1. Disorders of Childhood and Adolescence
Chapter Fifteen
Disorders of Childhood and Adolescence

2. Disorders of Childhood and Adolescence (cont’d.)
In a national sample of 6,483 adolescents (ages 13–18), almost two thirds of those with mental illness received no treatment

3. Disorders of Childhood and Adolescence (cont’d.)
Diagnosis requires that symptoms cause significant impairment in daily functioning over extended period of time
To determine if a child has an actual disorder, clinicians consider the child's age and developmental level as well as environmental factors
Include:
Internalizing disorders
Externalizing disorders
Neurodevelopmental disorders
Conditions involving impaired neurological development
One in fivechildren has serious emotional or behavioral problem
Two-thirds of those with mental illness received no treatment

4. Internalizing Disorders of Childhood
Conditions involving emotional symptoms directed inward
Heightened reactions to trauma, stressors or negative events and difficulty regulating emotions
Prevalent in early life and often lead to substance use and suicide
Of particular concern are the low treatment rates for youth experiencing major depression; this lack of intervention is particularly pronounced for African American, Latino/Hispanic American, and Asian American adolescents

5. Anxiety, Trauma, and Stressor-Related Disorders in Early Life
Most common mental health disorder in childhood and adolescence (32%)
Can significantly affect academic, social, and interpersonal functioning and can lead to adult anxiety disorders
Include:
Social phobia
Separation anxiety disorder
Selective mutism
Among the 32 percent of adolescents who have experienced an anxiety disorder, specific phobias (19 percent) and social phobia (9 percent) are most common. Specific phobias often begin in early to middle childhood, whereas social phobias typically begin in early to middle adolescence

6. Anxiety, Trauma, and Stressor-Related Disorders in Early Life (cont’d
Post-traumatic stress disorder in early life:
Recurrent, distressing memories of a shocking experience, such as experience with death, serious injury, or sexual violation
Memories may entail:
Distressing dreams
Intense physiological or psychological reactions to thoughts or cues associated with event and avoidance of those cues
Episodes of playacting the event
Dissociative reactions

7. Anxiety, Trauma, and Stressor-Related Disorders in Early Life (cont’d
Post-traumatic stress disorder in early life:
Children often display social withdrawal, diminished positive affect, and disinterest in previously-enjoyed activities
Lifetime prevalence:
8% for girls and 2.3% for boys
Effective treatments include:
Trauma-focused cognitive-behavioral therapies

8. Depressive Disorders in Early Life
Youth with depressive disorders have more negative self-concepts and are more likely to engage in self-blame and self-criticism
Early-onset depressive symptoms tends to predict a more chronic and severe course
Evidence-based treatment for depression:
Individual, group, or school-based cognitive-behavioral therapy
SSRIs increase suicidality but benefits may outweigh risk
Children are especially vulnerable to environmental factors because they lack the maturity and skills to deal with stressors.
Subsequent data analysis has indicated that although SSRIs may have only a moderate effect on milder depressive symptoms, they appear superior to some cognitive-behavioral therapies, especially in the first months of treatment, and that the benefits of using SSRIs (particularly fluoxetine) may outweigh the risk of increased suicidality, especially among youth who are severely depressed ( Bridge et al., 2007; Vitiello, 2009).
DSM V does not include a chapter on Disorders of Childhood and Adoescence - and does not include Pediatric Bipolar Disorder. DSM V includes a Chapter on Disruptive, Impulse-Control and Conduct Disorders and the Chapter "Disorders first Diagnsoed in Infancy, Childhood, or Adolescence" no longer exists. ADHD has been placed in tne "Neurodevelopmental" chapter in DSM V.

9. Nonsuicidal Self Injury
Involves induction of bleeding, bruising, or pain by means of intentional, self-inflicted injury, without suicidal intent
Intense negative affect or cognitions and a preoccupation with engaging in self-harm typically precede episodes of NSSI
Expectation that mood will improve after episode

10. Nonsuicidal Self Injury (cont’d.)
Prevalence:
14-17% of adolescents and young adults have engaged in self-injury at least once
Two thirds of those who engage in NSSI begin the behavior in adolescence.
Increased risk of attempted suicide
Treatment includes:
Teaching problem-solving, coping and emotional-regulation skills
Focus on emotional expression and improving interpersonal relationship skills
NSSI occurs with similar frequency in both genders, although males are more likely to hit or burn themselves, while females more frequently cut themselves. Only a minority engage in repeated self-injury. Those who engage in repeated NSSI tend to be highly self-critical and have difficulty expressing their emotions.

