Disorders of Childhood & Adolescence

Developmental Psychopathology

  • Focuses on origins and course of psych maladaptation in the context of normal development

  • Individual may “grow out” of certain problems, while others may severely impact future

  • Vulnerabilities

    • Dependence on others

      • Good or bad, abusive or exploitative

    • Lack of experience handling problems

    • Lack realistic views of world and self

      • Limited understanding of social expectations

      • Difficulty understanding why bad things happen

  • Resilience

    • better Ability to cope when negative things happen

    • better Ability to develop normally despite significant hardship

Childhood problems as risk factors

  • Externalizing problems

    • “undercontrolled”

    • Aggressive

    • ADHD

    • Conduct disorder

    • Oppositional defiance disorder

    • More boys

  • Internalizing problems

    • “overcontrolled”

    • Inner distress, shyness

    • More girls

    • Separation anxiety

    • Selective mutism

  • Disinhibited behavior is a trait of childhood

  • Children have poor impulse control, planning, delay of gratification, etc.

    • Think marshmallow/oreo test

  • If disinhibition persists into adolescence, it can result in increased risk taking, substance abuse, and suicide rates

Brain Development

  • Subcortical regions develop more rapidly

    • Responsible for emotions, impulses

  • Prefrontal regions develop more slowly

    • responsible for planning, impulse control

  • Greatest disparity in development occurs around 17, could account for disinhibition during teenage/early 20s

Externalizing disorders

Attention Deficit Hyperactivity Disorder

  • Generally arises before 12

  • More common in boys (13%) than girls (4%)

    • Boys more likely to develop hyperactivity/impulsivity

    • Girls more likely to develop inattention

  • 50% continue to have problems in adulthood

  • Prevalence has risen significantly in past 20 years

    • people with ADHD are eligible for disability services in 1992

    • Effective treatments are widely available

      • Stimulants

      • Effective for anyone trying to focus, regardless of ADHD diagnosis

  • Two aspects

    • Hyperactivity/impulsiveness

      • Fidgety

      • Leaving seat

      • Runs or climbs excessively when inappropriate

      • Excessive talking, difficulty staying quiet

      • Difficulty waiting turn

      • Interrupts questions, others, etc.

    • Inattention

      • Careless mistakes, poor attention to detail

      • Does not seem to listen

      • Difficulty following instructions (not oppositional)

      • Avoids/dislikes things that require sustained mental effort

      • Easily distracted by extraneous stimuli

      • Forgetful

  • Three subtypes

    • Hyperactivity/impulsivity subtype

    • Inattentive subtype

    • Combined subtype

Conduct disorder

  • Characterized by persistent antisocial behavior that violates

    • Rights of others

    • age appropriate social norms

  • Includes:

    • aggression towards people or animals

    • destruction of property

    • deceitfulness and theft

    • violation of rules

  • DSM Criteria:

    • Persistent violation of rights of others with 3 or more of the following:

      • Bullying

      • initiation of physical fights

      • use of weapons

      • cruel to people

      • cruel to animals

      • theft while confronting victim

      • rape

      • arson

      • deliberate destruction of other’s property

      • breaking and entering

      • conning others for personal gain

      • non-trivial theft

      • disregarding of parental rules

      • run away from home at least twice

      • truancy

  • Disorder of childhood; individuals over 18 can’t meet criteria

  • Other associated traits

    • Antisocial symptoms

    • peer/family rejection

    • academic skill deficit

    • low self esteem/depression

    • limited work and relationship opportunity

    • gravitation towards other deviant peers and behaviors

  • Prevalence

    • 10% general population

      • More common in males

    • Gender differences

      • Males exhibit more violent traits, like fighting/theft/vandalism

      • Females exhibit more lying, truancy, running away, substance abuse, etc.

  • Childhood onset is associated with

    • Inadequate parenting

    • severe hyperactivity

    • violent/antisocial behavior

    • “life-course persistent”

  • Adolescent onset

    • emerge alongside puberty

    • common, temporary, near-normative

    • “adolescence limited”

  • Delinquency is normal?

