Childpsychopathology

1
Intellectual Disability(Intellectual
Developmental Disorder ICD-11)

• DSM-5 Diagnostic Criteria
• A. Deficits in intellectual functions, such as
  reasoning, problem solving, planning, abstract
  thinking, judgment, academic learning, and
  learning from experience, confirmed by both
  clinical assessment and individualized,
  standardized intelligence testing. (Significantly
  subaverage general intellectual functioning is
  generally below 70 I.Q.)
• B. Deficits in adaptive functioning that result
  in failure to meet developmental and
  socio-cultural standards for personal
  independence and social responsibility. Without
  ongoing support, the adaptive deficits limit
  functioning in one or more activities of daily
  life, such as communication, social
  participation, and independent living, across
  multiple environments, such as home, school,
  work, and community.
• C. Onset of intellectual and adaptive deficits
  during the developmental period (18 years of
  age).
• Levels of severity (adaptive functioning is used
  now more often than IQ to determine the level of
  severity
• Mild 50-55 to 70 I.Q., Moderate 35-40 to 50-55
  I.Q.
• Severe 20-25 to 35-40 I.Q., Profound below 25
  I.Q.

2
Intellectual Disability

• Prevalence- About 2 of the population
• Gender- As many as 3 to 1 males. (Number of
  genetically linked disorders)
• Socioeconomic Status and Ethnicity
• Factors for racial differences
• cultural (e.g., value education
  less)
• environmental (e.g., lack of
  resources leads to understimulating home
  environment)
• biased testing
• discrimination which has led to
  genetic differences (Very politically sensitive
  issue)
• Comorbidity increased as much as 50 in
  the mild category
• Etiology genetic, prenatal, postnatal,
  familial-cultural (more risk factors increases
  the possibility)

3
Learning-Thinking Variables

• 1) Attention to Relevant Cues- Tested by
  discrimination learning Students need to see its
  importance and monitor it.
• 2) Attention-Difficulty in three areas
• 1) attention span (time on task)
• 2) focus (inhibition of distracting stimuli)
• 3) reaction time
• 3)Memory- Primarily short term memory problems
  mostly do to the lack of strategies including
  rehearsal, clustering, and mediation, retrieval,
  and metamemory. LTM is generally impacted by the
  lack of these strategies, but capacity is similar
  to others. (Stegens little blue book)
• Some improvement is possible, but since
  intellectually disabled students are inactive
  learners it is difficult.
• 4)Problem Solving Requires attention,
  abstraction, planning, and logical thinking.
  Cognitive development and abstract thinking
  Many will only reach concrete operations,
  therefore use of symbols, abstract thought, and
  problem-solving will all be deficient.
• 5)Generalization/Transfer Deficiencies in the
  ability to apply knowledge or skills to new tasks
  or problems. Inability to form a learning set

4
Intellectual Disability

• Personality-motivational factors
• The similar reaction hypothesis
• Zigler hypothesized that there is no basic
  difference between children who are and are not
  disabled in their reactions to life experiences.
  However, since there experiences might well be
  different, for example have repeated failure or
  institutionalization, the children with ID may
  have special motivational and personality
  characteristics.
• 1) Dependency and outerdirectedness
• Children with ID are more dependent
  upon adults and tend to constantly seek their
  attention and approval (positive reaction
  tendency). Along with this tendency goes
  outerdirectedness, an exaggerated need to look to
  others for the solution of problems.
• 2) Lower expectancy of success
• Because of repeated failure children
  who are retarded, have a lower expectancy of
  success.

5
Intellectual Disability

• 3) Lower mastery motivation
• There is a reduction in initiative.
  There is less interest and pleasure in tackling
  new tasks or meeting new challenges, less
  intrinsic reward in achievement for its own sake.
• 4) Poor self system-
• The self of a child who is disabled,
  is less differentiated than it is for children
  who are not disabled. In other words, this child
  does not often view the self in terms of
  different domains. For example, the normal child
  can tell you their strengths and weaknesses in
  different domains of the self, whereas the
  intellectually disabled child usually does not
  view themselves in these terms. Compared with
  nondisabled children, those with ID have a lower
  ideal self, perhaps due to their greater number
  of failures and to their being treated as
  incompetent.
• These children would not
• Know themselves as well (poor
  self-concept)
• Esteem themselves as highly
  (poor self-esteem)
• Be self-actualizing
  (poor self-realization)

