Transcript Disorders First Apparent in Childhood

Disorders First
Apparent in Childhood
Why “first apparent”?

May continue into adulthood
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May lead to other adult disorders
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May impact development
Disorders
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Attention Deficit Hyperactivity Disorder
Learning Disorders
Autism & Asperger’s Disorder
Mental Retardation (Axis II)
Conduct Disorder & Oppositional Defiant
Disorder
Symptoms of Inattention
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Inattention:
 lack of focus on
detail & careless
mistakes
 difficulty with
sustained attn
 not listening when
spoken to
 fails to follow
through on tasks
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organizational
problems
dislikes sustained
effort
easily distracted
forgetful in daily
activities
Symptoms of Hyperactivity
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Hyperactivity/Impulsivity
 Fidgets or squirms in
seat
 Leaves seat when it is
inappropriate
 Runs or climbs
excessively
 Difficulty playing
quietly
 Is often “on the go” or
acts as if “driven by a
motor”
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Talks excessively
Blurts out answers
before questions are
finished
Difficulty waiting for
his/her turn
Disrupts or interrupts
others
ADHD
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Symptoms are usually
evident before schoolage, but more relevant in
that setting
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Require more than one
setting
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6% of school-age
children (drops with age)
Associated Problems
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Significant social impairments
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Academic problems
Comorbidities with ADHD
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mood disorders
learning disorders
substance use
APD
neurological problems
physical accidents and injury
What Happens When they
Grow Up?
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Impulsivity decreases,
inattention does not
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Accidents, etc
Adults may self-select
environments that
result in less
noticeable symptoms
68% have attention
problems in adulthood
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Only 30% of children
retain the diagnosis in
adolescence, and
10% in young
adulthood
25% do not finish
school
1/5 develop APD w/
high levels of crime
What Causes ADHD?
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Large genetic component
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Subtle brain differences
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Smaller brain volume
Association with maternal smoking
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2-3 times more likely
What Causes ADHD?
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Higher rates of family general
psychopathology
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Inability to inhibit behavior
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Executive functioning deficit (goals, planning)
What Causes ADHD?
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Is the real problem our regimented modern
classrooms?
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Decreased time for active play
Change in environment penalizes students who
would be normal under different circumstances
Little evidence of brain abnormalities
ADHD looks like extreme playfulness
Function well outside the classroom (no control)
Does Diet Affect ADHD?
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Some argue that
dietary additives
affect/cause ADHD
(e.g., food coloring)
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Parents place children
on special diets
Evidence indicates
that NO, diet is not
responsible for
ADHD
How do we treat ADHD?
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Stimulant medications
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Increase arousal and help focus attention
Short half-life
Stimulants do affect growth hormones and
can suppress appetite
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Many children take only during school hours
Drug “holidays” are recommended
Use the lowest therapeutic dose
Multiple Approach to ADHD
School
Home
Child
How do we treat ADHD?
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Behavioral Therapy for Children
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Improve socialization skills
Reinforce and reward improved behavior until the
environment is rewarding alone
Main techniques
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Progressive muscle relaxation
Contingency plans
Cognitive therapy to increase awareness
How do we treat ADHD?
