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Developmental and Cognitive Disorders

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Title: Developmental and Cognitive Disorders


1
Developmental and Cognitive Disorders
  • Chapter 13

2
What are developmental disorders?
  • Disorders that usually first appear in childhood
    or adolescence (onset)
  • Note most of these conditions persist into
    adulthood

3
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4
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5
ICA D/O
  • As you answer the questions below, you will be
    better able to choose between the four categories
    introduced earlier.
  • 1. Is the predominant sx an impairment of
    learning or intellectual function?
  • 2. Is the predominant sx abnormal motor activity?
  • 3. Is the predominant sx socially inappropriate
    or self injurious behavior?
  • 4. Is the predominant sx an impairment in the
    ability to communicate or exchange meaningful
    information?

6
Perspectives on Developmental Disorders
  • Normal vs. Abnormal Development
  • Developmental Psychopathology
  • Study of how disorders arise and change with time
  • Childhood is associated with significant
    developmental changes
  • Disruption of early skills will likely disrupt
    development of later skills

7
Outline
  • Common developmental disorders (ADHD Learning
    Disorders)
  • Pervasive Developmental disorders (autism)
  • Mental Retardation
  • Cognitive Disorders (dementia)

8
Attention Deficit Hyperactivity Disorder (ADHD)
An Overview
  • Nature of ADHD
  • Central features Inattention, overactivity, and
    impulsivity
  • Difficulty w sustained attn (cant finish games,
    watch TV)
  • Constant motion, fidgeting
  • Blurt out answers, act without thinking
  • Associated with behavioral, cognitive, social,
    and academic problems

9
Attention Deficit Hyperactivity Disorder (ADHD)
An Overview
  • DSM-IV and DSM-IV-TR Symptom Clusters
  • Cluster 1 Symptoms of inattention
  • Cluster 2 Symptoms of hyperactivity and
    impulsivity cluster
  • Either cluster 1 or 2 must be present for a
    diagnosis

10
ADHD Facts and Statistics
  • Prevalence
  • Occurs in 4-12 of children who are 6 to 12
    years of age
  • Symptoms are usually present around age 3 or 4
  • 68 of children with ADHD have problems as adults
  • Impulsive component decreases over time
  • Gender Differences
  • Boys outnumber girls 4 to 1

11
ADHD Overdiagnosis?
  • Cultural Factors
  • Probability of ADHD diagnosis is greatest in the
    United States
  • Studies show more school-aged kids on stimulants
    than prevalence of Dx
  • College-aged people often present for assessment
    when academic problems emerge

12
ADHD Biological Contributions
  • Genetic Contributions
  • ADHD runs in families
  • Some studies suggest High heritability
  • Familial ADHD may involve deficits on chromosome
    20
  • The D4 receptor gene is more common in ADHD
    children (dopamine dysregulation?)

13
ADHD Biological Contributions
  • Neurobiological Contributions Brain Dysfunction
    and Damage
  • Used to be called minimal brain dysfunction
  • Inactivity of the frontal cortex and basal
    ganglia
  • Right hemisphere malfunction
  • Abnormal frontal lobe development and functioning
  • Yet to identify a precise neurobiological
    mechanism for ADHD

14
ADHD Biological Contributions
  • The Role of Toxins
  • Allergens and food additives do not appear to
    cause ADHD
  • Maternal smoking increases risk of having a child
    with ADHD

15
ADHD Psychosocial Contributions
  • Psychosocial Factors appear to Influence (not
    cause) the Disorder
  • Constant negative feedback from teachers,
    parents, and peers
  • Peer rejection and resulting social isolation
  • Such factors foster low self-image

16
Biological Treatment of ADHD
  • Goal of Biological Treatments
  • To reduce impulsivity/hyperactivity and to
    improve attention
  • Stimulant Medications
  • Reduce the core symptoms of ADHD in 70 of cases
  • Examples include Ritalin, Dexedrine, Cylert
  • Other Medications
  • Imipramine and Clonidine (antihypertensive) have
    some efficacy

17
Biological Treatment of ADHD
  • Effects of Medications
  • Improve compliance and decrease negative
    behaviors in many children
  • Not clear that academic performance or social
    skills are improved in the long-term
  • Beneficial effects are not lasting following drug
    discontinuation
  • Negative side effects include insomnia,
    drowsiness, and irritability

18
Behavioral and Combined Treatment of ADHD
  • Behavioral Treatment
  • Involve reinforcement programs
  • Aim to increase appropriate behaviors and
    decrease inappropriate behaviors
  • May also involve parent training
  • Combined Bio-Psycho-Social Treatments
  • Are highly recommended - it appears however that
    long-term psychosocial Tx is necessary to
    maintain gains

