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Overview of Clinical Psychiatry with Children

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Title: 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

62
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

63
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

64
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

65
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

66
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

67
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

68
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

69
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

70
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

71
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
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