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Chapter 13 Developmental and Cognitive Disorders Nature of Developmental Psychopathology: An Overview • Normal vs. abnormal development • Developmental psychopathology – Study of how disorders arise and change with time – Disruption of early skills can affect later development Nature of Developmental Psychopathology: An Overview Developmental disorders – Diagnosed first in infancy, childhood, or adolescence – Attention deficit hyperactivity disorder (ADHD) – Learning disorders – Autism – Mental retardation 3 Types of (Attention-deficit hyperactivity disorder (ADHD) • Predominately inattentive • Predominately hyperactive/impulsive • Combined – Associated with numerous impairments • Behavioral • Cognitive • Social and academic problems Barkley’s model (2006) ADHD: Facts and Statistics • Prevalence – Occurs in 3% - 7% of school-aged children – Symptoms are usually present around age three or four – Children with ADHD have problems as adults • Gender differences – Boys outnumber girls 3:1 • Comorbid with Conduct disorder, oppositional defiant disorder, obsessive-compulsive disorder, tic disorder The Causes of ADHD: Biological Contributions • Genetic contributions – ADHD seems to run in families – DAT1 - gene has been implicated The Causes of ADHD: Biological Contributions • Neurobiological contributions – Smaller brain volume (3-4%) – Inactivity of the frontal cortex and basal ganglia – Abnormal frontal lobe development and functioning The Causes of ADHD: Biological Contributions (continued) • The role of toxins – Small evidence that allergens and food additives are causes – Maternal smoking increases risk • Psychosocial factors – Can influence the nature of ADHD – Constant negative feedback from peers and adults Biological Treatment of ADHD • Goal of biological treatments – To reduce impulsivity and hyperactivity and to improve attention • Stimulant medications – Reduce core symptoms in 70% of cases – Examples include Ritalin, Dexedrine, Focalin, Cylert, Vyvanse, Adderall, Strattera Biological Treatment of ADHD • Other medications with more limited efficacy – Imipramine and clonidine (antihypertensive) – Designer drugs (psychopharmacogenetics) • Effects of medications – Improve compliance and decrease negative behaviors – Do not affect learning and academic performance – Benefits are not lasting following discontinuation Behavioral and Combined Treatment of ADHD • Behavioral treatment – Reinforcement programs • To increase appropriate behaviors • Decrease inappropriate behaviors – May also involve parent training • Combined bio-psycho-social treatments – Are highly recommended – Superior to medication or behavioral treatments alone Academic Characteristics • Deficits in: Reading (dyslexia) Written language Mathematics (dyscalculia) (dysgraphia) Learning Disorders: An Overview – Discrepancy between actual and expected achievement (IQ and achievement test) – Performance significantly below age or grade level – Response to Intervention (RTI) – Cannot be caused by sensory deficits or lack of educational possibilities Learning Disorders: Statistics • Prevalence of learning disorders – 5-10% prevalence in the United States – Highest in wealthier regions of the United States – Six million children have been diagnosed – School experience tends to be generally negative Biological and Psychosocial Causes of Learning Disorders • Genetic and neurobiological contributions – Dyslexia, dyscalculia run in families – “Minimal brain dysfunction” Dyslexia Disability in Metacognition • Lack of awareness of strategies and resources needed to perform effectively • Inability to monitor, evaluate, and adjust performance to ensure successful task completion Recommended Educational Practices • Strategy instruction – Techniques, principles, and rules that guide students to complete tasks independently A self-regulation model Direct Instruction • • • • • • Well-organized, sequenced lessons Short review of previously learned skills Clear statement of lesson goals Presentation of new material in small steps Frequent opportunities for practice Questions to check for understanding Autism Spectrum Disorder Pervasive Developmental Disorder (PDD) PDD Autism Asperger Childhood Disintegrative Disorder Rett’s Disorder PDD (NOS) – Not otherwise specified Pervasive Developmental Disorders: An Overview • Nature of pervasive developmental disorders – Problems occur in language, socialization, and cognition – Pervasive – problems span many life areas • Examples of autism spectrum disorders – Autistic disorder – Asperger’s syndrome – Pervasive developmental not otherwise specified (PDD-NOS) The Nature of Autistic Disorder: An Overview • Three central DSM-IV-TR features of autism – Qualitative impairment of social interaction – Problems in communication • 50% never acquire useful speech – Restricted patterns of behavior, interests, and activities Autistic Disorder: Statistics • Prevalence and features of autism – One in every 500 births – More prevalent in females with IQs below 35 – More prevalent in males with higher IQs – Occurs worldwide – Symptoms usually develop before 3 years of age Autistic Disorder: Statistics • Autism and intellectual functioning – 40-55% with autism have intellectual disabilities (IQ below 70) • Reliable indicators of good prognosis – Language ability and IQ Causes of Autism: Early and More Recent Contributions (continued) • Current understanding of autism – Medical conditions – not always related to autism – Genetic component is largely unclear – Neurobiological evidence of brain damage – Substantially reduced cerebellum size • Psychosocial contributions are unclear Treatment of Pervasive Developmental Disorders: Example of Autism • Psychosocial “behavioral” treatments – Skill building – Reduction of problem behaviors – Target communication and language problems – Address socialization deficits – Early intervention is critical Intellectual disability (ID): An Overview • DSM-IV-TR criteria – Significantly sub-average intellectual functioning (70 or less IQ) – Deficits or impairments in present adaptive functioning – Must be evident before the person is 18 years of age Vineland Adaptive Behavior Scales II (VABS – II) Parent/Caregiver Rating Form, Interview Form 0 through 90 Teacher Rating Form 3 through 21 years,11 months DSM-IV-TR Levels of Intellectual disability (ID) • Mild ID – IQ score between 55 and 70 • Moderate ID – IQ range of 40 to 54 • Severe ID – IQs ranging from 25 to 39 • Profound ID – IQ scores below 25 Intellectual disability (ID): Some Facts and Statistics • Prevalence – About 1-3% of the general population – 90% are labeled with mild intellectual disability • Course of ID – Tends to be chronic – Prognosis varies greatly from person to person Causes of Intellectual disability (ID): Biological Contributions • Hundreds of known causes – Environmental – deprivation, abuse – Prenatal – exposure to disease or a drug/toxin – Perinatal – difficulties during labor – Postnatal – head injury Causes of Intellectual disability (ID): Biological Contributions • Genetic research – Multiple genes, and at times single genes • Chromosomal abnormalities – Down syndrome and fragile X syndrome – PKU – Lesch-Nyhan syndrome Trisomy 21 Down Syndrome (Trisomy 21) • Physical Deformities flattening of the back of the head slanting of the eyelids short stubby limbs thick tongues • Cultural-familial intellectual disability – Believed to cause about 75% of ID cases – Is the least understood – Associated with • Mild levels of retardation on IQ tests • Good adaptive skills Treatment of Intellectual disability (ID) • Parallels treatment of pervasive developmental disorders • Teach needed skills – To foster productivity – To foster independence – Educational and behavioral management – Living and self-care skills via task analysis – Communication training – often most challenging Nature of Cognitive Disorders: An Overview • Perspectives on cognitive disorders – Affect learning, memory, and consciousness – Most develop later in life • Three classes of cognitive disorders – Delirium – temporary confusion and disorientation – Dementia – marked by broad cognitive deterioration – Amnestic disorders – memory dysfunctions Nature of Cognitive Disorders: An Overview • Shifting DSM perspectives – From “organic” mental disorders to “cognitive” disorders – Broad impairments in cognitive functioning – Profound changes in behavior and personality Delirium: An Overview • Nature of delirium – Central features – impaired consciousness and cognition – Develops rapidly over