Developmental and Cognitive Disorders Chapter 13

Perspectives on Developmental Disorders Normal vs. Abnormal Development Childhood is associated with significant developmental changes Disruption of early skills will likely disrupt development of later skills Developmental Disorders Diagnosed first in infancy, childhood, or adolescence Attention deficit hyperactivity disorder (ADHD) Learning disorders Autism Mental retardation

Attention Deficit Hyperactivity Disorder (ADHD): An Overview Nature of ADHD Central features – Inattention, overactivity, and impulsivity Associated with behavioral, cognitive, social, and academic problems DSM-IV and DSM-IV-TR Symptom Clusters Cluster 1 – Symptoms of inattention Cluster 2 – Symptoms of hyperactivity and impulsivity cluster Either cluster 1 or 2 must be present for a diagnosis

ADHD: Facts and Statistics Prevalence Occurs in 4%-12% of children who are 6 to 12 years of age Symptoms are usually present around age 3 or 4 68% of children with ADHD have problems as adults Gender Differences Boys outnumber girls 4 to 1 Cultural Factors Probability of ADHD diagnosis is greatest in the United States

ADHD: Biological Contributions Genetic Contributions ADHD runs in families Familial ADHD may involve deficits on chromosome 20 Neurobiological Contributions: Brain Dysfunction and Damage Inactivity of the frontal cortex and basal ganglia Right hemisphere malfunction Abnormal frontal lobe development and functioning Yet to identify a precise neurobiological mechanism for ADHD The Role of Toxins Allergens and food additives do not appear to cause ADHD Maternal smoking increases risk of having a child with ADHD

ADHD: Psychosocial Contributions Psychosocial Factors Can Influence the Disorder Itself Constant negative feedback from teachers, parents, and peers Peer rejection and resulting social isolation Such factors foster low self-image

Biological Treatment of ADHD Goal of Biological Treatments To reduce impulsivity/hyperactivity and to improve attention Stimulant Medications Reduce the core symptoms of ADHD in 70% of cases Examples include Ritalin, Dexedrine Effects of Medications Improve compliance and decrease negative behaviors in many children Beneficial effects are not lasting following drug discontinuation Negative side effects include insomnia, drowsiness, and irritability

Behavioral and Combined Treatment of ADHD Behavioral Treatment Involve reinforcement programs Aim to increase appropriate behaviors and decrease inappropriate behaviors May also involve parent training Combined Bio-Psycho-Social Treatments Are highly recommended

Learning Disorders Scope of Learning Disorders Problems related to academic performance in reading, mathematics, and writing Performance is substantially below what would be expected DSM-IV and DSM-IV-TR Reading Disorder Discrepancy between actual and expected reading achievement Reading is at a level significantly below that of a typical person of the same age Problem cannot be caused by sensory deficits (e.g., poor vision) DSM-IV and DSM-IV-TR Mathematics Disorder Achievement below expected performance in mathematics DSM-IV and DSM-IV-TR Disorder of Written Expression Achievement below expected performance in writing

Learning Disorders: Some Facts and Statistics Incidence and Prevalence of Learning Disorders 1% to 3% incidence of learning disorders in the United States Prevalence is highest in wealthier regions of the United States Prevalence rate is 10% to 15% among school age children Reading difficulties are the most common of the learning disorders About 32% of students with learning disabilities drop out of school School experience for such persons tends to be quite negative

Biological and Psychosocial Causes of Learning Disorders Genetic and Neurobiological Contributions Reading disorder runs in families, with 100% concordance rate for identical twins Evidence for subtle forms of brain damage is inconclusive Overall, genetic and neurobiological contributions are unclear Psychological and motivational factors seem to affect eventual outcome

Treatment of Learning Disorders Requires Intense Educational Interventions Remediation of basic processing problems (e.g., teaching visual skills) Efforts to improve of cognitive skills (e.g., instruction in listening) Targeting behavioral skills to compensate for problem areas Data Support Behavioral Educational Interventions for Learning Disorders

Pervasive Developmental Disorders: An Overview Nature of Pervasive Developmental Disorders Problems occur in language, socialization, and cognition Pervasive – Means the problems span the person’s entire life Examples of Pervasive Developmental Disorders Autistic disorder Asperger’s syndrome

