PowerPoint  Lecture Notes Presentation
Chapter 14
Disorders of Childhood
Abnormal Psychology, Eleventh Edition
by
Ann M. Kring, Gerald C. Davison, John M. Neale,
& Sheri L. Johnson
Classification and Diagnosis of
Childhood Disorders

Developmental psychopathology
» Studies disorders within context of normal child
development

Externalizing disorders
» Characterized by outward behaviors
» Noncompliance, aggressiveness, overactivity,
impulsiveness
» Includes attention-deficit/hyperactivity disorder,
conduct disorder, and oppositional defiant disorder.
» More common in boys

Internalizing disorders
» Characterized by inward behaviors
– Depression, anxiety, social withdrawal
» Includes childhood anxiety and mood disorders
» More common in girls
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Attention Deficit/Hyperactivity
Disorder

Excessive levels of activity
» Fidgeting, squirming, running around when
inappropriate, incessant talking

Distractibility and difficulty concentrating
» Makes careless mistakes, can’t follow instructions,
forgetful

Must be severe and persistent
» Present for at least 6 months and cause
impairments in functioning

Congress created National ADHD Awareness
Day
» First observed September 7, 2004
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Attention Deficit/Hyperactivity
Disorder

Three subcategories in DSM-IV-TR
1. Predominantly inattentive type
2. Predominantly hyperactive-impulsive type
3. Combined type

Differential diagnosis
»
»
ADHD or Conduct Disorder?
ADHD
–
»
More off-task behavior, cognitive & achievement deficits
Conduct Disorder
–
More aggressive, act out in most settings, antisocial
parents, family hostility
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Attention Deficit/Hyperactivity
Disorder
ADHD often comorbid with
anxiety and depression
Prevalence estimates 2 to
7% worldwide
More common in boys
than girls



»
May be because boys’
behavior more likely to be
aggressive
Symptoms persist beyond
childhood

»
»
Numerous longitudinal
studies show 65 to 80% still
exhibit symptoms
60% of adults continue to
meet criteria for ADHD in
remission
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Girls with Attention
Deficit/Hyperactivity Disorder

Hinshaw et al. (2006) large, ethnically diverse study of girls
» Combined type had:
– More disruptive behaviors than inattentive type
– More comorbid diagnoses of conduct disorder or oppositional
defiant disorder than girls without ADHD
– Viewed more negatively by peers than inattentive type or girls w/out
ADHD
» Inattentive type
– Viewed more negatively by peers than girls w/out ADHD
» Girls w/ADHD more likely to:
– Be anxious and depressed
– Exhibit neurological deficits (e.g., poor planning, problem-solving)
– Have symptoms of eating disorder and substance abuse by
adolescence
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Etiology of ADHD

Genetic factors
» Adoption and twin studies
– Heritability estimates as high as 70 to 80%
» Two dopamine genes implicated
– DRD4

Dopamine receptor gene
– DAT1

Dopamine transporter gene
» Mixed support for this gene
» Either gene associated with increased risk only when
prenatal maternal nicotine or alcohol use are present

Neurobiological factors
» Dopaminergic areas smaller in children with ADHD
– Frontal lobes, caudate nucleus, globus pallidus
» Poor performance on tests of frontal lobe function
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Etiology of ADHD

Perinatal and prenatal factors
» Low birth weight
– Can be mitigated by later maternal warmth
» Maternal tobacco and alcohol use

Environmental toxins
» Limited evidence that food additives can have a small
impact on hyperactive behavior
» No evidence that refined sugar causes ADHD
» Nicotine from maternal smoking
– Exposure to tobacco in utero associated with ADHD
symptoms
– May damage dopaminergic system resulting in behavioral
disinhibition
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Etiology of ADHD

Parent-child relationship
» Parents give more commands and have
more negative interactions
» Family factors
– Interact with genetic and neurobiological factors
– Contribute to or maintain ADHD behaviors but
do not cause them
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Treatment of ADHD

Stimulant medications (Ritalin, Adderall, Concerta,
Strattera)
»
»
»
»
»
Reduce disruptive behavior
Improve interactions with parents, teachers, peers
Improve goal-directed behavior and concentration
Reduce aggression
Side effects
– Loss of appetite, weight
– Sleep problems

Medication plus behavioral treatment (MTA study)
»
»
»
»
Slightly better than meds alone
Improved social skills whereas meds alone did not
No difference in groups at 3 year follow-up
Stimulant medication more effective for some children than
others
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Treatment of ADHD

