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Title: Chapter%20Fifteen

Chapter Fifteen
  • Disorders of Childhood and Adolescence

Disorders of Childhood and Adolescence
  • Child psychology
  • Emotional and behavioral manifestation of
    psychological disorders in children and
  • Prevalence of childhood disorders
  • One in five has serious emotional or behavioral
  • Two-thirds of those with mental illness received
    no treatment

Disorders of Childhood and Adolescence (contd.)
Disorders of Childhood and Adolescence (contd.)
  • Diagnosis requires that symptoms cause
    significant impairment in daily functioning over
    extended period of time
  • Include
  • Internalizing disorders
  • Externalizing disorders
  • Neurodevelopmental disorders
  • Conditions involving impaired neurological

Internalizing Disorders of Childhood
  • Conditions involving emotional symptoms directed
  • Heightened reactions to trauma, stressors or
    negative events and difficulty regulating
  • Prevalent in early life and often lead to
    substance use and suicide

Anxiety, Trauma, and Stressor-Related Disorders
in Early Life
  • Most common mental health disorder in childhood
    and adolescence (32)
  • Can significantly affect academic, social, and
    interpersonal functioning and can lead to adult
    anxiety disorders
  • Include
  • Social phobia
  • Separation anxiety disorder
  • Selective mutism

Anxiety, Trauma, and Stressor-Related Disorders
in Early Life (contd.)
  • Post-traumatic stress disorder in early life
  • Recurrent, distressing memories of a shocking
    experience, such as experience with death,
    serious injury, or sexual violation
  • Memories may entail
  • Distressing dreams
  • Intense physiological or psychological reactions
    to thoughts or cues associated with event and
    avoidance of those cues
  • Episodes of playacting the event
  • Dissociative reactions

Anxiety, Trauma, and Stressor-Related Disorders
in Early Life (contd.)
  • Post-traumatic stress disorder in early life
  • Children often display social withdrawal,
    diminished positive affect, and disinterest in
    previously-enjoyed activities
  • Lifetime prevalence
  • 8 for girls and 2.3 for boys
  • Effective treatments include
  • Trauma-focused cognitive-behavioral therapies

Depressive Disorders in Early Life
  • Youth with depressive disorders have more
    negative self-concepts and are more likely to
    engage in self-blame and self-criticism
  • Early-onset depressive symptoms tends to predict
    a more chronic and severe course
  • Evidence-based treatment for depression
  • Individual, group, or school-based
    cognitive-behavioral therapy
  • SSRIs increase suicidality but benefits may
    outweigh risk

Nonsuicidal Self Injury
  • Involves induction of bleeding, bruising, or pain
    by means of intentional, self-inflicted injury,
    without suicidal intent
  • Intense negative affect or cognitions and a
    preoccupation with engaging in self-harm
    typically precede episodes of NSSI
  • Expectation that mood will improve after episode

Nonsuicidal Self Injury (contd.)
  • Prevalence
  • 14-17 of adolescents and young adults have
    engaged in self-injury at least once
  • Increased risk of attempted suicide
  • Treatment includes
  • Teaching problem-solving, coping and
    emotional-regulation skills
  • Focus on emotional expression and improving
    interpersonal relationship skills

Pediatric Bipolar Disorder
  • Debilitating disorder that parallels mood
    variability, depressive episodes, and significant
    departure from individuals typical functioning
    seen in adult bipolar disorder
  • Episodes of recurring depression, rapid mood
    changes, and distinct periods of
    abnormally-elevated mood involving diminished
    need for sleep, increased activity,
    distractibility, talkativeness, and inflated
  • Lifetime prevalence estimated 3

Pediatric Bipolar Disorder (contd.)
  • Rapid cycling of moods combined with
    neurocognitively based difficulties processing
    emotional stimuli and regulating behavior and
    social-emotional functioning
  • Elevated responsiveness to emotional stimuli,
    reduced volume in amygdala, and other brain
  • Medications are often combined with psychosocial

Attachment Disorders
  • Exposure to early environments devoid of
    predictable caretaking and nurturing can cause
    significant difficulties with emotional
    attachment and social relationships
  • Includes
  • Reactive attachment disorder (RAD)
  • Disinhibited social engagement disorder (DSED)

Attachment Disorders (contd.)
  • Reactive attachment disorder
  • Inhibited, avoidant social behaviors and
    reluctance to seek or respond to attention or
  • Show little trust that needs will be attended to
    and do not readily seek nor respond to comfort,
    attention, or nurturing
  • Use avoidance or ambivalence as psychological
  • Limited positive emotion and may demonstrate
    irritability, sadness, or fearfulness when
    interacting with adults

