Transcript conduct disorder

Chapter 17
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Disorders Common Among Children
and Adolescents
• Abnormal functioning can occur at any time in
life
• Children of all cultures typically experience at
least some emotional and behavioral problems
as they encounter new people and situations
• Surveys indicate that worry is a common experience
• Bedwetting, nightmares, temper tantrums, and restlessness
are other problems experienced by many children
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Disorders of Childhood and Adolescence
Childhood and Adolescence
• Adolescence can also be a difficult period
• Bullying
– Over one-quarter of students report being bullied
frequently, and more than 70% report having been a
victim at least once
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– Physical and sexual changes, social and academic
pressures, personal doubts, and temptation cause
many teenagers to feel anxious, confused, and
depressed
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All victims of bullying are upset by
it, but some individuals seem to be
more traumatized by the
experience than others.
Why might this be so?
• Some disorders of children – childhood anxiety
disorders and childhood depression – have adult
counterparts
• Other childhood disorders – elimination
disorders, for example – usually disappear or
radically change form by adulthood
• There also are disorders that begin in birth or
childhood and persist in stable forms into adult
life
– These include autism spectrum disorder spectrum
disorder and intellectual developmental disorder
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Childhood and Adolescence
Separation Anxiety Disorder
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• Displayed by 4 to 10% of all children
• Extreme anxiety, often panic, whenever they are
separated from home or a parent
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Childhood Mood Problems: Major
Depressive Disorder
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• Around 2% of children and 9% of adolescents
currently experience major depressive disorder;
as many as 20 percent of adolescents
experience at least one depressive episode
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• Depression in the young may be triggered by
negative life events (particularly losses), major
changes, rejection, or ongoing abuse
• Childhood depression is characterized by such
symptoms as headaches, stomach pain,
irritability, and a disinterest in toys and games
• Clinical depression is much more common
among teenagers than among young children
– Suicidal thoughts and attempts are common in
teenagers
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Major Depressive Disorder
Bipolar Disorder
– Theorists suggest the diagnosis has become a clinical
“catchall” that is being applied to almost every explosive,
aggressive child
– The current shift in diagnoses has been accompanied by
an increase in the number of children who receive adult
medications
• The DSM-5 task force concluded that the childhood
bipolar label has been overapplied over the past two
decades. To help rectify this problem, DSM-5 now
includes a new category, disruptive mood
dysregulation disorder (DMDD)
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• Often considered an adult mood disorder, whose
earliest age of onset is the late teens
Oppositional Defiant Disorder
• Characterized by repeated arguments with adults, loss of
temper, anger, and resentment
• Children with this disorder ignore adult requests and
rules, try to annoy people, and blame others for their
mistakes and problems
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Oppositional defiant disorder: Children with this
disorder are repeatedly argumentative and defiant,
angry and irritable, and, in some cases, vindictive.
Conduct Disorder
– Often aggressive and may be physically cruel to
people and animals
– Many steal from, threaten, or harm their victims
– Begins between 7 and 15 years of age
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• Children with conduct disorder, a more severe
problem, repeatedly violate the basic rights of
others
Conduct Disorder
– Slander
– Rumor-starting
– Friendship manipulation
• More common among girls than boys
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• Relational aggression: individuals are socially
isolated and primarily display social misdeeds
• Many cases of conduct disorder have been
linked to genetic and biological factors, drug
abuse, poverty, traumatic events, and exposure
to violent peers or community violence
• They have most often been tied to troubled
parent-child relationships, inadequate parenting,
family conflict, marital conflict, and family
hostility
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What Are the Causes of Conduct Disorder?
• Treatments for conduct disorder are generally
most effective with children younger than 13
• Today's clinicians are increasingly combining
several approaches into a wide-ranging
treatment program
– Sociocultural treatments
– Child-focused treatments
– Prevention
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How Do Clinicians Treat Conduct Disorder?