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Behavioral Therapy for Parents
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Parents are trained in behavior management,
contingency management
Reduce family stress
Psychoeducation can reduce family blame
Best treatment is meds + therapy
Meds are often necessary for severe cases
Sample Changes
Home
 Reward plans
 Shorter lists of tasks
 Timers
 Reorganization of living
space
School
 Seating plans
 Folders for parents
 Reduced distractions for
exams
 Shortened HW
assignments
Learning Disorders
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Deficits in reading, math, or written
expression
Child’s achievement level is below what
would be predicted based upon their ability
level
Learning Disorders
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Diagnosis based on
comparison of those tests, in
those specific domains only
5% of American students
have a learning disorder
Reading is most common
Consequences of Learning
Disorders
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Many drop out of school (32%)
Low employment rates (60-70%)
Self-esteem problems
Causes of Learning Disorders
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Genetic basis
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Almost 100% concordance between identical
twins
Neurological differences
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E.g., in sound recognition
Treating Learning Disorders
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Remediate processing of problems
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Improve cognitive skills
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Listening, comprehension, memory
Target behavioral skills to compensate
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Visual and auditory perception skills
Extended time for tasks
Early diagnosis = better prognosis
Pervasive Developmental
Disorders: Autism
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Disruptions in
social interaction
Impaired
communication
skills
Restricted
behavior, interests
and activities
Disruptions in social
interaction
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Lack of joint attention
Lack of interaction with
parents or other
children
Lack of attention to
social cues
Supported by eye
tracking research
Impaired communication skills
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50% of patients do not acquire useful speech
Unusual communication
Echolalia (repeating of words/phrases)
Inability to understand irony, sarcasm,
pretend play
Restricted behavior, interests
and activities
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Restricted, repetitive, stereotyped
behavior, interests, activities
 Abnormal in intensity/focus
 E.g. dates, phone numbers
 Lining up objects
 Inflexible patterns, routines, rituals
 Preoccupation with parts of interest
Symptoms of Autism
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Apparent by age 3
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20% report normal
1-2 years of
development,
followed by
regression or lack
of milestones
Associated Features and
Disorders
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Hyperactivity, short attention span,
impulsivity, aggressiveness
Self-injurious behavior & temper tantrums
Odd responses to sensory stimuli (e.g. high
threshold for pain, sensitive to sound, touch,
light)
Abnormal affect or fear reaction
Asperger’s Disorder
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Mild autism
No significant delays in early language
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Other language may be “odd” and preoccupied
with certain topics
No delay in cognition or self-help skills,
adaptive behavior, curiosity about
environment
Little concern in infancy, may seem
precocious
Usually noticed after entrance to school
Prevalence & Course of
Autism
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1 in every 166 births
4:1 boys to girls
Some improve at school
Some improve during adolescence, but
others deteriorate
IQ & functional language predictors of
prognosis
Causes of Autism: Genetic
Contributions
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Strongest genetic component
Early studies thought not genetic
But, hard to study:
1 in 240,000 possible twin studies (1000 in
US)
Autistic adults unlikely to have children
Autistic children have less siblings
Twin Studies Solve the
Mystery:
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Heritability index = .90 (risk)
Genetically heterogeneous
Unable to isolate genes
Some evidence for viral infections during
pregnancy
Causes of Autism
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Few think psychological or social influences
play a role in the onset
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Psychologists (and other professionals) can
assist with management of disorder
Behavioral Treatments for
Autism
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Decrease undesirable behavior & shape
desirable
Positive reinforcement & extinction
Social punishment
Families are important
Language + social skills = improved
prognosis
Alternative Treatments for
Autism
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Vitamins
Other medications
Diet
Auditory Integration Training
Facilitated Communication
What are “Alternative”
Treatments?
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Scientifically
unverified
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Randomized
control studies
Replication
Large samples
What’s so bad about
alternative treatments?
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They give parents false hope
They can violate patient rights
Can allow others to control decisions “made
by” patients
In some cases, have led to abuse allegations
Facilitated Communication
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Provide assistance for communicating
Alphabet board, computer, typewriter, etc
Support hand/arm
May isolate fingers
Requires extensive training
Claims:
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Produces (“frees”)
unexpected literacy
Shows
normal/superior
intelligence
Provides a means to
communicate (for
those who have no
means, but otherwise
would)
What does the research say?
