Chapter 13 Developmental Disorders

Nature of Developmental Psychopathology: An Overview  Normal vs. Abnormal Development  Developmental Psychopathology – Study of how disorders arise and change with time – Disruption of early skills can affect later development

Nature of Developmental Psychopathology: An Overview (continued)  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 numerous impairments  Behavioral  Cognitive  Social and academic problems

Attention Deficit Hyperactivity Disorder (ADHD): An Overview (continued)  DSM-IV-TR Symptom Types – Inattentive type – Hyperactive type – Impulsive type

ADHD: Facts and Statistics  Prevalence – Occurs in 6% of school-aged children – Symptoms are usually present around age 3 or 4 – 68% of children with ADHD have problems as adults

ADHD: Facts and Statistics (continued)  Gender Differences – Boys outnumber girls 4 to 1  Cultural Factors  Probability of ADHD diagnosis – Greatest in the United States

The Causes of ADHD: Biological Contributions  Genetic Contributions – ADHD seems to run in families – DRD4, DAT1, and DRD5 genes have been implicated

The Causes of ADHD: Biological Contributions (continued)  Neurobiological Contributions – Smaller brain volume – Inactivity of the frontal cortex and basal ganglia – Abnormal frontal lobe development and functioning

The Causes of ADHD: Biological Contributions (continued)  The Role of Toxins – No evidence that allergens and food additives are causes – Maternal smoking increases risk

The Causes of ADHD: Psychosocial Contributions  Psychosocial Factors – Can influence the nature of ADHD – ADHD children are often viewed negatively by others – Constant negative feedback from peers and adults – Peer rejection and resulting social isolation – Such factors foster low self-esteem

Biological Treatment of ADHD  Goal of Biological Treatments – To reduce impulsivity and hyperactivity and to improve attention  Stimulant Medications – Reduce core symptoms in 70% of cases – Examples include Ritalin, Dexedrine

Biological Treatment of ADHD (continued)  Other Medications With More Limited Efficacy – Imipramine and Clonidine (antihypertensive)  Effects of Medications – Improve compliance and decrease negative behaviors – Do not affect learning and academic performance – Benefits are not lasting following discontinuation

Behavioral and Combined Treatment of ADHD  Behavioral Treatment – Reinforcement programs  To increase appropriate behaviors  Decrease inappropriate behaviors – May also involve parent training

Behavioral and Combined Treatment of ADHD (continued)  Combined Bio-Psycho-Social Treatments – Are highly recommended – Superior to medication or behavioral treatments alone

Learning Disorders: An Overview  Scope of Learning Disorders – Academic problems in reading, mathematics, and writing – Performance substantially below expected levels

Learning Disorders: An Overview (continued)  DSM-IV-TR Reading Disorder – Discrepancy between actual and expected achievement – Performance significantly below age or grade level – Cannot be caused by sensory deficits

Learning Disorders: An Overview (continued)  DSM-IV-TR Mathematics Disorder – Achievement below expected performance  DSM-IV-TR Disorder of Written Expression – Achievement below expected performance in writing

Learning Disorders: Some Facts and Statistics  Prevalence of Learning Disorders – 5-10% prevalence in the United States – Highest in wealthier regions of the United States – About 32% of these students drop out of school – 5-15% prevalence for reading difficulties – School experience tends to be generally negative

Fig. 13.1, p. 514

Biological and Psychosocial Causes of Learning Disorders  Genetic and Neurobiological Contributions – Reading disorder runs in families – 100% concordance rate for identical twins – Evidence for subtle forms of brain damage is inconclusive – Overall, contributions are unclear  Psychosocial Contributions are Largely Unknown

Treatment of Learning Disorders  Requires Intense Educational Interventions – Remediation of basic processing problems – Improvement of cognitive skills – Targeting skills to compensate for problem areas  Data Support Behavioral Educational Interventions

Pervasive Developmental Disorders: An Overview  Nature of Pervasive Developmental Disorders – Problems occur in Language, Socialization, and Cognition – Pervasive – Problems span many life areas  Examples of Pervasive Developmental Disorders – Autistic disorder – Asperger’s syndrome

The Nature of Autistic Disorder: An Overview  Autism – Significant Impairments – Social interactions and communication – Restricted patterns of behavior, interest, and activities

