Chapter Fifteen

1. Chapter Fifteen Disorders of Childhood and Adolescence

2. Disorders of Childhood and Adolescence (cont’d.)

3. Disorders of Childhood and Adolescence (cont’d.) • Diagnosis requires that symptoms cause significant impairment in daily functioning over extended period of time • To determine if a child has an actual disorder, clinicians consider the child's age and developmental level as well as environmental factors • Include: • Internalizing disorders • Externalizing disorders • Neurodevelopmental disorders • Conditions involving impaired neurological development

4. Internalizing Disorders of Childhood • Conditions involving emotional symptoms directed inward • Heightened reactions to trauma, stressors or negative events and difficulty regulating emotions • Prevalent in early life and often lead to substance use and suicide • Of particular concern are the low treatment rates for youth experiencing major depression; this lack of intervention is particularly pronounced for African American, Latino/Hispanic American, and Asian American adolescents

5. Anxiety, Trauma, and Stressor-Related Disorders in Early Life • Most common mental health disorder in childhood and adolescence (32%) • Can significantly affect academic, social, and interpersonal functioning and can lead to adult anxiety disorders • Include: • Social phobia • Separation anxiety disorder • Selective mutism

6. Anxiety, Trauma, and Stressor-Related Disorders in Early Life (cont’d.) • Post-traumatic stress disorder in early life: • Recurrent, distressing memories of a shocking experience, such as experience with death, serious injury, or sexual violation • Memories may entail: • Distressing dreams • Intense physiological or psychological reactions to thoughts or cues associated with event and avoidance of those cues • Episodes of playacting the event • Dissociative reactions

7. Anxiety, Trauma, and Stressor-Related Disorders in Early Life (cont’d.) • Post-traumatic stress disorder in early life: • Children often display social withdrawal, diminished positive affect, and disinterest in previously-enjoyed activities • Lifetime prevalence: • 8% for girls and 2.3% for boys • Effective treatments include: • Trauma-focused cognitive-behavioral therapies

8. Depressive Disorders in Early Life • Youth with depressive disorders have more negative self-concepts and are more likely to engage in self-blame and self-criticism • Early-onset depressive symptoms tends to predict a more chronic and severe course • Evidence-based treatment for depression: • Individual, group, or school-based cognitive-behavioral therapy • SSRIs increase suicidality but benefits may outweigh risk

9. Nonsuicidal Self Injury • Involves induction of bleeding, bruising, or pain by means of intentional, self-inflicted injury, without suicidal intent • Intense negative affect or cognitions and a preoccupation with engaging in self-harm typically precede episodes of NSSI • Expectation that mood will improve after episode

10. Nonsuicidal Self Injury (cont’d.) • Prevalence: • 14-17% of adolescents and young adults have engaged in self-injury at least once • Two thirds of those who engage in NSSI begin the behavior in adolescence. • Increased risk of attempted suicide • Treatment includes: • Teaching problem-solving, coping and emotional-regulation skills • Focus on emotional expression and improving interpersonal relationship skills

11. Attachment Disorders • Exposure to early environments devoid of predictable caretaking and nurturing can cause significant difficulties with emotional attachment and social relationships • Includes: • Reactive attachment disorder (RAD) • Disinhibited social engagement disorder (DSED)

12. Attachment Disorders (cont’d.) • Reactive attachment disorder: • Inhibited, avoidant social behaviors and reluctance to seek or respond to attention or nurturing • Show little trust that needs will be attended to and do not readily seek nor respond to comfort, attention, or nurturing • Use avoidance or ambivalence as psychological defense • Limited positive emotion and may demonstrate irritability, sadness, or fearfulness when interacting with adults

13. Attachment Disorders (cont’d.) • Disinhibited social engagement disorder: • Indiscriminate, superficial attachments and desperation for interpersonal contact • Socialize effortlessly, but indiscriminately, and become superficially “attached” to strangers or acquaintances • History of harsh punishment or inconsistent parenting, as well as emotional neglect and limited attachment opportunities • Exposure to maltreatment or maternal psychiatric hospitalizations are particularly vulnerable

