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Disorders First Apparent in Childhood Why “first apparent”? Childhood disorders may continue into adulthood Childhood disorders may lead to other adult disorders Childhood disorders may impact development Disorders 1. 2. 3. 4. 5. 6. Attention Deficit Hyperactivity Disorder Learning Disorders/Communication Disorders Autism & Asperger’s Disorder Mental Retardation (Axis II) Conduct Disorder & Oppositional Defiant Disorder Selective Mutism Attention Deficit Hyperactivity Disorder (ADHD) Inattention: lack of focus on detail & careless mistakes difficulty with sustained attn not listening when spoken to fails to follow through on tasks organizational problems dislikes sustained effort easily distracted forgetful in daily activities Attention-Deficit Hyperactivity Disorder Hyperactivity/Impulsivity Fidgets or squirms in seat Leaves seat when it is inappropriate Runs or climbs excessively Difficulty playing quietly Is often “on the go” or acts as if “driven by a motor” Talks excessively Blurts out answers before questions are finished Difficulty waiting for his/her turn Disrupts or interrupts others ADHD Symptoms are usually evident before schoolage, but more relevant in that setting Symptoms must be present in more than one setting 5% of school-age children have ADHD (drops with age) ADHD Significant social impairments Academic problems Comorbid with: mood disorders, learning disorders, substance use, APD, neurological problems, physical accidents and injury What Happens When they Grow Up? Adults may self-select environments that result in less noticeable symptoms 68% have attention problems in adulthood Only 30% of children retain the diagnosis in adolescence, and 10% in young adulthood 25% do not finish school 1/5 develop APD w/ high levels of crime What Causes ADHD? Large genetic component Subtle brain differences Association with maternal smoking Smaller brain volume 2-3 times more likely Inability to inhibit behavior Executive functioning deficit (goals, planning) What Causes ADHD? Is the real problem our regimented modern classrooms? Decreased time for active play Change in environment penalizes students who would be normal under different circumstances Little evidence of brain abnormalities ADHD looks like extreme playfulness Function well outside the classroom (no control) Does Diet Affect ADHD? Some argue that dietary additives affect/cause ADHD (e.g., food coloring) Parents place children on special diets Evidence indicates that NO, diet is not responsible for ADHD How do we treat ADHD? Stimulant medications Increase arousal and help focus attention Short half-life Stimulants do affect growth hormones and can suppress appetite Many children take only during school hours Drug “holidays” are recommended Use the lowest therapeutic dose How do we treat ADHD? Behavioral Therapy for Children Improve socialization skills Reinforce and reward improved behavior until the environment is rewarding alone Main techniques Progressive muscle relaxation Contingency plans Cognitive therapy to increase awareness How do we treat ADHD? Behavioral Therapy for Parents Parents are trained in behavior management, contingency management Reduce family stress Psychoeducation can reduce family blame Best treatment is meds + therapy Meds are often necessary for severe cases Learning Disorders Deficits in reading, math, or written expression Child’s achievement level is below what would be predicted based upon their ability level In DE, this difference must be present in less than 4% of children of the same age to qualify for services Learning Disorders Diagnosis based on comparison of those tests, in those specific domains only 5% of American students have a learning disorder Reading is most common Consequences of Learning Disorders Many drop out of school Low employment rates (60-70%) Self-esteem problems Causes of Learning Disorders Genetic basis Almost 100% concordance between identical twins Neurological differences E.g., in sound recognition Treating Learning Disorders Treatment such as distinguishing sounds Children usually require educational interventions Extra time Additional practice and assistance Special education Earlier diagnosis = better prognosis Communication Disorders Deficits in the ability to express or comprehend verbal language Expressive Language Disorder Phonological Disorder Stuttering Many are new categories to DSM-IV Usually the realm of Speech Language Pathologists Pervasive Developmental Disorders Disruptions in social interaction & communication skills Presence of stereotyped behaviors, interests, and/or activities Symptoms of Autism Abnormal/delayed development Socially Communication Apparent by age 3 (20% report normal 1-2 years) Failure to engage (e.g., reciprocal interactions) Inappropriate facial expressions, body postures, gestures, eye contact Symptoms of Autism Unable to form friendships - shared interests Social/emotional reciprocity Stereotypic behavior Self-destructive behavior* Symptoms of Autism Functional language deficits No language at all Repeat others Pragmatic language deficits Integrate words with gestures Inability to understand irony, sarcasm, pretend play