Transcript Developmental and Cognitive Disorders

Developmental and
Cognitive Disorders
Chapter 13
What are developmental
disorders?
Disorders that usually first appear in
childhood or adolescence (onset)
 Note: most of these conditions persist
into adulthood

ICA disorders
Intellectual & Cognitve impairment
-all MR
-all LD
Motor Function impairment
all motor skills d/o
all tic d/o
stereotypic movement d/o
Disruptive or self injurious behavior
all adhd & disruptive d/o
feeding & eating d/o
all elimnation d/o, seperation anxiety
Information exchange
all pervasive d/o
all communication d/o
selective mutism
ICA D/O

As you answer the questions below, you
will be better able to choose between
the four categories introduced earlier.
1. Is the predominant sx an impairment of
learning or intellectual function?
 2. Is the predominant sx abnormal motor
activity?
 3. Is the predominant sx socially
inappropriate or self injurious behavior?
 4. Is the predominant sx an impairment in
the ability to communicate or exchange
meaningful information?

Perspectives on
Developmental Disorders

Normal vs. Abnormal Development

Developmental Psychopathology

Study of how disorders arise and
change with time

Childhood is associated with significant
developmental changes

Disruption of early skills will likely
disrupt development of later skills
Outline
Common developmental disorders
(ADHD & Learning Disorders)
 Pervasive Developmental disorders
(autism)
 Mental Retardation
 Cognitive Disorders (dementia)

Attention Deficit Hyperactivity
Disorder (ADHD): An Overview

Nature of ADHD
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Central features – Inattention, overactivity, and
impulsivity
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Difficulty w sustained attn (can’t finish games, watch
TV)
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Constant motion, fidgeting
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Blurt out answers, act without thinking
Associated with behavioral, cognitive, social,
and academic problems
Attention Deficit Hyperactivity
Disorder (ADHD): An Overview

DSM-IV and DSM-IV-TR Symptom
Clusters

Cluster 1 – Symptoms of inattention
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Cluster 2 – Symptoms of hyperactivity
and impulsivity cluster
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Either cluster 1 or 2 must be present for
a diagnosis
ADHD: Facts and Statistics

Prevalence
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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


Impulsive component decreases over time
Gender Differences
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Boys outnumber girls 4 to 1
ADHD: Overdiagnosis?

Cultural Factors

Probability of ADHD diagnosis is
greatest in the United States

Studies show more school-aged kids on
stimulants than prevalence of Dx

College-aged people often present for
assessment when academic problems
emerge
ADHD: Biological
Contributions
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Genetic Contributions
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ADHD runs in families

Some studies suggest High heritability
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Familial ADHD may involve deficits on
chromosome 20

The D4 receptor gene is more common
in ADHD children (dopamine
dysregulation?)
ADHD: Biological
Contributions

Neurobiological Contributions: Brain
Dysfunction and Damage

Used to be called “minimal brain
dysfunction”

Inactivity of the frontal cortex and basal
ganglia

Right hemisphere malfunction
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Abnormal frontal lobe development and
functioning

Yet to identify a precise neurobiological
mechanism for ADHD
ADHD: Biological
Contributions

The Role of Toxins

Allergens and food additives do not
appear to cause ADHD

Maternal smoking increases risk of
having a child with ADHD
ADHD: Psychosocial
Contributions

Psychosocial Factors appear to
Influence (not cause) the Disorder
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Constant negative feedback from
teachers, parents, and peers
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Peer rejection and resulting social
isolation
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Such factors foster low self-image
Biological Treatment of ADHD
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Goal of Biological Treatments

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To reduce impulsivity/hyperactivity and to
improve attention
Stimulant Medications
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Reduce the core symptoms of ADHD in 70% of
cases
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Examples include Ritalin, Dexedrine, Cylert
Other Medications

Imipramine and Clonidine (antihypertensive)
have some efficacy
Biological Treatment of ADHD

Effects of Medications

Improve compliance and decrease negative
behaviors in many children

Not clear that academic performance or social
skills are improved in the long-term

