Overview of Clinical Psychiatry with Children

1
Overview of Clinical Psychiatry with Children
Adolescents

• Jennifer K. Yates, M.A.
• Jeff Baker, Ph.D.

2
Clinical Interview Evaluation

• Chapter 36

3
Child Psychiatry

• Must be familiar with normal development and
  remember what is normal for one age may be a
  problem for another
• Example Tantrum Behavior
• 2 year old normal and expected behavior
• 12 year old not expected within normal
  development
• Confidentiality directly related to age of
  child/adolescent
• Young child all information shared with
  caretaker
• Adolescent try to establish privacy agreement
  between caretaker and adolescent with
  understanding of what must be shared (significant
  danger to self and/or others, abuse)

4
Interview and Evaluation

• As developmental level and age of child increases
  
• Spend proportionally more time in direct
  interaction with child and adolescent and less
  with caregiver
• Continue to acquire thorough history from
  caregiver
• Clinical Interview with child, caregiver, and
  family
• Current concern and history of behavior/symptoms
  of concern
• Childs psychiatric, medical, and developmental
  history
• Familys psychiatric and medical history 3
  generations
• Current functioning in school setting history
  of such functioning
• Observation of interaction among family members
  and childs behavior independent of interaction
• Family social history and current make-up
  (marital status)
• Peer relationships history

5
Interview and Evaluation

• Additional methods of evaluation in psychiatric
  assessment
• Refer for Psychological Evaluation
• Standardized assessment of childs intellectual
  level, academic achievement, personality
  development, and emotional functioning
• Utilize structured interviews in conjunction with
  other interview
• K-SADS Kiddie Schedule for Affective Disorders
  and Schizophrenia
• DISC-R Diagnostic Interview Schedule for
  Children Revised
• Utilize behavioral rating scales input from
  teachers as well
• Child Behavior Checklist (CBCL) Teacher Report
  Form, Parent Form
• Behavioral Assessment Schedule for Children
  (BASC) Parent and Teacher Forms
• Conners Rating Scales Teacher and Parent
  Long/Short Forms (ADHD)

6
Interview and Evaluation

• Children are excellent informants about their
  symptoms
• Older children and adolescents are excellent
  informants about their feelings as well
• Very young children may be better and showing
  their feelings through play

7
Infant Referrals and Evaluation

• Potential infant referrals
• Irritability, difficulty being consoled, sleep or
  eating difficulties, withdrawn behavior, lack of
  engagement (initiation or response),
  developmental delay
• Components to Evaluation of an Infant
• Motor development - Activity Level
• Language Development - Adaptation to daily
  routines
• Social development
• Engagement in play
• Relationship History
• Social responsiveness and initiation

8
School Age Referral and Evaluation

• Potential referrals
• School problems, behavior problems at home or
  school, eating or sleeping difficulties,
  socialization difficulties, emotional concerns
• Format of Evaluation of School Aged Child
• Provide open-ended questions and/or multiple
  choice questions
• Allow time for unstructured play may need to
  occur throughout interview process
• Draw a picture of their family together and
  describe
• Ask them to list 3 wishes
• Ask them to describe their favorite and least
  favorite aspects of home and subjects/aspects of
  school
• Acquire thorough chronological history from
  caregiver

9
Adolescent Referral and Evaluation

• Always acquire adolescents view and caregivers
  view without taking sides (VERY DIFFICULT AT
  TIMES)
• Potential Referrals
• Substance use/abuse, sexuality, socialization and
  management of relationships, behavior problems,
  emotional concerns or lability, school problems,
  concern for future
• Format of Evaluation of Adolescents
• Initial time with adolescent and caregivers, time
  alone with adolescent, and time alone with
  caregiver
• Open ended questions
• Question about suicide, aggressive intent,
  psychosis, sexual relationships, and substance
  use/abuse

10
Additional Evaluation Formats

• Family Interview
• All family members present discussing concerns
• Validate all perspectives
• Neuropsychiatric Assessment
• Neurological Evaluation for hard signs focal
  lesions or deficits
• Neurological Evaluation for soft signs diffuse
  (e.g., PANESS)
• If necessary EEG, CT, MRI
• Developmental, Psychological, Educational Testing
• On pages 1134-1135 (Table 36-3) examples of tests
  
• CONSTANTLY UPGRADING ASSESSMENT INDICES

11
Standard Scores Comparison

• At times you will receive test scores and want to
  know how that child/adolescent rates when
  compared to same age peers

