Disorders First Apparent in Childhood Why “first apparent”? Childhood disorders may continue...
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Transcript of Disorders First Apparent in Childhood Why “first apparent”? Childhood disorders may continue...
Why “first apparent”?
Childhood disorders may continue into adulthood
Childhood disorders may lead to other adult disorders
Childhood disorders may impact development
Disorders
1. Attention Deficit Hyperactivity Disorder2. Learning Disorders/Communication Disorders3. Autism & Asperger’s Disorder4. Mental Retardation (Axis II)5. Conduct Disorder & Oppositional Defiant
Disorder6. Selective Mutism
Attention Deficit Hyperactivity Disorder (ADHD)
Inattention: lack of focus on
detail & careless mistakes
difficulty with sustained attn
not listening when spoken to
fails to follow through on tasks
organizational problems
dislikes sustained effort
easily distracted forgetful in daily
activities
Attention-Deficit Hyperactivity Disorder Hyperactivity/Impulsivity
Fidgets or squirms in seat
Leaves seat when it is inappropriate
Runs or climbs excessively
Difficulty playing quietly Is often “on the go” or
acts as if “driven by a motor”
Talks excessively Blurts out answers
before questions are finished
Difficulty waiting for his/her turn
Disrupts or interrupts others
ADHD
Symptoms are usually evident before school-age, but more relevant in that setting
Symptoms must be present in more than one setting
5% of school-age children have ADHD (drops with age)
ADHD
Significant social impairments Academic problems Comorbid with: mood disorders, learning
disorders, substance use, APD, neurological problems, physical accidents and injury
What Happens When they Grow Up?
Adults may self-select environments that result in less noticeable symptoms
68% have attention problems in adulthood Only 30% of children retain the diagnosis in
adolescence, and 10% in young adulthood 25% do not finish school 1/5 develop APD w/ high levels of crime
What Causes ADHD?
Large genetic component Subtle brain differences
Smaller brain volume Association with maternal smoking
2-3 times more likely Inability to inhibit behavior
Executive functioning deficit (goals, planning)
What Causes ADHD?
Is the real problem our regimented modern classrooms? Decreased time for active play Change in environment penalizes students who
would be normal under different circumstances Little evidence of brain abnormalities ADHD looks like extreme playfulness Function well outside the classroom (no control)
Does Diet Affect ADHD?
Some argue that dietary additives affect/cause ADHD (e.g., food coloring) Parents place children
on special diets Evidence indicates
that NO, diet is not responsible for ADHD
How do we treat ADHD?
Stimulant medications Increase arousal and help focus attention Short half-life
Stimulants do affect growth hormones and can suppress appetite Many children take only during school hours Drug “holidays” are recommended Use the lowest therapeutic dose
How do we treat ADHD?
Behavioral Therapy for Children Improve socialization skills Reinforce and reward improved behavior until the
environment is rewarding alone Main techniques
Progressive muscle relaxation Contingency plans Cognitive therapy to increase awareness
How do we treat ADHD?
Behavioral Therapy for Parents Parents are trained in behavior management,
contingency management Reduce family stress Psychoeducation can reduce family blame
Best treatment is meds + therapy Meds are often necessary for severe cases
Learning Disorders
Deficits in reading, math, or written expression
Child’s achievement level is below what would be predicted based upon their ability level In DE, this difference must be present in less than
4% of children of the same age to qualify for services
Learning Disorders
Diagnosis based on comparison of those tests, in those specific domains only
5% of American students have a learning disorder
Reading is most common
Consequences of Learning Disorders
Many drop out of school Low employment rates (60-70%) Self-esteem problems
Causes of Learning Disorders
Genetic basis Almost 100% concordance between identical
twins Neurological differences
E.g., in sound recognition
Treating Learning Disorders
Treatment such as distinguishing sounds Children usually require educational
interventions Extra time Additional practice and assistance Special education
Earlier diagnosis = better prognosis
Communication Disorders
Deficits in the ability to express or comprehend verbal language Expressive Language Disorder Phonological Disorder Stuttering
Many are new categories to DSM-IV Usually the realm of Speech Language
Pathologists
Disruptions in social interaction & communication skills
Presence of stereotyped behaviors, interests, and/or activities
Pervasive Developmental Disorders
Symptoms of Autism
Abnormal/delayed development Socially Communication
Apparent by age 3 (20% report normal 1-2 years)
Failure to engage (e.g., reciprocal interactions) Inappropriate facial expressions, body postures,
gestures, eye contact
Symptoms of Autism
Unable to form friendships - shared interests
Social/emotional reciprocity
Stereotypic behavior Self-destructive
behavior*
Symptoms of Autism
Functional language deficits No language at all Repeat others
