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Disorders of Childhood and

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

Adolescence

Disorders of Childhood and Disorders of Childhood and

Adolescence (cont’d.) Adolescence (cont’d.)
 Diagnosis requires that symptoms cause significant
impairment in daily functioning over extended period of
time
 Include:
 Internalizing disorders
 Externalizing disorders
 Elimination disorders
 Neurodevelopmental disorders
 Conditions involving impaired development of the brain and
CNS

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Internalizing Disorders of Anxiety Disorders in Early Life

Childhood
 Heightened reactions to stressors or negative events  Most common mental health disorder in childhood and
and difficulty regulating emotions adolescence (32%)
 Prevalent in early life and precede adolescent substance  Can significantly affect academic, social, and
use and abuse interpersonal difficulties and can lead to adult anxiety
 Include: disorders
 Anxiety disorders in early life
 Mood disorders in early life
 Non-suicidal self-injury
 Attachment disorders

Anxiety Disorders in Early Life Anxiety Disorders in Early Life

(cont’d.) (cont’d.)
 Posttraumatic stress disorder in childhood:  Posttraumatic stress disorder in childhood:
 Recurrent, distressing memories of a shocking experience,  Children often display negative affect, social withdrawal,
such as exposure with death, serious injury, or sexual diminished positive affect, and disinterest in previously-
violation enjoyed activities
 Memories may entail:  Lifetime prevalence:
 Distressing dreams  8% for females and 2.3% for males
 Intense physiological or psychological reactions to thoughts or  Effective treatments include:
cues associated with event and avoidance of those cues
 Trauma-focused and school-based cognitive-behavior therapies
 Episodes of playacting the event
 Dissociative reactions

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Mood Disorders in Early Life Mood Disorders in Early Life

(cont’d.)
 Early-onset mood disorders tends to predict a more  Pediatric bipolar disorder:
chronic and severe course  Debilitating disorder that parallels mood variability seen in
 Youth with mood disorders have more negative self- adult bipolar disorder
concepts  Display episodes of recurring depression, rapid mood
changes, and distinct periods of abnormally-elevated mood
 13% prevalence in one adolescent sample
involving diminished need for sleep, increased activity,
 Evidence-based treatment for depression: distractibility, talkativeness and inflated self-esteem

 Individual, group, or school-based cognitive-behavior  Lifetime prevalence: estimated 3%

therapy
 SSRIs increase suicidality

Mood Disorders in Early Life Non-Suicidal Self-Injury

(cont’d.)
 Pediatric bipolar disorder:  Involves induction of bleeding, bruising or pain by
 Rapid cycling of moods combined with neurocognitively- means of intentional, self-inflicted injury, without
based difficulties processing emotional stimuli and suicidal intent
regulating behavior and social-emotional functioning  Intense negative affect or cognitions and a
 Elevated responsiveness to emotional stimuli and reduced preoccupation with engaging in self-harm typically
volume in amygdala and other brain abnormalities precede episodes of NSSI
 Medications are often combined with psychosocial  Expectation that mood will improve after episode
treatment

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Non-Suicidal Self-Injury Attachment Disorders

(cont’d.)
 Prevalence:  Exposure to early environments devoid of predictable
 14-17% of adolescents and young adults have engaged in caretaking and nurturing can cause significant
self-injury at least once difficulties with emotional attachment and social
relationships
 Increased risk of attempted suicide
 Includes:
 Treatment includes:
 Reactive attachment disorder (RAD)
 Teaching problem-solving, coping and emotional-regulation
skills  Disinhibited social engagement disorder (DSED)

 Focus on emotional expression and improving

interpersonal relationship skills

Attachment Disorders Attachment Disorders

(cont’d.) (cont’d.)
 Reactive attachment disorder:  Disinhibited social engagement disorder:
 Individuals with RAD have little trust that needs will be  Individuals with DSED socialize effortlessly, but
attended to and do not readily seek nor respond to indiscriminately, and become superficially “attached” to
comfort, attention or nurturing strangers or acquaintances
 Use avoidance or ambivalence as psychological defense  History of harsh punishment or inconsistent parenting, as
well as emotional neglect and limited attachment
 Limited positive emotion and may demonstrate irritability,
opportunities
sadness, or fearfulness when interacting with adults
 Exposure to maltreatment or maternal psychiatric
hospitalizations are particularly vulnerable

