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Disorders of Childhood and Adolescence

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1 Disorders of Childhood and Adolescence
Chapter Fifteen Disorders of Childhood and Adolescence

2 Disorders of Childhood and Adolescence (cont’d.)
In a national sample of 6,483 adolescents (ages 13–18), almost two thirds of those with mental illness received no treatment

3 Disorders of Childhood and Adolescence (cont’d.)
Diagnosis requires that symptoms cause significant impairment in daily functioning over extended period of time To determine if a child has an actual disorder, clinicians consider the child's age and developmental level as well as environmental factors Include: Internalizing disorders Externalizing disorders Neurodevelopmental disorders Conditions involving impaired neurological development One in fivechildren has serious emotional or behavioral problem Two-thirds of those with mental illness received no treatment

4 Internalizing Disorders of Childhood
Conditions involving emotional symptoms directed inward Heightened reactions to trauma, stressors or negative events and difficulty regulating emotions Prevalent in early life and often lead to substance use and suicide Of particular concern are the low treatment rates for youth experiencing major depression; this lack of intervention is particularly pronounced for African American, Latino/Hispanic American, and Asian American adolescents

5 Anxiety, Trauma, and Stressor-Related Disorders in Early Life
Most common mental health disorder in childhood and adolescence (32%) Can significantly affect academic, social, and interpersonal functioning and can lead to adult anxiety disorders Include: Social phobia Separation anxiety disorder Selective mutism Among the 32 percent of adolescents who have experienced an anxiety disorder, specific phobias (19 percent) and social phobia (9 percent) are most common. Specific phobias often begin in early to middle childhood, whereas social phobias typically begin in early to middle adolescence

6 Anxiety, Trauma, and Stressor-Related Disorders in Early Life (cont’d
Post-traumatic stress disorder in early life: Recurrent, distressing memories of a shocking experience, such as experience with death, serious injury, or sexual violation Memories may entail: Distressing dreams Intense physiological or psychological reactions to thoughts or cues associated with event and avoidance of those cues Episodes of playacting the event Dissociative reactions

7 Anxiety, Trauma, and Stressor-Related Disorders in Early Life (cont’d
Post-traumatic stress disorder in early life: Children often display social withdrawal, diminished positive affect, and disinterest in previously-enjoyed activities Lifetime prevalence: 8% for girls and 2.3% for boys Effective treatments include: Trauma-focused cognitive-behavioral therapies

8 Depressive Disorders in Early Life
Youth with depressive disorders have more negative self-concepts and are more likely to engage in self-blame and self-criticism Early-onset depressive symptoms tends to predict a more chronic and severe course Evidence-based treatment for depression: Individual, group, or school-based cognitive-behavioral therapy SSRIs increase suicidality but benefits may outweigh risk Children are especially vulnerable to environmental factors because they lack the maturity and skills to deal with stressors. Subsequent data analysis has indicated that although SSRIs may have only a moderate effect on milder depressive symptoms, they appear superior to some cognitive-behavioral therapies, especially in the first months of treatment, and that the benefits of using SSRIs (particularly fluoxetine) may outweigh the risk of increased suicidality, especially among youth who are severely depressed ( Bridge et al., 2007; Vitiello, 2009). DSM V does not include a chapter on Disorders of Childhood and Adoescence - and does not include Pediatric Bipolar Disorder. DSM V includes a Chapter on Disruptive, Impulse-Control and Conduct Disorders and the Chapter "Disorders first Diagnsoed in Infancy, Childhood, or Adolescence" no longer exists. ADHD has been placed in tne "Neurodevelopmental" chapter in DSM V.

9 Nonsuicidal Self Injury
Involves induction of bleeding, bruising, or pain by means of intentional, self-inflicted injury, without suicidal intent Intense negative affect or cognitions and a preoccupation with engaging in self-harm typically precede episodes of NSSI Expectation that mood will improve after episode

10 Nonsuicidal Self Injury (cont’d.)
Prevalence: 14-17% of adolescents and young adults have engaged in self-injury at least once Two thirds of those who engage in NSSI begin the behavior in adolescence. Increased risk of attempted suicide Treatment includes: Teaching problem-solving, coping and emotional-regulation skills Focus on emotional expression and improving interpersonal relationship skills NSSI occurs with similar frequency in both genders, although males are more likely to hit or burn themselves, while females more frequently cut themselves. Only a minority engage in repeated self-injury. Those who engage in repeated NSSI tend to be highly self-critical and have difficulty expressing their emotions.

