Behavioral Disorders IN

Children & Adolescents

Prevalence

 

 

á    20% of children

 

á    40% of adolescents

 

(Romano et al., 2001)

 

Note: Includes all Axis I disorders & those

usually first diagnosed in childhood or adolescence
BEHAVIORAL DISORDERS OF

CHILDHOOD AND ADOLESCENCE:

General

 

 

á    Childhood is 20th century concept

   

 

á    Unknown if prevalence has changed over time

 

 

Note:  Prevalence mostly determined by what

           adults find to be acceptable behavior

STRESSORS IN MODERN CHILDHOOD:

General

 

 

á    Stressors ð increased risk of psychological disorders

(Flisher et al., 1997)

 

á    25% Severe physical abuse

 

á    20% Poverty

 

STRESSORS IN MODERN CHILDHOOD:

Violence

 

5th graders in poor area of New Orleans
(Hutson et al, 1994)

 

á    91% witnessed some violence in the past year

á    26% witnessed a shooting

á    40% had seen dead bodies in their neighborhood

á    49% had seen someone wounded

á   50% had been victims of violence 

STRESSORS IN MODERN CHILDHOOD:

Violence conÕd

 

á    Most children who face major stressors do NOT develop a psychological disorder

(Luthar et al., 2000)

 

á    Most children who DO develop psychological disorders have not had a major stressful life event

 

 Stressors do not sufficiently explain vulnerability
STRESSORS IN MODERN CHILDHOOD:

Resilience

 

 

á    At least one healthy, competent, & reliable adult

 

o  e.g., Masten et al. (1993) - same resilience among homeless children who have a relationship with a competent adult

 

o  e.g., Plomin (1994) - same resilience for children with "difficult" temperament

CHILDHOOD DISORDERS

 

á    ADHD 2 - 7%*

 

á    Conduct disorder 2 - 9%

 

á    Autistic disorder 0.05%

 

á   Mental retardation 3%

 

á   Learning disabilities 5%

 

* Attention-deficit/hyperactivity disorder

ADHD

 

INATTENTION

 

    and/or

 

HYPERACTIVITY - IMPULSIVITY

 

For 6 months

 

Some symptoms before age 7

 

Symptoms can continue into adulthood (20%)

 

Behavior is developmentally inappropriate

ADHD

Core Symptoms

 

Inattention

 

failure to concentrate on a task for an appropriate amount of time 

 

HYPERACTIVITY - IMPULSIVITY

 

failure to appropriately control motor movements

 

appropriate = ?
ADHD

Inattention

 

6+ of the following 9:

 

 

¥ Fails to pay close attention to details or makes careless mistakes in schoolwork, work, etc.

 

¥ Difficulty sustaining attention in tasks or play activities

 

 

¥ Does not seem to listen when spoken to directly 

 

ADHD

Inattention conÕd

 

6+ of the following 9 cont'd:

 

 

¥ Does not follow through on instructions & fails to finish schoolwork, chores, or duties in the workplace (not oppositional behavior or failure to understand instructions)

¥ Difficulty organizing tasks or activities

 

¥ Avoids, dislikes, or is reluctant to engage in tasks requiring sustained mental effort
(e.g., schoolwork, homework)

ADHD

Inattention conÕd

 

 

6+ of the following 9 cont'd:

 

¥ Loses things necessary for tasks or activities

 

  

¥ Easily distracted by extraneous stimuli

 

  

¥ Forgetful in daily activities

 

 

ADHD

Hyperactivity - Impulsivity

 

6+ of the following 9:

  

¥ Fidgets with hands or feet or squirms in seat

¥ Leaves seat in classroom or in other situations where remaining seated is expected

 

¥ Runs about / climbs excessively in inappropriate situations

(possibly limited to subjective feelings of restlessness as ages)

ADHD

Hyperactivity – Impulsivity conÕd

 

 

6+ of the following 9 cont'd:

 

 

¥ Difficulty engaging in leisure activities quietly

 

 

¥ "On the go" or acts as if "driven by a motor"

 

 

¥ Talks excessively

 

 

¥ Blurts out answers before question completed

 

 

¥ Difficulty waiting turn

 

 

¥ Interrupts or intrudes on others
(e.g. butts into conversations or games)

ADHD

Associated Features

 

¥ Low frustration tolerance

 

¥ Temper outbursts             ¥ Stubbornness

 

¥ Rejection by peers            ¥ Bossiness

 

¥ Impaired academics              ¥ Dysphoria

 

¥ Being labeled lazy            ¥ Poor self-esteem

 

¥ Being labeled irresponsible

 

¥ Learning disability (20%)

ADHD

Experiences of a child with ADHD

 

 

Quotes from taped therapy sessions with a nine-year-old boy

    (Ross & Ross, 1982)

 

" . . . The very first day Mrs. K. (teacher) says, 'Oh, you're David J.,' and right in front of everyone she says when do I take my pills."