12
Diagnosis

• Utilize DSM-IV-TR (APA, 2000)
• Will apply if concerns result in impairment in
  one or more settings (social, occupational,
  school functioning)
• Will need to address clinical situations and
  stressors that go beyond the DSM-IV-TR and
  intervene
• Impairment in family dynamics
• Learning difficulties that dont meet DSM-IV-TR
  criteria
• Psychiatric disturbance in caregiver
• Physical Abuse, Sexual Abuse, Neglect

13
Child Adolescent Psychological Disorders

• Chapters 37-49

14
Mental Retardation

• This disorder is characterized by significantly
  subaverage intellectual functioning (an IQ of
  approximately 70 or below) with onset before age
  18 years and concurrent deficits or impairments
  in adaptive functioning. (APA, 2000)
• American Association of Mental Retardation (AAMR)
  considers an IQ of 75 and below deficient
  intellectual functioning and maintains the
  necessity for concurrent impairment in adaptive
  functioning as well as onset before 18 years.

15
Mental Retardation

• International Statistical Classification of
  Diseases and Related Health Problems, Tenth
  Edition (ICD-10) has a divergent opinion on
  classification of mental retardation from the
  DSM-IV-TR and AAMR
• A condition of arrested or incomplete
  development of the mind characterized by
  impaired developmental skills that contribute to
  the overall level of intelligence.(Kaplan
  Sadock, 1998, p.1137)
• One must have a reduced level of intellectual
  functioning resulting in diminished ability to
  adapt to the daily demands of the normal social
  environment. (Kaplan Sadock, 1998, p. 1137)
• The difference in definition is related to the
  concern that tests of intelligence may be
  culturally biased and without specific norms that
  are created with local culture they believe a
  diagnosis based on such information is must be
  regarded as provisional.

16
Mental Retardation - Categorization

• The DSM-IV-TR and AAMRs classification systems
  separate mental retardation into categories based
  on the degree of severity (Intellectual Quotient)
• Mild Mental Retardation IQ level 50-55 to
  approximately 70
• AAMR would include up to IQ levels of 75
• Moderate Mental Retardation IQ level 35-40 to
  50-55
• Severe Mental Retardation IQ level 20-25 to
  35-40
• Profound Mental Retardation IQ level below 20
  or 25

17
Mental Retardation - Categorization

• The ICD-10 classification system separates the
  diagnosis into categories based on cognitive
  abilities and the extent of behavior impairment
• Cognitive Ability Classification
• Mild IQ range 50-69, Mental age - 9 to under
  12
• Moderate IQ range 35-49, Mental age - 6 to
  under 9
• Severe IQ range 20-34, Mental age - 3 to under
  6
• Profound IQ below 20, Mental Age Less than 3
• Extent of Associated Impairment of Behavior
• None or minimal
• Significant
• Requiring treatment or attention
• Other impairments
• No mention of impairments

18
Mental Retardation Adaptive Deficits

• Impairments/Deficits in Adaptive Functioning
• The persons effectiveness in meeting the
  standards expected for his or her age by his or
  her cultural group are effected (APA,
  2000)
• Such impairments/deficits must be present in at
  least 2 of the following areas
• Communication
• Self-care
• Home Living
• Social/Interpersonal Skills
• Use of Community Resources
• Self-Direction
• Functional Academic Skills
• Work
• Leisure
• Health and Safety

19
Mental Retardation Clinical Features

• Clinical features that occur with greater
  frequency in people who are mentally retarded
  than in the general population. (Kaplan
  Sadock, 1998, p. 1150)
• Hyperactivity
• Low Frustration Tolerance
• Aggression
• Affective Instability
• Repetitive, Stereotypic Motor Behaviors
• Self-Injurious Behaviors
• Part of comorbid psychiatric disorder or direct
  sequelae of mental retardation?