Autistic Disorder Autism Significant impairment in social interactions and communication Restricted patterns of behavior, interest, and activities Three Central DSM-IV and DSM-IV-TR Features of Autism Problems in socialization and social function Problems in communication – 50% never acquire useful speech Restricted patterns of behavior, interests, and activities

Autistic Disorder: Facts and Statistics Prevalence and Features of Autism Affects 2 to 20 persons for every 10,000 people More prevalent in females with IQs below 35, and in males with higher IQs Autism occurs worldwide Symptoms usually develop before 36 months of age Autism and Intellectual Functioning 50% have IQs in the severe-to-profound range of mental retardation 25% test in the mild-to-moderate IQ range (i.e., IQ of 50 to 70) Remaining people display abilities in the borderline-to-average IQ range Better language skills and IQ test performance predicts better lifetime prognosis

Causes of Autism: Early and More Recent Contributions Historical Views Bad parenting Unusual speech patterns Lack of self-awareness Echolalia Current Understanding of Autism Medical conditions – Not always associated with autism Autism has a genetic component that is largely unclear Neurobiological evidence for brain damage – Link with mental retardation Cerebellum size – Substantially reduced in persons with autism

Treatment of Pervasive Developmental Disorders Psychosocial “Behavioral” Treatments Skill building and treatment of problem behaviors Communication and language problems Address socialization deficits Early intervention is critical Biological and Medical Treatments Are Unavailable Integrated Treatments: The Preferred Model Focus on children, their families, parents, schools, and the home Build in appropriate community and social support

Mental Retardation (MR) Nature of Mental Retardation Disorder of childhood Below-average intellectual and adaptive functioning Range of impairment varies greatly across persons Mental Retardation and the DSM-IV and DSM-IV-TR Significantly subaverage intellectual functioning (IQ below 70) Concurrent deficits or impairments two or more areas of adaptive functioning MR must be evident before the person is 18 years of age

DSM-IV and DSM-IV-TR Levels of Mental Retardation (MR) Mild MR Includes persons with an IQ score between 50 or 55 and 70 Moderate MR Includes persons in the IQ range of 35-40 to 50-55 Severe MR Includes people with IQs ranging from 20-25 up to 35-40 Profound MR Includes people with IQ scores below 20-25

Other Classification Systems for Mental Retardation (MR) American Association of Mental Retardation (AAMR) Defines MR based on levels of assistance required Examples of levels include intermittent, limited, extensive, or pervasive assistance Classification of MR in Educational Systems Educable mental retardation (i.e., IQ of 50 to approximately 70-75) Trainable mental retardation (i.e., IQ of 30 to 50) Severe mental retardation (i.e., IQ below 30)

Mental Retardation (MR): Some Facts and Statistics Prevalence About 1% to 3% of the general population 90% of MR persons are labeled with mild mental retardation Gender Differences MR occurs more often in males, male-to-female ratio of about 1.6:1 Course of MR Tends to be chronic, but prognosis varies greatly from person to person

Mental Retardation (MR): Biological Contributions Genetic Research MR involves multiple genes, and at times single genes Chromosomal Abnormalities and Other Forms of MR Down syndrome – Trisomy 21 Fragile X syndrome – Abnormality on X chromosome Maternal Age and Risk of Having a Down’s Baby Nearly 75% of cases cannot be attributed to any known biological cause

Mental Retardation (MR): Psychosocial Contributions Cultural-Familial Retardation Believed to cause about 75% of MR cases and is the least understood Associated with mild levels of retardation on IQ tests and good adaptive skills Cultural-Familial Retardation: Difference vs. Developmental Views Difference view – Mild MR is a matter of degree and kind Developmental view – Mild MR reflects a slowing or delay of normal development

Treatment of Mental Retardation (MR) Parallels Treatment of Pervasive Developmental Disorders Teach needed skills to foster productivity and independence Educational and behavioral management Living and self-care skills via task analysis Communication training – Often most challenging treatment target! Community and supportive interventions Persons with MR Can Benefit from Such Interventions

Summary of Developmental Disorders Developmental Psychopathology and Normal and Abnormal Development Attention Deficit Hyperactivity Disorder Deficits in inattention, hyperactivity, or impulsivity Disrupt academic and social functioning Learning Disorders All share deficits in performance below expectations for IQ and school preparation Pervasive Developmental Disorder All share deficits in language, socialization, and cognition Mental Retardation Subaverage IQ, deficits in adaptive functioning, onset before age 18 Prevention and Early Intervention Are Critical for Developmental Disorders