6
Intervention

• Education- The PL 94-142 Education for All
  Handicapped Children Act provided a public
  education and related services for ID children
• 1) in the least restrictive environment which
  often means mainstreaming for some children
• 2) with an individualized education program
  (IEP)
• 3)Educable Intellectually Disabled (EID)
  (mild-I.Q. generally between 55 and 75 are
  expected to perform at a third grade level and as
  high as 6th grade at times)

7
Behavior Modification

• Operant conditioning- This involves changing
  undesirable behaviors by altering the specific
  consequences that reinforce them and by
  reinforcing new, more socially acceptable
  responses.
• Types of behaviors most often treated include
  self-help, work-oriented, social, nonacademic
  classroom, and undesirable behavior which is
  attention-getting, aggressive, or self-injurious.
• Prevention
• The most challenging work is done with mothers
  who are intellectually disabled, for their
  impaired parenting skills affect their children.
  
• In the Abecedarian Project the children at
  high risk for poor intellectual outcomes, were
  given an intensive preschool program (five full
  days a week), by the time they were three years
  old their I.Q. scores were 20 points higher.

8
Autismwww.autisticservices.org

• Autism was the first identified in 1943 by a
  psychiatrist at Harvard, Leo Kanner, who noticed
  that eleven of the disturbed children he was
  working with behaved in ways that were not
  typical of intellectual disability or
  schizophrenia.
• He named this syndrome infantile autism
  because he observed that there is from the start
  an extreme autistic aloneness that, whenever
  possible, disregards, ignores, shuts out anything
  that comes to the child from the outside.

9
Autism Spectrum Disorder

• Diagnostic criteria ( summary of DSM-5)
• A. Persistent deficits in social communication
  and social interaction.
• 1. Deficits in social emotional
  reciprocity, ranging, for example, from abnormal
  social approach and failure of normal
  back-and-forth conversation to reduced sharing
  of interests, emotions, or affect to failure to
  initiate or respond to social interactions.
• 2. Deficits in nonverbal communicative
  behaviors such as poorly integrated verbal and
  nonverbal communication, abnormal eye contact and
  body language, and total lack of facial
  expressions and nonverbal communication.
• 3. Deficits in developing, maintaining, and
  understanding relationships. For example
  difficulties adjusting behavior to suit various
  social contexts, difficulties in sharing
  imaginative play, and absence of interest in
  peers.

10
Autism Spectrum Disorder

• Diagnostic criteria (summary of DSM-5)
• B. Restricted repetitive patterns of behavior,
  interests, or activities as manifested by at
  least two of the following
• 1. Stereotyped or repetitive moter
  movements, use of objects, or speech (e.g.,
  simple motor stereotypies, lining up toys or
  flipping object, echolalia, idiosyncratic
  phrases).
• 2. Insistence on sameness, inflexible
  adherence to routines, or ritualized patterns of
  verbal or nonverbal behavior (e.g.,extreme
  distress at small changes, difficulties with
  transitions, rigid thinking patterns, greeting
  rituals, need to take same route or eat the same
  food every day).
• 3. Highly restricted, fixated interests that
  are abnormal in intensity or focus (e.g., strong
  attachment to or preoccupation with unusual
  objects, excessively circumscribed or
  perseverative interests).

11
Autism Spectrum Disorder

• Diagnostic criteria (summary of DSM-5)
• 4. Hyper- or hyporeactivity to sensory input or
  unusual interest in sensory aspects of the
  environment (e.g, apparent indifference to
  pain/temperature, adverse response to specific
  sounds or textures, excessive smelling or
  touching of objects, visual fascination with
  lights).
• C. Symptoms must be present in the early
  developmental period (but may not become fully
  manifest until social demands exceed limited
  activity capacities, or may be masked by learned
  strategies and later life).
• D. Symptoms cause clinically significant
  impairment in social, occupational, or other
  important areas of current functioning.

12
Features of Autism Spectrum Disorder

• Kanner delineated three essential features of
  autism which essentially characterize autism to
  this day (see the DSM-V).
• 1)social isolation (autistic aloneness)
• 2)need for sameness
• 3)noncommunicative speech
• Since Kanner considered autistic aloneness the
  most fundamental symptom let us study it in more
  detail and contrast it with the relatedness of a
  healthy child.