20
Mental Retardation - Statistics

• Prevalence
• Approximately 1
• Different studies report different rates due to
  various classification systems
• Also difficult to assess because of varied onset
• Mental Retardation is about 1 times more common
  among men than among women. (KS)
• Possibly due to existence of X-linked syndromes
  leading to Mental Retardation (Pulsifer, 1996)
• In older populations the prevalence of Mental
  Retardation is less due to high mortality rates

21
Mental Retardation - Etiology

• Many cases of Mental Retardation (MR) are of
  idiopathic origin (unknown cause)
• 45-62 of Mild MR cases the etiology is unknown
• 25-40 of Severe MR cases the etiology is unknown
• (Pulsifer, 1996)
• 85 of all mentally retarded individuals fall
  under the classification of Mild Mental
  Retardation

22
Mental Retardation - Etiology

• Known Causes of Mental Retardation
• Genetic Factors
• Downs Syndrome most common genetic cause of
  mental retardation (Pulsifer, 1996)
• Fragile X Syndrome most common known inherited
  cause of mental retardation (Pulsifer, 1996)
• Prader-Willi Syndrome
• Phenylketonuria
• Retts Disorder
• Adrenoleukodystrophy
• Prenatal Factors
• Fetal Alcohol Syndrome leading single known
  cause of mental retardation (Pulsifer, 1996),
  Prenatal Substance Exposure
• AIDS, Rubella, Herpes Simplex, Complications of
  Pregnancy (diabetes)

23
Mental Retardation - Etiology

• Known Causes of Mental Retardation (MR)
• Perinatal Factors
• Premature infants who sustain intracranial
  hemorrhages
• Acquired Childhood Disorders
• Infection
• Meningitis and Encephalitis
• Head Trauma
• Brain Damage
• Other than head trauma (e.g., near drowning)
• Environmental and Sociocultural Factors
• Prevalent among people of culturally deprived low
  socioeconomic groups
• Poor prenatal and postnatal care
• Family instability with inadequate caretakers is
  common
• Parents with psychiatric disorders more common in
  low socioeconomic populations

24
Mental Retardation - Assessment

• Referral is often for problem other than
  suspected mental retardation
• Academic problems, Learning Disorder, ADHD
• Typical Presentation
• Not doing well in school
• Often overactive and inattentive
• Often uncoordinated
• Social problems
• Generally compliant child not following
  directions
• Delays in reaching developmental milestones

25
Mental Retardation - Assessment

• History
• Pay particular attention to
• Family history of mental retardation
• Family history of chromosomal abnormalities
• Difficulties with pregnancy, labor, or delivery
• Exposure to toxins
• Socioeconomic status and cultural background
• Utilize the mentally retarded client as an
  informant as well as caregiver/guardian

26
Mental Retardation - Assessment

• Psychiatric Interview
• Supportive explanation of the diagnostic process
  is important to ensure valid responding
  especially when client is informant
• Do not interact with client based on their
  reported mental age
• Client may be aware of cognitive limitations be
  sensitive to this
• 10 year mental age does not mean client acts as a
  10 year old Client may feel degraded or believe
  they are expected act in younger manner
• Do not use leading questions or response options
  suggestible and may respond in manner based on
  wish to please others
• Give client plenty of time to respond may
  process information slowly
• Assess receptive/expressive language through
  observation
• Evaluate self-confidence, tenacity, impulse
  control, frustration tolerance, curiosity

27
Mental Retardation - Assessment

• Physical Examination
• Head size, dysmorphic facial features, facial
  expression, tone
• Neurological Examination
• Assess for motor disturbances, poor coordination,
  hearing deficits, visual deficits, presence of
  seizure activity, hydrocephalus, and/or cortical
  atrophy
• Laboratory Tests
• Examine urine and blood specimens for evidence of
  metabolic disorders and/or chromosomal disorders
• Hearing and Speech Evaluations
• Important to continue throughout development to
  rule in or out hearing and/or language deficits
  as explanation for overall deficits

28
Mental Retardation - Assessment

• Psychological Evaluation
• Psychological testing performed by an experienced
  psychologist is essential in diagnosis of MR
• Significant controversy about correlation between
  developmental quotients based on tests
  administered to infants/toddlers and intelligence
  quotients later in life
• Must administer
• Standardized Intelligence Tests (WISC-III, SB-IV)
• Noted to penalize culturally deprived individuals
• Standardized Adaptive Measures (Vineland, SIB-R)

29
Mental Retardation Intervention

• Special Education Services for Child/Adolescent
• Comprehensive program that addresses
• Adaptive Skills Training
• Social Skills Training
• Vocational Training
• Group Therapy Practice managing hypothetical
  real-life problems while receiving supportive
  feedback
• Behavioral and Cognitive Therapy
• Positive reinforcement for desired behaviors and
  punishment for objectionable behaviors
• Relaxation exercises with self-instruction

