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CHAPTER 15 CHAPTER OUTLINE I. II. Pervasive developmental disorders. Pervasive developmental disorders are severe disturbances affecting language, social relations, and emotions, distortions that would be abnormal at any developmental stage. Prevalence of autistic disorder is about 2 per 10,000 children; the other pervasive developmental disorders occur at a rate of about 6.7in 1,000. Autistic disorder was first described by Leo Kanner in 1943 and is characterized by great impairment in social interaction and/or communication, stereotyped interests and activities, and delays or abnormal functioning in major areas before age 3. Autistic children interact with others as though people were unimportant objects. Half do not speak; the other half often show echolalia—echoing whatever was just said—or pronoun reversal (where “you” is said instead of “I”). Most autistic children are mentally retarded, although splinter skills (special abilities) are found, most dramatically in autistic savants. Misdiagnosis as mental retardation only or as a different disorder or condition is common. About 22 in 10,000 children show some, but not all, of the characteristics of autistic disorder along with severe social impairment and would be diagnosed with pervasive developmental disorders that do not meet the criteria for autistic disorders. These include Asperger’s disorder (similar symptoms to autism, but more highly functional); childhood disintegrative disorder (at least two years of normal development), Rett’s disorder (normal for at least five months, onset between age 5 and 48 months, and deceleration of head growth seen only in females), and pervasive developmental disorder not otherwise specified. Biological dimension evidence points to genetic factors playing a prominent role in the causes for autism spectrum disorders. Concordance rates for autism are much higher for MZ (monozygotic) than DZ (dizygotic) twins. Furthermore, the prevalence of autistic disorder among siblings of individuals with autistic disorder ranges from 2 to 14 percent. In terms of the psychological dimension some research suggests that autism may be a disorder involving cognitive impairments that affect perception, particularly in the recognition and response to others. Early psychodynamic theories that involve social relationships of autism stressed the importance of deviant parent-child interactions in producing this condition. Kanner (1943), who named the syndrome, concluded that cold and unresponsive parenting is responsible for the development of autism. In terms of the sociocultural dimension Autism appears to vary according to sociocultural and demographic characteristics. Studies have found higher or equal prevalence of the disorder among African American mothers and lower prevalence among Mexican-born mothers than among white, Asian, and U.S.-born Hispanic mothers. The prognosis for children with pervasive developmental disorders is mixed. Most children diagnosed with autism retain their diagnosis at 9 years of age. However, many, especially those with initial higher levels of functioning (e.g., those with Asperger’s syndrome), improve. A minority have good outcomes. Because patients with these disorders have communication or social impairments, pervasive developmental disorders are very difficult to treat. Therapy with the parents, family therapy, drug therapy, and behavior modification techniques are all currently being used, with some success Attention deficit/hyperactivity disorder and disruptive behavior disorders. Attention deficit1hyperactive disorder (ADHD) is characterized by attention problems and may involve heightened motor activity. There are three types: predominantly hyperactive impulsive, predominantly inattentive, and combined (showing both hyperactivity and inattentiveness). ADHD is a relatively common disorder, far more common in boys than in girls. In some cases, ADHD children continue to have antisocial or psychiatric problems as adults; those with attention problems but not hyperactivity have better outcome. Attention-deficit/hyperactivity disorder is an earlyonset, highly prevalent neurobehavioral disorder, with genetic, biologic, and environmental etiologies, that persists into adolescence and adulthood in a sizable majority of afflicted children of both sexes. 75 to 90 percent of children with ADHD respond to stimulant medications. Children with ADHD are typically treated with stimulant medication, but there is considerable controversy about the overmedication of children and the poorly supervised prescription of drugs. Oppositional defiant disorder is characterized by negativistic and hostile behavior, but without serious violations of others’ rights. DSM-IV-TR criteria include “significant impairment in social and academic functioning,” a raising of the threshold for diagnosis. Conduct disorder involves a persistent pattern of antisocial behavior in which others’ rights are violated. Etiology, many cases of conduct disorder begin in early childhood. Some infants who are especially “fussy” seem to be at risk for developing conduct disorder. The etiology of conduct disorder probably involves an interaction of genetic/constitutional, psychological, social-familial, and sociocultural factors. Although conduct disorders have resisted traditional forms of psychotherapy, training in social and cognitive skills appears promising. One program, for example, focused on helping aggressive boys develop verbal skills to enter groups, play cooperatively, and provide reinforcement for peers. The cognitive element included using problem-solving skills to identify behavior problems, generate solutions to them, and select alternative behaviors. In addition, the children learned positive social skills through viewing videotapes and role-playing with therapists and peers. III. Elimination disorders. Enuresis (urination in inappropriate places that is usually involuntary) and encopresis (defecation in inappropriate places) may have biological and psychological origins. Treatment may include medication and behavior modification procedures. IV. Learning disorders. Disorders of childhood and adolescence also include cognitive and academic functioning. Learning disorders are characterized by academic functioning that is substantially below that expected in terms of the person’s chronological age, measured intelligence, and age-appropriate education. The disturbance significantly interferes with academic achievement or with activities of daily living. Learning disabilities are lifelong and cannot simply go away with treatment. However, persons with learning disabilities can adjust and adapt in order to function effectively in society. Severity of the disorder varies, and appropriate action involves the accurate assessment of the limitations of the disorder and individualized interventions. What has been helpful is to teach children with learning disabilities skills to capitalize on their abilities and strengths while correcting and compensating for disabilities and limitations. V. Mental retardation. Mental retardation (MR) is a disability characterized by significant limitations both in intellectual functioning and in adaptive behaviors as expressed in conceptual, social, and practical adaptive. Prevalence figures for the United States are 1 to 3 percent, depending primarily on the definition of adaptive functioning. Levels of Retardation DSM-IV-TR specifies four different levels of mental retardation, which are based on IQ score ranges, as measured on the revised Wechsler scales (WISC-R and WAIS-R): (1) mild (IQ score 50–55 to 70), (2) moderate (IQ score 35–40 to 50–55), (3) severe (IQ score 20–25 to 35–40), and (4) profound (IQ score below 20 or 25). In terms of Etiology mental retardation is thought to be produced by biological, psychological, social, and sociocultural factors. These factors are largely included into environmental conditions (such as poor living conditions), biological conditions, or some combination of the two. It can be caused by injury, disease, or a brain abnormality. The etiology is dependent to some extent on the level of mental retardation. Mild retardation is generally idiopathic (having no known cause) and familial, whereas severe retardation is typically related to genetic factors or to brain damage. Because mental retardation is a disability rather than a disease that can be “cured,” the goal of intervention is to develop the person’s potential to the fullest extent possible. Early intervention programs such as Head Start have not produced dramatic increases in intellectual ability among at-risk children (those from low-income families). School services received by children diagnosed with mental retardation can vary greatly between school districts. Employment programs for people with mental retardation can achieve more than was previously thought. Living arrangements, institutionalization of people with mental retardation is declining, as more individuals are placed in group homes or in situations in which they can live independently or semi independently within the community. VI. Implications. In this chapter, we have discussed the symptoms, causes, and treatment/prevention of childhood disorders. Because we are dealing with a population (i.e., children and adolescents) and not a disorder (e.g., depression), many kinds of disorders are included. Thus, some such as autism spectrum disorders and mental retardation have a strong biological etiology. Heredity, conditions during pregnancy, and early infant factors are likely to play a strong role in these disorders. Nevertheless, even in these and other childhood disorders, we see that psychological, social, and sociocultural factors are implicated.