13
Autism and Relatedness

• In autistic children early attachment is
  virtually absent.
• They do not smile, reach out, or look at their
  caregivers when fed. They often reject the
  parents affection by refusing to be held or
  cuddled, and arch their backs when they are
  picked up to minimize the contact that normal
  infants and parents love.
• Let us now take a look at factors having to do
  with the babys relatedness in the first stages
  of life.

14
Social Isolation

• Gaze Pattern
• Children make eye contact , after about a month
  caretakers typically react with pleasure, and
  say, wrongly that the infant now knows them.
• By six months, the infant will initiate social
  contact through gaze and will engage in
  coordinated patterns of interaction.
• Toddlers will use gaze to invite the partner to
  speak.

15
Social Isolation

• The gaze of children with autism is deviant. In
  extreme cases they look through or past the
  adult.
• When there is eye contact it often lacks the
  complementarity of normal glance exchange. The
  child often does not look at the adult even
  though engaged in an interaction.
• This deviant gaze is often responsible for the
  impression that the adult is being treated as an
  object, rather than as a person.

16
Social Isolation

• Affect - The social smile that appears in the
  normal infant at two and one half to three months
  does not exist for the autistic child.
• Autistic children from 30 -70 months old smile
  at their mothers as frequently as do normal
  children, but they do not combine smiling with
  eye contact in a single act (i.e. an odd coupling
  of affect and gaze).
• The human voice is innately attractive to the
  neonate, and normal infants and their mothers
  engage in alternating vocal exchanges at 2 to 4
  months, while autistic children essentially
  remain mute.

17
Social Isolation

• Social Imitation Autistic children have a
  significant impairment of imitation of other
  peoples movements.
• Such development is correlated with the
  subsequent development of social responsiveness,
  free play, and language.
• Autistic children between 8 and 26 months of age
  can imitate facial expressions, but often show
  bizarre and mechanical responses.

18
Social Isolation

• Initiative and Reciprocity- Normal infants begin
  to take the initiative in eliciting responses.
  This leads to simple back-and-forth sequences,
  which marks the beginning of reciprocity.
• For example, mother tickles-child giggles and
  flails arms-mother tickles (pleasure-signal-pleasu
  re sequence).

19
Social Isolation

• Joint Attention Behavior-The normal 6 to 9 month
  old will look between an object and the
  caretaker, as if to say, Look what I am looking
  at (referential looking)
• Toward the end of the first year of life an
  infant will use gestures, so that any interest
  can be shared.
• Autism often robs the child of referential and
  gestural behaviors, as well as the affective
  signals of smiling and laughter that play such an
  important role in adult-child interactions.

20
Social Isolation

• Attachment- Contrary to former opinion , 40 to
  50 of autistic children are securely attached
  using the Ainsworth Strange Situation (65 is
  normal).
• However, these children also show repetitive
  motor movements, such as hand flapping, rocking,
  and spinning.
• These children develop a working model of the
  mother as a source of security and pleasure but
  it is doubtful that they have a concept of the
  mother as a person in her own right, with her own
  thoughts , motives and desires.

21
Noncommunicative Speech

• Autistic children have difficulty in using
  symbols and although they can engage in pretend
  play (symbolic play) they tend to use simple
  forms and generally lack the motivation to play
  without being prompted.
• Difficulty with perspective-taking interferes
  with their communication, as well as pragmatics
  (learning to say what to whom).
• The mutism they often manifest is unaccounted
  for.

22
Need for Sameness

• The pathological need for sameness or low
  initiative is now being studied by looking at a
  childs executive functions, which underlie
  flexible goal oriented behavior.
• These functions consist of a number of
  components planning, or goal setting working
  memory, or maintaining information in an
  activated state in order to guide cognitive
  processes set shifting, or flexibility in
  discarding the inappropriate as a means of
  achieving a goal and inhibition, or the ability
  to hold back inappropriate actions.

23
Sensory Overload

• Children with autism may be hypersensitive or
  hyposensitive to stimuli. For example, adults
  who are no longer autistic have described hearing
  as an open microphone that picked up
  everything. Some children have a distress
  reaction to certain ordinary sounds.
• Autobiographical accounts contain references to
  sensory overload, such as being bombarded by
  bright lights, unpredictable movement, and being
  overwhelmed by noise.
• It seems the pathological need for sameness is a
  defense against being overwhelmed by ordinary
  environmental stimuli. The child seeks the safety
  of repetitive, low intensity sensory stimulation,
  such as humming the same note or concentrating on
  the movement of the spinning coin.