several hours or days – Appear confused, disoriented, and inattentive – Marked memory and language deficits Delirium: An Overview (continued) • Facts and statistics – Affects up 30% of persons in acute care facilities – Most prevalent in older adults • Those undergoing medical procedures • AIDS patients and cancer patients – Full recovery often occurs within several weeks Medical Conditions Related to Delirium • Medical conditions – Drug intoxication, poisons, withdrawal from drugs – Infections – Head injury and several forms of brain trauma – Sleep deprivation, immobility, and excessive stress Medical Conditions Related to Delirium • DSM-IV-TR subtypes of delirium – Delirium due to a general medical condition – Substance-induced delirium – Delirium due to multiple etiologies – Delirium not otherwise specified Treatment and Prevention of Delirium • Treatment – Attention to precipitating medical problems – Psychosocial interventions include reassurance • Focus on coping strategies • Inclusion of patients in treatment decisions • Prevention – Address proper medical care for illnesses – Address proper use and adherence to therapeutic drugs Dementia: An Overview • Nature of dementia – Gradual deterioration of brain functioning – Deterioration in judgment and memory – Deterioration in language / advanced cognitive processes – Has many causes and may be irreversible Dementia: Initial and Later Stages • Initial stages – Memory and visuospatial skills impairments – Agnosia – inability to recognize and name objects – Facial agnosia – inability to recognize familiar faces – Other symptoms • Delusions, apathy, depression, agitation, aggression Dementia: Initial and Later Stages • Later stages – Cognitive functioning continues to deteriorate – Total support is needed to carry out day-to-day activities – Death due to inactivity and onset of other illnesses DSM-IV-TR Classes of Dementia • Dementia of the Alzheimer’s type • Vascular dementia • Dementia due to other general medical conditions • Substance-induced persisting dementia • Dementia due to multiple etiologies • Dementia not otherwise specified Dementia of the Alzheimer’s Type: An Overview • DSM-IV-TR criteria and clinical features – Multiple cognitive deficits – Develop gradually and steadily – Memory, orientation, judgment, and reasoning deficits – Additional symptoms may include • Agitation, confusion, or combativeness • Depression and/or anxiety – “Sundowner syndrome” Dementia of the Alzheimer’s Type: Extent of Deficits • Range of cognitive deficits – Aphasia – difficulty with language – Apraxia – impaired motor functioning – Agnosia – failure to recognize objects – Difficulties with • • • • Planning Organizing Sequencing Abstracting information – Negative impact on social and occupational functioning Alzheimer’s Disease: Some Facts and Statistics • Nature and progression of the disease – Deterioration is slow during the early and later stages – Deterioration is rapid during middle stages – Average survival time is about eight years – Onset usually occurs in the 60s or 70s • Prevalence of Alzheimer’s disease – Prevalence greater in • Poorly educated persons – Prevalence rates are low in some ethnic groups Vascular Dementia: An Overview • Nature of vascular dementia – Caused by blockage or damage to blood vessels – Second leading cause of dementia next to Alzheimer’s – Onset is often sudden (e.g., stroke) – Patterns of impairment are variable – Most require formal care in later stages Vascular Dementia: An Overview • DSM-IV-TR criteria and incidence – Cognitive disturbances – identical to dementia – Obvious neurological signs of brain tissue damage – Prevalence 1.5% in people 70 and 15% for people over 80 – Risk slightly higher in men Other Causes of Dementia: Head Trauma • Head trauma – accidents are leading cause – Memory loss is the most common symptom Other Causes of Dementia: HIV-1 • HIV-1 – Causes neurological impairments and dementia – Cognitive slowness, impaired attention, and forgetfulness – Apathy and social withdrawal HIV (human immunodeficiency virus) and AIDS (acquired immune deficiency syndrome Other Causes of Dementia: Parkinson’s Disease • Parkinson’s disease – degenerative brain disorder – Affects about one out of 1,000 people worldwide – Motor problems – central feature of