Attachment Disorders (contd.)
  • Disinhibited social engagement disorder
  • Indiscriminate, superficial attachments and
    desperation for interpersonal contact
  • Socialize effortlessly, but indiscriminately, and
    become superficially attached to strangers or
  • History of harsh punishment or inconsistent
    parenting, as well as emotional neglect and
    limited attachment opportunities
  • Exposure to maltreatment or maternal psychiatric
    hospitalizations are particularly vulnerable

Attachment Disorders (contd.)
  • Course depends on severity of social deprivation,
    abuse, neglect or disruptions in caregiving, and
    subsequent events in the childs life
  • Symptoms of RAD can disappear whereas symptoms of
    DSED are more persistent
  • Effective intervention
  • Providing stable, nurturing environment, and
    opportunities to develop interpersonal trust and
    social skills

Externalizing Disorders of Childhood
  • Also known as disruptive behavior disorders
    conditions associated with socially disturbing
    symptoms and distressing others
  • Include
  • Disruptive mood dysregulation disorder
  • Oppositional defiant disorder
  • Conduct disorder
  • Early intervention is necessary

Externalizing Disorders of Childhood (contd.)
  • Diagnosis is controversial, and requires a
    pattern of behavior that is
  • Atypical for the childs gender, age, and
    developmental level
  • Persistent
  • Severe enough to cause significant impairment in
    social, academic, or vocational functioning

Disruptive Mood Dysregulation Disorder
  • Characterized by chronic irritability and
    significantly exaggerated anger reactions
  • Patterns begin in early childhood
  • Diagnosis requires that symptoms persist beyond
    age six
  • Predictive of later depressive and anxiety
  • Clinicians need to rule out PBD due to symptom

Oppositional Defiant Disorder
  • Pattern of negativistic, argumentative, and
    hostile behavior in which children often
  • Lose their temper
  • Argue and defy adult requests
  • Primarily directed toward parents, teachers, and
    others in authority
  • No serious violation of societal norms
  • Two components
  • Negative affect
  • Oppositional behavior

Conduct Disorders
  • Persistent pattern of behavior that violates
    rights of others
  • Reflect dysfunctions in individual and include
  • Serious violations of rules and social norms
  • Cruelty and deliberate aggression towards people
    or animals
  • Theft, deceit, and vandalism
  • Callous and unemotional subtype
  • Often exhibit antisocial personality disorder in

Conduct Disorders (contd.)
  • Prevalence
  • Approximately 2-9 of youth meet criteria
  • 50 display inattention and hyperactivity
  • Gender differences
  • Males display confrontational aggression
  • Females display truancy, substance abuse, or
    chronic lying
  • More persistent than other childhood disorders

Etiology of Externalizing Disorders
  • Figure 15-1 Multipath Model of Conduct Disorder
    The dimensions interact with one another and
    combine in different ways to result in a conduct

Etiology of Externalizing Disorders (contd.)
  • Biological factors
  • Appear to exert greatest influence
  • Aggressive behavior linked to brain abnormalities
    and reduced activity in amygdala
  • Low MAOA and childhood maltreatment
  • Reduced autonomic nervous system activity
  • Cortisol (stress levels)

Etiology of Externalizing Disorders (contd.)
  • Social and sociocultural
  • Family and social context play large role
  • Large families and marital breakdown
  • Economic stress
  • Crowded living conditions
  • Harsh or inconsistent discipline
  • Maternal or peer rejection
  • Parent-child conflict and power struggles
  • Limited parental supervision

Etiology of Externalizing Disorders (contd.)
  • Psychological factors
  • Difficult child temperament (irritable,
    resistant, impulsive tendencies)
  • Underlying emotional issues
  • Depression frequently coexists with ODD and DMDD

Treatment of Externalizing Disorders
  • Must consider family and social context of
    behaviors and psychosocial skills deficits
  • CD is particularly difficult to treat
  • Effective when implemented before patterns of
    disruptive behavior are established
  • Parent-focused interventions regarding child
    management techniques

Treatment of Externalizing Disorders (contd.)
  • Psychosocial interventions that focus on
  • Assertiveness-training
  • Anger management techniques
  • Building skills in empathy, communication, social
    relationships and problem-solving
  • Mobilizing adult mentors

Neurodevelopmental Disorders
  • Involve impaired development of the brain and
    central nervous system
  • Symptoms become increasingly evident as child
    grows and develops
  • Include
  • Tic disorders
  • Attention-deficit hyperactivity disorder
  • Autism spectrum disorders
  • Intellectual and learning disorders