The Nature of Autistic Disorder: An Overview (continued)  Three Central DSM-IV-TR Features of Autism – Qualitative impairment of social interaction – 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 – 1 in every 500 births – More prevalent in females with IQs below 35 – More prevalent in males with higher IQs – Occurs worldwide – Symptoms usually develop before 36 months of age

Autistic Disorder: Facts and Statistics (continued)  Autism and Intellectual Functioning – 50% have IQs in the severe-to-profound range – 25% test in the mild-to-moderate IQ range – Remaining test in the borderline-to- average IQ range  Reliable indicators of good prognosis – Language ability and IQ

Causes of Autism: Early and More Recent Contributions  Historical Views – Bad parenting – Unusual speech patterns – Lack of self-awareness – Echolalia

Causes of Autism: Early and More Recent Contributions (continued)  Current Understanding of Autism – Medical conditions – Not always related with autism – Genetic component is largely unclear – Neurobiological evidence of brain damage – Substantially reduced cerebellum size  Psychosocial Contributions Are Unclear

Asperger’s Disorder: Part of the Autistic Spectrum  The Nature of Asperger’s Disorder – Show significant social impairments – Restricted and repetitive stereotyped behaviors – May be clumsy – Often quite verbal – No severe language and/or cognitive delays

Asperger’s Disorder: Part of the Autistic Spectrum (continued)  Prevalence of Asperger’s Disorder – Often under diagnosed – Affects about 1 to 36 persons per 10,000 people  Causes of Asperger’s Disorder Are Somewhat Unclear

Treatment of Pervasive Developmental Disorders: Example of Autism  Psychosocial “Behavioral” Treatments – Skill building – Reduction of problem behaviors – Target communication and language problems – Address socialization deficits – Early intervention is critical

Treatment of Pervasive Developmental Disorders: Example of Autism (continued)  Biological and Medical Treatments Are Unavailable  Integrated Treatments: The Preferred Model – Focus on children, their families, schools, and home – Build in appropriate community and social support

Mental Retardation (MR): An Overview  Nature of Mental Retardation – Disorder of childhood – Below-average intellectual and adaptive functioning – Range of impairment varies greatly across persons

Mental Retardation (MR): An Overview (continued)  DSM-IV-TR criteria – Significantly sub-average intellectual functioning – Deficits or impairments in present adaptive functioning – Must be evident before the person is 18 years of age

DSM-IV-TR Levels of Mental Retardation (MR)  Mild MR – IQ score between 50 or 55 and 70  Moderate MR – IQ range of to  Severe MR – IQs ranging from up to  Profound MR – 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 – Levels of assistance  Intermittent, limited, extensive, pervasive

Other Classification Systems for Mental Retardation (MR) (continued)  Classification of MR in Educational Systems – Educable (IQ of 50 to 70-75) – Trainable (IQ of 30 to 50) – Severe (IQ below 30)  Implications of Different MR Classification Systems

Mental Retardation (MR): Some Facts and Statistics  Prevalence – About 1-3% of the general population – 90% are labeled with mild mental retardation

Mental Retardation (MR): Some Facts and Statistics (continued)  Gender Differences – MR occurs more often in males – Male-to-female ratio of about 1.6:1  Course of MR – Tends to be chronic – Prognosis varies greatly from person to person

Causes of Mental Retardation (MR): Biological Contributions  Hundreds of known causes – Environmental – Deprivation, abuse – Prenatal – Exposure to disease or a drug / toxin – Perinatal – Difficulties during labor – Postnatal – Head injury

Causes of Mental Retardation (MR): Biological Contributions (continued)  Genetic Research – Multiple genes, and at times single genes  Chromosomal Abnormalities – Down syndrome and Fragile X syndrome  Maternal Age and Risk of Having a Down’s Baby  Nearly 75% of Cases Have No Known Cause

Causes of Mental Retardation (MR): Psychosocial Contributions  Cultural-Familial Retardation – Believed to cause about 75% of MR cases – Is the least understood – Associated with  Mild levels of retardation on IQ tests  Good adaptive skills

Causes of Mental Retardation (MR): Psychosocial Contributions (continued)  Difference vs. Developmental Views – Difference view - Kind and degree of impairment – Developmental view – Rate of developmental delay

