CHAPTER 10
DISORDERS OF CHILDHOOD
10-1
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Aims and Objectives

Expose myths and highlight research challenges in the field
of childhood disorders

Describe the diagnosis and epidemiology of a range of
childhood disorders

Discuss the aetiology, treatment and prevention of these
disorders
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PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood

Myths, realities, and research challenges

Psychological and behavioural problems in children are very
common

In NSW, parents of 31% of children 4-12 years old reported their child
to have had an emotional or behavioural problem in the past 6 months

Few children receive help, despite evidence that early childhood
problems persist over time

Traditionally, research on childhood disorders has relied on adult
models and intervention approaches, which may not be
appropriate

It is essential to consider both risk and protective factors

Ongoing debate regarding how genetic and environmental factors
influence developmental outcomes

Overall children are resilient, but a combination of stressors
increases the risk of psychological disturbance
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PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood

Historical and current approaches to the understanding and
classification of childhood disorders


Children are vulnerable to mental illness and special
consideration needs to be taken into account when diagnosing
and treating children

Alfred Binet developed the first intelligence test in 1905

Sigmund Freud drew attention to importance of childhood to later
problems
Childhood diagnoses were not included until DSM-III



Considerable modification in DSM-III-R; fine tuning in DSM-IV and
DSM-IV-TR
Most common forms of psychological disorders

Internalising - over-controlled, feelings and states are inner-directed

Externalising - under-controlled, behaviours directed at others
Field of developmental psychopathology emerged in the mid1980s
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PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood – Externalising
disorders

Diagnosis and epidemiology of oppositional defiant disorder
Persistent pattern of negativistic, irritable, non-compliant
behaviour
 Need to consider the child’s developmental stage/gender when
making diagnosis
 One of the most common diagnoses among children, affecting up
to 4% of children


Aetiology of oppositional defiant disorder

Biological





Evidence of alterations in androgen (hormone related to
aggressiveness)
Differences in patterns of frontal brain activation
Autonomic under-arousal
Traumatic brain injury
Parenting practices and interactions between parent and child


Punitive, critical, use of restrictive control
Patterson’s Coercive Processes Model – parents and children engage
in progressively more coercive interactions with each other
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PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood – Externalising
disorders

The diagnosis and epidemiology of conduct disorder

Characterised by a persistent pattern of violation of rules and the rights
of others

Develop from an earlier oppositional defiant disorder and precursor to
adult criminality and antisocial personality disorder

More common in boys than girls, 2-6% prevalence

Children who showed persistent antisocial and conduct behaviour may
be differentiated on a number of characteristics by age 5-6 (Vassallo et
al., 2002)


Negativity, behaviour problems, social competence, parenting practices
The aetiology of conduct disorder

Biological factors include low cortisol

Psychological factors include temperamental characteristics such as
negativity, low persistence, and callous unemotional personality traits

Social factors include poor social skills and associating with antisocial
peers
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PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood – Externalising
disorders

The diagnosis and epidemiology of attention-deficit /
hyperactivity disorder (ADHD)

Defined by symptoms of inattention, hyperactivity, and impulsivity

Inattention includes not paying attention to task details, making careless
mistakes, being easily distracted, and being forgetful

Hyperactivity includes fidgeting, moving about excessively, blurting out
answers, interrupting

Combined Type, Predominantly Inattentive Type, and Predominantly
Hyperactive-Impulsive Type

In surveys, ADHD is approximately 2%; more boys than girls

In general, ADHD diminishes with age, in some cases it continues
into adulthood
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PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood – Externalising
disorders

The aetiology of attention-deficit/hyperactivity disorder
(ADHD)

Considerable genetic contribution

Specific pattern of executive functioning deficits



Specific to ADHD rather than to externalising disorders in general
Goal-setting, planning how to achieve goals, and monitoring one’s
behaviour while pursuing the goal
Problems may lie in switching the executive functions on and off
rather than the function itself

Autonomic arousal and lower response to reinforcement

Family and parenting variables


Same as for oppositional defiant and conduct disorder
Some controversial suggestions regarding the role of diet on
ADHD (e.g., artificial sweeteners and preservatives)
10-8
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood – Externalising
disorders