24
Autism

• Age of onset- It may appear up to the age of 30
  months.
• Prevalence- 6.6 to 13.6 per 10,000 children
• Gender and Socioeconomic Status- More boys than
  girls are diagnosed with autism (2.61 to 5.71).
  Autism appears in all classes.
• Comorbidity - Between 76 and 89 have impaired
  intelligence, with IQ scores falling below 70.
  Children with autism are better at nonverbal and
  visual-spatial tasks than at verbal ones. Both
  grand mal and psychomotor seizures develop in
  about one third of the autistic population.

25
Intervention

• Significant progress has been made in treating
  autistic children in the last decade or so.
• The intervention programs have five features in
  common.
• 1) Treatment focuses on a broad range of autistic
  behaviors (i.e. attention, compliance, motor
  imitation, communication, appropriate use of
  toys, and social skills).
• 2) Generalization of skills.
• 3) Emphasis on structure and predictability.
• Structure Any strategy or device that
  helps to compensate for an internal deficit.
• 4) High level of family involvement.
• 5) Learning particular skills that are needed for
  school.

26
Intervention

• Operant conditioning model- Lovaas (1977) has
  developed a model that relies heavily on
  imitation and reinforcement.
• The child is reinforced for making a verbal
  response in relation to an object (expressive
  discrimination).
• In receptive discrimination the stimulus is
  verbal and the response is nonverbal. For
  example, someone saying, Give me a Cup, should
  result in the child giving the person a cup.

27
Insecure Attachment

• Patterns of attachment are assessed by observing
  an infant, the caregiver, and a stranger in a
  setup call the strange situation. There are
  prearranged separations and reunions with the
  caretaker, along with interactions with a
  stranger.
• The critical variables are the infants responses
  to separation and reunion, along with their
  exploration of various attractive toys that have
  been placed in the room.
• We must always be aware of the reciprocal
  interaction between the care giving and the
  behavior. For example, does a child avoid
  attachment, because the parent is distancing
  themselves and shows anger or irritation when the
  child is close, or is it the childs avoidance
  behavior that prompts the distancing and anger.

28
Reactive Attachment Disorder

• Diagnostic criteria (summary of DSM-5)
• A. a consistent pattern of inhibited,
  emotionally withdrawn behavior toward adult
  caregivers, manifested by both of the following
• 1. The child rarely were minimally seeks
  comfort when distressed.
• 2. The child rarely were minimally responds
  to comfort when distressed.
• B. a persistent social and emotional
  disturbance characterized by at least two of the
  following
• 1. Minimal social and emotional
  responsiveness to others.
• 2. Limited positive affect.
• 3. Episodes of unexplained irritability,
  sadness, or fearfulness that are evident even
  during nonthreatening interactions with adult
  caregivers.

29
Reactive Attachment Disorder

• C. The child has experienced a pattern of
  extremes of insufficient care as evidenced by at
  least one of the following
• 1. Social neglect of deprivation in the
  form of persistent lack of having basic emotional
  needs for comfort, stimulation, and affection met
  by caregiving adults.
• 2. Repeated changes of primary caregivers
  that limit opportunities to form stable
  attachments (e.g., frequent changes in foster
  care).
• 3. Rearing in unusual settings that
  severely limit opportunities to form selective
  attachments (e.g., institutions with high
  child-care-giver ratios).
• D. The care in criterion C is presumed to be
  responsible for the disturbed behavior in
  criterion A.

30
Insecure Attachment

• Below we will look at variables related to
  attachment that suggest insecure attachment is a
  risk factor. Note that insecure attachment must
  act in concert with other risk factors when it is
  to predict the development of a disturbance.
• Security- The most important affective aspect of
  attachment is felt security. Children are built
  to associate proximity to the caregiver with
  safety and security, and separation from the
  caregiver with danger and anxiety. There are a
  number of behaviors that act in concert to
  achieve the goal of closeness to the caregiver
  (i.e. crying, clinging, etc.)
• Exploration- Attachment enables infants and
  toddlers to explore from a secure base.