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Attachment Disorders Externalizing Disorders of

(cont’d.) Childhood
 Course depends on severity of abuse, neglect or  Also known as disruptive behavior disorders: conditions
disruption of attachments and subsequent events in the associated with socially disturbing symptoms and
child’s life distressing others
 Symptoms of RAD can disappear whereas symptoms of  Include:
DSED are more persistent  Temper dysregulation disorder with dysphoria
 Research on treatment is limited  Oppositional defiant disorder
 Providing secure and nurturing environment, exposure to  Conduct disorder
positive parenting practices, and opportunities to develop
interpersonal trust and social skills  Early intervention is necessary

Externalizing Disorders of Externalizing Disorders of

Childhood (cont’d.) Childhood (cont’d.)
 Diagnosis is controversial, and requires a pattern of  Temprer dysregulation disorder with dysphoria:
behavior that is:  Characterized by chronic irritability and severe mood
 Atypical for the child’s age and developmental level dysregulation
 Persistent  Patterns begin in early childhood
 Severe enough to cause significant impairment in social,  Diagnosis requires that symptoms persist beyond age 6,
academic, or vocational functioning and begin prior to age 10
 Lifetime prevalence of 3.3%
 Associated with later depression

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Externalizing Disorders of Externalizing Disorders of

Childhood (cont’d.) Childhood (cont’d.)
 Oppositional defiant disorder:  Conduct disorders:
 Pattern of negativistic, argumentative, and hostile  Persistent pattern of antisocial behavior that violates
behavior in which children often: rights of others
 Lose their temper  Reflect dysfunctions in individual and include:
 Argue and defy adult requests  Serious violations of rules and social norms
 Primarily directed toward parents, teachers, and others in  Cruelty and deliberate aggression towards people or animals
authority
 Theft, deceit, and vandalism
 No serious violation of societal norms
 Callous and unemotional subtype
 Two components:
 Often exhibit antisocial personality disorder in adulthood
 Negative affect
 Oppositional behavior

Etiology of Externalizing Disorders

Externalizing Disorders of
Childhood (cont’d.)
 More on conduct disorders:
 Prevalence:
 Approximately 2-9% of youth meet criteria

 Gender differences:
 Males display confrontational aggression
 Females display truancy, substance abuse, or chronic lying

 More persistent than other childhood disorders

Figure 16-1 Multipath Model for Conduct Disorders The dimensions interact with one
another and combine in different ways to result in a conduct disorder

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Etiology of Externalizing Etiology of Externalizing

Disorders (cont’d.) Disorders (cont’d.)
 Biological factors:  Social and sociocultural:
 Aggressive behaviors linked to abnormal neural circuitry  Family and social context play large role
and reduced activity in amygdala
 Large families and marital breakdown
 “Low MAOA” and childhood maltreatment
 Economic stress
 Reduced autonomic nervous system activity
 Crowded living conditions
 Cortisol (stress levels)
 Harsh or inconsistent discipline
 Maternal or peer rejection
 Parent-child conflict and power struggles
 Limited parental supervision

Etiology of Externalizing Etiology of Externalizing

Disorders (cont’d.) Disorders (cont’d.)
 Patterson’s classic psychological-behavioral model of  Psychological factors:
disruptive behavior:  Difficult child temperament (irritable, resistant, impulsive
 Parent addresses misbehavior or makes an unpopulated tendencies)
request  Underlying emotional issues
 Child responds by arguing or counter-attacking  Depression frequently coexists with ODD and TDD
 Parent withdraws from the conflict or gives in to the
child’s demands
 Child does not learn to respect authority

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Treatment of Externalizing Treatment of Externalizing

Disorders Disorders (cont’d.)
 Must consider family and social context of behaviors and  Psychosocial interventions that focus on:
psychosocial skills deficits  Assertiveness-training
 CD is particularly difficult to treat  Anger management techniques
 Effective when implemented before patterns of  Building empathy, communication, social and problem-
disruptive behavior are established solving skills
 Parent education regarding child management  Day treatment programs using evidence-based
techniques strategies
 Interventions are challenging

