Developmental & Disruptive
Disorders of Childhood and
Adolescence
January 18, 2012
Will Beyer, LSPE-HSP, LPC-MHSP
The ADHD/LD Clinic of Tennessee
731-660-2850
willbeyerlpe@gmail.com
There is nothing new under
the sun. (Solomon- Book of
Ecclesiasties)
“You will never accomplish
greatness without loving what
you do. Steve Jobs- CEOApple Computers.
“Stay Hungry, Stay Foolish”
Where is happiness not found?
 Alcohol or drugs
 Sex, food, or money
 Education or knowledge
 Power or position
 Any “Thing”
 In the past or in the future
 In “Control”
Where do we find happiness?
 Healthy Relationships
 Special Moments
 Practicing Forgiveness
 Regularly engaging in acts of kindness
 In Healthy Living
 In our Spiritual Lives
The Words and Wisdom of
Forrest Gump
 “I may not be a smart man, but I know what love
is.”
 “Sometimes there just aren’t enough rocks.”
 “I could run like the wind blows!”
 “I gave Bubba’s mother his share. I had to keep
my promise.”
 “You can sit here.” Jenny
 “I love to beat up on Notre Dame!” (I don’t recall
where this is in the movie, but I’m kinda sure it is
in there somewhere.)
Keymakers
 Some people see a closed door and turn
away. Some people see a closed door, try
the knob and if the door doesn’t open, turn
away. Some people see a closed door, try
the knob, and if the door doesn’t open, they
find a key, and if the key doesn’t fit they
turn away. A rare few see a closed door, try
the knob and if it doesn’t open, find a key,
and if the key doesn’t fit… they make one!
What Have I Learned About Kids?
 All children need and desire love and approval. “Tell them you care and
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want to help. Be real, and don’t fake it.”
Most children with anger problems have been deeply hurt and are
grieving. “Acknowledge their losses and comfort them.”
Children with anger problems have difficulty seeing a future. They often
feel helpless and hopeless. “Give them hope and help them regain a
vision for the future.”
Human behavior is complicated. Do not oversimplify behavior. “Think
like a scientist, use methodology, study hard and ask lots of questions.”
All children need safety in times of “storm and stress”. “Provide a safe
haven.” Programs do not change people-Relationships do!
Self-control begins with self-talk. “When what they say to you and what
they say to themselves is the same, trust has been established.”
If we punish or scare children into compliance, we increase the need for
supervision and decrease their self-control and individual initiative.
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What I have learned about kids,
cont.,
 Treat the child with fairness, consistency and respect while clearly
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communicating expected behavior, reasonable consequences and
reward for success. Take them from where they are, not where they
should be.
Parent’s generally love their children, but they may not understand
why their child is having problems, nor how to help. Therefore, treat
the parent with respect and seek to form a collaborative relationship.
Children themselves may not understand why they are are struggling
with self-control.
Tantrums represent a signal of helplessness and a test to assert one’s
own independence.
Violence demands that people listen. It empowers the person.
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Sequence of Topics for this Program
 Brain Development and etiological factors
 Observing and interviewing for developmental
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problems/Biological mechanisms in psychopathology
ADHD
Oppositional Defiant Disorder
The Angry/Aggressive Child
Effects of Divorce
Abuse/ Maltreatment/Trauma/R.A.D.
Mental Retardation/Developmental Delay
Learning Disabilities
Tic Disorders/Tourette’s/Impulse Control Disorders
Autism/Pervasive Developmental Disorders
Fear and Anxiety/PTSD
Childhood Depression
Neurogenetic Disorders
DSM-IV Disorders of Infancy,
Childhood or Adolescent
Mental
Retardation
Learning
Disorders
(Reading,
Math,
Written
Language
Motor Skills
Disorders,
Development
al
coordination
Communicati
on Disorders
(expressive
languagemixed recepexpres,
phonological
disorders)
Pervasive
Development
al Disorders
(Autistic,
Rett’s
Asperger’s)
ADHD and
Disruptive
Behavior
Disorders
(ODD, C.D.)
Feeding and
Eating
Disorders
(Pica, etc.)
Tic Disorders
(Tourette’s,
Chronic vocal
or Motor Tic,
Transient Tic)
Elimination
Disorders
(Encopresis,
Enuresis
Other:
Selective
Mutism, RAD,
etc.
DSM-V Revisions
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Intellectual Developmental Disorder/ IDD or Global
Developmental Delay-NOS (not M.R.)
Bi-Polar Disorder- More stringent criteria for children
Gender Dysphoria (Moved out of sexual disorders)
Hypersexual Disorder
Oppositional Defiant Disorder- (Angry/Irritable
Mood/Headstrong Behavior, and Vindictiveness)
Behavioral Addictions-gambling
New Suicidal Scales to determine risk.