The treatment and prevention of externalising disorders


Parenting interventions

Derived from social learning theory and cognitive-behavioural therapy
principles

Training parents to use positive parenting strategies for desired
behaviours (e.g., star charts) and consistent consequences for problem
behaviours, such as planned ignoring and time out

Randomised control trials have suggested positive effects for pre-school
children, less evidence with older children
Child focused approaches


School-based approaches


Problem solving skills training, learned through therapist modelling, child
rehearsing, therapist feedback, and child being positively reinforced
Application of behaviour-change principles, such as teacher’s use of
attention and reward contingencies
Pharmacological approaches

Psychostimulant medication (used in conjunction with psychosocial
treatment)
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
10-9
Disorders of childhood – Externalising
disorders

The diagnosis and epidemiology of separation anxiety disorder
Fear specifically related to separation experiences and greatly
reduced in the presence of the attachment figure
 Occurs in approximately 3-5% of children, more common among
girls
 Occurs most commonly during middle childhood (7-9 years)



Most cases tend to improve over time, for children who continue
to meet criteria there is a high level of comorbid diagnoses
The aetiology of separation anxiety disorders

Non-specific genetic vulnerability


Parental anxiety


Behavioural inhibition – tendency to display anxiety in unfamiliar
situations
Parents accidentally reward their children for being anxious or are too
protective
Attachment insecurity and parental absence
10-10
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood – Externalising
disorders

The treatment of separation anxiety disorder

Treatment of choice is cognitive-behavioural therapy





Psychoeducation – teaching child and parents about anxiety and how
it is maintained
Coping skills training – teaching the child coping strategies for
dealing with anxiety-provoking situations
Relaxation skills – slow deep breathing and imaginal relaxation
Exposure – Hierarchy of feared situations, listing separation events
from the least anxiety-provoking to the most and working through the
hierarchy
Reinforcement – used by parents to encourage the child to continue
with the exposures, includes praise as well as special treats and
outings
10-11
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood- Internalising disorders

The diagnosis and epidemiology of selective mutism







Persistent failure to speak in select settings for at least one month
Generally, children speak to their families and a few selected others but
do not speak in school or other major social situations
Occurs in less than 1% of children, more common among girls
Onset is usually gradual
Other comorbid disorders are common
The aetiology of selective mutism

May be a manifestation of a shy, inhibited temperament

Some evidence that is a variant of social phobia
The treatment of selective mutism

Address 3 basic problems: child’s high level of anxiety in social
situations, limited experience speaking in front of others, high level of
reinforcement for nonverbal communication
10-12
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood – Externalising
disorders

The diagnosis and epidemiology of enuresis

The involuntary emptying of the bladder in the absence of an
organic cause, either at night-time (nocturnal enuresis) or daytime (diurnal enuresis)

In order to meet criteria, the child needs to be 5 or older

There are two categories: primary enuresis when the child has
never been dry and secondary enuresis when the child has had a
period of dryness for at least 6 months

Nocturnal enuresis is relatively common

15-22% in boys, 7-15% in girls at age 7

Most children grow out of the disorder

Children with enuresis experience embarrassment, social
isolation, behavioural problems, and low self-esteem
10-13
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood – Externalising
disorders


The aetiology of enuresis

Psychosocial factors rarely contribute to primary enuresis and specific
psychosocial events are much more common in secondary enureiss

Inherited factors are thought to play a substantial role

High level of heritability but the specific factor has not been pinpointed

Children with enuresis tend to have lower than average height and later
development of milestone
The treatment of enuresis

Treatment usually involves a conditioning approach, with a success rate
of approximately 66%

The bell and pad intervention is the most effective for nocturnal enureis

Urine sensitive pad place on bed and connected to an alarm

When the child wets the bed, the alarm is activated and the child is woken
10-14
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood – Externalising
disorders



The diagnosis and epidemiology of encopresis

Repetitive soiling in inappropriate places for at least 1/month for 3
months in a child at least 4 years old

Medical and physical problems need to be ruled out

Retentive and non-retentive

Diagnosed in 1.5 - 7.5% of children, tends to decline in age
The aetiology of encopresis

Model proposed by Cox et al. (1996) suggests that the child
experiences constipation, which leads to painful stool

The child anticipates future difficulties and avoids going to the
toilet, leading to chronic constipation and overflow incontinence
The treatment of encopresis

