These notes are based on the course Developmental Psychopathology in 2016/2017.

Lecture: Introduction

Determining abnormality

We use developmental norms to make decisions about behavior. Developmental norms are norms about the normal development of for example, blather control. Behavioral indicators of disorder are developmental delay, developmental regression or deterioration, extremely high of low frequency of behavior, extremely high of low intensity of behavior, behavioral difficulty persisting over time, behavior inappropriate to the situation, abrupt changes in behavior, several problem behaviors and behavior qualitatively different from normal. This is summed-up in table 1.1 in abnormal child and adolescent psychology (Wicks-Nelson & Isreal, 8^th edition, 2013, page 3).

We are influenced by cultural norms, gender norms and situational norms. Situational norms are used in situations where for example a child is running. This is appropriate when de child is outside and playing, but inside it’s less appropriate behavior. The role of adults is also important. Adults decide whether something is seen as normal or not. The definition of abnormality is ever changing and it’s important when deciding about someone’s behavior, to look at if it’s harming the person of interfering with their lives.

Classification

Classification can be done by using the empirical approach or the clinical approach. Generally, problem behavior exists when there is a cluster of symptoms, also called a syndrome. The symptoms must be persistent, causing stress and interfere with functioning.

The clinical approach is clinically derived, categorical, qualitative, used a lot and the concepts of disorders keep changing. Characteristics of a disorder are emphasized. Critique on this approach is that behavior is over diagnosed, is has too little validity, no clear rules for making decisions and it views abstract disorders as concrete ones. There’s also no emphasis on the context of situations and on developmental differences.

The empirical approach is based on statistics, clusters of problem behaviors, also known as syndromes, broad and narrowband and dimensional, so also quantitative. Data of normative samples are used in the empirical approach of classification.

Models

Different models are used to look at behavior, like the bio-psycho-social model and the ongoing interplay-individual model. The first one is a search for factors and processes and the second one looks at temperament and context and can be seen as an ecological model. In the bio-psycho-social model, influences are genetics and problems around birth, learning experiences and cognitive processes, family, peers and society and social context.

Risk and protective factors

Risk factors have a large non-specific negative effect. They come in small or bigger groups and can pile up. The onset and maintenance of these factors are important to look at, as well as processes or mechanisms. Protective factors together with vigilance, can prevent a negative outcome.

Moderators and mediators

Factors can be moderators of mediators. Moderators can enhance or weaken an outcome and can also change the course of this outcome. This is not a causal effect, because the moderator is not in the equation, but next to it. Like this: A  outcome, while the moderator has an effect on the arrow. Mediators are in the equation and have a direct influence on the outcome, like this: A  B  outcome. A mediator can lead to an outcome or explain it.

Direct and indirect

If there are many factors between A and the outcome, these are called indirect influences. These can also be distal factors, if you’re not looking at an equation but at a circle and circles of influences in that circle, with a child as the center of that circle. Direct of proximal influences are close to the child in the circle model and are alone in an equation.

Equifinaty and multifinaty

Equifinaty means that multiple factors can cause the same outcome. Multifinaty is the opposite, one factor has many different outcomes.

Heterotypic and homotypic continuity

Continuity is about whether a person has of doesn’t have a disorder, put in a timeline. Heterotypic continuity means that a person has a disorder for a while and then the symptoms fade or the disorder expresses itself differently. Homotypic continuity means that a person has a disorder for a while and it stays the same in frequency and expresses itself in the same way.

Lecture: Anxiety disorders

Anxiety

The prevalence of anxiety disorders is about 6-20% in the population and in panic disorders, OCD and PTSD the prevalence is about 12-20% in children.

Worry

First it’s important to understand that there’s a difference between fear (phobia) and anxiety, which can become a disorder. Worry can be a part of the cognitive component of anxiety. In children, there’s a correlation between fear, worry and thinking. This is not the case in adults. Worry and rumination have in common that, in both cases a person thinks repetitively in a negative way. On the other hand, worry is about potential negative outcomes, associated with anxiety and difficult to control. Rumination is about symptoms, causes and outcomes, mostly associated with depression and passive response to distress. These are some differences.

The tripartite model

The tripartite model of fear and anxiety is a complex pattern of three types of reactions to a perceived threat. One of these types is an overt behavioral response, like freezing, running away, closing eyes, trembling voice, fidgeting, crying, screaming, tantrum and seeking reassurance. The second type of response is a physiological one, like sweating, change in heartrate, nausea, dizziness and multiple trips to the bathroom. The last type of reactions is a cognitive response, like worry, expecting the worst, picturing bodily harm, difficulty concentrating, confusion, mind going blank, fear of losing control, thoughts of being scared and self-deprecatory thoughts.

Normal fears

For babies, it’s normal to be afraid of loud noises and unfamiliar people and objects. For toddlers it’s normal to be afraid of people leaving them and animals. For pre-scholars it’s normal to be afraid in the dark and to be afraid of war and monsters. These are more abstract subjects of fear. For children who are old enough to go to school, it’s normal to be afraid of embarrassment, critique and physical injuries. In adolescents is normal to be afraid of social evaluations and death.