Temper dysregulation with Dysphoria (TDD)
Communication Disorders (Language, Speech, Social
Communication)
Autism Spectrum Disorder (inclusive of PDD & Aspergers)
Deleting specific categories of Schizophrenia
Attention Deficit Hyperactivity Disorder-Age change and
number of criteria required.
Specific Learning Disability
Case Study
 13 year old female, African-American/Professional parents
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recently relocated/private school.
Not paying attention in class/ Acted like she had a hearing
problem. Previously diagnosed ADD and prescribed meds.
Not much help.
Headaches, impaired appetite/obese, Ringing in ears
Flattened affect- looked depressed/spacing out
Speech and language had diminished/slow talking.
Expressive language was impaired.
Slow writing and weak motor movement.
*Not athletic/poor balance.
Case Study… Cont.,
 Elevated scores on ADHD checklist consistent with ADD
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I.T.
Clinically significant scores on Child Depression Inventory
Underachieving in school.
Complained of body aches/Didn’t feel good.
Daydreamed/lost in her own thoughts/slept
excessively/Schizoid features/Poor Socialization
WISC-IV: VCI = 78, PRI =84, WMI = 72, PSI = 68
WIAT-III- Reading Comp- 78
Adaptive: 88
Emotionality: P-MACI= Elevated -Somatization, ADD,
GAD. OCD
Differential Diagnosis?
 ADHD-Inattentive Type
 Borderline Intellectual functioning
 Learning Disability/Language Disorder
 Adjustment Disorder
 Dysthymia or Mood Disorder
 Selective Mutism
 Early somatization symptoms
 Early onset schizophrenia or psychosis
Then I noticed….
 A few café au lait splotches on her legs and arms.
 Small subcutaneous bumps starting under her
skin, swollen joints.
 I remembered Tinnitis symptoms, headache,
balance problems, flattened affect in face
(paralysis).
 Hypotonicity in arm and leg strength
 *Then I had a “House” moment… what if she
has….?
NF-1 Neurofibromatosis-Type 1
 Long arm q of chromosome 17
 Encodes for the protein (neurofibromin)
which is a tumor suppressor (usually
benign). Subcutaneous tumors begin to
grow and café au lait clusters with
neurological symptoms emerging.
(headache, lethargy, depression, attention
deficits, facial paralysis, learning
disabilities, etc.)
 NF-2 is chromosome 22q-
Case Study: Timmy Tornado
Development: Born 10 weeks
premature, mother used
methamphetamine in utero and heavy
smoker. Emergency C-Section/fetal
distress
Age 9: Hasn’t spoken, Makes
sounds, extremely hyperactive, PICA,
Lives in old house, self-injuriousbites, hits, head butts, younger sibling
in the home.
Timmy Cont.,
2-3 simple gestures
Meds: Seroquel, Trileptal, Ambien,
Risperdal, Melatonin, (Has been on Haldol,
Ritalin, Neurontin, and Depakote in the
past) *Only seen Physician Assistant.
*Severe PICA: Feces, balloons, pins, glass,
buttons, teeth, toys, insects, rocks, etc. etc.
Impaired Social Interaction, Motor
Movement, impaired communication,
restricted or repetitive patterns of behavior.
Discuss: Assessments and
Treatment Plan
1. Initial diagnostic Impression?
2. What assessments may prove
useful?
3. Where do you start?
4. To whom do you refer and why?
5. *Complication: Indigent family/TN
Care only.
To get it right we may need..
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Direct Observations
Rating Scales
Hearing, Vision, Speech and Language
Play Based Assessments
Functional Assessments
Occupational Therapy
Physical Therapy
Intellect and Achievement
Developmental Inventories
Adaptive Behavior
Brain Development
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Begins in week three with
neuroectoderm and forms the neural
plate
Cell Proliferation-Neural plate-neural
tube-brain and spinal cord
Cell Migration-neurons move to
specific regions to their final positions
Cell Differentiation- segmenting
Cell Death (apoptosis) (Pruning)
(Stress, nutrition, drugs, chemical
contaminants, hypoxia, gene expression,
etc.)
Neurodevelopmental
Disorders-Etiology
• Deprivation
• Genetic
• Immune Dysfunction
• Infectious Disease
• Metabolic Disorders
• Nutrition
• Trauma
• Toxic and Environmental Factors
Common Neurotoxins to the
Fetal Brain
Affect the transmission of chemical signals
between the neurons:
Lead, Mercury, Toluene, Dioxins, PCB’s,
Arsenic, Alcohol
There are both presynaptic and
postsynaptic effects such as interfering
with production of transmitters, to
conduction of action potentials, transmitter
storage, transporter molecules and
transmitter metabolism
Biological Mechanisms involved
in Psychopathology
 Severe Maltreatment-(3 million cases per year/one-third
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between ages 3 and 7.)
