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Chapter Fifteen Disorders of Childhood and Adolescence.

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Presentation on theme: "Chapter Fifteen Disorders of Childhood and Adolescence."— Presentation transcript:

1 Chapter Fifteen Disorders of Childhood and Adolescence

2 Disorders of Childhood and Adolescence (cont’d.)

3 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

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

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

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

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

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

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

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

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

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

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)

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

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 Tics: – 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

29 Tics and Tourette’s Disorder (cont’d.) Tics: – 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)

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

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

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

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

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

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

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.

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

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 – Severe: IQ score to – Profound: IQ score below 20-25

50 Intellectual Developmental Disorder (cont’d.)

51 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

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)

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

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

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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