Treatment of Mental Retardation (MR)  Parallels Treatment of Pervasive Developmental Disorders  Teach Needed Skills – To foster productivity – To foster independence – Educational and behavioral management – Living and self-care skills via task analysis – Communication training – Often most challenging

Treatment of Mental Retardation (MR) (continued)  Community and Supportive Interventions – Persons with MR can benefit from such interventions

Summary of Developmental Disorders  Developmental Psychopathology  Attention Deficit Hyperactivity Disorder – Deficits in attention, hyperactivity, or impulsivity  Learning Disorders – Deficits in performance below expectations

Summary of Developmental Disorders (continued)  Pervasive Developmental Disorder – All share deficits in language, socialization, and cognition  Mental Retardation – Sub-average IQ, deficits in adaptive functioning – Onset before age 18  Prevention and Early Intervention Are Critical

Nature of Cognitive Disorders: An Overview  Perspectives on Cognitive Disorders – Affect learning, memory, and consciousness – Most develop later in life

Nature of Cognitive Disorders: An Overview (continued)  Three Classes of Cognitive Disorders – Delirium – Temporary confusion and disorientation – Dementia – Marked by broad cognitive deterioration – Amnestic disorders – Memory dysfunctions

Nature of Cognitive Disorders: An Overview (continued)  Shifting DSM Perspectives – From “organic” mental disorders to “cognitive” disorders – Broad impairments in cognitive functioning – Profound changes in behavior and personality

Delirium: An Overview  Nature of Delirium – Central features – Impaired consciousness and cognition – Develops rapidly over several hours or days – Appear confused, disoriented, and inattentive – Marked memory and language deficits

Delirium: An Overview (continued)  Facts and Statistics – Affects 10% to 30% of persons in acute care facilities – Most prevalent in older adults  Those undergoing medical procedures  AIDS patients and cancer patients – Full recovery often occurs within several weeks

Medical Conditions Related to Delirium  Medical Conditions – Drug intoxication, poisons, withdrawal from drugs – Infections – Head injury and several forms of brain trauma – Sleep deprivation, immobility, and excessive stress

Medical Conditions Related to Delirium (continued)  DSM-IV-TR 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  Treatment – Attention to precipitating medical problems – Psychosocial interventions include reassurance  Focus on coping strategies  Inclusion of patients in treatment decisions

Treatment and Prevention of Delirium (continued)  Prevention – Address proper medical care for illnesses – Address proper use and adherence to therapeutic drugs

Dementia: An Overview  Nature of Dementia – Gradual deterioration of brain functioning – Deterioration in judgment and memory – Deterioration in language / advanced cognitive processes – Has many causes and may be irreversible

Dementia: Initial and Later Stages  Initial Stages – Memory and visuospatial skills impairments – Agnosia – Inability to recognize and name objects – Facial agnosia – Inability to recognize familiar faces – Other symptoms  Delusions, apathy, depression, agitation, aggression

Dementia: Initial and Later Stages (continued)  Later Stages – Cognitive functioning continues to deteriorate – Total support is needed to carry out day-to- day activities – Death due to inactivity and 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 years of age – Affects over 10% of persons 85 years and older

Dementia: Facts and Statistics (continued)  Incidence of Dementia – Affects 2.3% of those years of age – Affects 8.5% of those 85 and older – Rates seem to double with every 5 years of age

Dementia: Facts and Statistics (continued)  Gender and Sociocultural Factors – Occurs equally in men and women – Occurs equally across educational level and social class

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: An Overview  DSM-IV-TR Criteria and Clinical Features – Multiple cognitive deficits – Develop gradually and steadily – Memory, orientation, judgment, and reasoning deficits – Additional symptoms may include  Agitation, confusion, or combativeness  Depression and/or anxiety – “Sundowner syndrome”

Dementia of the Alzheimer’s Type: Extent of Deficits  Range of Cognitive Deficits – Aphasia – Difficulty with language – Apraxia – Impaired motor functioning – Agnosia – Failure to recognize objects

Dementia of the Alzheimer’s Type: Extent of Deficits (continued) – Difficulties with  Planning  Organizing  Sequencing  Abstracting information – 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 – Deterioration is rapid during middle stages – Average survival time is about 8 years – Onset usually occurs in the 60s or 70s