Medical management combined with behavioural treatments

Behavioural treatments include reinforcement schedule for
encouraging children to use the toilet
10-15
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of childhood – Externalising
disorders

Learning disorders diagnosed when the child’s achievement is below
what would be expected given his/her age and intellectual ability

The diagnosis and epidemiology of reading disorders
Characterised by difficulties in reading accuracy and comprehension that
are unexpected given the child’s chronological age and level of
intelligence
 Prevalence rates are between 4 and 7%
 High degree of overlap between reading disorder and behaviour problems


The aetiology of reading disorders
Some evidence for the heritability of reading disorder
Deficits in phonological awareness, working memory, and the speed of
processing written language may contribute to the development of reading
disorder
 Limitations in the speed of processing written language may also
contribute



The treatment of reading disorders

Most effective interventions combine both phonological (sounding out
words) and strategy based (whole word reading) approaches
10-16
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of Childhood:
Pervasive developmental disorders

Characteristics include marked social impairment, communication
difficulties, play and imagination deficits, and repetitive behaviour and
interests

There are five diagnostic categories: autistic disorder, Rett’s
disorder, childhood disintegrative disorder, and Asperger’s disorder

The diagnosis and epidemiology of autistic disorder

Symptoms include qualitative impairments in social interactions,
impairment in communication, and repetitive or stereotyped patterns of
behaviour

Two essential core deficits that lead to difficulties in social interaction


Communication problems – significant language delays and difficulty
comprehending non-verbal communication
Deficits in theory of mind – understanding that others have perspective that
differs from their own

Prevalence of about 1 to 1000; more boys than girls (ratio of 2:1)

Age of onset is about 3 years old
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PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of Childhood:
Pervasive developmental disorders

The aetiology of autistic disorder

Genetic vulnerability for pervasive developmental disorders
generally, rather than one specific to autism

Other possible biological factors include:



Pre-natal and perinatal insults, such as maternal ill-health during
pregnancy
Extremely severe social deprivation
The treatment of autistic disorder

Early intervention is very important


Behaviour modification programs have been found to be effective


Aim is to help the child develop better social and emotional
relationships, learn better communication skills, and decrease
stereotypic behaviours
Analysis of the child’s environment and reinforcement procedures
Pharmacotherapy can be used to target specific problems such as
aggression and hyperactivity
10-18
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of Childhood:
Pervasive developmental disorders

The diagnosis and epidemiology of intellectual impairment
(mental retardation)

Heterogeneous group of disorders with multiple causes, all of
which involve
a) cognitive limitations due to organic brain dysfunction
b) functional limitations in daily-living skills, communication skills, and
social skills

An intellectual quotient (IQ) of less than 70

The estimated prevalence is 1%, with 85% of those within the mild
range of intellectual impairment

More boys than girls are diagnosed

The onset must occur no later than 18 years of age
10-19
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Disorders of Childhood:
Pervasive developmental disorders

The aetiology of intellectual impairment

In 43-70% of cases of severe intellectual impairment there is a
known cause, versus 20-24% of cases with mild intellectual
impairment

Possible causes include:





More than 500 genetic conditions
Exposure to toxic agents during pregancy
Perinatal conditions such as maternal infection and low birth weight
Traumatic brain injury
The treatment of intellectual impairment
Important to treat any underlying condition
Early interventions such as physical therapy, speech therapy, family
support
 Identify any associated or co-occurring physical conditions
 Finally any mental health problems need to be identified and treated



This includes ongoing assessment and support to monitor any emerging
conditions
10-20
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd
Summary


Approaches to the understanding and classification of childhood
disorders
Externalising disorders
Diagnosis, epidemiology, and aetiology of oppositional defiant disorder,
conduct disorder, and attention deficit hyperactivity disorder
 The treatment and prevention of externalising disorders


Internalising disorders


Elimination disorders


Diagnosis, epidemiology, aetiology and treatment of enuresis and
encopresis
Learning disorders


Diagnosis, epidemiology, aetiology and treatment of separation anxiety
disorder and selective mutism
Diagnosis, epidemiology, aetiology and treatment of reading disorder
Pervasive developmental disorders

Diagnosis, epidemiology, aetiology and treatment of autistic disorder
and intellectual impairment
10-21
PPTs t/a Abnormal Psychology 1e by Rieger - Copyright  2009 McGraw-Hill Australia Pty Ltd