11 Attachment Disorders Exposure to early environments devoid of predictable caretaking and nurturing can cause significant difficulties with emotional attachment and social relationships Includes: Reactive attachment disorder (RAD) Disinhibited social engagement disorder (DSED)

12 Attachment Disorders (cont’d.)
Reactive attachment disorder: Inhibited, avoidant social behaviors and reluctance to seek or respond to attention or nurturing Show little trust that needs will be attended to and do not readily seek nor respond to comfort, attention, or nurturing Use avoidance or ambivalence as psychological defense Limited positive emotion and may demonstrate irritability, sadness, or fearfulness when interacting with adults These attachment disorders are diagnosed only when symptoms are apparent before age 5 and when early circumstances prevent the child from forming stable attachments. Children w RAD often behave in a very inhibited, watchful, or avoidant manner, even with family and caregivers.

13 Attachment Disorders (cont’d.)
Disinhibited social engagement disorder: Indiscriminate, superficial attachments and desperation for interpersonal contact Socialize effortlessly, but indiscriminately, and become superficially “attached” to strangers or acquaintances History of harsh punishment or inconsistent parenting, as well as emotional neglect and limited attachment opportunities Exposure to maltreatment or maternal psychiatric hospitalizations are particularly vulnerable Reactive Attachment Disorder and Disinhibited Social Engagement Disorder are included as distinct diagnoses in DSM V, and are included in the Chapter on Trauma and Stressor-Related Disorders.

14 Attachment Disorders (cont’d.)
Course depends on severity of social deprivation, abuse, neglect or disruptions in caregiving, and subsequent events in the child’s life Symptoms of RAD can disappear whereas symptoms of DSED are more persistent Effective intervention: Providing stable, nurturing environment, and opportunities to develop interpersonal trust and social skills Symptoms of RAD often disappear if children are provided an opportunity for predictable caretaking and nurturance, whereas symptoms of DSED are more persistent.

15 Externalizing Disorders of Childhood
Also known as disruptive behavior disorders: conditions associated with socially disturbing symptoms and distressing others Include: Disruptive mood dysregulation disorder Oppositional defiant disorder Conduct disorder Early intervention is necessary

16 Externalizing Disorders of Childhood (cont’d.)
Diagnosis is controversial, and requires a pattern of behavior that is: Atypical for the child’s gender, age, and developmental level Persistent Severe enough to cause significant impairment in social, academic, or vocational functioning

17 Disruptive Mood Dysregulation Disorder
Characterized by chronic irritability and significantly exaggerated anger reactions Patterns begin in early childhood Diagnosis requires that symptoms persist beyond age six Predictive of later depressive and anxiety disorders Clinicians need to rule out PBD due to symptom overlap

18 Oppositional Defiant Disorder
Pattern of negativistic, argumentative, and hostile behavior in which children often: Lose their temper Argue and defy adult requests Primarily directed toward parents, teachers, and others in authority No serious violation of societal norms Two components: Negative affect Oppositional behavior Do not demonstrate pervasive antisocial behavior and serious violations of societal norms Symptoms of ODD often resolve. Approximately half of those with ODD also display inattention and hyperactivity ( McBurnett & Pfiffner, 2009).

19 Conduct Disorders Persistent pattern of behavior that violates rights of others Reflect dysfunctions in individual and include: Serious violations of rules and social norms Cruelty and deliberate aggression towards people or animals Theft, deceit, and vandalism Callous and unemotional subtype Often exhibit antisocial personality disorder in adulthood A callous and unemotional subtype refers to those with CD who display minimal guilt or remorse and are consistently unconcerned about the feelings of others, their own wrongdoing, or poor performance at school or work. With this subtype, emotional expression is very superficial and is used primarily to manipulate others (DSM-5 Work Groups, 2012). MRI documented this callousness in one sample of adolescents with CD—they demonstrated strong pleasure responses to video clips of people experiencing pain and distress ( Decety, Michalska, Akitsuki, & Lahey, 2009) .

