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abnormal PSYCHOLOGY Third Canadian Edition Chapter 15 Disorders of Childhood Prepared by: Tracy Vaillancourt, Ph.D. Scope of the Problem • 14% of Canadian children have clinical disorders that cause significant distress and impairment – anxiety disorders most prevalent – < 25% of children receive specialized treatment – > 50% of children with 1 disorder have 2+ concurrent disorders ADHD • Attention-deficit/hyperactivity disorder (ADHD) – Deficits in attention – Hyperactivity – Impulsivity • Three subcategories of ADHD: • primarily poor attention – ADHD primarily inattentive • primarily hyperactive-impulsive behaviour – ADHD primarily hyperactive • both sets of problems – ADHD combined type – majority of all children ADHD cont. • Children with ADHD have – Peer-relations difficulty – Learning disabilities in math, reading, or spelling • 15-20% – 50% placed in special education programs because of their difficulties – Considerable overlap with conduct problems • combined sub-type ADHD cont. • Prevalence= 3 to 5% worldwide • More common in boys than in girls • severity of symptoms in adolescence – 65-80% still meet criteria for disorder in adolescence and adulthood Biological Theories of ADHD • Genetic component supported by adoption and twin studies – 50% of offspring have disorder (1 affected parent) – family environment does not make a significant contribution • Frontal lobes under-responsive to stimulation • Cerebral blood flow in frontal lobes • frontal lobes, caudate nucleus, globus pallidus • Poorer performance on neuropsychological tests of frontal-lobe functioning Theories cont. • Environmental toxins – 22% of mothers of children with ADHD reported smoking pack of cigarettes/day during pregnancy, compared with 8% of mothers whose children were normal Psychological Theories of ADHD • Diathesis-stress theory of ADHD – hyperactivity develops when predisposition to disorder is coupled with an authoritarian upbringing – Learning may play a role in hyperactivity • reinforced by the attention it elicits thus increasing in frequency or intensity Treatment of ADHD • Typically treated with drugs and behavioural methods based on operant conditioning • Stimulant Drugs – Methylphenidate (MPH) or Ritalin – Supported by double-blind studies comparing stimulants with placebos • in concentration, goal-directed activity, classroom behaviour, and social interactions and in aggressiveness and impulsivity in about 75% • Psychological Treatment – Parent training and changes in classroom management based on operant conditioning principles Conduct Disorder and ODD • Conduct Disorder – Behaviours that violate basic rights of others and major societal norms • Oppositional Defiant Disorder (ODD) – Diagnosed if child does not meet the criteria for conduct disorder – Physical aggression, losing temper, arguing with adults, lack of compliance with requests from adults, deliberately annoying others, being angry, spiteful, touchy, or vindictive. • Comorbidity is the norm rather than the exception – ODD, conduct disorder, and ADHD – Anxiety and depression are also common among children with conduct disorder • Prevalence – 8% of boys and about 3% of girls aged 4 to 16 Etiology of Conduct Disorders • Biological Factors – Genetic influence • Aggressive behaviour clearly heritable • Delinquent behaviour seems not to be • Neuropsychological deficits – poor verbal skills, difficulty with executive functioning and problems with memory Etiology of Conduct Disorders • Psychological Factors – Children with conduct disorder seem to be deficient in moral awareness – Lax parental discipline and parental adjustment difficulties – Learning theories • modelling and operant conditioning – Cognitive Biases • social-information processing theory – Socio-cultural context factors • neighbourhood and classroom environments Biopsychosocial Model of CD Treatment of Conduct Disorder • Fairer distribution of income • Alleviate material deprivation in lower SES groups • Jailing juvenile delinquents does not reduce crime. – In fact, harsh discipline (imposed by government or parents), contributes to further delinquency and criminal activity in adulthood • Family Interventions – Parental Management Training • Multi-systemic Treatment • Cognitive Approaches Learning Disabilities • Inadequate development in specific area of academic, language, speech, or motor skills • Not due to mental retardation, autism, a demonstrable physical disorder, or deficient educational opportunities Learning Disabilities • Usually of average or above-average intelligence • Term LD not used in DSM-IV-TR – learning disorders, communication disorders, and motor skills disorder • Usually identified and treated in school system • More common in males than in females Learning Disorders • Three categories: – Reading disorder – Disorder of written expression – Mathematics disorder Learning Disorders • Reading Disorder (dyslexia) – Significant difficulty with word recognition and reading comprehension – Written spelling as may also be a problem – Prevalence 2 to 8% of school-age children • Disorder of Written Expression – Impairment in ability to compose written word • Spelling errors, errors in grammar, or very poor handwriting • Mathematics Disorder – Difficulty rapidly and accurately recalling arithmetic facts, counting objects correctly and quickly, or aligning numbers in columns Communication Disorders • Expressive Language Disorder – Difficulty expressing in speech – Trouble finding words • Phonological Disorder – speech is not clear – articulation poor for r, sh, th, f, z, l, and ch • Stuttering – Disturbance in verbal fluency characterized by one or more of the following speech patterns • • • • frequent repetitions prolongations of sounds long pauses between words substituting easy words for those that are difficult to articulate Etiology of Learning Disabilities • Etiology of Dyslexia – Heritable component – Chromosome 13 (13q21) directly implicated as a dyslexia phenotype • Brain Structure Differences – left temporoparietal cortex less activated • Problems with perception of speech and analysis of the sounds of spoken language and their relation to printed words