Symptoms of Autism Restricted, repetitive, stereotyped behavior, interests, activities Abnormal in intensity/focus E.g. dates, phone numbers Lining up objects Inflexible patterns, routines, rituals Preoccupation with parts of interest Associated Features and Disorders Hyperactivity, short attention span, impulsivity, aggressiveness Self-injurious behavior & temper tantrums Odd responses to sensory stimuli (e.g. high threshold for pain, sensitive to sound, touch, light) Abnormal affect or fear reaction Asperger’s Disorder Mild autism No significant delays in early language Other language may be “odd” and preoccupied with certain topics No delay in cognition or self-help skills, adaptive behavior, curiosity about environment Little concern in infancy, may seem precocious Usually noticed after entrance to school Prevalence & Course 1 in every 166 births 4:1 boys to girls Deficits sometimes noticed early Some improve at school Some improve during adolescence, but others deteriorate IQ & functional language predictors Causes of Autism: Genetic Contributions 1. 2. 3. Strongest genetic component Early studies thought not genetic But, hard to study: 1 in 240,000 possible twin studies (1000 in US) Autistic adults unlikely to have children Autistic children have less siblings Twin Studies Solve the Mystery: Heritability index = .90 (risk) Genetically heterogeneous Unable to isolate genes Some evidence for viral infections during pregnancy Causes of Autism: Biological Abnormalities 75% = neurological abnormalities Abnormal reflexes/muscle tone Perceptual/motor coordination Movement/posture problems Increase of seizures Reduced brain size Behavioral Treatments for Autism Decrease undesirable behavior & shape desirable Positive reinforcement & extinction Social punishment Families are important Language + social skills Alternative Treatments for Autism Vitamins Other medications Diet Auditory Integration Training Facilitated Communication What are “Alternative” Treatments? Scientifically unverified Randomized control studies Replication Large samples What’s so bad about alternative treatments? They give parents false hope They can violate patient rights Can allow others to control decisions “made by” patients In some cases, have led to abuse allegations Facilitated Communication Provide assistance for communicating Alphabet board, computer, typewriter, etc Support hand/arm May isolate fingers Requires extensive training Claims: Produces (“frees”) unexpected literacy Shows normal/superior intelligence Provides a means to communicate (for those who have no means, but otherwise would) What does the research say? Facilitators unintentionally influence May even actively influence Many well-designed studies: Single- and double-blind Repeated measures Participant as control Auditory Integration Training 1. 2. 3. Conduct detailed audiogram, determining which frequencies sensitive to Modify music by computer to remove those frequencies Listen to music 10 hours/day, at least twice a day, for 10-12 days Auditory Integration Training Berard, France, 1960s (US in 1991) 1991 -> published book “cured” 10 hours Autistic children (and other patients) are hypersensitive to certain frequencies Claims: 76.2% of 1850 children “very positive results” Claims: Improved attention Improved auditory processing Decreased irritability Reduced lethargy Improved expressive language Improved auditory comprehension The Critics No scientific evidence for hearing impairments in autism Inconsistent with medical knowledge re: structure & mechanism of ear No measurement is valid enough to discriminate peaks of hypersensitivity Weak, irrelevant, insignificant evidence Sound levels are unsafe The Best Type of Treatment… Structured educational programs geared to the person’s developmental level of functioning It is, however, important to be openminded Majority of other treatments not scientifically proven Be educated Consider the individual child Do a thorough assessment and reevaluate Mental Retardation Sufficiently low cognitive ability (IQ) Significant social/functional impairment Assessing Cognitive Ability Intelligence - a collection of adaptive skills You can be good at one, but not another Intelligence effects our functioning IQ is normally distributed. Mean = 100, SD = 10 Scores below 70 = diagnostic of retardation 2-3% of the population falls below this cut-off Assessing Social/Functional Deficits Deficits must be present in 2+ areas: Communication Self-care Home living Interpersonal Skills Use of Community Resources Self-direction Functional academic skills Work Leisure Health & Safety Levels of Mental Retardation Mild (IQ = 50-55) Benefit from education (intense) Learn to read/write and do basic math Difficulties usually apparent after begin schooling May need supervision/guidance, but can live alone with support Profound (IQ below 20-25) Usually physical disorder accounts for problems Inability to manage even basic self-care tasks What Causes Mental Retardation? Chromosomal abnormalities (e.g., Down’s syndrome & Fragile-X syndrome) Down’s syndrome leading cause of organic MR Moderate to severe Females with fragile x = mild to moderate; males = moderate to severe What Causes