Developmental and Cognitive Disorders

1. Developmental and Cognitive Disorders Chapter 13

2. Perspectives on Developmental Disorders • Normal vs. Abnormal Development • Childhood is associated with significant developmental changes • Disruption of early skills will likely disrupt development of later skills • Developmental Disorders • Diagnosed first in infancy, childhood, or adolescence • Attention deficit hyperactivity disorder (ADHD) • Learning disorders • Autism • Mental retardation

3. Attention Deficit Hyperactivity Disorder (ADHD): An Overview • Nature of ADHD • Central features – Inattention, overactivity, and impulsivity • Associated with behavioral, cognitive, social, and academic problems • DSM-IV and DSM-IV-TR Symptom Clusters • Cluster 1 – Symptoms of inattention • Cluster 2 – Symptoms of hyperactivity and impulsivity cluster • Either cluster 1 or 2 must be present for a diagnosis

4. ADHD: Facts and Statistics • Prevalence • Occurs in 4%-12% of children who are 6 to 12 years of age • Symptoms are usually present around age 3 or 4 • 68% of children with ADHD have problems as adults • Gender Differences • Boys outnumber girls 4 to 1 • Cultural Factors • Probability of ADHD diagnosis is greatest in the United States

5. ADHD: Biological Contributions • Genetic Contributions • ADHD runs in families • Familial ADHD may involve deficits on chromosome 20 • Neurobiological Contributions: Brain Dysfunction and Damage • Inactivity of the frontal cortex and basal ganglia • Right hemisphere malfunction • Abnormal frontal lobe development and functioning • Yet to identify a precise neurobiological mechanism for ADHD • The Role of Toxins • Allergens and food additives do not appear to cause ADHD • Maternal smoking increases risk of having a child with ADHD

6. ADHD: Psychosocial Contributions • Psychosocial Factors Can Influence the Disorder Itself • Constant negative feedback from teachers, parents, and peers • Peer rejection and resulting social isolation • Such factors foster low self-image

7. Biological Treatment of ADHD • Goal of Biological Treatments • To reduce impulsivity/hyperactivity and to improve attention • Stimulant Medications • Reduce the core symptoms of ADHD in 70% of cases • Examples include Ritalin, Dexedrine • Effects of Medications • Improve compliance and decrease negative behaviors in many children • Beneficial effects are not lasting following drug discontinuation • Negative side effects include insomnia, drowsiness, and irritability

8. Behavioral and Combined Treatment of ADHD • Behavioral Treatment • Involve reinforcement programs • Aim to increase appropriate behaviors and decrease inappropriate behaviors • May also involve parent training • Combined Bio-Psycho-Social Treatments • Are highly recommended

9. Learning Disorders • Scope of Learning Disorders • Problems related to academic performance in reading, mathematics, and writing • Performance is substantially below what would be expected • DSM-IV and DSM-IV-TR Reading Disorder • Discrepancy between actual and expected reading achievement • Reading is at a level significantly below that of a typical person of the same age • Problem cannot be caused by sensory deficits (e.g., poor vision) • DSM-IV and DSM-IV-TR Mathematics Disorder • Achievement below expected performance in mathematics • DSM-IV and DSM-IV-TR Disorder of Written Expression • Achievement below expected performance in writing

10. Learning Disorders: Some Facts and Statistics • Incidence and Prevalence of Learning Disorders • 1% to 3% incidence of learning disorders in the United States • Prevalence is highest in wealthier regions of the United States • Prevalence rate is 10% to 15% among school age children • Reading difficulties are the most common of the learning disorders • About 32% of students with learning disabilities drop out of school • School experience for such persons tends to be quite negative

11. Biological and Psychosocial Causes of Learning Disorders • Genetic and Neurobiological Contributions • Reading disorder runs in families, with 100% concordance rate for identical twins • Evidence for subtle forms of brain damage is inconclusive • Overall, genetic and neurobiological contributions are unclear • Psychological and motivational factors seem to affect eventual outcome

12. Treatment of Learning Disorders • Requires Intense Educational Interventions • Remediation of basic processing problems (e.g., teaching visual skills) • Efforts to improve of cognitive skills (e.g., instruction in listening) • Targeting behavioral skills to compensate for problem areas • Data Support Behavioral Educational Interventions for Learning Disorders

13. Pervasive Developmental Disorders: An Overview • Nature of Pervasive Developmental Disorders • Problems occur in language, socialization, and cognition • Pervasive – Means the problems span the person’s entire life • Examples of Pervasive Developmental Disorders • Autistic disorder • Asperger’s syndrome

