Presentation on theme: "Disorders of Childhood and Adolescence"— Presentation transcript:
1 Disorders of Childhood and Adolescence Chapter FifteenDisorders 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 timeTo determine if a child has an actual disorder, clinicians consider the child's age and developmental level as well as environmental factorsInclude:Internalizing disordersExternalizing disordersNeurodevelopmental disordersConditions involving impaired neurological developmentOne in fivechildren has serious emotional or behavioral problemTwo-thirds of those with mental illness received no treatment
4 Internalizing Disorders of Childhood Conditions involving emotional symptoms directed inwardHeightened reactions to trauma, stressors or negative events and difficulty regulating emotionsPrevalent in early life and often lead to substance use and suicideOf 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 disordersInclude:Social phobiaSeparation anxiety disorderSelective mutismAmong 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 violationMemories may entail:Distressing dreamsIntense physiological or psychological reactions to thoughts or cues associated with event and avoidance of those cuesEpisodes of playacting the eventDissociative 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 activitiesLifetime prevalence:8% for girls and 2.3% for boysEffective 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-criticismEarly-onset depressive symptoms tends to predict a more chronic and severe courseEvidence-based treatment for depression:Individual, group, or school-based cognitive-behavioral therapySSRIs increase suicidality but benefits may outweigh riskChildren 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 intentIntense negative affect or cognitions and a preoccupation with engaging in self-harm typically precede episodes of NSSIExpectation 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 onceTwo thirds of those who engage in NSSI begin the behavior in adolescence.Increased risk of attempted suicideTreatment includes:Teaching problem-solving, coping and emotional-regulation skillsFocus on emotional expression and improving interpersonal relationship skillsNSSI 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 DisordersExposure to early environments devoid of predictable caretaking and nurturing can cause significant difficulties with emotional attachment and social relationshipsIncludes: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 nurturingShow little trust that needs will be attended to and do not readily seek nor respond to comfort, attention, or nurturingUse avoidance or ambivalence as psychological defenseLimited positive emotion and may demonstrate irritability, sadness, or fearfulness when interacting with adultsThese 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 contactSocialize effortlessly, but indiscriminately, and become superficially “attached” to strangers or acquaintancesHistory of harsh punishment or inconsistent parenting, as well as emotional neglect and limited attachment opportunitiesExposure to maltreatment or maternal psychiatric hospitalizations are particularly vulnerableReactive 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 lifeSymptoms of RAD can disappear whereas symptoms of DSED are more persistentEffective intervention:Providing stable, nurturing environment, and opportunities to develop interpersonal trust and social skillsSymptoms 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 othersInclude:Disruptive mood dysregulation disorderOppositional defiant disorderConduct disorderEarly 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 levelPersistentSevere enough to cause significant impairment in social, academic, or vocational functioning
17 Disruptive Mood Dysregulation Disorder Characterized by chronic irritability and significantly exaggerated anger reactionsPatterns begin in early childhoodDiagnosis requires that symptoms persist beyond age sixPredictive of later depressive and anxiety disordersClinicians 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 temperArgue and defy adult requestsPrimarily directed toward parents, teachers, and others in authorityNo serious violation of societal normsTwo components:Negative affectOppositional behaviorDo not demonstrate pervasive antisocial behavior and serious violations of societal normsSymptoms of ODD often resolve.Approximately half of those with ODD also display inattention and hyperactivity ( McBurnett & Pfiffner, 2009).