    • Pushing boundaries and behavioral problems could be considered a normal part of teenage and young adulthood

Oppositional Defiant Disorder

  • Defiant or vindictive behavior

  • Resentment or anger towards authority

  • Similar to Conduct disorder, but less severe

    • Doesn’t include:

      • Physical aggression

      • property destruction

      • theft

  • Acting out is directed towards figures of authority more than peers

  • DSM criteria

    • Hostile, defiant behavior with at least 4 of the following

      • Loses temper

      • argues with adults

      • actively defies or refuses to comply with adult requests

      • deliberately annoys people

      • blames others for personal mistakes

      • touchy, easily annoyed

      • angry/resentful

      • spiteful or vindictive

  • Severity

    • Mild: sx occurs in 1 setting

    • moderate: sx occurs in 2 settings

    • severe: sx present in 3+ settings

  • Prevalence

    • 10% in general population

      • Greater in males prior to puberty

      • roughly equal after puberty

  • appear before 8yo and usually persist through adolescence

  • Sxs usually seen in multiple settings

  • Associated features

    • Considered precursor to conduct disorder

      • Only 25% of ODD develop CD

    • Common comorbidities

      • ADHD

      • Depression

      • Substance use

  • effective treatments

    • Reward of appropriate behaviors

    • punishment of defiant behaviors

Internalizing disorders

Separation anxiety disorder

  • Most common type of childhood anxiety disorder

  • excessive anxiety about separation from attachment figures

  • child is terrified something terrible will happen to self or parents after separation

  • to a developmentally inappropriate degree

  • DSM Criteria

  • Inappropriate anxiety evidenced by 3 or more:
     Recurrent, excessive distress upon separation from primary caregiver
    (“attachment figure”)
     Persistent fear of harm coming to attachment figures
     Persistent worry about something bad happening that will prevent child from
    seeing attachment figures
     School refusal due to anxiety about separation
     Persistent fear of being alone without attachment figures
     Need to sleep near attachment figures
     Repeated nightmares about separation
     Physical Sxs upon separation

  • Duration of at least 4 weeks

  • Onsets prior to 18

  • 4% of children and adolescents develop SAD

    • Equally common across sexes

    • Adolescent onset is uncommon

  • Could be prompted by life stress

    • parent’s divorce, death of loved one

  • Associated features

    • social withdrawal

    • school refusal

    • difficulty concentrating, academic problems

    • Concerns about death and dying

Selective Mutism

  • Consistent failure to speak in specific social settings

    • normal speech in other situations

  • Disturbance interferes with educational, social, or occupational achievement

  • Duration of at least 1 month, not associated with start of school

  • Failure to speak is not due to lack of knowledge or comfort with the spoken language

Autism Spectrum Disorder

  • DSM criteria

    • Persistent deficits in social communication and interaction across multiple contexts, examples including

      • Abnormal social approach and failure of normal conversation

      • deficits in nonverbal communication, abnormal eye contact and body language

      • deficits in developing, maintaining, and understanding relationships. limited imaginative play or interest in peers

    • Restricted, repetitive behavior patterns

      • Interests, need for sameness, adherence to routine, repetitive motor movements or speech

      • Hyper or hyporeactivity to sensory input

    • Must be present in early development

    • cause clinically significant impairment

    • not better explained by intellectual disability

  • Intellectual disability is often present, but not always

    • verbal skills suffer most

  • Associated behaviors

    • hyperactivity

    • short attention span

    • impulsivity

    • aggression/tantrums

  • Prevalence

    • old diagnosis (autism disorder) was about 1 in 2000

    • rate of ASD is about 1 in 50

    • 4-5 times higher rate in males than females

      • when females are affected, there tends to be greater intellectual disability

  • Etiology

    • Most established causes are genetic

    • Some common variants identified by genome-wide association study

    • Many severe cases attributable to de novo variants

      • neither parent has genetic risk factors, but child has severe ASD often with intellectual disability

      • occurs through genetic mutation in utero

    • There are certainly environmental factors that increase the risk of ASD, but not enough proof yet

Intellectual Disability

  • Significant subaverage IQ of approx 70 or below

  • Inability to care for themselves

  • DSM Criteria

    • Deficits in at least 2 of the following areas

      • communication

      • self care

      • home living

      • social/interpersonal skills

      • use of resources

      • self direction

      • functional academic skills

      • work

      • leisure

      • health

      • safety

    • Onset prior to 18yo

  • Severity (IQ criteria)

    • Mild (55-70)

    • Moderate (40-55)

    • Severe (20-40)

    • Profound (<20)

  • Co-morbidity is difficult to determine

    • Presentation of other symptoms or diagnoses can be modified by ID

  • Etiology

    • Causes are varied

    • Mild ID is very multifactored with polygenic and pol-environmental causes

    • Severe ID tends to have some other genesis

      • Trauma

      • Toxins

      • Genetic/chromosomal conditions

        • PKU, Down’s, Fragile X, etc.