Chapter 13 Developmental Disorders & Cognitive 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 DSM-IV TR has 43 different categories/types Mental Health vs. Educational categories – IDEA 2004

IDEA 97 Categories - PL 105-17 IDEA 2004 – (Same) Individual Disabilities Education Act Blind or Visually Impaired Hearing impaired (includes deaf) Orthopedic Other Health Impaired Mentally Retarded Specific Learning Disability Autism Emotional Disturbance Speech & Language Impaired Traumatic Brain Injury Developmental Delay (DD) < age 9 Needs special education services

Kentucky Regulations - IDEA Mental Disability (mild/functional) Hearing impairments Communication Disorders Visual Impairment Emotional Behavioral Disability Autism Deaf-Blind Orthopedic/physically disabled Traumatic Brain Injury Other Health Impaired Specific Learning Disability Multiple Disabilities Developmental Delay (DD) <age 9

Nature of Developmental Psychopathology: An Overview (continued) Developmental Disorders Diagnosed first in infancy, childhood, or adolescence (43 diagnoses) 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

Figure 13.1 More than half of all schoolchildren classified as disabled have learning disabilities; almost 30 years ago, the proportion was around 25%. 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/Intellectual Disability (new term) 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/ID IQ score between 50 or 55 and 70 Moderate MR/ID IQ range of 35-40 to 50-55 Severe MR/ID IQs ranging from 20-25 up to 35-40 Profound MR/ID 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/ID in Educational Systems Educable (IQ of 50 to 70-75) Trainable (IQ of 30 to 50) Severe (IQ below 30) Implications of Different MR/ID Classification Systems

Mental Retardation (MR)/Intellectual Disabilities (ID): 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

p. 558-559

p. 558-559

p. 558-559

p. 558-559

p. 558-559

p. 558-559

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence  New additions Posttraumatic Stress Disorder in Preschool Children   Temper Dysregulation Disorder with Dysphoria   Callous and Unemotional Specifier for Conduct Disorder   Learning Disabilities   Non-Suicidal Self Injury   Non-Suicidal Self Injury Not Otherwise Specified   Language Impairment Late Language Emergence   Specific Language Impairment   Social Communication Disorder   Voice Disorder

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence  Reclassification Pica: Move to Eating Disorders Rumination Disorder: Move to Eating Disorders Feeding Disorder of Infancy or Early Childhood: Move to Eating Disorders; Renamed Avoidant/Restrictive Food Intake Disorder Separation Anxiety Disorder: Moved to Anxiety Disorders

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence  Disorders to be removed Expressive Language Disorder Mixed Receptive-Expressive Language Disorder Communication Disorder Not Otherwise Specified Rett's Disorder Reactive Attachment Disorder of Infancy or Early Childhood: Division into Reactive Attachment Disorder of Infancy or Early Childhood & Disinhibited Social Engagement Disorder Disorder of Written Expression and Learning Disorder Not Otherwise Specified: Subsumed under Learning Disorder Childhood Disintegrative Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder: Subsumed under Autistic Disorder (Autism Spectrum Disorder)

ADHD A. Either (1) and/or (2) 1. Inattention 2.  Hyperactivity and Impulsivity B.   Several noticeable inattentive or hyperactive-impulsive symptoms were present by age 12. C.   The symptoms are apparent in two or more settings (e.g., at home, school or work, with friends or relatives, or in other activities). D.   There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning. E.   The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). Specifiers: Combined, Predominately Inattentive, Predominately Hyperactive/Impulsive, Inattentive (Restrictive)

Communication & Learning Disorders Phonological Disorder: Renamed to Speech Sound Disorder Stuttering: Renamed to Childhood Onset Fluency Disorder Reading Disorder: Renamed to Dyslexia Mathematics Disorder: Renamed to Dyscalculia

Mental Retardation Mental Retardation: Renamed Intellectual Disability Mental Retardation, Severity Unspecified: Renamed to Intellectual or Global Developmental Delay Not Further Specified

Autistic (Autism Spectrum) Disorder Autistic Disorder: Renamed Autism Spectrum Disorder Must meet criteria A, B, C, and D A. Persistent deficits in social communication and social interaction across contexts B. Restricted, repetitive patterns of behavior, interests, or activities C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) D. Symptoms together limit and impair everyday functioning

Tic Disorders Tic Disorders Tourette’s Disorder Chronic Motor or Vocal Tic Disorder Transient Tic Disorder Tic Disorder NOS All proposed to be classified as Neurodevelopmental Disorders

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

p. 558-559

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 (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 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) 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) 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 65-74 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 75-79 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

10 Warning Signs of Alzheimer’s Disease 1. Memory loss that disrupts daily life 2. challenging in planning or solving problems 3. Difficulty completing familiar tasks 4. Confusion as to time and place 5. Trouble understanding visual images and spatial relationships 6. New problems with words in speaking and writing 7. Misplacing things and losing the ability to retrace steps 8. Decreased or poor judgment 9. Withdrawal from work or social activities 10. Change in mood or personality See – www.alz.org

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 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 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 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 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

Source: Adapted from Hebert, Scherr, Bienias, Bennett, & Evans, 2003. Table 13.1, p. 540

*The examination also includes an assessment of the patient’s level of consciousness: Alert Drowsy Stupor Coma. †Total maximum score is 30. Source: Adapted from the Mini Mental State examination form, Folstein, Folstein, & McHugh. Table 13.2, p. 543

p. 560-561

p. 560-561

p. 560-561

p. 560-561

p. 560-561

p. 561

p. 561

p. 561