14. Attachment Disorders (cont’d.) • Course depends on severity of social deprivation, abuse, neglect or disruptions in caregiving, and subsequent events in the child’s life • Symptoms of RAD can disappear whereas symptoms of DSED are more persistent • Effective intervention: • Providing stable, nurturing environment, and opportunities to develop interpersonal trust and social skills

15. Externalizing Disorders of Childhood • Also known as disruptive behavior disorders: conditions associated with socially disturbing symptoms and distressing others • Include: • Disruptive mood dysregulation disorder • Oppositional defiant disorder • Conduct disorder • Early intervention is necessary

16. Externalizing Disorders of Childhood (cont’d.) • Diagnosis is controversial, and requires a pattern of behavior that is: • Atypical for the child’s gender, age, and developmental level • Persistent • Severe enough to cause significant impairment in social, academic, or vocational functioning

17. Disruptive Mood Dysregulation Disorder • Characterized by chronic irritability and significantly exaggerated anger reactions • Patterns begin in early childhood • Diagnosis requires that symptoms persist beyond age six • Predictive of later depressive and anxiety disorders • Clinicians need to rule out PBD due to symptom overlap

18. Oppositional Defiant Disorder • Pattern of negativistic, argumentative, and hostile behavior in which children often: • Lose their temper • Argue and defy adult requests • Primarily directed toward parents, teachers, and others in authority • No serious violation of societal norms • Two components: • Negative affect • Oppositional behavior

19. Conduct Disorders • Persistent pattern of behavior that violates rights of others • Reflect dysfunctions in individual and include: • Serious violations of rules and social norms • Cruelty and deliberate aggression towards people or animals • Theft, deceit, and vandalism • Callous and unemotional subtype • Often exhibit antisocial personality disorder in adulthood

20. Conduct Disorders (cont’d.) • Prevalence: • Approximately 2-9% of youth meet criteria • 50% display inattention and hyperactivity • Gender differences: • Males display confrontational aggression • Females display truancy, substance abuse, or chronic lying • More persistent than other childhood disorders

21. Etiology of Externalizing Disorders Figure 15-1 Multipath Model of Conduct Disorder The dimensions interact with one another and combine in different ways to result in a conduct disorder

22. Etiology of Externalizing Disorders (cont’d.) • Biological factors: • Appear to exert greatest influence on CD. • Aggressive behavior linked to brain abnormalities and reduced activity in amygdala • “Low MAOA” and childhood maltreatment • Reduced autonomic nervous system activity • Cortisol (stress levels)

23. Etiology of Externalizing Disorders (cont’d.) • Social and sociocultural: • Family and social context play large role • Large families and marital breakdown • Economic stress • Crowded living conditions • Harsh or inconsistent discipline • Maternal or peer rejection • Parent-child conflict and power struggles • Limited parental supervision

24. Etiology of Externalizing Disorders (cont’d.) • Psychological factors: • Difficult child temperament (irritable, resistant, impulsive tendencies) • Underlying emotional issues • Depression frequently coexists with ODD and DMDD

25. Treatment of Externalizing Disorders • Must consider family and social context of behaviors and psychosocial skills deficits • CD is particularly difficult to treat • Effective when implemented before patterns of disruptive behavior are established • Parent-focused interventions regarding child management techniques

26. Treatment of Externalizing Disorders (cont’d.) • Psychosocial interventions that focus on: • Assertiveness-training • Anger management techniques • Building skills in empathy, communication, social relationships and problem-solving • Mobilizing adult mentors

27. Neurodevelopmental Disorders • Involve impaired development of the brain and central nervous system • Symptoms become increasingly evident as child grows and develops • Include: • Tic disorders • Attention-deficit hyperactivity disorder • Autism spectrum disorders • Intellectual and learning disorders

