Conduct Disorders
Conduct problems—age-inappropriate actions and attitudes of a child that
violate family expectations, societal norms, and the personal or property
rights of others
 Context—most kids do this stuff (some of it) sometimes
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80% of teens have tried alcohol
60% have tried cigarettes
50% have tried marijuana
Most of these beh appear and then decline
50% of parents of preschoolers report that they lie, steal, disobey, destroy
property—but 10% of parents of young adolescents
Aggression is pretty stable over time ---.7 –same as IQ
Social and economic costs
– About 5% of kids, but these kids are responsible for about 50% of all crime and
30-50% of clinic referrals
– More teens die from firearms than all diseases combined
– Figure 6.2—cost of one lost youth—drop out due to life of crime—about $2
Million
Oppositional Defiant Disorder
Defiant, oppositional, hostile, negative beh for at least 6 mos
 Must be beyond what is expected for age and gender
 At least 4 of
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Loses temper
Argues with adults
Blames others
Angry or resentful
Actively defies reasonable requests
Deliberately annoys
Touchy or irritable
Spiteful or vindictive
Can’t be comorbid with CD
Prevalence 2-16% of kids
– Higher rates in adopted kids (20%), especially those with preadoption abuse or
neglect
– More common in boys before puberty, = after, probably because boys move to
CD
– Low SES more at risk, 75% of clinic referred preschoolers are low income
Conduct Disorder
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At least 3 of 15
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Initiates physical fights
Bullies, threatens, intimidates
Stealing
Fire setting
B&E
Runs away overnight
Physically cruel to animals
Physically cruel to people
Sexual coercion
Destruction of property
Lies frequently
Truant
Two Types of CD

Childhood onset (life course persistent)
– More severe, more likely to persist into adulthood, more likely to
begin with early problems in infant temperament and with early
troubles in parent-child relationships

Adolescent onset or limited
– More likely to be associated with troubled peers; may go until
20s
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Other important distinctions:
– Socialized/unsocialized
– Degree of callous-unemotional traits—lack of guilt or remorse—
low empathy
– Lack of behavioral inhibition—this subtype has more freq contact
with police, stronger parental hx of ADHD
Associated Characteristics
Oppositional attitudes toward parents,
teachers, authority figures
 Academic problems—early dropout, failing
classes
 Peer rejection
 Substance use
 Early, risky sexual behavior
 Increased risk for ADHD

Cognitive, Verbal and Academic
Deficits in CD

8 pts lower on IQ tests (15 pts lower in childhood onset)
– Performance > verbal
Children with both verbal impairments and family
adversity have 4x as much aggression as kids with only
one of these
 School and learning problems—increased levels of
special education, retention, dropout, suspension,
expulsion
 Underachievement in language and reading, but this
goes away when we control for ADHD

Self-Esteem and Peer Relationships

Self-esteem
– Inflated, unstable, tentative view of self
– Overestimate acceptance by other kids

Peer problems
– Social rejection in elementary school is a strong risk factor for
adolescent conduct problems
– Able to make friends by often like-minded antisocial friends
– Deviant peers—strong predictor of substance use, delinquent
behavior, violence (group tx may be damaging---deviancy
training)
– Overestimate amount of aggression directed at them (hostile
attributional bias)
– Underestimate their own aggression and its negative impact
CD and ODD

Much debate over whether these are separate or
not
– ODD emerges 2-3 yrs earlier than CD (6 vs 9)
– But most don’t progress to CD
 About 25% move to CD
 About 25% sx remit and no longer have ODD
 About 50% hold at ODD

Possible that CD criteria aren’t sensitive enough
for younger kids—same requirement for number
of sx, but fewer opportunities
CD and APD
40-50% dev APD as adults
 APD may also show psychopathy—callous,
manipulative, deceitful, remorseless
 Less is known about psychopathy in kids,
but some 3-5 yo have been found to have
a lack of conscience

Family Problems in CD
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Among the strongest and most consistent correlates of antisocial
behavior
2 types—
– General family disruptions—parental psychopathology, family hx of ASB,
marital discord, limited resources, antisocial family values
– Specific disturbances in parenting practices and family functioning—
harsh discipline, lack of supervision, lack of emotional support and
involvement, parental disagreement about discipline
– These 2 are interrelated
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High levels of conflict—common
Poor parenting practices—ineffective discipline, negative control,
inappropriate punish and reward, lack of involvement and child
rearing
Parents may show similar social-cognitive deficits
Especially high levels of conflict in CD kids and their sibs
Health Related Problems

Premature death (before 30) is 3-4x
higher in boys with CPs
– Homicide, suicide, accidental poisoning, traffic
accident, overdose
Associated with early onset and
persistence of risky sex behavior
 Associated with illicit drug use
 Commit more than 50% of all felony
assaults and thefts
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Prevalence of CD
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1-4 million in North America
1-10-26% (6-16% boys, 2-9% girls)
Boys: more confrontational, aggressive beh
Girls: more nonconfrontational—running away, skipping
school, abusing substances—onset is also later—gender
diff is evident by age 4
– Gender diff is much greater (10:1) for chronic rather than
transient (2:1)
– Gender diff has decreased over past 50 yrs by more than 50%
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More prevalent in low SES
40-50% will grow up to have APD—fairly stable over
time
35-75% of clinic referrals
Comorbidity