11. Attachment Disorders
Exposure to early environments devoid of predictable caretaking and nurturing can cause significant difficulties with emotional attachment and social relationships
Includes:
Reactive attachment disorder (RAD)
Disinhibited social engagement disorder (DSED)

12. Attachment Disorders (cont’d.)
Reactive attachment disorder:
Inhibited, avoidant social behaviors and reluctance to seek or respond to attention or nurturing
Show little trust that needs will be attended to and do not readily seek nor respond to comfort, attention, or nurturing
Use avoidance or ambivalence as psychological defense
Limited positive emotion and may demonstrate irritability, sadness, or fearfulness when interacting with adults
These attachment disorders are diagnosed only when symptoms are apparent before age 5 and when early circumstances prevent the child from forming stable attachments.
Children w RAD often behave in a very inhibited, watchful, or avoidant manner, even with family and caregivers.

13. Attachment Disorders (cont’d.)
Disinhibited social engagement disorder:
Indiscriminate, superficial attachments and desperation for interpersonal contact
Socialize effortlessly, but indiscriminately, and become superficially “attached” to strangers or acquaintances
History of harsh punishment or inconsistent parenting, as well as emotional neglect and limited attachment opportunities
Exposure to maltreatment or maternal psychiatric hospitalizations are particularly vulnerable
Reactive Attachment Disorder and Disinhibited Social Engagement Disorder are included as distinct diagnoses in DSM V, and are included in the Chapter on Trauma and Stressor-Related Disorders.

14. Attachment Disorders (cont’d.)
Course depends on severity of social deprivation, abuse, neglect or disruptions in caregiving, and subsequent events in the child’s life
Symptoms of RAD can disappear whereas symptoms of DSED are more persistent
Effective intervention:
Providing stable, nurturing environment, and opportunities to develop interpersonal trust and social skills
Symptoms of RAD often disappear if children are provided an opportunity for predictable caretaking and nurturance, whereas symptoms of DSED are more persistent.

15. Externalizing Disorders of Childhood
Also known as disruptive behavior disorders: conditions associated with socially disturbing symptoms and distressing others
Include:
Disruptive mood dysregulation disorder
Oppositional defiant disorder
Conduct disorder
Early intervention is necessary

16. Externalizing Disorders of Childhood (cont’d.)
Diagnosis is controversial, and requires a pattern of behavior that is:
Atypical for the child’s gender, age, and developmental level
Persistent
Severe enough to cause significant impairment in social, academic, or vocational functioning

17. Disruptive Mood Dysregulation Disorder
Characterized by chronic irritability and significantly exaggerated anger reactions
Patterns begin in early childhood
Diagnosis requires that symptoms persist beyond age six
Predictive of later depressive and anxiety disorders
Clinicians need to rule out PBD due to symptom overlap

18. Oppositional Defiant Disorder
Pattern of negativistic, argumentative, and hostile behavior in which children often:
Lose their temper
Argue and defy adult requests
Primarily directed toward parents, teachers, and others in authority
No serious violation of societal norms
Two components:
Negative affect
Oppositional behavior
Do not demonstrate pervasive antisocial behavior and serious violations of societal norms
Symptoms of ODD often resolve.
Approximately half of those with ODD also display inattention and hyperactivity ( McBurnett & Pfiffner, 2009).

19. Conduct Disorders
Persistent pattern of behavior that violates rights of others
Reflect dysfunctions in individual and include:
Serious violations of rules and social norms
Cruelty and deliberate aggression towards people or animals
Theft, deceit, and vandalism
Callous and unemotional subtype
Often exhibit antisocial personality disorder in adulthood
A callous and unemotional subtype refers to those with CD who display minimal guilt or remorse and are consistently unconcerned about the feelings of others, their own wrongdoing, or poor performance at school or work. With this subtype, emotional expression is very superficial and is used primarily to manipulate others (DSM-5 Work Groups, 2012). MRI documented this callousness in one sample of adolescents with CD—they demonstrated strong pleasure responses to video clips of people experiencing pain and distress ( Decety, Michalska, Akitsuki, & Lahey, 2009) .

