Disorders Usually 1 st Diagnosed in Infancy, Childhood, & Adolescence

1. Disorders Usually 1st Diagnosed in Infancy, Childhood, & Adolescence Core Concept of Diagnostic Group: • Categorized by time of onset • Predominantly disorders of abnormal development and maturation. • Emphasis of disorders is on the inability of the individual to attain certain normal developmental milestones and the associated functions, capabilities, & behaviors.

2. 10 Diagnostic Subgroups (DSM-IV-TR) • Mental Retardation • Learning Disorders • Motor Skills Disorders • Communication Disorders • Pervasive Developmental Disorders • Attention Deficit and Disruptive Behavior Disorders • Feeding & Eating Disorders of Infancy & Early Childhood • Tic Disorders • Elimination Disorders • Other Disorders of Infancy, Childhood, or Adolescence

3. Mental Retardation Characteristics: • IQ is significantly below average (< 70) • Accompanied by deficits in adaptive functioning, e.g. communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, academic skills, work, leisure, health, safety • Onset before age 18 years • Coding: coded on axis II • Code based on degree of severity, reflecting level of intellectual impairment: • Mild Mental Retardation – IQ from 50-55 to 70 • Moderate Mental Retardation – IQ from 35-40 to 50-55 • Severe Mental Retardation – IQ from 20-25 to 35-40 • Profound Mental Retardation – IQ below 20-25

4. Mental Retardation • Prevalence: 1-3% of population; 90% are mild MR • Course: chronic • Prognosis: variable, depending on IQ & level of impairment • Gender differences: more prevalent for males (1.6 to 1); no gender differences for severe & profound MR • Causes: genetic; chromosomal (Down syndrome, Fragile X syndrome, Lesch-Nyhan syndrome); environmental (deprivation, abuse, neglect); prenatal (exposure to disease, alcohol, drugs, chemicals, poor maternal nutrition); perinatal (difficulties during labor & delivery); postnatal (malnutrition, infections, & head injuries) • Treatment: behavioral skills training; communication training; supported living and employment; mainstreaming

5. Learning Disorders Characteristics: • Inadequate development of specific academic skills, such as reading, writing, and math. • Specific academic skills are substantially below expected for age, intelligence, and education • Significantly interferes with aspects of life requiring those skills. Subtypes: • Reading Disorder • Mathematics Disorder • Disorder of Written Expression • Learning Disorder Not Otherwise Specified

6. Learning Disorders • Prevalence: • general population: 5-10% • reading disorders: 5-15% • math disorders: 6% • Racial: more common in black children • Negative outcomes: negative school experiences; school drop-out; lower employment rates; lower educational & career goals • Causes: genetics; structural & functional differences in the brain • Treatment: educational interventions (processing skills; cognitive skills; behavioral skills)

7. Tic Disorder: Tourette’s Disorder • Symptoms: characterized by multiple motor tics and one or more vocal tics (involuntary, sudden, rapid, nonrhythmic, stereotyped motor movements or vocalizations), which occur many times a day, nearly every day, or intermittently for more than a year. • Common motor tics: eye-blinking, eye-rolling, spitting, flipping/twirling hair, rolling head around, bending/jumping, skin picking, shrugging/jerking shoulders, thrusting pelvic movements, tapping fingers/feet • Common vocal tics: throat clearing, tongue-clicking, whistling, grunting, humming, hoots, howls, burps/belches, animal noises, repetition of one’s own words, repetition of others’ words

8. Tourette’s Disorder • Causes: genetic (32% have relatives with TD); abnormal metabolism of 5HT & D; brain processing problem (basal ganglia) • Prevalence: decreases with age; 5-30 per 10,000 in childhood; 1-2 per 10,000 in adulthood • Gender: 2-5x as common for males • Onset: as early as 2 yrs; average age of onset is 6-7 yrs; typically develops by age 14 • Course: severity, frequency, and disruptiveness of sx diminish during adolescence & adulthood • Treatment: antipsychotics; antihypertensive medications; SSRI’s; self-monitoring; relaxation training; habit reversal

9. Attention Deficit/Hyperactivity Disorder • Includes two major syndromes: 1) Inattention 2) Hyperactivity-Impulsivity • Syndromes may occur independently or together, but usually some components of each are present. • Symptoms begin before age 7 • Symptoms cause some impairment in 2 or more settings.

