Developmental Psychopathology

Disorders of Childhood

Classifying Childhood Disorders

 Diagnosticians must determine what’s normal for a given age.

(temper tantrums at 10, not normal)

Disorders of Under-controlled behavior

 1. Attention-Deficit/Hyperactivity Disorder (ADHD)  2. Conduct Disorder

ADHD: Symptoms (overall)

 Child in constant motion  Fidgeting  Disorganization  Impulsivity  Difficulty getting along with others  Aggressiveness  Have difficulty reading social cues  Difficulty sustaining attention/poor concentration

ADHD: Three Subcategories

 1. Children with problems primarily of poor attention (ADD).

 2. Children whose difficulties result primarily from hyperactive-impulse behavior.

 3. Children who have both sets of problems.

Prevalence of ADHD:

 Difficult to determine, because of varied definitions of this disorder over time.

 Estimates—2 - 7% in the US  3 –5% worldwide  More likely in boys than girls, boys more likely to be comorbid with conduct disorder.

ADHD: When does it become a problem???

 Becomes noticeable in preschool years, when children have difficulty controlling their activity & interacting with their peers.

 Big myth of ADHD—hyperactivity doesn’t disappear in adolescence as was once thought.

65 - 80% of kids with ADHD still meet criteria in adolescence & adulthood.

Prevalence of symptoms in ADHD & normal adolescents (Barkley, 1990)



Symptom

 Fidgets  Easily distracted  Difficulty remaining  Seated  Blurts out answers  Difficulty (attention)  Interrupts others  Talks excessively

ADHD%

73.2

82.1

60.2

65.0

79.7

65.9

43.9

Normal%

10.6

15.2

3.0

10.6

16.7

10.6

6.1

Theories of ADHD



Biological-

---

Genetic factors

— When parents have ADHD, 50% of their child do too.

Adoption studies & twin studies show genetic link ---

Neurological factors

— Frontal lobes under responsive to stimulation & cerebral blood flow is reduced. Kids with ADHD have brains that developed differently, not resulting from brain damage.

Theories of ADHD (cond)

 ADHD

not

linked to:  sugar/preservatives  Lead ADHD

is

linked to: Maternal smoking (prenatal)!!!

--increases dopamine release in baby’s brain—leading to hyperactivity

ADHD: Treatment

 1.

Medication

- stimulants prescribed since 1960s (Ritalin).  Stimulant effects-paradoxical –improve ability to concentrate/reduce disruptions.

 In double-blind designed studies, 75% of kids with ADHD showed dramatic improvements with stimulants.

Treatment (cond)

 2.

Psychological techniques

—  behavioral techniques based on operant conditioning work well.

 Applied Behavior Analysis  Improves academic achievement, ability to concentrate, social interactions, etc.

Conduct Disorder:

  Is a repetitive & persistent pattern of seriously antisocial behavior, usually criminal (illegal) in nature & marked by extreme callousness. Diagnosis is made in individuals

under 18

       Behaviors may include (but not limited to): Cruelty toward animals and/or people Vandalism Lying Theft Physical aggressiveness Behavior is often—vicious, callous, remorseless

DSM-IV TR Criteria for Conduct Disorder

 Repetitive & persistent behavior pattern that violates the basic rights of others or conventional social norms as manifested by the presence of 3 or more of the following in the previous 12 mos. & at least one of them in the previous 6 mos.:     A. Aggression to people & animals (e.g., bullying, initiating physical fights, being physically cruel to people or animals, forcing someone into sexual activity).

B. Destruction of property (e.g.,fire-setting, vandalism).

C. Deceitfulness or theft (e.g., breaking into another’s house or car, conning, shoplifting).

D. Serious violation of rules (e.g., staying out at night before age 13 in defiance of parental rules, truancy before age 13).

  **Significant impairment in social, academic, or occupational functioning.

**Person must be under 18 years of age.

Conduct Disorder & comorbidity

    ADHD Substance use disorders (alcohol, marijuana) Note—CD & drug use occur concomitantly & exacerbate each other. Anxiety Depression (15-45%)  Girls with CD are significantly more likely than boys to develop these other disorders, suggesting greater psychopathology in the girls than in the boys.

What is prevalence of conduct disorder?

 A review of several epidemiological studies indicates that prevalence rates range from 4 to 16% for boys & 1.2 to 9% in girls (Loeber et al., 2000).  Violent crimes (rape, assault) are largely crimes of male adolescents.  Incidence & prevalence of illegal activity

peaks by age 17

& then drops precipitously in young adulthood.