20 Conduct Disorders (cont’d.)
Prevalence: Approximately 2-9% of youth meet criteria 50% display inattention and hyperactivity Gender differences: Males display confrontational aggression Females display truancy, substance abuse, or chronic lying More persistent than other childhood disorders Approximately 50 percent of those with CD also display inattention and hyperactivity. Childhood-onset CD is associated with chronic, serious offenses, criminal behavior, and substance abuse in adulthood.

21 Etiology of Externalizing Disorders
Figure 15-1 Multipath Model of Conduct Disorder The dimensions interact with one another and combine in different ways to result in a conduct disorder

22 Etiology of Externalizing Disorders (cont’d.)
Biological factors: Appear to exert greatest influence on CD. Aggressive behavior linked to brain abnormalities and reduced activity in amygdala “Low MAOA” and childhood maltreatment Reduced autonomic nervous system activity Cortisol (stress levels) Risk of CD is particularly increased when carriers of the genotype “low MAOA” (an allele associated with fear-regulating circuitry in the amygdala) are subjected to childhood maltreatment ( First, 2007). Reduced activity of the autonomic nervous system (associated with increased need for stimulation to achieve optimal arousal) is also associated with CD in males; this may account for the increased risk taking associated with the disorder. Elevated stress hormones (cortisol) are associated with symptoms of impulsive aggression, whereas low cortisol levels have been linked with callous and unemotional traits and predatory aggression

23 Etiology of Externalizing Disorders (cont’d.)
Social and sociocultural: Family and social context play large role Large families and marital breakdown Economic stress Crowded living conditions Harsh or inconsistent discipline Maternal or peer rejection Parent-child conflict and power struggles Limited parental supervision

24 Etiology of Externalizing Disorders (cont’d.)
Psychological factors: Difficult child temperament (irritable, resistant, impulsive tendencies) Underlying emotional issues Depression frequently coexists with ODD and DMDD

25 Treatment of Externalizing Disorders
Must consider family and social context of behaviors and psychosocial skills deficits CD is particularly difficult to treat Effective when implemented before patterns of disruptive behavior are established Parent-focused interventions regarding child management techniques A well-established intervention for externalizing disorders is parent education. Multiple factors, including poverty, parental immaturity, and lack of parenting skills, contribute to child maltreatment. The more maltreatment or trauma a child encounters, the greater the risk of subsequent psychiatric illness. There is a particular need for programs to prevent the maltreatment of infants and young children.

26 Treatment of Externalizing Disorders (cont’d.)
Psychosocial interventions that focus on: Assertiveness-training Anger management techniques Building skills in empathy, communication, social relationships and problem-solving Mobilizing adult mentors

27 Neurodevelopmental Disorders
Involve impaired development of the brain and central nervous system Symptoms become increasingly evident as child grows and develops Include: Tic disorders Attention-deficit hyperactivity disorder Autism spectrum disorders Intellectual and learning disorders

28 Tics and Tourette’s Disorder
Involuntary, repetitive movements or vocalizations Motor tic: Eye-blinking, facial-grimacing, head-jerking, foot tapping, flaring of nostrils, and contractions of the shoulders or abdominal muscles Vocal tics: Coughing, grunting, throat clearing, sniffling, or sudden repetitive and stereotyped outburst of words Note that American Idol James Derbin suffers from Tourette’s Disorder but did not experience symptoms when singing.

29 Tics and Tourette’s Disorder (cont’d.)
Short-term suppression of a tic is possible, but results in subsequent increases in the tic Some report feeling tension build prior to tic, followed by a sense of relief after tic occurs Stress can increase frequency and intensity Provisional tic disorders (2.6% of children) Chronic motor or vocal tic disorders (3.7% of children) Most tics in children are transient and disappear without treatment. Stress can increase the frequency and intensity of tics. When a tic has been present for less than a year, a diagnosis of provisional tic disorder is given; chronic motor or vocal tic disorder refers to tics lasting more than a year.