Tics and Tourettes Disorder
  • Tics
  • Involuntary, repetitive movements or
  • Motor tic
  • Eye-blinking, facial-grimacing, head-jerking,
    foot tapping, flaring of nostrils, and
    contractions of the shoulders or abdominal
  • Vocal tics
  • Coughing, grunting, throat clearing, sniffling,
    or sudden repetitive and stereotyped outburst of

Tics and Tourettes Disorder (contd.)
  • Tics
  • Short-term suppression of a tic is possible, but
    results in subsequent increases in the tic
  • Some report feeling tension build prior to tic,
    followed by a sense of relief after tic occurs
  • Stress can increase frequency and intensity
  • Provisional tic disorders (2.6 of children)
  • Chronic motor or vocal tic disorders (3.7 of

Tics and Tourettes Disorder (contd.)
  • Tourettes disorder (TD)
  • Characterized by multiple motor tics and one or
    more vocal tic, present for at least one year
  • Onset is prior to age 18
  • About 8 show complete remission
  • Symptoms can be severe or mild
  • Coprolalia and motor movements involving
  • Comorbid conditions

Tics and Tourettes Disorder (contd.)
  • Etiology
  • Both chronic tic disorder and TD appear to be
    genetically transmitted
  • Involvement of basil ganglia and orbital frontal
  • Possible involvement of neurotransmitters
  • Treatment
  • Psychotherapy can help with distress
  • Habit reversal technique
  • Antipsychotic medication used for severe tics

Tics and Tourettes Disorder (contd.)
  • Tourette's Syndrome Introduction Meet Isabella,
    Devon, Nikki, Amanda as they attend Camp
    Tic-a-Palooza, a camp designed for children with
    Tourette's Syndrome. Explore the many
    difficulties they encountered when integrating
    with other children in school, and even with
    their families.

Attention-Deficit/Hyperactivity Disorder
  • Characterized by persistent inattention and/or
    impulsive, hyperactive behaviors
  • Symptoms must interfere with social, academic, or
    occupational activities
  • Diagnosis requires that symptoms begin before age
    12 and persist for at least six months
  • Poor regulation of attentional processes

Attention-Deficit/Hyperactivity Disorder (contd.)
  • Prevalence rates vary between studies
  • One study 8.7
  • More than twice as likely in boys than in girls
  • Symptoms tend to improve in late adolescence
  • Associated with behavioral and academic problems
  • Risk of coexisting conditions is four times
    greater among children living in poverty

Attention-Deficit/Hyperactivity Disorder Etiology
  • Biological dimension
  • Highly heritable with up to 80 of symptoms
    explainable by genetic factors
  • Rare inherited gene mutations
  • Chromosomal DNA deletions and duplications
  • Genes affecting regulation of dopamine and
  • Hypotheses about neurological mechanisms
  • Reduced activity in prefrontal cortex
  • Differences in brain structure and circuitry in
    frontal cortex, cerebellum, and parietal lobes
  • Low dopamine levels

Attention-Deficit/Hyperactivity Disorder
Etiology (contd.)
  • ABC Video Brain Activity and ADHD See an
    in-depth look at the brain and how the brains of
    people with ADHC differ and are similar to those
    who do not have ADHD using brain imaging

Attention-Deficit/Hyperactivity Disorder
Etiology (contd.)
  • Biological dimension
  • Prematurity
  • Oxygen deprivation during birth
  • Low-birth weight
  • Lead and PCB exposure
  • Viral infections, meningitis, and encephalitis
  • Maternal smoking, drug, and alcohol abuse during
  • Possible involvement of food additives

Attention-Deficit/Hyperactivity Disorder
Etiology (contd.)
  • Social and sociocultural dimensions
  • Sociocultural and social adversity including
  • Stressors in family
  • Low social class
  • Foster care placement
  • Cultural and regional expectations
  • Psychological dimension
  • Interpersonal conflict

Attention-Deficit/Hyperactivity Disorder
Etiology (contd.)
  • Figure 15-3 Prevalence of ADHD Among Youth (Ages
    4-17) by State, 2007-2008 The prevalence of
    parent-reported attention-deficit/hyperactivity
    disorder varied significantly from state to
    state, ranging from a low of 5.6 in Nevada to a
    high or 15.6 in North Carolina. What might
    account for the variability in ADHD diagnoses
    from state to state?
  • Source Centers for Disease Control and
    Prevention (2010b)

Attention-Deficit/Hyperactivity Disorder
  • Stimulants such as methylphenidate (Ritalin)
    receive most evidence-based support
  • Normalize neurotransmitter functioning and
    increased neurological activation in frontal
  • Increased rates of stimulant medication use in