Mental Retardation? Genetic Problems PKU - lack of enzyme to break down phenylalanine & build-up causes brain damage Normal at birth - diagnosis results in food changes What Causes Mental Retardation? Pregnancy and Birth Complications Fetal alcohol syndrome (detectable only in infants exposed to large amounts) Exposure to other drugs Therapeutic drugs (e.g., for seizures, bipolar, Accutane for acne) Radiation (e.g., for cancer) Infections, such as rubella Physical damage to head, blood supply during birth What Causes Mental Retardation? Cultural-Familial MR Low end of IQ due to development or environment Heritability index for IQ = .60-.80 Genes predominantly cause MR, environment has less of an impact (But is important!) Appropriate stimulation during certain periods is necessary E.g. child requires stimulation of certain brain areas as they develop Behavior Disorders - Conduct Disorder A pervasive pattern of disrespect for rights of others + violation of rules/norms Bullies, threatens, intimidates others Initiates physical fights, uses weapons Physically cruel to people and/or animals Stolen while confronting a victim Forced sexual activity Conduct Disorder Deliberately sets fires w/ intention of doing damage or destroys property in other ways Broken into someone’s house/building/car Lies to obtain goods or avoid responsibility Stolen costly items without confronting victim Stays out at night before age 13 Has run away, overnight, >2 times Is truant from school prior to age 13 Conduct Disorder Children also have poor interpersonal skills Often experience peer rejection Seem to have problem-solving deficits Do not generate as many options as non-CD children Inability to take another’s perspective Interpret ambiguous gestures as hostile Prevalence = 3-6% (boys 2:1) Oppositional Defiant Disorder Pattern of negative, hostile, defiant behaviors Arguing for the sake of arguing, hostility toward parents/teachers Usually begins at home (which can impede diagnosis) May develop into later conduct disorder Typically emerge by age 8, est. 5-10% prevalence What Causes Conduct Disorders? Neurological differences Temperament Poor coordination, fine motor skills Usually have significantly lower IQ than peers Easily distressed, reactive to change, react to intense stimuli (more likely behavior problems) Family Links Parent with APD increases chances of CD Criminal and/or alcoholic parents Family history of aggression What Causes Conduct Disorders? Family Links cont.. Poor maternal mental health, prenatal health Poor supervision Spousal aggression Lax, erratic and inconsistent parenting/discipline Less acceptance, warmth, affection, support Reinforce CD behavior, ignore/reward other (coercive process) Child-parent interactions are also bidirectional The Coercive Process Jimmy’s parents tell him to go to bed Jimmy refuses: “I want to play 1 more video game!” Parent says “No! Its late and you have school.” Jimmy gets upset, hitting table, screaming “Just one more game. You’re mean - you never let me have fun!” Parent feels guilty at having spent little time together, and is too tired after work to argue - says “Okay, 1 more game” Jimmy stops screaming and plays his game Parent, relieved fight is over, goes to kitchen. Does not monitor or play with child The Coercive Process What happens as a result of this process? 1. Jimmy is rewarded for screaming 2. Reward for screaming = increased probability of screaming in future 3. Parent is rewarded for giving in 4. Parents likelihood of giving in is increased * If this pattern is typical, it is a risk factor. It also tends to escalate over time Conduct Disorder & APD A minority of CD children develop Antisocial Personality Disorder Treatment for conduct disorder is of interest, as preventing APD would reduce associated financial and criminal costs to society Remember, APD is untreatable! Treating CD and ODD 1. 2. 3. 4. Problem-Solving Skills Parent Management Training Family Therapy School & Community Based Treatments Problem-Solving Skills Children tend to have poor problem-solving & interpret intentions/actions as hostile Combines modeling, role-playing, and reinforcement contingencies to increase problemsolving and prosocial behavior Parent Training & Family Therapy Break cycle of coercive process Promote prosocial behavior in child Apply proper discipline techniques by parent Increase reciprocity & positive reinforcement between family members Parent Training and Family Therapy Outcomes look good (reduce arrest, increase school performance, family relationships) Most families may be unwilling/able to participate School & Community Based Treatments Target children at school (easier) Often has more attendance than individual therapy Available to all children (universal intervention) Increased likelihood of reaching those who need it Minimizes stigma Offers opportunity to interact with other children Selective Mutism Selective Mutism Consistent failure to speak in specific social situations (where these is an expectation for speaking) despite speaking in other situations Not due to a lack of knowledge or comfort with spoken language An anxiety disorder Is not merely a child refusing to speak in a situation