30 Tics and Tourette’s Disorder (cont’d.)
Tourette’s disorder (TD): Characterized by multiple motor tics and one or more vocal tic, present for at least one year Onset is prior to age 18 About 8% show complete remission Symptoms can be severe or mild Coprolalia (involuntary uttering of obscenities or inappropriate remarks) or motor movements involving self-harm (e.g., punching oneself) occur in about 10 percent of those with TD Comorbid conditions Usually the first symptoms are noticed between the ages of 7 and 10, with symptoms increasing in the middle teen years and improving in early adulthood; about 8 percent of those with TD eventually show a complete remission of symptoms. Comorbid conditions include poor anger control, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, impulsive behavior, and poor social skills.

31 Tics and Tourette’s Disorder (cont’d.)
Etiology: Both chronic tic disorder and TD appear to be genetically transmitted Treatment: Psychotherapy can help with distress the technique of habit reversal , which involves teaching a behavior that is incompatible with the tic, is an effective treatment Although antipsychotic medication used for severe tics, medication is not typically used to treat tic disorders.

32 Attention-Deficit/Hyperactivity Disorder
Characterized by persistent inattention and/or impulsive, hyperactive behaviors Symptoms must interfere with social, academic, or occupational activities Diagnosis requires that symptoms begin before age 12 and persist for at least six months Poor regulation of attentional processes

33 Attention-Deficit/Hyperactivity Disorder (cont’d.)
Prevalence rates vary between studies One study: 8.7% More than twice as likely in boys than in girls Symptoms tend to improve in late adolescence Associated with behavioral and academic problems Risk of coexisting conditions is four times greater among children living in poverty ADHD is the most frequently diagnosed disorder in school-age children. Children who are the youngest in their class are more likely to receive an ADHD diagnosis and to take medication for ADHD.

34 Attention-Deficit/Hyperactivity Disorder: Etiology
Biological dimension: Highly heritable with up to 80% of symptoms explainable by genetic factors Rare inherited gene mutations Chromosomal DNA deletions and duplications Genes affecting regulation of dopamine and glutamate Hypotheses about neurological mechanisms Reduced activity in prefrontal cortex Differences in brain structure and circuitry in frontal cortex, cerebellum, and parietal lobes Low dopamine levels Two thirds of those with ADHD had other mental health conditions (including CD, ODD, anxiety, and depression) or learning disabilities and other neurodevelopmental disorders; the risk of coexisting conditions is almost 4 times greater among children living in poverty Youth with ADHD also have a high risk of smoking and use of alcohol and illicit drugs. neuroimaging has confirmed differences in brain structure and circuitry in the frontal cortex, cerebellum, and parietal lobes. Smaller frontal lobes in children with ADHD, especially those with more severe symptoms Some children with ADHD show slower development of the cerebrum, particularly prefrontal regions associated with attention and motor planning. Inadequate dopamine and associated neurotransmitters that affect signal flow to and from the frontal lobes.

35 Attention-Deficit/Hyperactivity Disorder: Etiology (cont’d.)
Biological dimension: Prematurity Oxygen deprivation during birth Low-birth weight Lead and PCB exposure Viral infections, meningitis, and encephalitis Maternal smoking, drug, and alcohol abuse during pregnancy Possible involvement of food additives Kids with ADHD often encounter negative reactions from others that further exacerbate symptoms.

36 Attention-Deficit/Hyperactivity Disorder: Treatment
Stimulants such as methylphenidate (Ritalin) receive most evidence-based support Normalize neurotransmitter functioning and increased neurological activation in frontal cortex Increased rates of stimulant medication use in U.S.

37 Attention-Deficit/Hyperactivity Disorder: Treatment (cont’d.)
Evidence that behavioral and psychological treatments are highly effective Modifying environment and social context can enhance feelings of competence, motivation, and self-efficacy Coordination of all services result in most successful interventions

38 Autism Spectrum Disorders
Characterized by impairment in social communication and restricted, stereotyped interests and activities Symptoms range from mild to severe Prevalence: Affects one out of children Four times as common in boys Approximately two thirds have IQ scores lower than 70

39 Autism Spectrum Disorders (cont’d.)
Symptoms of autism spectrum disorder: Deficits in social communication and social interaction Atypical social-emotional reciprocity Atypical nonverbal communication Difficulties developing and maintaining relationships