50-90% also meet criteria for ADHD
– Why the overlap?—common underlying factor such as impulsivity, poor
self-regulation, temperament may lead to both
– ADHD may be a catalyst for CD—contributes to persistence and
escalation
– ADHD may lead to childhood onset CD
– But—2 distinct disorders—ADHD is more likely to be associated with
cognitive impairment, neurodevelopmental abnormalities, increased
accidental injuries, increased inattention in class
– Both are worse than either alone

Internalizing disorders common in girls
– 1/3 meet criteria for depression or anxiety
– Most girls with CD will develop depression or anxiety by early adulthood
– More severe ASB, more severe mood/anxiety dis
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CD is also a risk factor for suicide
Substance abuse—common
Course of the Disorder
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Begins with difficult temperament
Aggression in kindergarten predicts years later
– Earlier and later aggression--.6 to .9 corr—comparable to IQ
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Tends to decrease gradually—less severe before more severe;
diversification of behavior over time
More stability over time (& a progression from ODDCDAPD) is
assoc with
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Parental hx of APD or criminal involvement
Problematic family environments
Low ses
Early onset
Severe aggression
Comorbidity with ADHD
Low IQ
High #s and large variability in conduct problems
Adult Outcome
By early 20s, # of active offenders decreases by
1/2. By late 20s, 85% of former offenders have
stopped
 But-coercive interpersonal styles, family, health,
and work difficulties may persist
 LCP (childhood onset)—as adults
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Lower skill attainment—erratic work hx
Difficulty getting along with coworkers
More violent marriages
Increased rates of divorce
More likely to select partners with similar
backgrounds
Causes of CD
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Multiple causes that operate in a transactional way
Genetic influences—
– More minor physical anomalies and allergies—like ADHD
– CPs are not inherited, but difficulty temperament, hyperactivityimpulsivity, lack of fear in the face of danger are
– Multiple studies have shown a link between temperament and
externalizing problems
– Age 3—restless, impulsive, risk-taking, emotionally labileincr
ASB in adolescence
– Adoption and twin studies—about 50% inherited
 LCP pattern—2x genetic risk of AL pattern
– Aggressive—more heritable than non-aggressive in childhood but
genes and environ are = in adolescent onset
Biological Pathways
Temperament, impulsivity, insensitivity to punishment, etc. can create
antisocial propensity
– Such factors may increase likelihood that a child will be exposed to
other risk factors-divorce, maltreatment, etc.
– Genotype may moderate sensitivity to environment
 Prenatal and birth complications
– Malnutrition
– Lead poisoning
– Mother’s use of marijuana, alcohol, nicotine
 Neurobiological factors
– Gray 1987—two subsystems of the brain, each with its own region and
neurotransmitters
– BAS-stimulates beh in response to reward or nonpunishment
– BIS-produces fear and inhibits ongoing beh
– Proposed that CD kids have overactive BAS, underactive BIS
– Early onset—decreased cortical arousal, low autonomic reactivity—may
lead to fearless, stimulus seeking temperament—may lead to lack of
necessary anticipatory fear
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Family Factors in CD
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Lots of factors implicated, nature of causal role is still debated
Family difficulties are more related to CD than ODD and more to LCP than
AL
Reciprocal influence—child’s beh both influences and is influenced by the
beh of others
Coercion theory—Gerald Patterson—parent-child interactions set stage for
ASB
– Reinforcement trap
Attachment theories
Increased stress is assoc with – beh in the home
Poverty is a strong predictor of CD and high rates of crime
–
Costello et al
Amplifier hypothesis—stress amplifies the maladaptive predispositions of
the parents, disrupting their family management and ability to be
supportive
 Parent criminality and psychopathology
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Societal Factors
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Neighborhood and school—increased rates in poor neighborhoods
with criminal subculture. Antisocial people select neighborhoods
with those like them—social selection hypothesis.
Poor schools increase risk, positive schools decrease risk
Media
– By grade 6—have seen 8000 murders on tv and 100,000acts of violence
– Can be short term precipitating factor and a long term predisposing
factor
– Wingood et al 2003—hip hop videos
– Huesmann et al 2003—tracked 329 adults originally studied in late
1970s at age 6-9
– Appears causal, debate persists

Cultural factors—rates vary widely around the world
Treatment and Prevention
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Restrictive approaches—residential tx, inpatient tx, incarceration
– Expensive and not terribly effective.
– Deviancy training.
Boot camps, wilderness programs, etc.
– Also not effective
Office-based individual tx is cheap, but not effective
So what works?
– Two-pronged approach
– Ongoing interventions for older youth and parents
– Early intervention/prevention for young kids just starting out
Parent management training—
– Teaches parents to change beh at home—specific new skills
– Can be individual or group, clinic or home
– Minimal or no intervention of therapist with child
– Parents learn to promote + beh, decrease ASB
– Sessions cover use of commands, rule setting, praise, tangible rewards,
use of mild punishment, etc.
– Need to address parents’ beliefs about why beh is occurring
Treatment and Prevention II
Problem-Solving Social Skills training
– Focus on cognitive deficiencies and distortions
– Steps to solve problems
 Multisystemic Treatment (MST)
– Family and community based—work with parents, schools, peers,
juvenile justice staff, etc
– Uses PMT, PSST, marital tx, spec ed if necessary, etc
– Long term benefits, which make it cost effective
 Prevention
– Easier to prevent than to treat
– More cost effective
– Webster-Stratton—2-8 yo or at risk for CPs
 Teaches child management skills
 Personal self-control strategies for parents
 Teachers taught to improve relationships with students, to teach
social skills, improve anger management
 Effective for 2/3 of kids whose parents are involved
 Other programs exist that work with the kids themselves

