DISORDERS OF CHILDHOOD
LECTURE OUTLINE
• Overview
• Externalizing disorders - Attentiondeficit/Hyperactivity disorder (ADHD), oppositional
defiant disorder (ODD), and conduct disorder (CD)
• Internalizing disorders – Separation anxiety
disorder (SAD)
• Other disorders – tic disorders, elimination
disorders
• Pervasive developmental disorder – including
autism
DISORDERS OF CHILDHOOD
OVERVIEW
• The DSM and childhood disorders
• Developmental psychopathology
• Risk and protective factors
• Special considerations in treating children
• Prevalence of childhood disorders
DISORDERS OF CHILDHOOD
OVERVIEW
Ontario Child Health Study (Offord et al., 1987)
• studied rates of 4 disorders (conduct disorder,
hyperactivity, emotional disorders, somatization)
for children 4-16 years of age
• 6-month prevalence rate for any disorder was
18%
• boys have higher rates of conduct disorders
(8%) and hyperactivity (9%) than girls (3% for
both)
DISORDERS OF CHILDHOOD
OVERVIEW
Ontario Child Health Study (Offord et al., 1987)
• girls have higher rates of emotional (14%) and
somatization (11%) disorders than boys (8% &
5%)
• for boys, rates of conduct disorder increase
with age, while rates of hyperactivity and
emotional problems decrease
• for girls, rates of emotional problems increase
with age
DISORDERS OF CHILDHOOD
ADHD – History and background
• originally called MBD (minimal brain
dysfunction), then Hyperkinetic Reaction of
Childhood
• most common presenting problem in
mental health clinics for children
• more common for boys than girls (3:1 to
5:1)
DISORDERS OF CHILDHOOD
ADHD – Core features
• age-inappropriate levels of inattention
(e.g., difficulty sustaining attention with
school work, easily distracted)
• impulsivity (e.g., not waiting turn, blurting
out answers)
• hyperactivity (fidgets, squirms, talks
excessively)
DISORDERS OF CHILDHOOD
ADHD - Subtypes
• Children can be diagnosed as ADHD
combined type, predominantly inattentive,
or predominantly impulsive-hyperactive
• Research by Virginia Douglas at McGill
demonstrated that inability to sustain
attention and control impulses, not higher
activity levels, were key features of this
disorder
DISORDERS OF CHILDHOOD
ADHD and other disorders
• high rates of comorbidity with
oppositional defiant disorder (80%),
conduct disorder (40%), and antisocial
personality disorder (25%) in adolescence
• also, high rates of comorbidity with
learning disabilities
• assessed primarily with rating scales
(e.g., Connors)
DISORDERS OF CHILDHOOD
ADHD – Long-term prognosis
• Follow-up studies of children with ADHD
show elevated rates of school problems,
conduct disorders or antisocial
personality, substance abuse, criminal
behaviour
• But this long-term trend is observed
mostly with aggression associated with
ADHD
DISORDERS OF CHILDHOOD
ADHD – Long-term prognosis
• Moreover, some children seem to
outgrow ADHD (see figure 5.1 in text)
• at age 10, 250 cases per 1000 for ADHD in
boys; drops to < 50 cases per 1000 by age
20
• girls remain at low rates (75 cases per
1000) from ages 10 to 20
DISORDERS OF CHILDHOOD
ADHD - Etiology
• likely some biological predisposition
• 30-50% heritability component
• food additives and sugar – no evidence
that these are causal factors
• PET and MRI research suggests some
brain abnormalities, such as reduced
glucose metabolism
DISORDERS OF CHILDHOOD
ADHD - Treatment
• stimulant medications – Ritalin,
Dexedrine, Cylert
• reduced impulsiveness and hyperactivity
and improved attention, but little evidence
of improvement in academic achievement
DISORDERS OF CHILDHOOD
ADHD - Treatment
• proliferation of medications for treatment
of ADHD
• rates of use quadrupled in Canada from
1990 to 1995, then increased by 85% per
year from 1996-98 (McCubbin & Cohen,
1999)
• concerns about side effects about use of
stimulant medication
DISORDERS OF CHILDHOOD
ADHD - Treatment
• behavioural management at home and
school
• these strategies can also help, but appear
less powerful and are more demanding of
adults than medications
• combination of medication and
behavioural treatment may be most
beneficial
DISORDERS OF CHILDHOOD
OPPOSITIONAL DEFIANT DISORDER
(ODD)
• diagnosed when children behave in a
negative, hostile, or defiant manner;
related to problems in relationships and at
school
• symptoms emerge before age 8
• 1 in 4 boys will go on to develop CD
DISORDERS OF CHILDHOOD
CONDUCT DISORDER (CD)
• “repetitive and persistent pattern of conduct
in which the basic rights of others and major