10. Attention Deficit/Hyperactivity Disorder Inattention: 6+ of the following for 6+ months • Often fails to give close attention to details • Often makes careless mistakes in school, work, etc. • Often has difficulty sustaining attention • Often doesn’t seem to listen when spoken to directly • Often doesn’t follow instructions • Often fails to finish schoolwork, chores, or work duties • Has difficulty organizing tasks & activities • Avoids or dislikes tasks requiring sustained mental effort • Often loses things • Is easily distracted by extraneous stimuli • Is forgetful in daily activities

11. Attention Deficit/Hyperactivity Disorder Hyperactivity-Impulsivity 6+ of following for 6+ months Hyperactivity: • Fidgets with hands or feet; squirms in seat • Difficulty staying in seat • Excessive running, climbing, or restlessness • Difficulty playing or engaging in leisure activities quietly • Often “on the go;” acts as if “driven by a motor” • Often talks excessively Impulsivity: • Often blurts out statements • Impatient; difficulty awaiting turn • Often interrupts or intrudes on others

12. Attention Deficit/Hyperactivity Disorder • Subtypes: • AD/HD, Predominantly Inattentive Type • AD/HD, Predominantly Hyperactive-Impulsive Type • AD/HD, Combined Type • AD/HD, Not Otherwise Specified • Onset:3-4 years old • Age: 68% have ongoing sx in adulthood; inattentive subtype is more common in adolescents and adults • Gender: ratios of males to females range from 2:1 to 9:1; Combined and Hyperactive Subtypes are much more common in males than females • Prevalence: up to 3-7% of school-age children

13. ADHD: Associated Features • Academic deficits • School-related problems • Peer rejection • Low frustration tolerance • Tantrums • Poor self-esteem • Mood swings • Bossiness • Stubbornness • Accidents • Driving difficulties – speeding, accidents

14. ADHD: Diagnostic Considerations • Difficulty of distinguishing normal activity from hyperactivity and normal distractibility from attention deficit distractibility. • Need to evaluate behavior in terms of what’s normal for others of same gender, age, developmental level, cultural background. • Behaviors must occur in multiple settings. • Behaviors must cause clinically significant impairment. • Symptoms must have been present and caused impairment by age 7. • Combined and Hyperactive Subtypes are less likely to be missed.

15. ADHD: Contributing Factors • Genetics: increased incidence of ADHD & psychopathology in families & relatives • Prenatal factors: inadequate oxygen; drug exposure; maternal smoking • Neurotransmitters: inadequate availability of dopamine; NE, 5HT, GABA also implicated • Brain abnormalities: frontal cortex, basal ganglia, & cerebellar vermis are smaller • Exposure to toxins: allergens, food additives • Parenting: negative attempts to control their behavior; intrusive, over-bearing parenting

16. Attention Deficit/Hyperactivity Disorder Treatments: • Medication – stimulants, Strattera (SNRI), Wellbutrin • Psychoeducation & bibliotherapy • Skills-based training – time management, organizational skills, study skills, problem-solving, social skills

17. Conduct Disorder • Repetitive, persistent pattern of behavior in which the basic rights of others or major societal norms or rules are violated. • 3 or more of the following are present in the past 12 months, and at least one of the following is present in the past 6 months. • Aggression to people and animals • Destruction of property • Deceitfulness or theft • Serious violations of rules

18. Conduct Disorder • Aggression to People and Animals: • Bullying, threats, intimidation • Physical fights • Use of weapons • Physical cruelty to people • Physical cruelty to animals • Mugging, purse snatching, extortion, armed robbery • Forced sexual activity

19. Conduct Disorder 2) Destruction of Property: • Deliberate fire-setting • Deliberate destruction of others’ property 3) Deceitfulness or Theft • Breaking & entering • Lying; conning • Stealing; shoplifting; forgery 4) Serious Violations of Rules • Breaking curfew prior to age 13 • School truancy prior to age 13 • Running away from home

20. Conduct Disorder Subtypes: • Conduct Disorder, Childhood Onset – onset of at least 1 criterion prior to age 10 • Conduct Disorder, Adolescent Onset – absence of any criteria prior to 10 • Conduct Disorder, Unspecified Onset – age of onset is unknown Specifiers: • Mild – few, if any, conduct problems in excess of those required to make dx; cause only minor harm to others • Moderate – number of conduct problems and effect on others are in the intermediate range • Severe – many conduct problems in excess of those required to make dx; cause considerable harm to others