40 Autism Spectrum Disorders (cont’d.)
Symptoms of autism spectrum disorder: Repetitive behavior or restricted interests or activities involving at least two of following: Repetitive speech, movement, or use of objects Intense focus on rituals or routines and strong resistance to change Intense fixations or restricted interests Atypical sensory reactivity Autistic savants Individual with ASD who performs exceptionally well on certain tasks many infants with ASD symptoms fail to attend to human motion, such as a parent's movement or demonstrate interest in human faces,

41 Autism Spectrum Disorders (cont’d.)
Problems diagnosing autism: Typical procedures include clinical observation, parent interviews, developmental histories, autism screening inventories, communication assessment, and psychological testing Autism is usually diagnosed at age three or later symptoms sometimes appear following a period of apparently normal social and intellectual development, with deterioration of skills beginning around 6–12 months of age Children with this pattern of regression (referred to as regressive autism) often develop more severe symptoms compared to autistic children without this pattern

42 Autism Spectrum Disorders: Etiology
Biological dimension: Unique patterns of metabolic brain activity Abnormally high levels or serotonin Differences in brain anatomy and connectivity in brain regions associated with autistic traits Accelerated growth or amygdala Accelerated head growth Genetic mutations have been implicated when ASD is diagnosed in multiple family members Closely space pregnancies Accelerated head growth may, in fact, be an endophenotype (biological marker) for ASD Male infants later diagnosed with ASD exhibited a pattern of rapid head growth 6–9 months after birth. MRI with toddlers diagnosed with ASD has confirmed extra growth in multiple regions of the brain. Children born less than 1 year after the birth of a sibling were almost 300 percent more likely to develop ASD compared to children born at least 4 years after a sibling.

43 Autism Spectrum Disorders: Etiology (cont’d.)
Biological dimension: Genetic factors Heritability estimated to be around .73 percent for males and .87 for females Autistic traits have high heritability Clear evidence for genetic susceptibility Innate vulnerability triggered by environment Nutritional deficits, changes in immune system, low birth weight The study relating ASD to vaccine was deemed fraudulent when it was found that the lead author had manipulated the data for monetary gain. Children who develop ASD appear to have an innate vulnerability that is triggered by environmental factors. children with ASD appear to metabolize toxins such as lead and mercury differently.

44 Autism Spectrum Disorders: Etiology (cont’d.)
Psychological dimension: Children with ASD seldom make eye contact, seek social connectedness, or bid for attention Prefer to be alone and ignore parental efforts at connection High stress levels among family due to ASD Psychological and social factors play a role in manifestation of symptoms, but ASD is primarily influenced by biological factors In response, others’ attempts to maintain social connection often diminish, further adding to the child's isolation.

45 Autism Spectrum Disorders: Intervention and Treatment
Prognosis is mixed; most children retain diagnosis and require support for life Individuals with higher levels of cognitive-adaptive functioning fare better than those with intellectual disabilities and severe autistic symptoms Significant recovery linked with intense early intervention Autistic symptoms sometimes improve and then abruptly return when a child with ASD has a fever.

46 Autism Spectrum Disorders: Intervention and Treatment (cont’d.)
Medications are used to decrease anxiety, repetitive behaviors, and hyperactivity Minimally effective and may be harmful Risperidone alone received FDA approval: Preliminary research suggests that oxytocin (a hormone related to social bonding) can increase social interactions in adults and teens with mild ASD Comprehensive treatment programs have enabled children with ASD to develop more functional skills

47 Autism Spectrum Disorders: Intervention and Treatment (cont’d.)
Interventions with most significant gains: Social communication Environmental enrichment Reinforcing appropriate attention and response to social stimuli Preventing repetitive behaviors Sustained practice of weaker skills Reducing environmental stress Improving sleep and nutrition

48 Intellectual Developmental Disorder
Limitations in intellectual functioning and adaptive behaviors including: Significantly below average general intellectual functioning (generally IQ of 70 or less) Deficiencies in adaptive behavior that are lower than would be expected based on age or cultural background Only diagnosed when low intelligence is accompanied by impaired adaptive functioning

49 Intellectual Developmental Disorder (cont’d.)
Four distinct categories: Mild: IQ score to 70 Moderate: IQ score to 50-55 Severe: IQ score to 35-40 Profound: IQ score below 20-25

50 Intellectual Developmental Disorder (cont’d.)

51 Intellectual Developmental Disorder (cont’d.)
American Association on Intellectual and Developmental Disabilities: IQ score may be used to approximate intellectual functioning More important to focus on adaptive functioning and nature of psychosocial supports needed Given ongoing, individualized support, overall functioning of individual with ID will improve Approximately 1 percent of students in public schools in the United States are identified as having an IDD.