Anxiety Disorders
JPSP Dec 2000—two meta-analyses
Trait anxiety—both studies—1 of 40,192 college students
and the other of 12,056 kids aged 9-17—found evidence
of large increase in anxiety levels such that normal
children today report more anxiety than child psychiatric
pts in 1950s.
 Anxiety disorders general characteristics
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Presence of anxiety
Unacceptability of sx to the sufferer
Relative intactness of reality testing
Sx do not actively violate social norms
Approx ½ of adult sx originate before age 15
Anxiety disorders in childhood increase risk of later problems
Separation Anxiety Disorder
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Characterized by extreme, developmentally inappropriate worry that
child will get hurt or caregiver will get hurt if not with child
Somatic complaints are common
Considered abnormal only when it occurs after the normal period
Common after stress
Onset is often sudden
Progresses from mild to severe
More common in girls or = depending on the study
School avoidance in ¾
1/3 meet criteria for depression
Course is variable—from spontaneous remission to chronic
Chronicity assoc with later onset, psychopathology in the family,
and comorbidity
Prevalence about 4-10%
Peak onset between 7 and 9; age of referral 10-11
School Refusal
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AKA school phobia—no actual dx
Can be part of other disorders; not the same as SAD
17/1000 kids
Not truants
Big difference—refusers want to be home with parents
Somatic sx disappear within an hour of being allowed to stay home
Unrelated to IQ
Huge secondary gains from being allowed to stay home
Berg—3 yr follow-up—1/3 little improved, 1/3 quite a bit. 1/3 remitted
– ½ were still unable to go to school some of the time
In HS may be prodromal sign of schizophrenia
Ok in non-school settings
Older onset than SAD
More males
 Tx—warmly but firmly send kid to school
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Generalized Anxiety Disorder
Formerly overanxious disorder of childhood
Excessive and uncontrollable anxiety and worry about
many events or activities on most days
 Apprehensive expectation
 Worry about everything; future
 95% worry all the time
 Seems to be chronic
 3-6% prevalence (some estimates as high as 19%)
 = in boys and girls; more common in girls in
adolescence and adulthood
 Average onset 10-14
 Sx diminish with age
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Fears and Phobias
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Fear—normal reaction to an environmental threat
Most research is on fears
1935—Jersid & Holmes—kids age 2-6 had between 2 and 4 fears
Parents report fewer fears in kids than kids do
Most fears are transient and disappear in 3 mos
Most research shows more fears in girls than boys, but it may be more acceptable for
girls to report them
Both # and intensity of fears decline with age
Morris and Kratchowill (89)—ages of fears
Toddler—separation, animals, dark
Preschool—strangers, toddler fears, bodily harm
School age—being alone, imaginary beings, violence, death, dark, injury,
storms, peer teasing
Teens—peer rejection, achievement, family problems, global issues
Starting in childhood and declining—doctors, injections, darkness, strangers
Declining slowly—specific animals, heights, storms, enclosed spaces
Some fears persist into adulthood—crowds, death, injury, illness
Specific Phobias
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Marked and persistent fear of a specific situation or object that is excessive
and unreasonable
Inappropriate for age
Almost immediate anxiety response when exposed
Adults and adolescents must acknowledge that fear is unreasonable but this
criterion doesn’t hold for kids
Subtypes
Prevalence—2-4% (2.5% of kids, 3.5% adolescents) in general population
meet criteria, but few are referred for tx—parents my not view these as
harmful to dev
Not a lot of conclusive data on gender diff—some are more common in girls
(blood)
Most common comorbid dx is another anxiety dx, but comorbidity rates are
somewhat lower for phobias than for other dx
Age of onset—typically begin 7-9 for animals, blood, darkness, injury
Likely to decline with age, though less so than other fears
Stable for about 5-15% of kids
Peak 10-13
Social Phobia
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Marked fear of acting in an embarrassing or humiliating way
Occurs when exposed to unfamiliar people or to scrutiny by others
Must be demonstrated that kids actually have social skills
Cannot occur just with adults
Many social phobics meet criteria for depression (20%) or other anxiety
disorders
Hard to distinguish from GAD
Common fears—public speaking, taking tests, performing in front of others,
having a test returned, writing on the board, reading a report out loud,
being called on in class
Not as many negative cognitions in kids
Occurs in 1-3 % of kids, increases with age (self-conscious teens)—most
often dev after puberty. Rare under 10
May be overlooked because shyness is common and these kids don’t call
attention to themselves
Average onset 11-12
Girls>boys
Selective Mutism
Formerly known as elective mutism
 When children fail to speak in 1 or more situations when
they can speak in other situations
 Typical—speaks home but not at school or away from
home
 High anxiety—not oppositional
 Shy!
 90% meet criteria for social phobia
 .5% of kids
 > in younger kids
 > in girls
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Obsessive-Compulsive Disorder
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Obsessions vs. compulsions
Prevalence by adolescence is about 1%, <1% under 10 yo. Some
estimates are 2-3%,
Many try to keep it a secret
Gender is about =, but boys > before puberty, girls>after
Onset 9-12—two peaks—early childhood and early adolescence
20-30% have first degree relatives with sx
½-1/3 have comorbid dx
Likely to be chronic—up to 50% may continue to have problems
into adulthood
Washing, repeating, and checking are the most common rituals
Fear of contamination and concerns about hurting oneself or a
family member are most common obsessions
Some kids with OCD may be starting a psychosis
Panic
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Sudden, overwhelming period of intense fear or
discomfort
10-30 min or a few hrs
Extremely rare in young kids
3-4% of teens have panic attacks
Panic disorder is less common
Females>males
½ of those with PD have no other dx.
Onset 15-19
95% are postpubertal
Post-Traumatic Stress Disorder
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3.7% boys, 6.3% girls 12-17
75% comorbid depression or substance abuse
Maybe 30-40% of those exposed to trauma
Often see them replaying what happened
Intense distress—may be clingy
Hallucinations or flashbacks
Distancing, social withdrawal
Regress or stop developmentally
Restricted affect, hypervigilance
May occur after kids become able to cog understand what happened
More likely if child is immediately present
Subjective experience of threat
More severe if parents are compromised and unable to offer help
May be chronic, relapse and remit, or improve
All Anxiety Disorders
No relation to IQ
 Selectively attend to potentially threatening info
 Cognitive errors in interpretation
 Comorbidity is quite common—most common
between two anxiety disorders or mood
disorders