20. Conduct Disorders (cont’d.)
Prevalence:
Approximately 2-9% of youth meet criteria
50% display inattention and hyperactivity
Gender differences:
Males display confrontational aggression
Females display truancy, substance abuse, or chronic lying
More persistent than other childhood disorders
Approximately 50 percent of those with CD also display inattention and hyperactivity.
Childhood-onset CD is associated with chronic, serious offenses, criminal behavior, and substance abuse in adulthood.

21. Etiology of Externalizing Disorders
Figure 15-1 Multipath Model of Conduct Disorder The dimensions interact with one another and combine in different ways to result in a conduct disorder

22. Etiology of Externalizing Disorders (cont’d.)
Biological factors:
Appear to exert greatest influence on CD.
Aggressive behavior linked to brain abnormalities and reduced activity in amygdala
“Low MAOA” and childhood maltreatment
Reduced autonomic nervous system activity
Cortisol (stress levels)
Risk of CD is particularly increased when carriers of the genotype “low MAOA” (an allele associated with fear-regulating circuitry in the amygdala) are subjected to childhood maltreatment ( First, 2007). Reduced activity of the autonomic nervous system (associated with increased need for stimulation to achieve optimal arousal) is also associated with CD in males; this may account for the increased risk taking associated with the disorder.
Elevated stress hormones (cortisol) are associated with symptoms of impulsive aggression, whereas low cortisol levels have been linked with callous and unemotional traits and predatory aggression

23. Etiology of Externalizing Disorders (cont’d.)
Social and sociocultural:
Family and social context play large role
Large families and marital breakdown
Economic stress
Crowded living conditions
Harsh or inconsistent discipline
Maternal or peer rejection
Parent-child conflict and power struggles
Limited parental supervision

24. Etiology of Externalizing Disorders (cont’d.)
Psychological factors:
Difficult child temperament (irritable, resistant, impulsive tendencies)
Underlying emotional issues
Depression frequently coexists with ODD and DMDD

25. Treatment of Externalizing Disorders
Must consider family and social context of behaviors and psychosocial skills deficits
CD is particularly difficult to treat
Effective when implemented before patterns of disruptive behavior are established
Parent-focused interventions regarding child management techniques
A well-established intervention for externalizing disorders is parent education.
Multiple factors, including poverty, parental immaturity, and lack of parenting skills, contribute to child maltreatment. The more maltreatment or trauma a child encounters, the greater the risk of subsequent psychiatric illness. There is a particular need for programs to prevent the maltreatment of infants and young children.

26. Treatment of Externalizing Disorders (cont’d.)
Psychosocial interventions that focus on:
Assertiveness-training
Anger management techniques
Building skills in empathy, communication, social relationships and problem-solving
Mobilizing adult mentors

27. Neurodevelopmental Disorders
Involve impaired development of the brain and central nervous system
Symptoms become increasingly evident as child grows and develops
Include:
Tic disorders
Attention-deficit hyperactivity disorder
Autism spectrum disorders
Intellectual and learning disorders

28. Tics and Tourette’s Disorder
Involuntary, repetitive movements or vocalizations
Motor tic:
Eye-blinking, facial-grimacing, head-jerking, foot tapping, flaring of nostrils, and contractions of the shoulders or abdominal muscles
Vocal tics:
Coughing, grunting, throat clearing, sniffling, or sudden repetitive and stereotyped outburst of words
Note that American Idol James Derbin suffers from Tourette’s Disorder but did not experience symptoms when singing.

29. Tics and Tourette’s Disorder (cont’d.)
Short-term suppression of a tic is possible, but results in subsequent increases in the tic
Some report feeling tension build prior to tic, followed by a sense of relief after tic occurs
Stress can increase frequency and intensity
Provisional tic disorders (2.6% of children)
Chronic motor or vocal tic disorders (3.7% of children)
Most tics in children are transient and disappear without treatment. Stress can increase the frequency and intensity of tics.
When a tic has been present for less than a year, a diagnosis of provisional tic disorder is given; chronic motor or vocal tic disorder refers to tics lasting more than a year.