Psychological treatment
» Parental training
» Change in classroom management
» Behavior monitoring and reinforcement of
appropriate behavior

Supportive classroom structure
»
»
»
»
Brief assignments
Immediate feedback
Task-focused style
Breaks for exercise
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Conduct Disorder (CD)

Pattern of engaging in behaviors that violate
social norms, the rights of others, and are
often illegal.
»
»
»
»
»
»
Aggression
Cruelty towards other people or animals
Lying
Stealing
Vandalism
Often accompanied by lack of remorse and
callousness
» Frequent and severe offenses
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Oppositional Defiant Disorder (ODD)

ODD behaviors do not meet criteria for CD but
child displays pattern of defiant behavior
»
»
»
»
»
»

Argumentative
Loses temper
Lack of compliance
Deliberately aggravates others
Hostile, vindictive, spiteful, or touchy
Blames others for their problems
Comorbid with ADHD, learning and
communication disorders
» Disruptive behavior of ODD more deliberate than ADHD

Most often diagnosed in boys but may be as
prevalent in girls
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Conduct Disorder (CD)

CD behavior impacts others


Many times first identified by criminal justice system
Substance abuse common
» Unclear whether it precedes or is concomitant
with disorder

Comorbid with anxiety and depression
» Comorbidity rates vary from 15 to 45%
» CD precedes anxiety and depression

Prevalence
» Boys
– 4 to 16%
» Girls
– 1.2 to 9%
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Figure 14.1 Arrest Rates Across Ages for
Homicide, Forcible Rape, Robber, Aggravated
Assault, and Auto Theft
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Conduct Disorder (CD)
Moffitt (1993, 2006, 2007) two distinct CD types

1.
Life-course-persistent
–
2.
10 – 15x more common in boys than girls
Adolescence-limited
Follow-up longitudinal studies of life-coursepersistent show more severe problems into early
adulthood including:

»
»
»
»
Psychopathology
Lower levels of education
Partner and child abuse
Violent behavior
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Figure 14.2 Etiology of Conduct
Disorder

Insert Figure 14.2
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Etiology of Conduct Disorder (CD)

Genetic factors
»
»
»

Meta-analysis of twin and adoption studies
suggest 40 – 50% of antisocial behavior is
heritable
»

Heritability likely plays a part
Twin study data show mixed results
Adoption studies focused on criminal behavior, not
conduct disorder
Genetics a stronger influence when behaviors begin
in childhood rather than adolescence
Genetics and environment interact (Caspi et al.,
2002)
»
Abuse as a child PLUS low MAOA activity most likely
to develop CD
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Etiology of Conduct Disorder (CD)
Neurobiological factors

»
»
»
»
Poor verbal skills
Difficulty with executive functioning
Low IQ
Lower levels of resting skin conductance and HR
Psychological factors

»
»
»
»
»
Deficient moral development, especially lack of remorse
Modeling and reinforcement of aggressive behavior
Harsh and inconsistent parenting
Lack of parental monitoring
Cognitive bias (Kenneth Dodge)
–
Neutral acts by others perceived as hostile
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Figure 14.3 Dodge’s Cognitive
Theory of Aggression
Insert
figure 14.3
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Etiology of Conduct Disorder (CD)

Peer influence
»
»

Sociocultural factors
»
»

Acceptance or rejection by peers
Affiliation with deviant peers
Poverty
Urban environment
Higher rates of delinquent acts among
African American males linked to living in
poorer neighborhoods rather than race.
(Peeples & Loeber,1994)
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Treatment of Conduct Disorder

Family interventions
» Family check-ups (FCU) associated with
less disruptive behavior
» Parental management train (PMT; Gerald
Patterson)
– Teach parents to reward prosocial behavior

Cognitive therapy
» Anger-control training
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Figure 14.4 Multisystemic Treatment
of CD

Insert Figure 14.4
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Depression in Children and
Adolescents

Symptoms common to
children, adolescents,
and adults
» Depressed mood
» Inability to experience
pleasure
» Fatigue
» Problems concentrating
» Suicidal ideation

Symptoms specific to
children & adolescents
» Higher rates of suicide
attempts and guilt
» Lower rates of
– Early morning
awakening
– Early morning
depression
– Loss of appetite
– Weight loss
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Depression and Anxiety in
Children and Adolescents