Fears generally decrease with age and it changes the subjective experience of the concept of normality. Next to this general decrease, there is an age specific increase in fear. Culture, direct environment and gender also have an influence on fear and anxiety. There is a normative increase in social-related fears, but this doesn’t mean that a person with an increase in social-related fears has an anxiety disorder.

Females show more fear than men. They have a larger amount of subjects which fear them and the intensity of the fear in women is higher. An explanation might be that the expectations of women are different than those of men. The stereotypic picture we have of women is that they can be afraid, but we expect men to be heroes. This can influence the way we perceive men and women, but it can also influence the way men and women handle fear. These gender role expectations depend on culture. Another explanation is, that women might express their fear more than men, so it gets reported more.

Problematic anxiety can be categorized with the empirical approach of classification and the clinical approach, as explained in the first lecture.

Specific phobia

A specific phobia is fear or anxiety about a specific object or situation. In DSM-IV, the person had to recognize that the fear is excessive or unreasonable, but this was not required of children. The duration is at least 6 months for young people under 18 years. Young children may not understand the concept of avoidance and so extra information is required from parents, teachers, etcetera.

Social anxiety disorder

Social anxiety disorder is fear of anxiety about one or more social situations in which the individual is exposed to judgement. In children, the anxiety can occur with peers and not just during interactions with adults. The individual fears being negatively evaluated and is afraid of embarrassment. Situations with strangers are especially scary. In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking or failing to speak. If a medical condition is present, the fear, anxiety or avoidance is clearly unrelated or is excessive.

Selective mutism

People with selective mutism fail to speak in specific social situations in which there is an expectation of speaking, despite speaking in other situations and this is consistent. The disturbance interferes with functioning and it has to last for at least one month, not limited to the first month of school. The failure to speak is not associated with a lack of knowledge or comfort with the language. The disturbance is not better explained by a communication disorder and does not occur exclusively during autism spectrum disorder, schizophrenia or another psychotic disorder.

Separation anxiety disorder

This anxiety disorder only occurs in children. These children are extremely afraid of being left alone and their caretakers leaving them or losing an important person. Nightmares and physical symptoms can occur, like stomach aches.

Generalized anxiety disorder

An individual with generalized anxiety disorder, experiences excessive anxiety and worry occurring more days than not. The anxiety and worry are associated with 3 or more symptoms, but only one symptom is required in children. A person with GAD experiences restlessness, being on edge, being easily fatigued, difficulty concentrating, mind going blank, irritability, muscle tension and sleep disturbance.

Agoraphobia

This fear of anxiety is present in two or more of the following situations: using public transport, boing in open spaces, being in enclosed places, standing in line or being in a crowd and being outside the home alone. People with agoraphobia fear of avoid these situations because of thoughts that escape might be difficult or help unavailable in the event of panic-like symptoms. These situations almost always provoke fear or anxiety and are avoided, require company or endured with intense fear or anxiety. This fear is out of proportion, typically last 6 months or more and causes clinically significant distress and/or impairment. If medical condition is present, the fear is clearly unrelated or excessive. The fear is not better explained by the symptoms of another mental disorder.

General characteristics of anxiety

For specific phobia, social anxiety disorder, separation anxiety disorder, goes that the object or situation that causes fear or anxiety almost always provokes this and is avoided or endured with intense fear of anxiety. The fear or anxiety is out of proportion to the actual threat posed. The fear, anxiety of avoidance is persistent, typically lasting for 6 months or more, causes clinically significant distress or impairment in functioning and is not better explained by the symptoms of another mental disorder. In children and adolescents with separation anxiety disorder, the symptoms have to last at least 4 weeks. The disturbance is also not attributable to the physiological effects of a substance or another medical condition.

Because generalized anxiety disorder doesn’t have a specific object or situation that causes fear or anxiety, some of these things don’t apply, but the symptoms have to last for at least 6 months, in different situations, the anxiety, worry or physical symptoms cause clinically significant distress or impairment and the disturbance is not better explained by another metal disorder.

Related disorders

Some related disorders to anxiety, are reactions to traumatic events, like posttraumatic stress disorder (PTSD), acute stress disorder, reactive attachment disorder, disinhibited social engagement disorder and adjustment disorders. For PTSD there are parallel criteria for children of age 6 or younger, but fewer symptoms are required to get the diagnoses. Obsessive compulsive disorders are also related to anxiety.

Obsessive compulsive disorder

An individual with OCD has obsessions and compulsions. By completing some ritual or compulsion, this person thinks that a problem that’s related to the obsession is being solved. OCD might be a normal development being overreacted, but it could also be qualitatively different from the normal development.

Lecture: Mood disorders

Anxiety

Causes of an anxiety disorder

Biological influences an have cause an anxiety disorder. This can be looked at with different kinds of studies, like twins, brain images, temperament, family aggregation and co-occurring disorders. Shy children are more likely to develop an anxiety disorder in their adulthood.

Psychological influences are direct experience, modeling, prompts and reward, transmission from information and parenting style.