Attention-Deficit/Hyperactivity Disorder
Treatment (contd.)
  • Evidence that behavioral and psychological
    treatments are highly effective
  • Modifying environment and social context can
    enhance feelings of competence, motivation, and
  • Coordination of all services result in most
    successful interventions

Autism Spectrum Disorders
  • Characterized by impairment in social
    communication and restricted, stereotyped
    interests and activities
  • Symptoms range from mild to severe
  • Prevalence
  • Affects one out of 100-110 children
  • Four times as common in boys

Autism Spectrum Disorders (contd.)
  • ABC Video Underdiagnosed Autism in Girls
    Discover the ways in which autism is more often
    diagnosed, and often easier to diagnose, in boys,
    and the problems this can lead to for young girls
    with autism spectrum disorders

Autism Spectrum Disorders (contd.)
  • Symptoms of autism spectrum disorder
  • Deficits in social communication and social
  • Atypical social-emotional reciprocity
  • Atypical nonverbal communication
  • Difficulties developing and maintaining

Autism Spectrum Disorders (contd.)
  • Symptoms of autism spectrum disorder
  • Repetitive behavior or restricted interests or
    activities involving at least two of following
  • Repetitive speech, movement, or use of objects
  • Intense focus on rituals or routines and strong
    resistance to change
  • Intense fixations or restricted interests
  • Atypical sensory reactivity
  • Autistic savants
  • Individual with ASD who performs exceptionally
    well on certain tasks

Autism Spectrum Disorders (contd.)
  • Problems diagnosing autism
  • Typical procedures include clinical observation,
    parent interviews, developmental histories,
    autism screening inventories, communication
    assessment, and psychological testing
  • Autism is usually diagnosed at age three or later
  • Symptoms may appear following a period of normal
    social and intellectual development

Autism Spectrum Disorders Etiology
  • Biological dimension
  • Unique patterns of metabolic brain activity
  • Abnormally high levels or serotonin
  • Differences in brain anatomy and connectivity in
    brain regions associated with autistic traits
  • Accelerated growth or amygdala
  • Accelerated head growth
  • Genetic mutations implicated in familial autism

Autism Spectrum Disorders Etiology (contd.)
  • Biological dimension
  • Genetic factors
  • Heritability estimated to be around .73 percent
    for males and .87 for females
  • Autistic traits have high heritability
  • Clear evidence for genetic susceptibility
  • Innate vulnerability triggered by environment
  • Nutritional deficits, changes in immune system,
    low birth weight

Autism Spectrum Disorders Etiology (contd.)
  • Figure 15-5 Changes in the Prevalence of Autism
    Spectrum Disorder Among 8 Year-Old Children in 10
    U.S. States 2002 to 2006 The prevalence of autism
    spectrum disorder among 8-year-old children
    increased between 2002 and 2006 in all 10 state
    sites monitored. What might account for these
    increases and the state-to-state variations in
    prevalence of the disorder?
  • Source Center for Disease Control and Prevention

Autism Spectrum Disorders Etiology (contd.)
  • Psychological dimension
  • Children with ASD seldom make eye contact, seek
    social connectedness, or bid for attention
  • Prefer to be alone and ignore parental efforts at
  • High stress levels among family due to ASD
  • Psychological and social factors play a role in
    manifestation of symptoms, but ASD is primarily
    influenced by biological factors

Autism Spectrum Disorders Intervention and
  • Prognosis is mixed most children retain
    diagnosis and require support for life
  • Individuals with higher levels of
    cognitive-adaptive functioning fare better than
    those with intellectual disabilities and severe
    autistic symptoms
  • Significant recovery linked with intense early

Autism Spectrum Disorders Intervention and
Treatment (contd.)
  • ABC Video Autism Diagnosis Early intervention
    can help Autistic children lead more normal
    lives. Find out what parents can do to help
    identify this disorder early-on.