Elimination Disorders Elimination Disorders

(cont’d.)
 Enuresis:  Enuresis:
 Periodic voiding of urine during the day or night into  Psychological stressors:
clothes, bed, or floor
 Disturbed family patterns
 Usually involuntary  Presence of emotional problems increase risk
 Diagnosis:  Sporadic bedwetting associated with social and emotional
stressors
 Must be at least five years old and void at least twice a week
for at least three months  Biological factors:
 Prevalence: 4.9-10.5% of seven- to seventeen-year-olds  Nocturnal enuresis due to hereditary factors
 Delays in maturation of urinary track
 Development of normal rhythms of urine production

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Elimination Disorders Neurodevelopmental

(cont’d.) Disorders
 Encopresis:  Involve impaired development of the brain and central
 Defecation onto one’s clothes, floor, or other nervous system
inappropriate places  Symptoms become increasingly evident as child grows
 Diagnosis: and develops
 Must be at least four years old and have defecated  Include:
inappropriately at least once a month for at least three
months  Tic disorders
 Prevalence: .7-4.4% in children  Attention-deficit hyperactivity disorder
 Intense social problems may arise  Autism spectrum disorders
 Can continue intermittently for years  Intellectual and learning disabilities

Tics and Tourette’s Disorder Tics and Tourette’s Disorder

(cont’d.)
 Tics:  Tics:
 Involuntary, repetitive movements or vocalizations  Short-term suppression of a tic is possible, but results in
subsequent increases in the tic
 Motor behaviors:
 Some report feeling tension build prior to tic, followed by
 Eye-blinking, facial-grimacing, head-jerking, foot tapping,
flaring of nostrils and contractions of the shoulders or a sense of relief after tic occurs
abdominal muscles  Stress can increase frequency and intensity
 Vocal tics:  Provisional tic disorders (2.6% of children)
 Coughing, grunting, throat-clearing, sniffling, or sudden
repetitive and stereotyped outburst of words
 Chronic tic disorders (3.7% of children)
 4-5% more prevalent in boys

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Tics and Tourette’s Disorder Tics and Tourette’s Disorder

(cont’d.) (cont’d.)
 Tourette’s disorder (TD):  Etiology:
 Characterized by multiple motor tics and one or more  Both chronic tic disorder and TD appear to be genetically
vocal tic, present for at least one year transmitted
 Onset is prior to age 18  Involvement of basil ganglia and orbital frontal cortex
 About 8% show complete remission  Possible involvement of neurotransmitters
 Symptoms can be severe or mild  Treatment:
 Comorbid conditions  Psychotherapy can help with distress
 Antipsychotic medication may be used for severe tics

Attention-Deficit Attention-Deficit Hyperactivity

Hyperactivity Disorder Disorder (cont’d.)

 Characterized by inattention and/or hyperactivity and  Prevalence rates vary between studies
impulsivity  One study: 8.7%
 Symptoms must interfere with social, academic, or  Twice as likely in boys than in girls
occupational activities
 Symptoms tend to improve in late adolescence
 Diagnosis requires that symptoms begin before age 12
and persist for at least six months  Associated with behavioral and academic problems

 Poor regulation of attentional processes  Risk of coexisting conditions is four times greater among
children living in poverty

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Attention-Deficit Hyperactivity Attention-Deficit Hyperactivity

Disorder: Etiology Disorder: Etiology (cont’d.)

 Biological dimension:  Biological dimension:

 Highly heritable with up to 80% of symptoms explainable  Prematurity
by genetic factors
 Oxygen deprivation during birth
 Rare inherited gene mutations
 Low-birth weight
 Chromosomal DNA deletions and duplications
 Lead and PCB exposure
 Genes affecting the regulation of dopamine
 Viral infections, meningitis, and encephalitis
 Hypotheses about neurological mechanisms
 Maternal smoking, drug, and alcohol abuse during
 Reduced activity in prefrontal cortex
pregnancy
 Differences in brain structure and circuitry in frontal cortex,
cerebellum, and parietal lobes  Possible involvement of food additives
 Low dopamine levels

Attention-Deficit Hyperactivity
Attention-Deficit Hyperactivity Disorder: Etiology (cont’d.)
Disorder: Etiology (cont’d.)