What is prognosis of Conduct Disorder?



Prognosis is mixed

. More than half of children with conduct disorder

do not

become antisocial personalities in adulthood (Loeber, 1991; Zoccolillo et al., 1992).

 However, research shows that most conduct disordered boys do continue to demonstrate some conduct problems into adulthood (Lahey et al., 1995).

Do kids with conduct disorder become antisocial adults?



Yes

, some children diagnosed with conduct disorder meet criteria for antisocial personality disorder into adulthood.

 Males with conduct disorder who had fathers with antisocial behavior & poor verbal intelligence, more likely to develop APD.

Moffitt’s theory: Two courses of conduct disorder:

 Moffitt argues that two different courses of conduct problems should be distinguished.

 1.

Life-course persistent

–Some individuals show a pattern of antisocial behavior beginning with problems by age 3 & continuing into adulthood.

 2.

Adolescent-limited

– Other conduct disorder individuals started out with normal childhoods, but produced high levels of antisocial behavior during adolescence that does not continue into adulthood.

Etiological factors for Conduct Disorder

    1.

Biological Factors

Is conduct disorder heritable??

*There is some evidence that conduct disorder is

genetic

. Twin studies show a genetic link for conduct disorder, although the extent of link varies with the samples examined.

 Adoption studies in Sweden, Denmark, & U.S. show that criminal & aggressive behavior is accounted for by both genetic & environmental factors.

2. Neuropsychological deficits in children with conduct disorder

   Poor verbal skills Difficulty with executive function Memory impairments  Children who develop conduct disorder at an earlier age have been shown to have an IQ score of 1 standard deviation below age-matched peers without conduct disorder.

 This IQ deficit is not attributable to lower SES, race, or school failure (Lynam, Moffitt, & Stouthamer Loeber, 1993).

2. Psychological factors

 A.

Deficient moral awareness

-- Children with conduct disorder often lack guilt & remorse for their antisocial & aggressive behaviors.  B.

Conduct behaviors are learned

- 1.

Modeling

– children learn aggressive behaviors by observing parental aggression and/or abuse in the home. Evidence supports both of these factors. 2.

Imitation

- kids will imitate antisocial peers

3. Faulty thinking/perceptions

 Cognitive processes of aggressive children have a specific bias—children perceive ambiguous acts as evidence of hostile intent.  Children with these faulty perceptions may retaliate to “perceived attacks” that were actually not intended to be hostile.  This may lead to aggressive behavior in response to these attacks…. The vicious cycle then continues.

4. Peer Influences

 Peers influence aggressive & antisocial behaviors in others in 2 ways:  1.

Rejection by peers has been shown to be causally related to increased aggressive behavior

(e.g., Dylan Klebold & Eric Harris— Columbine High School massacre).

 2.

Association with Deviant Peers

with the wrong crowd”). —increases frequency of deviant behavior in others (“Running



Treatment

A.

Family Interventions

—treatment involves parents & families of antisocial child.

 Using a behavioral program of

parental management training (PMT)

, Patterson & coworkers have taught parents to modify their responses to children so that positive social behavior is rewarded.  Parents use positive reinforcement (rewards) when the child produces positive behaviors & time out/loss of privileges for aggressive or antisocial acts.

B. Multisystemic Treatment

 Henggeler’s MST has demonstrated reductions in arrests 4 years following treatment (Borduin et al., 1995).  MST—is an intensive & comprehensive therapy that provides services for the adolescent, his/her community, the family, school, & peer group.  Therapy targets not just child but all individuals in the child’s life (hence, multisystemic).

 Treatment is provided in home, school, church, community centers, etc.

Does MST work??



Yes!!!!

Compared with a control group who received standard individual therapy, the MST group demonstrated fewer antisocial behaviors & arrests over the following 4 years.

 While 70% of adolescents receiving standard therapy were arrested in the 4 years after treatment, 22% of the subjects receiving MST were arrested (Davison, Neale, & Kring, 2004).

Pervasive Developmental Disorders:

 Rett’s disorder, Childhood disintegrative disorder, Asperger’s disorder, Autism

What is Autism?

 Autistic disorder, first identified by Leo Kanner in 1943, is a disorder of that impairs an individuals social and cognitive functioning.

     

DSM diagnosis-Autistic Disorder

A total of 6 or more items from A, B, and C below, with at least two from A and one each from B and C:

A.

