Disorders of Childhood and Adolescence

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Chapter 17

• Disorders of Childhood and Adolescence

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Disorders of Childhood and Adolescence

• Abnormal functioning can occur at any time in
  life
• Some patterns of abnormality, however, are more
  likely to emerge during particular periods

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Childhood and Adolescence

• Adolescence can be a difficult period
• Physical and sexual changes, social and academic
  pressures, personal doubts, and temptation cause
  many teenagers to feel anxious, confused, and
  depressed

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Childhood and Adolescence

• Along with these common psychological
  difficulties, at least one-fifth of all children
  and adolescents in North America also experience
  a diagnosable psychological disorder
• Boys with disorders outnumber girls with
  disorders, even though most of the adult
  psychological disorders are more common in women

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Childhood and Adolescence

• Certain disorders of children childhood anxiety
  disorders and childhood depression have adult
  counterparts
• In contrast, other childhood disorders conduct
  disorders, ADHD, and elimination disorders, for
  example usually disappear or radically change
  form by adulthood
• There also are disorders that begin in birth or
  childhood and persist in stable forms into adult
  life
• These include mental retardation and autism

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Childhood Anxiety Disorders

• Certain childhood disorders are different enough
  from the adult disorder to be listed as a
  separate category in the DSM-IV
• Separation anxiety disorder
• Children feel extreme anxiety or panic whenever
  they are separated from home or a parent
• Many cases are triggered by a stressful event
• School phobia or school refusal
• Separation anxiety disorder sometimes takes this
  form
• A common problem in which children fear going to
  school and often stay home for a long period
• Can also be caused by social or academic fears,
  depression, or fears of specific objects or
  persons at school

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Childhood Depression

• Children and teenagers may develop depression
  similar to adults
• Between 2 and 4 of children under 17 years of
  age experience major depressive disorder
• Symptoms are likely to include
• Physical discomfort, irritability, social
  withdrawal
• There appears to be no difference in the rates of
  depression in boys and girls before the age of 11
• By the age of 16 girls are twice as likely as
  boys to be depressed

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Childhood Depression

• Explanations of childhood depression are similar
  to those of adult depression
• Contributing factors include
• Loss
• Learned helplessness
• Negative cognitions
• Low serotonin or norepinephrine activity
• Many cases seem to be triggered by a negative
  life event, major change, rejection, or ongoing
  abuse

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Disruptive Behaviors Disorders

• If children consistently display extreme
  hostility and defiance they may qualify for a
  diagnosis of a disruptive behavior disorder
• Oppositional defiant disorder
• Children argue repeatedly with adults
• Lose their temper
• Feel great anger and resentment
• Often ignore adult requests and try to annoy
  other people
• Blame others for their own mistakes and problems
• Many boys with this disorder worsen during
  adolescence and develop conduct disorder

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Disruptive Behaviors Disorders

• Between 2 and 16 of children will display this
  pattern
• The disorder is more common in boys than girls
  before puberty but equal in both sexes after
  puberty

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Oppositional Defiant Disorder

• Children consistently displaying extreme
  hostility and defiance may qualify for a
  diagnosis of oppositional defiant disorder
• This disorder is characterized by repeated
  arguments with adults, loss of temper, anger, and
  resentment
• Children with this disorder ignore adult requests
  and rules, try to annoy people, and blame others
  for their mistakes and problems
• Approximately 8 of children qualify for this
  diagnosis
• The disorder is more common in boys than girls
  before puberty but equal in both sexes after
  puberty

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Conduct Disorder

• Children with conduct disorder, a more severe
  problem, repeatedly violate the basic rights of
  others
• They are often aggressive and may be physically
  cruel and violent
• Many steal from, threaten, or harm their victims,
  committing such crimes as shoplifting, vandalism,
  mugging, and armed robbery

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Oppositional Defiant Disorder and Conduct Disorder

• Conduct disorder usually begins between 7 and 15
  years of age
• Around 10 of children, three-quarters of them
  boys, qualify for this diagnosis
• Children with a mild conduct disorder may improve
  over time, but severe cases frequently continue
  into adulthood
• These cases may turn into antisocial personality
  disorder or other psychological problems

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Oppositional Defiant Disorder and Conduct Disorder

• More than one-third of boys and one-half of girls
  with conduct disorder also display
  attention-deficit/hyperactivity disorder (ADHD)
• In most cases, ADHD is believed to precede and
  help cause the conduct disorder

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What Are the Causes of Conduct Disorder?