30. Tics and Tourette’s Disorder (cont’d.)
Tourette’s disorder (TD):
Characterized by multiple motor tics and one or more vocal tic, present for at least one year
Onset is prior to age 18
About 8% show complete remission
Symptoms can be severe or mild
Coprolalia (involuntary uttering of obscenities or inappropriate remarks) or motor movements involving self-harm (e.g., punching oneself) occur in about 10 percent of those with TD
Comorbid conditions
Usually the first symptoms are noticed between the ages of 7 and 10, with symptoms increasing in the middle teen years and improving in early adulthood; about 8 percent of those with TD eventually show a complete remission of symptoms.
Comorbid conditions include poor anger control, attention-deficit/hyperactivity disorder, obsessive-compulsive disorder, impulsive behavior, and poor social skills.

31. Tics and Tourette’s Disorder (cont’d.)
Etiology:
Both chronic tic disorder and TD appear to be genetically transmitted
Treatment:
Psychotherapy can help with distress
the technique of habit reversal , which involves teaching a behavior that is incompatible with the tic, is an effective treatment
Although antipsychotic medication used for severe tics, medication is not typically used to treat tic disorders.

32. Attention-Deficit/Hyperactivity Disorder
Characterized by persistent inattention and/or impulsive, hyperactive behaviors
Symptoms must interfere with social, academic, or occupational activities
Diagnosis requires that symptoms begin before age 12 and persist for at least six months
Poor regulation of attentional processes

33. Attention-Deficit/Hyperactivity Disorder (cont’d.)
Prevalence rates vary between studies
One study: 8.7%
More than twice as likely in boys than in girls
Symptoms tend to improve in late adolescence
Associated with behavioral and academic problems
Risk of coexisting conditions is four times greater among children living in poverty
ADHD is the most frequently diagnosed disorder in school-age children.
Children who are the youngest in their class are more likely to receive an ADHD diagnosis and to take medication for ADHD.

34. Attention-Deficit/Hyperactivity Disorder: Etiology
Biological dimension:
Highly heritable with up to 80% of symptoms explainable by genetic factors
Rare inherited gene mutations
Chromosomal DNA deletions and duplications
Genes affecting regulation of dopamine and glutamate
Hypotheses about neurological mechanisms
Reduced activity in prefrontal cortex
Differences in brain structure and circuitry in frontal cortex, cerebellum, and parietal lobes
Low dopamine levels
Two thirds of those with ADHD had other mental health conditions (including CD, ODD, anxiety, and depression) or learning disabilities and other neurodevelopmental disorders; the risk of coexisting conditions is almost 4 times greater among children living in poverty
Youth with ADHD also have a high risk of smoking and use of alcohol and illicit drugs.
neuroimaging has confirmed differences in brain structure and circuitry in the frontal cortex, cerebellum, and parietal lobes.
Smaller frontal lobes in children with ADHD, especially those with more severe symptoms
Some children with ADHD show slower development of the cerebrum, particularly prefrontal regions associated with attention and motor planning.
Inadequate dopamine and associated neurotransmitters that affect signal flow to and from the frontal lobes.

35. Attention-Deficit/Hyperactivity Disorder: Etiology (cont’d.)
Biological dimension:
Prematurity
Oxygen deprivation during birth
Low-birth weight
Lead and PCB exposure
Viral infections, meningitis, and encephalitis
Maternal smoking, drug, and alcohol abuse during pregnancy
Possible involvement of food additives
Kids with ADHD often encounter negative reactions from others that further exacerbate symptoms.

36. Attention-Deficit/Hyperactivity Disorder: Treatment
Stimulants such as methylphenidate (Ritalin) receive most evidence-based support
Normalize neurotransmitter functioning and increased neurological activation in frontal cortex
Increased rates of stimulant medication use in U.S.

37. Attention-Deficit/Hyperactivity Disorder: Treatment (cont’d.)
Evidence that behavioral and psychological treatments are highly effective
Modifying environment and social context can enhance feelings of competence, motivation, and self-efficacy
Coordination of all services result in most successful interventions

38. Autism Spectrum Disorders
Characterized by impairment in social communication and restricted, stereotyped interests and activities
Symptoms range from mild to severe
Prevalence:
Affects one out of children
Four times as common in boys
Approximately two thirds have IQ scores lower than 70

39. Autism Spectrum Disorders (cont’d.)
Symptoms of autism spectrum disorder:
Deficits in social communication and social interaction
Atypical social-emotional reciprocity
Atypical nonverbal communication
Difficulties developing and maintaining relationships