– E.g., 30-50% of those with SAD also meet criteria for
depression

Disorder in childhood increases risk for problems
in adulthood
Theories and Causes

Genetic—family and twin studies indicate bio vulnerability, but link
isn’t to specific disorders.
– Perhaps 1/3 of variance
– Heritability may be greater for girls than boys.

Bio/neurobio—Abnormalities (larger volume) in brain regions assoc
with social info processing and fear conditioning
– Amygdala and superior temporal gyrus in GAD
– PTSD-overactive behavior inhibition system.

Family functioning
– Parenting practices or rejection, overcontrol, overprotection, modeling
of anxious beh
– Overinvolved, instrusive, or limiting of independence
– Expectations that child will be upset
– Insecure attachment may be a risk
Theories and Causes

Behavioral models
– Classical conditioning of Little Albert
– Two-factor theory—phobia is put in place
initially by classical conditioning and
maintained by operant conditioning
– Social learning theory
Treatment
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Behavior tx
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–
–
–
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Exposure—75% of kids with anx are helped by this
Graded exposure
Flooding
Response prevention
CBT-skills training
– Improvement in 71%

Meds—typically in combo with CBT or when CBT
has failed
– If severe, kids may need meds first
– OCD-results positive, but results are inconsistent in
other disorders
Mood Disorders

Historical views
– Through the 1960s, analysts believed that kids
couldn’t show depression because their personality
structure was too
– Anaclitic depression-1940s-term for infants who lost
primary caregiver or whose caregiver was abusive
 Related concept—failure to thrive—Bowlby
– Masked depression—late 60s-early 70s
 Any negative behavior was a sign of child warding off
feelings of depression
 Problem: very hard to put into practice—highly inferential—
but other disorders like aggression are highly comorbid.
 Masked is a misnomer—if someone looked at these kids,
depression could be found
Problems in Using Adult Criteria
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Developmental research that shows little depression in children and
higher rates in adolescence
Change in sex ratio at puberty
Cognitive diff
– Ability to feel shame doesn’t emerge until around 7 or 8
– Young kids don’t understand guilt/failure
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Problems in the ability to report sx
Children have more somatic complaints, SAD, phobias,
hallucinations, psychomotor agitation
Adolescents—helpless/hopeless, anhedonia, hypersomnia, drugs and
alcohol
In depressed kids—depressed appearance, low s-e, somatic
complaints decrease with age
Somatic complaints and social withdrawal so common in children
that some propose including them as criteria in this age group
Major Depressive Disorder
More than just feeling blue
Can be a single episode or recurrent
 Prevalence rates—2-8% of children and adolescents at
any one time--<1% in preschool, 2% in school age
 10-50% of kids in in or outpatient facilities experience
MDD
 Increases with age.
 Before puberty, = between boys and girls or boys
greater
 After puberty, girls>boys 2:1
 Why the gender diff? Girls are more likely to ruminate.
In girls, negative cognitions are more salient.
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Comorbidity
Depression is often found in kids who meet
criteria for other dx
 Anxiety—one study found 75% comorbidity of
anxiety in kids with depression

– Especially high in girls
One study found that 97% of adolescents with
depression met criteria for another dx
 Commonly: SAD, CD, ODD, social phobia,
substance use

Course of the Disorder
Preschoolers—more likely to be irritated and
have somatic sx than dysphoria or hopelessness
 Older kids—more sleep problems, decreased
self-esteem, hopelessness, report of depressed
mood
 Average length of episode—16-36 weeks
 Recovery is high, but so is relapse.

– One study showed recurrence of MDD in 54% after 3
yrs.
– Different study—69% in 2 yrs. 25% in one yr, 70%
in 5 yrs
Etiology

Bio influences
– Genetic—children of depressed parents are more likely to be
depressed, even if raised by nondepressed adoptive parents
– MZ twins have higher concordance than DZ or sibs
– Rutter et al 1999—estimates that 50% of variance in
development of depression is due to genetics
– Some differences in hormones and neurotransmitters may also
play a role

Cognitive-behavioral perspective
– Like adults, show maladaptive cogs—internal, global, stable
attributions for – events
– Coyne 1976—interpersonal theory—individuals who seek
excessive reassurance tend to be rejected by others. This is
linked to increased feelings of depression
Etiology II
Family environment and functioning
– Less supportiveness, more conflict
– Higher levels of critical EE
– Also high rates of loss among kids referred for tx
– Maternal depression—kids are at increased risk of depression
 Depression in mothers is related to other psychological problems
and to interpersonal problems.
 Assortative mating
 Tiffany Field 1992—children of depressed moms already have a
depressive mood style by 8 mos that carries over to other adults.
 In preschool—kids of depressed moms exhibit more negative
behaviors
 Related to lower self-esteem in 8 yo
 Maternal depression is most strongly related in middle childhood
and before—then declines in importance
 Why?
 Peers—neglected or rejected kids show increased rates of depression.