Disease (CNS infections (cytomegalovirus, toxoplamosis,
rubella, herpes simplex, HIV, HIB meningitis)
Nutrition
Accidental Injury
Genetics: (ADHD, Fragile X, PKU, etc.)
Exposure to Toxins: Lead, ETOH, cocaine, etc.
In utero: Stroke, hemorrhage, anoxia, etc.
Most Common Causes of
Neurological Insult
 Prenatal (includes genetic), 80-85%
 Perinatal (most often asphyxia), 5-10%
 Postnatal- 5-10%
 Testing for hypothyroidism (1 in 4000) and
Phenylketonuria (1 in 12,000) has reduced M.R.
 Most common chromosomal-Down’s-1 in 700,
Fragile X, 1 in 800 males, Trisomy 18-1 in 4000.
(Prader-Willi syndrome, Wilson’s Disease)
Medical Assessments
• Genetic Studies
• Brain Image Studies ( MRI, FMRI,
CT, EEG, SPECT, PET, etc.)
• Metabolic Screens (blood and
urine- for how the child
metabolizes food.
• Lead Chelation (Pica)
Drugs that affect the fetus
Tobacco
Vaccines Vitamins Alcohol
Narcotics
Anti
Cancer
Agents
Anti
Seizure
Antibiotics
Sex
hormones
Barbituates
Stimulants
Designer
Drugs
Aspirin
Anti
Anti
Coagulants Psychotics
The Mental Health of the
Child begins in Utero
Low Birth Weight
Precipitous Birth
Exposure to Toxins/drugs
Tobacco
STD’s
Poor Nutrition
Absence of Prenatal Care
The Relationship between AOD Use
and Psychiatric Symptoms and
Disorders
 AOD can mask psychiatric symptoms and disorders.
 AOD can worsen the symptoms of psychiatric disorders.
 AOD withdrawal can cause psychiatric symptoms and
mimic psychiatric disorders.
 Psychiatric disorders and AOD disorders can co-exist.
 Psychiatric disorders can mimic behaviors associated with
AOD abuse.
 AOD can cause psychiatric symptoms and mimic
psychiatric disorders.
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Environmental Factors
Pre or postnatal
Acute or Chronic
Single or Additive or multiplicative
Biochemical or Social
(Parenting style, family interaction,
peer interaction, education, culture,
community)
Prevention of Childhood
Disorders
Good prenatal care.
Targeting low income
teenage mothers linking to
community services.
Character Development in
early years
Protect against abuse and
neglect.
Targeting caregivers/Increase
Training Opportunities.
Environmental change.
Enhance educational
opportunity.
Target 5th-7th grade
males at risk for
delinquency.
Protect against accidental
head injury or
Neurological Insult
Educating Parents About Risks
 Drowning- Pools, 5
 Bicycle helmets/ car
gallon buckets,
bathtub, etc.
 Suffocation-dry
cleaner bags, coins,
toys, refrigerators,
ropes, hanging,
chemical, ageappropriate foods
 Burns- matches,
gasoline, etc.
seats
 Toxic chemicals
 Child Safety gates
 Bars on upstairs
windows.
 Child resistant
containers
 *Safety walkthrough/checklist
Birth Psychology- What have we
learned?
 The placenta doesn’t always protect the prenate.
(Pollution-solvents, metals, radiation, pesticides)
 Ubiquitous exposure to adults-nicotine, caffeine,
aspirin affect growth and development.
 Prenates are learning: voices, music, stories
 Brain growth spurt-Beginning of third trimester to
age 2. R.H. maturation- once and for all
opportunity.
 The effects of nutrients: folic acid, taurine, etc.
 The importance of attachment.
Chromosomes
Humans normally have 46 chromosomes in
each cell, divided into 23 pairs. Each
parent contributes 23. Changes in genomic
imprinting disrupt the regulations of genes
resulting in inaccurate copying from either
the paternal or maternal copy. A missing
piece of the chromosome is called a
“deletion”
(p) Is the short arm for petit.
(q) Is the long arm (next letter in the
alphabet)
Behavioral Genetics
100,000 genes in human genome.
Tens of thousands of genes contribute
to neuroanatomical and
neurophysiological substrates in the
CNS.
The expression of a gene depends on
the genetic milieu in which it is
placed and the interaction with the
environment.
Chromosome 11
Chromosome 11 contains 134 million
DNA building blocks (base pairs) and
represent 4 percent of the total DNA
in cells.