28. Tics and Tourette’s Disorder • Tics: • Involuntary, repetitive movements or vocalizations • Motor tic: • Eye-blinking, facial-grimacing, head-jerking, foot tapping, flaring of nostrils, and contractions of the shoulders or abdominal muscles • Vocal tics: • Coughing, grunting, throat clearing, sniffling, or sudden repetitive and stereotyped outburst of words

29. Tics and Tourette’s Disorder (cont’d.) • Tics: • Short-term suppression of a tic is possible, but results in subsequent increases in the tic • Some report feeling tension build prior to tic, followed by a sense of relief after tic occurs • Stress can increase frequency and intensity • Provisional tic disorders (2.6% of children) • Chronic motor or vocal tic disorders (3.7% of children)

30. Tics and Tourette’s Disorder (cont’d.) • Tourette’s disorder (TD): • Characterized by multiple motor tics and one or more vocal tic, present for at least one year • Onset is prior to age 18 • About 8% show complete remission • Symptoms can be severe or mild • Coprolalia (involuntary uttering of obscenities or inappropriate remarks) or motor movements involving self-harm (e.g., punching oneself) occur in about 10 percent of those with TD • Comorbid conditions

31. Tics and Tourette’s Disorder (cont’d.) • Etiology: • Both chronic tic disorder and TD appear to be genetically transmitted • Treatment: • Psychotherapy can help with distress • the technique of habit reversal , which involves teaching a behavior that is incompatible with the tic, is an effective treatment • Although antipsychotic medication used for severe tics, medication is not typically used to treat tic disorders.

32. Attention-Deficit/Hyperactivity Disorder • Characterized by persistent inattention and/or impulsive, hyperactive behaviors • Symptoms must interfere with social, academic, or occupational activities • Diagnosis requires that symptoms begin before age 12 and persist for at least six months • Poor regulation of attentional processes

33. Attention-Deficit/Hyperactivity Disorder (cont’d.) • Prevalence rates vary between studies • One study: 8.7% • More than twice as likely in boys than in girls • Symptoms tend to improve in late adolescence • Associated with behavioral and academic problems • Risk of coexisting conditions is four times greater among children living in poverty

34. Attention-Deficit/Hyperactivity Disorder: Etiology • Biological dimension: • Highly heritable with up to 80% of symptoms explainable by genetic factors • Rare inherited gene mutations • Chromosomal DNA deletions and duplications • Genes affecting regulation of dopamine and glutamate • Hypotheses about neurological mechanisms • Reduced activity in prefrontal cortex • Differences in brain structure and circuitry in frontal cortex, cerebellum, and parietal lobes • Low dopamine levels

35. Attention-Deficit/Hyperactivity Disorder: Etiology (cont’d.) • Biological dimension: • Prematurity • Oxygen deprivation during birth • Low-birth weight • Lead and PCB exposure • Viral infections, meningitis, and encephalitis • Maternal smoking, drug, and alcohol abuse during pregnancy • Possible involvement of food additives

36. Attention-Deficit/Hyperactivity Disorder: Treatment • Stimulants such as methylphenidate (Ritalin) receive most evidence-based support • Normalize neurotransmitter functioning and increased neurological activation in frontal cortex • Increased rates of stimulant medication use in U.S.

37. Attention-Deficit/Hyperactivity Disorder: Treatment (cont’d.) • Evidence that behavioral and psychological treatments are highly effective • Modifying environment and social context can enhance feelings of competence, motivation, and self-efficacy • Coordination of all services result in most successful interventions

38. Autism Spectrum Disorders • Characterized by impairment in social communication and restricted, stereotyped interests and activities • Symptoms range from mild to severe • Prevalence: • Affects one out of 100-110 children • Four times as common in boys • Approximately two thirds have IQ scores lower than 70