Sociocultural Treatments
• Family interventions
– Parent-child interaction therapy
– Parent management training
– Community-based
• School programs
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• Residential treatment
Child-Focused Treatments
• Focus primarily on the child with conduct
disorder
• Cognitive-behavioral interventions
• modeling, practice, role-playing, and systematic rewards
– Anger Coping and Coping Power Program
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– Problem-solving skills training
Prevention
– These programs try to change unfavorable social
conditions before a conduct disorder is able to
develop
– All such approaches work best when they educate
and involve the family
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• Greatest hope for reducing the problem of
conduct disorder lies in prevention programs
that begin in early childhood
• Children with elimination disorders repeatedly
urinate or pass feces in their clothes, in bed, or
on the floor
• They have already reached an age at which they
are expected to control these bodily functions
– These symptoms are not caused by physical illness
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Elimination Disorders
Enuresis
• Typically occurs at night during sleep but may also
occur during the day
• The problem may be triggered by a stressful event
• Children must be at least 5 years of age to receive
this diagnosis
• Most cases of enuresis correct themselves without
treatment
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Enuresis: repeated involuntary (or in
some cases intentional) bedwetting or
wetting of one's clothes
Encopresis
•
•
•
•
Is usually involuntary
Seldom occurs during sleep
Starts after the age of 4
Is more common in boys than girls
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Encopresis– is less common than
enuresis and less well researched
Disorder
Usual Age of
Identification
Prevalence
Among All
Children
Gender with
Greater
Prevalence
Elevated Family
History
Recovery by
Adulthood
Separation anxiety
disorder
Before 12 years
4%–10%
Females
Yes
Usually
Conduct disorder
7–15 years
1%–10%
Males
Yes
Often
ADHD
Before 12 years
5%
Males
Yes
Often
Enuresis
5–8 years
5%
Males
Yes
Usually
Encopresis
After 4 years
1.5%–3%
Males
Unclear
Usually
Specific learning
disorders
6–9 years
5%
Males
Yes
Often
Autism spectrum
disorder
0–3 years
1.60%
Males
Yes
Sometimes
Intellectual
disability
Before 10 years
1%–3%
Males
Unclear
Sometimes
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Comparison of Childhood Disorders
Neurodevelopmental Disorders
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• Neurodevelopmental disorders are a group of
disabilities in the functioning of the brain that
emerge at birth or during very early childhood
and affect the individual’s behavior, memory,
concentration, and/or ability to learn.
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• Children who display attentiondeficit/hyperactivity disorder (ADHD) have great
difficulty attending to tasks, behave overactively
and impulsively, or both
• The primary symptoms of ADHD may feed into
one another, but in many cases one of the
symptoms stands out more than the other
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Attention-Deficit/Hyperactivity Disorder
Attention-Deficit/Hyperactivity Disorder
–
–
–
–
–
Learning or communication problems
Poor school performance
Difficulty interacting with other children
Misbehavior, often serious
Mood or anxiety problems
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• About half the children with ADHD also have:
What Are the Causes of ADHD?
– Biological causes, particularly abnormal dopamine
activity, and abnormalities in the frontal-striatal
regions of the brain
– High levels of stress
– Family dysfunctioning
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• Clinicians generally consider ADHD to have
several interacting causes, including:
How Is ADHD Treated?