Alzheimer’s Disease: Some Facts and Statistics (continued)  Prevalence of Alzheimer’s Disease – About 4 million Americans and many more worldwide – Prevalence greater in  Poorly educated persons and females – Prevalence rates are low in some ethnic groups

Vascular Dementia: An Overview  Nature of Vascular Dementia – 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 – Most require formal care in later stages

Vascular Dementia: An Overview (continued)  DSM-IV-TR Criteria and Incidence – Cognitive disturbances – Identical to dementia – Obvious neurological signs of brain tissue damage – Incidence is about 4.7% of men and 3.8% of women

Other Causes of Dementia: HIV  HIV – Causes neurological impairments and dementia – Cognitive slowness, impaired attention, and forgetfulness – Apathy and social withdrawal

Other Causes of Dementia: Head Trauma  Head Trauma – Accidents are leading cause – Memory loss is the most common symptom

Other Causes of Dementia: Parkinson’s Disease  Parkinson’s Disease – Degenerative brain disorder – Affects about 1 out of 1,000 people worldwide – Motor problems – Central feature of this disorder  Caused by damage to dopamine pathways – Impairments appear similar to sub-cortical dementia

Other Causes of Dementia: Huntington’s  Huntington’s Disease – Genetic autosomal dominant disorder – Manifests initially as chorea, usually later in life – About 20-80% display dementia – Dementia also follows a subcortical pattern

Other Causes of Dementia: Pick’s Disease  Pick’s Disease – Rare neurological condition – 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  Creutzfeldt-Jakob Disease – Affects 1 out of 1,000,000 persons – Linked to mad cow disease

Other Dementias: Substance-Induced Dementia  Substance-Induced Persisting Dementia – Results from drug use in combination with poor diet – Several drugs can lead to symptoms of dementia – Resulting brain damage may be permanent

Other Dementias: Substance-Induced Dementia (continued) – Dementia is similar to that of Alzheimer’s – Deficits may include  Aphasia, apraxia, agnosia  Disturbed executive functioning

Causes of Dementia: The Example of Alzheimer’s Disease  Early and Largely Unsupported Views – Implicated aluminum and smoking

Causes of Dementia: The Example of Alzheimer’s Disease (continued)  Current Neurobiological Findings – Neurofibrillary tangles – Amyloid plaques – The role of deterministic genes  Beta-amyloid precursor gene  Presenilin-1 and Presenilin-2 genes – The role of susceptibility genes - ApoE4 gene – Brains of Alzheimer’s patients tend to atrophy

Causes of Dementia: The Example of Alzheimer’s Disease (continued)  Current Neurobiological Findings – 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  Psychosocial Factors – Do not cause dementia directly – May influence onset and course – Lifestyle factors – Drug use, diet, exercise, stress

The Contributions of Psychosocial Factors in Dementia (continued) – Cultural factors  Risk for certain conditions 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 exist for most types of dementias – Most attempt to slow progression of deterioration – Do not stop progression of dementia

Medical and Psychosocial Treatment of Dementia (continued)  Psychosocial Treatments - Aims – To enhance lives of patients and their families – To teach compensatory skills – To use memory enhancement devices, if needed – Psychosocial interventions appear to focus on caregivers

Prevention of Dementia  Reducing Risk of Dementia in Older Adults – Estrogen-replacement therapy – 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: An Overview  Nature of Amnestic Disorder – Circumscribed loss of memory – Inability to transfer information into long- term memory – No loss of other high-level cognitive functions

Amnestic Disorder: An Overview (continued)  Causes May Include – Medical conditions, head trauma, or long- term drug use  DSM-IV-TR Criteria – Inability to  Learn new information or recall learned information – Significant impairment in functioning

Amnestic Disorder: An Overview (continued)  The Example of Wernicke-Korsakoff Syndrome – Damage to the thalamus – Thiamine (Vitamin B-1) deficiency – Resulting from stroke or chronic heavy alcohol use  Prevention – Use of thiamine supplements with heavy drinkers  Research on Amnestic Disorders Is Scant

Summary of Cognitive Disorders  Cognitive Disorders Span a Range of Deficits – Affect attention, memory, language, and motor behavior – Causes include  Medical conditions  Drug use  Environmental factors

Summary of Cognitive Disorders (continued)  Most Result in Progressive Deterioration of Functioning  Few Treatments Exist to Reverse Damage and Deficits