30
Mental Retardation - Intervention

• Family Education
• Education about methods to enhance childs
  competence and self-esteem while maintaining
  realistic expectations
• Education regarding balance between fostering
  independence and providing a supportive
  environment
• Encourage family members participation in
  psychotherapy
• Express guilt, despair, anger, frustration
• Provide family members with basic and current
  medical information regarding causes and
  treatment of mental retardation

31
Mental Retardation - Intervention

• Social Intervention
• Address social isolation and social skills
  deficits
• Special Olympics raises social competence
• Pharmacological Intervention
• Aggression and Self-injurious Behaviors
• Stereotypical Motor Movements
• Explosive Rage Behavior
• Attention-Deficit/Hyperactivity Disorder
• Emotional Concerns (e.g., Depression, Anxiety,
  Etc.)

32
Learning Disorders

• These disorders are characterized by academic
  functioning that is substantially below that
  expected given the persons chronological age,
  measured intelligence, and age-appropriate
  education. (APA, 2000)
• Must be distinguished from difficulties arising
  from lack of opportunity, poor teaching, and/or
  cultural factors
• Types of Learning Disorders
• Reading Disorder
• Mathematics Disorder
• Disorder of Written Expression
• Learning Disorder Not Otherwise Specified

33
Learning Disorders

• ICD-10 Description
• Developmental Disorders of Scholastic Skills
  within Disorders of Psychological Development
  category
• Onset during infancy or childhood
• Delay or impairment of development strongly
  related to maturation of the central nervous
  system
• Must exhibit a steady course
• Usually of unknown cause possible family
  history of related difficulties indicative of
  genetic origin
• Specific Developmental Disorders of Scholastic
  Skills
• Specific reading disorder
• Specific spelling disorder
• Specific disorder of arithmetic skills,
• Mixed disorder or scholastic skills
• Developmental disorders of scholastic skills
  unspecified

34
Learning Disorders Typical Presentation

• Parents may report
• Hes just not doing very well at math
• Reading has always been really hard for her
• All his other grades are ok
• Hes not stupid, I dont know why he doesnt do
  well in school
• Her dad has always had trouble with reading too

35
Learning Disorders - Assessment

• Administer an individually administered
  standardized intelligence test
• Administer an individually administered
  standardized academic achievement test
• Compare the childs IQ score with the childs
  achievement standard score
• A significant discrepancy between these two
  scores is indicative of a learning disorder
• Different states have different standards for
  ascertaining significance of discrepancy
• Some require 1.5 standard deviation discrepancy
  approximately 22 points
• Some require 2 standard deviation discrepancy
  30 points

36
Learning Disorders - Reading

• Reading Disorder Dyslexia
• Reading achievement is substantially below that
  expected given chronological age, measured
  intelligence, and age-appropriate education
• Measured by individually administered
  standardized test of reading accuracy, rate, or
  comprehension
• Equal among males and females with accurate
  assessment
• More males may be identified initially due to
  disruptive behaviors
• Prevalence 4 of school-aged children
• Etiology
• Tends to be more prevalent among family members
  of those affected by the disorder genetic
  studies not definitive currently
• Possibly related to subtle deficits in particular
  cortical regions of the brain specifically
  associated with oral language, encoding, and
  working memory

37
Learning Disorders - Reading

• Treatment
• Modifications/accommodations provided by the
  school
• Extra time on written tests
• Marking but not downgrading spelling errors
• Oral exams for severely impaired dyslexics
• Individual tutoring in phonics based approach to
  reading phonological coding skills
• Older dyslexics may need help with reading
  comprehension strategies and study skills
• Caregivers take on the role of advocate,
  facilitator of appropriate interventions, and
  source of emotional support
• Individuals with a Reading Disorder can learn
  phonological coding and reading comprehension
  strategies rate of learning is slower than
  general population (Pennington, 1991)

38
Learning Disorders - Mathematics

• Mathematics Disorder
• Mathematical ability is substantially below that
  expected given the persons chronological age,
  measured intelligence, and age-appropriate
  education (APA, 2000)
• Measured by an individually administered
  standardized test of mathematical calculation
  or reasoning
• Skills potentially impaired in Mathematics
  Disorder
• Linguistic Skills understanding or naming
  mathematical terms, operations, or concepts and
  decoding written problems into mathematical
  symbols
• Perceptual Skills recognizing or reading
  numerical symbols or arithmetic signs and
  clustering objects into groups
• Attention Skills copying numbers or figures
  correctly, remembering to add in carried numbers,
  and observing operational signs
• Mathematical Skills following sequences of
  mathematical steps, counting objects, and
  learning multiplication tables

