again seen as causal ©

  • Behavior to meet my needs: do not have one specific person to meet my needs

Feeding and eating disorders 

• Issues related to feeding in early childhood:

  • Limited appetites or poor appetites

    • May be too distressed or irritable to eat

  • Communicate poorly

    • Don’t know when they are hungry - often related to other issues

  • Developmental disorders, including those on the autism spectrum and those with intellectual disability

  • Highly sensitive or may have sensory integration disorders

  • Fear of feeding, sometimes around painful medical procedures they have endured

  • Children who have experienced neglect and/or other aspects of poor parenting 

• PICA 

• Rumination

• ARFID

PICA 

• A person’s appetite for substances that are largely non-nutritive

• For at least 1 month consistently 

• At least 2 years old 

  • To exclude developmentally normative mouthing of objects 

• Most commonly ingested substances 

  • Ice 

  • Dirt 

  • Clay 

  • Paint chips 

  • Plaster 

  • Chalk 

  • Cornstarch 

  • Coffee grounds 

  • Cigarette ashes  

• Self-soothing 

• Most closely related with neurodevelopmental disorders such as ASD

Rumination 

• Repeated regurgitation of food 

• Self-soothing 

• Most closely related with neurodevelopmental disorders such as ASD

ARFID

• Avoidant restrictive food intake disorder 

• Increased disinterest in food 

• Occurs in early childhood

• Prevents the consumption of certain foods 

  • Selective or restrictive eating habits 

• Avoidance which is associated to sensory characteristics of food 

• May be related to parent-childhood relationship 

• Results in significant weight loss, nutritional deficiency, marked difficulty in psychosocial functioning  

Sleep disorders 

• Sleep-wake disorders 

  • Difficulties falling asleep or staying asleep 

  • Disorders of arousal 

    • Sleepwalking 

    • Sleep terrors 

  • Nightmare disorder 

• More common in children with neurodevelopmental issues and diagnoses such as ASD or ADHD

Elimination 

• Inappropriate elimination of urine or feces 

• First seen in childhood or adolescence 

• The diagnosis is considered when a child does not accomplish control over their bladder (enuresis) and/or bowels (encopresis) within a reasonable expected time frame or if there has been a regression

  • Enuresis 

    • 5 years old+ 

    • Occurs at least twice a week for at least 3 months 

    • Primary = continence has never been established 

    • Secondary = develops after a period of continence 

    • No physiological effects → need to ask a physician 

    • 3 specifiers:

      • Nocturnal only - night only 

      • Diurnal - waking hours only

      • Nocturnal and diurnal - both

    • Risk factors

      • Stress 

      • Abuse/neglect 

  • Encopresis 

    • 4 years old+

    • Occurs at least 1/month for 3 months 

    • Control is either voluntary or involuntary 

    • No physiological effects → need to ask a physician 

    • Pass feces in inappropriate places 

      • Underwear 

      • Bathroom wall 

• Contributing factors

  • Delayed development 

    • Neurodevelopmental disorders 

  • Difficult temperament 

  • Maternal depression 

  • Toxic/traumatic stress  

• Associated issues 

  • Potential for anger, punishment and rejection from caregivers 

  • Avoidance of social situations 

  • Bullying and teasing from peers 

  • Low self-esteem and shame 

  • Smearing feces intentionally could be related to ODD or conduct disorder 

February 11: Lecture 5 - Neurodevelopmental Disorders

Agenda

1. Quiz next week 

2. Introduction to neurodevelopmental disorders 

   1. ASD 

   2. Motor disorders 

   3. Intellectual developmental disorder

Quiz 

• Pay attention to the title of the diagnosis 

• Content from lectures 2-5 inclusive

• MCQs

• Includes small vignettes 

• “Most likely diagnosis” 

• 25 questions 

Neurodevelopmental disorders 

• “Neuro” = brain, “developmental” 

  • Characterized by abnormalities in how the brain develops 

• Some are more global, some are more specific 

  • Can affect: 

