Clinical psychology
Chapter 13
Disorders of childhood
Most theories of childhood disorder, consider childhood experience and development critically important to adult mental health.
Before making a diagnosis of a particular disorder in children, clinicians must first consider what is typical for a particular age.
Some childhood disorders are unique to children.
The more prevalent childhood disorders are often divided into two broad domains,
Children and adolescents may exhibit symptoms form both domains.
Across cultures, externalizing behaviors are consistently found more often among boys and internalizing behaviors more often among girls, at least in adolescence.
Childhood disorders involve an interaction of genetic, neurobiological, and psychological factors.
Clinical descriptions, prevalence, and prognosis of ADHD
DSM-5 criteria for attention-deficit/hyperactivity disorder
Although children with ADHD are usually friendly and talkative, they often miss subtle social cues.
Children with ADHD can know what the socially correct action is in hypothetical situations but be unable to translate this knowledge into appropriate behavior in real-life social interactions.
DSM-5 includes three specifiers to indicate which symptoms predominate
The combined specifier comprises the majority of children with ADHD.
A difficult differential diagnosis is between ADHD and conduct disorder, which involves gross violation of social norms.
These two disorders frequently co-occur and share some features in common.
But there are differences.
When both conduct disorder and ADHD occur in the same child, the worst features of each are manifest.
Internalizing disorders, such as anxiety and depression, also frequently co-occur with ADHD.
The hyperactive symptoms of ADHD predicted subsequent substance use.
Prevalence of ADHD is 3 to 7 percent.
ADHD symptoms may decline with age, but they do not entirely go away for many people.
Etiology of ADHD
Genetic factors
Genetic factors play are role in ADHD.
Heritability estimates of 70 to 80 percent.
Genes associated with the neurotransmitter dopamine.
A single gene will not ultimately be fount to account for ADHD.
Neurobiological factors
Brain structure and function differ in children with and without ADHD, particularly in brain areas linked to the neurotransmitter dopamine.
Children with ADHD exhibit less activation in frontal areas of the brain while performing different cognitive tasks.
Children with ADHD perform poorly on neuropsychological tests that rely on the frontal lobes. A basic deficit in this part of the brain may be related to the disorder.
Perinatal and prenatal factors
Environmental toxins
Exposure to tobacco in utero is associated with ADHD symptoms.
Chronic exposure to nicotine increases dopamine release in the brain and causes hyperactivity.
Withdrawal form nicotine is associated with decreases in dopamine release in the brain and causes irritability.
Maternal smoking might affect the dopaminergic system of the developing fetus, increasing the risk of developing behavioral disinhibition and ADHD.
Psychological factors in ADHD
The parent-child relationship interacts with neurobiological factors in a complex way to contribute to ADHD symptom expression.
It is also important to consider a parents own history of ADHD.
Treatment of ADHD
ADHD is typically treated with medication and with behavioral therapies based on operant conditioning.
Stimulant medications
The drugs used to treat ADHD reduce disruptive behavior and improve ability to concentrate.
Psychological treatment
Promising treatments for ADHD involve parent training and changes in classroom management.
In these treatments, children’s behavior is monitored at home and in school, and they are reinforced for behaving appropriately. Point systems and daily report cards (DRCs) are typical components of these programs. Children earn points or stars for behaving in certain ways, the children can spend their earnings for rewards.
School interventions for children with ADHD include training teachers to understand the unique needs for these children and to apply operant techniques in the classroom, providing peer tutoring in academic skills, and having teachers provide daily reports to parents about in-school behavior, which are followed by rewards at home.
Certain classroom structures can help children with ADHD.
Ideally, teachers vary the presentation format and materials used for tasks, keep assignments brief and provide immediate feedback on whether they have been done correctly, have an enthusiastic and task-focused style, provide breaks for physical exercise, and schedule academic work during the morning hours.
Intensive behavior therapies can be very helpful to children with ADHD.
Conduct disorder is another externalizing disorder.
The DSM-5 criteria focus on behaviors that violate the basic rights of others and violate major societal norms. Nearly all such behaviors are illegal.
The symptoms of conduct disorder must be frequent and severe enough to go beyond the mischief and pranks common among children and adolescents.
DSM-5 includes a ‘limited prosocial emotions’ diagnostic specifier for children who show characteristics such as lack of remorse, callousness, or shallow emotions.
A related but less well understood externalizing disorder is oppisitional defiant disorder (ODD)
Diagnosed if a child does not meet the criteria for conduct disorder, but exhibits such behaviors as losing his or her temper, arguing with adults, repeatedly refusing to comply with requests from adults, deliberately doing things to annoy others, and being angry, spiteful, touchy, or vindictive.