Chromosome 11 Disorders include:
Beckwith-Widemann (p) short arm
JacobsenSyndrome (q) long arm
Neuroblastoma/Leukemias/lymphomas
Ewing Sarcoma ( (t) fuses Chromosome 11 and
22)
Genetically Determined
Disorders of Cognition
• Chromosome 11 q-syndrome
• Down’s Syndrome- 1/1000
• Fragile X Syndrome- 1/1250 males
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and 1/
Kleinfelter Syndrome 1/1000
males
Turner Syndrome-1/2500 females
Prader-Willi Syndrome
Phenylketonuria- 1/10,000
Classification of Neurogenetic Disorders
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Autosomal Recessive Disorders- (Ex. PKU,
Tay-Sachs)
Autosomal Dominant Disorders-(Ex.
Huntingdon’s Disease)
Sex-Linked Disorders (Ex. Fragile X, Turner’s
Syndrome)
Genetic Deletion Disorders- (Ex. Prader-Willi
Syndrome, Monosomy 21)
Multifactorial Chromosomal Abnormalities
(Dyslexia, Schizophrenia, Parkinson’s,
Tourette’s, Alzheimer’s, Depression)
Extra Genetic Material DisordersKlinefelter’s Syndrome XXY, Jacob
Syndrome XYY
Developmental Delay
 D.D. is more appropriate when cognitive
ability and adaptive behavior are
significantly below average.
 Used when clear-cut data is not available to
diagnose mental retardation.
 Parent or pediatrician may first raise
concerns that the child “seems behind”.
 Motor skills, speech, language, cognition,
social, emotional delays
Human Behavior is defined
as…Vt=Vg +Ve+Vg+Ve
Phenotype: The observable physical or
biochemical characteristics of an organism, as
determined by both genetic and environmental
influence. Genotype is the genetic makeup of a
cell (the combnation of allele makeup of the
individual)
Vt, the total phenotype variance, equals Vg, the
component of variance due to genetic factors plus
Ve, the component of phenotypic variance due to
environmental factors, plus a component of
variance which reflects specific geneenvironmental interactions.
Restriction Fragmentation Length Polymorphism (RFLP)
DNA is cut by a restriction enzyme
The DNA fragments are separated
by electrophoresis
The fragments are transferred to a
membrane by the Southern blot
procedure
Hybridization of the membrane to
a labeled DNA probe
Each fragment is considered an
allele
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Genotyping is the process of elucidating the genotype
of an individual with a biological assay.
Restriction fragment length
polymorphism (RFLP)
Terminal restriction fragment length
polymorphism (t-RFLP)
Amplified fragment length
polymorphism (AFLP)
Multiplex ligation dependent probe
amplification (MLPA)
Chromosome 18q-Syndrome
Deletion of long arm of (q) of
chromosome.
Symptoms: short stature, hypotonia,
abnormalities of skull, face, deeply
seated eyes, prominent ears,
visual/hearing abnormalities, heart
defects, malformations of hand and
feet. Carp shaped mouth, *Lots of
variability in severity of symptoms.
Not always low functioning.
Rett Syndrome
 Normal pre-perinatal development through first 5
months (boys), first 28 months (girls).
 Decelerated head growth from age 5 to 48 months
(neurodegenerative disorder) MECP2 gene
(Seizures, gastrointestinal problems, No verbal
skills,
 Progressive loss of motor, then cognitive skills.
*Hand movements, stereotypic hand movements
such as hand wringing and poorly coordinated
gait.
 Mental retardation. *Severe to Profound.
Down’s Syndrome
 Down’s Syndrome-Trisomy 21. Increasing
risk with maternal age. Mean IQ = 47-50.
 10% are institutionalized.
 Physical characteristics-high cheek bones,
microcephaly, large tongue, small round
ears, hypertonic muscles.
 Prone to congenital heart defects, infections,
and injury. Temperament is typically
friendly and love music.
Huntington’s Disease
(Chorea)
Chromosome 4 (CAG Repeat) Huntingtin gene (HTT) codes
for protein Huntingtin
Trinucleotide repeat (CAGCAGCAG) Cytosin-adenineguanine)
Symptoms: Behavioral disturbance, hallucinations,
irritability, restlessness, psychosis, facial movements,
unsteady gait, anxiety, speech impairment, “prancing” walk,
etc. (basal ganglia in striatum) 250,000 Americans have
H.D.
Symptoms can begin anytime but usually begin between 3544 years of age. *Search youtube (The Real Huntington’s
Disease The Sequel)
Dopamine blockers may slow progression, possible coenzyme Q10, Amantadine may help.