39
Learning Disorders - Mathematics

• Prevalence estimated at 1 of school-aged
  children
• Treatment
• Modifications/accommodations within school
  setting
• Utilize graph paper to address perceptual
  difficulties
• Highlight arithmetic sign to address attention
  difficulties
• Extra tutoring to address deficits in
  mathematical skills and linguistic skills
• Additional instruction/tutoring with focus on
  problem solving activities including word
  problems addresses social skills deficits as
  well

40
Learning Disorders Writing

• Disorder of Written Expression
• Writing skills are substantially below those
  expected given the persons chronological age,
  measured intelligence, and age-appropriate
  education (APA, 2000)
• Measured by an individually administered
  standardized test or functional assessment of
  writing skills
• Difficulties in the individuals ability to
  compose written texts as evidenced by
• Grammatical or punctuation errors within
  sentences
• Poor paragraph organization
• Multiple spelling errors
• Excessively poor handwriting
• Diagnosis typically not provided if deficits in
  only spelling or only poor handwriting

41
Learning Disorders - Writing

• Etiology
• Possible neurological deficits in the central
  information processing centers of the brain
• Most children with a disorder or written
  expression have relatives with the disorder
• Treatment
• Positive response to remedial treatment
  intensive, continuous, individually tailored,
  one-to-one expressive and creative writing
  therapy (provided in school)
• Psychological treatment of secondary emotional
  and behavioral problems

42
Motor Skills Disorder

• Developmental Coordination Disorder
• Performance in daily activities that require
  motor coordination is substantially below that
  expected given the persons chronological age and
  measured intelligence
• May be manifested by
• Marked delays in achieving motor milestones
  (walking)
• Dropping things
• Clumsiness
• Poor performance in sports
• Poor handwriting
• Keep in mind varies with age and cannot be result
  of medical condition
• Prevalence 6 for children between 5 and 11
  years of age

43
Motor Skills Disorder

• Etiology
• Unknown currently hypotheses include organic
  and developmental causes
• Risk factors prematurity, hypoxia, perinatal
  malnutrition
• Treatment
• School may provide occupational or physical
  therapy related services as an accommodation
• Perceptual motor training
• Modified physical education

44
Communication Disorders

• Disorders characterized by difficulties in
  speech or language (APA, 2000).
• Types of Communication Disorders (DSM-IV-TR)
• Expressive Language Disorder
• Mixed Receptive-Expressive Language Disorder
• Phonological Disorder
• Stuttering
• Communication Disorder Not Otherwise Specified
• ICD-10 Specific Developmental Disorders of
  Speech and Language
• Specific speech articulation disorder Expressive
  language disorder Receptive language disorder
  Acquired aphasia with epilepsy Other
  developmental disorders of speech and language

45
Communication Disorders - Assessment

• Similar to learning disorders
• Specific abilities deficit in relation to
  intellectual functioning
• Typically assessed by speech-language pathologist
• Indices typically used
• IQ test Nonverbal IQ Test typically needed
  (C-TONI)
• Standardized achievement test of language
  (CELF-III)
• Absolutely critical to rule out hearing
  impairment
• Must take into account cultural and language
  context (bi-lingual)

46
Communication Disorders Expressive Language
Disorder

• An impairment in expressive language development
  as demonstrated by scores on standardized
  individually administered measures of expressive
  language development substantially below those
  obtained from standardized measures of both
  nonverbal intellectual capacity and receptive
  language development (APA, 2000).
• May include
• Limited amount of speech - Limited range of
  vocabulary
• Difficulty acquiring new words - Word finding or
  vocabulary errors
• Shortened sentences - Simplified grammatical
  structures
• Limited varieties of grammatical structures
• Omissions of critical parts of sentences
• Use of unusual word order - Slow rate of
  language development

47
Communication Disorders Expressive Language
Disorder

• Prevalence
• In children under 3 10 to 15 of children
  (common)
• School-age 3 to 7 of children
• More common in boys than girls
• More likely to occur in individuals with a family
  history of communication or learning disorders

48
Communication Disorders Expressive Language
Disorder

• Etiology
• Primarily unknown
• Possible causes
• Subtle cerebral damage, maturational lags in
  cerebral development
• Left-handedness or ambilaterality increases risk
• Unknown genetic factors
• Treatment
• Language therapy designed to improve
  communication strategies and social interaction
  using language
• Prognosis good in most cases