Cognitive Disorders: An Overview Perspectives on Cognitive Disorders Affect cognitive processes such as learning, memory, and consciousness Most develop later in life Three Classes of Cognitive Disorders Delirium – Often temporary confusion and disorientation Dementia – Degenerative condition marked by broad cognitive deterioration Amnestic disorders – Memory dysfunctions caused by disease, drugs, or toxins Shifting DSM Perspectives From “organic” mental disorders to “cognitive” disorders Broad impairments in memory, attention, perception, and thinking Profound changes in behavior and personality

Delirium Nature of Delirium Central features – Impaired consciousness and cognition Impairments develop rapidly over several hours or days Examples include confusion, disorientation, attention, memory, and language deficits Facts and Statistics Affects 10% to 30% of persons in acute care facilities Most prevalent in older adults, AIDS patients, and medical patients Full recovery often occurs within several weeks

Medical Conditions Related to Delirium Drug intoxication, poisons, withdrawal from drugs Infections, head injury, and several forms of brain trauma Sleep deprivation, immobility, and excessive stress DSM-IV and DSM-IV Subtypes of Delirium Delirium due to a general medical condition Substance-induced delirium Delirium due to multiple etiologies Delirium not otherwise specified

Treatment and Prevention of Delirium Attention to precipitating medical problems Psychosocial interventions include reassurance, coping strategies Prevention Address proper medical care for illnesses Address proper use and adherence to therapeutic drugs

Dementia Nature of Dementia Gradual deterioration of brain functioning Affects judgment, memory, language, and advanced cognitive processes Dementia has many causes and may be reversible or irreversible Progression of Dementia: Initial Stages Memory impairment, visuospatial skills deficits Agnosia – Inability to recognize and name objects (most common symptom) Facial agnosia – Inability to recognize familiar faces Other symptoms – Delusions, depression, agitation, aggression, and apathy Progression of Dementia: Later Stages Cognitive functioning continues to deteriorate Person requires almost total support to carry out day-to-day activities Death results from inactivity combined with onset of other illnesses

Dementia: Facts and Statistics Onset and Prevalence Can occur at any age, but most common in the elderly Affects 1% of those between 65-74 years of age Affects over 10% of persons 85 years and older 47% of adults over the age of 85 have dementia of the Alzheimer’s type Incidence of Dementia Affects 2.3% of those 75-79 years of age and 8.5% of persons 85 and older Rates of new cases appear to double with every 5 years of age Gender and Sociocultural Factors Dementia occurs equally in men and women Dementia occurs equally across educational level and social class

DSM-IV and DSM-IV-TR Classes of Dementia Dementia of the Alzheimer’s type Vascular Dementia Dementia Due to Other General Medical Conditions Substance-Induced Persisting Dementia Dementia Due to Multiple Etiologies Dementia Not Otherwise Specified

Dementia of the Alzheimer’s Type DSM-IV-TR Criteria and Clinical Features Multiple cognitive deficits that develop gradually and steadily Predominant impairment in memory, orientation, judgment, and reasoning Can include agitation, confusion, depression, anxiety, or combativeness Symptoms are usually more pronounced at the end of the day Range of Cognitive Deficits Aphasia – Difficulty with language Apraxia – Impaired motor functioning Agnosia – Failure to recognize objects Difficulties with planning, organizing, sequencing, or abstracting information Impairments have a marked negative impact on social and occupational functioning An Autopsy Is Required for a Definitive Diagnosis

Alzheimer’s Disease: Some Facts and Statistics Nature and Progression of the Disease Deterioration is slow during the early and later stages, but rapid during middle stages Average survival time is about 8 years Onset usually occurs in the 60s or 70s, but may occur earlier Prevalence of Alzheimer’s Disease Affects about 4 million Americans and many more worldwide Prevalence is greater in poorly educated persons and women Prevalence rates are low in some ethnic groups (e.g., Japanese, Nigerian, Amish)

Vascular Dementia Nature of Vascular Dementia Progressive brain disorder caused by blockage or damage to blood vessels Second leading cause of dementia next to Alzheimer’s Onset is often sudden (e.g., stroke) Patterns of impairment are variable, and most require formal care in later stages DSM-IV and DSM-IV Criteria and Incidence Cognitive disturbances are identical to dementia Unlike Alzheimer’s, obvious neurological signs of brain tissue damage occur Incidence is believed to be about 4.7% or men and 3.8% of women