Treatment of LD • Most often occurs within special-education programs in the public schools Mental Retardation • Mental retardation – sub-average intellectual functioning along – deficits in adaptive behaviour – occurring before age 18 • Traditional Criteria for Mental Retardation 1. Intelligence-Test Scores 2. Adaptive Functioning 3. Age of Onset Classification of Mental Retardation • Four levels of MR – Mild mental retardation • 50–55 to 70 IQ • 85% of people with MR – Moderate mental retardation • 35-40 to 50-55 IQ • 10% of people with MR – Severe mental retardation • 20-25 to 35-40 IQ • 3 to 4% of people with MR – Profound mental retardation • below 20 to 25 IQ • 1-2% of people with MR Etiology of Mental Retardation • No Identifiable Etiology – many people with MR have no identifiable etiology • Known Biological Etiology – 25% of people with MR have a known biological cause – Genetic or Chromosomal Anomalies • Down syndrome, or trisomy 21 • Fragile X syndrome – Recessive-Gene Diseases Several • Phenylketonuria (PKU) – Infectious Diseases • Cytomegalovirus, toxoplasmosis, rubella, herpes simplex, syphilis and HIV infection – Accidents – Environmental Hazards • mercury, lead Prevention and Treatment of MR • Environmental Interventions and Enrichment Programs • Behavioural Interventions Based on Operant Conditioning – Applied Behaviour Analysis • Residential Treatment • Cognitive Interventions – Self-instructional training • Computer-Assisted Instruction Pervasive Developmental Disorders Autism Asperger’s Syndrome • Impairments in social interaction, social communication and imagination • Often regarded as a mild form of autism • Poor social relationships • Stereotyped behaviour • Language and intelligence are intact – triad of impairments • More boys than girls • Onset— infancy or very early childhood • Often co-occurs with MR and epileptic seizures PDD cont. Rett’s Disorder • Very rare; found only in girls • Development normal until 1st-2nd year of life • Head growth decelerates • Loses ability to use hands purposefully • Stereotyped movements such as handwringing or handwashing • Walks in an uncoordinated manner • Poor speech Childhood Disintegrative Disorder • Very rare • Normal development in the first 2 years of life then significant loss of – social, play, language, and motor skills Characteristics of Autism • Autism and MR – 80% score below 70 on standardized IQ tests • Extreme Autistic Aloneness • Communication Deficits – Echolalia – Pronoun reversal • Obsessive-Compulsive and Ritualistic Acts Etiology of Autistic Disorder • Biological bases – Strongly evidence in support of a biological basis • Genetic Factors – Risk of autism in siblings of people with the disorder is about 75 times greater • 60 to 91% concordance for MZ twins • 0 to 20% concordance for DZ twins – Linked genetically to broader spectrum of deficits in communicative and social areas Etiology of Autistic Disorder • Neurological Factors – Abnormal brainwave patterns – Larger brains but reduced brain volume – Abnormalities in the cerebellum • See also Focus on Discovery 15.1 Treatment of Autistic Disorder • Most effective treatments use modelling and operant conditioning techniques – Example ABA • Most commonly used medication for treating problem behaviours in autistic children is haloperidol (Haldol) Childhood Fears and Anxiety Disorders • 1/3rd of Canadian children (ages 4 -11) rated by parents as too fearful or anxious • Fears and phobias reported more often for girls than for boys • 10 to 15% of children and adolescents have an anxiety disorder – Most common disorders of childhood Separation Anxiety Disorder • Unrealistic concern about separation from major attachment figures • Symptoms associated with SAD must be experienced for at least eight weeks – unrealistic and persistent worries about harm to major attachment figures – fears of abandonment – refusal to attend school – avoidance of being alone – experience of nightmares involving separation themes – experience of physical complaints in anticipation of being separated from attachment figures School Phobia • Related to separation anxiety – But not all children with SAD refuse to go to school • Two types identified – 1. more common type is associated with SAD • children worry constantly that some harm will befall parents or themselves when they are away from parents – 2. second type associated with true phobia of school • either a fear specifically related to school or a more general social phobia • generally begin refusing to go to school later in life • have more severe and pervasive avoidance of school Social Phobia • Selective Mutism – Refusal to speak when it is expected of a person • Example: refusing to speak to a teacher • Social Phobia – Prevalence 1% of children and adolescents – Processes and mechanisms • social learning • genetic factors Treatment of Fears and Phobias • Similar to that employed with adults – Exposure to feared object while performing some action to inhibit their anxiety – CBT shows great promise in treating childhood anxiety Depression in Childhood and Adolescence • Resemble adult depression in terms of depressed mood, inability to experience pleasure, fatigue, concentration problems, and suicidal ideation – but higher rates of suicide attempts and guilt in children and adolescents • Masked depression – acting aggressively or misbehaving at school or at home • Prevalence – < 1% of preschoolers – 2 to 3% of school-age children – adolescents similar to adult rates • 9% in females and 3 -5% in males • lifetime prevalence is 21.4% for females and 10.7% for males Etiology of Depression • Genetic factors • Family and other relationships as sources of stress – might interact with a biological diathesis • Serious emotional problem in a parent • Poor social skills and impaired relationships with siblings and friends • Likely stems from a complex interplay of – – – – biological vulnerability factors parental factors psychosocial factors “social capital” resources Treatment of Depression • Controversy regarding effectiveness of drug therapies • Interpersonal therapy (IPT) • CBT Copyright Copyright © 2008 John Wiley & Sons Canada, Ltd. 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