Pragmatic language deficits Integrate words with gestures Inability to understand irony,
sarcasm, pretend play
Symptoms of Autism
Restricted, repetitive, stereotyped behavior, interests, activities
Abnormal in intensity/focusE.g. dates, phone numbersLining up objects
Inflexible patterns, routines, rituals Preoccupation with parts of interest
Associated Features and Disorders
Hyperactivity, short attention span, impulsivity, aggressiveness
Self-injurious behavior & temper tantrums Odd responses to sensory stimuli (e.g. high
threshold for pain, sensitive to sound, touch, light)
Abnormal affect or fear reaction
Asperger’s Disorder
Mild autism No significant delays in early language
Other language may be “odd” and preoccupied with certain topics
No delay in cognition or self-help skills, adaptive behavior, curiosity about environment
Little concern in infancy, may seem precocious
Usually noticed after entrance to school
Prevalence & Course
1 in every 166 births 4:1 boys to girls Deficits sometimes noticed early Some improve at school Some improve during adolescence, but
others deteriorate IQ & functional language predictors
Causes of Autism: Genetic Contributions
Strongest genetic component Early studies thought not genetic But, hard to study:
1. 1 in 240,000 possible twin studies (1000 in US)
2. Autistic adults unlikely to have children
3. Autistic children have less siblings
Twin Studies Solve the Mystery:
Heritability index = .90 (risk) Genetically heterogeneous Unable to isolate genes Some evidence for viral infections during
pregnancy
Causes of Autism: Biological Abnormalities
75% = neurological abnormalities Abnormal reflexes/muscle tone Perceptual/motor coordination Movement/posture problems
Increase of seizures Reduced brain size
Behavioral Treatments for Autism
Decrease undesirable behavior & shape desirable
Positive reinforcement & extinction Social punishment Families are important Language + social skills
Alternative Treatments for Autism
Vitamins Other medications Diet Auditory Integration Training Facilitated Communication
What are “Alternative” Treatments?
Scientifically unverified Randomized
control studies Replication Large samples
What’s so bad about alternative treatments?
They give parents false hope They can violate patient rights Can allow others to control decisions “made
by” patients In some cases, have led to abuse allegations
Facilitated Communication
Provide assistance for communicating Alphabet board, computer, typewriter, etc Support hand/arm May isolate fingers Requires extensive training
Claims:
Produces (“frees”) unexpected literacy
Shows normal/superior intelligence
Provides a means to communicate (for those who have no means, but otherwise would)
What does the research say?
Facilitators unintentionally influence May even actively influence
Many well-designed studies: Single- and double-blind Repeated measures Participant as control
Auditory Integration Training
1. Conduct detailed audiogram, determining which frequencies sensitive to
2. Modify music by computer to remove those frequencies
3. Listen to music 10 hours/day, at least twice a day, for 10-12 days
Auditory Integration Training
Berard, France, 1960s (US in 1991) 1991 -> published book “cured” 10 hours
Autistic children (and other patients) are hypersensitive to certain frequencies
Claims: 76.2% of 1850 children “very positive results”
Claims:
Improved attention Improved auditory processing Decreased irritability Reduced lethargy Improved expressive language Improved auditory comprehension
The Critics
No scientific evidence for hearing impairments in autism
Inconsistent with medical knowledge re: structure & mechanism of ear
No measurement is valid enough to discriminate peaks of hypersensitivity
Weak, irrelevant, insignificant evidence Sound levels are unsafe
The Best Type of Treatment…
Structured educational programs geared to the person’s developmental level of functioning
It is, however, important to be open-minded Majority of other treatments not scientifically
proven Be educated Consider the individual child Do a thorough assessment and reevaluate
Assessing Cognitive Ability
Intelligence - a collection of adaptive skills You can be good at one, but not another Intelligence effects our functioning
IQ is normally distributed. Mean = 100, SD = 10
Scores below 70 = diagnostic of retardation 2-3% of the population falls below this cut-off
Assessing Social/Functional Deficits
Deficits must be present in 2+ areas: Communication Self-care Home living Interpersonal Skills Use of Community Resources Self-direction Functional academic skills Work Leisure Health & Safety
Levels of Mental Retardation
Mild (IQ = 50-55) Benefit from education (intense) Learn to read/write and do basic math Difficulties usually apparent after begin schooling May need supervision/guidance, but can live
alone with support Profound (IQ below 20-25)
Usually physical disorder accounts for problems Inability to manage even basic self-care tasks
What Causes Mental Retardation?
Chromosomal abnormalities (e.g., Down’s syndrome & Fragile-X syndrome) Down’s syndrome leading cause of organic MR Moderate to severe Females with fragile x = mild to moderate; males
= moderate to severe
What Causes Mental Retardation?