49
Communication Disorders Mixed
Receptive-Expressive Language Disorder

• An impairment in both receptive and expressive
  language development as demonstrated by scores on
  standardized individually administered measures
  of both receptive and expressive language
  development that are substantially below those
  obtained from standardized measures of nonverbal
  intellectual capacity (APA, 2000)
• Impairment in language comprehension is the
  primary feature differentiating this from
  Expressive Language Disorder
• May include
• Intermittently appears not to hear, be confused,
  or not pay attention when spoken to
• Follows directives incorrectly or not at all
• Give tangential or inappropriate responses to
  questions
• Poor conversational skills (taking turn,
  maintaining a topic)

50
Communication Disorders Mixed
Receptive-Expressive Language Disorder

• Prevalence
• May occur in up to 5 of preschool children
• May occur in up to 3 of school-age children
• More common in males than females
• More common among first-degree biological
  relatives of those with the disorder than among
  general population
• Etiology primarily unknown
• Treatment
• Speech-language therapy (both individualized and
  in natural classroom setting)
• Prognosis worse than Expressive Language deficit
  alone and language acquisition is slower

51
Communication Disorders Phonological Disorder

• Failure to use developmentally expected speech
  sounds that are appropriate for the individuals
  age and dialect (APA, 2000).
• May include
• Errors in sound production, use, representation,
  or organization such as
• Substitutions of one sound for another
• Omissions of sounds
• Prevalence
• Approximately 2 in 6 to 7 year old children
• 0.5 by age 17 years
• More common in males

52
Communication Disorders Phonological Disorder

• Etiology
• Primarily unknown - Unknown genetic impairment
• Perinatal difficulties - Hearing impairment
• Maturational delay in neurological process
  underlying speech
• Neurological impairment
• Dysarthria poor articulation impairment in
  neural mechanisms regulating the muscular control
  of speech
• Apraxia loss of movement impairment in the
  muscle function itself
• Treatment
• Speech Therapy speech-language pathologist

53
Communication Disorders - Stuttering

• Disturbance in normal fluency and time
  patterning of speech that is inappropriate for
  the individuals age (APA, 2000)
• May include
• Frequent repetitions of prolongations of sounds
  or syllables
• Broken words (pauses within a word)
• Interjections
• Audible or silent blocking (filled or unfilled
  pauses in speech)
• Circumlocution (word substitutions to avoid
  problematic words)
• Words produced with an excess of physical tension
• Monosyllabic whole word repetitions

54
Communication Disorders - Stuttering

• Prevalence
• 1 in pre-pubertal childrenusually develops
  before the age of 12
• 0.8 in adolescence
• More common in males male to female ratio 31
• Etiology
• Unknown genetic factor
• Risk among first degree biological relatives is
  more than three times the risk in the general
  population
• Men with a history of stuttering about 10 of
  their daughters and 20 of their sons with
  stutter (APA, 2000)
• Exacerbated by stressful situations
• Associated with social anxiety, withdrawal, and
  secondary anxiety disorders ANXIETY DOES NOT
  CAUSE STUTTERING

55
Communication Disorders - Stuttering

• Etiology continued
• Organic theories
• Incomplete lateralization or abnormal cerebral
  dominance
• Over-representation of left-handedness and
  ambidexterity
• Learning theories
• Stuttering is a learned response to normative
  early childhood dysfluencies
• Stuttering is classically conditioned to certain
  environmental factors
• Treatment
• Breathing exercises relaxation techniques
• Speech therapy to help children slow the rate of
  speaking and modulate speech volume

56
Pervasive Developmental Disorders

• Disorders characterized by severe deficits and
  pervasive impairment in multiple areas of
  development. These include impairment in
  reciprocal social interaction impairment in
  communication, and the presence of stereotyped
  behavior, interests, and activities (APA, 2000).
• Types of Pervasive Developmental Disorders
• Autistic Disorder
• Retts Disorder
• Childhood Disintegrative Disorder
• Aspergers Disorder
• Pervasive Developmental Disorder Not Otherwise
  Specified

