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CHAPTER SIXTEEN
Psychological Disorders
of Childhood
Childhood Disorders
 Childhood psychopathology
 Internalizing Disorders
 Externalizing Disorders
 ADHD, ODD, CD
 Epidemiology
 Etiology
 Treatment
 Childhood disorders outcome summary
Defining
Childhood Psychopathology
 Definitions of “normal” depend on age
 Classification of many childhood
disorders rests on our knowledge of
normal childhood behavior
Childhood Disorders
 Externalizing Disorders
 problems in conforming to expected
norms; often causes problems for others
 Internalizing Disorders
 experience of subjective distress; others
often unaware of their difficulties
Childhood Disorders
 Childhood psychopathology
 Internalizing Disorders
 Externalizing Disorders
 ADHD, ODD, CD
 Epidemiology
 Etiology
 Treatment
 Childhood disorders outcome summary
Diagnosing Internalizing
Disorders: Depression and Anxiety
 Children can be diagnosed with “adult” anxiety
disorders (e.g., MDD, OCD, GAD)
 Specific symptoms may differ from adults
 Some symptoms may be absent due to children’s
developmental differences
 Difficulty in obtaining reliable information due to
problems with self-reports
Separation Anxiety Disorder
 General symptoms
 Excessive distress associated with
separation
 Worry for separation and/or harm to
attachment figure
 School refusal
 Nightmares & complaints of physical
symptoms
 Onset: before 18 years old
 Duration: at least 4 weeks
 Impairment
Separation Anxiety Disorder:
Prevalence & Comorbidity
 SAD is the most common anxiety disorder of
childhood occurring in about 6% to 12% of
all children
 Equally common in boys and girls
 About 80% to 90% of all children with SAD
have another disorder (e.g., GAD,
depression)
 Children showing school refusal due to SAD
tend to be younger, female, of lower SES,
and from single parent families.
Childhood Disorders
 Childhood psychopathology
 Internalizing Disorders
 Externalizing Disorders
 ADHD, ODD, CD
 Epidemiology
 Etiology
 Treatment
 Childhood disorders outcome summary
Externalizing Disorders:
Key Features
 rule violations
 negativity, anger &
aggression
 impulsivity
 hyperactivity
 deficits in attention
Diagnosing Externalizing
Disorders
 DSM-IV-TR divides externalizing
disorders in to three major subtypes:
 Attention deficit/hyperactivity disorder
(ADHD)
 Oppositional defiant disorder (ODD)
 Conduct disorder (CD)
ADHD Diagnostic Criteria
 Key features: hyperactivity, attention
deficit and impulsivity
 symptoms begin before age 7
 6 of 9 DSM-IV symptoms for 6 months
 symptoms visible across settings
 Three subtypes
 Predominantly Inattentive Type
 Predominantly Hyperactive-Impulsive
Type
 Combined Type
ODD Diagnostic Criteria
 A pattern of negativistic, hostile and
defiant behavior
 e.g. loses temper, argues with adults,
defies or refuses to comply with adults’
requests
 Behavior causes significant impairment
 Impairment last for
at least 6 months
CD Diagnostic Criteria
 Persistent and repetitive pattern of rule
violations/social norms
 aggression to people, animals
 destruction of property
 deceitfulness or theft
 serious rule violation
 About 50% exhibit antisocial behavior into
adulthood
Epidemiology: ADHD
 Problems may appear before age 3
 Prevalence:
 approximately 5% of school-age children
 50-60% of children in special education
 Some children continue to have ADHD
as adults
 The symptoms interfere with daily
functioning in different ways over life
Epidemiology: ODD & CD
 Prevalence rates
 ODD about 5-7%
 Conduct Disorder about 2-4%
 Higher in boys than girls
Etiology: Biological Factors
 Behavior Genetics
 Recent study of 4000 Australian found
80% concordance for MZ twins, 40%
for DZ twins in ADHD, suggesting a
strong genetic component.
 Neuropsychological Abnormalities
 Food Additives and Sugar
 No evidence
 Temperament
Etiology: Biological Factors
Temperament
 Easy
 quickly form social relationships and
follow discipline
 Difficult
 challenge parental authority
 Slow-to-warm-up
 shy & withdrawn
Etiology: Social Factors
 Peers, Neighborhoods, Television
 Parenting styles
 Coercion
Etiology: Social Factors
Parenting Styles
Etiology: Social Factors
Coercion
behavior is
reinforced
Child wants
a cookie
Child stops screamingNegatively reinforcing
parent for giving in
Parent gives in,
positively reinforcing child
for throwing tantrum
Parent says
“no”
Child starts
screaming
Etiology: Psychological Factors
 Attachment Theory
 Secure attachments facilitate both
closeness and exploration
 Insecure (may be anxious, avoidant, or
disorganized) attachments predict later
internalizing and externalizing problems
and social difficulties
 The “Strange Situation” Test
 Self-Control
Treatment
 ADHD:
 psychostimulants (e.g. Ritalin, Adderral)
 antidepressants
 selective norepinephrine reuptake inhibitor
(e.g. Strattera)
 psychosocial treatment
 ODD:
 behavior family
therapy
Treatment
 CD:
 Multisystemic
Therapy
 residential programs
 diversion programs
 alternative to
juvenile justice
system
Childhood Disorders
 Childhood psychopathology
 Internalizing Disorders
 Externalizing Disorders
 ADHD, ODD, CD
 Epidemiology
 Etiology
 Treatment
 Childhood disorders outcome summary
Childhood Disorders:
Epidemiology
 Approximately 20% of children have a mental
disorder
Anxiety Disorders
13%
Mood Disorders
6.2%
Externalizing Disorders
10.3%
 Suicide
 Gender differences
 Boys are more likely to be in treatment than
girls
 Referral differences between children and
adults
Childhood Disorders:
Course & Outcome
 Prevalence rates of internalizing disorders
increase with age
 Externalizing disorders often continue
into adulthood, but antisocial behavior
rarely begins during adult life
 better prognosis for later-onset CD
 better prognosis for ADHD if NOT
comorbid w/ CD or ODD
Optional Slides
Etiological Factors
Common to Most or All Childhood
Disorders
 Difficult Temperament
 Insecure Attachment
 Ineffective Parenting Styles
 Emotion Dysregulation
Emotion Dysregulation
 Children fail to learn to
recognize and control
their emotions
Additional Etiological Factors
 Family risk factors
 Troubled peer relationships
Sociometric Ratings & Childhood
Disorders
 Popular: many “liked most,” few “liked least”
nominations
 Average: few “liked least” but not as many
“liked most” as popular
 Rejected: many “liked least,” few “liked most”
(opposite of popular)
 Neglected: few “liked least,” few “liked most”
 Controversial: many “liked least” and many
“liked most”
Cognitive Responses to Failure:
Examples
Arbitrary Inference
conclusions drawn in the absence of sufficient
evidence or of any evidence at all
Example
A young girl approaches a playground and finds two
children laughing. Before having a chance to say hello,
the others walk away and look towards her direction.