14. Autistic Disorder • Autism • Significant impairment in social interactions and communication • Restricted patterns of behavior, interest, and activities • Three Central DSM-IV and DSM-IV-TR Features of Autism • Problems in socialization and social function • Problems in communication – 50% never acquire useful speech • Restricted patterns of behavior, interests, and activities

15. Autistic Disorder: Facts and Statistics • Prevalence and Features of Autism • Affects 2 to 20 persons for every 10,000 people • More prevalent in females with IQs below 35, and in males with higher IQs • Autism occurs worldwide • Symptoms usually develop before 36 months of age • Autism and Intellectual Functioning • 50% have IQs in the severe-to-profound range of mental retardation • 25% test in the mild-to-moderate IQ range (i.e., IQ of 50 to 70) • Remaining people display abilities in the borderline-to-average IQ range • Better language skills and IQ test performance predicts better lifetime prognosis

16. Causes of Autism: Early and More Recent Contributions • Historical Views • Bad parenting • Unusual speech patterns • Lack of self-awareness • Echolalia • Current Understanding of Autism • Medical conditions – Not always associated with autism • Autism has a genetic component that is largely unclear • Neurobiological evidence for brain damage – Link with mental retardation • Cerebellum size – Substantially reduced in persons with autism

17. Treatment of Pervasive Developmental Disorders • Psychosocial “Behavioral” Treatments • Skill building and treatment of problem behaviors • Communication and language problems • Address socialization deficits • Early intervention is critical • Biological and Medical Treatments Are Unavailable • Integrated Treatments: The Preferred Model • Focus on children, their families, parents, schools, and the home • Build in appropriate community and social support

18. Mental Retardation (MR) • Nature of Mental Retardation • Disorder of childhood • Below-average intellectual and adaptive functioning • Range of impairment varies greatly across persons • Mental Retardation and the DSM-IV and DSM-IV-TR • Significantly subaverage intellectual functioning (IQ below 70) • Concurrent deficits or impairments two or more areas of adaptive functioning • MR must be evident before the person is 18 years of age

19. DSM-IV and DSM-IV-TR Levels of Mental Retardation (MR) • Mild MR • Includes persons with an IQ score between 50 or 55 and 70 • Moderate MR • Includes persons in the IQ range of 35-40 to 50-55 • Severe MR • Includes people with IQs ranging from 20-25 up to 35-40 • Profound MR • Includes people with IQ scores below 20-25

20. Other Classification Systems for Mental Retardation (MR) • American Association of Mental Retardation (AAMR) • Defines MR based on levels of assistance required • Examples of levels include intermittent, limited, extensive, or pervasive assistance • Classification of MR in Educational Systems • Educable mental retardation (i.e., IQ of 50 to approximately 70-75) • Trainable mental retardation (i.e., IQ of 30 to 50) • Severe mental retardation (i.e., IQ below 30)

21. Mental Retardation (MR): Some Facts and Statistics • Prevalence • About 1% to 3% of the general population • 90% of MR persons are labeled with mild mental retardation • Gender Differences • MR occurs more often in males, male-to-female ratio of about 1.6:1 • Course of MR • Tends to be chronic, but prognosis varies greatly from person to person

22. Mental Retardation (MR): Biological Contributions • Genetic Research • MR involves multiple genes, and at times single genes • Chromosomal Abnormalities and Other Forms of MR • Down syndrome – Trisomy 21 • Fragile X syndrome – Abnormality on X chromosome • Maternal Age and Risk of Having a Down’s Baby • Nearly 75% of cases cannot be attributed to any known biological cause

23. Mental Retardation (MR): Psychosocial Contributions • Cultural-Familial Retardation • Believed to cause about 75% of MR cases and is the least understood • Associated with mild levels of retardation on IQ tests and good adaptive skills • Cultural-Familial Retardation: Difference vs. Developmental Views • Difference view – Mild MR is a matter of degree and kind • Developmental view – Mild MR reflects a slowing or delay of normal development

24. Treatment of Mental Retardation (MR) • Parallels Treatment of Pervasive Developmental Disorders • Teach needed skills to foster productivity and independence • Educational and behavioral management • Living and self-care skills via task analysis • Communication training – Often most challenging treatment target! • Community and supportive interventions • Persons with MR Can Benefit from Such Interventions

25. Summary of Developmental Disorders • Developmental Psychopathology and Normal and Abnormal Development • Attention Deficit Hyperactivity Disorder • Deficits in inattention, hyperactivity, or impulsivity • Disrupt academic and social functioning • Learning Disorders • All share deficits in performance below expectations for IQ and school preparation • Pervasive Developmental Disorder • All share deficits in language, socialization, and cognition • Mental Retardation • Subaverage IQ, deficits in adaptive functioning, onset before age 18 • Prevention and Early Intervention Are Critical for Developmental Disorders