Characterisics of an anxiety disorder

Anxiety is characterized by the feeling of personal thread and avoidant behavior. When parents influenced the children in a situation in which they have already showed avoidant behavior, they show even more avoidant behavior. This is called the Family Enhacement of Avoidant behavioR of FEAR effect. The long term impact of anxiety disorders are school drop-out and other psychopathologies in childhood and/ or adulthood. The short term effects are that adults with an anxiety disorder, still get diagnosed with the same disorder a few months later.

Studying the course of a disorder, helps to improve the classification of this disorder. Comorbidity in people with anxiety are evident in longitudinal data and in this same data, homotypic continuity is found. There’s some support for the fact that problems of different types of fear may be separate phenomenon.

Development of psychopathology perspective, or DPP: if a child fulfils the criteria for adults for a diagnoses of anxiety disorder, does this mean that the child actually has an anxiety disorder?

Depression

There are two types of mood disorders: depression and bipolar disorders. Depression can be unipolar, meaning it just goes one way, so a person just feels depressed and nothing else. It can also be bipolar, meaning the depression goes two ways, so a person feels depressed some times and experiences mania the rest of the time. There are differences between depressive mood, depressive disorder, when someone actually gets the diagnoses and depressive syndrome, which is a cluster of depressive symptoms.

Categories of depression

Depression can be divided up into different categories. Major depression means a person experiences a depressive mood, less interest in things (anhedonia), change in eating and appetite, changes in sleeping pattern, psychomotor retardation, fatigue, less concentration, thoughts of death and feelings of worthlessness and/or guilt.

Persistent depressive disorder means a person is suffering from all of the symptoms mentioned above and experiences these for at least two years with more depression than mania. This is also called dysthymia.

Disruptive mood dysregulation disorder means that a person experiences inappropriate to the situation temper tantrums, which are also inappropriate to the level of development of that person. There have to be at least five outbursts a week and the person is always angry of irritated in three or more settings.

When a person is diagnosed with double depression, it means that that person fits the criteria for both major depression as persistent depressive disorder.

Other disorder related to depression are premenstrual dysphoric disorder (PDD), substance/medication-induced depressive disorder, depressive disorder due to another medical condition, other specified depressive disorders (OSDD) and unspecified depressive disorder (UDD). PDD was considered a disorder, because it responded to treatment, but this is not a very good reason to call something a disorder. OSDD means that a person has for of the five symptoms needed to get the diagnoses depression. UDD means that a person has some kind of depression, but it’s not quite clear which one.

Bipolar and related disorders

People who experience a manic episode experience grandiosity, less need of sleep, talkativeness, racing thoughts, distractibility, more goal-directed activity of psychomotor irritation, which isn’t goal-directed activity, an increase in activities which are likely to have a negative outcome. Mania is rare in pre-pubescent children. They do experience positive mood (elation), grandiosity, less need of sleep, racing thoughts and hyper sexuality. Bipolar disorders have a high comorbidity rate with ADHD.

Causes of bipolar and related disorders

Causes of bipolar and related disorders are socio-psychological influences, biological influences and depression in parents. Behavioral theories include different aspects like less social skills, being able to do less fun things, less positive reinforcement and this acts as a downward spiral. These theories try to turn this downward spiral up, with pleasant events scheduling.

Cognitive aspect of bipolar and related disorders

The cognitive aspect of an bipolar and related disorders focuses on automatic thoughts or cognitive products, interpreting or cognitive operations of processes and schemas of core thoughts, also known as cognitive structures. When a person starts to predict negative things, or personalizes things, uses selective attention and uses minimization, it will make a person anxious. Minimization means that a person interprets something good in a very minimalistic way. This means a person thinks: my soccer team won, but I probably had nothing to do with it. Also, my soccer team lost and it’s completely my fault. These are called cognitive errors.

Beck’s theory: negative cognitive triad and cognitive errors can cause a person to develop a way of thinking, consistent with the way people with a bipolar or related disorder think.

Hopelessness theory: cognitive vulnerability paired with stress, internal, stable and global attribution will make a person develop a way of thinking, consistent with the way people with a bipolar or related disorder think. The example with the soccer team applies here as well. A person might think: my soccer team lost, it’s my fault (internal), it’s always my fault when we lose (stable) and in every situation I play with a soccer ball, I will fail (global).

Lecture: School refusal problems

School attendance problems

Normal versus problematic

Normal absence from school includes being sick, funerals and religious holidays, so for an actual reason. These are agreed upon by school and parents. Problematic absence from school is when a child misses a quarter of school time or experiences severe difficulty attending school or missed more than ten days during a 15 week period. In the Netherlands absence of school needs to be reported when a child is absent from school for more than 3 consecutive days or spread out over a period of 4 consecutive weeks.

Types of attendance problems

Different types of attendance problems are school withdrawal, school refusal and truancy. The most important about attendance problems, is the fact that a child doesn’t want to go to school, even if the child does go to school because of parents for example. All of these behaviors can lead to school dropout.

