Transcript Disorders First Apparent in Childhood

Disorders First
Apparent in Childhood
Why “first apparent”?
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Childhood disorders may continue into
adulthood
Childhood disorders may lead to other adult
disorders
Childhood disorders may impact
development
Disorders
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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)
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Inattention:
 lack of focus on
detail & careless
mistakes
 difficulty with
sustained attn
 not listening when
spoken to
 fails to follow
through on tasks
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organizational
problems
dislikes sustained
effort
easily distracted
forgetful in daily
activities
Attention-Deficit Hyperactivity
Disorder
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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”
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Talks excessively
Blurts out answers
before questions are
finished
Difficulty waiting for
his/her turn
Disrupts or interrupts
others
ADHD
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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
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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?
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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?
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Large genetic component
Subtle brain differences
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Association with maternal smoking
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Smaller brain volume
2-3 times more likely
Inability to inhibit behavior
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Executive functioning deficit (goals, planning)
What Causes ADHD?
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Is the real problem our regimented modern
classrooms?
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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?
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Some argue that
dietary additives
affect/cause ADHD
(e.g., food coloring)
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Parents place children
on special diets
Evidence indicates
that NO, diet is not
responsible for ADHD
How do we treat ADHD?
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Stimulant medications
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Increase arousal and help focus attention
Short half-life
Stimulants do affect growth hormones and
can suppress appetite
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Many children take only during school hours
Drug “holidays” are recommended
Use the lowest therapeutic dose
How do we treat ADHD?
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Behavioral Therapy for Children
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Improve socialization skills
Reinforce and reward improved behavior until the
environment is rewarding alone
Main techniques
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Progressive muscle relaxation
Contingency plans
Cognitive therapy to increase awareness
How do we treat ADHD?
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Behavioral Therapy for Parents
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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
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Deficits in reading, math, or written
expression
Child’s achievement level is below what
would be predicted based upon their ability
level
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In DE, this difference must be present in less than
4% of children of the same age to qualify for
services
Learning Disorders
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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
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Many drop out of school
Low employment rates (60-70%)
Self-esteem problems
Causes of Learning Disorders
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Genetic basis
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Almost 100% concordance between identical
twins
Neurological differences
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E.g., in sound recognition
Treating Learning Disorders
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Treatment such as distinguishing sounds
Children usually require educational
interventions
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Extra time
Additional practice and assistance
Special education
Earlier diagnosis = better prognosis
Communication Disorders
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Deficits in the ability to express or
comprehend verbal language
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Expressive Language Disorder
Phonological Disorder
Stuttering
Many are new categories to DSM-IV
Usually the realm of Speech Language
Pathologists
Pervasive Developmental
Disorders
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Disruptions in
social interaction &
communication
skills
Presence of
stereotyped
behaviors,
interests, and/or
activities
Symptoms of Autism
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Abnormal/delayed development
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Socially
Communication
Apparent by age 3 (20% report normal 1-2
years)
Failure to engage (e.g., reciprocal
interactions)
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Inappropriate facial expressions, body postures,
gestures, eye contact
Symptoms of Autism
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Unable to form
friendships - shared
interests
Social/emotional
reciprocity
Stereotypic behavior
Self-destructive
behavior*
Symptoms of Autism
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Functional language deficits
 No language at all
 Repeat others
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Pragmatic language deficits
 Integrate words with gestures
 Inability to understand irony, sarcasm,
pretend play
Symptoms of Autism
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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
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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
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Mild autism
No significant delays in early language
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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
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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
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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:
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Heritability index = .90 (risk)
Genetically heterogeneous
Unable to isolate genes
Some evidence for viral infections during
pregnancy
Causes of Autism: Biological
Abnormalities
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75% = neurological abnormalities
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Abnormal reflexes/muscle tone
Perceptual/motor coordination
Movement/posture problems
Increase of seizures
Reduced brain size
Behavioral Treatments for
Autism
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Decrease undesirable behavior & shape
desirable
Positive reinforcement & extinction
Social punishment
Families are important
Language + social skills
Alternative Treatments for
Autism
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Vitamins
Other medications
Diet
Auditory Integration Training
Facilitated Communication
What are “Alternative”
Treatments?
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Scientifically
unverified
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Randomized
control studies
Replication
Large samples
What’s so bad about
alternative treatments?
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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
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Provide assistance for communicating
Alphabet board, computer, typewriter, etc
Support hand/arm
May isolate fingers
Requires extensive training
Claims:
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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?
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Facilitators unintentionally influence
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May even actively influence
Many well-designed studies:
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Single- and double-blind
Repeated measures
Participant as control
Auditory Integration Training
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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
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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:
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Improved attention
Improved auditory processing
Decreased irritability
Reduced lethargy
Improved expressive language
Improved auditory comprehension
The Critics
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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…
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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
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Sufficiently low cognitive ability (IQ)
Significant social/functional impairment
Assessing Cognitive Ability
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Intelligence - a collection of adaptive skills
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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
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2-3% of the population falls below this cut-off
Assessing Social/Functional
Deficits
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Deficits must be present in 2+ areas:
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Communication
Self-care
Home living
Interpersonal Skills
Use of Community Resources
Self-direction
Functional academic skills
Work
Leisure
Health & Safety
Levels of Mental Retardation
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Mild (IQ = 50-55)
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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)
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Usually physical disorder accounts for problems
Inability to manage even basic self-care tasks
What Causes Mental
Retardation?
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Chromosomal abnormalities (e.g., Down’s
syndrome & Fragile-X syndrome)
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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?
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Genetic Problems
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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?
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Pregnancy and Birth Complications
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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?
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Cultural-Familial MR
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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
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E.g. child requires stimulation of certain brain areas as
they develop
Behavior Disorders - Conduct
Disorder
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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
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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
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Children also have poor interpersonal skills
Often experience peer rejection
Seem to have problem-solving deficits
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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
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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?
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Neurological differences
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Temperament
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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
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Parent with APD increases chances of CD
Criminal and/or alcoholic parents
Family history of aggression
What Causes Conduct
Disorders?
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Family Links cont..
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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
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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
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Conduct Disorder & APD
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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
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Remember, APD is untreatable!
Treating CD and ODD
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Problem-Solving Skills
Parent Management Training
Family Therapy
School & Community Based Treatments
Problem-Solving Skills
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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
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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
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Outcomes look good (reduce arrest, increase
school performance, family relationships)
Most families may be unwilling/able to
participate
School & Community Based
Treatments
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Target children at school (easier)
Often has more attendance than individual
therapy
Available to all children (universal
intervention)
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Increased likelihood of reaching those who need it
Minimizes stigma
Offers opportunity to interact with other children
Selective Mutism
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Selective Mutism
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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