26. Cognitive Disorders: An Overview • Perspectives on Cognitive Disorders • Affect cognitive processes such as learning, memory, and consciousness • Most develop later in life • Three Classes of Cognitive Disorders • Delirium – Often temporary confusion and disorientation • Dementia – Degenerative condition marked by broad cognitive deterioration • Amnestic disorders – Memory dysfunctions caused by disease, drugs, or toxins • Shifting DSM Perspectives • From “organic” mental disorders to “cognitive” disorders • Broad impairments in memory, attention, perception, and thinking • Profound changes in behavior and personality

27. Delirium • Nature of Delirium • Central features – Impaired consciousness and cognition • Impairments develop rapidly over several hours or days • Examples include confusion, disorientation, attention, memory, and language deficits • Facts and Statistics • Affects 10% to 30% of persons in acute care facilities • Most prevalent in older adults, AIDS patients, and medical patients • Full recovery often occurs within several weeks

28. Medical Conditions Related to Delirium • Medical Conditions • Drug intoxication, poisons, withdrawal from drugs • Infections, head injury, and several forms of brain trauma • Sleep deprivation, immobility, and excessive stress • DSM-IV and DSM-IV Subtypes of Delirium • Delirium due to a general medical condition • Substance-induced delirium • Delirium due to multiple etiologies • Delirium not otherwise specified

29. Treatment and Prevention of Delirium • Treatment • Attention to precipitating medical problems • Psychosocial interventions include reassurance, coping strategies • Prevention • Address proper medical care for illnesses • Address proper use and adherence to therapeutic drugs

30. Dementia • Nature of Dementia • Gradual deterioration of brain functioning • Affects judgment, memory, language, and advanced cognitive processes • Dementia has many causes and may be reversible or irreversible • Progression of Dementia: Initial Stages • Memory impairment, visuospatial skills deficits • Agnosia – Inability to recognize and name objects (most common symptom) • Facial agnosia – Inability to recognize familiar faces • Other symptoms – Delusions, depression, agitation, aggression, and apathy • Progression of Dementia: Later Stages • Cognitive functioning continues to deteriorate • Person requires almost total support to carry out day-to-day activities • Death results from inactivity combined with onset of other illnesses

31. Dementia: Facts and Statistics • Onset and Prevalence • Can occur at any age, but most common in the elderly • Affects 1% of those between 65-74 years of age • Affects over 10% of persons 85 years and older • 47% of adults over the age of 85 have dementia of the Alzheimer’s type • Incidence of Dementia • Affects 2.3% of those 75-79 years of age and 8.5% of persons 85 and older • Rates of new cases appear to double with every 5 years of age • Gender and Sociocultural Factors • Dementia occurs equally in men and women • Dementia occurs equally across educational level and social class

32. DSM-IV and DSM-IV-TR Classes of Dementia • Dementia of the Alzheimer’s type • Vascular Dementia • Dementia Due to Other General Medical Conditions • Substance-Induced Persisting Dementia • Dementia Due to Multiple Etiologies • Dementia Not Otherwise Specified

33. Dementia of the Alzheimer’s Type • DSM-IV-TR Criteria and Clinical Features • Multiple cognitive deficits that develop gradually and steadily • Predominant impairment in memory, orientation, judgment, and reasoning • Can include agitation, confusion, depression, anxiety, or combativeness • Symptoms are usually more pronounced at the end of the day • Range of Cognitive Deficits • Aphasia – Difficulty with language • Apraxia – Impaired motor functioning • Agnosia – Failure to recognize objects • Difficulties with planning, organizing, sequencing, or abstracting information • Impairments have a marked negative impact on social and occupational functioning • An Autopsy Is Required for a Definitive Diagnosis

34. Alzheimer’s Disease: Some Facts and Statistics • Nature and Progression of the Disease • Deterioration is slow during the early and later stages, but rapid during middle stages • Average survival time is about 8 years • Onset usually occurs in the 60s or 70s, but may occur earlier • Prevalence of Alzheimer’s Disease • Affects about 4 million Americans and many more worldwide • Prevalence is greater in poorly educated persons and women • Prevalence rates are low in some ethnic groups (e.g., Japanese, Nigerian, Amish)

35. Vascular Dementia • Nature of Vascular Dementia • Progressive brain disorder caused by blockage or damage to blood vessels • Second leading cause of dementia next to Alzheimer’s • Onset is often sudden (e.g., stroke) • Patterns of impairment are variable, and most require formal care in later stages • DSM-IV and DSM-IV Criteria and Incidence • Cognitive disturbances are identical to dementia • Unlike Alzheimer’s, obvious neurological signs of brain tissue damage occur • Incidence is believed to be about 4.7% or men and 3.8% of women