Dementia Due to HIV Disease Overview and Clinical Features HIV causes neurological impairments and dementia Cognitive slowness, impaired attention, forgetfulness, and clumsiness Repetitive movements (e.g., tremors/leg weakness), apathy, and social withdrawal Progression of HIV-Related Cognitive Impairments Tend to occur during the later stages of HIV infection Impairments are observed in 29% to 87% of people with AIDS Subcortical dementia – Refers to deficits that affect inner brain regions Aphasia is uncommon in subcortical dementia, but anxiety and depression occur

Other Causes of Dementia: Head Trauma and Parkinson’s Disease Accidents are leading causes of such cognitive impairments Memory loss is the most common symptom Parkinson’s Disease Degenerative brain disorder Affects about 1 out of 1,000 people worldwide Motor problems are characteristic of this disorder Damage to dopamine pathways is believed to cause motor problems Pattern of impairments are similar to subcortical dementia

Other Causes of Dementia: Huntington’s and Pick’s Disease Huntington’s Disease Genetic autosomal dominant disorder (i.e., chromosome 4) Manifests initially as chorea, usually later in life (around 40s or 50s) About 20% to 80% of persons go on to display dementia of the subcortical pattern Pick’s Disease Rare neurological condition that produces a cortical dementia like Alzheimer’s Also occurs later in life (around 40s or 50s) Little is known about what causes this disease

Other Dementias: Creutzfeldt-Jakob Disease and Substance-Induced Dementia Affects 1 out of 1,000,000 persons Linked to mad cow disease Substance-Induced Persisting Dementia Results from drug use in combination with poor diet Examples include alcohol, inhalants, and sedative, hypnotic, and anxiolytic drugs Resulting brain damage may be permanent Dementia is similar to that of Alzheimer’s Deficits may include aphasia, apraxia, agnosia, or disturbed executive functioning

Causes of Dementia: The Example of Alzheimer’s Disease Early and Largely Unsupported Views: The Example of Smoking Current Neurobiological Findings Neurofibrillary tangles – Occur in all brains of Alzheimer’s patients Amyloid plaques – Accumulate excessively in brains of Alzheimer’s patients Brains of Alzheimer’s patients tend to atrophy Multiple genes are involved in Alzheimer’s disease (chromosomes 21, 19, 14, 12, 1) Chromosome 14 – Associated with early onset Alzheimer’s Chromosome 19 – Associated with a late onset Alzheimer’s

The Contributions of Psychosocial Factors in Dementia Do not cause dementia directly, but may influence onset and course Lifestyle factors – Drug use, diet, exercise, stress Cultural factors – Risk for certain diseases and accidents vary by ethnicity and class Psychosocial factors – Educational attainment, coping skills, social support

Medical and Psychosocial Treatment of Dementia Medical Treatment: Best if Enacted Early Few medical treatments exist for most types of dementia Most medical treatments attempt to slow progression of deterioration Examples include glial cell-derived neurotrophic factor, Cognex, vitamin E, aspirin Medical treatments do not stop progression of dementia Psychosocial Treatments Focus on enhancing the lives of dementia patients and their families/caregivers Teach adaptive skills Use memory enhancement prosthetic devices (e.g., memory wallet) Main emphasis of psychosocial interventions appears to be on the caregivers

Prevention of Dementia Reducing Risk of Dementia in Older Adults Via Estrogen-replacement therapy – Reduces risk of Alzheimer’s dementia in women Proper treatment of cardiovascular diseases Use of anti-inflammatory medications Other Targets of Prevention Efforts Increasing safety behaviors to reduce head trauma Reducing exposure to neurotoxins and use of drugs

Amnestic Disorder Nature of Amnestic Disorder Inability to transfer information from short-term memory into long- term memory Often results from medical conditions, head trauma, or long-term drug use DSM-IV and DSM-IV-TR Criteria for Amnestic Disorder Cover the inability to learn new information Inability to recall previously learned information Memory disturbance causes significant impairment in functioning The Example of Wernicke-Korsakoff Syndrome Caused by thalamic damage resulting from stroke or chronic heavy alcohol use Attempt to restore thiamine deficiency in the case of chronic alcohol abuse Research on Amnestic Disorders Is Scant