Treatment and Prevention

Treatment—
– No standard tx for all
– Medication—evidence is not as compelling as for adults
– Several studies have not shown that SSRIs or tricyclics work
better than placebo. Two are approved.
– Rate was increasing before suicide ideation scare. Trend unclear
now.
– Tx that focus on cognitive-behavioral techniques work well
– Family tx—effective at reducing conflict

Prevention
– Social-problem solving
– Improving parenting skills
– Improving coping skills
Dysthymic Disorder
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Inability to experience joy
Must last at least one year
1-5% prevalence
Average length—3.9 years
Double depression—70% will have depressive
episode
Not much research
Lasts longer in kids with comorbid dx
Onset around 11 or 12
Bipolar Disorder
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Rare in young kids
20% with bipolar have onset in adolescence-age 15-19
Prevalence of .4-1.2% in older adolescents
Recovery and relapse are high
63% of adolescents with bipolar have one first
degree relative with dx
Often misdiagnosed as schizophrenia or ADHD
Stimulants can worse bipolar
20% are comorbid with CD or ODD
Suicide
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2,000-2,500 adolescents per year
3rd leading cause of death in 15-24 after
accidents and homicide
6-10% of adolescents report attempting suicide
Rate tripled from 1957 (4.0/100,000) to 1977
(13.3/100,000). Has leveled off around
13.0/100,000.
Rates for whites have always been higher than
for other groups—but is increasing for African
Americans, Hispanics, Native Americans
Males outnumber females 5:1
Suicide






70% occur in the home
Most common method for males and females:
firearms and explosives. 2nd—males—hanging;
females—drugs.
Suicidal adolescents with access to guns are 75x
more likely to kill themselves than suicidal
adolescents with no guns
Not all suicides are depression related
Overall—79-96% met criteria for something
Rare but increasing in children and
preadolescents
Suicide Attempters





Rate of attempts to completion 10:1
Most important variable is hopelessness
Deficit in interpersonal problem solving
Feelings preceding attempt: anger, feeling lonely and unwanted, worried about the
future, sorry and ashamed, hopeless
Adolinks 1987—reasons given
–
–
–
–
–
–

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Relief from intolerable state of mind, escape from an impossible situation
Making people see how desperate they were
Making people sorry for the way they’ve been treated/getting back at someone
Trying to get someone to change his/her mind
Showing someone how much he/she cared seeing if someone really cared
Seeking help
Only ½ said they wanted to die. 40% said that they didn’t care if they lived or died
Little premeditation
Many cases—done where it would be discovered
Majority improve in a month
1/3 subsequently experience major difficulties—increased psych and phys dis etc
1/10 will repeat the attempt
Suicide Completers


High intention, high lethality
Drug and alcohol abuse in15-33%
– Intent increases after use
70% exhibit some antisocial behavior from
shoplifting to prostitution
 Primary risk factor—impulsivity—only ¼-1/3
show evidence of planning. Other risk factors—
low frustration tolerance, alienation, imitation,
poor family relationships with little affection
 83% of completers told someone the week
before

Risk Factors for Suicide



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

Clinical disorders
Personality/interpersonal factors like hopelessness,
impulsivity
Prior attempt
Family factors like abuse
Stressful life events
Exposure to suicide
Access to lethal methods
Primary medical factors-chronic illness, pregnancy, STD
Suicidal plan
Prevention of Suicide



Suicide hotlines—rates of suicide are lower in towns with them than
without them, but svc is used most by white
Primary prevention programs—
Focus on education in schools
– Raise awareness
– Train participants to be on the lookout for signs
– Educate about community resources and referral process

Mixed results
– May impart information, but many are ineffective, even disturbing
– One study found that suicidal students found the program upsetting—
not reassuring and helpful

Need programs that
–
–
–
–
Decrease risk factors
Improve family support and functioning
Decrease avail of guns
Such programs would help other areas of teens’ lives as well
Intellectual Disability

Assessing intelligence
–
–
–
–





Began about 1900—Binet and Simon dev test for France
Decided to measure judgment and reasoning
Became Stanford-Binet when Terman brought it to US
Other tests of general intellectual functioning—WISC-IV, Kaufman Assessment Battery for
Children (KABC)
Controversial IQ—innate and fixed vs environmentally based
No correlation between first years and later IQ
–
By age 4, r = .77 with age 12
–
–
Need to renorm every 15-20 yrs
Why? –standards of living, improved nutrition, complex toys, better schooling, improved
medicine
At lower levels, IQ is even more stable at young ages
Flynn effect—adding about 3 pts per decade since 1940s
Bias in IQ tests?
–
–
–
Average for African Americans is about 15 pts below whites
Likely due to economic and social inequality
Differential has been decreasing since 1980
DSM-IV Criteria
A) Significantly subaverage intellectual
functioning
 B) Concurrent deficits or impairments in
adaptive functioning in at least 2 areas:
communication, self-care, home living,
social/interpersonal, use of community
resources, self-direction, functional academic
skills, work, leisure, health and safety
 C) Onset before 18

