Disorders of childhood - summary of chapter 13 of Abnormal Psychology by Kring, Davison, Neale & Johnson (12th edition)

Clinical psychology
Chapter 13
Disorders of childhood

Most theories of childhood disorder, consider childhood experience and development critically important to adult mental health.

Classification and diagnosis of childhood disorders

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,

• Externalizing disorders
  Characterized by outward-directed behaviors
  • Attention-deficit/hyperactivity disorder
  • Conduct disorder
  • Oppositional defiant disorder
• Internalizing disorders
  Characterized by more inward-focused experiences and behaviors
  • Childhood anxiety disorder
  • Mood disorders

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.

Attention-deficit/hyperactivity disorder

Clinical descriptions, prevalence, and prognosis of ADHD

DSM-5 criteria for attention-deficit/hyperactivity disorder

• Either A or B
• A. Six or more manifestations of inattention present for at least 6 months to a maladaptive degree and greater that what would expected given a person’s developmental level, e.g., careless mistakes, not listening well, not following instructions, easily distracted, forgetful in daily activities
• B. Six or more manifestations of hyperactivity-impulsivity present for at least 6 months to a maladaptive degree and greater than would be expected given a person’s developmental level e.g., fidgeting, running about inappropriately (in adults, restlessness), acting as is ‘driven by a motor’, interrupting or intruding, incessant talking.
  • Several of the above present before age 12
  • Present in two or more settings, e.g., at home, school, or work
  • Significant impairment in social, academic, or occupational functioning
  • For people age 17 or older, only five signs of inattention and/or five signs of hyperactivity-imupulsivity are needed to meet the diagnoses.

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

• Predominantly inattentive: children whose problems are primarily those of poor attention
• Predominantly hyperactive-impulsive: children whose difficulties result primarily from hyperactive/impulsive behavior
• Combined: children who have both sets of problems

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.

• ADHD is associated more with off-task behavior in school, cognitive and achievement deficits, and better long-term prognosis.
• Children with ADHD act out less in school and elsewhere and are less likely to be aggressive and to have antisocial parents.
• Children with ADHD home life is also usually marked by less family hostility, and they are at less risk for delinquency and substance abuse in adolescence compared with children with conduct disorder

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

• Low birth weight is a predictor of the development of ADHD, but this impact can be mitigated by greater maternal warmth.
• Other complications associated with childbirth, as well as mothers’ use of substances are predictive of ADHD symptoms.

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

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

• Repetitive and persistent behavior pattern that violates the basic rights of others or conventional social norms as manifested by the presence of three or more of the following in the previous 12 months and at least one of the m in the previous 6 months
• A. Aggression to people and animals e.g., bullying, initiating physical fights, physical cruel to people or animals, forcing someone into sexual activity
• B. destruction of property, e.g., fire-setting, vandalism
• C. Deceitfulness or theft, e.g., breaking into another’s house or car, conning, shoplifting
• D. Serious violation of rules, e.g., staying out at night before age 13 in defiance of parental rules, truancy before age 13
• Significant impairment in social, academic, or occupational functioning.

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.

• 4-6 percent for boys and 1,2 to 9 percent for girls.

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

• Poor verbal skills
• Difficulty with executive functioning
• Problems with memory
  Lower IQ.

Autonomic nervous system abnormalities are associated with antisocial behavior in adolescents.

• Lower arousal levels
  Less fear of being caught

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.

• Parenting characteristics such as harsh and inconsistent discipline and lack of monitoring are consistently associated with conduct problems
  Perhaps children who do not experience negative consequences for early misbehavior later develop more serious conduct problems

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 in children and adolescents

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:

• Depressed mood
• Inability to experience pleasure
• Fatigue
• Concentration problems
• Suicidal ideation

Children differ from adolescents in showing:

• More guilt
• Lower rates of early-morning wakefulness
• Early-morning depression
• Loss of appetite
• Weight loss

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

• Negative interactions with parents
• Impaired relationships with siblings, friends, and romantic partners
  Children with depression are often rejected by peers because there are not enjoyable to be around.
  The negative interactions in turn may aggravate the negative self-image and sense of worth that the depressed child has.