• Cases of conduct disorder have been linked to
  genetic and biological factors, drug abuse,
  poverty, traumatic events, and exposure to
  violent peers or community violence
• They have most often been tied to troubled
  parent-child relationships, inadequate parenting,
  family conflict, marital conflict, and family
  hostility

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Attention-Deficit/Hyperactivity Disorder

• Children who display attention-deficit/hyperactivi
  ty disorder (ADHD) have great difficulty
  attending to tasks or behave overactively and
  impulsively, or both
• The primary symptoms of ADHD may feed into one
  another, but often one of the symptoms stands out
  more than the other

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Attention-Deficit/Hyperactivity Disorder

• Around 5 of schoolchildren display ADHD, as many
  as 90 of them boys
• Problems common to the disorder
• Learning or communication problems
• Poor school performance
• Difficulty interacting with other children
• Misbehavior, often serious
• Mood or anxiety problems

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What Are the Causes of ADHD?

• Clinicians generally consider ADHD to have
  several interacting causes, including
• Biological causes, particularly abnormal dopamine
  activity
• High levels of stress
• Three other explanations have received
  considerable press
• ADHD is typically caused by sugar or food
  additives
• ADHD results from environmental toxins such as
  lead
• Excessive exposure to television and other
  sources of stimulation can contribute to ADHD

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How Do Clinicians Assess ADHD?

• ADHD is a difficult disorder to assess
• Ideally, the childs behavior should be observed
  in several environmental settings because
  symptoms must be present across multiple settings
  in order to meet DSM-IV-TRs criteria
• It also is important to obtain reports of the
  childs symptoms from their parents and teachers

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How Is ADHD Treated?

• Behavioral therapy is also applied widely in
  cases of ADHD
• Parents and teachers learn how to apply operant
  conditioning techniques to change behavior
• These treatments have often been helpful,
  especially when combined with drug therapy

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Attention-Deficit/Hyperactivity Disorder(ADHD)

• The most common treatment approach has been the
  use of stimulant drugs
• Methylphenidate (Ritalin)

Its use has been increasing since the early
1980s, when researchers discovered that it helped
people with ADHD. Sales more than doubled during
the 1990s alone.

• Behavioral therapy is also applied widely
• Parents and teachers learn how to reward
  attentiveness or self-control on their children
  or students

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The Sociocultural Landscape ADHD and Race

• Race seems to come into play with regard to ADHD
• A number of studies indicate that African
  American and Hispanic American children with
  significant attention and activity problems are
  less likely than white American children to be
  assessed for ADHD, receive an ADHD diagnosis, or
  undergo treatment for the disorder
• Those who do receive a diagnosis are less likely
  than white children to be treated with the
  interventions that seem to be of most help

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Elimination Disorders

• Children with elimination disorders repeatedly
  urinate or pass feces in their clothes, in bed,
  or on the floor
• They have already reached an age at which they
  are expected to control these bodily functions
• These symptoms are not caused by physical illness

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Enuresis

• Enuresis is repeated involuntary (or in some
  cases intentional) bedwetting or wetting of ones
  clothes
• It typically occurs at night during sleep but may
  also occur during the day
• The problem may be triggered by a stressful event
• Children must be at least 5 years of age to
  receive this diagnosis
• Prevalence of enuresis decreases with age

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Enuresis

• Research has not favored one explanation for the
  disorder over others
• Psychodynamic theorists explain it as a symptom
  of broader anxiety and underlying conflicts
• Family theorists point to disturbed family
  interactions
• Behaviorists often view it as the result of
  improper toilet training
• Biological theorists suspect that the physical
  structure of the urinary system develops more
  slowly in some children

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Encopresis

• Encopresis repeatedly defecating in ones
  clothing is less common than enuresis and less
  well researched
• The problem
• Is usually involuntary
• Seldom occurs during sleep
• Starts after the age of 4
• Is more common in boys than girls

