Chapter 13

1. Chapter 13 Childhood Disorders

2. Externalizing vs. Internalizing • Externalizing disorders • Disorders that include behaviors that are aggressive or disruptive. • E.g., ADD/ADHD, Conduct disorder, oppositional defiant disorder, Tic disorders • Internalizing disorders • Disorders that stem from an underlying anxiety or depression. • E.g., Separation anxiety disorder, reactive attachment disorder, other anxiety and mood disorders not unique to children • These disorders are often overlooked.

3. Separation Anxiety Disorder • Children can be diagnosed with OCD, GAD, panic disorder, PTSD, depression, etc. • However, separation anxiety disorder is specific to childhood. • Marked by the display of heightened anxiety and distress in the child when that child is separated from caregivers. • May stem from a slow development of object permanence.

4. Separation Anxiety Disorder • Excessive distress when separated from home or caregivers or when anticipating separation. • Persistent and excessive worry about losing, or harm coming to, caregivers. • Persistent reluctance or refusal to go to school or elsewhere because of fear of separation. • Excessive fear of being alone. • Reluctance to go to sleep without caregivers nearby. • Repeated nightmares involving themes of separation. • Repeated complaints of physical symptoms when separation occurs or is anticipated.

5. Separation Anxiety Disorder • Often develops after the child experiences some major life stress (parental separation, divorce). • More likely to be seen in children coming from families that are caring and close-knit (that don’t promote independence). • Problems in attachment during the first two years of life (e.g., insecure attachment). • Anxious-inhibited temperament • Behavioral treatments very effective for this disorder.

6. Reactive Attachment Disorder • The child must exhibit a disturbed and developmentally inappropriate pattern of social relating in most situations before the age of 5. • Meets one of the following: • Failure to initiate or respond in a developmentally appropriate way to most social interactions, as shown by inhibited, overly vigilant, or highly ambivalent and contradictory responses (inhibited type) • Indiscriminate sociability, with noticeable inability to show appropriate selective attachment (e.g., excessive familiarity with strangers) (disinhibited type)

7. Reactive Attachment Disorder • Behaviors stem from a child’s reaction to pathological care from a caregiver (e.g., childhood abuse, neglect) • Child must also have experienced: • Persistent disregard of basic emotional needs for comfort, stimulation, and affection • Persistent disregard of basic physical needs • Repeated changes of primary caregiver that prevent formation of stable attachments

8. Elimination Disorders Enuresis • Wetting of the bed or clothes at least twice a week for three months. • Most often occurs at night. • Quite common (15 to 20% of 5 year-olds)

10. Enuresis • May have its root in anxiety or an inability to express fears and need for attention. • Bell and pad method most effective treatment

11. Encopresis • Repeated defecation into clothing or onto the floor. • Rarer than enuresis (fewer than 1 % and more common in boys). • Underlying cause is not directly clear, although may stem from episodes of severe constipation. • May also be rooted in anxiety. • In severe cases, you may see fecal build-up or hardening or even leakage of fecal material.

12. Pervasive Development Disorders • Characterized by severe and lasting impairment in several areas of development, including social interactions, communication with others, everyday behaviors, interests, and activities. • Autism is the most common • Others include Asperger’s syndrome, Rett’s disorder, and childhood disintegrative disorder.

13. Autism • Deficits in social interaction • Little use of nonverbal behaviors that indicate a connection • Failure to develop peer relationships • Little expression of pleasure when others are happy • Little reciprocity in social interactions • Deficits in communication • Delay in, or total absence of, spoken language • In those who do speak, trouble initiating and maintaining conversations. • Lack of make-believe play or imitation of others

14. Autism • Deficits in activities and interests • Pre-occupation with certain activities or toys; compulsive adherence to routines and rituals. • Stereotyped and repetitive movements, such as head banging. • Preoccupation with parts of objects and unusual uses of objects. • Preference for sameness, routine, and lack of social contact may be due to an attempt to control exposure to overstimulation.

15. Autism • Effects 2 to 5 people, on average, in every 10,000. • About 75% of individuals with autism are also mentally retarded and most require lifelong care. • The rate of autism is four to five times higher in boys than in girls. • Girls more likely to exhibit severe mental retardation.

16. Theories • Two deficits that may be central to autism are in theory of mind and executive functions. • Theory of mind • The ability to infer the mental states of others (e.g., their intentions, beliefs, and desires) and to engage in abstract or symbolic thinking. • Executive functions • The cognitive operations (e.g., planning, inhibition of response, flexibility, and working memory) that are thought to be driven by the prefrontal cortex.

17. Treatment • To be successful, interventions must be intensive (at least 15 hours per week) and last six months or more. • Behavioral training • Shaping • Prompting • Discrimination training (learning when to make a response and when a response is not appropriate) • SSRI’s (improves some behavioral symptoms of autism)

18. Asperger’s Syndrome • Milder form of Autism. • Characterized by autism-like deficits in social interaction and in activities and interests. • No delays in language. • In the first three years of life, children with Asperger’s show normal exploratory behavior (that is often absent in children with autism).

19. Asperger’s Syndrome • Difficulties with interpersonal relationships. • Display unusual obsessive-like behaviors (e.g., memorizing, counting). • Usually average intelligence although sometimes display extraordinary cognitive abilities. • Formal in speech. • “Little professor syndrome.”

20. Conduct Disorder • Chronic pattern of unconcern for the rights of others. • 3 to 7% of children. • Boys more often diagnosed with the disorder (3X more likely). • Associated with the later development of Antisocial Personality Disorder, as well as criminality and violent behavior.

21. Conduct Disorder • Bullies, threatens, or intimidates others. • Initiates physical fights. • Uses weapons in fights. • Engages in theft and burglary. • Is physically abusive to people and animals. • Forces others into sexual activity. • Lies and breaks promises often. • Violates parents’ rules. • Runs away from home. • Sets fires deliberately. • Vandalizes • Skips school often.

22. Oppositional Defiant Disorder • Less severe than conduct disorder. • Symptoms • Often loses temper • Often argues with adults • Refuses to comply with requests or rules • Tries to annoy others • Blames others for his/her mistakes • Easily annoyed • Angry and resentful • Spiteful or vindictive • Onset is earlier than conduct disorder. • May develop in to conduct disorder.

23. Theories • Temperament of impulsivity • Genetics • Exposure to neurotoxins and drugs in the womb (may result in poor neurodevelopment which manifests itself through poor impulse control). • Low cortisol • High serotonin • Higher levels of testosterone (dependent upon a context of social deviance)

24. Social Factors • Family environment marked by abuse, neglect, substance use, psychopathology • Poor parenting • Maladaptive cognitive processing (biased towards interpreting interactions as being aggressive) • Maladaptive behavior reinforced by peer group or parents • Modeling