Beneficial effects are not lasting following
drug discontinuation

Negative side effects include insomnia,
drowsiness, and irritability
Behavioral and Combined
Treatment of ADHD

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Behavioral Treatment
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Involve reinforcement programs

Aim to increase appropriate behaviors and
decrease inappropriate behaviors
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May also involve parent training
Combined Bio-Psycho-Social Treatments
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Are highly recommended - it appears however
that long-term psychosocial Tx is necessary to
maintain gains
Learning Disorders
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Scope of Learning Disorders
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Problems related to academic performance in
reading, mathematics, and writing

Performance is substantially below what would
be expected (IQ - Ach discrepancy)
DSM-IV and DSM-IV-TR Reading,
Mathematics, Written Expression
Disorders

Performance is at a level significantly below
that of a typical person of the same age
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Problem cannot be caused by sensory deficits
(e.g., poor vision)
Learning Disorders: Some
Facts and Statistics

Incidence and Prevalence of Learning
Disorders
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1% to 3% incidence of learning disorders in the United States
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Prevalence is highest in wealthier regions of the United States
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Prevalence rate is 10% to 15% among school age children

Reading difficulties are the most common of the learning
disorders

School experience for such persons tends to be quite negative

About 32% of students with learning disabilities drop out of
school
Half of school children classified as
disabled have learning disabilities.
Twenty years ago the proportion was
50% lower
Figur
e 13.1
Biological and Psychosocial
Causes of Learning Disorders
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Genetic and Neurobiological
Contributions
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Reading disorder runs in families, with 100%
concordance rate for identical twins
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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
Treatment of Learning
Disorders
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Medications not typically used

Requires Intense Educational
Interventions


Remediation of basic processing problems
(e.g., teaching visual skills)
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Efforts to improve of cognitive skills (e.g.,
instruction in listening)
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Targeting behavioral skills to compensate for
problem areas
Data Support Behavioral Educational
Interventions for Learning Disorders
Pervasive Developmental
Disorders

PDD is an umbrella term
 severe and pervasive impairments in
several areas of development: reciprocal
social interaction skills, communication
skills, presence of stereotyped behavior,
interests, and activities
 Symptoms are on a continuum
 5 PDD’s: autistic disorder, Asperger’s
disorder, Rett’s disorder, Childhood
Disintegrative Disorder, PDD/NOS
(distinctions among these not particularly clear)
Autistic Disorder
Approximately 10 cases per 10,000
individuals
 More common in males (4-5:1)
 Impairment in Social Interactions
 Impairment in Communication
 Restricted, Repetitive and
Stereotyped Behaviors, Interests,
and Activities
 Onset of delays prior to age 3 years
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Autistic Disorder (cont.)
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Qualitative Impairment in Social
Interaction (needs at least 2)
marked impairment in the use of
nonverbal behaviors
Failure to develop peer relationships
appropriate to developmental level
A lack of spontaneous seeking to share
enjoyment, interests, or achievements
lack of social or emotional reciprocity
Autistic Disorder (cont.)

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Qualitative impairment in Communication
(needs a lest one)
delay or total lack of development of
spoken language (no compensation)
marked impairment in the ability to initiate
or sustain a conversation with others in
individuals that can speak
stereotyped and repetitive use of language
or idiosyncratic language
lack of carried , spontaneous makebelieve play or social imitative play
appropriate to developmental level.
Autistic Disorder (cont.)



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Restricted, Repetitive and Stereotyped
Behaviors, Interests, and Activities
(needs at least one)
encompassing preoccupation with one
or more stereotyped and restricted
patterns of interest that is abnormal
either in intensity or focus
apparently inflexible adherence to
specific, nonfunctional routines or
rituals
stereotyped mannerisms
persistent preoccupation with parts of
objects
Other issues related to autism
Sensory issues (e.g., high threshold
for pain, oversensitivity to sounds,
fascination with touch or smell)
 Abnormalities in mood and affect
 Feeding issues (limited diet, pica)
 Behavior difficulties (SIB, Tantrums,
short attention span, hyperactivity,
sleep problems)
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Phenomenology of Autism
20/20 Video
 What is it like to be autistic?