A child with school refusal is reluctant to go to school or refuses to attend school. They usually stay at home and experience severe emotional upset. In these children there is an absence of antisocial characteristics. Parents put in effort to get their kids to go to school, but know about it when their children stay at home. Children with school refusal don’t have to be absent from school all the time, they just have to have trouble with going to school. This is often related to anxiety, but not just about anxiety, because some high-anxious children attend school, children with school refusal have underdeveloped problem-solving strategies and students coping with school-related demands and distress by avoidance. School refusal is linked to separation disorder and depression.

Truancy is described as willfully not going to school, often without parents knowing and consent. The student conceals non-attendance and avoids being home when not going to school. There is an overlap between school refusal and truancy. If a child shows truancy and school refusal, this behavior can lead to the diagnoses separation anxiety, conduct disorder, ADHD, a panic disorder or substance abuse.

School withdrawal is the withdrawal of the child because of the parents. This can include condoned absence or covert support for non-attendance. These children aren’t motivated for or interested in school and often have learning disabilities. This kind of attendance problem is motivated by parents, because they don’t encourage children to go to school. It’s also possible that the children have to stay at home to help their parents or that the parents don’t care about their children going to school. This behavior can lead to the diagnose conduct disorder, depression or oppositional defiant disorder.

Causes and maintaining factors

Different hypothesis have been proposed about the causes of school refusal. There is the fear of leaving the mother or home hypothesis, the fear of school hypothesis and the unrealistic self-evaluation hypothesis. The first two don’t really need explanation, but the unrealistic self-evaluation hypothesis describes that children have the idea that they can’t do anything. They might have social or academic problems. When looking at the cause of school refusal, there is multicausality. Multiple factors all contribute to school refusal and these factors can be divided in to individual, familial and social factors. Individual factors: vulnerability to developing anxiety or depression, trouble with language and trouble with learning. Familial factors: overprotective or overinvolved mother, distant relationship with family members, marital problems between parents and psychopathology in parents. Social factors: school characteristics or values and attitude of society or culture.

Predisposing factors are causal and indirect, like being shy (temperament). Precipitating factors are causal and direct, like a sick mother and her reaction to it. Precipitating factors like being bullied, being excluded, social problems, academic problems or divorce can lead to school refusal. Precipitating factors that can lead to truancy, are avoiding tough situations, wanting adventure and independence and conformity of peers. Of other children are skipping school, the child is less likely to skip school himself. Perpetuating factors are maintaining factors, like the mother likes having the child at home (reinforcement). Protective factors can stop attendance problems from developing.

School refusal assessment scale: functional categories

• Avoidance of negative-affectivity provoking stimuli. This can be solved by psychoeducation and relaxation training, anxiety hierarchy, exposure and self-reward.

• Escape from aversive social or evaluative situations. This can be solved by psychoeducation, social skills training, restructuring of social cognitions and exposure.

• Attention-seeking or separation anxiety. This can be solved by training the parents to give clear messages, planned ignoring of inappropriate behavior, morning and evening routines, consequences for non-attendance and enforced attendance.

• Behavior yielding positive tangible reinforcement. This can be solved by making sure the parents and child communicate effectively, have an effective strategy for problem-solving, the parents monitor non-attendance and making sure that the child has academic assistance.

Course

Attendance problems cause problems in educational, social and emotional areas. This means that problems can arise in development, in the mental health of a child and the quality of life can decrease. School refusal leads to lack of education and this leads to children who can’t handle their environment. People who have shown school refusal, needed psychiatric help more often than people without school refusal. They usually spent more time at home. Children who skipped school, are more likely to develop an anti-social personality and alcohol or drug abuse.

Lecture: Behavior disorder

Conduct disorders and ADHD

Externalizing behavior

Disruptive Behavior Disorder and Attention Deficit Hyperactive Disorder. DBD: Conduct Disorder and Oppositional Defiant Disorder. CD is more serious than ODD. Externalizing behavior is characterized by not being able to cope with negative feelings. This behavior often goes together with smoking, alcohol abuse and smoking marihuana.

ADHD

ADHD means that a child is suffering from inattention and hyperactivity and impulsivity. It also has a high co-morbidity rate, especially with learning disorders and CD and ODD. ADHD goes together with internalizing behavior too, like with anxiety, depression and bipolar disorder. There is a neurodevelopmental disturbance in the brain with lifelong implications, that causes ADHD. There has been a shift in thinking from inattention to being the most important, to hyperactivity and impulsivity being equally important. ADHD is treated with Ritalin, which increases brain arousal, since the brain is under aroused. There are some genetic influences and unique marks in children with ADHD.

Six or more of the symptoms described are needed to get the diagnoses ADHD, before the child is 12 years old. The symptoms need to be experienced in two or more settings and it need to cause a clinically significant impairment. The symptoms also can’t be explained by any other disorder. If a child is 17 or older, only 5 symptoms are needed to meet the criteria for ADHD.