19
Learning Disorders
  • Scope of Learning Disorders
  • Problems related to academic performance in
    reading, mathematics, and writing
  • Performance is substantially below what would be
    expected (IQ - Ach discrepancy)
  • DSM-IV and DSM-IV-TR Reading, Mathematics,
    Written Expression Disorders
  • Performance is at a level significantly below
    that of a typical person of the same age
  • Problem cannot be caused by sensory deficits
    (e.g., poor vision)

20
Learning Disorders Some Facts and Statistics
  • Incidence and Prevalence of Learning Disorders
  • 1 to 3 incidence of learning disorders in the
    United States
  • Prevalence is highest in wealthier regions of the
    United States
  • Prevalence rate is 10 to 15 among school age
    children
  • Reading difficulties are the most common of the
    learning disorders
  • School experience for such persons tends to be
    quite negative
  • About 32 of students with learning disabilities
    drop out of school

21
Figure 13.1
  • Half of school children classified as disabled
    have learning disabilities. Twenty years ago the
    proportion was 50 lower

22
Biological and Psychosocial Causes of Learning
Disorders
  • Genetic and Neurobiological Contributions
  • Reading disorder runs in families, with 100
    concordance rate for identical twins
  • Evidence for subtle forms of brain damage is
    inconclusive
  • Overall, genetic and neurobiological
    contributions are unclear
  • Psychological and motivational factors seem to
    affect eventual outcome

23
Treatment of Learning Disorders
  • Medications not typically used
  • Requires Intense Educational Interventions
  • Remediation of basic processing problems (e.g.,
    teaching visual skills)
  • Efforts to improve of cognitive skills (e.g.,
    instruction in listening)
  • Targeting behavioral skills to compensate for
    problem areas
  • Data Support Behavioral Educational Interventions
    for Learning Disorders

24
Pervasive Developmental Disorders
  • PDD is an umbrella term
  • severe and pervasive impairments in several areas
    of development reciprocal social interaction
    skills, communication skills, presence of
    stereotyped behavior, interests, and activities
  • Symptoms are on a continuum
  • 5 PDDs autistic disorder, Aspergers disorder,
    Retts disorder, Childhood Disintegrative
    Disorder, PDD/NOS (distinctions among these not
    particularly clear)

25
Autistic Disorder
  • Approximately 10 cases per 10,000 individuals
  • More common in males (4-51)
  • Impairment in Social Interactions
  • Impairment in Communication
  • Restricted, Repetitive and Stereotyped Behaviors,
    Interests, and Activities
  • Onset of delays prior to age 3 years

26
Autistic Disorder (cont.)
  • Qualitative Impairment in Social Interaction
    (needs at least 2)
  • marked impairment in the use of nonverbal
    behaviors
  • Failure to develop peer relationships appropriate
    to developmental level
  • A lack of spontaneous seeking to share enjoyment,
    interests, or achievements
  • lack of social or emotional reciprocity

27
Autistic Disorder (cont.)
  • Qualitative impairment in Communication (needs a
    lest one)
  • delay or total lack of development of spoken
    language (no compensation)
  • marked impairment in the ability to initiate or
    sustain a conversation with others in individuals
    that can speak
  • stereotyped and repetitive use of language or
    idiosyncratic language
  • lack of carried , spontaneous make-believe play
    or social imitative play appropriate to
    developmental level.

28
Autistic Disorder (cont.)
  • Restricted, Repetitive and Stereotyped
    Behaviors, Interests, and Activities (needs at
    least one)
  • encompassing preoccupation with one or more
    stereotyped and restricted patterns of interest
    that is abnormal either in intensity or focus
  • apparently inflexible adherence to specific,
    nonfunctional routines or rituals
  • stereotyped mannerisms
  • persistent preoccupation with parts of objects

29
Other issues related to autism
  • Sensory issues (e.g., high threshold for pain,
    oversensitivity to sounds, fascination with touch
    or smell)
  • Abnormalities in mood and affect
  • Feeding issues (limited diet, pica)
  • Behavior difficulties (SIB, Tantrums, short
    attention span, hyperactivity, sleep problems)

30
Phenomenology of Autism
  • 20/20 Video
  • What is it like to be autistic?

31
Autism and Intellectual Functioning
  • 75 of individuals have mental retardation
  • 50 have IQs in the severe-to-profound range of
    mental retardation
  • 25 test in the mild-to-moderate IQ range (i.e.,
    IQ of 50 to 70)
  • Remaining people display abilities in the
    borderline-to-average IQ range
  • Better language skills and IQ test performance
    predicts better lifetime prognosis

