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

2. Disorders of Childhood and Adolescence
Child psychology:
Emotional and behavioral manifestation of psychological disorders in children and adolescents
Prevalence of childhood disorders:
One in five has serious emotional or behavioral problem
Two-thirds of those with mental illness received no treatment

3. Disorders of Childhood and Adolescence (cont’d.)

4. Disorders of Childhood and Adolescence (cont’d.)
Diagnosis requires that symptoms cause significant impairment in daily functioning over extended period of time
Include:
Internalizing disorders
Externalizing disorders
Neurodevelopmental disorders
Conditions involving impaired neurological development

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Nonsuicidal Self Injury (cont’d.)
Prevalence:
14-17% of adolescents and young adults have engaged in self-injury at least once
Increased risk of attempted suicide
Treatment includes:
Teaching problem-solving, coping and emotional-regulation skills
Focus on emotional expression and improving interpersonal relationship skills

12. Pediatric Bipolar Disorder
Debilitating disorder that parallels mood variability, depressive episodes, and significant departure from individual’s typical functioning seen in adult bipolar disorder
Episodes of recurring depression, rapid mood changes, and distinct periods of abnormally-elevated mood involving diminished need for sleep, increased activity, distractibility, talkativeness, and inflated self-esteem
Lifetime prevalence: estimated 3%

13. Pediatric Bipolar Disorder (cont’d.)
Rapid cycling of moods combined with neurocognitively based difficulties processing emotional stimuli and regulating behavior and social-emotional functioning
Elevated responsiveness to emotional stimuli, reduced volume in amygdala, and other brain abnormalities
Medications are often combined with psychosocial treatment

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Etiology of Externalizing Disorders (cont’d.)
Biological factors:
Appear to exert greatest influence
Aggressive behavior linked to brain abnormalities and reduced activity in amygdala
“Low MAOA” and childhood maltreatment
Reduced autonomic nervous system activity
Cortisol (stress levels)

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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)

33. 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 and motor movements involving self-harm
Comorbid conditions

34. Tics and Tourette’s Disorder (cont’d.)
Etiology:
Both chronic tic disorder and TD appear to be genetically transmitted
Involvement of basil ganglia and orbital frontal cortex
Possible involvement of neurotransmitters
Treatment:
Psychotherapy can help with distress
Habit reversal technique
Antipsychotic medication used for severe tics

35. Tics and Tourette’s Disorder (cont’d.)
Tourette's Syndrome: Introduction Meet Isabella, Devon, Nikki, Amanda as they attend “Camp Tic-a-Palooza,” a camp designed for children with Tourette's Syndrome. Explore the many difficulties they encountered when integrating with other children in school, and even with their families.

36. 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

37. 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

38. 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

39. Attention-Deficit/Hyperactivity Disorder: Etiology (cont’d.)
ABC Video: Brain Activity and ADHD See an in-depth look at the brain and how the brains of people with ADHC differ and are similar to those who do not have ADHD using brain imaging techniques

40. 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

41. Attention-Deficit/Hyperactivity Disorder: Etiology (cont’d.)
Social and sociocultural dimensions:
Sociocultural and social adversity including:
Stressors in family
Low social class
Foster care placement
Cultural and regional expectations
Psychological dimension:
Interpersonal conflict

42. Attention-Deficit/Hyperactivity Disorder: Etiology (cont’d.)
Figure 15-3 Prevalence of ADHD Among Youth (Ages 4-17) by State, The prevalence of parent-reported attention-deficit/hyperactivity disorder varied significantly from state to state, ranging from a low of 5.6% in Nevada to a high or 15.6% in North Carolina. What might account for the variability in ADHD diagnoses from state to state?
Source: Centers for Disease Control and Prevention (2010b)

43. 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.

44. 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

45. 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

46. Autism Spectrum Disorders (cont’d.)
ABC Video: Underdiagnosed Autism in Girls Discover the ways in which autism is more often diagnosed, and often easier to diagnose, in boys, and the problems this can lead to for young girls with autism spectrum disorders

47. 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

48. 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

49. 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 may appear following a period of normal social and intellectual development

50. 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 implicated in familial autism

51. 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

52. Autism Spectrum Disorders: Etiology (cont’d.)
Figure 15-5 Changes in the Prevalence of Autism Spectrum Disorder Among 8 Year-Old Children in 10 U.S. States 2002 to 2006 The prevalence of autism spectrum disorder among 8-year-old children increased between 2002 and 2006 in all 10 state sites monitored. What might account for these increases and the state-to-state variations in prevalence of the disorder?
Source: Center for Disease Control and Prevention (2009b)

53. 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

54. 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

55. Autism Spectrum Disorders: Intervention and Treatment (cont’d.)
ABC Video: Autism Diagnosis Early intervention can help Autistic children lead more normal lives. Find out what parents can do to help identify this disorder early-on.

56. 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 on effects of oxytocin
Comprehensive treatment programs have enabled children with ASD to develop more functional skills

57. 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

58. 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

59. 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

60. Intellectual Developmental Disorder (cont’d.)

61. 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

62. 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

63. 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

64. 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)

65. 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

66. Intellectual Developmental Disorder: Etiology (cont’d.)
Developmental Disabilities Children with developmental disabilities are said to have exceptionalities, which are diagnosed based on delays or differences in what we know of typical development

67. 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

68. 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

69. 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

70. Learning Disorders (cont’d.)
Etiology:
Little is known about precise causes of LD
Appear to have slower brain maturation
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

71. Support for Individuals with Neurodevelopmental Disorders
Produce lifelong disability, goal of intervention is to build skills and develop potential to the fullest extent possible
Support should begin in infancy and extend across the life span
Different levels of support

72. 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

73. 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