Autism Spectrum Disorders Intervention and
Treatment (contd.)
  • Medications are used to decrease anxiety,
    repetitive behaviors, and hyperactivity
  • Minimally effective and may be harmful
  • Risperidone alone received FDA approval
  • Preliminary research on effects of oxytocin
  • Comprehensive treatment programs have enabled
    children with ASD to develop more functional

Autism Spectrum Disorders Intervention and
Treatment (contd.)
  • Interventions with most significant gains
  • Social communication
  • Environmental enrichment
  • Reinforcing appropriate attention and response to
    social stimuli
  • Preventing repetitive behaviors
  • Sustained practice of weaker skills
  • Reducing environmental stress
  • Improving sleep and nutrition

Intellectual Developmental Disorder
  • Limitations in intellectual functioning and
    adaptive behaviors including
  • Significantly below average general intellectual
    functioning (generally IQ of 70 or less)
  • Deficiencies in adaptive behavior that are lower
    than would be expected based on age or cultural
  • Only diagnosed when low intelligence is
    accompanied by impaired adaptive functioning

Intellectual Developmental Disorder (contd.)
  • Four distinct categories
  • Mild IQ score 50-55 to 70
  • Moderate IQ score 35-40 to 50-55
  • Severe IQ score 20-25 to 35-40
  • Profound IQ score below 20-25

Intellectual Developmental Disorder (contd.)
Intellectual Developmental Disorder (contd.)
  • American Association on Intellectual and
    Developmental Disabilities
  • IQ score may be used to approximate intellectual
  • More important to focus on adaptive functioning
    and nature of psychosocial supports needed
  • Given ongoing, individualized support, overall
    functioning of individual with ID will improve

Intellectual Developmental Disorder (contd.)
  • Prevalence
  • Approximately 1 of students in public school
  • Increases in low and middle income countries
  • Coexisting conditions are common
  • One-fourth have seizure disorders

Intellectual Developmental Disorder Etiology
  • Etiology differs depending on level of
    intellectual impairment
  • Mild IDD is often idiopathic (no known cause)
  • Pronounced IDD related to genetic factors, brain
    abnormalities, or brain injury

Intellectual Developmental Disorder Etiology
  • Genetic factors
  • In up to 80 percent of cases of IDD, underlying
    cause is unknown
  • Unidentified genetic factors
  • Genetic variations
  • Normal distribution of traits (upper vs. lower
  • Genetic abnormalities
  • Chromosomal abnormalities
  • Down syndrome most common
  • Inheritance of single gene
  • Fragile X syndrome most common (mild to severe

Intellectual Developmental Disorder Etiology
  • Down syndrome (DS)
  • Extra copy of chromosome 21 originates during
    gamete development
  • Majority have mild to moderate IDD
  • With support many can have jobs and live
  • Medical interventions improve outcome, but
    significant risks remain
  • Prenatal detection of DS through amniocentesis

Intellectual Developmental Disorder Etiology
  • Developmental Disabilities Children with
    developmental disabilities are said to have
    exceptionalities, which are diagnosed based on
    delays or differences in what we know of typical

Intellectual Developmental Disorder Etiology
  • Nongenetic biological factors
  • Influences during prenatal, perinatal, or
    postnatal period
  • Fetus is susceptible to viruses and infections,
    drugs and alcohol, radiation, and poor nutrition
  • Fetal alcohol spectrum effects and fetal alcohol
  • Birth trauma, prematurity, and low birth weight
  • Head injuries, brain infections, tumors, and
    prolonged malnutrition
  • Exposure to environmental toxins, including lead

Intellectual Developmental Disorder Etiology
  • Psychological, social, sociocultural dimensions
  • Genetic background interacts with environmental
  • Effects of low SES
  • Parents with mild IDD
  • Long-term effects of prematurity
  • Enriching and encouraging home environment, as
    well as ongoing education intervention

Learning Disorders
  • Academic disability characterized by reading,
    writing, and math skills deficits
  • Primarily interferes with academic achievement
    and activities of daily living in which reading,
    writing, or math skills are needed (e.g.,
    dyscalculia, dyslexia)
  • Prevalence
  • Around 5 of students in public schools
  • Boys are almost twice as likely as girls

Learning Disorders (contd.)
  • Etiology
  • Little is known about precise causes of LD
  • Appear to have slower brain maturation
  • Lifelong differences in neurological processing
    of information related to basic academic skills
  • May be similar to biological explanations for IDD
    and ADHD
  • Runs in families, suggesting genetic component

Support for Individuals with Neurodevelopmental
  • Produce lifelong disability, goal of intervention
    is to build skills and develop potential to the
    fullest extent possible
  • Support should begin in infancy and extend across
    the life span
  • Different levels of support

Support for Individuals (contd.)
  • Support in childhood
  • Individualized home-based or school-based
  • Parent involvement is integral part of early
    intervention programs
  • School services are individualized to meet
    childs needs and to maximize learning
  • Rates of improvement decrease once programs are

Support for Individuals (contd.)
  • Support in adulthood
  • Programs focusing on specific job skills
  • Institutionalization is rare, but many live with
    family members
  • Least restrictive environment possible
  • As much independence and personal choice as is
    safe and practical
  • Most normalized living arrangements vary from
    setting to setting