32
Etiology of Autism
  • Psychosocial Contributions Are Unclear
  • Autism has a genetic component that is largely
    unclear
  • Neurobiological evidence for brain damage Link
    with mental retardation
  • Cerebellum size Substantially reduced in
    persons with autism

33
Aspergers Disorder
  • Qualitative impairment in social interaction
  • Restrictive Repetitive and stereotyped patterns
    of behavior, interest, and activities
  • Disturbance causes clinically significant
    impairment
  • no clinically significant general delay in
    language
  • no clinically significant delay in cognitive or
    adaptive functioning

34
Retts Disorder
  • Only reported in females
  • Apparent normal pre and perinatal development
  • Normal head circumference at birth
  • Deceleration of head growth between 5 and 48
    months
  • Loss of hand skills between 5 and 30 months with
    development of stereotyped hand movement, loss of
    social engagement, poorly coordinated gait or
    trunk movements, severely impaired expressive and
    receptive language development with severe
    psychomotor retardation
  • Severe or Profound MR

35
Applied Behavior Analysis
  • Breaks down autism into separate behavioral
    problems and attempts to treat as many of these
    problems as possible.
  • By far the most well documented treatment
    approach with hundreds of studies on behavioral
    treatment for children with autism.
  • Goal is remediation (recovery) from the disorder
    to the point that children are indistinguishable
    from their peers.

36
UCLA Young Autism Project (Lovaas)
  • Intensive one-on-one training for app. 40 hours a
    week.
  • Training prg carried out in homes, school,
    community
  • commences at age no older than 46 months
  • 1st phase, focuses on teaching compliance, simple
    imitation, appropriate play, suppress
    self-stimulation and non-compliant behavior
  • 2nd phase teaching expressive skills, early
    abstract language, social play with peers
  • Third phase teaching expression of emotions,
    functional academics and more complex cognitive
    abilities (e.g., cause-to-effect relationships)

37
  • UCLA Young Autism Project - study design
  • Initial 2 year treatment
  • N 59 children
  • 3 groups
  • (a) Experimental group (N19) - 40 hours a week
    of treatment for 2 years
  • Control group 1 (N19) - 10 hours of treatment
    for 2 years on average
  • Control group 2 (N21) - No treatment provided
    by UCLA
  • Blind Evaluations pre post treatment

38
UCLA Young Autism Project pre-treatment
  • Exp Group Control Group 1
  • Treatment 40 hrs/week 10 hrs/week
  • Pre Treatment Measures
  • Age at Dx 32 months 34 months
  • Age _at_ Beg. trt 35 months 40 months
  • IQ 53 46

39
UCLA Young Autism Project pre-treatment
  • Exp Gr Control Group 1
  • (N19) (N19)
  • Mute 58 47
  • Reject Adults 63 42
  • Not Toilet Trained 68 63
  • Gross Inattention 89 74
  • Tantrums 89 79
  • Absent Toy Play 53 63
  • Self Stimulation 95 89
  • Absent Peer Play 100 100

40
UCLA Young Autism Project- Results
  • Blind evaluation pre treatment 2 years later
    (Age 6-7)
  • Experimental Group Results
  • Average IQ Gain 20 points
  • 9/19 (47) Completed first grade in regular
    class
  • IQ Gain for these 9 subjects 37 points
  • 8/19 (42) Continued in a learning disabled class
  • 2/19 (11) Severe MR / autistic classroom
  • Control Group Results Group
    1 Group 2
  • IQ no significant changes
  • Completed first grade in regular class 0/19 (
    0) 1/21 (5)
  • Continued in a learning disabled class 8/19
    (42) 10/21 (48)
  • Continued in a Severe MR Class 11/19
    (58) 10/21 (48)

41
UCLA Young Autism Project- Results 1993 Follow
Up Study Results
  • Blind Evaluations of the 9 children in the Best
    Outcome Group
  • Age at follow up evaluation - 13 years old.
  • IQ gains remained.
  • Normal functioning on tests of
  • emotional functioning
  • social functioning
  • intellectual functioning.
  • 8/9 (88) Remained in typical classrooms.
  • 1/9 was in an LD classroom.