 Social and sociocultural dimensions:

 Social adversity
 Stressors in family
 Cultural and regional expectations
 Psychological dimension:
 Interpersonal conflict

Figure 16-3 Prevalence of Youth (4-17) diagnosed with ADHD: Percentage by State, 2007

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Attention-Deficit Hyperactivity Attention-Deficit Hyperactivity

Disorder: Treatment Disorder: Treatment (cont’d.)

 Stimulants such as methylphenidate (Ritalin) receive  Evidence that behavioral and psychological treatments
most evidence-based support are highly effective
 Normalize neurotransmitter functioning and increased  Modifying environment and social context can enhance
neurological activation in frontal cortex feelings of competence, motivation, and self-efficacy
 Increased rates of stimulant medication use in U.S.  Coordination of all services result in most successful
 66.3% of children with ADHD are taking medication interventions

Autism Spectrum Disorders Autism Spectrum Disorders

(cont’d.)
 Characterized by impairment in social communication  Symptoms of autism:
and restricted, stereotyped interests and activities  Deficits in social communication and social interaction
 Symptoms range from mild to severe  Atypical social-emotional reciprocity
 Prevalence:  Atypical nonverbal communication

 Affects one out of 100-110 children  Difficulties developing and maintaining relationships

 Occurs five times more frequently in boys

 Can significantly affect cognitive development

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Autism Spectrum Disorders Autism Spectrum Disorders

(cont’d.) (cont’d.)
 Symptoms of autism:  Problems diagnosing autism:
 Repetitive behavior or restricted interests or activities  No medical test can pinpoint autism
involving at least two of following:  Autism is usually diagnosed at age three or later
 Repetitive speech, movement, or use of objects  Symptoms may appear following a period of normal social
 Intense focus on rituals or routines and strong resistance to and intellectual development
change
 Intense fixations or restricted interests
 Atypical sensory reactivity

Autism Spectrum Disorders: Autism Spectrum Disorders:

Etiology Etiology (cont’d.)
 Biological dimension:  Biological dimension:
 Unique patterns of metabolic brain activity  Genetic mutations implicated in familial autism
 Poor connectivity involving amygdala  Genetic factors involving multiple brain regions:
cerebellum, frontal/temporal lobes
 Correlations between levels of biochemicals
 Innate vulnerability triggered by environment
 Abnormally high levels or serotonin
 Clear evidence for genetic susceptibility
 Decreased size of occipital cortex
 Nutritional deficits, changes in immune system, and
 Accelerated head growth
abnormal immune responses
 Mitochondrial dysfunction

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Autism Spectrum Disorders: Etiology

(cont’d.) Autism Spectrum Disorders:
Etiology (cont’d.)
 Psychological dimension:
 Attentional and perceptual systems are affected
 Poor face recognition
 Lack of eye contact or social connectedness

 High stress levels among family due to ASD

 Psychological and social factors play a role in
manifestation of symptoms, but ASD is primarily
influenced by biological factors

Figure 16-5 The Prevalence of Autism Spectrum Disorder Among 8 Year-Old Children Has
Increased in 10 State Sites Monitored from 2002 to 2006

Autism Spectrum Disorders: ASD: Intervention and

Intervention and Treatment Treatment (cont’d.)
 Prognosis is mixed; most children retain diagnosis and  Medications are used to decrease anxiety, repetitive
require support for life behaviors and hyperactivity
 Individuals with higher levels of cognitive-adaptive  Minimally effective and may be harmful
functioning fare better than those with intellectual  Risperidone alone received FDA approval:
disabilities and severe autistic symptoms
 Preliminary research on effects of oxytocin
 Significant recovery linked with intense early
 Specialized programs include:
intervention
 Structure, intense, appropriate educational activities,
behavior modification procedures, parent education, and
opportunities to apply learned skills

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ASD: Intervention and Intellectual Disabilities

Treatment (cont’d.)
 Interventions with most significant gains:  Lifelong cognitive deficits characterized by limitations
 Social communication and social imitation in intellectual functioning and adaptive behaviors

 Environmental enrichment  Prevalence:

 Reinforcing appropriate attention and response to social  Approximately 1% of students in public school
stimuli  Increases in low and middle income countries
 Preventing repetitive behaviors  Coexisting conditions are common
 Sustained practice of weaker skills
 Reducing environmental stress
 Improving sleep and nutrition