The young girl concludes that she is unattractive and
that the other children were laughing at her.
Cognitive Responses to Failure:
Examples
Selective Magnification and Minimization
exaggerations in evaluating performance
Example 1
A young boy makes a couple of mistakes while trying
out for a school play; he believes that he will never get
the part for which he is auditioning (magnification).
Example 2
The same boy gets the part that he is hoping to have in
a school play; he believes that the teacher just made a
mistake in choosing him (minimization).
Special Topic
Childhood Depression
Childhood Depression
 Myths about childhood
depression
 Children can’t get depressed
 Childhood depression is rare
 Childhood depression is
“just a phase”
Developmental Differences
 Distressed infants
show symptoms such
as:
 lethargy
 eating and sleep problems
 irritability
 decreased attention &
emotional expression
Developmental Differences
 Preschoolers may demonstrate:
 irritability and anger
 sad facial expressions
and crying
 anhedonia
 somatic complaints, lethargy
 eating and sleep problems
Developmental Differences
 Middle Childhood (6-12)
 Unhappiness, decreased, socialization, sleep problems,
irritability, lethargy.
 Beginning around age 9, aggression, self-reports of low
self-esteem & helplessness, suicidal ideation
 Adolescence
 Similar to middle childhood, plus pessimism, feelings of
worthlessness and apathy, comorbid substance abuse,
eating disorders, antisocial behavior
Areas of Impairment
 Intellectual functioning
 Interpersonal difficulties
Epidemiology
 Elementary school
 2-4% of community sample,
8-15% of inpatients
 Adolescence
 7% of community sample
 Gender Differences
 Pre-puberty, either no gender difference or slightly
higher rates in boys
 By age 15, gender difference parallels that of adults:
rates among girls are twice those among boys
Etiology:
Familial & Biological Factors
 Having a parent with a
psychological disorder,
especially a mood disorder,
increases children’s risk of
depression
 Genetic/Biological
Vulnerability
 May be similar to the
vulnerability for adult
depression.
Etiology: Cognitive Factors
 Depressed kids have more
distorted cognitions than nondepressed kids
 Learned Helplessness Model
Depressed youth more likely to
report:
 Higher “personal helplessness” and
“universal helplessness”
 More internal, global, and stable
attributional style for negative
Etiology: Attachment
 Vulnerabilities to
Depression
 Failing to form stable,
secure attachments
with parents
 Abrupt separation of
human and primate from mothers
Etiology: Home Environment
 Kids from divorced or
single-parent families
are at an increased
risk
 Hostile, tense, and
punitive
communication
patterns within the
family are more
Treatment
 Difficult to use adult treatments with kids
because they have limited memory,
attentional, and verbal capabilities
 Because of kids’
involvement with
family, family therapy
may be crucial
Treatment (cont’d)
 Cognitive Restructuring
 Focuses on identifying and changing cognitions
 Role Playing
 Acting out interpersonal problems to improve kids’
abilities to find solutions
 Antidepressants
 No more effective than placebo
End of Special Topic
Fear & Anxiety in Children
 Children develop different fears for the first time at
different ages; the onset may be sudden and may have
no apparent environmental cause.
 Some fears are both common and relatively stable
across different ages.
 Other fears become less frequent as children grow
older.
Treatment of Childhood
Anxiety Disorders
 Behavior Therapy
 Main technique for behavior therapy for anxiety
disorders is exposure
 Cognitive Behavioral Therapy
 Teaches children to understand how their thinking
contribute to their anxiety symptoms and how to modify
their maladaptive thoughts
 Family Intervention
 Anxiety disorders often occur in family context
Separation Anxiety
 Distress expressed following separation from
an attachment figure
 A normal developmental phase
 Children who fail to “outgrow” separation
anxiety may be diagnosed with Separation
Anxiety Disorder (SAD)
Age of Onset, Developmental
Course & Outcome
 The earliest reported age of onset for SAD is 7 to 8 years,
but children are often referred around 10 to 11 years
 SAD typically progresses from mild to severe avoidance
 SAD may be chronic or the onset may be sudden in a
child who did not show any prior signs of a problem.