American Association on
Intellectual and Developmental
Disabilities
Original definition was just abnormal
intelligence, but in 1959 AAMR added
adaptive behavior as a criterion
 1992 revision of the definition goes
beyond this to require scrutiny of the
environment
 New definition changes the name to
Intellectual Disability

AAIDD Definition





Intellectual disability is a disability characterized by significant
limitations both in intellectual functioning and in adaptive behavior,
which covers many everyday social and practical skills
Intellectual functioning
Adaptive behavior
– Conceptual skills
– Social skills
– Practical skills
Many-sided evaluations
Additional factors
– Community environment typical of the individual’s peers and
culture
– Linguistic diversity and cultural differences
Intellectual Deficit





Typically measured by Stanford-Binet or WISC
More than 2 sds below the mean (68 or 70)
Within this, there are distinctions made
Theoretically 2.3 % of kids would have ID based on IQ
alone, but this isn’t absolute because many extra kids
will land here because of organic damage
Subtypes:
–
–
–
–

Mild (50/55 to 70)—educable--85% of ID population
Moderate (35-40 to 50/55)—trainable—10% of ID population
Severe (20/25 to 35/40)—3-4% of ID population
Profound (below 20/25)—custodial—1-2% of ID population
How stable is IQ? Fairly
Adaptive Behavior
Related to intellectual functioning, r = .4 to .6
 What is adaptive behavior?

– Developmental—differs for age groups, expected to grow
 Infancy/early childhood—sensorimotor, communication, self-help, primary social skills
 Later child/adol-reasoning and judgments about environment and social relationships
 Later still—vocational performance and social responsibility
– Domains of functioning
– Affected by culture
– Make judgments about specific situations

How do we measure this?
– Vinelind Adaptive Behavior scales
 Yields score of social adaptation
 Behavioral domains—communication, daily living skills, socialization, motor skills
 Semistructured

Prevalence--% of ID drops when adaptive behavior is included-1-3%
Levels of Needed Support
Third criterion
 From AAIDD

– Intermittent—as needed
– Limited—more consistent over time, such as
with transitions
– Extensive—regular (daily) involvement in at
least some environments
– Pervasive—consistent/high intensity
Associated Features
of Intellectual Disability

Motivation—
–
–
–
–
–

Susceptible to helplessness/frustration
Expect failure, even for tasks they can master
Set lower goals for themselves
Adults are less likely to push ID kids
But mild ID –increase in ability to stay on task over time
Changes in progress—
– Slowing and stability hypothesis—alternate between periods of
gain and periods of little or no advance

Language and social behavior
–
–
–
–
Most research is on Down
Delay in expressive language development
Less likely to be securely attached
Delayed internal state language
Associated Features

Emotional and behavioral problems
– Similar to non-ID in those with mild to
moderate ID
– Most common—impulse control disorders,
anxiety disorders, mood disorders
Self-injurious behavior (SIB) 8% of ID
 Other disabilities—12% with mild, 45%
with moderate-profound have at least one
other disability

Learning

Discrimination learning
– Non-ID learn to test hypotheses very quickly and then learn rapidly and
level off
– ID kids take longer to pay attention to relevant cues. Once they do—
learn more quickly



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Operant conditioning—works well
Basic attentional deficit may be present—slower reaction times
No evidence of STM deficit
Hard to assess LTM because this assumes effective use of aids to
improve retention
– ID kid are deficient in basic skill of rehearsal; will use techniques if
trained


ID kids typically do not generalize from one sit to another
Tend to be very dependent, seek help after every failure or to be
reluctant to interact socially
Causes

Most cases—no clear cause
– Only 25% known organic cause
– 30-40% have no id’d cause

Familial risk
– No ID in parent, 1 ID sib—13%
– 1 ID parent-20%
– 2 ID parents—42%

2 groups of causes
– Organic or pathological—more commonly severe or
profound
– Cultural-familial—mild ID
Genetic and Constitutional Factors
– Chromosomal anomalies—Prader-Willi; Klinefelters (XXY);
Turners (XO); Fragile X
– Fragile X—mostly males are affected—females are carriers..
– Down Syndrome—1/1000 births—trisomy 21 in 95% of cases
 Occurrence increases with maternal age—rarely due to
fathers
 Almond-shaped eyes that slant up
 Facial flatness, thick tongues, broad hands and feet, poor
muscle tone, increased risk for heart and hearing problems
 IQ is usually moderate to profound, but occasionally higher;
M around 50
 Social skills are usually high
 Smiling is delayed—less frequent, less intense than other
infants
 Less fear at visual cliff
 Developmental changes
 Families and Down—most families cope adequately, but
worry about the future—doesn’t disrupt family life
Other Organic Causes
– Single-gene inheritance
 PKU—phenylketonuria—recessive gene
– Prenatal and birth complications—
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Drugs or injury
Syphilis
Rubella (German measles) in first trimester
Radiation in first few mos of pregnancy
Age at pregnancy (over 35)
Severe emotional stress throughout pregnancy
Chronic alcoholism
Anoxia 5/1000—20% of these are adversely affected
Premature babies—associated with neurological insults
– Postnatal





Seizures
Head injury
Encephalitis/meningitis
Malnutrition
Lead/mercury poisoning
Psychosocial and Cultural
Influences
Severe social isolation
 Educationally deprived parents
 Parenting practices