Genetic Problems PKU - lack of enzyme to break down
phenylalanine & build-up causes brain damage Normal at birth - diagnosis results in food
changes
What Causes Mental Retardation?
Pregnancy and Birth Complications Fetal alcohol syndrome (detectable only in infants
exposed to large amounts) Exposure to other drugs Therapeutic drugs (e.g., for seizures, bipolar,
Accutane for acne) Radiation (e.g., for cancer) Infections, such as rubella Physical damage to head, blood supply during birth
What Causes Mental Retardation?
Cultural-Familial MR Low end of IQ due to development or
environment Heritability index for IQ = .60-.80 Genes predominantly cause MR, environment
has less of an impact (But is important!) Appropriate stimulation during certain periods is
necessary E.g. child requires stimulation of certain brain areas as
they develop
Behavior Disorders - Conduct Disorder
A pervasive pattern of disrespect for rights of others + violation of rules/norms
Bullies, threatens, intimidates others Initiates physical fights, uses weapons Physically cruel to people and/or animals Stolen while confronting a victim Forced sexual activity
Conduct Disorder Deliberately sets fires w/ intention of doing
damage or destroys property in other ways Broken into someone’s house/building/car Lies to obtain goods or avoid responsibility Stolen costly items without confronting victim Stays out at night before age 13 Has run away, overnight, >2 times Is truant from school prior to age 13
Conduct Disorder
Children also have poor interpersonal skills Often experience peer rejection Seem to have problem-solving deficits
Do not generate as many options as non-CD children
Inability to take another’s perspective Interpret ambiguous gestures as hostile Prevalence = 3-6% (boys 2:1)
Oppositional Defiant Disorder
Pattern of negative, hostile, defiant behaviors Arguing for the sake of arguing, hostility
toward parents/teachers Usually begins at home (which can impede
diagnosis) May develop into later conduct disorder Typically emerge by age 8, est. 5-10%
prevalence
What Causes Conduct Disorders?
Neurological differences Poor coordination, fine motor skills Usually have significantly lower IQ than peers
Temperament Easily distressed, reactive to change, react to
intense stimuli (more likely behavior problems) Family Links
Parent with APD increases chances of CD Criminal and/or alcoholic parents Family history of aggression
What Causes Conduct Disorders?
Family Links cont.. Poor maternal mental health, prenatal health Poor supervision Spousal aggression Lax, erratic and inconsistent parenting/discipline Less acceptance, warmth, affection, support Reinforce CD behavior, ignore/reward other
(coercive process) Child-parent interactions are also
bidirectional
The Coercive Process Jimmy’s parents tell him to go to bed Jimmy refuses: “I want to play 1 more video game!” Parent says “No! Its late and you have school.” Jimmy gets upset, hitting table, screaming “Just one
more game. You’re mean - you never let me have fun!” Parent feels guilty at having spent little time together,
and is too tired after work to argue - says “Okay, 1 more game”
Jimmy stops screaming and plays his game Parent, relieved fight is over, goes to kitchen. Does not
monitor or play with child
The Coercive Process
What happens as a result of this process?1. Jimmy is rewarded for screaming2. Reward for screaming = increased
probability of screaming in future3. Parent is rewarded for giving in4. Parents likelihood of giving in is increased* If this pattern is typical, it is a risk factor. It
also tends to escalate over time
Conduct Disorder & APD
A minority of CD children develop Antisocial Personality Disorder
Treatment for conduct disorder is of interest, as preventing APD would reduce associated financial and criminal costs to society Remember, APD is untreatable!
Treating CD and ODD
1. Problem-Solving Skills
2. Parent Management Training
3. Family Therapy
4. School & Community Based Treatments
Problem-Solving Skills Children tend to have
poor problem-solving & interpret intentions/actions as hostile
Combines modeling, role-playing, and reinforcement contingencies to increase problem-solving and prosocial behavior
Parent Training & Family Therapy
Break cycle of coercive process Promote prosocial behavior in child Apply proper discipline techniques by parent Increase reciprocity & positive reinforcement
between family members
Parent Training and Family Therapy
Outcomes look good (reduce arrest, increase school performance, family relationships)
Most families may be unwilling/able to participate
School & Community Based Treatments
Target children at school (easier) Often has more attendance than individual
therapy Available to all children (universal
intervention) Increased likelihood of reaching those who need it Minimizes stigma Offers opportunity to interact with other children
Selective Mutism
Selective Mutism Consistent failure to speak in specific social
situations (where these is an expectation for speaking) despite speaking in other situations
Not due to a lack of knowledge or comfort with spoken language
An anxiety disorder Is not merely a child refusing to speak in a
situation