Impairment in social interactions as manifested by at least 2 of the following: Marked impairment in use of nonverbal behaviors such as eye contact, facial expression, body language.

Deficit in development of peer relationships appropriate to developmental level.

Lack of spontaneous sharing of things or activities with others.

Lack of social or emotional reciprocity.

    

B.

Impairment in communication as manifest by at least one of the following: Delay in or total lack of spoken language without attempts to compensate by nonverbal gestures.

In those with speech, marked impairment in ability to sustain/initiate a conversation with another.

Repetitive or idiosyncratic language Lack of developmentally appropriate play     

C

. Repetitive or stereotyped behaviors or interests, manifested by at leaste one of the following: Abnormal preoccupation with objects/activities Rigid adherence to certain rituals Stereotyped mannerisms Abnormal preoccupation with parts of objects  Delays or abnormal functioning in at least one of the following areas, beginning before age 3: social interactions, language for communication with others, or imaginative play.

 Disturbance not better described as Retts disorder or childhood disintegrative disorder.

Autism: Symptoms

 Poor eye-contact  Poor social interaction-don’t initiate play with others  Language delay (regression)- 50% never learn to speak at all.

 May be preoccupied with objects (spinning, twirling)  Rigidity; lack of adaptiveness, rituals important.

 Tactile aversion

Etiology: Autism

 1.

Biological factors

 There is a genetic link.  --60-91% concordance rate in monozygotic twins.

 is only 0-20% in dizygotic twins.

 Brains of autistic males significantly larger than in normal males.

2. Psychological theories:

 Lack of maternal love (long been dispelled).

 3. Other theories: (these have been ruled out)  --MMR & other vaccines (ruled out)  Abdominal parasites—yeast (ruled out)

Treatment: Autism

 Best—

Applied Behavior Analysis

!!!!

 Lovaas method—multiple discrete trials targeting child’s ability to attend, imitate actions, play with objects, learn social skills, etc.

What is Korsakoffs Syndrome?:

 A

disease

that develops in individuals who chronically consume alcohol.



-

caused by a thiamine (vitamin B 1) deficiency that occurs almost exclusively in severe alcoholics.

 -memory loss—severe retrograde & anterograde amnesia.  neurological damage is diffuse, striking damage in dorsal medial nucleus of thalamus, frontal cortex.

What is Alzheimer’s Disease?:

 Is a progressive degenerative disease that ultimately results in death, marked by severe retrograde & anterograde amnesia.



Early onset

: late 40’s early 50’s prior to 60’s, is more severe that late onset!

 -

Late onset

: after

65, we have 50% chance of developing this by age 85.

Alzheimer’s Disease: Symptoms

 starts with minor forgetfulness (where’s checkbook, etc.)  Steadily progresses to serious memory loss  Depression  Restlessness  Hallucinations & delusions (seeing dead relatives)  Anterograde & retrograde amnesia

Alzheimer’s Disease: Genetic basis???

 -does seem to run in families, especially in families with early onset.

 -Best evidence--nearly all Down’s Syndrome patients will eventually develop the disease if they survive to middle age.

 -It may depend on at least 2 or 3 different genes

Alzheimer’s Disease: Neurological damage

 1. There is widespread atrophy of the cortex with plaques & tangles in the hippocampus.

 2. Entorhinal cortex is also destroyed, acetylcholine neurons are diseased.

 3. The plaques contain deposits of a protein known as Beta-amyloid. An injection of this protein into a rat’s brain can damage neurons & produce symptoms resembling those of Alzheimer’s disease.

. Open-Head Injuries:

 Puncture or penetration of the skull through projectiles (gunshots/missile wounds) or other moving objects.

 Most people with open-head injuries do not lose consciousness & produce distinctive symptoms that may undergo rapid & spontaneous recovery.

 Deficits are specialized & often resemble those of surgical excisions.

Closed-Head Injuries

 Caused by a blow to the head (car accident, blunt instrument swung at head).

 Damage at site of blow is called a

coup

.  With severe blow, the brain may shift & hit the opposite side of the skull producing an additional bruise (contusion) known as a

countercoup

.

  

Closed-Head Injuries (Contd.)

Finally, the brain may suffer additional damage, from the shearing of nerve fibers resulting in microscopic lesions.

 Frontal & temporal areas most likely to be damaged in closed-head injuries.

 These injuries are common accompanied by loss of consciousness (from damage to brainstem fibers), edema (swelling), and hemorrhaging.  Length of coma often is positively correlated with severity of damage.