36. Dementia Due to HIV Disease • Overview and Clinical Features • HIV causes neurological impairments and dementia • Cognitive slowness, impaired attention, forgetfulness, and clumsiness • Repetitive movements (e.g., tremors/leg weakness), apathy, and social withdrawal • Progression of HIV-Related Cognitive Impairments • Tend to occur during the later stages of HIV infection • Impairments are observed in 29% to 87% of people with AIDS • Subcortical dementia – Refers to deficits that affect inner brain regions • Aphasia is uncommon in subcortical dementia, but anxiety and depression occur

37. Other Causes of Dementia: Head Trauma and Parkinson’s Disease • Head Trauma • Accidents are leading causes of such cognitive impairments • Memory loss is the most common symptom • Parkinson’s Disease • Degenerative brain disorder • Affects about 1 out of 1,000 people worldwide • Motor problems are characteristic of this disorder • Damage to dopamine pathways is believed to cause motor problems • Pattern of impairments are similar to subcortical dementia

38. Other Causes of Dementia: Huntington’s and Pick’s Disease • Huntington’s Disease • Genetic autosomal dominant disorder (i.e., chromosome 4) • Manifests initially as chorea, usually later in life (around 40s or 50s) • About 20% to 80% of persons go on to display dementia of the subcortical pattern • Pick’s Disease • Rare neurological condition that produces a cortical dementia like Alzheimer’s • Also occurs later in life (around 40s or 50s) • Little is known about what causes this disease

39. Other Dementias: Creutzfeldt-Jakob Disease and Substance-Induced Dementia • Creutzfeldt-Jakob Disease • Affects 1 out of 1,000,000 persons • Linked to mad cow disease • Substance-Induced Persisting Dementia • Results from drug use in combination with poor diet • Examples include alcohol, inhalants, and sedative, hypnotic, and anxiolytic drugs • Resulting brain damage may be permanent • Dementia is similar to that of Alzheimer’s • Deficits may include aphasia, apraxia, agnosia, or disturbed executive functioning

40. Causes of Dementia: The Example of Alzheimer’s Disease • Early and Largely Unsupported Views: The Example of Smoking • Current Neurobiological Findings • Neurofibrillary tangles – Occur in all brains of Alzheimer’s patients • Amyloid plaques–Accumulate excessively in brains of Alzheimer’s patients • Brains of Alzheimer’s patients tend to atrophy • Current Neurobiological Findings • Multiple genes are involved in Alzheimer’s disease (chromosomes 21, 19, 14, 12, 1) • Chromosome 14 – Associated with early onset Alzheimer’s • Chromosome 19 – Associated with a late onset Alzheimer’s

41. The Contributions of Psychosocial Factors in Dementia • Do not cause dementia directly, but may influence onset and course • Lifestyle factors – Drug use, diet, exercise, stress • Cultural factors – Risk for certain diseases and accidents vary by ethnicity and class • Psychosocial factors – Educational attainment, coping skills, social support

42. Medical and Psychosocial Treatment of Dementia • Medical Treatment: Best if Enacted Early • Few medical treatments exist for most types of dementia • Most medical treatments attempt to slow progression of deterioration • Examples include glial cell-derived neurotrophic factor, Cognex, vitamin E, aspirin • Medical treatments do not stop progression of dementia • Psychosocial Treatments • Focus on enhancing the lives of dementia patients and their families/caregivers • Teach adaptive skills • Use memory enhancement prosthetic devices (e.g., memory wallet) • Main emphasis of psychosocial interventions appears to be on the caregivers

43. Prevention of Dementia • Reducing Risk of Dementia in Older Adults Via • Estrogen-replacement therapy – Reduces risk of Alzheimer’s dementia in women • Proper treatment of cardiovascular diseases • Use of anti-inflammatory medications • Other Targets of Prevention Efforts • Increasing safety behaviors to reduce head trauma • Reducing exposure to neurotoxins and use of drugs

44. Amnestic Disorder • Nature of Amnestic Disorder • Inability to transfer information from short-term memory into long-term memory • Often results from medical conditions, head trauma, or long-term drug use • DSM-IV and DSM-IV-TR Criteria for Amnestic Disorder • Cover the inability to learn new information • Inability to recall previously learned information • Memory disturbance causes significant impairment in functioning • The Example of Wernicke-Korsakoff Syndrome • Caused by thalamic damage resulting from stroke or chronic heavy alcohol use • Attempt to restore thiamine deficiency in the case of chronic alcohol abuse • Research on Amnestic Disorders Is Scant