Download Disorders Usually Diagnosed in Infancy, Childhood, & Adolescence

Disorders Usually 1st Diagnosed in
Infancy, Childhood, & Adolescence
Core Concept of Diagnostic Group:
• Categorized by time of onset
• Predominantly disorders of abnormal
development and maturation.
• Emphasis of disorders is on the inability of
the individual to attain certain normal
developmental milestones and the
associated functions, capabilities, &
behaviors.
10 Diagnostic Subgroups (DSM-IV-TR)
1)
2)
3)
4)
5)
6)
7)
Mental Retardation
Learning Disorders
Motor Skills Disorders
Communication Disorders
Pervasive Developmental Disorders
Attention Deficit and Disruptive Behavior Disorders
Feeding & Eating Disorders of Infancy & Early
Childhood
8) Tic Disorders
9) Elimination Disorders
10) Other Disorders of Infancy, Childhood, or
Adolescence
Mental Retardation
Characteristics:
• IQ is significantly below average (< 70)
• Accompanied by deficits in adaptive functioning, e.g.
communication, self-care, home living, social/interpersonal
skills, use of community resources, self-direction,
academic skills, work, leisure, health, safety
• Onset before age 18 years
• Coding: coded on axis II
• Code based on degree of severity, reflecting level of
intellectual impairment:
– Mild Mental Retardation – IQ from 50-55 to 70
– Moderate Mental Retardation – IQ from 35-40 to 50-55
– Severe Mental Retardation – IQ from 20-25 to 35-40
– Profound Mental Retardation – IQ below 20-25
Mental Retardation
• Prevalence: 1-3% of population; 90% are mild MR
• Course: chronic
• Prognosis: variable, depending on IQ & level of
impairment
• Gender differences: more prevalent for males (1.6 to 1);
no gender differences for severe & profound MR
• Causes: genetic; chromosomal (Down syndrome, Fragile
X syndrome, Lesch-Nyhan syndrome); environmental
(deprivation, abuse, neglect); prenatal (exposure to
disease, alcohol, drugs, chemicals, poor maternal
nutrition); perinatal (difficulties during labor & delivery);
postnatal (malnutrition, infections, & head injuries)
• Treatment: behavioral skills training; communication
training; supported living and employment;
mainstreaming
Learning Disorders
Characteristics:
• Inadequate development of specific academic skills, such
as reading, writing, and math.
• Specific academic skills are substantially below expected
for age, intelligence, and education
• Significantly interferes with aspects of life requiring those
skills.
Subtypes:
• Reading Disorder
• Mathematics Disorder
• Disorder of Written Expression
• Learning Disorder Not Otherwise Specified
Learning Disorders
• Prevalence:
– general population: 5-10%
– reading disorders: 5-15%
– math disorders: 6%
• Racial: more common in black children
• Negative outcomes: negative school experiences;
school drop-out; lower employment rates; lower
educational & career goals
• Causes: genetics; structural & functional
differences in the brain
• Treatment: educational interventions (processing
skills; cognitive skills; behavioral skills)
Tic Disorder: Tourette’s Disorder
• Symptoms: characterized by multiple motor tics and
one or more vocal tics (involuntary, sudden, rapid,
nonrhythmic, stereotyped motor movements or
vocalizations), which occur many times a day, nearly
every day, or intermittently for more than a year.
• Common motor tics: eye-blinking, eye-rolling,
spitting, flipping/twirling hair, rolling head around,
bending/jumping, skin picking, shrugging/jerking
shoulders, thrusting pelvic movements, tapping
fingers/feet
• Common vocal tics: throat clearing, tongue-clicking,
whistling, grunting, humming, hoots, howls,
burps/belches, animal noises, repetition of one’s own
words, repetition of others’ words
Tourette’s Disorder
• Causes: genetic (32% have relatives with TD); abnormal
metabolism of 5HT & D; brain processing problem (basal
ganglia)
• Prevalence: decreases with age; 5-30 per 10,000 in
childhood; 1-2 per 10,000 in adulthood
• Gender: 2-5x as common for males
• Onset: as early as 2 yrs; average age of onset is 6-7 yrs;
typically develops by age 14
• Course: severity, frequency, and disruptiveness of sx
diminish during adolescence & adulthood
• Treatment: antipsychotics; antihypertensive medications;
SSRI’s; self-monitoring; relaxation training; habit
reversal
Attention Deficit/Hyperactivity Disorder
• Includes two major syndromes:
1) Inattention
2) Hyperactivity-Impulsivity
• Syndromes may occur independently or
together, but usually some components of
each are present.
• Symptoms begin before age 7
• Symptoms cause some impairment in 2 or
more settings.