40. Autism Spectrum Disorders (cont’d.)
Symptoms of autism spectrum disorder:
Repetitive behavior or restricted interests or activities involving at least two of following:
Repetitive speech, movement, or use of objects
Intense focus on rituals or routines and strong resistance to change
Intense fixations or restricted interests
Atypical sensory reactivity
Autistic savants
Individual with ASD who performs exceptionally well on certain tasks
many infants with ASD symptoms fail to attend to human motion, such as a parent's movement or demonstrate interest in human faces,

41. Autism Spectrum Disorders (cont’d.)
Problems diagnosing autism:
Typical procedures include clinical observation, parent interviews, developmental histories, autism screening inventories, communication assessment, and psychological testing
Autism is usually diagnosed at age three or later
symptoms sometimes appear following a period of apparently normal social and intellectual development, with deterioration of skills beginning around 6–12 months of age
Children with this pattern of regression (referred to as regressive autism) often develop more severe symptoms compared to autistic children without this pattern

42. Autism Spectrum Disorders: Etiology
Biological dimension:
Unique patterns of metabolic brain activity
Abnormally high levels or serotonin
Differences in brain anatomy and connectivity in brain regions associated with autistic traits
Accelerated growth or amygdala
Accelerated head growth
Genetic mutations have been implicated when ASD is diagnosed in multiple family members
Closely space pregnancies
Accelerated head growth may, in fact, be an endophenotype (biological marker) for ASD
Male infants later diagnosed with ASD exhibited a pattern of rapid head growth 6–9 months after birth.
MRI with toddlers diagnosed with ASD has confirmed extra growth in multiple regions of the brain. Children born less than 1 year after the birth of a sibling were almost 300 percent more likely to develop ASD compared to children born at least 4 years after a sibling.

43. Autism Spectrum Disorders: Etiology (cont’d.)
Biological dimension:
Genetic factors
Heritability estimated to be around .73 percent for males and .87 for females
Autistic traits have high heritability
Clear evidence for genetic susceptibility
Innate vulnerability triggered by environment
Nutritional deficits, changes in immune system, low birth weight
The study relating ASD to vaccine was deemed fraudulent when it was found that the lead author had manipulated the data for monetary gain.
Children who develop ASD appear to have an innate vulnerability that is triggered by environmental factors.
children with ASD appear to metabolize toxins such as lead and mercury differently.

44. Autism Spectrum Disorders: Etiology (cont’d.)
Psychological dimension:
Children with ASD seldom make eye contact, seek social connectedness, or bid for attention
Prefer to be alone and ignore parental efforts at connection
High stress levels among family due to ASD
Psychological and social factors play a role in manifestation of symptoms, but ASD is primarily influenced by biological factors
In response, others’ attempts to maintain social connection often diminish, further adding to the child's isolation.

45. Autism Spectrum Disorders: Intervention and Treatment
Prognosis is mixed; most children retain diagnosis and require support for life
Individuals with higher levels of cognitive-adaptive functioning fare better than those with intellectual disabilities and severe autistic symptoms
Significant recovery linked with intense early intervention
Autistic symptoms sometimes improve and then abruptly return when a child with ASD has a fever.

46. Autism Spectrum Disorders: Intervention and Treatment (cont’d.)
Medications are used to decrease anxiety, repetitive behaviors, and hyperactivity
Minimally effective and may be harmful
Risperidone alone received FDA approval:
Preliminary research suggests that oxytocin (a hormone related to social bonding) can increase social interactions in adults and teens with mild ASD
Comprehensive treatment programs have enabled children with ASD to develop more functional skills

47. Autism Spectrum Disorders: Intervention and Treatment (cont’d.)
Interventions with most significant gains:
Social communication
Environmental enrichment
Reinforcing appropriate attention and response to social stimuli
Preventing repetitive behaviors
Sustained practice of weaker skills
Reducing environmental stress
Improving sleep and nutrition

48. Intellectual Developmental Disorder
Limitations in intellectual functioning and adaptive behaviors including:
Significantly below average general intellectual functioning (generally IQ of 70 or less)
Deficiencies in adaptive behavior that are lower than would be expected based on age or cultural background
Only diagnosed when low intelligence is accompanied by impaired adaptive functioning

49. Intellectual Developmental Disorder (cont’d.)
Four distinct categories:
Mild: IQ score to 70
Moderate: IQ score to 50-55
Severe: IQ score to 35-40
Profound: IQ score below 20-25

50. Intellectual Developmental Disorder (cont’d.)

51. Intellectual Developmental Disorder (cont’d.)
American Association on Intellectual and Developmental Disabilities:
IQ score may be used to approximate intellectual functioning
More important to focus on adaptive functioning and nature of psychosocial supports needed
Given ongoing, individualized support, overall functioning of individual with ID will improve
Approximately 1 percent of students in public schools in the United States are identified as having an IDD.