31
Insecure Attachment

• Working Models of the Caregiving Relationship-
  The child increasingly develops the capacity to
  represent the caregiver and caregiving mentally.
• This image is called a working model. It
  reflects past experiences and involves
  expectations as to security, trustworthiness, and
  the pleasure of future relationships (e.g.
  securely attached will view the parent as
  receptive and trustworthy, whereas the avoidant
  attached child will view the parent with
  suspicion and be perpetually on guard).

32
Secure Attachment

• The Self- The child develops
• 1) Self-confidence and
  autonomy as the child explores from a secure base
  and is successful in meeting challenges or finds
  help readily available from parents when the task
  is beyond their ability.
• 2) Emotion
  regulation-Security brings with it protection
  from potentially overwhelming anxiety and rage,
  and at the same time fosters a view of the self
  as being in control of affect.
• 3) Love-worthy image is
  developed when the child is well cared for.

33
Oppositional-Defiant Disorder

• Diagnostic criteria (summary of DSM-5)
• A. A pattern of angry/irritable mood,
  argumentative/defiant behavior, or vindictiveness
  lasting at least six months as evidenced by at
  least four symptoms from any of the following
  categories
• Angry/irritable Mood
• 1. Often loses temper.
• 2. Is often touchy or easily annoyed.
• 3. Is often angry and resentful.
• Argumentative/defiant Behavior
• 4. Often argues with authority figures or,
  for children and adolescents, with adults.
• 5. Often actively defies or refuses to
  comply with requests from authority figures or
  with rules.
• 6. Often deliberately annoys others.
• 7. Often blames others for his or her
  mistakes or misbehavior.
• Vindictiveness
• 8. has been spiteful or vindictive at
  least twice within the past six months.

34
Oppositional Defiant Disorder

• ODD is more common in boys than girls, but this
  reverses in adolescence. Could this be the origin
  of girls are harder to raise than boys which is
  usually said after girls become teenagers?
• ODD is more prevalent in groups with lower
  socioeconomic status.
• ODD and CD are related. The most important
  determinant of subsequent CD is the level of
  aggression, while variables such as parental
  antisocial behavior, neglect, lack of parental
  monitoring, and father separation all play a
  role.
• ODD is related to ADHD- The comorbidity ranges
  from 20 to 57 percent and ADHD increases the risk
  of early onset of ODD. Comorbidity is clearly
  associated with substantial impairment in the
  personal, interpersonal and family domains.

35
Oppositional Defiant Disorder

• Etiology-
• ODD is rooted in normal behaviors such as
  disobedience, defiance, tantrums, and negative
  mood.
• Psychopathology results when the behavior
  increases in frequency and intensity or when it
  persists into later periods.
• Intrapersonal Context
• Insecure attachment in general, and perhaps an
  anxious-avoid attachment in particular, along
  with difficult temperament are risk factors for
  ODD.
• The least skillful social strategies, direct
  defiance and passive compliance decreased with
  age and were predictive of externalizing problem
  behaviors at 5 years of age. (Defiance is a risk
  factor and capacity to negotiate is a protective
  factor.)
• As early as two years of age defiance and
  self-assertion are independent of each other.
  (e.g. No, I wont versus I will do it this
  way). A rigid and compulsive form of compliance
  is related to internalizing problems.

36
Oppositional Defiant Disorder

• Interpersonal Context-
• Mothers of oppositional children have been
  described clinically as overcontrolling and
  aggressive, while fathers have been described as
  passive, peripheral, and distant.
• Objective study shows that these mothers are more
  negative toward and more critical of their
  children, than are mothers of normal children.
  These mothers engage in more threatening, angry,
  and nagging behaviors.
• Both parents give their children, significantly
  more commands and instructions, while not
  allowing enough time for the children to comply.

37
Oppositional Defiant Disorder

• Social learning theorists examine specific
  parental behaviors that elicit and maintain
  noncompliance.
• Forehand and his colleagues found that
  noncompliant behavior was reinforced by the
  attention of the parents, although such
  attention, often took the form of anger and
  punitiveness.
• e.g. planned ignoring a technique developed to
  end the reinforcement of behavior that provides
  negative attention.