19 Conduct DisordersPersistent pattern of behavior that violates rights of othersReflect dysfunctions in individual and include:Serious violations of rules and social normsCruelty and deliberate aggression towards people or animalsTheft, deceit, and vandalismCallous and unemotional subtypeOften exhibit antisocial personality disorder in adulthoodA 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 criteria50% display inattention and hyperactivityGender differences:Males display confrontational aggressionFemales display truancy, substance abuse, or chronic lyingMore persistent than other childhood disordersApproximately 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 maltreatmentReduced autonomic nervous system activityCortisol (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 roleLarge families and marital breakdownEconomic stressCrowded living conditionsHarsh or inconsistent disciplineMaternal or peer rejectionParent-child conflict and power strugglesLimited parental supervision
24 Etiology of Externalizing Disorders (cont’d.) Psychological factors:Difficult child temperament (irritable, resistant, impulsive tendencies)Underlying emotional issuesDepression frequently coexists with ODD and DMDD
25 Treatment of Externalizing Disorders Must consider family and social context of behaviors and psychosocial skills deficitsCD is particularly difficult to treatEffective when implemented before patterns of disruptive behavior are establishedParent-focused interventions regarding child management techniquesA 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-trainingAnger management techniquesBuilding skills in empathy, communication, social relationships and problem-solvingMobilizing adult mentors
27 Neurodevelopmental Disorders Involve impaired development of the brain and central nervous systemSymptoms become increasingly evident as child grows and developsInclude:Tic disordersAttention-deficit hyperactivity disorderAutism spectrum disordersIntellectual and learning disorders
28 Tics and Tourette’s Disorder Involuntary, repetitive movements or vocalizationsMotor tic:Eye-blinking, facial-grimacing, head-jerking, foot tapping, flaring of nostrils, and contractions of the shoulders or abdominal musclesVocal tics:Coughing, grunting, throat clearing, sniffling, or sudden repetitive and stereotyped outburst of wordsNote 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 ticSome report feeling tension build prior to tic, followed by a sense of relief after tic occursStress can increase frequency and intensityProvisional 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 yearOnset is prior to age 18About 8% show complete remissionSymptoms can be severe or mildCoprolalia (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 TDComorbid conditionsUsually 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 transmittedTreatment:Psychotherapy can help with distressthe technique of habit reversal , which involves teaching a behavior that is incompatible with the tic, is an effective treatmentAlthough 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 behaviorsSymptoms must interfere with social, academic, or occupational activitiesDiagnosis requires that symptoms begin before age 12 and persist for at least six monthsPoor regulation of attentional processes
33 Attention-Deficit/Hyperactivity Disorder (cont’d.) Prevalence rates vary between studiesOne study: 8.7%More than twice as likely in boys than in girlsSymptoms tend to improve in late adolescenceAssociated with behavioral and academic problemsRisk of coexisting conditions is four times greater among children living in povertyADHD 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 factorsRare inherited gene mutationsChromosomal DNA deletions and duplicationsGenes affecting regulation of dopamine and glutamateHypotheses about neurological mechanismsReduced activity in prefrontal cortexDifferences in brain structure and circuitry in frontal cortex, cerebellum, and parietal lobesLow dopamine levelsTwo 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 povertyYouth 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 symptomsSome 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:PrematurityOxygen deprivation during birthLow-birth weightLead and PCB exposureViral infections, meningitis, and encephalitisMaternal smoking, drug, and alcohol abuse during pregnancyPossible involvement of food additivesKids 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 supportNormalize neurotransmitter functioning and increased neurological activation in frontal cortexIncreased rates of stimulant medication use in U.S.