Sydenham’s chorea
Etiology: Infection with Group A betahemolytic streptococcus. (basal ganglia
and corpus striatum)
Occurs in 20-30% with acute rheumatic
fever. (youtube: Syndenham’s chorea:
Rebekah Everest
May occur 6 months after infection.
Symptoms: chorea, slowed cognition,
facial grimacing, hypotonia, hand milking,
(Not PANDAS)
50% recover in 6 months.
What are the needs of the children I
serve?
 Self-Control (Impulse, aggression, etc.)
 Mood Stability
 Cognitive (Reasoning, Problem Solving)
 Self-care skills (hygiene, cleanliness)
 Social skills: (Conflict Resolution)
 Academic: (Reading, Writing, Arithmetic)
 Motor skills: (fine & gross motor)
 Language/Communication skills
 Virtues and Character Development
Intelligence
 Fluid-strong heritability, independent of
education and experience. Matrices, figural
relations, abstract, non-verbal.
 Crystallized-increases with experience and
education. Verbal Comprehension,
Arithmetic, Vocabulary, Knowledge of
facts, Deductive Reasoning, Associative
memory
Substance Abuse in those
with Intellectual Deficiency
2.6% with I.D. have S.A. (Slater, 2010)
Start drinking a couple years later than peers.
Less likely to be Caucasian.
Less likely to seek help and less likely to receive it
when sought.
More likely to be prescribed medication.
Greater risk of accidental overdose.
More likely to have legal issues.
More likely to have another co-morbid mental
illness.
Poor reading skills limit access to materials and
programming.
Functional Delay
“A continuous, significant delay in intellectual
functioning and achievement which adversely
affects the students ability to function in the
general school program, but adaptive behavior in
the home or community is not significantly
impaired.
Significantly impaired intellectual functioning two or
more standard deviations from the mean.
B. Deficient academic achievement below the 4th percentile
in two areas: basic reading, reading fluency, reading
comprehension, math problem solving, math
calculation, written expression.
C. Home or school adaptive behavior above that for
intellectual deficiency.
A.
Diagnosis of Mental Retardation
 Intelligence 70 or below (SEM = 3)
 Adaptive Behavior- In at least two areas:
Communication, self-care, etc.
 Not a single disease, syndrome or symptom,
but rather a state of cognitive impairment
that is identified by the behavior of the
individual.
 Not always readily identifiable. They can
look, act, and talk normally.
Diagnosis of M.R. cont.
 May be classified as M.R. at one time
during their lives and not at another.
 Etiology is varied and complex. May
include both genetic and environmental
factors.
 IQ’s of 70 to 84 are considered borderline
intelligence.
Category of Mental Retardation
 Mild = 50-55 to 69
 Moderate = 35-40 to 50-55
 Severe = 20-25 to 35-40
 Profound = below 20
Adaptive Deficits
 Self-care
 Leisure
 Communication
 Health
 Safety
 Academic Skills
 Self-direction
 Home living
 Social Interpersonal
 Tests: Vineland
 Use of Community
Resources
Adaptive Behavior
Scales and Adaptive
Behavior Evaluation
Scales
Social Skills
 The ability to communicate and interact
with peers and adults in an appropriate
manner.
 The ability to adapt to new environments.
 The ability to interact in groups and
conform to expected social behaviors.
 Basic knowledge of facts and social
judgment.
 The ability to solve conflicts.
Teaching Strategies to promote
skill acquisition
 Check frequently for understanding.
 Teach students to use self-talk.
 Use the skill in several different learning
environments to promote generalization.
 Prompt to focus attention.
 Prompts-Natural, Visual, Verbal, Modeling,
Physical Guidance
Methods for teaching students
with low cognitive functioning
 Break task down into small steps.
 Demonstrate/model
 Positive reinforcement of desired behavior
 Shaping-Operant Conditioning
 Community Based instruction
 Individualized instruction
 Self-contained classrooms/LRE
Curriculum for Students with MR
 Basic academics-
 Accepting
reading, math, writing.
 Math- counting, telling
time, measurement.
 Reading- functional
vocabulary
 Social Skills
 Life Skills
 Making choices,
decisions
responsibility
 Safety Issues
 Self-determination
 Legal issues
 Conflict Resolution
 Health issues
 Vocational
Assessing Motor Skills
 Eye Tracking
 Balance in seat with
 Palm Rotation
feet and arms extended
 Number Recognition
(1,3,9)
 Skipping
 Touch finger with arm
extended.
 Resistance
 Hand grip
 Finger to thumb
 Balance on one foot
 Heel to toe- Front and
back.
 Draw a circle, line,
square, triangle
Coordination Disorder
 Delays in achieving motor milestones, e.g.
walking, crawling, sitting) dropping things,
clumsiness, poor performance in sports,
handwriting, etc.