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Encopresis

• Encopresis causes intense social problems, shame,
  and embarrassment
• Cases may stem from stress, constipation,
  improper toilet training, or a combination of all
  three
• The most common treatments are behavioral and
  medical approaches, or combinations of the two
• Family therapy has also been helpful

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Long-Term Disorders That Begin in Childhood

• Two of the disorders that emerge during childhood
  are likely to continue unchanged throughout a
  persons life
• Pervasive developmental disorders
• Mental retardation
• Clinicians have developed a range of treatment
  approaches that can make a major difference in
  the lives of people with these problems

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Pervasive Developmental Disorders

• Pervasive developmental disorders are a group of
  disorders marked by impaired social interactions,
  unusual communications, and inappropriate
  responses to stimuli in the environment
• The group includes autistic disorder, Aspergers
  disorder, Retts disorder, and childhood
  disintegrative disorder
• Because autistic disorder initially received so
  much more attention than the others, these
  disorders are often referred to as
  autistic-spectrum disorders

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Autistic Disorders

• Autistic disorder, or autism, was first
  identified in 1943
• Children with this disorder are extremely
  unresponsive to others, uncommunicative,
  repetitive, and rigid
• Symptoms appear early in life, before age 3
• There has been a steady increase in the number of
  children diagnosed and it appears that at least
  one in 600 and maybe as many as one in 200
  children display the disorder
• Around 80 of all cases appear in boys

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Autistic Disorders

• As many as 90 of children with autism remain
  severely disabled into adulthood and are unable
  to lead independent lives
• Even the highest-functioning adults with autism
  typically have problems in social interactions
  and communication and have restricted interests
  and activities

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What Are the Features of Autism?

• The central feature of autism is the individuals
  lack of responsiveness, including extreme
  aloofness and lack of interest in people
• Language and communication problems take various
  forms
• One common speech peculiarity is echolalia, the
  exact echoing of phrases spoken by others
• Another is pronominal reversal, or confusion of
  pronouns

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What Are the Features of Autism?

• Autism is also marked by limited imaginative play
  and very repetitive and rigid behavior
• This has been called a perseveration of
  sameness
• Many sufferers become strongly attached to
  particular objects plastic lids, rubber bands,
  buttons, water and may collect, carry, or play
  with them constantly

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What Are the Features of Autism?

• The motor movements of people with autism may be
  unusual
• Often called self-stimulatory behaviors may
  include jumping, arm flapping, and making faces
• Children with autism may engage in self-injurious
  behaviors
• Children may at times seem overstimulated and/or
  understimulated by their environments

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Aspergers Disorder

• Those with Aspergers disorder (or syndrome)
  experience the kinds of social deficits,
  impairments in expressiveness, idiosyncratic
  interests, and restricted and repetitive
  behaviors that characterize individuals with
  autism, but at the same time they often have
  normal intellectual, adaptive, and language
  skills

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What Are the Causes of Pervasive Developmental
Disorders?

• A variety of explanations for autism have been
  offered
• Sociocultural explanations are now seen as having
  been overemphasized
• Recent work in the psychological and biological
  spheres has persuaded clinical theorists that
  cognitive limitations and brain abnormalities are
  the primary causes of the disorder

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What Are the Causes of Pervasive Developmental
Disorders?

• Psychological causes
• According to some theorists, people with autism
  have a central perceptual or cognitive
  disturbance
• One theory holds that individuals fail to develop
  a theory of mind an awareness that other people
  base their behaviors on their own beliefs,
  intentions, and other mental states, not on
  information they have no way of knowing
• Repeated studies have shown that people with
  autism have this kind of mindblindness
• It has been theorized that early biological
  problems prevented proper cognitive development

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What Are the Causes of Pervasive Developmental
Disorders?

• Biological causes
• While a clear biological explanation for autism
  has not yet been developed, promising leads have
  been uncovered
• Family studies suggest a genetic factor in the
  disorder
• Prevalence rates are higher among siblings and
  highest among identical twins
• Chromosomal abnormalities have been discovered in
  10 to 12 of people with the disorder

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What Are the Causes of Pervasive Developmental
Disorders?