Treatment


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
Behavioral—single most important innovation in the tx of
ID
Individual tx for behavior problems, also family tx
Cognitive-behavioral—self-instructional training
Medication—won’t change ID. Can alleviate problems
that go with ID.
In home vs out of home care
– Families are content with whatever decision they make
– Reasons for placement out of home




81%
75%
60%
55%
day to day stress
level of functioning, potential for future learning
child’s behavior
feelings of non-handicapped kids
Mainstreaming vs. Self-Contained
Classrooms
Mainstreaming produces only modest improvements in social and play
interactions
o Non-ID kids speak more simply, act like adults
 Mainstreaming is out of idea of “normalization”—tx should aim to produce
beh that are as normal as possible in setting that is as normal as possible
– Outcome can be predicted by classroom variables such as teaching style
and activities promoting student interaction
– No – effects for non-ID kids
– Can allow modeling of academic and social skills
– Requires considerable time, effort, resources, teaches support
– Nothing will remove the disabilities
 Negatives of self-contained classrooms
– Limited social contacts due to segregation
– Minority overrepresentations
– If with lower level kids, may not be challenged or given enough attn
 Positives of self-contained classrooms
– Student:teacher ratio
– IEP (but this is all classified kids)
– Individual programming (this can happen in regular classes)

Severe and Persistent Disorders

Pervasive Developmental Disorders
– Group of severely disabling conditions
– Result of structural differences in the brain
– Examples include Asperger’s and Autism
– All are early occurring
– Qualitative impairments
– Prevalence unclear, but increasing, maybe
3.2% of clinic cases
Autism


Kanner, 1943
Three primary features:
– Mutism or noncommunicative speech—latter marked
by echolalia, phrases that are irrelevant to the
situation, extreme literalness, personal pronoun
reversal
– Extreme social isolation
– Need for sameness—both in environment & own
behavior—often activities are simple. Intensity of this
need is marked by rigidity of behavior and panic and
rage when routine is changed

Other behaviors may be present but are not
necessary
Features of Autism

Appears as early as 1 yr to 18 months
–

May show up after up to 30 mos of normal dev
Intelligence is a question.
– Some studies show ¼ to 1.5 have normal to borderline
intelligence
 80% have iq below 70 and 30% between 50 & 70.
– New study compared Ravens with WISC—with Ravens, IQ went
up from 30th percentile to an avg of 56th percentile (Dawson et
al, 2007)




Found in all social classes
Can coexist with other known brain pathologies—1/4-1/3
Disorders that most often accompany autism: ID,
epilepsy
Also see self-injurious behavior
Other Characteristics

Sensory and perceptual impairments
–
–
–

Sights, sounds, smell, textures can be confusing or painful
Sensory dominance—tendency to focus on certain types of sensory input over others
Stimulus overselectivity—tendency to focus on feature of an object or event over =
important features
Cognitive deficits
–
–
Theory of Mind—awareness of mental states in self and others—15-60% have some TOM
knowledge
General deficits



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Executive functioning
Weak drive for central coherence
Physical characteristics
–
–
About 10% may have coexisting medical condition that may play a causal role in autism
1/5 have larger than normal head size
–
–
–
–
–
25% dev splinter skills or islets of activity
True savantism is rare—maybe 5/1000 autistics
May have Rain Man-like skills
There is no explanation for this—tend to be related to repetitious and obsessive beh
No obvious genetic link—no training—skills emerge early
Savantism
Prevalence and Age of Onset
About 1 million in US; $90 billion/yr in US
 4-5 per 10,000 at least may be 6-14 per 10,000.
Autism Society says 1 in 500 (20 per 10,000)

– As high as 30-60 per 10,000 for all types
– Prevalence is increased probably due to broader
definition and better recognition of milder forms
3-4x more common in boys than girls
 Age of Onset

– Most parents become concerned before 2nd birthday
– 12-18 mos – earliest age for reliable detection
Course and Outcome

Most show gradual improvement with age
– 10% will do well as adults
– Poor prognostic signs
 No communicative speech by age 5
 IQ below 60
 Early seizure onset

Early work: Lotter, 1978
– 1-2% look normal
– 10% good outcomes—near normal functioning—some oddities in
speech or personality
– 20% fair outcome—make gains, significant handicaps
– 70% poor outcome—limited progress, not an independent
existence
– Among those who do well—stick scrupulously to the rules
Things that DO NOT CAUSE
AUTISM

Failed parenting—
– Early proposal that blamed cold (refrigerator) parenting
– Parental rejection causes retreat into autistic “empty fortress”
– Also early—operant conditioning—parents fail to shape and reinforce
beh so kids don’t learn right
– No support for either

Childhood vaccines
– Popular explanation because of age of onset and timing of vaccines
– No support (eg Smeeth et al, 2004 in Lancet)
– Honda et al 2005—MMR rate in Yokohama declined in 1988-1992, not
administered after, but autism spectrum continued to increase

Television viewing—Waldman et al
– Kids from rainier cultures have higher rates
– Those growing up in counties with high cable rates in the 70s and 80s—
higher rates—Also higher rates in CA, OR, WA in 80s.
Biologically-based
Neurodevelopmental Disorder with
Multiple Causes

Problems in early dev
– More health problems during pregnancy, at birth, or immediately following birth
– 25% of children with autism
– Not a primary cause