Attention Deficit/Hyperactivity Disorder
Inattention: 6+ of the following for 6+ months
• Often fails to give close attention to details
• Often makes careless mistakes in school, work, etc.
• Often has difficulty sustaining attention
• Often doesn’t seem to listen when spoken to directly
• Often doesn’t follow instructions
• Often fails to finish schoolwork, chores, or work duties
• Has difficulty organizing tasks & activities
• Avoids or dislikes tasks requiring sustained mental effort
• Often loses things
• Is easily distracted by extraneous stimuli
• Is forgetful in daily activities
Attention Deficit/Hyperactivity Disorder
Hyperactivity-Impulsivity 6+ of following for 6+ months
Hyperactivity:
• Fidgets with hands or feet; squirms in seat
• Difficulty staying in seat
• Excessive running, climbing, or restlessness
• Difficulty playing or engaging in leisure activities quietly
• Often “on the go;” acts as if “driven by a motor”
• Often talks excessively
Impulsivity:
• Often blurts out statements
• Impatient; difficulty awaiting turn
• Often interrupts or intrudes on others
Attention Deficit/Hyperactivity Disorder
• Subtypes:
– AD/HD, Predominantly Inattentive Type
– AD/HD, Predominantly Hyperactive-Impulsive Type
– AD/HD, Combined Type
– AD/HD, Not Otherwise Specified
• Onset: 3-4 years old
• Age: 68% have ongoing sx in adulthood; inattentive
subtype is more common in adolescents and adults
• Gender: ratios of males to females range from 2:1 to 9:1;
Combined and Hyperactive Subtypes are much more
common in males than females
• Prevalence: up to 3-7% of school-age children
ADHD: Associated Features
•
•
•
•
•
•
•
•
•
•
•
Academic deficits
School-related problems
Peer rejection
Low frustration tolerance
Tantrums
Poor self-esteem
Mood swings
Bossiness
Stubbornness
Accidents
Driving difficulties – speeding, accidents
ADHD: Diagnostic Considerations
• Difficulty of distinguishing normal activity from
hyperactivity and normal distractibility from attention
deficit distractibility.
• Need to evaluate behavior in terms of what’s normal for
others of same gender, age, developmental level, cultural
background.
• Behaviors must occur in multiple settings.
• Behaviors must cause clinically significant impairment.
• Symptoms must have been present and caused impairment
by age 7.
• Combined and Hyperactive Subtypes are less likely to be
missed.
ADHD: Contributing Factors
• Genetics: increased incidence of ADHD &
psychopathology in families & relatives
• Prenatal factors: inadequate oxygen; drug
exposure; maternal smoking
• Neurotransmitters: inadequate availability of
dopamine; NE, 5HT, GABA also implicated
• Brain abnormalities: frontal cortex, basal
ganglia, & cerebellar vermis are smaller
• Exposure to toxins: allergens, food additives
• Parenting: negative attempts to control their
behavior; intrusive, over-bearing parenting
Attention Deficit/Hyperactivity Disorder
Treatments:
• Medication – stimulants, Strattera (SNRI),
Wellbutrin
• Psychoeducation & bibliotherapy
• Skills-based training – time management,
organizational skills, study skills, problemsolving, social skills
Conduct Disorder
• Repetitive, persistent pattern of behavior in
which the basic rights of others or major
societal norms or rules are violated.
• 3 or more of the following are present in the
past 12 months, and at least one of the
following is present in the past 6 months.
1) Aggression to people and animals
2) Destruction of property
3) Deceitfulness or theft
4) Serious violations of rules
Conduct Disorder
1) Aggression to People and Animals:
– Bullying, threats, intimidation
– Physical fights
– Use of weapons
– Physical cruelty to people
– Physical cruelty to animals
– Mugging, purse snatching, extortion,
armed robbery
– Forced sexual activity
Conduct Disorder
2) Destruction of Property:
– Deliberate fire-setting
– Deliberate destruction of others’ property
3) Deceitfulness or Theft
– Breaking & entering
– Lying; conning
– Stealing; shoplifting; forgery
4) Serious Violations of Rules
– Breaking curfew prior to age 13
– School truancy prior to age 13
– Running away from home
Conduct Disorder
Subtypes:
• Conduct Disorder, Childhood Onset – onset of at least 1
criterion prior to age 10
• Conduct Disorder, Adolescent Onset – absence of any
criteria prior to 10
• Conduct Disorder, Unspecified Onset – age of onset is
unknown
Specifiers:
• Mild – few, if any, conduct problems in excess of those
required to make dx; cause only minor harm to others
• Moderate – number of conduct problems and effect on
others are in the intermediate range
• Severe – many conduct problems in excess of those required
to make dx; cause considerable harm to others
Conduct Disorder
• Etiology: genetics; decreased arousal; low levels of 5HT;
neurological deficits
• Prevalence: 2-9% of nonclinical population; up to 1/31/2 of child mental health referrals; 87-91% of
incarcerated juveniles
• Gender Differences: mostly males
• Onset: as early as preschool
• Prognosis: poor; 2/3rds of cases develop into Antisocial
Personality Disorder
• Treatment: parent management training; communitybased interventions (group homes, wilderness programs;
therapeutic boarding schools); CBT (social skills,
problem solving, cognitive restructuring)
Oppositional Defiant Disorder
• Pattern of negativistic, hostile, and defiant behavior for at
lease 6 months.