    • Motor 

    • Emotion

    • Learning-ability 

    • Speech 

    • Self-control 

    • Memory 

    • Attention 

  • These are all things children should be developing 

  • We have an understanding of normative development 

  • Disorders = not developing in a typical way 

• These should be diagnosed in early childhood (3-6 years old) 

  • Significant consequences in kids already struggling if they have not been diagnosed 

• Development of the nervous system is disturbed leading to a structurally compromised brain

• Includes autism spectrum disorders, intellectual disability, learning disorders, communication and motor disorders, and ADHD 

• Risk factors:

  • Related to what goes on in-utero, during birth or after birth 

    • Childhood deprivation 

    • Genetic processes that disrupt brain processes

    • Metabolic diseases, immune disorders, diseases, nutrition

    • Physical trauma 

    • Toxic and environmental factors 

Autism spectrum disorder (ASD)

• ASD is now an umbrella term 

• ASD now includes autism, asperger’s, childhood disintegrative disorder, pervasive developmental disorders not otherwise specified (PDD-NOS)

• There is a big continuum now

• Research

  • Abnormality in cells that produce myelin

    • Myelin allows cells to quickly and reliably carry electrical signals from one area to another 

    • Too much or too little can lead to neurological problems 

• Characterized by two domains:

  • Social communication symptoms 

    • Social and communication deficits 

    • Problems in social emotional reciprocity 

    • Reduced sharing of interests, emotions or affect

  • Restricted repetitive patterns of behavior 

    • Stereotyped or repetitive motor movements 

    • Use of objects or speech

• Typical development 

  • Learn what is important - people over things 

  • Social learning - from others and about others 

  • Joint attention - “serve and return” responding back and forth 

  • Perspective taking - learning mental states 

• Atypical development

  • Less engagement with people, more engagement with things 

  • Delays in SE reciprocity (A)

    • Difficulties related to the experience, perception and processing of emotions 

    • More negative emotion and less well-regulated emotion

  • Deficits in nonverbal communicative behaviors used for social interaction 

  • Deficits in developing, maintaining and understanding relationships 

  • Restricted, repetitive behaviors (B)

    • Fixated interests 

      • More intense interests 

      • Focus-specific 

      • Fact/object/sensory based 

    • Repetitive behaviors 

      • Behaviors connected to anxiety 

      • Stimming 

    • Routines 

      • Insist on sameness in their environment 

      • Very inflexible 

    • Sensory sensitivity 

    • Externalizing difficulties 

• Early signs ©

  • No ASD

    • Engages others in his play 

    • Shows meaningful, purposeful and pretend play 

    • Shares enjoyment by smiling at people 

    • Synchronizes with others through imitation 

  • ASD

    • Unusually strong interest in phone 

    • Does not engage with people during play 

    • No response to name 

    • Enjoys tickle but not looking at mom to share enjoyment 

  • No ASD

    • Looks in response to bid to share attention 

    • Socially engaged

    • Coordinates gaze, vocalization, and gesture to communicate 

  • ASD

    • Hand flapping 

    • No response to name 

    • No response to other’s bids to share attention

    • Not socially engaged

• Additional diagnostic considerations

  • Can come with cognitive delays or intellectual disability 

  • Severity 

    • Level 1 = requiring support 

    • Level 2 = requiring substantial support 

    • Level 3 = requiring very substantial support 

  • Diagnosed 4x more in males than females 

    • Male-model 

    • Further research shows 

      • Girls have less of that B category 

      • Girls struggling with undiagnosed autism often develop dep/anx/self-esteem issues 

      • Girls are more likely to mask 

        • Develop social skills and coping mechanisms that allow them to blend in socially 

• Polyvagal theory and autism 

  • We have circuits for dealing with threat for social engagement 

  • Our polyvagal nerve communicates between our brain stem and bodily organs (heart/lungs/digestive system) 

    • Perception is based on thinking about our sensory experience 

  • Researchers suggest that people with autism have more reactive nervous systems → live in a state of threat (more reactive) more than typically developing youth 