Genetic influences
– Chromosomal and gene disorders
 Fragile x in 2-3% of kids with autism
 In general, kids with autism are at elevated risk (5%) for chromosomal anomalies
 Also assoc with tuberous sclerosis--25% of kids with this dx also have autism
– Family and twin studies
 3-7% of sibs and extended family members of autistic kids also have autism—about
50-100x greater than would be expected by chance
 Concordance in identical twins is 60-90%
– Neuropsych/neurobiology
 Consistent findings of abnormalities in frontal lobe, cerebellum (motor movement,
language, etc), temporal lobe and limbic system (emotion regulation and learning and
memory)
Treatment
Widely publicized tx such as facilitated comm., dietary modifications
(gluten-free, etc), secretin (hormone to control digestion), etc.—don’t work
 Hard to find reinforcers

– Don’t like change
– Self-stimulation interferes with teaching
– Difficulty generalizing learning

Goals for low-functioning children
– Elimination of harmful beh
– Self-help skills, compliance with simple requests and rules, basic social and
emotional beh, communication of needs, appropriate play
– Reward progress, no matter how small

Goals for high-functioning children
– Concentrated doses of early intervention
– Language fluency, age appropriate social interactions with normal peers

Lovaas’ UCLA Autism Project—intensive beh tx, can improve dev,
controversial
– 46% moved to normal level of intellect functioning
Treatment

Keys to tx
– Emphasis on core tx
– Supportive teaching environment
– Predictability and routine
– Functional approach to problem behavior
– Family involvement
– Intensive intervention
– May also include things like speech tx,
occupational tx, social skills training
Asperger’s
Similar to autism, but without severe lang
deficits
 IQ normal or above
 Language not delayed, but idiosyncratic

– Egocentric—hard to make adjustments for social
contexts
Clumsy gait
 Limited social interactions
 Rare, but more prevalent than autism 3/1000
 Boys>girls

Rhett’s
Primarily females
 Normal neonatal and early development for first
6-12 mos
 Then—loss of purposeful hand skills

– Loss of social engagement (interaction may improve
later)
– Poorly coordinated gait or trunk movements
– Receptive and expressive language deficits
– 1-4/10,000 females
– X-linked—fatal in male fetuses
Childhood-Onset Schizophrenia








Used to be thought to be the same or related to autism, but…
–
–
–
–
–
Later onset
Less intellectual impairment
Less severe, social and language deficits
Hallucinations and delusions
Periods of remission and relapse
–
–
Difficulty concentrating, sleeping or doing school work
Start to avoid friends
–
–
Disordered thinking
Hallucinations, paranoia, delusions
Initial stages
As it progresses
Almost unheard of before 5, rare before 15
69% of kids with schizophrenia meet criteria for something else—54% comorbid
substance abuse
Somewhat lowered IQ
Onset is gradual—wide range of impairments preceding sx
Sx gradually persist into adolescence and adulthood
DSM-IV

2 or more of
– Delusions
– Hallucinations
– Disorganized speech
– Grossly disorganized or catatonic beh
– Negative sx (affective flattening, avolition,
alogia)
Major Symptoms

Delusions
–




–
–
–
–
–
Disturbance in thinking involving disordered thought content and strong beliefs that are
misrepresentations of reality
Bizarre
Persecutory
Somatic
Reference
Grandiose
–
–
Disturbances in perceptions in which things are sensed that aren’t real or present
Auditory—unrelated to affective state—present in 80%
Hallucinations

Command, Religious, Persecutory, Commenting
–
–
–
Visual
Somatic
Tactile
–
–
Form of thought
Loose associations, clang, tangential
40-60% also experience visual hallucinations, delusions, thought disorder
Content of hallucinations and delusions
Thought Disorder
Prevalence
.14 to 1.0 per 10,000—maybe .25% of all
up to age 19
 100x more common in adults than kids
 Earlier onset in boys than girls by 2-4 yrs

– 2x as common in boys, but gender difference
disappears in adolescence

70% meet criteria for another dx—usually
substance abuse, ODD, CD, or depression
Associated Features









90% show some hx of behavioral and psychological
disturbances prior to onset
Awkwardness
Delayed milestones
Peculiar posture
Poor coordination
Lack of emotion or inappropriate affect
Social withdrawal/isolation
Impaired communication
IQ somewhat deficient—10-20% show low IQ
– Evidence says that IQ decreases after psychotic sx appear

Early onset—nonpsychotic sx first
Outcome

Eggers and Buunk 1997
– 50% show poor outcome
– 25% recover
– Other studies show higher rates of ongoing sx
Early onset—worse prognosis
 Acute onset—better prognosis
 Good adjustment prior to onset—better
prognosis

Causes

Neurological abnormalities—soft signs, deficits in attn and memory,
structural abnormalities in temporal-limbic and frontal lobes
– Central nervous system dysfunction
– Shrinkage in brain gray matter, beginning in areas responsible for attn
and perception
– No single lesion in all cases
– Lesions aren’t specific to schizophrenia

Genetic influences—seem stronger than in adults
– Concordance 48-88% in MZ, 17% DZ, 13% one parent

Environmental factors
–
–
–
–
–
–
Possible factors:
Infectious, toxic, or traumatic insults
Stress during pre or postnatal dev
Psychiatric illness in parents—poor parenting
Economic distress
Broken home
Treatment
Multimethod
 Mostly known from later onset
 Meds!
 Psychosocial tx—family intervention, social
skills training, educational support
 Few controlled studies with kids
