1. Chapter 17 Disorders of Childhood and Adolescence Slides & Handouts by Karen Clay Rhines, Ph.D. Seton Hall University

2. Slide 2 Disorders of Childhood and Adolescence  Abnormal functioning can occur at any time in life  Some patterns of abnormality, however, are more likely to emerge during particular periods Sometimes the special pressures of the particular life stage help trigger the dysfunctioning In other cases, unique experiences or biological abnormalities may be the key factor

3. Slide 3 Childhood and Adolescence  Theorists often view life as a series of stages on the road from birth to death Freud proposed five stages of psychosexual development: oral, anal, phallic, latency, and genital Erikson added the old age stage  Although theorists may disagree with the details of these schemes, most agree with the idea that we face key pressures during each stage in life and either grow or decline depending on how we meet those pressures

4. Slide 4 Childhood and Adolescence  People often think of childhood as a carefree and happy time – yet it can also be frightening and upsetting Children of all cultures typically experience at least some emotional and behavioral problems as they encounter new people and situations Surveys indicate that worry is a common experience Bedwetting, nightmares, and temper tantrums are other problems experienced by many children

5. Slide 5 Childhood and Adolescence  Adolescence can also be a difficult period Physical and sexual changes, social and academic pressures, personal doubts, and temptation cause many teenagers to feel anxious, confused, and depressed

6. Slide 6 Childhood and Adolescence  Along with these common psychological difficulties, around one-fifth of all children and adolescents in North America also experience a diagnosable psychological disorder Boys with disorders outnumber girls, even though most of the adult psychological disorders are more common in women

7. Slide 7 Childhood Anxiety Disorders  As in adults, the anxiety disorders experienced by children and adolescents include specific phobias, social phobias, generalized anxiety disorder, and OCD  One form of anxiety listed separately in the DSM and specific to children is separation anxiety disorder

8. Slide 8 Childhood Anxiety Disorders  Separation anxiety disorder is characterized by extreme anxiety, often panic, when the sufferer is separated from home or a parent Many cannot travel away from their families and may be unable to stay alone in a room  It is estimated that about 4% of children and young adolescents suffer from this disorder Girls are diagnosed more often than boys

9. Slide 9 Childhood Anxiety Disorders  Separation anxiety disorder sometimes takes the form of school phobia, although most cases of school phobia have other causes  Childhood anxiety disorders are generally explained in much the same way as adult anxiety disorders, with biological, behavioral, and cognitive factors pointed to most often The special features of childhood may play an important role

10. Slide 10 Childhood Anxiety Disorders  Psychodynamic, behavioral, cognitive, and family therapies, separately or in combination, have been used to treat anxiety disorders in children, often with success  Clinicians have also used drug therapy and play therapy as part of treatment

11. Slide 11 Childhood Depression  Children, like adults, may develop depression  Between 2 and 4% of children under 17 years of age experience major depressive disorder The symptoms are likely to include physical discomfort, irritability, and social withdrawal  There appears to be no difference in the rates of depression in boys and girls before age 11 By age 16, girls are twice as likely as boys to be depressed

12. Slide 12 Childhood Depression  Explanations of childhood depression are similar to those of adult depression  Theorists have pointed to factors such as loss, learned helplessness, negative cognitions, and low serotonin or norepinephrine activity

13. Slide 13 Childhood Depression  Like depression in adults, childhood depression is often helped by cognitive therapy or interpersonal approaches Family therapy may also be effective  Antidepressant medications have not proved consistently useful in cases involving children, but they do seem to help some depressed adolescents

14. Slide 14 Disruptive Behavior Disorders  Children displaying extreme hostility and defiance may qualify for a diagnosis of oppositional defiant disorder This disorder is characterized by repeated arguments with adults, loss of temper, anger, and resentment Children with this disorder ignore adult requests and rules, try to annoy people, and blame others for their mistakes and problems Between 2 and 16% of children will display this pattern The disorder is more common in boys than girls before puberty but equal in both sexes after puberty

15. Slide 15 Disruptive Behavior Disorders  Children with conduct disorder display a more extensive and severe antisocial pattern and repeatedly violate the basic rights of others They are often aggressive and may be physically cruel and violent Many steal from, threaten, or harm their victims, committing such crimes as shoplifting, vandalism, mugging, and armed robbery

16. Slide 16 Disruptive Behavior Disorders  Conduct disorder usually begins between 7 and 15 years of age  Between 1 and 10% of children display this pattern, boys more than girls  Children with a mild conduct disorder may improve over time, but severe cases frequently continue into adulthood These cases may turn into antisocial personality disorder or other psychological problems