– The most commonly applied approaches are drug
therapy, behavioral therapy, or a combination
– Millions of children and adults with ADHD are
currently treated with methylphenidate (Ritalin), a
stimulant drug that has been available for decades
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• About 80% of all children and adolescents with
ADHD receive treatment
• There is, however, heated disagreement about
the most effective treatment for ADHD
• Many with ADHD are treated with
methylphenidate (Ritalin), or other stimulant
drugs
• It is estimated that 2.2 million children in the US,
3% of all school children, take Ritalin or other
stimulant drugs for ADHD
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Drug Therapy
Behavior Therapy and Combination
Approaches
– Parents and teachers learn how to apply operant
conditioning techniques to change behavior
– These treatments have often been helpful, especially
when combined with drug therapy
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• Behavioral therapy has been applied in many
cases of ADHD
• Studies indicate that African American and
Hispanic American children with significant
attention and activity problems are less likely
than white American children to be assessed for
ADHD, receive an ADHD diagnosis, or undergo
treatment for the disorder
– Those who do receive a diagnosis are less likely than
white children to be treated with the interventions that
seem to be of most help, including the promising (but
more expensive) long-acting stimulant drugs
– In part, racial differences in diagnosis and treatment
are tied to economic factors
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Multicultural Factors and ADHD
Long-Term Disorders That Begin in
Childhood
– Autism spectrum disorders
– Intellectual developmental disorder
• Autism spectrum disorders are a group of
disorders marked by impaired social
interactions, unusual communications, and
inappropriate responses to stimuli in the
environment
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• Two groups of disorders that emerge during
childhood are likely to continue unchanged
throughout a person's life:
• Autism spectrum disorder, or autism, was first
identified in 1943
• Children with this disorder are extremely
unresponsive to others, uncommunicative,
repetitive, and rigid
• Symptoms appear early in life, before age 3
• Around 80% of all cases appear in boys
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Autism Spectrum Disorder
Autism Spectrum Disorder
• As many as 90% of children the disorder remain
significantly disabled into adulthood
• Lack of responsiveness and social reciprocity
• Language and communication problems take
various forms
– One common speech peculiarity is echolalia, the exact
echoing of phrases spoken by others
– Another is pronominal reversal, or confusion of pronouns
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– Even the highest-functioning adults with autism spectrum
disorder typically have problems in social interactions and
communication, and have restricted interests and activities
The DSM-5 task force determined that
Asperger’s Disorder is not a distinct
disorder. Those who would previously
receive a diagnosis of Asperger’s
should now receive a diagnosis of
autism spectrum disorder
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Autism Spectrum Disorder: Asperger's
Disorder
What Are the Causes of Autism Spectrum
Disorder?
• Some theorists say people with autism spectrum disorder have
a central perceptual or cognitive disturbance
• Individuals fail to develop a theory of mind – an awareness
that other people base their behaviors on their own beliefs,
intentions, and other mental states, not on information they
have no way of knowing
• It has been theorized that early biological problems prevented
proper cognitive development
Sociocultural causes
• Some clinical theorists have proposed that a high degree of
family dysfunction, social and environmental stress is a factor in
the disorder
• Research does not support this theory
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Psychological causes
What Are the Causes of Autism Spectrum
Disorder?
• While a detailed biological explanation for autism
spectrum disorder has not yet been developed,
promising leads have been uncovered
• Examination of relatives keeps suggesting a
genetic factor in the disorder
• Prevalence rates are higher among siblings
and highest among identical twins
• Researchers have also identified specific
biological abnormalities that may contribute to
the disorder, particularly in the cerebellum
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Biological causes
• Treatment can help people with autism spectrum
disorder adapt better to their environment,
although no known treatment totally reverses the
autistic pattern
• Treatments of particular help are cognitivebehavioral therapy, communication training,
parent training, and community integration
– In addition, psychotropic drugs and certain vitamins
have sometimes helped when combined with other
approaches
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How Do Clinicians and Educators Treat
Autism Spectrum Disorder?
How Do Clinicians and Educators Treat
Autism Spectrum Disorder?
• Behavioral approaches have been used in cases of autism
spectrum disorder to teach new, appropriate behaviors –
including speech, social skills, classroom skills, and self-help
skills – while reducing negative behaviors
• Most often, therapists use modeling and operant conditioning
• Therapies are ideally applied when they are started early in the
children's lives
• Given the recent increases in the prevalence of autism spectrum
disorder, many school districts are now trying to provide
education and training for autistic children in special classes
• Most school districts, however, remain ill equipped to meet the
profound needs of these students
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Cognitive-Behavioral therapy
How Do Clinicians and Educators Treat
Autism Spectrum Disorder?
• Even when given intensive behavioral treatment, half of
the people with autism spectrum disorder remain
speechless
• They are often taught other forms of communication,
including sign language and simultaneous
communication
• They may also use augmentative communication
systems, such as “communication boards” or
computers that use pictures, symbols, or written words,
to represent objects or needs
• Such programs also now use child-initiated interactions
to help improve communication skills
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Communication training
How Do Clinicians and Educators Treat
Autism Spectrum Disorder?
• Today's treatment programs involve parents
in a variety of ways
• For example, behavioral programs train
parents so they can apply behavioral
techniques at home
• In addition, individual therapy and support
groups are becoming more available to help
parents deal with their own emotions and
needs
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Parent training
How Do Clinicians and Educators Treat
Autism Spectrum Disorder?