52. Intellectual Developmental Disorder (cont’d.)
Prevalence:
Approximately 1% of students in public school
Increases in low and middle income countries
Coexisting conditions are common
One-fourth have seizure disorders

53. Intellectual Developmental Disorder: Etiology
Etiology differs depending on level of intellectual impairment
Mild IDD is often idiopathic (no known cause)
Pronounced IDD related to genetic factors, brain abnormalities, or brain injury

54. Intellectual Developmental Disorder: Etiology (cont’d.)
Genetic factors:
In up to 80 percent of cases of IDD, underlying cause is unknown
Unidentified genetic factors
Genetic variations
Normal distribution of traits (upper vs. lower range)
Genetic abnormalities
Chromosomal abnormalities
Down syndrome most common
Inheritance of single gene
Fragile X syndrome most common (mild to severe ID)
IDD caused by normal genetic variation reflects the fact that in a normal distribution of any trait (such as intelligence), some individuals fall in the lower range.

55. Intellectual Developmental Disorder: Etiology (cont’d.)
Down syndrome (DS):
Extra copy of chromosome 21 originates during gamete development
Majority have mild to moderate IDD
With support many can have jobs and live semi-independently
Medical interventions improve outcome, but significant risks remain
Prenatal detection of DS through amniocentesis
In the vast majority of cases, an extra copy of chromosome 21 originates during gamete development (involving either the egg or the sperm); this extra chromosome produces the physical and neurological characteristics associated with DS.
Although medical intervention has improved health outcomes and increased life expectancy ( Weijerman & de Winter, 2010), those with DS continue to have a significantly increased risk of early dementia, including early-onset Alzheimer's disease.

56. Intellectual Developmental Disorder: Etiology (cont’d.)
Nongenetic biological factors:
Influences during prenatal, perinatal, or postnatal period
Fetus is susceptible to viruses and infections, drugs and alcohol, radiation, and poor nutrition
Fetal alcohol spectrum effects and fetal alcohol syndrome
Birth trauma, prematurity, and low birth weight
Head injuries, brain infections, tumors, and prolonged malnutrition
Exposure to environmental toxins, including lead
Iodine deficiency either during pregnancy or during early infancy can impair intellectual development
11/17/2013
The most common perinatal birth conditions associated with IDD are prematurity and low birth weight.

57. Intellectual Developmental Disorder: Etiology (cont’d.)
Psychological, social, sociocultural dimensions:
Genetic background interacts with environmental factors
Effects of low SES
Parents with mild IDD
Long-term effects of prematurity
Enriching and encouraging home environment, as well as ongoing education intervention

58. Learning Disorders
Academic disability characterized by reading, writing, and math skills deficits
Primarily interferes with academic achievement and activities of daily living in which reading, writing, or math skills are needed (e.g., dyscalculia, dyslexia)
Prevalence:
Around 5% of students in public schools
Boys are almost twice as likely as girls

59. Learning Disorders (cont’d.)
Etiology:
Little is known about precise causes of LD
Children with LD that eventually resolves appear to have slower brain maturation.
prematurity
maternal alcohol use during pregnancy
Lifelong differences in neurological processing of information related to basic academic skills
May be similar to biological explanations for IDD and ADHD
Runs in families, suggesting genetic component

60. Support for Individuals (cont’d.)
Support in childhood:
Individualized home-based or school-based programs
Parent involvement is integral part of early intervention programs
School services are individualized to meet child’s needs and to maximize learning opportunities
Rates of improvement decrease once programs are completed

61. Support for Individuals (cont’d.)
Support in adulthood:
Programs focusing on specific job skills
Institutionalization is rare, but many live with family members
“Least restrictive environment” possible
As much independence and personal choice as is safe and practical
Most normalized living arrangements vary from setting to setting