Inattention

A child who is suffering from inattention has no close attention for details, makes careless mistakes, doesn’t listen, has difficulty sustaining attention, can’t follow through on instructions, has difficulty organizing tasks, doesn’t do tasks that require sustained mental effort, loses things, is easily distracted and often forgetful.

Hyperactivity

A child who is suffering from hyperactivity often fidgets or squirms, leaves his or her seat inappropriately, runs or climbs excessively and inappropriately, has difficulty playing quietly, is described as on the go and talks excessively.

Impulsive

A child who is suffering from impulsivity blurts out answers before the question is completed, has difficulty waiting their turn and interrupts or intrudes others.

Subtypes

There are three subtypes of ADHD: ADHD-I (for inattention), ADHD-HI (for hyperactive-impulsivity) and ADHD-C (for a combination of these two). Perhaps ADHD-HI precedes ADHD-C.

Secondary features

Secondary features a child with any type of ADHD can experience are deficits in motor skills, intelligence and academic achievements (caused by a learning disability), deficits in executive functions (this causes trouble with organizing and planning), problems with adaptive behavior like problematic self-care, problematic social behavior and relationships (with parents, peers and teachers). This is causes by the aggressive and intrusive behavior of children with ADHD. Children who are inattentive are more withdrawn, so there is a greater chance that they are excluded by their peers. Parents are less rewarding of their children with ADHD and often show symptoms of ADHD themselves. Medication can explain the poor health and children with ADHD are more involved in accidents.

Prevalence

3-7% of school-age children get the diagnoses ADHD. It’s more prevalent in boys and perhaps in Caucasians.

Course

In preschool ADHD may involve temper tantrums. In childhood more children get diagnosed with ADHD, because they go to school now, so the fact that they can’t concentrate suddenly makes them stand out. In adolescence and adulthood ADHD symptoms decrease, but if they are still present, they have a serious negative effect on the rest of their lives.

Etiology

Influences on the development of ADHD are, genetics (a combination of many different genes and an interaction with the environment), parental influences, complications during pregnancy and birth (like alcohol and smoking), neurobiology and psychosocial influences. Neurobiology can influence the development of ADHD because there might be damage to the brain, but this is not proven yet. There are several abnormalities in the brain, but that could be explained by the fact that the brains haven’t matured yet. Psychosocial influences have an effect on the severity and duration of ADHD.

Assessment

Children with ADHD need to be observed in different types of situations. Also the child, the parents and teachers need to be interviewed and rating scales can be used to assess ADHD.

Treatment

ADHD can be treated with stimulant medication, like Ritalin and behavior and multimodal therapy, like parent training and classroom management. Medication increases certain hormone levels, that causes the brain to activate, so the child becomes less hyperactive. Medication can become a risk factor for later substance abuse. The best solution is using medication and therapy.

Conduct problems

Disruptive Behavior Disorder consists of Conduct Disorder and Oppositional Defiant Disorder. In both cases, a child is suffering from aggression to people and animals, deceitfulness and theft, property destruction and serious violation of rules. ADHD might precede ODD, because ODD is a reaction to dealing with constant negative reactions to behavior.

Oppositional Defiant Disorder

A child who suffers from ODD loses his or her temper, argues with adults, actively defies rules and refuses to comply with adults’ rules, deliberately annoys people, blames others for his or her mistakes or misbehavior, is touchy or easily annoyed by others, is angry and resentful and is spiteful or vindictive. ODD is stable over time and the onset age is 6 years old. The prevalence is 2-15% and is more prevalent in boys. The symptoms can’t be explained by any other disorder and 4 of the symptoms need to be persistent over a period of 6 months.

Conduct Disorder

A child who suffers from CD bullies, threatens or intimidates others, initiates physical fights, uses a weapon to cause physical harm to others, is physically cruel to people and animals, steals while confronting a victim and forces someone into sexual activity. The child also engages in fire setting, destroying others’ property, breaking in, lying to obtain goods or favors or to avoid obligations, stealing items without confronting the victim. If the child is under the age of 13, staying out at night despite parental prohibitions and playing truant are seen as symptoms of CD, next to running away from home overnight. The symptoms can’t be explained by any other disorder. CD increases over time and the onset age is 9 years old.

Subtypes and pathways

There are three subtypes of CD, which are childhood-onset, adult-onset and unspecified-onset. All of these types come with externalizing behavior, like being aggressive and breaking the rules. Aggressive behavior decreases over time and rule-breaking is stable over time. There is a genetic component, so the parents are likely to show symptoms as well. There are two different pathways of developing a conduct disorder, which are early onset life-course persistent or adolescence-limited later onset. There is also a distinction between overt (like fighting) and covert (like stealing, lying and fire starting) behavior. Girls tent to show more covert behavior. Destructive behavior (like aggression) is different from non-destructive behavior (like defiance, tantrums and substance abuse). There are some gender differences. People who have been victims of violence of bullying are likely to develop problem behaviors themselves. Bullying is caused by a power imbalance, because the victim of bullying can’t defend himself or herself.