Commonly comorbid with ODD are ADHD, specific learning disorder, and communication disorders.
ODD is different from ADHD in that the defiant behavior is not thought to arise from attentional deficits or sheer impulsiveness.
More common among boys.
Clinical description, prevalence, and prognosis of conduct disorder
DSM-5 criteria for Conduct disorder
Conduct disorder is defined by the impact of the child’s behavior on people and surroundings.
Many children with conduct disorder display other problems, such as substance abuse and internalizing disorders.
Anxiety and depression are common among children with conduct disorder.
Conduct disorder precedes depression and most anxiety disorders.
Conduct disorder is fairly common, with a prevalence of 9.5 percent.
The prognosis for children diagnosed as having conduct disorder is mixed.
Men and women with the life-course-persistent type of conduct disorder will likely continue to have all sorts of problems in adulthood, including violent and antisocial behavior.
But, conduct disorder in childhood does not inevitably lead to antisocial behavior in adulthood.
Etiology of conduct disorder
Genetic factors
Heritability likely plays a part.
Both environment and genes matters.
Being maltreated was linked to later antisocial behavior via genetics.
Neuropsychological factors and the autonomic nervous system
Childhood profiles of children with conduct disorder
Autonomic nervous system abnormalities are associated with antisocial behavior in adolescents.
Psychological factors
Children with conduct disorder seem to be deficient in moral awareness, lacking remorse for their wrongdoings.
Behavioral theories that look both to modeling and operant conditioning provide useful explanations of the development and maintenance of conduct problems
Aggression is often an effective, albeit unpleasant, means of achieving a goal, it is likely to be reinforced.
Social-cognitive perspective
Aggressive children interpreted ambiguous acts as evidence of hostile intend.
This can create a vicious cycle.
Peer influences
Being rejected by peers is causally related to aggressive behavior, particularly in combination with ADHD.
Associating with other deviant peers also increases the likelihood of delinquent behavior.
Children with conduct disorder choose to associate with like-minded peers and being around deviant peers help initiate antisocial behavior.
Environmental influence, particularly neighborhood and family, factors play a role in whether children associate with deviant peers, and this in turn influences and exacerbates conduct disorder.
Sociocultural factors
The combination of early antisocial behavior in the child and socioeconomic disadvantage in the family predicts early criminal arrests.
Treatment of conduct disordered
The treatment of conduct disorder appears to be most effective when it addresses the multiple systems involve in the life of a child.
Family interventions
Some of the most promising approaches to treating conduct disorder involve intervening with the parents and families of the child.
Intervening early, even just briefly, can make an impact.
Parent management training (PMT)
Parents are taught to modify their responses to their children so that prosocial rather than antisocial behavior is consistently rewarded.
Parents are taught to use techniques such as positive reinforcement when the child exhibits positive behavior and time-out and loss of privileges for aggressive or antisocial behaviors.
Multisystemic treatment
Multisystemic treatment (MST)
Involves delivering intensive and comprehensive therapy services in the community, targeting the adolescent, the family, the school, and, in some cases, the peer group.
The treatment is based on the view that conduct problems are influenced by multiple factors within the family as well as between the family and other social systems.
The therapy’s uniqueness lies in emphasizing individual and family strengths, identifying the social context for the conduct problems, using present-focused and attention-oriented interventions, and using interventions that require daily or weekly efforts by family members.
Treatment is provided in ‘ecologically valid’ settings, such as the home or school to maximize the chances that improvement will carry through into the regular lives of children and their families.
Depression and anxiety commonly co-occur with each other.
Depression
Clinical descriptions and prevalence of depression in childhood and adolescence
Children and adolescents ages 7 to 17 and adults both tend to show the following symptoms:
Children differ from adolescents in showing:
Depression in children is recurrent.
Depression occurs in less than 1 percent of preschoolers.
2 to 3 percent of school-age children.
In adolescence, rates are around 6 percent for girls and 4 percent for boys.
Etiology of depression in childhood and adolescence
Genetic factors play a role.
Early adversity and negative life events also play a role.
Rejection by parents is modestly associated with depression in childhood.
Other interpersonal factors are associated with depression in children
Cognitive distortions and negative attributional styles are associated with depression in children and adolescents in ways similar to what has been found in adults.
Negative thoughts and hopelessness also predict a slower time to recovery from depression among adolescents.
Attribution style does not interact with negative life events to predict depression for young children.
Treatment of childhood and adolescent depression
There are safety concerns about the use of antidepressants among children and adolescents.
Most psychosocial interventions are modeled after treatments developed for adults.
Two types of preventive interventions for depression:
Anxiety
Fears are reported more often for girls than for boys.
Clinical descriptions and prevalence of anxiety in childhood and adolescence
For fears and worries to be classified as disorders according to DSM criteria, children’s functioning must be impaired.