17. Slide 17 Disruptive Behavior Disorders  Many children with conduct disorder are suspended from school, placed in foster homes, or incarcerated When children between the ages of 8 and 18 break the law, the legal system often labels them juvenile delinquents

18. Slide 18 Disruptive Behavior Disorders  Cases of conduct disorder have been linked to genetic and biological factors, drug abuse, poverty, traumatic events, and exposure to violent peers or community violence They have most often been tied to troubled parent-child relationships, inadequate parenting, family conflict, marital conflict, and family hostility

19. Slide 19 Disruptive Behavior Disorders  Because disruptive behavior patterns become more locked in with age, treatments for conduct disorder are generally most effective with children younger than 13  Given the importance of family factors in this disorder, therapists often use family interventions

20. Slide 20 Disruptive Behavior Disorders  Sociocultural approaches such as residential treatment programs have helped some children  Individual approaches are sometimes effective as well, particularly those that teach the child how to cope with anger  Recently, the use of drug therapy has been tried  Institutionalization in juvenile training centers has not met with much success and may, in fact, increase delinquent behavior

21. Slide 21 Disruptive Behavior Disorders  It may be that the greatest hope for reducing the problem of conduct disorder lies in prevention programs that begin in early childhood These programs try to change unfavorable social conditions before a conduct disorder is able to develop

22. Slide 22 Attention-Deficit/ Hyperactivity Disorder  Children who display attention- deficit/hyperactivity disorder (ADHD) have great difficulty attending to tasks or behave overactively and impulsively, or both  The primary symptoms of ADHD may feed into one another, but often one of the symptoms stands out more than the other

23. Slide 23 Attention-Deficit/ Hyperactivity Disorder  Problems common to the disorder: Learning or communication problems Poor school performance Difficulty interacting with other children Misbehavior, often serious Mood or anxiety problems

24. Slide 24 Attention-Deficit/ Hyperactivity Disorder  Around 5% of schoolchildren display ADHD, as many as 90% of them boys  Many children show a lessening of symptoms as they move into adolescence At least half continue to have problems One-third of those affected have symptoms into adulthood  Those whose parents have had ADHD are more likely than others to develop it

25. Slide 25 Attention-Deficit/ Hyperactivity Disorder  Clinicians generally consider ADHD to have several interacting causes, including: Biological causes High levels of stress Family dysfunctioning  Each of these causes has received some research support

26. Slide 26 Attention-Deficit/ Hyperactivity Disorder  Sociocultural theorists also point out that ADHD symptoms and a diagnosis of ADHD may themselves create interpersonal problems and produce additional symptoms in the child  Two other explanations have received considerable press (though neither has been supported by research): ADHD is typically caused by sugar or food additives ADHD results from environmental toxins such as lead

27. Slide 27 Attention-Deficit/ Hyperactivity Disorder  There is heated disagreement about the most effective treatment for ADHD The most common approach has been the use of stimulant drugs such as methylphenidate (Ritalin) These drugs have a quieting effect on as many as 80% of children with ADHD and sometimes increase their ability to solve problems, perform in school, and control aggression However, some clinicians worry about the possible long-term effects of the drugs

28. Slide 28 Attention-Deficit/ Hyperactivity Disorder  Behavioral therapy is also applied widely in cases of ADHD Parents and teachers learn how to apply operant conditioning techniques to change behavior These treatments have often been helpful, especially when combined with drug therapy

29. Slide 29 Elimination Disorders  Children with elimination disorders repeatedly urinate or pass feces in their clothes, in bed, or on the floor  They have already reached an age at which they are expected to control these bodily functions These symptoms are not caused by physical illness

30. Slide 30 Enuresis  Enuresis is repeated involuntary (or in some cases intentional) bedwetting or wetting of one’s clothes  It typically occurs at night during sleep but may also occur during the day The problem may be triggered by a stressful event  Children must be at least 5 years of age to receive this diagnosis  Prevalence of enuresis decreases with age

31. Slide 31 Enuresis  Research has not favored one explanation for the disorder over others Psychodynamic theorists explain it as a symptom of broader anxiety and underlying conflicts Family theorists point to disturbed family interactions Behaviorists often view it as the result of improper toilet training Biological theorists suspect that the physical structure of the urinary system develops more slowly in some children

32. Slide 32 Enuresis  Most cases of enuresis correct themselves without treatment Therapy, particularly behavioral therapy, can speed up the process

33. Slide 33 Encopresis  Encopresis – repeatedly defecating in one’s clothing – is less common than enuresis and less well researched  The problem: Is usually involuntary Seldom occurs during sleep Starts after the age of 4 Is more common in boys than girls