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Facilitators unintentionally influence
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May even actively influence
Many well-designed studies:
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Single- and double-blind
Repeated measures
Participant as control
The Best Type of Treatment…
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Structured educational programs geared to
the person’s developmental level of
functioning
It is, however, important to be openminded
Majority of other treatments not scientifically
proven
Be educated
Consider the individual child
Do a thorough assessment and reevaluate
Behavioral Disorders
Conduct Disorder
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General pattern of
disrespect for others
Violation of norms
Includes criminal
activity
Oppositional Defiant
Disorder
 Pattern of
negative,
hostile, defiant
behaviors
Symptoms of Conduct
Disorder
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Disrespect for rights of others + violation of
rules/norms
Bullies, threatens, intimidates others
Initiates physical fights, uses weapons
Physically cruel to people and/or animals
Stolen while confronting a victim
Forced sexual activity
Symptoms of Conduct
Disorder
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Deliberately sets fires w/ intention of doing
damage or destroys property in other ways
Broken into someone’s house/building/car
Lies to obtain goods or avoid responsibility
Stolen costly items without confronting victim
Stays out at night before age 13
Has run away, overnight, >2 times
Is truant from school prior to age 13
Conduct Disorder
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Children also have poor interpersonal skills
Often experience peer rejection
Seem to have problem-solving deficits
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Do not generate as many options as non-CD
children
Inability to take another’s perspective
Interpret ambiguous gestures as hostile
Oppositional Defiant Disorder
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Pattern of negative, hostile, defiant behaviors
Arguing for the sake of arguing, hostility
toward parents/teachers
Usually begins at home (which can impede
diagnosis)
May develop into later conduct disorder
Typically emerge by age 8, est. 5-10%
prevalence
What Causes Conduct
Disorders?
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Neurological differences
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Temperament
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Poor coordination, fine motor skills
Usually have significantly lower IQ than peers
Easily distressed, reactive to change, react to
intense stimuli (more likely behavior problems)
Family Links
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Parent with APD increases chances of CD
Criminal and/or alcoholic parents
Family history of aggression
What Causes Conduct
Disorders?
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Family Links cont..
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Poor maternal mental health, prenatal health
Poor supervision
Spousal aggression
Lax, erratic and inconsistent parenting/discipline
Less acceptance, warmth, affection, support
Reinforce CD behavior, ignore/reward other
(coercive process)
Child-parent interactions are also
bidirectional
The Coercive Process
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Jimmy’s parents tell him to go to bed
Jimmy refuses: “I want to play 1 more video game!”
Parent says “No! Its late and you have school.”
Jimmy gets upset, hitting table, screaming “Just one
more game. You’re mean - you never let me have
fun!”
Parent feels guilty at having spent little time together,
and is too tired after work to argue - says “Okay, 1
more game”
Jimmy stops screaming and plays his game
Parent, relieved fight is over, goes to kitchen. Does
not monitor or play with child
The Coercive Process
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Jimmy is rewarded for screaming
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Reward for screaming = increased
probability of screaming in future
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Parent is rewarded for giving in
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Parents likelihood of giving in is increased
Conduct Disorder & APD
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A minority of CD children develop Antisocial
Personality Disorder
Treatment for conduct disorder is of interest,
as preventing APD would reduce associated
financial and criminal costs to society
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Remember, APD is untreatable!