Unlike adults, children need not regard their fear as excessive or unreasonable, because children sometimes are unable to make such judgments.
Prevalence: 3-5%
Separation anxiety disorder
Separation anxiety disorder is characterized by worry that some harm will befall their parents or themselves when they are away from their parents.
When at home, such children shadow one or both of their parents.
DSM-5 criteria for Separation anxiety disorder
Another anxiety disorder among children and adolescents is social anxiety disorder.
Selective mutism: refusing to speak at all in unfamiliar social circumstances.
At home, such children ask their parents endless questions about situations that worry them.
Withdrawn children usually have warm and satisfying relationships with family members and family friends, and they show a desire for affection and acceptance.
Prevalence for social anxiety disorder among children and adolescents is around 1%
Children who are exposed to traumas such as chronic abuse, community violence, and natural disasters may experience symptoms of posttraumatic stress disorder (PTSD) similar to those experienced by adults.
Obsessive compulsive disorder is also found among children and adolescents.
Prevalence 1 to 4%
The symptoms in childhood are similar to symptoms in adulthood.
More common in boys than in girls, but this difference does not remain in adolescence and adulthood.
Etiology of anxiety disorders in childhood and adolescence
Theories of the etiology of social anxiety in children are generally similar to theories of social anxiety in adults.
Children overestimate the danger in many situations and underestimate their ability to cope with them.
The anxiety created by these cognitions then interferes with social interaction, causing the child to avoid social situations and thus not to get much practice at social skills.
Behavioral inhibition is an important risk factor for the development of social anxiety.
Theories about the causes of PTSD in children are similar to the theories for adults.
Some theories suggest that parental reactions to trauma can help to lessen children’s distress. If parents appear in control and calm in the face of stress, a child’s reaction may be less severe.
Treatment of anxiety in childhood and adolescence
Many fears simply dissipate with time and maturation.
For the most part, treatment of such fears is similar to that employed with adults, with suitable modifications to accommodate the different abilities and circumstances of childhood.
The major focus of these treatments is on exposure to the feared object.
Cognitive behavior therapy can be helpful to many children with anxiety disorders.
This type of treatment typically involves working with both children and parents.
One of the more widely used treatments is called the Coping Cat.
Used with children between the ages 7 and 13.
Focuses on confronting fears, developing new ways to think about fears, exposure to feared situations, practice, and relapse prevention.
Parents are also included in a couple of sessions.
A learning disability: a condition in which a person shows a problem in a specific area of academic, language, speech, or motor skills that is not due to intellectual disability or deficient educational opportunities.
Clinical descriptions
DSM-5 criteria for Specific learning disorder
Learning disabilities groups together three categories of disorders
Any of these disorders may apply to a child who fails to develop to the degree appropriate to his or her intellectual level in a specific academic, language, or motor skill area.
Learning disabilities are often identified and treated within the school system.
More common in boys.
Prevalence is 4 -7 percent.
Etiology of learning disabilities
Dyslexia and dyscalculia are coded as specifiers for the DSM-5 category specific learning disorder.
Etiology of dyslexia
There is a heritable component to dyslexia.
The genes that are associated with dyslexia are the same genes associated with typical reading abilities.
Genes play a bigger role in dyslexia among children whose parents have more education.
The core deficits in dyslexia include problems in language processing.
One or more problems in language processing that might underlie dyslexia.
Many of these fall under phonological awareness, which is believed to be critical to development of reading skills
Areas in the left temporal, parietal, and occipital regions of the brain are involved in dyslexia.
Etiology of dyscalculia
Some genetic influence. Particular, the type of math disability that involves poor semantic memory is most likely to be heritable.
Genes associated with dyscalculia are also associated with mathematics ability.
Areas of the parietal lobe are less active. The intraparietal sulcus is less active.
Treatment of learning disabilities
Phonics instruction is beneficial for children with learning difficulties.
Diagnosis and assessment of intellectual disability
DSM-5 criteria for Intellectual disability
The DSM-5 diagnostic criteria for intellectual disability include three criteria.
IQ score most be considered within a person’s cultural context.
Adaptive functioning must be assessed and considered in the light of the person’s age and cultural group.
Severity is assessed in three domains
Etiology of intellectual disability
Genetic or chromosomal abnormalities
One chromosomal abnormality that has been linked with intellectual disability is trisomy 21.
Having an extra copy.
Down syndrome.
Fragile X syndrome.
Underdeveloped ears and a long, thin face.
Many people with fragile X syndrome have intellectual disability. Others may not have intellectual disability, but nonetheless have learning disabilities, difficulties on neuropsychological tests, and mood swings.