• Biological causes
• Some studies have linked autism to prenatal
  difficulties or birth complications
• Some theorists have proposed that a postnatal
  event the MMR vaccine might produce autism in
  some children, although subsequent research has
  found no link
• Researchers have also identified specific
  biological abnormalities that may contribute to
  the disorder

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How Do Clinicians and Educators Treat Pervasive
Developmental Disorders?

• Treatment can help people with autism adapt
  better to their environment, although no known
  treatment totally reverses the autistic pattern
• Treatments of particular help are behavioral
  therapy, communication training, parent training,
  and community integration
• In addition, psychotropic drugs and certain
  vitamins have sometimes helped when combined with
  other approaches

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How Do Clinicians and Educators Treat Pervasive
Developmental Disorders?

• Behavioral therapy
• Behavioral approaches have been used in cases of
  autism to teach new, appropriate behaviors,
  including speech, social skills, classroom
  skills, and self-help skills, while reducing
  negative ones
• Most often, therapists use modeling and operant
  conditioning
• Therapies are ideally applied when people with
  autism are young

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How Do Clinicians and Educators Treat Pervasive
Developmental Disorders?

• Communication training
• Even when given intensive behavioral treatment,
  half of the people with autism remain speechless
• Better speech skills predict better social
  interaction in adulthood.

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How Do Clinicians and Educators Treat Pervasive
Developmental Disorders?

• Community integration
• Many of todays school-based and home-based
  programs for autism teach self-help,
  selfmanagement, and living skills
• In addition, greater numbers of group homes and
  sheltered workshops are available for teens and
  young adults with autism
• These programs help individuals become a part of
  their community and also reduce the concerns of
  aging parents

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Mental Retardation

• The term mental retardation has been applied to
  a varied population
• In recent years, the less stigmatizing term
  developmental disability has become synonymous
  with mental retardation in many clinical settings
• Approximately three of every 100 persons meets
  the criteria for this disorder
• Around three-fifths of them are male and the vast
  majority are considered mildly retarded

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Mental Retardation

• According to the DSM-IV-TR, people should receive
  a diagnosis of mental retardation when they
  display general intellectual functioning that is
  well below average, in combination with poor
  adaptive behavior
• IQ must be 70 or lower
• The person must have difficulty in such areas as
  communication, home living, self-direction, work,
  or safety
• Symptoms must appear before age 18

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Assessing Intelligence

• Educators and clinicians administer intelligence
  tests to measure intellectual functioning
• These tests consist of a variety of questions and
  tasks that rely on different aspects of
  intelligence
• Having difficulty in one or two of these subtests
  or areas of functioning does not necessarily
  reflect low intelligence
• An individuals overall test score, or
  intelligence quotient (IQ), is thought to
  indicate general intellectual ability

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Assessing Adaptive Functioning

• Diagnosticians cannot rely solely on a cutoff IQ
  score of 70 to determine whether a person suffers
  from mental retardation
• Several scales, such as the Vineland and AAMR
  adaptive behavior scales, have been developed to
  assess adaptive behavior
• For proper diagnosis, clinicians should observe
  the functioning of each individual in his or her
  everyday environment, taking both the persons
  background and the community standards into
  account

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What Are the Characteristics of Mental
Retardation?

• The most consistent sign of mental retardation is
  that the person learns very slowly
• Other areas of difficulty are attention,
  shortterm memory, planning, and language
• Those who are institutionalized with mental
  retardation are particularly likely to have these
  limitations

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What Are the Characteristics of Mental
Retardation?

• The DSM-IV-TR describes four levels of mental
  retardation
• Mild (IQ 5070)
• Moderate (IQ 3549)
• Severe (IQ 2034)
• Profound (IQ below 20)

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Mild Retardation

• Approximately 80-85 of all people with mental
  retardation fall into the category of mild
  retardation (IQ 5070)
• They are sometimes called educably retarded
  because they can benefit from schooling
• People with mild retardation typically need
  assistance but can work in unskilled or
  semiskilled jobs
• Intellectual performance seems to improve with age

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Mild Retardation

• Research has linked mild mental retardation
  mainly to sociocultural and psychological causes,
  particularly
• Poor and unstimulating environments
• Inadequate parent-child interactions
• Insufficient early learning experiences
• Biological FAS