57
Pervasive Development Disorders Autistic
Disorder

• Presence of markedly abnormal or impaired
  development in social interaction and
  communication and a markedly restricted
  repertoire of activity and interests (APA,
  2000).
• Onset in at least one area prior to age 3
• May include
• Lack of spontaneous seeking to share enjoyment
  and activities
• Impairment in nonverbal behaviors eye
  contact/body language
• Delay or total lack of the development of spoken
  language
• Stereotyped or repetitive use of language
• Preoccupation with one or more stereotyped and
  restricted patterns of interest ABNORMAL IN
  INTENSITY OR FOCUS
• Stereotyped and repetitive motor mannerisms

58
Pervasive Developmental Disorders Autistic
Disorder

• Prevalence
• 5 cases per 10,000 individuals (0.05) reported
  rates range from 2 to 20 cases per 10,000
  individuals
• Approximately one-fifth of autistic children have
  a normal nonverbal intelligence
• Rates of Autistic Disorder are 4 to 5 times
  higher in males, however, females with Autistic
  Disorder are more likely to exhibit severe Mental
  Retardation
• Increased risk of Autistic Disorder among
  siblings of individual with the disorder
  approximately 5 of siblings also exhibiting the
  condition

59
Pervasive Developmental Disorders Autistic
Disorder

• Etiology
• Neurological Factors lesions, seizures
• Genetic Factors high concordance in twin
  studies
• Immunological Factors incompatibility between
  mother fetus
• Perinatal Factors nonspecific perinatal
  complications
• Neuroanatomical Factors total increased brain
  volume
• Biochemical Factors elevated plasma serotonin
• Treatment
• Goals
• Increase socially acceptable and prosocial
  behavior, decrease odd behavioral symptoms, and
  aid in the development of verbal/nonverbal
  communication
• Behavior modification programs with as much
  structure as possible Can be EXHAUSTING for
  parents
• Some medications used to treat aggression/self-inj
  urious behaviors

60
Pervasive Developmental Disorders Retts
Disorder

• Development of multiple specific deficits
  following a period of normal functioning after
  birth. Individuals have an apparently normal
  prenatal and perinatal period with normal
  psychomotor development through the first 5
  months of life. (APA, 2002)
• Must include
• Steady decline of functioning consistent with
  encephalopathy
• Head growth decelerates between 5 and 48 months
• Loss of previously acquired purposeful hand
  skills between ages 5 and 30 months, with
  development of stereotyped hand movements
• Interest in the social environment diminishes
• Appearance of poorly coordinated gait or trunk
  movements
• Severe impairment in receptive and expressive
  language development (loss of speech) with severe
  psychomotor retardation

61
Pervasive Developmental Disorders Retts
Disorder

• Prevalence
• Less common than Autistic Disorder
• Reported only in females shortened life span
• Etiology
• Unknown
• Progressive deteriorating course after an initial
  normal period is compatible with a metabolic
  disorder (Kaplan Sadock, 1998)
• Likely a genetic component twin studies with
  concordance
• Treatment
• Symptomatic intervention primarily
• Physiotherapy for muscular dysfunction
• Anticonvulsant treatment for seizures
• Behavior therapy to control self-injurious
  behaviors and help manage breathing
  disorganization

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Pervasive Developmental Disorders Childhood
Disintegrative Disorder

• Marked regression in multiple areas of
  functioning following a period of at least 2
  years of apparently normal developmentreflected
  in age appropriate verbal and nonverbal
  communication, social relationships, play, and
  adaptive behavior (APA, 2000).
• After first 2 years of life and before 10 years
  of age, un-explained significant loss of
  previously acquired skills in
• Expressive or Receptive Language
• Social skills or Adaptive Behavior
• Bowel or Bladder Control
• Play
• Motor skills
• Typically, acquired skills are lost in almost all
  areas

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Pervasive Developmental Disorders Childhood
Disintegrative Disorder

• Will exhibit social and communication deficits
  observed in Autistic Disorder after deterioration
  
• Qualitative impairment in social interaction
• Qualitative impairments in communication
• Restricted, repetitive, and stereotyped patterns
  of behavior, interests, and activities
• Prevalence
• Very rare, less common than Autistic Disorder
• Initial studies found equal sex ratio, current
  research states more common among males

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Pervasive Developmental Disorders Childhood
Disintegrative Disorder

• Etiology
• Unknown
• Been associated with other neurological
  conditions seizures, tuberous sclerosis and
  metabolic disorders
• Treatment
• Identical to Autistic Disorder
• Want to increase socially appropriate behavior,
  aid in development of language skills, and
  decrease repetitive stereotypies
• Utilize Behavior Therapy and Psychopharmacologicl
  treatment for aggression/self-injurious behaviors