• Many of today's school-based and home-based
programs for autism spectrum disorder teach
self-help and selfmanagement, as well as living,
social, and work skills
• In addition, greater numbers of group homes
and sheltered workshops are available for teens
and young adults with autism spectrum disorder
• These programs help individuals become a
part of their community and also reduce the
concerns of aging parents
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Community integration
Intellectual Developmental Disorder
– IQ must be 70 or lower
– The person must have difficulty in such areas as
communication, home living, self-direction, work, or
safety
• Symptoms must appear before age 18
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• According to the DSM-5, people should receive
a diagnosis of intellectual developmental
disorder when they display general intellectual
functioning that is well below average, in
combination with poor adaptive behavior
Assessing Intelligence
• Educators and clinicians administer intelligence
tests to measure intellectual functioning
• Having difficulty in one or two of these subtests or areas of
functioning does not necessarily reflect low intelligence
• An individual's overall test score, or intelligence quotient (IQ),
is thought to indicate general intellectual ability
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– These tests consist of a variety of questions and tasks
that rely on different aspects of intelligence
• Many theorists have questioned whether IQ tests
are indeed valid
• Intelligence tests also appear to be socioculturally
biased
• If IQ tests do not always measure intelligence
accurately and objectively, then the diagnosis of
intellectual developmental disorder may also be
biased
– That is, some people may receive the diagnosis partly
because of test inadequacies, cultural differences,
discomfort with the testing situation, or the bias of a tester
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Assessing Intelligence
• Diagnosticians cannot rely solely on a cutoff IQ
score of 70 to determine whether a person
suffers from intellectual developmental disorder
• Several scales, such as the Vineland and AAMR
Adaptive Behavior Scales, have been developed
to assess adaptive behavior
– For proper diagnosis, clinicians should observe the
functioning of each individual in his or her everyday
environment, taking both the person's background
and the community standards into account
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Assessing Adaptive Functioning
• The most consistent sign of intellectual
developmental disorder is that the person learns
very slowly
• Other areas of difficulty are attention, shortterm
memory, planning, and language
– Those who are institutionalized with intellectual
developmental disorder are particularly likely to have
these limitations
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What Are the Features of Intellectual
Developmental Disorder?
What Are the Features of Intellectual
Developmental Disorder?
–
–
–
–
Mild (IQ 50–70)
Moderate (IQ 35–49)
Severe (IQ 20–34)
Profound (IQ below 20)
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• Traditionally four levels of intellectual
development disorder have been distinguished:
Mild IDD
• Approximately 80% to 85% of all people with
intellectual developmental disorder fall into the
category of mild IDD (IQ 50–70)
• Research has linked mild intellectual
developmental disorder mainly to sociocultural
and psychological causes, particularly:
– Poor and unstimulating environments
– Inadequate parent-child interactions
– Insufficient early learning experiences
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– Interestingly, intellectual performance seems to
improve with age
Moderate, Severe, and Profound IDD
• Approximately 10% of persons with intellectual
developmental disorder function at a level of
moderate IDD (IQ 35–49)
• Approximately 3% to 4% of persons with
intellectual developmental disorder display
severe IDD (IQ 20–34)
– They usually require careful supervision and can
perform only basic work tasks
– They are rarely able to live independently
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– They can care for themselves, benefit from vocational
training, and can work in unskilled or semiskilled jobs
Moderate, Severe, and Profound IDD
• About 1% to 2% of persons with intellectual
developmental disorder fall into the category of
profound IDD (IQ below 20)
• Severe and profound levels of intellectual
developmental disorder often appear as part of
larger syndromes that include severe physical
handicaps
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– With training they may learn or improve basic skills
but they need a very structured environment
What Are the Causes of Intellectual
Developmental Disorder?
– Sometimes genetic factors are at the root of these
biological problems
• Other biological causes come from unfavorable conditions
that occur before, during, or after birth
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• The primary causes of moderate, severe, and
profound IDD are biological, although people
who function at these levels are also greatly
affected by their family and social environment
What Are the Causes of Intellectual
Developmental Disorder?