37 Attention-Deficit/Hyperactivity Disorder: Treatment (cont’d.) Evidence that behavioral and psychological treatments are highly effectiveModifying environment and social context can enhance feelings of competence, motivation, and self-efficacyCoordination of all services result in most successful interventions
38 Autism Spectrum Disorders Characterized by impairment in social communication and restricted, stereotyped interests and activitiesSymptoms range from mild to severePrevalence:Affects one out of childrenFour times as common in boysApproximately 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 interactionAtypical social-emotional reciprocityAtypical nonverbal communicationDifficulties 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 objectsIntense focus on rituals or routines and strong resistance to changeIntense fixations or restricted interestsAtypical sensory reactivityAutistic savantsIndividual with ASD who performs exceptionally well on certain tasksmany 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 testingAutism is usually diagnosed at age three or latersymptoms sometimes appear following a period of apparently normal social and intellectual development, with deterioration of skills beginning around 6–12 months of ageChildren 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 activityAbnormally high levels or serotoninDifferences in brain anatomy and connectivity in brain regions associated with autistic traitsAccelerated growth or amygdalaAccelerated head growthGenetic mutations have been implicated when ASD is diagnosed in multiple family membersClosely space pregnanciesAccelerated head growth may, in fact, be an endophenotype (biological marker) for ASDMale 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 factorsHeritability estimated to be around .73 percent for males and .87 for femalesAutistic traits have high heritabilityClear evidence for genetic susceptibilityInnate vulnerability triggered by environmentNutritional deficits, changes in immune system, low birth weightThe 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 attentionPrefer to be alone and ignore parental efforts at connectionHigh stress levels among family due to ASDPsychological and social factors play a role in manifestation of symptoms, but ASD is primarily influenced by biological factorsIn 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 lifeIndividuals with higher levels of cognitive-adaptive functioning fare better than those with intellectual disabilities and severe autistic symptomsSignificant recovery linked with intense early interventionAutistic 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 hyperactivityMinimally effective and may be harmfulRisperidone 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 ASDComprehensive 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 communicationEnvironmental enrichmentReinforcing appropriate attention and response to social stimuliPreventing repetitive behaviorsSustained practice of weaker skillsReducing environmental stressImproving 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 backgroundOnly diagnosed when low intelligence is accompanied by impaired adaptive functioning
49 Intellectual Developmental Disorder (cont’d.) Four distinct categories:Mild: IQ score to 70Moderate: IQ score to 50-55Severe: IQ score to 35-40Profound: IQ score below 20-25
51 Intellectual Developmental Disorder (cont’d.) American Association on Intellectual and Developmental Disabilities:IQ score may be used to approximate intellectual functioningMore important to focus on adaptive functioning and nature of psychosocial supports neededGiven ongoing, individualized support, overall functioning of individual with ID will improveApproximately 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 schoolIncreases in low and middle income countriesCoexisting conditions are commonOne-fourth have seizure disorders
53 Intellectual Developmental Disorder: Etiology Etiology differs depending on level of intellectual impairmentMild 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 unknownUnidentified genetic factorsGenetic variationsNormal distribution of traits (upper vs. lower range)Genetic abnormalitiesChromosomal abnormalitiesDown syndrome most commonInheritance of single geneFragile 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 developmentMajority have mild to moderate IDDWith support many can have jobs and live semi-independentlyMedical interventions improve outcome, but significant risks remainPrenatal detection of DS through amniocentesisIn 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 periodFetus is susceptible to viruses and infections, drugs and alcohol, radiation, and poor nutritionFetal alcohol spectrum effects and fetal alcohol syndromeBirth trauma, prematurity, and low birth weightHead injuries, brain infections, tumors, and prolonged malnutritionExposure to environmental toxins, including leadIodine deficiency either during pregnancy or during early infancy can impair intellectual development11/17/2013The 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 factorsEffects of low SESParents with mild IDDLong-term effects of prematurityEnriching and encouraging home environment, as well as ongoing education intervention
58 Learning DisordersAcademic disability characterized by reading, writing, and math skills deficitsPrimarily 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 schoolsBoys are almost twice as likely as girls
59 Learning Disorders (cont’d.) Etiology:Little is known about precise causes of LDChildren with LD that eventually resolves appear to have slower brain maturation.prematuritymaternal alcohol use during pregnancyLifelong differences in neurological processing of information related to basic academic skillsMay be similar to biological explanations for IDD and ADHDRuns in families, suggesting genetic component
60 Support for Individuals (cont’d.) Support in childhood:Individualized home-based or school-based programsParent involvement is integral part of early intervention programsSchool services are individualized to meet child’s needs and to maximize learning opportunitiesRates of improvement decrease once programs are completed
61 Support for Individuals (cont’d.) Support in adulthood:Programs focusing on specific job skillsInstitutionalization is rare, but many live with family members“Least restrictive environment” possibleAs much independence and personal choice as is safe and practicalMost normalized living arrangements vary from setting to setting