 

 

ADHD

Experiences of a child with ADHD conÕd

 

 

 

"Chrissie Wilson had her Reckless Robert Robot in science class and it got started and wouldn't stop and Randy said, 'Man that robot's hyper just like Davey! Give it a pill, Davey,' and everyone laughed."

 

 

 

ADHD

Experiences of a child with ADHD conÕd

 

 

" . . . when it's special like a party I have to go to the sitter's . . . I heard my Mom say, 'If only we could send him away to school.'"

 

 

"I don't get them (pills) weekends so I can grow and it's scary because I'm one of the smallest in my class now and how can I catch up on only growing two days a week?"

ADHD

Experiences of a child with ADHD conÕd

 

 

" . . . medications is like in a big thick space suit with ear muffs and things get real fuzzy like far off."

 

"I got no friends coz I don't play good and when they call me Dope Freak and David Dopey I cry, I just can't help it."

 

 

Etiology of ADHD

 

Biological

 

á    heredity (adoptee evidence 6%)

 

á    brain differences

 

á    environmental toxins

 

Behavioral

 

 childrearing environment reinforces and models inattention and hyperactivity (bi-directional)

 

 

Treatments of ADHD

 

Biological:  Medication (amphetamines)

 

¥ Positive short-term effect for behavior disruption for 75%

 

¥ No effect on academic achievement

 

? 10% children on Ritalin (3 – 7% meet dx) in U.S. but not in any other country

? some just poor training

? some sold on street for recreational use

(Production has increased from 5000 KG to 21,000 KG in past decade)

Treatments of ADHD conÕd

 

Biological:  Medication (amphetamines) conÕd

 

¥ Side-effects

 

    - Loss of appetite

    - Reduced rate of growth

    - Message cannot control own behavior

    - 186 deaths 1990-2000 (Ritalin)

     - Recreational use of amphetamines?

     -Visual hallucinations

      -Suicidal ideation

      - Psychotic behavior, aggression

 

Treatments of ADHD conÕd

 

Biological:  Medication (amphetamines) conÕd

Side –effects conÕd

 

-Aggression or violent behavior

-Hypertension

-Chest pain, arrhythmias and tachycardia, or rapid heartbeat

 

 

 

 

Treatments of ADHD conÕd

 

 

Behavior therapy

 

á    Operant conditioning (shaping)

 

á    Works in short-term for behavior disruption & academic achievement

 

á    Works in long-term (if continued) for 70%

 

o  Concern about effort (caregiver, teacher)

o 50% adults fail to implement TX

CHILDHOOD DISORDERS - ADHD

Treatments of ADHD

 

 

 

Combination of medication & behavior therapy

 

Best results in both short- & long-term

 

95% response rate

 

 

 

CHILDHOOD DISORDERS - Conduct Disorder

 

Repetitive

 

&

 

Persistent (1 yr +) VIOLATION OF:

 

-Basic rights of others

 

    -Major age-appropriate societal norms

 

    or

 

    -Rules

 

CHILDHOOD DISORDERS - Conduct Disorder

General

 

 

3+ of the following 4:

 

á   Aggression to People & Animals

 

á   Destruction of Property

 

á   Deceitfulness or Theft

 

á   Serious Violation of Rules

 

Etiology of Conduct Disorder

 

Biological

¥ Genetics: Greater role in aggressive behavior,
   but lesser role in delinquency-related behaviors

  - e.g. stealing, running away

 

Cognitive-behavioral

¥ Deficiencies in moral training and awareness

¥ Modeling of aggressive behavior

¥ Cognitive distortions in which ambiguous actions are interpreted as hostile

 

Treatment of Conduct Disorder

 

Cognitive-behavioral
(Eddy et al. (2003) also preventive of arrests)

 

á    Training parents & teachers to reward prosocial behaviors & moral reasoning

 

á    Anger control training

 

á    Problem-solving training

 

á    Social skills training

 

50% develop antisocial PD

100% of antisocial PD exhibited CD
CHILDHOOD DISORDERS – Autistic Disorder

 

 

Qualitative Impairment of Social Interaction

 

á   Preference to be alone

 

 

Qualitative Impairment in Communication

 

á   Severely limited language skills

 

Restricted Repetitive & Stereotyped Patterns of Behavior, Interests, & Activities

 

á   Prefer a constant environment

 

Autistic Disorder

Cognitive-intellectual functioning

 

 

80% have IQ < 70

 

20% have IQ 70 - 150

 

Many have highly developed skills (savant)

 

 

 

Etiology of Autistic Disorder

 

 

á   not schizophrenia (no hallucinations or delusions)

 

á   not mental retardation (20% have IQ above 70)

 

á   deficits in a range of developmental milestones

 

á   causes unknown but assumed to be biological

 

 

Etiology of Autistic Disorder

 

Biological

 