 Additional problems may include: cerebral
palsy, hemiplegia, muscular dystrophy.
To Improve Disorganization
 Reinforce organization
 Is the task too difficult?
efforts.
 Use a peer model.
 Provide time for
organization.
 Provide storage space
 Evaluate: Is the length
of time to complete
the task appropriate?
 Increase prompting and
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cueing.
Demonstrate and rehearse
procedure.
Establish routine.
Use color coded
organizational system.
Minimize needed
materials.
Autism/PDD
 Impairment in Communication- Receptive skills
tend to be better than expressive.*Loudness,
intonation, rhythm, stress. *Echolalia
 Social impairments- eye contact, facial
expressions, gestures, (how skillful does the child
relate to peers) Difficulty in imitation, affective
expression.
 Stereotypic Motor Movements.
 Lower intellectual ability
 *Significant heterogeneity
 *Six symptoms across two categories, with at least
two symptoms in the social category and one in
the restrictive/repetitive behavior category.
Interesting Facts about Autism
 20-33% have seizures
 Elevated Serotonin
 Frequent
levels (also in first
degree relatives)
 Fragile X is present in
8% of individuals with
autism.
 Higher rate in
monozygotic than
dizygotic twins
complications in
pregnancy
 Occurs more often
with viral infections.
 Difficulty with
autonomic arousal
Asperger’s Syndrome
 *May be high functioning autism.
 Higher cognitive and language ability.
 Clear social impairments: Social
awkwardness, motor clumsiness,
idiosyncratic or engrossing interest.
 *Absence of deficits in intellect, adaptive,
or language abilities.
Communication Disorders
 Expressive Language
 Receptive Language
 Mixed Expressive-Receptive Language
 Phonological (articulation)
 Stuttering
 Dyslexia, Dysgraphia
Sex Errors of the Body
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Triple X Syndrome XXX- Increased M.R.
Turner Syndrome: X (Short stature, missing ovaries or
testicles, low IQ,
Klinefelter Syndrome XXY- male, insuffient
masculination, sterility, low sex drive, learning
problems
Androgen Insensitivity Syndrome- Male
hermaphroditism, defective gene on x chromosome (Sex
assignment is female) Remove testicles and female
hormone replacement)
Congenital adrenal hyperplasia- female
hermaphrodistism- female internal organs, male external
organs
Gender Identity Disorder
*(1) Strong and persistent crossgender identification, as manifested
in a desire to be or belief that one is
the opposite sex, preferences for
stereotypical cross-gender clothing,
etc.
(2) Persistent discomfort with one’s
own sex in aversion to one’s own
genitalia or sex typed behavior,
activities or clothing.
Homosexuality
*Not a mental disorder.
*Possible genetic basis: Twin studies
concordance rate is 52% for MZ and 22%
for DZ, 11% for adopted brothers, and 9%
for sons of homosexual fathers.
Possible prenatal hormonal influence
Possible Maternal immune response
Differential socialization
Identification with opposite-sex parent
Intrauterine Causes
 Fetal Alcohol Syndrome- 1 in 600, flat
cheeks, short nose, thin upper lip, flat
filtrum, growth retardation, weak cognitive
abilities, hyperactivity, attention deficits
 Fetal Alcohol Effected- 1 in 200-300,
ADHD, lower IQ, math deficits,
 Asphyxia- maternal hypertension, toxemia,
placenta previa, etc.
Learning Disabilities
Learning disabilities is a generic term that
refers to a heterogeneous group of disorders
manifested by significant difficulty in the
mastery of one or more of the following:
Listening, speaking, writing, reasoning,
mathematical, reading, etc. Even though it
may occur concomitantly with emotional
disturbance, cultural differences,
environmental influences, sensory impairment,
etc. it is not the direct result of the conditions
of influences.
Subtypes of L.D.
 BASIC
 NONVERBAL
LEARNING
PHONOLOGICAL
DISABILITY
PROCESSING
 Neuropsychological
DISORDER
Deficits: visual/tactile
 Neuropsychological
perception/visual
Deficits: auditory
memory/concept
attention/auditory
formation
perception/verbal
 Early graphomotor
memory/word
deficits
decoding/spelling/R.C.
Tests commonly utilized
when testing for learning
disabilities:
Intellectual: (WISC-IV, WAISIV,SBIV, WJ)
Achievement: (WIAT-III, WJ)
Rating Scales: (Vanderbilt, Conner’s,
etc.)