39. Autism Spectrum Disorders (cont’d.) • Symptoms of autism spectrum disorder: • Deficits in social communication and social interaction • Atypical social-emotional reciprocity • Atypical nonverbal communication • Difficulties developing and maintaining relationships

40. Autism Spectrum Disorders (cont’d.) • Symptoms of autism spectrum disorder: • Repetitive behavior or restricted interests or activities involving at least two of following: • Repetitive speech, movement, or use of objects • Intense focus on rituals or routines and strong resistance to change • Intense fixations or restricted interests • Atypical sensory reactivity • Autistic savants • Individual with ASD who performs exceptionally well on certain tasks

41. Autism Spectrum Disorders (cont’d.) • Problems diagnosing autism: • Typical procedures include clinical observation, parent interviews, developmental histories, autism screening inventories, communication assessment, and psychological testing • Autism is usually diagnosed at age three or later • symptoms sometimes appear following a period of apparently normal social and intellectual development, with deterioration of skills beginning around 6–12 months of age • Children with this pattern of regression (referred to as regressive autism) often develop more severe symptoms compared to autistic children without this pattern

42. Autism Spectrum Disorders: Etiology • Biological dimension: • Unique patterns of metabolic brain activity • Abnormally high levels or serotonin • Differences in brain anatomy and connectivity in brain regions associated with autistic traits • Accelerated growth or amygdala • Accelerated head growth • Genetic mutations have been implicated when ASD is diagnosed in multiple family members • Closely space pregnancies

43. Autism Spectrum Disorders: Etiology (cont’d.) • Biological dimension: • Genetic factors • Heritability estimated to be around .73 percent for males and .87 for females • Autistic traits have high heritability • Clear evidence for genetic susceptibility • Innate vulnerability triggered by environment • Nutritional deficits, changes in immune system, low birth weight • The study relating ASD to vaccine was deemed fraudulent when it was found that the lead author had manipulated the data for monetary gain.

44. Autism Spectrum Disorders: Etiology (cont’d.) • Psychological dimension: • Children with ASD seldom make eye contact, seek social connectedness, or bid for attention • Prefer to be alone and ignore parental efforts at connection • High stress levels among family due to ASD • Psychological and social factors play a role in manifestation of symptoms, but ASD is primarily influenced by biological factors • In response, others’ attempts to maintain social connection often diminish, further adding to the child's isolation.

45. Autism Spectrum Disorders: Intervention and Treatment • Prognosis is mixed; most children retain diagnosis and require support for life • Individuals with higher levels of cognitive-adaptive functioning fare better than those with intellectual disabilities and severe autistic symptoms • Significant recovery linked with intense early intervention

46. Autism Spectrum Disorders: Intervention and Treatment (cont’d.) • Medications are used to decrease anxiety, repetitive behaviors, and hyperactivity • Minimally effective and may be harmful • Risperidone alone received FDA approval: • Preliminary research suggests that oxytocin (a hormone related to social bonding) can increase social interactions in adults and teens with mild ASD • Comprehensive treatment programs have enabled children with ASD to develop more functional skills

47. Autism Spectrum Disorders: Intervention and Treatment (cont’d.) • Interventions with most significant gains: • Social communication • Environmental enrichment • Reinforcing appropriate attention and response to social stimuli • Preventing repetitive behaviors • Sustained practice of weaker skills • Reducing environmental stress • Improving sleep and nutrition

48. Intellectual Developmental Disorder • Limitations in intellectual functioning and adaptive behaviors including: • Significantly below average general intellectual functioning (generally IQ of 70 or less) • Deficiencies in adaptive behavior that are lower than would be expected based on age or cultural background • Only diagnosed when low intelligence is accompanied by impaired adaptive functioning

49. Intellectual Developmental Disorder (cont’d.) • Four distinct categories: • Mild: IQ score 50-55 to 70 • Moderate: IQ score 35-40 to 50-55 • Severe: IQ score 20-25 to 35-40 • Profound: IQ score below 20-25

50. Intellectual Developmental Disorder (cont’d.)