á   Genetic, brain structure; no marker

 

Psychoanalytic

 

á   Separation of the breast during oral stage results in rejection of parents

 

Cognitive Behavioral

 

á   Caregivers do not function as secondary reinforcement

 

Treatment of Autistic Disorder

 

Biological

 

á   Anti-psychotic medication for motor symptoms

 

Cognitive Behavioral

 

á     Operant conditioning

 

á     Developed by Ivar Lovaas at UCLA

 

á   Best empirically-supported treatment for all symptoms

 

Treatment of Autistic Disorder

 

Cognitive Behavioral contÕd

 

á    50% attain an IQ of 80+ & adjustment to mainstream classroom

 

á    40% live independently

 

á    Shaping with immediate primary reinforcement

 

á    Classical conditioning of social reinforcement

 

á    Modeling

 

á    Labor intensive

 

CHILDHOOD DISORDERS – Mental Retardation

 

Axis II (long-standing)

 

á    Subaverage intellectual functioning

o  IQ score below 70-75

 

á    Deficits in adaptive behaviors

o  i.e. dressing, use of money, use of tools, & public transportation

 

á    Onset prior to age 18

o  Typical onset is in infancy

o  Diagnosis when enters school

CHILDHOOD DISORDERS – Mental Retardation

Subtypes of Mental Retardation

 

 

Mild/educable

 

á    IQ 50/55 — 70

 

á    85% of MR

 

á    Learn up to 6th grade level

 

CHILDHOOD DISORDERS – Mental Retardation

Subtypes of Mental Retardation

 

 

Moderate/trainable

 

á    IQ 35/40 — 50/55

 

á    10% of MR

 

á    2nd grade level

 

 

CHILDHOOD DISORDERS – Mental Retardation

Subtypes of Mental Retardation

 

 

Severe

 

á    IQ 20/25 — 35/40

 

á    3-4% of MR

 

á    Elementary self-care skills

 

CHILDHOOD DISORDERS – Mental Retardation

Subtypes of Mental Retardation

 

 

Profound

 

á    IQ < 20/25

 

á    1 — 2% of MR

 

á    need constant supervision

 

CHILDHOOD DISORDERS – Mental Retardation

Etiology of Mental Retardation

 

á   No cause evident for 75% of mental retardation

 

á    25% related to biological causes

 

á    Biological causes:

 

o  Genetic anomalies (i.e. DownÕs syndrome)

 

o  Recessive-gene diseases (i.e. PKU)
(phenylketonuria; liver enzyme deficiency)

 

o  Infectious diseases (i.e. Rubella and HIV)

 

o  Environmental hazards (i.e. mercury or lead poisoning)

CHILDHOOD DISORDERS – Mental Retardation

Treatment of Mental Retardation

 

Behavioral

 

á    Reinforcement

 

á    Successive approximation/Shaping

 

á    Modeling

 

á    Self-instruction (model speaks aloud steps; after imitation, silent self-speech is acquired)

CHILDHOOD DISORDERS – Learning Disabilities

 

 

Inadequate development in a specific area of academic, language or motor skills

 

Normal IQ (i.e. greater than 75)

 

15 - 30 point difference in IQ and achievement test scores

 

Deficit is not due to mental retardation, autism or reduced educational opportunities
CHILDHOOD DISORDERS – Learning Disabilities

General

 

á    50% greater chance than average of dropping out of school

 

á    Associated with poor social skills & self-esteem

 

á    DSM covers 3 areas of learning disabilities

 

o  Learning disorders

 

o  Communication disorders

 

o  Motor skills involving impairment of motor coordination

CHILDHOOD DISORDERS – Learning Disabilities

Learning Disorders

 

á   Conditions that impair success in the classroom

 

á   Specific learning disorders identified by DSM-IV include:

 

o Reading disorder (Dyslexia) - word recognition & comprehension (global reading problems)

 

o Written expression disorder - writing & composition problems

 

o Mathematics disorder - difficulty recalling math facts & manipulating numbers

CHILDHOOD DISORDERS – Learning Disabilities

Communication Disorders

 

 

Expressive language disorder

 

    e.g. Difficulty in speech expression

á    Difficulty finding correct word for a concept

 

á    Use of grammar below grade level

 

 

CHILDHOOD DISORDERS – Learning Disabilities

Communication Disorders

 

Phonological disorder

    e.g. Difficulty articulating speech sounds

           necessary for learning words later

 

á    Can comprehend words

 

á    Stuttering

 

á   Problem with verbal fluency where words are repeated or prolonged

 

CHILDHOOD DISORDERS – Learning Disabilities

Treatment of Learning Disabilities

 

Behavioral

 

á   Academic strengths to compensate for weaknesses

 

á   Successive approximation or shaping
(break down tasks to smaller, logical, sequential, multi-sensory steps; model & reinforce each step)

 

á   Model & reinforce study skills

 

á   Time management training