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Pervasive Developmental Disorders Aspergers
Disorder

• Severe and sustained impairment in social
  interaction and the development of restricted,
  repetitive patterns of behavior, interests, and
  activities (APA, 2000)
• Social impairments may include restricted
  interests and behaviors
• Unlike Autistic Disorder, there are no
  clinically significant delays or deviance in
  language acquisition (APA, 2000)
• Single non-echoed words are used communicatively
  by age 2
• Spontaneous communicative phrases are used by age
  3
• There can be no clinically significant delay in
  cognitive development or in the development of
  self-help skills and/or adaptive behavior

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Pervasive Developmental Disorders Aspergers
Disorder

• Prevalence
• No definitive data currently (APA, 2000)
• Diagnosed more frequently (five times greater) in
  males
• Etiology
• Unknown
• Due to similarity with Autistic Disorder,
  genetic, metabolic, infectious, and perinatal
  hypotheses have been provided
• Treatment
• Similar to Autistic Disorder
• Increase socially appropriate behavior and
  decrease repetitive stereotyped mannerisms,
  interests, or activities

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Attention-Deficit/Hyperactivity Disorder

• Persistent pattern of inattention and/or
  hyperactivity-impulsivity that is more frequently
  displayed and more severe than is typically
  observed in individuals at a comparable level of
  development (APA, 2000).
• Some hyperactive-impulsive or inattentive
  symptoms that cause impairment must have been
  present before age 7 years, although many
  individuals are diagnosed after the symptoms have
  been present for a number of years (APA,
  2000).
• Some impairment must be present in at least two
  settings

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Attention-Deficit/Hyperactivity Disorder

• Symptoms of Inattention must have 6 or more
• Often fails to give close attention to details or
  makes careless mistakes in schoolwork, work, or
  other activities
• Often has difficulty sustaining attention in
  tasks or play activities
• Often does not seem to listen when spoken to
  directly
• Often does not follow through on instructions and
  fails to finish school-work, chores, or duties in
  the workplace (not oppositional)
• Often has difficulty organizing tasks and
  activities
• Often avoids, dislikes, or is reluctant to engage
  in tasks that require a sustained mental effort
• Often loses things necessary for tasks or
  activities
• Often easily distracted by extraneous stimuli
• Often forgetful in daily activities

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Attention-Deficit/Hyperactivity Disorder

• Symptoms of Hyperactivity-Impulsivity Must have
  6 or more
• Hyperactivity
• Often fidgets with hands or feet or squirms in
  seat
• Often leaves seat in classroom or in other
  situations in which remaining seated is expected
• Often runs about or climbs excessively in
  situations in which it is inappropriate
  (adolescents may be subjective feelings of
  restlessness)
• Often has difficulty playing or engaging in
  leisure activities quietly
• Often on the go or often acts as if driven by
  a motor
• Often talks excessively
• Impulsivity
• Often blurts out answers before questions have
  been completed
• Often has difficulty awaiting turn
• Often interrupts or intrudes on others

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Attention-Deficit/Hyperactivity Disorder

• Subtypes of Attention-Deficit/Hyperactivity
  Disorder
• Attention-Deficit/Hyperactivity Disorder,
  Combined Type
• Meet both inattentive and hyperactivity-impulsivit
  y criteria for past six months
• Attention-Deficit/Hyperactivity Disorder,
  Predominantly Inattentive Type
• Meet inattentive criteria for past six months
  but, does not meet hyperactivity-impulsivity
  criteria for past six months
• Attention-Deficit/Hyperactivity Disorder,
  Predominantly Hyperactive-Impulsive Type
• Meet hyperactivity-impulsivity criteria for past
  six months but, dont meet inattentive criteria
  in past six months

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References

• American Psychiatric Association Diagnostic and
  statistical manual of mental disorders, Fourth
  Edition, Text Revision. Washington, DC, American
  Psychiatric Association, 2000.
• Kaplan, H.I., Sadock, B.J. (1998). Synopsis of
  psychiatry Behavioral sciences/clinical
  psychiatry (8th ed.). Baltimore, Maryland
  Lippincott Williams Wilkins.
• Pennington, B.F. (1991). Diagnosing learning
  disorders a neuropsychological framework. New
  York The Guilford Press
• Pulsifer, M.B. (1996). The neuropsychology of
  mental retardation. Journal of the International
  Neuropsychological Society, 2, 159-176