    • Could explain why kids with autism cannot emotionally regulate as well 

  • Interventions focus on flipping the switch to cognitively understand a chronic threat and moving to a sense of safety 

Motor disorders 

• A subcategory of neurodevelopmental disorders 

• Includes: 

  • Developmental coordination disorder 

    • Dyspraxia 

    • “Clumsy child syndrome”

    • Characterized by impaired skills requiring motor coordination  

  • Stereotypic movement disorder 

    • Involves repetitive, non-functional motor behaviors 

      • Ex: hand waving, head banging 

    • Interferes with normal activities to be diagnosed 

    • Not diagnosed separately if it is a component of ASD

    • Ex: romanian orphanage babies self-soothing with rocking 

• Tics

  • Can range from simple to complex 

  • Motor, vocal or both 

    • Simple: short duration 

      • Eye blinking, shoulder shrugging, vocal tics

    • Complex: longer duration 

      • A combination of simple tics 

      • Obscene gestures and verbalizations 

      • Ex: repeating the last word someone said, repeating one’s own words

  • Coexisting diagnosis with motor disorders:

    • OCD in 50%

    • ADHD in 20% 

    • Neurobiological disorders 

  • Do not always need treatment 

• Tourette’s

  • Between age 3 - 9 

  • Child must exhibit multiple motor tics for more than a year 

  • At least one vocal tic for more than a year 

  • Must be under the age of 18 

  • May have coprolalia = involuntary cursing 

  • Comorbid with disorders such as OCD, anx, ADHD, ASD 

  • Can be made worse with stress, poor sleep and sickness 

  • Better when the child is relaxed and focused 

  • Intervention includes habit reversal (HRT) and CBT

    • Child has to be old enough to be aware of the tic for therapy to be helpful 

  • Medication include clonidine and risperidone

Intellectual disability or intellectual developmental disorder (ID or IDD)

• Appears in childhood 

  • Can be diagnosed at birth or in utero

• Characterized by an individual’s significantly impaired cognitive functioning and deficits in adaptive behaviors (tying shoes, using knife and fork)

• Could also include communication and interpersonal issues as well

• IDD is an IQ score below 70

  • Range below 70 can indicate mild, moderate and severe IDD

• Typically diagnosed by a medical professional 

• SWs can provide intervention and support 

• Risk factors 

  • Not just one genetic mechanism and consequent brain process being disrupted 

  • Prenatal 

    • Chromosomal disorders

      • Down syndrome 

      • FMRI gene in Fragile X syndrome  

    • Metabolic disorders 

    • Exposure to toxins 

    • Infections 

      • Rubella 

      • HIV

  • Perinatal 

    • Prematurity 

    • Birth injury → mostly with lack of oxygen 

      • Ex: cord wrapped around baby's neck

    • Parental rejection of caretaking 

    • Abandonment 

  • Postnatal 

    • Malnutrition 

    • TBI 

    • Toxins 

• Differential assessment 

  • Diagnosis considers the child’s adaptive functioning along with IQ scores 

    • Intellectual functions (A)

      • IQ score ranging from 65 to 70 have an ID

      • Below 55 is profound ID 

    • Adaptive functioning (B)

      • How well are they able to manage, navigate and take care of themselves across environments

    • Symptom onset during the developmental period ©

• IDD

  • Characterized by a slower rate of cognitive development and often a cap/plateau 

  • Mild = growth a 6th grade level 

  • Moderate = growth a 2nd to 4th grade level 

  • Severe = very little language 

  • Likely to see more behavioral problems because they cannot communicate and cannot get their needs met 

  • Adaptive functioning varies 

    • Some people show steady improvements 

    • Some show variable 

    • Others decline 

  • Treatment focus is on supporting child’s development and functioning 

    • Recognizing strengths 

      • Positive mood 

      • Emotional skills 

      • Humor 

      • Capacity for complex emotional relationship 

    • Understanding the whole child