Comorbidity

ADHD is likely to go together with CD or ODD. If a child meets the criteria for CD, it always meets the criteria for ODD, but not the other way around. Also, ODD may precede CD. CD and ODD often go together with substance abuse and internalizing disorders, like anxiety, depression and bipolar disorder.

Course

Of a child has CD or ODD, this can have serious negative effects for the child later on. The model from Loeber describes three different pathways of the course of CD an ODD, which are overt, covert and authority conflict.

Etiology

A low social economic status can influence developing ADHD, as well as aggression as a learned behavior, family influences, peer relations, cognitive-emotional influences, biological influences like genetics and neurobiological influences. Children with ADHD often act before they think.

Lecture: Language & learning disabilities

Language and learning disabilities

Language disorders

A learning disability can be recognized by a discrepancy between IQ and a specific function. A child may have a high IQ, but scores low on a test which measures language or math skills. Another way to determine if a child has a disability, is to see if the child reacts very differently to an intervention. There are three types of interventions: intense individual, in a small group and in the core of a classroom.

Children with a specific language impairment have a normal IQ, but a smaller vocabulary and have fewer tip-of-the-tongue states. They also don’t talk with their hands and have trouble with talking in turns. They can’t see the connection between the past tense of a verb and the present form.

Language disorder: speech sound disorder

A speech sound disorder is present when a child fails to display age appropriate and dialect appropriate speech sounds. This can be mild, when there is a slight difference in pronunciation of words, and severe, when there is a huge difference in how the child speaks when comparing with other children. This isn’t because of a physical abnormality, but the children just have a hard time getting the sounds right.

Language disorder: difficulty talking or understanding talk

Children with this disorder have a difficulty talking, for example with making complete sentences and with grammar, and have a difficulty understanding talk.

Language disorder: expressive or receptive problems

Children have trouble with expressing themselves with words and receiving the message of what is being said, like a question or a command.

Course

A specific language disorder is heterogenic, which means it presents itself differently in different children and is about 3-7% prevalent in children of 5 years old. It exist in every language and is more prevalent in boys. Genetics play a role in developing a specific language disorder. This is more prevalent in families with a low social-economic status.

If a child is a late talker, he or she will probably develop some sort of language disorder and later on, he or she will suffer from social-emotional problems, learning disabilities and poor reading comprehension. They might get bullied.

Cognitive deficits

Cognitive deficits that might underlie a language disorder are slow information processing, a deficient in auditory processing and an deficient in verbal non-word short term memory. They have trouble perceiving short words without emphasis and repeating words. They may have a language or analytic deficiency.

Treatment

Treating a specific language disorder often consists of interactive computer games, which challenge the skills to know the difference between pear and bear for example.
 

Stuttering

Children who suffer from stuttering, often repeat words or parts of words, prolongate speech sounds and pause in the middle of a sentence. Stuttering is less likely on later syllables and on later words and with external timing, during singing or speaking in chorus. This may indicate that stuttering is about the preparation of speaking, planning and timing.

Course

When a young child has a normal, but repetitive speech, this is likely to turn into stuttering. This may cause collateral non-speech behaviour, fear of speech situations and avoidance of words, but halve of the people recover spontaneously. They may have a neural deficit. Stuttering is 1% prevalent in children from ages 6 to 12 and is more prevalent in boys. Genetics also play a role in developing stuttering, next to a neurological basis. The rolandic operculum in the brain is less active. Treating kids before the age of 6 is very effective.

Language problems are often secondary to other problems, like a hearing problem, autism or mental retardation. Williams syndrome means that a child has a mild to severe mental handicap, a deformity in blood vessels and a characteristic appearance.

Learning disabilities: reading disability

Phonological complexity and orthographic transparency (do the letters say their sounds?) are two important aspects in learning a language. Children with a reading disability have a poor non-word reading, when it comes to analogous and Japanese words for example. Frequent content words aren’t as hard for them to read.

Course

The developmental course of a reading disability starts with poor phonological awareness and ends with this disability being a burden. It can persist into adulthood, but intelligent people can compensate with other skills. There is a phonological deficit in a reading disability; they may read a word and often have a complete different representation of how the word sounds in their head. This disorder has a neural basis. There is a difference between the parietal and occipital lobe in normal readers and readers with a disability. They also have problems with brain connectivity.
Learning disabilities: mathematics disability

Children who have a mathematics disability, use a primitive way of solving a mathematic problem, like counting with their fingers, and they solve this problem very slowly and randomly. Cognitive dificients which underlie this disability may be a deficient in the visuo-spatial short term memory and a deficiency in inhibition. This means that children with this disability aren’t able to inhibit a wrong answer, when asked which number is greater. A small 9 is shown and a larger 8 and the child picks the 8, even though this isn’t correct.

Lecture: Physical functions disorders

Physical functions

Problems of elimination

A baby would have only purely reflexive actions initially. The sequence of accomplishments is: nighttime bowel control --> daytime bowel control --> daytime bladder control --> nighttime bladder control. Parents train their children using an impression of the child’s readiness and hints given by the child. This is usually around the age of three. An example is that the child gives a hint, like “I need to pee” and the parent reacts to this by putting the child on a potty. The child then pees on the potty and the parent praises the child and helps it get dressed again. Through that positive reaction from parents, children understand that they’ve done something good.