38
Parental Commands

• Social learning theorists have also looked at
  parental commands in relation to noncompliant
  behavior.
• Alpha commands are specific and clear, and are
  less likely to produce noncompliance.
• e.g. Eat your peas, or there will be no
  dessert. You can finish watching this program,
  but then the TV will go off.
• Besides setting clear and specific boundaries,
  what else is being done here?
• The notion of social reality, and
  consequences are being used.

39
Parental Commands

• Beta commands are vague and interrupted.
  Sometimes they are difficult or impossible to
  obey, because of ambiguity or because the parent
  issues another command before the child has time
  to comply.
• e.g. Do you think that you might want to do
  something not so noisy or not.
• Westerman (1990) found parents of healthy
  children coordinated their behavior with that of
  their children. They became more specific in
  their directives when their children failed and
  less specific when they succeeded.
• Parents of noncompliant children were less likely
  to regulate their directives, according to their
  childrens activities.(Child late because they
  comforted friend.)
• It seems this sensitive response may be perceived
  as the parent with me, rather than against me
  to impose things on me.

40
Intervention and ODD

• Psychodynamic approach explores the childs
  conscious and unconscious feelings toward parents
  and about autonomy and control.
• What are the limitations of this approach with
  children?
• Atheoretical approach asks parents not to
  demand, coax, and to avoid being authoritarian or
  overprotective.
• Social learning approach in addition to
  the planned ignoring and Alpha commands
  mentioned previously, this approach usually
  advocates
• 1) operant conditioning rather than punishment
• 2) timeout procedures to respond to
  noncompliance

41
Enuresis

• Enuresis repeated (twice a week for three
  consecutive months) involuntary or intentional
  discharge of urine into bed or clothes beyond the
  expected age for controlling urination (Five
  years old).
• Nocturnal enuresis occurs at night
• Diurnal enuresis occurs in the day
• Mixed enuresis occurs day and night
• Primary enuresis refers to children who have
  never been trained (fixation)
• Secondary enuresis refers to children who
  revert back to wetting (regression)

42
Prevalence and Developmental Course

• Prevalence changes with age
• i.e. 20 at five, 5 at 10, 2 at 12 to 14, 1 of
  adults
• Remission rates are better for girls (e.g.
  prevalence is equal for boys and girls early
  on, but there are twice as many boys as girls by
  11)
• Etiology
• Recent findings are mixed. Perhaps this is the
  result of not looking at the interaction between
  interpersonal and intrapersonal variables.
• Stress may be a variable with secondary enuresis.
• Clinicians see different variables that might
  trigger a regression (e.g. family move, birth of
  a baby, separation, etc.)

43
Developmental Study of Enuresis

• Kaffman and Elizur (1977) studied children in a
  kibbutz in Israel. They found the usual genetic
  and physiological predisposing factors, such as
  siblings with enuresis, smaller functional
  bladder, impaired motor coordination
  developmental delay.
• Intrapersonal context
• Two high-risk personality patterns
• 1) hyperactive, aggressive, negativistic,
  low frustration tolerance, and resistant to
  change.
• 2) dependent, unassertive, low achievement
  need, masturbate frequently (Why?).
• not enuretic are self-reliant, independent,
  adaptable, and high achievement motivation.

44
Enuresis

• Interpersonal context
• There is a clear relationship between
  caregivers disinterest, permissiveness, low
  achievement demands, and enuresis, whereas
  structured, goal oriented, and directive toilet
  training in a loving relationship enhanced
  bladder control.
• For higher-risk children delay training increases
  the risk of a disorder.
• Organic context
• Since enuresis can be caused by a number of
  organic factors, the clinician should always seek
  a medical opinion to rule out physiological
  causation.
• A genetic component is definite i.e. 70 of
  enuretic children have two parents with an
  enuretic history.
• 68 concordance rate for monozygotic twins
• 36 Concordance rate for dizygotic twins

45
Intervention

• Behavioral techniques have been found to be most
  effective with enuresis.
• Pad-and-bell method
• The child is awakened by an alarm when they
  wet the bed. They then finish voiding in the
  bathroom. Ultimately the child anticipates the
  bell and gets up before wetting.
• This is a helpful method (70 to 95
  success), but the relapse rate is around 40.
• Two approaches to relapse are
• 1) retrain
• 2) intermittent reinforcement (the Bell
  only rings, 70 at random intervals)