34. Slide 34 Encopresis  Encopresis causes intense social problems, shame, and embarrassment  Cases may stem from stress, constipation, or improper toilet training  The most common treatments are behavioral and medical approaches, or combinations of the two Family therapy has also been helpful

35. Slide 35 Long-Term Disorders That Begin in Childhood  Two of the disorders that emerge during childhood are likely to continue unchanged throughout a person’s life: Autism Mental retardation  Clinicians have developed a range of treatment approaches that can make a major difference in the lives of people with these problems

36. Slide 36 Autism  Autistic disorder, or autism, was first identified in 1943  Children with this disorder are extremely unresponsive to others, uncommunicative, repetitive, and rigid  Symptoms appear early in life, before age 3  Only 5 of every 10,000 children are affected, and 80% are boys

37. Slide 37 Autism  As many as 90% of children with autism remain severely disabled into adulthood and are unable to lead independent lives Even the highest-functioning adults with autism typically have problems in social interactions and communication and have restricted interests and activities  Several other disorders are similar to autism but differ to some degree in symptoms or time of onset These disorders are categorized as pervasive developmental disorders

38. Slide 38 What Are the Features of Autism?  The central feature of autism is the individual’s lack of responsiveness, including extreme aloofness and lack of interest in people  Language and communication problems take various forms One common speech peculiarity is echolalia, the exact echoing of phrases spoken by others

39. Slide 39 What Are the Features of Autism?  Autism is also marked by limited imaginative play and very repetitive and rigid behavior This has been called a “perseveration of sameness”  Many sufferers become strongly attached to particular objects – plastic lids, rubber bands, buttons, water – and may collect, carry, or play with them constantly

40. Slide 40 What Are the Features of Autism?  The motor movements of people with autism may be unusual Often called “self-stimulatory” behaviors; may include jumping, arm flapping, and making faces Children with autism may engage in self-injurious behaviors  Children may at times seem overstimulated and/or understimulated by their environments

41. Slide 41 What Causes Autism?  A variety of explanations for the disorder have been offered Sociocultural explanations are now seen as having been overemphasized Recent work in the psychological and biological spheres has persuaded clinical theorists that cognitive limitations and brain abnormalities are the primary causes of the disorder

42. Slide 42 What Causes Autism?  Sociocultural causes Theorists initially thought that family dysfunction and social stress were the primary causes of autism Notion of “refrigerator parents” These claims had enormous influence on the public and the self- image of parents, but research totally failed to support this model Some clinicians have proposed a high degree of social and environmental stress as a factor, a theory also unsupported by research

43. Slide 43 What Causes Autism?  Psychological causes According to some theorists, people with autism have a central perceptual or cognitive disturbance One theory holds that individuals fail to develop a theory of mind – an awareness that other people base their behaviors on their own beliefs, intentions, and other mental states, not on information they have no way of knowing Repeated studies have shown that people with autism have this kind of “mindblindness” It has been theorized that early biological problems prevented proper cognitive development

44. Slide 44 What Causes Autism?  Biological causes While a clear biological explanation for autism has not yet been developed, promising leads have been uncovered Family studies suggest a genetic factor in the disorder Prevalence rates are higher among siblings and highest among identical twins Chromosomal abnormalities have been discovered in 10 to 12% of people with the disorder

45. Slide 45 What Causes Autism?  Biological causes Some studies have linked autism to prenatal difficulties or birth complications Some theorists have proposed that a postnatal event – the MMR vaccine – might produce autism in some children, although subsequent research has found no link Researchers have also identified specific biological abnormalities that may contribute to the disorder

46. Slide 46 What Causes Autism?  Biological causes Many researchers believe that autism may have multiple biological causes Perhaps all relevant biological factors lead to a common problem in the brain – a “final common pathway” – that produces the features of the disorder

47. Slide 47 How Is Autism Treated?  Treatment can help people with autism adapt better to their environment, although no treatment yet known totally reverses the autistic pattern  Treatments of particular help are behavioral therapy, communication training, parent training, and community integration

48. Slide 48 How Is Autism Treated?  Behavioral therapy Behavioral approaches have been used in cases of autism to teach new, appropriate behaviors, including speech, social skills, classroom skills, and self-help skills, while reducing negative ones Most often, therapists use modeling and operant conditioning Therapies are ideally applied when people with autism are young

49. Slide 49 How Is Autism Treated?  Communication training Even when given intensive behavioral treatment, half of the people with autism remain speechless Many therapists include sign language and simultaneous communication – a method of combining sign language and speech – into therapy They may also use augmentative communication systems, such as “communication boards” or computers that use pictures, symbols, or written words to represent objects or needs