Classification of problems

Enuresis means wetting. Primary enuresis means that the child has never been dry (wet from birth) and secondary enuresis means that the child has been dry, but starts wetting itself again. Diurnal enuresis means that the child wets itself during the day and nocturnal enuresis means at night. Diurnal enuresis may happen because the child is doing something it enjoys, like playing video games, and decides that he or she has ‘no time’ to go to the toilet. Nocturnal enuresis may come from a delay in Central Nervous System maturation. This involves an interplay of defective sleep arousal, nocturnal polyuria and bladder factors like bladder over activity. Enuresis declines with age and has a hereditary component. It helps to wake children up around the time that the need to go to the bathroom, but some of the children sleep too deep to notice that they have to go. Sometimes children mistake their underwear for a diaper and think is okay to pee. This depends on culture. Specific training can help.

Encopresis means soiling. Primary encopresis means that the child has always soiled itself and the secondary encopresis means that the child has stopped soiling itself, but started again. There may be a combination of primary and secondary enuresis. There are three types of encopresis: constipation, stress (low self-esteem) and manipulation (on purpose). This is prevalent for 8% in three year olds and declines with age. It is also more prevalent in boys. Treatment for stress-encopresis is focusing on coping style of a child. With constipation-encopresis a more medical route is needed, like removing the hardened poop and changing diet.

Sleep problems

A normal development would be to fall asleep when tired, quiet or relaxed, to sleep through the night at 6 months and to wake up many times per night. There are some cultural differences.

Classification of problems

Dyssomnia means that a person has difficulty initiating and maintaining sleep. There are two forms of dyssomnia: early childhood dyssomnia and difficulty falling asleep. Early childhood dyssomnia includes bedtime tantrums and night walking. Infantile colic can lead to very early childhood dyssomnia and this can lead to early childhood dyssomnia. Parental practices have a big influence on these last two. Difficulty falling asleep includes the roles of stress and bed habits. Stimulus control instructions include lie down intending to go to sleep only when you are sleepy, do not use your bed for anything except sleep, if you find yourself unable to fall asleep, get up, if you still cannot fall asleep, repeat step 3, set your alarm and get up at the same time every morning and do not nap during the day. Dyssomnia declines with age. It can present when the child often falls asleep when parents are around and illness and stress can play a role. The reaction of parents when a child wakes up is very important. A baby that cries excessively for two months, has a greater chance of developing dyssomnia.

Parasomnia means that a person experiences an abnormal event during sleep. This includes bedwetting, sleepwalking during non-REM, nightmares during REM, and sleep terrors during non-REM, sleep apnea and bruxism (teeth grinding).

Problems of feeding, eating and nutrition

Normal eating behavior includes adjusting energy intake at successive meals, having a preference for sweet and salt and neophobia or being afraid of everything new. Modeling through parents can help, but it can also help form an eating disorder. The effects of presentation are very important, like repeated exposure and food-context associations. A means-end relationship means that a child may eat broccoli that the child hates, to get a desert.

Classification of problems

Different problems with eating, are rumination disorder, pica, avoidant/ restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, Other Specified Feeding or Eating disorder and Unspecified Feeding Eating Disorder. Only the first three are mentioned in this lecture. Rumination disorder means that a child spits his or her food back up to chew on it again. The acids that come with the food are harmful. Neglect plays a role in developing a rumination disorder. Pica means that children eat uneatable things. This is most prevalent in young children, mentally disabled and pregnant women. This can develop because children are hungry or because they can’t tell the difference between eatable things and uneatable things. Modeling can also play a role. Avoidant/restrictive food intake disorder means that a child eats too little or in an all too selective way. This is associated with forced feeding, much, negative and vague parental talk and reduced parental sensitivity. Neglect also plays a role in avoidant/restrictive food intake disorder.

Lecture: Austim & schizophrenia

Autism and schizophrenia

Autism

30 in 10.000 people are diagnosed with autism. It is more prevalent in boys than in girls and the earlier the onset, the worse the prognoses. Asperger’s disorder and pervasive developmental disorder not otherwise specified (PDDNOS) are two types of autism. Criteria for adults and children are atypical behavior, communication and social limitations. Atypical behavior consists of repeated motor movements, like flapping, obsessions and occupations, limited interests and clinging to routines. At least 6 characteristics have to be shown across these three dimensions.

30% of children with autism don’t develop speech. If they do, atypical speech consists of tone, tempo, content and echolalia (automatic repetition wat another person says). People with autism use reversed pronouns, don’t understand social pragmatics and have an atypical way of communication nonverbally.

Social limitations consist of less reactivity and not reciprocating responses. People with autism don’t like being touched, avoid eye contact, don’t react to their own name and show atypical emotional reactions. Children with autism can have trouble recognizing phases and have less attention for faces and facial expressions.