Commonly co-occur with ADHD and CD
Also co-occur with each other
Early research suggested that depression and
anxiety could be distinguished from one another
in the same way they are in adults:
» Depression – high negative affect, low positive
affect
» Anxiety – high negative affect but not low levels of
positive affect
» More recent research calls this finding into
question
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Depression in Children and
Adolescents
Depression recurrent
 Prevalence

» 1% of preschoolers
» 2 – 3% of school age children
» Adolescent rates equivalent to adult levels
» Girls
– 7 – 13% - Twice that of boys
– No difference in symptoms experienced
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Etiology of Depression in Children
and Adolescents



Genetic factors
Early adversity and negative life events
Family and relationship factors
» A parent who is depressed
» Parental rejection only modestly associated with depression
» Children with depression and their parents interact in
negative ways
– Less warmth
– More hostility


Cognitive distortions and negative attributional style
Stable attributional style (Cole et al., 2008)
» Develops by early adolescence
» By middle school, attributional style serves as a cognitive
diathesis for depression.
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Treatment of Depression in Children
and Adolescents

Medications
SSRIs more effective than tricyclics
» Meta-analysis showed medications most effective for anxiety
other than OCD

– Less effective for depression and OCD

Concerns about medications
» Side effects including diarrhea, nausea, sleep problems, and
agitation
» Possibility of increased risk of suicide attempts

CBT
» More effective for Caucasian adolescents, those with
pretreatment good coping skills, and recurrent depression

Interpersonal psychotherapy (IPT)
» Focuses on peer pressures, transition to adulthood, and
issues related to independence

Psychotherapy generally only modestly effective with
children and adolescents
» CBT no better than non-CBT therapies
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Anxiety in Children and Adolescents


Fears and worries common in childhood
Anxiety disorder
» More severe and persistent worry
» Must interfere with functioning

Most childhood fears disappear but adults
with anxiety disorders report feeling
anxious as children
» “I’ve always been this way”

Prevalence
» 12 to 20% of children and adolescents would
be diagnosed with anxiety disorder
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School Phobia (School Refusal)

Two types
1. Separation anxiety
» Worry about parental or personal safety when
at school
2. Fear of school
» Specific aspect of school environment (e.g.,
academic failure) or social phobia
» Begins later in childhood
» More severe and pervasive avoidance
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Social Phobia


Extreme shyness and withdrawal
May exhibit selective mutism
» Refusal to speak in unfamiliar social setting

Prevalence
» 1% of children and adolescents

Etiology
» Overestimation of threat
» Underestimation of coping ability
» Poor social skills
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PTSD
Exposure to trauma

»
»
»
Chronic physical or sexual abuse
Community violence
Natural disasters
Symptom categories

»
»
»
Flashbacks, nightmares, intrusive thoughts
Avoidance
Hyperarousal and vigilance
Etiology

»
»
»
Preexisting anxiety
Family stress and coping styles
Parental response to trauma
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OCD
Prevalence 1 to 4%
 Symptoms similar to those in adults
 Most common obsessions

» Contamination from dirt and germs
» Aggression
» Thoughts about sex and religion more
common in adolescence

OCD more common in boys than girls
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Etiology of Anxiety Disorders

Genetics
» Heritability estimates from 29 – 50%
» Genetics plays a stronger role in separation anxiety in
context of more negative life events

Parenting plays a small role in anxiety disorders
» Only 4% of variance



Emotion regulation and attachment problems also play a
role
Perception of lack of acceptance by peers a factor in social
phobia
Risk factors for PTSD include:
» Family stress and coping style
» Past experience with trauma
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Treatment of Anxiety Disorders in
Childhood and Adolescence

Exposure to feared object
» Reward approach behavior

CBT Kendall’s Coping Cat program
» Shows to be effective in two randomized clinical trials
» For kids between 7 and 13 years old
» Cognitive restructuring
– Develop new ways to think about feats
»
»
»
»
»
Psychoeducation
Modeling and exposure
Skills training
Relapse prevention
Family involved in treatment
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Learning Disability

Evidence of inadequate development in a
specific area of academic, language, speech
or motor skills
» e.g., arithmetic or reading


Not due to mental retardation, autism,
physical disorder or lack of educational
opportunity
Individual usually average or above average
intelligence
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Learning Disability

DSM-IV-TR categories
» Learning disorders
» Communication disorders
» Motor skills disorder
Often identified and treated in school
 Reading disorders more common in
boys

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Table 14.3 Learning Disorders in
DSM-IV-TR
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Etiology of Learning Disabilities:
Dyslexia

Genetic factors
» Evidence from family and twin studies
» Genes are those associated with typical reading abilities
“generalist genes”