50. Slide 50 How Is Autism Treated?  Parent training Today’s treatment programs involve parents in a variety of ways For example, behavioral programs train parents so they can apply behavioral techniques at home In addition, individual therapy and support groups are becoming more available to help parents deal with their own emotions and needs

51. Slide 51 How Is Autism Treated?  Community integration Many of today’s school-based and home-based programs for autism teach self-help, self­ management, and living skills In addition, greater numbers of group homes and sheltered workshops are available for teens and young adults with autism These programs help individuals become a part of their community and also reduce the concerns of aging parents

52. Slide 52 Mental Retardation  According to the DSM-IV, people should receive a diagnosis of mental retardation when they display general intellectual functioning that is well below average, in combination with poor adaptive behavior IQ must be 70 or below The person must have difficulty in such areas as communication, home living, self-direction, work, or safety  Symptoms must appear before age 18

53. Slide 53 Assessing Intelligence  Educators and clinicians administer intelligence tests to measure intellectual functioning These tests consist of a variety of questions and tasks that rely on different aspects of intelligence Having difficulty in one or two of these subtests or areas of functioning does not necessarily reflect low intelligence An individual’s overall test score, or intelligence quotient (IQ), is thought to indicate general intellectual ability

54. Slide 54 Assessing Intelligence  Many theorists have questioned whether IQ tests are indeed valid  Intelligence tests also appear to be socioculturally biased  If IQ tests do not always measure intelligence accurately and objectively, then the diagnosis of mental retardation may also be biased That is, some people may receive the diagnosis partly because of cultural difference, discomfort with the testing situation, or the bias of the tester

55. Slide 55 Assessing Adaptive Functioning  Diagnosticians cannot rely solely on a cutoff IQ score of 70 to determine whether a person suffers from mental retardation  Several scales, such as the Vineland and AAMR adaptive behavior scales, have been developed to assess adaptive behavior For proper diagnosis, clinicians should observe the functioning of each individual in his or her everyday environment, taking both the person’s background and the community standards into account

56. Slide 56 What Are the Characteristics of Mental Retardation?  The most consistent sign of mental retardation is that the person learns very slowly  Other areas of difficulty are attention, short­ term memory, planning, and language Those who are institutionalized with mental retardation are particularly likely to have these limitations

57. Slide 57 What Are the Characteristics of Mental Retardation?  The DSM-IV describes four levels of mental retardation: Mild (IQ 50–70) Moderate (IQ 35–49) Severe (IQ 20–34) Profound (IQ below 20)

58. Slide 58 Mild Retardation  Some 85% of all people with mental retardation fall into the category of mild retardation (IQ 50–70) They are sometimes called “educably retarded” because they can benefit from schooling  People with mild retardation typically need assistance but can work in unskilled or semiskilled jobs Intellectual performance seems to improve with age

59. Slide 59 Mild Retardation  Research has linked mild mental retardation mainly to sociocultural and psychological causes, particularly: Poor and unstimulating environments Inadequate parent-child interactions Insufficient early learning experiences

60. Slide 60 Mild Retardation  Although these factors seem to be the leading causes of mild mental retardation, at least some biological factors may also be operating Studies have linked mothers’ moderate drinking, drug use, or malnutrition during pregnancy to cases of mild retardation

61. Slide 61 Moderate, Severe, and Profound Retardation  Approximately 10% of persons with mental retardation function at a level of moderate retardation (IQ 35–49) They can care for themselves and benefit from vocational training  About 4% of persons with mental retardation display severe retardation (IQ 20–34) They usually require careful supervision and can perform only basic work tasks

62. Slide 62 Moderate, Severe, and Profound Retardation  About 1% of persons with mental retardation fall into the category of profound retardation (IQ below 20) With training they may learn or improve basic skills but they need a very structured environment  Severe and profound levels of mental retardation often appear as part of larger syndromes that include severe physical handicaps

63. Slide 63 What Are the Causes of Mental Retardation?  The primary causes of moderate, severe, and profound retardation are biological, although people who function at these levels are also greatly affected by their family and social environment Sometimes genetic factors are at the root of these biological problems Other biological causes come from unfavorable conditions that occur before, during, or after birth

64. Slide 64 What Are the Causes of Mental Retardation?  Chromosomal causes The most common chromosomal disorder leading to mental retardation is Down syndrome Several types of chromosomal abnormalities may cause Down syndrome, but the most common is trisomy 21 Fragile X syndrome is the second most common chromosomal cause of mental retardation