Teacher Observations: (Auditory,
Visual, Behavior)
Language Functioning:
Recognizing Tics
Simple
Motor:
Eye
Blinking
Neck
Jerking
Shoulder
Shrugging
Facial
Grimacing
Complex
Motor:
Facial
Gestures
Jumping
Simple
Vocal:
 Barking
Coughing
Grunting
Hitting
Throat
Biting
Clearing
Stamping Sniffing
Smelling Snorting
objects
Complex
Vocal:
Echolalia
Coprolalia
Palilalia
Tourette’s Syndrome
 A tic is defined (DSM-IV-TR) as a “sudden, rapid,
recurrent, nonrhythmic, stereotyped motor
movement or vocalization.
 Three times more males than females.
 Co-morbid with OCD, ADHD, and LD
 TS requires at least two motor tics and one vocal
tic. Must occur several times a day and be present
for one year or longer.
 Coprolalia occurs in about 60%- clicks, grunts,
yelps, barks, sniffs, snorts, coughs.
Stereotypic Movement Disorders
 Head banging, body rocking, self-biting, self
picking at skin, self-hitting, mouthing of objects.
 3.5 times more often in boys than girls.
 In a study of 60 children under 10 years of age
referred for EEG testing, 40% had pseudoseizures
consisting of rhythmic movements or staring
episodes.
 May be related to avoidance of aversive
consequences. *Higher rates in abused children.
Teeth Grinding/Bruxism
 Habitual gnashing, grinding, clicking, or
clenching of the teeth. (male to female 3:1)
 May occur nocturnally or diurnally.
 Etiology: Learned behavior related to
response to stress./ Malocclusion, rough
teeth, oral infections
 Treatment: Bite block, psychotherapy,
biofeedback, anxiety reduction
Thumb Sucking
 Sucking of one or both thumbs, but may also
include finger or fist sucking.
 Incidence: 45% of 2 year olds, 42% of 3 year olds,
36% of 4 year olds, 20% of 5 year olds, 5% of 11
year olds.
 Tends to occur when hungry, sleepy, frustrated,
fatigue. May suck a blanket, rub a cheek with a
pillow or blanket.
 Etiology: Tension Reduction
 Treatment: Aversion-nagging, gloves, splints,
bandages, palital crib, pacifiers, foul tasting
liquids
PICA (307.52)
*Commonly associated M.R.
*Potential risk of lead, toxoplasmosis,
hair balls, intestinal perforation.
*For at least one month of eating
non-nutritive substances
inappropriate to developmental level.
Obsessive-Compulsive Disorder
 Incidence: 0.2 %
 Obsessions: Irrational thoughts (fear, anxiety,
need to avert perceived danger) “It doesn’t feel
right.”
 Compulsions: Irrational behaviors (counting,
checking, cleaning, etc.)
 Frequently co-morbid with ODD, ADHD, Anxiety
disorders, phobias, learning disabilities (reading or
language delays)
 Etiology: Unknown (PANDAS)
 Treatment: Psychodynamic, behavioral, family,
pharmacotherapy
Posttraumatic Stress Disorder
 Constellation of symptoms associated with
trauma:
 A. Reexperiencing symptoms
 B. Avoidance
 C. Hyperarousal
 Intrusive thoughts, images, distressing
dreams, detachment,
Stressors associated with PTSD
 Parental Conflict,
 Family Deaths or
Separation or Divorce
 Witnessing or learning
of a traumatic event
 Child Physical or
Sexual Abuse
 Serious Accident
Serious Illness
 Natural DisasterTornado, Hurricane,
Flooding, Earthquake,
etc.
 Frequent Moveschanges in schools
 Victim of Assault
Symptoms of PTSD
 Hypervigilance
 Difficulty sleeping
 Restricted Emotions
 Irritability or Anger
 Exaggerated Startle
 Avoidance of
Response
 Nightmares
 Intrusive, distressing
thoughts
 Flashbacks
activities associated
with the trauma: “I’m
not going back to
school.”
 Disruption of routine
 Detachment
PTSD Continued
 Prevalence: 5-13 % following exposure to
hurricanes, burns, physical abuse, cancer
treatment. 43-70% following sexual abuse,
schoolyard sniper attack, war trauma.
 Etiology: Cognitive,Behavioral,
Neurobiological
 Treat 7-14 days after exposure. Individual
and family therapy; medication, co-morbid
problems.
Trauma and the Brain
 Activation of higher cortisol levels.
 Chronic pain, digestive problems, weakened
immune response.
 Hyper-vigilance (higher adrenal output)
 Changes in brain arousal level (dopamine,
norepinephrine)
 Problems in shifting (serotonergic) controlling
thoughts.
 Brain atrophy in multiple areas: amygdala,
hippocampus, prefrontal, striatal, etc.
87
When working with trauma
victims …
 Men do not disclose their histories of sexual and
physical abuse easily.