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Moderate, Severe, and Profound Retardation

• Approximately 10 of persons with mental
  retardation function at a level of moderate
  retardation (IQ 3549)
• They can care for themselves and benefit from
  vocational training
• Approximately 3-4 of persons with mental
  retardation display severe retardation (IQ 2034)
• They usually require careful supervision and can
  perform only basic work tasks

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Moderate, Severe, and Profound Retardation

• About 1-2 of persons with mental retardation
  fall into the category of profound retardation
  (IQ below 20)
• With training they may learn or improve basic
  skills but they need a very structured
  environment
• Severe and profound levels of mental retardation
  often appear as part of larger syndromes that
  include severe physical handicaps

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What Are the Causes of Mental Retardation?

• The primary causes of moderate, severe, and
  profound retardation are biological, although
  people who function at these levels are also
  greatly affected by their family and social
  environment
• Sometimes genetic factors are at the root of
  these biological problems
• Other biological causes come from unfavorable
  conditions that occur before, during, or after
  birth

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What Are the Causes of Mental Retardation?

• Chromosomal causes
• The most common chromosomal disorder leading to
  mental retardation is Down syndrome
• Fewer than 1 of every 1000 live births result in
  Down syndrome, but this rate increases greatly
  when the mothers age is over 35
• Several types of chromosomal abnormalities may
  cause Down syndrome, but the most common is
  trisomy 21
• Fragile X syndrome is the second most common
  chromosomal cause of mental retardation

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What Are the Causes of Mental Retardation?

• Metabolic causes
• In metabolic disorders, the bodys breakdown or
  production of chemicals is disturbed
• The metabolic disorders that affect intelligence
  and development are typically caused by the
  pairing of two defective recessive genes, one
  from each parent
• Examples include
• Phenylketonuria (PKU)
• Tay-Sachs disease

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What Are the Causes of Mental Retardation?

• Prenatal and birth-related causes
• As a fetus develops, major physical problems in
  the pregnant mother can threaten the childs
  healthy development
• Low iodine may lead to cretinism
• Alcohol use may lead to fetal alcohol syndrome
  (FAS)
• Certain maternal infections during pregnancy
  (e.g., rubella, syphilis) may cause childhood
  problems including mental retardation
• Birth complications, such as a prolonged period
  without oxygen (anoxia), can also lead to mental
  retardation

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What Are the Causes of Mental Retardation?

• Childhood problems
• After birth, particularly up to age 6, certain
  injuries and accidents can affect intellectual
  functioning
• Examples include poisoning, serious head injury,
  excessive exposure to x-rays, and excessive use
  of certain chemicals, minerals, and/or drugs
• Certain infections, such as meningitis and
  encephalitis, can lead to mental retardation if
  they are not diagnosed and treated in time

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Interventions for People with Mental Retardation

• What is the proper residence?
• Since deinstitutionalization, reforms have led to
  the creation of small institutions and other
  community residences that teach self-sufficiency,
  devote more time to patient care, and offer
  education and medical services
• Residences include group homes, halfway houses,
  local branches of larger institutions, and
  independent residences
• These programs follow the principle of
  normalization they try to provide living
  conditions similar to those enjoyed by the rest
  of society

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Interventions for People with Mental Retardation

• What is the proper residence?
• Today the vast majority of children with mental
  retardation live at home rather than in an
  institution
• Most people with mental retardation, including
  almost all with mild mental retardation, now
  spend their adult lives either in the family home
  or in a community residence

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Interventions for People with Mental Retardation

• Which educational programs work best?
• Many teachers use operant conditioning principles
  to improve the self-help, communication, social,
  and academic skills of individuals with mental
  retardation
• Many schools also employ token economy programs

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Interventions for People with Mental Retardation

• How can opportunities for personal, social, and
  occupational growth be increased?
• Adults with mental retardation need the financial
  security and personal satisfaction that comes
  from holding a job
• Many can work in sheltered workshops, but there
  are too few training programs available
• Additional programs are needed so that more
  people with mental retardation may achieve their
  full potential, as workers and as human beings

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Comparing Childhood Psychological Disorders