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Transcript of Disorders First Apparent in Childhood Why “first apparent”? May continue into adulthood May lead...
Disorders First Apparent in Childhood
Why “first apparent”?
May continue into adulthood
May lead to other adult disorders
May impact development
Disorders
1. Attention Deficit Hyperactivity Disorder2. Learning Disorders3. Autism & Asperger’s Disorder4. Mental Retardation (Axis II)5. Conduct Disorder & Oppositional Defiant
Disorder
Symptoms of Inattention
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
Symptoms of Hyperactivity 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
Require more than one setting
6% of school-age children (drops with age)
Associated Problems
Significant social impairments
Academic problems
Comorbidities with ADHD
mood disorders learning disorders substance use APD neurological problems physical accidents and injury
What Happens When they Grow Up?
Impulsivity decreases, inattention does not Accidents, etc
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
What Causes ADHD?
Higher rates of family general psychopathology
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
Multiple Approach to ADHD
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
Sample Changes
Home Reward plans Shorter lists of tasks Timers Reorganization of living
space
School Seating plans Folders for parents Reduced distractions for
exams Shortened HW
assignments
Learning Disorders
Deficits in reading, math, or written expression
Child’s achievement level is below what would be predicted based upon their ability level
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 (32%) 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
1. Remediate processing of problems Visual and auditory perception skills
2. Improve cognitive skills Listening, comprehension, memory
3. Target behavioral skills to compensate Extended time for tasks
Early diagnosis = better prognosis
Disruptions in social interaction
Impaired communication skills
Restricted behavior, interests and activities
Pervasive Developmental Disorders: Autism
Disruptions in social interaction
Lack of joint attention Lack of interaction with
parents or other children
Lack of attention to social cues
Supported by eye tracking research
Impaired communication skills
50% of patients do not acquire useful speech Unusual communication Echolalia (repeating of words/phrases) Inability to understand irony, sarcasm,
pretend play
Restricted behavior, interests and activities
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
Symptoms of Autism
Apparent by age 3
20% report normal 1-2 years of development, followed by regression or lack of milestones
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 of Autism
1 in every 166 births 4:1 boys to girls Some improve at school Some improve during adolescence, but
others deteriorate IQ & functional language predictors of
prognosis
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
Few think psychological or social influences play a role in the onset
Psychologists (and other professionals) can assist with management of disorder
Behavioral Treatments for Autism
Decrease undesirable behavior & shape desirable
Positive reinforcement & extinction Social punishment Families are important Language + social skills = improved
prognosis
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
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
Behavioral DisordersConduct Disorder General pattern of
disrespect for others Violation of norms Includes criminal
activity
Oppositional Defiant Disorder
Pattern of negative, hostile, defiant behaviors
Symptoms of Conduct Disorder
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
Symptoms of 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
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
1. Jimmy is rewarded for screaming
2. Reward for screaming = increased probability of screaming in future
3. Parent is rewarded for giving in
4. Parents likelihood of giving in is increased
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 positive (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
Cognitive Disorders - Dementia
Dementia
Gradual deterioration of brain function
Affects judgment, memory, language, other executive functions Some are reversible Others are degenerative and eventually fatal
Emotional changes are common
Kinds of Dementia (DSM)
1. Alzheimer’s Disease
2. Vascular Dementia
3. Dementia due to HIV, Head Trauma, Parkinson’s, Huntington’s
4. Pick’s Disease
5. Creutzfeldt-Jakob Disease
6. Substance Abuse
Other Causes of Dementia
Drugs & alcohol Nutritional deficits Brain tumors Thyroid Problems Neurosyphilis Korsakoff’s Disease
Alzheimer’s Disease
Most develop during old age
Prevalence for < 65 = 1%, 90+ = 22%
Higher rates, as people are living longer
Annual Cost = $112 billion US
Associated Symptoms of Alzheimer’s
Impaired memory, orientation, judgement, reasoning
Inability to integrate/learn new information Forget events, lose objects Decreased interest in nonroutine activities Increasing depression, agitation, aggression
with disease progession
Symptoms & Course
Increased Speed of Disease Progression
Global Deterioration Scale(Reisberg et al., 1982)
1. No cognitive/functional impairment2. Mild forgetfulness, some work problems3. Mild concentration problems, some problems
working/travelling alone4. Increased problems in planning, finances, denial of
symptoms & withdrawal5. Poor recall of recent events. Reminders needed6. Daily Living Assistance, Personality Changes7. Loss of verbal abilities, incontinence, walking,
coma
Normal Aging vs. Possible AD(Hooyma & Kiyak, 2002)
Forgetting to set alarm clock
Forgetting a name & remembering later
Having to search for keys b/c forgot location
Forgetting where your car is
Forgetting how to set alarm clock
Forgetting a name & never remembering it even when told
Forgetting places you might find keys
Forgetting how you arrived at a location
Intellectual Functioning and Alzheimer’s
Less formal education = increased risk “mental reserve” Cognitive reserve hypothesis
More synapses an individual requires, the more neuronal death required before dementia is obvious
Causes of Dementia
Proximal causes Distal Causes
Biological Causes Psychological & Social Influences
Neurofibrillary Tangles & Amyloid Plaques
Normal, but excessive
Proximal Causes - Senile Plaques
Protein deposits Also normal, but excessive
Unclear why, or how this impacts Both overrepresented in hippocampus &
parts of cerebral cortex = thought process
What are Distal Causes?
Genes (esp. early onset) Estrogen can be protective Down syndrome = virtually guaranteed
Alzheimer’s by 40 Education & Cognitive Ability
Protecting with Cognitive Ability
2x more likely in people with < 8th gr. Education
Friedland et al. 2000 - 193 AD vs. 358 Control Control elderly more likely intellectual & physical
noneducational past-times in middle years Greatest effect for intellectual past-times Regardless of education, gender, current age
Assessment of Alzheimer’s
Medical evaluation Neuropsychological Tests Observations Interviews Self-reports
How do we definitively diagnose Alzheimer’s?
Rule out other possible diagnoses Autopsy following patient death
Tangles Plaques
Dementia is a very heterogeneous disorder
Dementia & Pseudodementia
Depression most common psychopathology in old age Est. 20% for elderly community sample (Hooyman &
Kiyak)
10-15% for institutionalized elderly sample Older adults often have “masked depression”
Does not express/denies mood changes Reports somatic complaints Complains of problem solving/memory problems
Medical Treatment for Dementia
Medication enhancing cognitive ability Initial effect (to 6 months earlier) No long-term improvement over placebo Prevent breakdown of acetylcholine
Decline continues Loss of gain if medication is quit $250/month
Psychosocial Treatments for Dementia
Compensation for lost abilities Memory wallets Cues and reminders