• The most common chromosomal disorder leading to
intellectual developmental disorder is Down syndrome
• Fewer than 1 of every 1000 live births result in Down
syndrome, but this rate increases greatly when the
mother's age is over 35
• Several types of chromosomal abnormalities may
cause Down syndrome, but the most common is
trisomy 21
• Fragile X syndrome is the second most common
chromosomal cause of intellectual developmental
disorder
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Chromosomal causes
What Are the Causes of Intellectual
Developmental Disorder?
• In metabolic disorders, the body's breakdown
or production of chemicals is disturbed
• The metabolic disorders that affect
intelligence and development are typically
caused by the pairing of two defective
recessive genes, one from each parent
• Examples include:
• Phenylketonuria (PKU)
• Tay-Sachs disease
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Metabolic causes
What Are the Causes of Intellectual
Developmental Disorder?
• As a fetus develops, major physical problems in the
pregnant mother can threaten the child's healthy
development
• Low iodine may lead to cretinism
• Alcohol use may lead to fetal alcohol syndrome (FAS)
• Certain maternal infections during pregnancy (e.g.,
rubella, syphilis) may cause childhood problems
including intellectual developmental disorder
• Birth complications, such as a prolonged period without
oxygen (anoxia), can also lead to intellectual
developmental disorder
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Prenatal and birth-related causes
What Are the Causes of Intellectual
Developmental Disorder?
• After birth, particularly up to age 6, certain injuries
and accidents can affect intellectual functioning
• Examples include poisoning, serious head injury,
excessive exposure to x-rays, and excessive
use of certain chemicals, minerals, and/or drugs
(e.g., lead paint)
• Certain infections, such as meningitis and
encephalitis, can lead to intellectual
developmental disorder if they are not
diagnosed and treated in time
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Childhood problems
Interventions for People with Intellectual
Developmental Disorder
– Intervention programs try to provide comfortable and
stimulating residences, social and economic
opportunities, and a proper education
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• The quality of life attained by people with
intellectual developmental disorder depends
largely on sociocultural factors
• Until recently, parents of children with intellectual
developmental disorder would send them to live
in public institutions – state schools – as early as
possible
• During the 1960s and 1970s, the public became
more aware of these conditions and, as part of
the broader deinstitutionalization movement,
demanded that many people be released from
these schools
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What is the Proper Residence?
What is the Proper Residence?
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• Since deinstitutionalization, reforms have led to
the creation of small institutions and other
community residences that teach selfsufficiency, devote more time to patient care,
and offer education and medical services
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Which Educational Programs Work Best?
– In special education, children with intellectual
developmental disorder are grouped together in a
separate, specially designed educational program
– Mainstreaming places them in regular classes
– Neither approach seems consistently superior
– Teacher preparedness is a factor that plays into decisions
about mainstreaming
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• Because early intervention seems to offer such
great promise, educational programs for individuals
with intellectual developmental disorder may begin
during the earliest years
• At issue are special education versus mainstream
classrooms
When Is Therapy Needed?
– Around 30% or more have a diagnosable
psychological disorder other than intellectual
developmental disorder
– Some suffer from low self-esteem, interpersonal
problems, and adjustment difficulties
• These problems are helped to some degree by
individual or group therapy
– Psychotropic medication is sometimes prescribed
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• People with intellectual developmental disorder
sometimes experience emotional and behavioral
problems
• People need to feel effective and competent to
move forward in life
• Those with intellectual developmental disorder
are most likely to achieve these feelings if their
communities allow them to grow and make many
of their own choices
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How Can Opportunities For Personal,
Social, And Occupational Growth Be
Increased?
• Socializing, sex, and marriage are difficult issues
for people with intellectual developmental
disorder and their families
• With proper training and practice, individuals
with intellectual developmental disorder can
learn to use contraceptives and carry out
responsible family planning
– The National Association for Retarded Citizens offers
guidance in these matters
– Some clinicians have developed dating skills
programs
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How Can Opportunities For Personal,
Social, And Occupational Growth Be
Increased?
How Can Opportunities For Personal,
Social, And Occupational Growth Be
Increased?
– Many can work in sheltered workshops, but there are
too few training programs available
– Additional programs are needed so that more people
with intellectual developmental disorder may achieve
their full potential, as workers and as human beings
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• Adults with intellectual developmental disorder
need the financial security and personal
satisfaction that comes from holding a job