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.

• Interpersonal therapy has been modified for use with depressed adolescents by focusing on issues of concern to adolescents.
• Cognitive behavioral therapy in school settings

Two types of preventive interventions for depression:

• Selective
  Target particular youth based on family risk factors, environmental factors, or personal factors.
• Universal
  Targeted toward large groups and seek to provide education and information about 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

• Excessive anxiety that is not developmentally appropriate about being away from home and parents or other attachment figures, with at least three symptoms that last for at least 4 weeks (for adults symptoms must last for 6 months or more)
  • Recurrent and excessive distress when separated
  • Excessive worry that something bad will happen to parent or attachment figure
  • Refusal or reluctance to go to school, work, or elsewhere
  • Refusal or reluctance to sleep away from home
  • Nightmares about separation
  • Repeated physical complaints

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

• Genetics play a role in anxiety among children.
  Hertiablity ranging from 29 to 50 percent.
• Parenting practices play a small role in childhood anxiety.
  Parental control and over-protectiveness, more than parental rejection, is associated with childhood anxiety.
• Emotion-regulation problems
• Insecure attachment in infancy

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.

• There must be exposure to trauma
• Children who have a propensity to experience anxiety may be at more risk for developing PTSD after exposure to trauma.
• Specific risk factors for children may include
  • Level of family stress
  • Coping styles of the family
  • Past experiences with trauma.

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.

• Beyond exposure, treatment includes psychoeducation, cognitive restructuring, modeling, skill training, and relapse prevention.

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.

Learning disabilities

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

• Difficulties in learning basic academic skills inconsistent with person’s age, schooling, and intelligence persisting for at least 6 months.
• Significant interference with academic achievement or activities of daily living.

Learning disabilities groups together three categories of disorders

• Specific learning disorder
• Communication disorders
• Motor 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.

• Perception of speech and analysis of the sounds of spoken language and their relation to printed words
• Difficulty recognizing rhyme and alliteration
• Problems with rapidly naming familiar objects
• Delays in learning syntactic rules

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.

Intellectual disability

Diagnosis and assessment of intellectual disability

DSM-5 criteria for Intellectual disability

• Intellectual deficits (e.g., in solving problems, reasoning, abstract thinking) determined by intelligence testing and broader clinical assessment
• Significant deficits in adaptive functioning relative to the person’s age and cultural group in one or more of the following areas: communication, social participation, work or school, independence at home or in the community, requiring the need for support at school, work, or independent life.
• Onset during childhood development.

The DSM-5 diagnostic criteria for intellectual disability include three criteria.

• Deficits in intellectual functioning
• Deficits in adaptive behavior
• Onset during development.

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

• Conceptual
• Social
• Practical

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.

Autism spectrum disorder

Clinical descriptions, prevalence, and prognosis of autism spectrum disorder

DSM-5 criteria for Autism spectrum disorder

• A. Deficits in social communication and social interactions as exhibited by the following:
  • Deficits in nonverbal behaviors such as eye contact, facial expression, body language
  • Deficit in development of peer relationships appropriate to developmental level
  • Deficits in social or emotional reciprocity such as not approaching others, not having a back-and-forth conversation, reduced sharing of interests and emotions
• B. Restricted, repetitive behavior patterns, interests, or activities exhibited by at least two of the following:
  • Stereotyped or repetitive speech, motor movements, or use of objects
  • Excessive adherence to routines, rituals in verbal or nonverbal behavior, or extreme resistance to change
  • Very restricted interests that are abnormal in focus, such as preoccupation with parts of objects
  • Hyper- or hypereactivity to sensory input or unusual interest in sensory environment, such as fascination with lights or spinning objects
• C. Onset in early childhood
• D. Symptoms limit and impair functioning.

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:

• Children with intellectual disability usually score poorly on all parts of an intelligence tests, but children with ASD may score poorly on those subtests related to language.
• Children with ASD usually obtain better scores on items requiring visualspatial skills.

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.