• At least 4 of the following are present:
– Often loses temper
– Often argues with adults
– Often actively defies or refuses to comply with adults’
requests or rules
– Often deliberately annoys others
– Often blames others for own mistakes or misbehavior
– Is often touchy or easily annoyed by others
– Is often angry or resentful
– Is often spiteful or vindictive
• Absence of behavior that violate the rights of others
Oppositional Defiant Disorder
• Prevalence: 1-6%
• Gender differences: more prevalent for males prior to
puberty; ratio evens out after puberty
• Prognosis: relatively persistent – some of the behaviors
persist into adulthood, others are outgrown; higher
divorce rate, employment difficulties, and drug/alcohol
abuse for those with ODD
• Causes: marital conflict; family discord; inconsistent
parenting; overly lenient or rigid parent; coercive or
aversive parent-child interactions; genetics
• Treatment: parent training; family therapy; behavioral
therapy (anger management, social skills training,
problem solving, frustration tolerance); cognitive
interventions to reduce negativity
Separation Anxiety Disorder
At least 4 weeks of inappropriate or excessive anxiety about
separation from home or major attachment figures, as
evidenced by at least 3 of the following:
– excessive anxiety regarding separation
– excessive fears of losing major attachment figures
– nightmares involving the theme of separation
– refusal to go to school
– refusal to be alone or without major attachment figures
– refusal to sleep away from home or attachment figures
– repeated physical complaints when separation occurs
or is anticipated
Onset prior to age 18
Pervasive Developmental
Disorders
Characterized by:
• A broad-based impairment or a loss of functions
expected for child’s age.
• Includes 3 components:
1) Impairment in social interactions/relationships
2) Impairment in communication/language
3) Restricted, repetitive, and stereotyped patterns
of behavior, interests, and activities
Autistic Disorder
•
Abnormal functioning in at least one of the
following areas, with onset prior to 3:
1) Social interaction
2) Language and communication
3) Symbolic, imaginative play
•
•
•
Qualitative impairment in social interaction
and relationship development
Qualitative impairment in communication,
language, and conversation skills
Restricted, repetitive, stereotyped patterns of
behavior, interests, activities.
Autism
• Mental retardation: 75-80%; 50% are profoundly or severely
MR; 25% are moderately MR; 25% borderline to average IQ
• Gender differences: higher IQ – more prevalent among
males; IQ < 35 – more prevalent among females
• Prevalence: 1 in 500 births
• Onset: first apparent in infancy & toddlerhood
• Course: chronic; life-long impairment; 50% never acquire
speech
• Causes: abnormalities in brain structure and function (5HT
synthesis, cerebellum); genetics
• Treatments: intensive behavioral Tx focusing on improving
communication, social and daily living skills and reducing
problem behaviors; early intervention programs; applied
behavior analysis; parent training; mainstreaming for
education; community interventions (supportive living
arrangements & work settings)
Asperger’s Disorder
• Qualitative impairment in social
interaction and relationship
development
• Restricted, repetitive, and stereotyped
patterns of behavior, interests, and
activities
• But lack any clinically significant
delay in language or cognitive
development
Asperger’s Syndrome
What you see:
• Anxious, excessive desire for sameness
• Preoccupation with stereotyped, repetitive activities
• Obsess about objects
• Limited interests
• Can’t relate to others
• Can’t read emotions
• Can’t understand social cues
• Social isolation, socially inept
• Average IQ scores
• Motor clumsiness
• Poor coordination
Asperger’s Syndrome
• Gender: up to 4x as common for males
• Prevalence: up to 5x as common as
Autism
• Onset: later onset than Autism
• Course: chronic, life-long
• Etiology: genetics; brain abnormalities
(limbic system, 5HT & D systems, right
hemisphere)
Asperger’s Syndrome: Treatments
• Behavioral treatments/skills building:
interventions targeting problem behaviors,
problem solving, social skills, communication
skills, empathy-building, daily living skills
• School-based interventions: mainstreaming;
tutoring; special aides; multiple modalities for
presenting information
• Psychotherapy to address accompanying
psychiatric disorders, such as depression and
anxiety
• Medications: antidepressants, antipsychotics