52 Intellectual Developmental Disorder (cont’d.)
Prevalence: Approximately 1% of students in public school Increases in low and middle income countries Coexisting conditions are common One-fourth have seizure disorders

53 Intellectual Developmental Disorder: Etiology
Etiology differs depending on level of intellectual impairment Mild IDD is often idiopathic (no known cause) Pronounced IDD related to genetic factors, brain abnormalities, or brain injury

54 Intellectual Developmental Disorder: Etiology (cont’d.)
Genetic factors: In up to 80 percent of cases of IDD, underlying cause is unknown Unidentified genetic factors Genetic variations Normal distribution of traits (upper vs. lower range) Genetic abnormalities Chromosomal abnormalities Down syndrome most common Inheritance of single gene Fragile X syndrome most common (mild to severe ID) IDD caused by normal genetic variation reflects the fact that in a normal distribution of any trait (such as intelligence), some individuals fall in the lower range.

55 Intellectual Developmental Disorder: Etiology (cont’d.)
Down syndrome (DS): Extra copy of chromosome 21 originates during gamete development Majority have mild to moderate IDD With support many can have jobs and live semi-independently Medical interventions improve outcome, but significant risks remain Prenatal detection of DS through amniocentesis In the vast majority of cases, an extra copy of chromosome 21 originates during gamete development (involving either the egg or the sperm); this extra chromosome produces the physical and neurological characteristics associated with DS. Although medical intervention has improved health outcomes and increased life expectancy ( Weijerman & de Winter, 2010), those with DS continue to have a significantly increased risk of early dementia, including early-onset Alzheimer's disease.

56 Intellectual Developmental Disorder: Etiology (cont’d.)
Nongenetic biological factors: Influences during prenatal, perinatal, or postnatal period Fetus is susceptible to viruses and infections, drugs and alcohol, radiation, and poor nutrition Fetal alcohol spectrum effects and fetal alcohol syndrome Birth trauma, prematurity, and low birth weight Head injuries, brain infections, tumors, and prolonged malnutrition Exposure to environmental toxins, including lead Iodine deficiency either during pregnancy or during early infancy can impair intellectual development 11/17/2013 The most common perinatal birth conditions associated with IDD are prematurity and low birth weight.

57 Intellectual Developmental Disorder: Etiology (cont’d.)
Psychological, social, sociocultural dimensions: Genetic background interacts with environmental factors Effects of low SES Parents with mild IDD Long-term effects of prematurity Enriching and encouraging home environment, as well as ongoing education intervention

58 Learning Disorders Academic disability characterized by reading, writing, and math skills deficits Primarily interferes with academic achievement and activities of daily living in which reading, writing, or math skills are needed (e.g., dyscalculia, dyslexia) Prevalence: Around 5% of students in public schools Boys are almost twice as likely as girls

59 Learning Disorders (cont’d.)
Etiology: Little is known about precise causes of LD Children with LD that eventually resolves appear to have slower brain maturation. prematurity maternal alcohol use during pregnancy Lifelong differences in neurological processing of information related to basic academic skills May be similar to biological explanations for IDD and ADHD Runs in families, suggesting genetic component

60 Support for Individuals (cont’d.)
Support in childhood: Individualized home-based or school-based programs Parent involvement is integral part of early intervention programs School services are individualized to meet child’s needs and to maximize learning opportunities Rates of improvement decrease once programs are completed

61 Support for Individuals (cont’d.)
Support in adulthood: Programs focusing on specific job skills Institutionalization is rare, but many live with family members “Least restrictive environment” possible As much independence and personal choice as is safe and practical Most normalized living arrangements vary from setting to setting

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