Treating CD and ODD
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Problem-Solving Skills
Parent Management Training
Family Therapy
School & Community Based Treatments
Problem-Solving Skills
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Children tend to have
poor problem-solving &
interpret
intentions/actions as
hostile
Combines modeling,
role-playing, and
reinforcement
contingencies to
increase problemsolving and prosocial
behavior
Parent Training & Family
Therapy
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Break cycle of coercive process
Promote prosocial behavior in child
Apply proper discipline techniques by parent
Increase reciprocity & positive reinforcement
between family members
Parent Training and Family
Therapy
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Outcomes positive (reduce arrest, increase
school performance, family relationships)
Most families may be unwilling/able to
participate
School & Community Based
Treatments
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Target children at school (easier)
Often has more attendance than individual
therapy
Available to all children (universal
intervention)
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Increased likelihood of reaching those who need it
Minimizes stigma
Offers opportunity to interact with other children
Cognitive Disorders Dementia
Dementia
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Gradual deterioration of brain function
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Affects judgment, memory, language, other
executive functions
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Some are reversible
Others are degenerative and eventually fatal
Emotional changes are common
Kinds of Dementia (DSM)
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Alzheimer’s Disease
Vascular Dementia
Dementia due to HIV, Head Trauma,
Parkinson’s, Huntington’s
Pick’s Disease
Creutzfeldt-Jakob Disease
Substance Abuse
Other Causes of Dementia
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Drugs & alcohol
Nutritional deficits
Brain tumors
Thyroid Problems
Neurosyphilis
Korsakoff’s Disease
Alzheimer’s Disease
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Most develop during old age
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Prevalence for < 65 = 1%, 90+ = 22%
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Higher rates, as people are living longer
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Annual Cost = $112 billion US
Associated Symptoms of
Alzheimer’s
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Impaired memory, orientation, judgement,
reasoning
Inability to integrate/learn new information
Forget events, lose objects
Decreased interest in nonroutine activities
Increasing depression, agitation, aggression
with disease progession
Symptoms & Course
Mild
memory &
attention
Language
problems
Forgetting
appts,
directions,
names
Loss of
ability to
do basic
tasks
Personality
changes
Increased Speed of Disease Progression
Loss of
function,
death
Global Deterioration Scale
(Reisberg et al., 1982)
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No cognitive/functional impairment
Mild forgetfulness, some work problems
Mild concentration problems, some problems
working/travelling alone
Increased problems in planning, finances, denial of
symptoms & withdrawal
Poor recall of recent events. Reminders needed
Daily Living Assistance, Personality Changes
Loss of verbal abilities, incontinence, walking,
coma
Normal Aging vs. Possible AD
(Hooyma & Kiyak, 2002)
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Forgetting to set alarm
clock
Forgetting a name &
remembering later
Having to search for
keys b/c forgot location
Forgetting where your
car is
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Forgetting how to set alarm
clock
Forgetting a name & never
remembering it even when
told
Forgetting places you might
find keys
Forgetting how you arrived
at a location
Intellectual Functioning and
Alzheimer’s
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Less formal education = increased risk
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“mental reserve”
Cognitive reserve hypothesis
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More synapses an individual requires, the more
neuronal death required before dementia is obvious
Causes of Dementia
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Proximal causes
Distal Causes
Biological Causes
Psychological & Social Influences
Neurofibrillary Tangles &
Amyloid Plaques
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Normal, but excessive
Proximal Causes - Senile
Plaques
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Protein deposits
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Also normal, but excessive
Unclear why, or how this impacts
Both overrepresented in hippocampus &
parts of cerebral cortex = thought process
What are Distal Causes?
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Genes (esp. early onset)
Estrogen can be protective
Down syndrome = virtually guaranteed
Alzheimer’s by 40
Education & Cognitive Ability
Protecting with Cognitive
Ability
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2x more likely in people with < 8th gr.
Education
Friedland et al. 2000 - 193 AD vs. 358
Control
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Control elderly more likely intellectual & physical
noneducational past-times in middle years
Greatest effect for intellectual past-times
Regardless of education, gender, current age
Assessment of Alzheimer’s
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Medical evaluation
Neuropsychological Tests
Observations
Interviews
Self-reports
How do we definitively
diagnose Alzheimer’s?
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Rule out other possible diagnoses
Autopsy following patient death
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Tangles
Plaques
Dementia is a very heterogeneous disorder
Dementia & Pseudodementia
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Depression most common psychopathology
in old age
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Est. 20% for elderly community sample (Hooyman &
Kiyak)
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10-15% for institutionalized elderly sample
Older adults often have “masked depression”
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Does not express/denies mood changes
Reports somatic complaints
Complains of problem solving/memory problems
Medical Treatment for
Dementia
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Medication enhancing cognitive ability
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Initial effect (to 6 months earlier)
No long-term improvement over placebo
Prevent breakdown of acetylcholine
Decline continues
Loss of gain if medication is quit
$250/month
Psychosocial Treatments for
Dementia
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Compensation for lost abilities
Memory wallets
Cues and reminders