42
Autism - Pharmacotherapy
  • No known effective medications

43
Mental Retardation
  • Nature of Mental Retardation
  • Disorder of childhood
  • Below-average intellectual and adaptive
    functioning
  • Range of impairment varies greatly across persons
  • Mental Retardation and the DSM-IV and DSM-IV-TR
  • Significantly subaverage intellectual functioning
    (IQ below 70 - about 2-3 of the population)
  • Concurrent deficits or impairments two or more
    areas of adaptive functioning
  • MR must be evident before the person is 18 years
    of age

44
Levels of MR
  • Mild MR
  • Includes persons with an IQ score between 50 or
    55 and 70 (often can lead independent lives)
  • Moderate MR
  • Includes persons in the IQ range of 35-40 to
    50-55
  • Severe MR
  • Includes people with IQs ranging from 20-25 up to
    35-40
  • Profound MR
  • Includes people with IQ scores below 20-25
    (typically require complete assistance)

45
Other Classification Systems for Mental
Retardation (MR)
  • American Association of Mental Retardation (AAMR)
  • Defines MR based on levels of assistance required
  • Examples of levels include intermittent, limited,
    extensive, or pervasive assistance
  • Not that widely adopted
  • Classification of MR in Educational Systems
  • Based on whether person is Educable
  • Stigmatizing system

46
Mental Retardation (MR) Some Facts and
Statistics
  • Prevalence
  • About 1 to 3 of the general population
  • 90 of MR persons are labeled with mild mental
    retardation
  • Gender Differences
  • MR occurs more often in males, male-to-female
    ratio of about 1.61
  • Course of MR
  • Tends to be chronic, but prognosis varies greatly
    from person to person

47
Mental Retardation (MR) Psychosocial
Contributions
  • Cultural-Familial Retardation
  • Believed to cause about 75 of MR cases and is
    the least understood
  • Believed to result from combination of biological
    (low IQ) and social factors
  • Neglect, abuse, poor nutrition
  • Associated with mild levels of retardation on IQ
    tests and good adaptive skills
  • Lower end of distribution but probably distinct
    etiology from those w clear organic causes

48
Mental Retardation (MR) Biological Contributions
  • Genetic Research
  • MR involves multiple genes, and at times single
    genes
  • Chromosomal Abnormalities and Other Forms of MR
  • Down syndrome Trisomy 21
  • Fragile X syndrome Abnormality on X chromosome
  • Maternal Age and Risk of Having a Downs Baby
  • Nearly 75 of cases cannot be attributed to any
    known biological cause

49
Specific genetic syndromes associated with MR
  • Down Syndrome
  • Fragile X syndrome

50
Down Syndrome
51
Down Syndrome
  • Most common chromosomal form of MR
  • Prevalence about 1 out of every 700 live births
  • As many of 75 of trisomy 21 result in
    miscarriages or stillbirths.
  • The older the mother, the higher the (p) of DS
    (e.g., Maternal age of 20 1 in 2000 35 1 in
    500 45 1 in 18)
  • Theory - ova (eggs) produced in youth are exposed
    to toxins, radiation - damaged

52
Down Syndrome (cont.)
  • Health issues Congenital heart defects (50),
    hearing loss (66-89), ophthalmic conditions (60),
    endocrine conditions (e.g., hypothyroidism)
    (50-90), obesity (50-60), dental problems
    (60-100), seizure disorders (6-13), high risk of
    Alzheimer's disease.

53
Down Syndrome (cont.)
  • Adaptive behavior In general children with DS
    show higher AB levels than intelligence
  • Personality Sociable and pleasant.
  • Dual DX Less often and less severe maladaptive
    behavior and psychopathology

54
Fragile X Syndrome
55
Fragile X syndrome
  • Most common known inherited form of MR
  • Prevalence 1 in 4000 males and at least half
    that in females.
  • The marker was an X chromosome with a small,
    pinched-off piece of genetic material
  • Mothers often have learning disabilities

56
Fragile X syndrome (cont.)
  • Physical features 80 of post pubertal boys and
    men with this disorder have enlarged testicules
    (about twice the size).
  • Other physical features long narrow face and
    prominent ears, flat feet, hyper extensible
    finger joints, soft skin
  • Features become more pronounced with age and are
    subtle in childhood
  • Few significant medical problems are associated
    with fragile X (seizures in about 20)

57
Fragile X syndrome (cont.)
  • IQ levels vary from moderate levels of MR to the
    average range of functioning (varies with genetic
    status, gender, and age)
  • In general, females are less impaired than males
  • Many males seem to show declines in their IQ
    scores over time.

58
Treatment of MR
  • For mild MR, tx is similar to that for learning
    disabilities
  • For more severe MR, treatment is similar to that
    for PDD
  • Goals include communication, social development,
    independent living and job skills
  • People with MR often Benefit from Such
    Interventions
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