65. Slide 65 What Are the Causes of Mental Retardation?  Metabolic causes In metabolic disorders, the body’s breakdown or production of chemicals is disturbed The metabolic disorders that affect intelligence are typically caused by the pairing of two defective recessive genes, one from each parent Examples include: Phenylketonuria (PKU) Tay-Sachs disease

66. Slide 66 What Are the Causes of Mental Retardation?  Prenatal and birth-related causes As a fetus develops, major physical problems in the pregnant mother can threaten the child’s healthy development Low iodine may lead to cretinism Alcohol use may lead to fetal alcohol syndrome (FAS) Certain maternal infections during pregnancy (e.g., rubella, syphilis) may cause childhood problems including mental retardation Birth complications, such as a prolonged period without oxygen (anoxia), can also lead to mental retardation

67. Slide 67 What Are the Causes of Mental Retardation?  Childhood problems After birth, particularly up to age 6, certain injuries and accidents can affect intellectual functioning Examples include poisoning, serious head injury, excessive exposure to x-rays, and excessive use of certain chemicals, minerals, and/or drugs Certain infections, such as meningitis and encephalitis, can lead to mental retardation if they are not diagnosed and treated in time

68. Slide 68 Interventions for People with Mental Retardation  The quality of life achieved by people with mental retardation depends largely on sociocultural factors Thus, intervention programs try to provide comfortable and stimulating residences, social and economic opportunities, and a proper education

69. Slide 69 Interventions for People with Mental Retardation  What is the proper residence? Until recently, parents of children with mental retardation would send them to live in public institutions – state schools – as early as possible These overcrowded institutions provided basic care, but residents were neglected, often abused, and isolated from society

70. Slide 70 Interventions for People with Mental Retardation  What is the proper residence? During the 1960s and 1970s, the public became more aware of these sorry conditions, and, as part of the broader deinstitutionalization movement, demanded that many people be released from these schools People with mental retardation faced similar challenges by deinstitutionalization as people with schizophrenia

71. Slide 71 Interventions for People with Mental Retardation  What is the proper residence? Since deinstitutionalization, reforms have led to the creation of small institutions and other community residences that teach self-sufficiency, devote more time to patient care, and offer education and medical services Residences include group homes, halfway houses, local branches of larger institutions, and independent residences These programs follow the principle of normalization – they try to provide living conditions similar to those enjoyed by the rest of society

72. Slide 72 Interventions for People with Mental Retardation  What is the proper residence? Today the vast majority of children with mental retardation live at home rather than in an institution Most people with mental retardation, including almost all with mild mental retardation, now spend their adult lives either in the family home or in a community residence

73. Slide 73 Interventions for People with Mental Retardation  Which educational programs work best? Because early intervention seems to offer such great promise, educational programs for individuals with mental retardation may begin during the earliest years At issue are special education versus mainstream classrooms In special education, children with mental retardation are grouped together in a separate, specially designed educational program Mainstreaming places them in regular classes with nonretarded students Neither approach seems consistently superior

74. Slide 74 Interventions for People with Mental Retardation  Which educational programs work best? Many teachers use operant conditioning principles to improve the self-help, communication, social, and academic skills of individuals with mental retardation Many schools also employ token economy programs

75. Slide 75 Interventions for People with Mental Retardation  When is therapy needed? People with mental retardation sometimes experience emotional and behavioral problems At least 10% have a diagnosable psychological disorder other than mental retardation Some suffer from low self-esteem, interpersonal problems, and adjustment difficulties These problems are helped to some degree with individual or group therapy Medication is sometimes prescribed

76. Slide 76 Interventions for People with Mental Retardation  How can opportunities for personal, social, and occupational growth be increased? People need to feel effective and competent in order to move forward in life Those with mental retardation are most likely to achieve these feelings if their communities allow them to grow and make many of their own choices

77. Slide 77 Interventions for People with Mental Retardation  How can opportunities for personal, social, and occupational growth be increased? Socializing, sex, and marriage are difficult issues for people with mental retardation and their families With proper training and practice, the individuals can learn to use contraceptives and carry out responsible family planning The National Association for Retarded Citizens offers guidance in these matters Some clinicians have developed dating skills programs

78. Slide 78 Interventions for People with Mental Retardation  How can opportunities for personal, social, and occupational growth be increased? Some states restrict marriage for people with mental retardation These laws are rarely enforced Between one-quarter and one-half of all people with mild mental retardation eventually marry

79. Slide 79 Interventions for People with Mental Retardation  How can opportunities for personal, social, and occupational growth be increased? Adults with mental retardation need the financial security and personal satisfaction that comes from holding a job Many can work in sheltered workshops, but there are too few training programs available Additional programs are needed so that more people with mental retardation may achieve their full potential, as workers and as human beings