21. Conduct Disorder • Etiology: genetics; decreased arousal; low levels of 5HT; neurological deficits • Prevalence: 2-9% of nonclinical population; up to 1/3-1/2 of child mental health referrals; 87-91% of incarcerated juveniles • Gender Differences: mostly males • Onset: as early as preschool • Prognosis: poor; 2/3rds of cases develop into Antisocial Personality Disorder • Treatment: parent management training; community-based interventions (group homes, wilderness programs; therapeutic boarding schools); CBT (social skills, problem solving, cognitive restructuring)

22. Oppositional Defiant Disorder • Pattern of negativistic, hostile, and defiant behavior for at lease 6 months. • At least 4 of the following are present: • Often loses temper • Often argues with adults • Often actively defies or refuses to comply with adults’ requests or rules • Often deliberately annoys others • Often blames others for own mistakes or misbehavior • Is often touchy or easily annoyed by others • Is often angry or resentful • Is often spiteful or vindictive • Absence of behavior that violate the rights of others

23. Oppositional Defiant Disorder • Prevalence: 1-6% • Gender differences: more prevalent for males prior to puberty; ratio evens out after puberty • Prognosis: relatively persistent – some of the behaviors persist into adulthood, others are outgrown; higher divorce rate, employment difficulties, and drug/alcohol abuse for those with ODD • Causes: marital conflict; family discord; inconsistent parenting; overly lenient or rigid parent; coercive or aversive parent-child interactions; genetics • Treatment: parent training; family therapy; behavioral therapy (anger management, social skills training, problem solving, frustration tolerance); cognitive interventions to reduce negativity

24. Separation Anxiety Disorder At least 4 weeks of inappropriate or excessive anxiety about separation from home or major attachment figures, as evidenced by at least 3 of the following: • excessive anxiety regarding separation • excessive fears of losing major attachment figures • nightmares involving the theme of separation • refusal to go to school • refusal to be alone or without major attachment figures • refusal to sleep away from home or attachment figures • repeated physical complaints when separation occurs or is anticipated Onset prior to age 18

25. Pervasive Developmental Disorders Characterized by: • A broad-based impairment or a loss of functions expected for child’s age. • Includes 3 components: • Impairment in social interactions/relationships • Impairment in communication/language • Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities

26. Autistic Disorder • Abnormal functioning in at least one of the following areas, with onset prior to 3: • Social interaction • Language and communication • Symbolic, imaginative play • Qualitative impairment in social interaction and relationship development • Qualitative impairment in communication, language, and conversation skills • Restricted, repetitive, stereotyped patterns of behavior, interests, activities.

27. Autism • Mental retardation: 75-80%; 50% are profoundly or severely MR; 25% are moderately MR; 25% borderline to average IQ • Gender differences: higher IQ – more prevalent among males; IQ < 35 – more prevalent among females • Prevalence: 1 in 500 births • Onset: first apparent in infancy & toddlerhood • Course: chronic; life-long impairment; 50% never acquire speech • Causes: abnormalities in brain structure and function (5HT synthesis, cerebellum); genetics • Treatments: intensive behavioral Tx focusing on improving communication, social and daily living skills and reducing problem behaviors; early intervention programs; applied behavior analysis; parent training; mainstreaming for education; community interventions (supportive living arrangements & work settings)

28. Asperger’s Disorder • Qualitative impairment in social interaction and relationship development • Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities • But lack any clinically significant delay in language or cognitive development

29. Asperger’s Syndrome What you see: • Anxious, excessive desire for sameness • Preoccupation with stereotyped, repetitive activities • Obsess about objects • Limited interests • Can’t relate to others • Can’t read emotions • Can’t understand social cues • Social isolation, socially inept • Average IQ scores • Motor clumsiness • Poor coordination

30. Asperger’s Syndrome • Gender: up to 4x as common for males • Prevalence: up to 5x as common as Autism • Onset: later onset than Autism • Course: chronic, life-long • Etiology: genetics; brain abnormalities (limbic system, 5HT & D systems, right hemisphere)

31. Asperger’s Syndrome: Treatments • Behavioral treatments/skills building: interventions targeting problem behaviors, problem solving, social skills, communication skills, empathy-building, daily living skills • School-based interventions: mainstreaming; tutoring; special aides; multiple modalities for presenting information • Psychotherapy to address accompanying psychiatric disorders, such as depression and anxiety • Medications: antidepressants, antipsychotics