Intellectual Disabilities Intellectual Disabilities

(cont’d.) (cont’d.)
 Intellectual impairment defined as:  Four distinct categories:
 Significantly subaverage general intellectual functioning  Mild: IQ score 50-55 to 70
(generally IQ of 70 or less)
 Moderate: IQ score 35-40 to 50-55
 Deficiencies in adaptive behavior that are lower than
 Severe: IQ score 20-25 to 35-40
would be expected based on age or cultural background
 Profound: IQ score below 20-25
 Only diagnosed when low intelligence is accompanied by
impaired adaptive functioning

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Intellectual Disabilities Intellectual Disabilities

(cont’d.) (cont’d.)
 American Association of Intellectual and Developmental
Disabilities’ assumptions:
 Identified deficits should be considered within context
age, peer group, culture and community environment
 Assessment should take into account cultural and linguistic
diversity, and sensory, motor, and behavioral factors
 Every individual possesses strengths and limitations

Intellectual Disabilities Intellectual Disabilities:

(cont’d.) Etiology
 American Association of Intellectual and Developmental  Etiology differs depending on level of intellectual
Disabilities’ assumptions: impairment
 The purpose of identifying limitations is to plan for  Mild ID is often idiopathic (no known cause)
providing needed support
 Pronounced ID related to genetic factors, brain
 Given ongoing, individualized support, overall functioning abnormalities, or brain injury
of individual with ID will improve

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Intellectual Disabilities: Intellectual Disabilities:

Etiology (cont’d.) Etiology (cont’d.)
 Genetic factors:  Down syndrome (DS):
 Genetic variations  Extra copy of chromosome 21 originates during gamete
development
 Normal distribution of traits (upper vs. lower range)

 Genetic abnormalities  Mild to moderate ID

 Chromosomal abnormalities  With support many can have jobs and live semi-
independently
 Down syndrome most common
 Medical interventions improve outcome
 Inheritance of single gene
 Fragile X syndrome most common (mild to severe ID)

Intellectual Disabilities: Intellectual Disabilities:

Etiology (cont’d.) Etiology (cont’d.)
 Nongenetic biological factors:  Psychological, social, sociocultural dimensions:
 Influences during prenatal, perinatal, or postnatal period  Genetic background interacts with environmental factors
 Fetus is susceptible to viruses and infections, drugs and  Effects of low SES
alcohol, radiation, and poor nutrition
 Parents with mild ID
 Fetal alcohol syndrome
 Parenting style
 Birth trauma, prematurity, and low birth weight
 Enriching and encouraging home environment, as well as
 Head injuries, brain infections, tumors, and prolonged
ongoing education intervention
malnutrition
 Exposure to lead

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Learning Disabilities Learning Disabilities (cont’d.)

 Academic disability characterized by reading and math  Etiology:

skills deficits  Little is known about precise causes of LD
 Primarily interferes with academic achievement and  Appear to have slower brain maturation
activities of daily living in which reading or math skills
 Lifelong differences in neurological processing of
are needed
information related to basic academic skills
 Prevalence:  May be similar to biological explanations for ID and ADHD
 Around 5% of students in public schools  Runs in families, suggesting genetic component
 Boys are almost twice as likely as girls

Comorbidity of Support for Individuals with

Neurodevelopmental Disorders Neurodevelopmental Disorders

 Many overlapping environmental influences that can  Produce lifelong disability, goal of intervention is to
significantly affect brain development, causing disorder build skills and develop potential to the fullest extent
possible
 Focus on comorbidity and genetic similarities between
disorders  Support should begin in infancy and and extend across
 Similarities between autism and severe ID
the life span

 One-half of those with ASD have symptoms of ADHD  Different levels of support
 ADHD and schizophrenia

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Support for Individuals Support for Individuals

(cont’d.) (cont’d.)
 Support in childhood:  Support in adulthood:
 Individualized home-based or school-based programs  Programs focusing on specific job skills
 Parent involvement is integral part or early intervention  Institutionalization is rare, but many live with family
programs members
 In U.S. if academic progress is significantly compromised,  “Least restrictive environment” possible
children are entitled to free educational services from age  As much independence and personal choice as is safe and
3 to 21 practical
 Individualized education plan (IEP)  Comorbid depression and anxiety require environmental
 Rates of improvement decrease once programs are completed modification, social and coping skill development, and
cognitive or behavioral therapy

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