Autism and Intellectual
Functioning
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75% of individuals have mental retardation

50% have IQs in the severe-to-profound range
of mental retardation
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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
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Better language skills and IQ test performance
predicts better lifetime prognosis
Etiology of Autism
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Psychosocial Contributions Are Unclear

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
Asperger’s Disorder
Qualitative impairment in social
interaction
 Restrictive Repetitive and
stereotyped patterns of behavior,
interest, and activities
 Disturbance causes clinically
significant impairment
 no clinically significant general delay
in language
 no clinically significant delay in
cognitive or adaptive functioning
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Rett’s
Disorder
 Only reported in females
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Apparent normal pre and perinatal
development
Normal head circumference at birth
Deceleration of head growth between 5 and
48 months
Loss of hand skills between 5 and 30 months
with development of stereotyped hand
movement, loss of social engagement, poorly
coordinated gait or trunk movements,
severely impaired expressive and receptive
language development with severe
psychomotor retardation
Severe or Profound MR
Applied Behavior Analysis
Breaks down autism into separate behavioral
problems and attempts to treat as many of
these problems as possible.
 By far the most well documented treatment
approach with hundreds of studies on
behavioral treatment for children with autism.
 Goal is remediation (recovery) from the
disorder to the point that children are
indistinguishable from their peers.
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UCLA Young Autism Project (Lovaas)
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Intensive one-on-one training for app. 40 hours a
week.
 Training prg carried out in homes, school,
community
 commences at age no older than 46 months
 1st phase, focuses on teaching compliance,
simple imitation, appropriate play, suppress selfstimulation and non-compliant behavior
 2nd phase teaching expressive skills, early
abstract language, social play with peers
 Third phase teaching expression of emotions,
functional academics and more complex
cognitive abilities (e.g., cause-to-effect
relationships)
UCLA Young Autism Project - study design
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Initial 2 year treatment
N = 59 children
3 groups:
(a) Experimental group (N=19) - 40 hours a week
of treatment for 2 years
Control group # 1 (N=19) - 10 hours of treatment
for 2 years on average
Control group #2 (N=21) - No treatment provided
by UCLA
Blind Evaluations pre & post treatment
UCLA Young Autism Project
pre-treatment
Exp Group
Treatment:
40 hrs/week
Pre Treatment Measures:
Age at Dx
32 months
Age @ Beg. trt
35 months
IQ
53
Control Group # 1
10 hrs/week
34 months
40 months
46
UCLA Young Autism Project
pre-treatment
Exp Gr
(N=19)
Mute
58%
Reject Adults
63%
Not Toilet Trained 68%
Gross Inattention 89%
Tantrums
89%
Absent Toy Play
53%
Self Stimulation 95%
Absent Peer Play 100%
Control Group # 1
(N=19)
47%
42%
63%
74%
79%
63%
89%
100%
UCLA Young Autism Project- Results
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Blind evaluation: pre treatment & 2 years later (Age 6-7)
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Experimental Group Results:
 ** Average IQ Gain = 20 points
 ** 9/19 (47%) Completed first grade in regular class
 ** IQ Gain for these 9 subjects = 37 points
 8/19 (42%) Continued in a learning disabled class
 2/19 (11%) Severe MR / autistic classroom
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Control Group Results:
Group # 1
Group # 2
 IQ
no significant changes
 Completed first grade in regular class:
0/19 ( 0%)
1/21 (5%)
 Continued in a learning disabled class: 8/19 (42%)
10/21 (48%)
 Continued in a Severe MR Class:
11/19 (58%)
10/21 (48%)
UCLA Young Autism Project- Results
1993 Follow Up Study Results