Problems in language processing
»
»
»
»
»
»
Speech perception
Analysis of sounds and their relationship to printed words
Difficulty recognizing rhyme and alliteration
Problems naming familiar objects rapidly
Delays learning syntactic rules
Deficient phonological awareness
– Inadequate left temporo-parietal-occipital activation
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Treatment of Learning Disabilities

Reading and writing disorders
» Multisensory instruction in listening, speaking, and
writing skills
» Readiness skills in younger children as preparation
for learning to read
» Phonics instruction

Communication disorders
» Fast ForWord
– Involves computer games and audiotapes that slow
speech sounds
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Mental Retardation

Significantly below average intellectual
functioning
» IQ less than 70

Deficits in adaptive functioning
» Self-care, communication, home living, decision
making, etc.



Onset before age 18
Most professionals focus on strengths of
individual to assess ability to function
Intellectual disability now preferred term over
mental retardation
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Table 14.4 Sample Items from
Vineland Adaptive Behavior Scales
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Table 14.5 DSM-IV-TR Categories of
Mental Retardation
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Table 14.6 AAMR Definition of
Mental Retardation
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Etiology of Mental Retardation:
Neurological Factors

Down’s syndrome
» Chromosomal trisomy
» 47 instead of 46 chromosomes

Fragile X syndrome
» Mutation in the fMRI gene on the X chromosome

Recessive-gene disease
» Phenylketonuria (PKU)

Maternal infectious disease, especially during 1st
trimester
» HIV, rubella, syphilis


Brain injuries from falls or auto accidents
Lead or mercury poisoning
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Treatment of Mental Retardation

Residential treatment
» Small to medium sized community residences

Behavioral treatments
» Language, social, and motor skills training
» Method of successive approximation to teach
basic self-care skills in severely retarded
– e.g., holding a spoon, toileting
» Applied behavioral analysis

Cognitive treatments
» Problem-solving strategies

Computer assisted instruction
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Pervasive Developmental
Disorder: Autistic Disorder


Kanner’s (1943) autistic aloneness
Impairments in social interactions (at least
2 of the following):
» Deficient use of nonverbal behaviors
» Poorly developed peer relationships
» Lack of social or emotional reciprocity

Impairments in communication (at least 1
of the following)
» Delay in or total lack of spoken language
» Difficulty initiating or sustaining conversation
– Repetitious or idiosyncratic language
– Echolalia
– Pronoun reversal
» Lack of developmentally appropriate play
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Pervasive Developmental
Disorder: Autistic Disorder

Repetitious or stereotyped behaviors (at
least 1 of the following)
» Abnormal preoccupation with objects
» Ritualized behaviors
– Body rocking, hand flapping
» Stereotyped mannerisms
» Abnormal preoccupation with parts of an
object

Begins before age 3
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Autistic Disorder

A study with adults found that people
with autism pay attention to different
parts of faces than do people without
autism (Spezio et al., 2007).
» Adults with autism focused their gaze
mostly on the mouth region and almost
entirely neglected the eye region.
» This neglect likely contributes to difficulties
in perceiving emotion in other people
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Etiology of Autistic Disorder

Bettleheim’s psychoanalytic theory
(1967)
» Rejecting and unresponsive parents
» Child withdraws into his own world
» Theory unsupported by empirical data

Genetic factors
» Twin studies
– 60 to 91% concordance rates
» Genetic flaw
– Deletion on chromosome 16
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Etiology of Autistic Disorder

Neurobiological factors
» Brain size
– Although normal size at birth, brains of autistic
adults and children are larger than normal.
– Pruning of neurons may not be occurring

“Overgrown” areas include the frontal,
temporal, and cerebellar, which have
been linked with language, social, and
emotional functions
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Treatment of Autistic Disorder



Intensive operant conditioning (Lovaas, 1987)
Parent training and education
Pivotal response treatment (Koegel et al., 2003)
» Focus on increasing child’s motivation and
responsiveness rather than discrete behaviors


Joint attention intervention & symbolic play used
to improve attention and expressive skills
Medication most common used
» Haloperidol (Haldol)
– Antipsychotic
– Reduces aggression and stereotyped motor behavior
– Does not improve language and interpersonal
relationships
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Pervasive Developmental Disorders

Asperger’s disorder
» Less severe form of autism
» Language and intelligence intact
» Poor social relationships and rigid,
stereotyped behaviors
» Recently recognized more in adult
population
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Table 14.7 Additional Pervasive
Developmental Disorders
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