age-appropriate societal norms or rules are
violated”
• aggression is a major concern; also
property destruction, lying, theft, rule
violation
• poor interpersonal skills and peer rejection
DISORDERS OF CHILDHOOD
Diagnostic issues in ODD & CD
• more common in boys (2:1)
• many boys with ODD do not develop CD
• minority of those with CD don’t develop
antisocial personality disorder
• CD linked with ADHD and substance
abuse
DISORDERS OF CHILDHOOD
Etiology of ODD & CD
• subclinical neurological signs
• temperament
• inter-generational patterns
• marital conflict, divorce, abuse
• attachment problems
• parenting
DISORDERS OF CHILDHOOD
Long-term development of ODD & CD
• form of behaviour changes over time –
from overt to covert
• severity and frequency of problems best
predictors of who will continue to have
problems in the future
• many children do improve over time
DISORDERS OF CHILDHOOD
Treatment of ODD & CD
Coercive process – Gerry Patterson
• parents behaviour impacts on child;
child’s behaviour impacts on adult
• in families of children with ODD or CD,
parents lack child management skills and
often end up in coercive interactions that
sprial out of control and are selfperpetuating
DISORDERS OF CHILDHOOD
Treatment of ODD & CD
Parents’ impact on child
Brother Children play Parent
and
cooperatively ignores
sister at
children
play
Extinction of
cooperative
play
Brother Children fight
and
sister at
play
Positive
reinforcement
for fighting
Parent
criticizes
or scolds
children
DISORDERS OF CHILDHOOD
Treatment of ODD & CD
Childs’ impact on parent
Children Parent
Children stop
fight
criticizes fighting
or scolds (temporarily)
Negative
reinforcement
for criticism or
scolding
DISORDERS OF CHILDHOOD
Patterson’s parent training for ODD & CD
Defining and pinpointing behaviour
• “I want Johnny to be a good student”
• “I want Johnny to stop being aggressive”
• “I want Johnny to stop hitting his peers”
DISORDERS OF CHILDHOOD
Patterson’s parent training for ODD & CD
Focusing on the positive – alternative,
incompatible behaviours
• yelling
• whining
• interrupting
• non-compliance
DISORDERS OF CHILDHOOD
Patterson’s parent training – key focus is
on obtaining compliance from child
• commands vs. requests
• positive reinforcement (praise)
• extinction (ignoring)
• punishment (timeout)
DISORDERS OF CHILDHOOD
Community Parent Education Program
(COPE) for ODD & CD – Cunningham et al.
(1993)
• parent training in schools and community
centres
• school-based intervention
DISORDERS OF CHILDHOOD
Other treatments for ODD & CD
• Problem-solving skills training
• Family therapy – multisystemic therapy
• the earlier the treatment, the better longterm prognosis
DISORDERS OF CHILDHOOD
Separation Anxiety Disorder
• only SAD remains in DSM-IV as an
anxiety disorder unique to childhood
• distress upon being separated from a
parent or fears that parent will be harmed
• average age of onset is 9
• typically occurs after a major stressor
DISORDERS OF CHILDHOOD
SAD – Diagnosis and assessment
• severe and excessive anxiety when faced
with separation from a parent
• also related to mood problems, school
refusal, somatic complaints
• need for multi-dimensional assessment
DISORDERS OF CHILDHOOD
SAD – Long-term development
• social withdrawal, poor school
performance
• not much known about long-term course
if left untreated, possibly related to adult
anxiety disorders such as agoraphobia and
panic disorder
DISORDERS OF CHILDHOOD
SAD – Etiology
• strong heritability component,
concordance for anxiety disorders is 3
times higher in MZ than DZ twins
• temperament – behavioural inhibition
(shyness, vigilance, avoidance)
• insecure attachment
DISORDERS OF CHILDHOOD
SAD – Treatment
• cognitive-behaviour therapy
• play therapy
• medication
• overall, shy and anxious children respond
well to treatment, again early treatment is
needed
• SAD is far less researched than the
externalizing disorders
DISORDERS OF CHILDHOOD
Other disorders
• tic disorders – Tourette syndrome,
responds well to anti-psychotic medication
Haldol
• elimination disorders – enuresis and
encopresis, Mowrer bell and pad treatment
based on classical conditioning
DISORDERS OF CHILDHOOD
SUMMARY
• childhood disorders have high
prevalence (OCHS)
• externalizing disorders (ADHD, ODD, CD)
have received the most attention because
of negative impacts on others and their
damaging long-term impacts
• less well understood are internalizing
disorders, such as SAD