Blind Evaluations of the 9 children in the “Best
Outcome” Group
 Age at follow up evaluation - 13 years old.
 IQ gains remained.
 Normal functioning on tests of:
 emotional functioning;
 social functioning;
 intellectual functioning.
 8/9 (88%) Remained in typical classrooms.
 1/9 was in an LD classroom.
Autism - Pharmacotherapy
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No known effective medications
Mental Retardation
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Nature of Mental Retardation
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Disorder of childhood
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Below-average intellectual and adaptive functioning
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Range of impairment varies greatly across persons
Mental Retardation and the DSM-IV and DSM-IV-TR
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Significantly subaverage intellectual functioning (IQ
below 70 - about 2-3% of the population)
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Concurrent deficits or impairments two or more areas of
adaptive functioning
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MR must be evident before the person is 18 years of age
Levels of MR
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Mild MR
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Moderate MR
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Includes persons in the IQ range of 35-40 to
50-55
Severe MR
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
Includes persons with an IQ score between 50
or 55 and 70 (often can lead independent lives)
Includes people with IQs ranging from 20-25
up to 35-40
Profound MR

Includes people with IQ scores below 20-25
(typically require complete assistance)
Other Classification Systems
for Mental Retardation (MR)
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
American Association of Mental Retardation
(AAMR)

Defines MR based on levels of assistance required

Examples of levels include intermittent, limited,
extensive, or pervasive assistance

Not that widely adopted
Classification of MR in Educational Systems

Based on whether person is “Educable”
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Stigmatizing system
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
Mental Retardation (MR):
Psychosocial Contributions

Cultural-Familial Retardation

Believed to cause about 75% of MR cases and
is the least understood

Believed to result from combination of
biological (low IQ) and social factors

Neglect, abuse, poor nutrition

Associated with mild levels of retardation on
IQ tests and good adaptive skills

Lower end of distribution but probably distinct
etiology from those w clear organic causes
Mental Retardation (MR):
Biological Contributions
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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
Specific genetic syndromes
associated with MR
 Down
Syndrome
 Fragile X syndrome
Down Syndrome
Down Syndrome

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
Most common chromosomal form of MR
Prevalence: about 1 out of every 700 live
births
As many of 75% of trisomy 21 result in
miscarriages or stillbirths.
The older the mother, the higher the (p)
of DS (e.g., Maternal age of 20 = 1 in
2000; 35 = 1 in 500; 45 = 1 in 18)
Theory - ova (eggs) produced in youth
are exposed to toxins, radiation damaged
Down Syndrome (cont.)

Health issues: Congenital heart defects
(50), hearing loss (66-89), ophthalmic
conditions (60), endocrine conditions
(e.g., hypothyroidism) (50-90), obesity
(50-60), dental problems (60-100),
seizure disorders (6-13), high risk of
Alzheimer's disease.
Down Syndrome (cont.)
 Adaptive
behavior: In general
children with DS show higher AB
levels than intelligence
 Personality: Sociable and
pleasant.
 Dual DX: Less often and less
severe maladaptive behavior and
psychopathology
Fragile X Syndrome
Fragile X syndrome
Most common known inherited form
of MR
 Prevalence = 1 in 4000 males and at
least half that in females.
 The marker was an X chromosome
with a small, pinched-off piece of
genetic material
 Mothers often have learning
disabilities

Fragile X syndrome (cont.)

Physical features: 80% of post pubertal
boys and men with this disorder have
enlarged testicules (about twice the size).
 Other physical features: long narrow face
and prominent ears, flat feet, hyper
extensible finger joints, soft skin
 Features become more pronounced with
age and are subtle in childhood
 Few significant medical problems are
associated with fragile X (seizures in
about 20%)
Fragile X syndrome (cont.)

IQ levels vary from moderate levels of MR
to the average range of functioning (varies
with genetic status, gender, and age)
 In general, females are less impaired than
males
 Many males seem to show declines in their
IQ scores over time.
Treatment of MR

For mild MR, tx is similar to that for learning
disabilities
 For more severe MR, treatment is similar to
that for PDD
 Goals include communication, social
development, independent living and job
skills
 People with MR often Benefit from Such
Interventions