this disorder • Caused by damage to dopamine pathways – 75% survival rate for 10 years Other Causes of Dementia: Huntington’s • Huntington’s disease – Genetic autosomal dominant disorder – Manifests initially as chorea, usually later in life – About 20-80% display dementia – Dementia follows a subcortical pattern HUNTINGTON’S DISEASE Single dominant gene on chromosome 4 Rapid, jerky involuntary movements Dementia, cognitive decline, depression, occasional delusions Hallucinations, OCD Other Causes of Dementia: Pick’s Disease • Pick’s disease – Rare neurological condition – Produces a cortical dementia like Alzheimer’s – Also occurs later in life (around 40s or 50s) – Little is known about what causes this disease • Creutzfeldt-Jakob disease – Affects one out of 1,000,000 persons – Linked to mad cow disease Other Dementias: Substance-Induced Dementia • Substance-induced persisting dementia – Results from drug use in combination with poor diet – Several drugs can lead to symptoms of dementia – Resulting brain damage may be permanent – Dementia is similar to that of Alzheimer’s – Deficits may include • Aphasia, apraxia, agnosia • Disturbed executive functioning Causes of Dementia: The Example of Alzheimer’s Disease • Early and largely unsupported views – Implicated smoking, negative correlation Causes of Dementia: The Example of Alzheimer’s Disease • Current neurobiological findings – Neurofibrillary tangles – Amyloid plaques – The role of deterministic genes • Beta-amyloid precursor gene • Presenilin-1 and Presenilin-2 genes – The role of susceptibility genes - ApoE4 gene – Brains of Alzheimer’s patients tend to atrophy Causes of Dementia: The Example of Alzheimer’s Disease • Current neurobiological findings – Multiple genes are involved in Alzheimer’s disease – Chromosomes 21, 19, 14, 12, – Chromosome 14 • Associated with early onset Alzheimer’s – Chromosome 19 • Associated with late onset Alzheimer’s The Contributions of Psychosocial Factors in Dementia • Psychosocial factors – Do not cause dementia directly – May influence onset and course – Lifestyle factors – drug use, diet, exercise, stress – Cultural factors • Risk for certain conditions vary by ethnicity and class – Psychosocial factors • Educational attainment, coping skills, social support Medical and Psychosocial Treatment of Dementia • Medical treatment: Best if enacted early – Few exist for most types of dementias – Most attempt to slow progression of deterioration – Do not stop progression of dementia – Caregiver can be negatively impacted Medical and Psychosocial Treatment of Dementia • Psychosocial treatments – aims – To enhance lives of patients and their families – To teach compensatory skills – To use memory enhancement devices, if needed – Psychosocial interventions appear to focus on caregivers Prevention of Dementia • Reducing risk of dementia in older adults – Estrogen-replacement therapy – Proper treatment of cardiovascular diseases – Use of anti-inflammatory medications – Control blood pressure and lead an active social life • Other targets of prevention efforts – Increasing safety behaviors to reduce head trauma – Reducing exposure to neurotoxins and use of drugs Amnestic Disorder: An Overview • Nature of amnestic disorder – Circumscribed loss of memory – Inability to transfer information into long-term memory – No loss of other high-level cognitive functions Amnestic Disorder: An Overview • Causes may include – Medical conditions, head trauma, or long-term drug use • DSM-IV-TR criteria – Inability to • Learn new information or recall learned information – Significant impairment in functioning Amnestic Disorder: An Overview • The example of Wernicke-Korsakoff syndrome – Damage to the thalamus – Thiamine (vitamin B-1) deficiency – Resulting from stroke or chronic heavy alcohol use • Prevention – Use of thiamine supplements with heavy drinkers • Research on amnestic disorders is scant Dementia: Statistics • Onset and prevalence – Can occur at any age, but most common in the elderly – Affects over 10% of persons 85 years and older • Incidence of dementia – Affects 8.5% of those 85 and older – Rates seem to double with every five years of age • Gender and sociocultural factors – Occurs equally in men and women – Occurs equally across educational level and social class