Recessive-gene diseases
Several hundred recessive-gene diseases have been identified, and many of them can cause intellectual disability.
Phenylketonuria (PKU)
The infant, born without obvious signs of difficulty, soon begins to suffer from a deficiency of a liver enzyme, phenylalanine hydroxylase. This enzyme is needed to convert phenylalanine, an amino acid contained in protein, to tyrosine, an amino acid that is essential for the production of certain hormones.
Because of this enzyme deficiency, phenylalanine and its derivative, phenylpyruvic acid, are not broken down and instead build up in the body’s fluid.
This build up eventually damages the brain because the unmetabolized amino acid interferes with the process of myelination. The frontal lobes are particularly affected, and intellectual disabilities can be profound.
Infectious diseases
While in utero the fetus is at increased risk of intellectual disabilities resulting from maternal infectious diseases such as rubella.
The consequences of these diseases are most serious during the first trimester of pregnancy, when the fetus has not detectable immunological response.
Infectious diseases can also affect a child’s developing brain after birth.
In adulthood, these infections are usually far less serious.
Environmental hazards
Several environmental pollutants are implicated in intellectual disability.
Treatment of intellectual disability
Residential treatment
Adults with intellectual developmental disorder live in small to medium-sized residents that are integrated into the community.
Behavioral treatment
Early-intervention programs using behavioral techniques have been developed to improve the level of functioning of people with intellectual disability.
Specific behavioral objectives are defined, and children are taught skills in small, sequential steps.
Children with more severe intellectual disability need intensive instruction.
To teach a child a particular routine, the therapist usually begins by dividing the target behavior into smaller components. Operant conditioning is applied. → applied behavior analysis.
Cognitive treatments
Self-instructional training teaches children to guide their problem-solving efforts trough speech.
Computer-assisted instruction
The visual and auditory components of computers can help to maintain the attention of distractible students.
The level of the material can be geared to the individual.
The computer can meet the need for numerous repetitions of the material.
Clinical descriptions, prevalence, and prognosis of autism spectrum disorder
DSM-5 criteria for Autism spectrum disorder
Social and emotional disturbances
Children with ASD can have profound problems with the social world.
They may rarely approach others and may look through or past people or turn their backs on them.
Few children with ASD initiat play with other children, and they are usually unresponsive to anyone who approaches them.
Children with ASD sometimes make eye contact, but their gaze may have an unusual quality.
Problem with joint attention.
Children with ASD do not pay attention to other people’s faces or capture their gaze.
Children with ASD spend much less time in symbolic play.
Disturbances in Theory of mind.
Communication deficits
Even before they acquire language, some children with ASD show deficits in communication.
Babbling is less frequent in infants with ASD and conveys less information.
Language deficits.
Echolalia: the child echoes, usually with remarkable fidelity, what he or she has heard another person say.
Pronoun reversal: children refer to themselves as ‘he’, ‘she’, or ‘you’.
Repetitive and ritualistic acts
Children with ASD can become extremely upset over changes in their daily routines and surroundings.
An obsessional quality may pervade the behavior of children with ASD.
Children with ASD are likely to perform a limited number of behaviors and are less likely to explore new surroundings.
Children with ASD may display stereotypical behavior.
Some children with ASD can become preoccupied with and form strong attachments to simple inanimate objects and more complex mechanical objects.
Comorbidity and ASD
Many children with ASD score below 70 on standardized intelligence tests, which can make it difficult to distinguish between ASD and intellectual disability.
Differences:
ASD is comorbid with learning disorders.
ASD is also comorbid with anxiety.
Prevalence of autism spectrum disorder
ASD begins in early childhood and can be evident in the first months of life.
More body than girls.
Diagnosis is stable
Prognosis for autism spectrum disorder
Children with higher Iqs who learn to speak before age 6 have the best outcomes, and few of these function fairly well in adulthood.
Etiology of autism spectrum disorder
Genetic factors
A genetic component with heritability estimates of around 0.8.
ASD is linked genetically to a broader spectrum of deficits in communication and social interaction.
Neurobiological factors
The brains of adults and children with ASD are larger.
Neurons might not being pruned correctly.
Overgrown areas are the frontal, temporal, and cerebellar, which have been linked to language, social, and emotional functions.
Treatment of autism spectrum disorder
The most promising efforts at treatment of ASD are psychological.
Treatments are usually aimed at reducing unusual behavior and improving their communication and social skills
In most cases, the earlier the intervention begins, the better the outcome.
Behavioral treatment
Operant conditioning.
Education provided by parents is beneficial.
This is a summary of Abnormal Psychology by Kring, Davison, Neale & Johnson. This summary focuses on clincal psychology and mental health. Discussed are etliolgies of disorders and treatments.
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