People with autism are oversensitive, less intelligent, they focus on detail, have less feeling for coherence and have trouble understanding and anticipating intentions, emotions and behavior of others. Less intelligence may be tested in a biased way, because they have trouble with language and intelligence is tested through language, amongst other things.

People with Asperger’s appear to be able to have normal conversations, but the conversation is mostly about the person with Asperger’s and they almost never ask questions. Someone with PDDNOS has a milder version of autism.

Theory of mind: understanding behavior of others, based on their intentions, desires and beliefs. Children who have ToM, show joint attention. This is a shared focus of two individuals on an object and is achieved by eye-gazing or pointing. False belief is tested by checking if a child beliefs that everyone knows what they know. If they belief that a person looking for a marble knows that it has been moved, while that person doesn’t, this shows false belief. They should belief that a person looking for a marble, will look for it where he or she has last seen it, not where the child has last seen it.

People with autism don’t necessarily prefer being alone. They have trouble with processing information from their social environment and this takes time. They don’t know how to be social and they have trouble understanding relationships. They see everyone in their class as a friend, which is an example of unrealistic ideas they have about social situations. They show problems in friendships and dating.

Development

Autism in toddlers was confused with deafness, but now the diagnoses can be made and have a better prognoses. They now look at bodily reactions instead of reaction to sound, like the vibrations in the inner ears. Symptoms can decrease in childhood and adolescence, but this depends on intelligence. There is a greater chance of psychopathology, like depression and aggression in later life.

Schizophrenia

Childhood onset schizophrenia (COS) only happens to 1 in 10.000 people. Symptoms of schizophrenia present itself in two ways, positive and negative. Negative symptoms are the loss of something, like anhedonia or the loss of experiencing pleasure. Abolition is also a good example, which means that a person has a lack of desire, motivation and drive. Positive symptoms are the extra things a person with schizophrenia experiences.

Risk factors for early problems in children are affect, motor development, social problems and positive symptoms. Before the criteria of schizophrenia are met, abnormalities in languages can be seen, as well as motor skills, social functioning and neuropsychological functioning. Family characteristics are also a source of information.

Prodromal phase

Schizophrenia has three phases: prodromal, acute and residual. Prodromal means that someone shows symptoms for at least a day, but it may last for many years. These people show social withdrawal and isolation, decreased interest, limited functioning, odd ideas and behavior, self-neglect and flat affect or anxiousness and depression. The criteria for a diagnoses aren’t met yet and mostly negative symptoms are shown.

Prosome in adolescence means that people no longer have contact with old friends, are socially isolated, have academic problems, are absent from school and have changes in personality at home. They’re also agitated, withdrawn and show flat affect. Generally adolescents show magical ideation, have a changed perspective of experiences and a limited functioning. Normally, this is being researched in a retrospective way, but experience in these researches can create a biased view. If a risk group of students is being researched in a prospective way, this can predict that 80% of them will develop a psychoses in adulthood.

Acute phase

Positive symptoms are catatonic characteristics, psychoses, like hallucinations, thought disorders and delusions. In children auditory hallucinations are found most often (up to 80%), visual hallucinations less often (up to 50%) and delusion (up to 50%). Thought disorders consist of odd thoughts, loose associations and illogical thought, which stands out when taking an IQ test. In this phase, mostly positive symptoms are shown.

Residual phase

Negative symptoms consist of anhedonia, flat affect, decreased attention, apathy of not having willpower, disoriented speech and behavior or catatonic behavior and negative symptoms. Flat affect means that a person has a lack of emotional reactivity. Motor development is limited in fine and gross development, decreased coordination and catatonic. Children with schizophrenia show withdrawal, inappropriate behavior, anxiety and hyperactivity. Again, in this phase mostly positive symptoms are shown.

DSM

Characteristic symptoms are delusions, hallucinations, disoriented speech and behavior of catatonic behavior and negative symptoms. At least two of these have to be persistent over one month and the schizophrenia has to be persistent over a period of 6 months. Large areas of functioning have to be limited by the disorder, like work, interpersonal relations or self-care. This is called work dysfunction.

Development

In toddlers, schizophrenia is shown through motor skills and speech, in preschoolers through withdrawal, in childhood through attention and affect and in adolescence through decreased IQ. The criteria must be met before the child urns 12, but schizophrenia is almost never observed in children of an age below 5 years old. The earlier the onset, the more serious the abnormalities in the brain are and the more damage is done to the development of neurons. This makes for a worse prognoses.

Etiology

Diasthesis-stress hypotheses: schizophrenia is caused by genetic influences, neurobiological influences and neuropsychological influences. Schizophrenia is genetic for the most part, but has to be trigger by an intense trauma involving a lot of stress, like alcoholism. It is treated by therapy and medication. People often refuse to take their medication when they’re out of the acute phase. They believe that they are cured, but this increases the chance of falling back into the acute phase.

Prognoses

The prognoses is worse if the onset is before the age of 10 and when there are more suicide attempts. This can be chronic of acute and is worse if not treated immediately. People can recover from schizophrenia completely, partially of schizophrenia can be chronic. About 85% of the adults learn to prevent of to delay a psychoses.