 Victims fear being judged, feelings minimized,
labels, being medicated, disbelief of others.
 Understand the power of threat.. “If you tell I will
kill your sister.”
 *If you go there… you better have the skills to
help! Do no harm!
88
Differential Response to Threat
(Matthew Perry, Ph.D.
www.childtraumaacademy.com)
 DISSOCIATION
 HYPERAROUSAL
 Detached
 Alarm Response
 Numb
 Flight-Panic
 Compliant
 Fight-Terror
 Suspension of Time
 Anxious
 Brief Psychosis
 Reactive
 Fainting
 Hypervigilance
 Freeze-Fear
89
Brain Plasticity
 Brain Plasticity means the brain changes
because of experience.
 Neural connections occur because of
learning.
 The brain becomes thicker and denser with
learning.
 Depression may result in brain atrophy.
 Drug use results in neurochemical
dysfunction.
Mental Health Goals
 Reduce self-injurious behaviors
 Reduce agitation and aggression/Improve Self-
control.
 Reduce anxiety/phobic behavior
 Reduce defiance/Improve Compliance
 Reduce psychotropic use.
 Reduce distractibility/Improve Attention to Task
 Reduce impulsivity/Improve Executive
Functioning
Symptoms of Depression in
Children
 Depressed mood
 Irritability or
 Diminished interest in
oppositionality
 Decreased energy or
motivation
 Psychomotor
retardation or agitation
*2 weeks duration-5 or
more symptoms.
activities
 Sleep disturbance
 Weight loss or gain
 Inability to
concentrate (attention
problems)
Assessment of Depression
Self-Report Questionnaires: Child
Depression Inventory, Reynolds
Child Depression Scale, Beck
Depression Inventory-II, Child
Behavior Checklist, K-SADS
(Co-morbid: learning disabilities,
PTSD, ODD, ADHD, etc.)
Rule-out: PDD, Anemia, PCS,
Disease, Substance Abuse
Meds for Adolescent
Depression
Avoid Tricyclic (cardiac/lethality)
Avoid MAOI’s
Avoid St. John’s Wort
SSRI’s and SSNI are most commonly
used.
Some use of heterocyclics such as
wellbutrin (bupropion)
Consider- fish oils, melatonin,
Vitamin D, B-12, B-6
Dysthymic Disorder
 Depressed Mood, most of the day, more days than
not, for at least one year.
 *Two or more of the following:
 Poor appetite or overeating
 Low energy or fatigue
 Low self-esteem
 Poor concentration or difficulty making decisions
 Feelings of hopelessness
The Delineation of Causation
 Predisposition
 Initiation
 Perpetuation
 Exacerbation
96
DSM-IV-TR Disorders of Childhood
ADHD/ADD
Autism
PDD, Rett’s
Childhood
Disintegrative
Disorder
Asperger’s
Oppositional
Defiant
Disorder
Mental
Retardation
Reactive
Attachment
Disorder
Tourette’s
Learning
Syndrome/
Disabilities
Tic Disorders
Disorders of
Communication
Depression
Mood Dis.
Motor Skills
Disorder
Separation
Anxiety
Selective Mutism,
Conduct
Disorder
Feeding and Adjustment
Eating
Disorders
Disorders
PostTraumatic Stress
Disorder
Elimination
Disorders
Interviewing Children
 Use Age-Appropriate
language: Children are
are not likely to point
out words they don’t
understand. Avoid
words such as, “guilty,
depressed, anxious,
disappointed”. They
do understand “mad,
sad, glad, and scared.”
 Sharing a snack or
drink may build
rapport.
 Be observant: activity
level, physical
appearance,
mood/affect, parentchild interaction,
coordination, etc.
The Role of Attachment
 Children rely on a parents availability to provide
comfort, safety and support.
 Insecurely attached children ignore their
caretakers when distressed and have difficulty
being soothed.
 RAD develops out of a pattern of parental
psychopathology, abuse, neglect, etc.
 RAD tends to predict increased rates of aggression
and mood lability.
99
Social Learning
 Exposure to aggression results in vicarious
learning experiences. (Television, video
games, role-models)
 Delinquent behavior can be learned through
direct observation.
 Delinquent behavior can be reinforced and
maintained by operant conditioning
(affiliation, acceptance, reward)
100
Assessing Minority Children
Guard against Inappropriate
Generalizations: There is no
monolithic black, HispanicAmerican, Native American, or
Asian-American subculture. This can
include lower-socioeconomic
children. We must check for our own
bias and prejudices as we assess.
The Disruption of Community
 Abandonment
 Hostility/Fear
 Hopelessness
 Degradation
 Abuse/Neglect
 Poverty
102
Endocrinatic Influences
Pituitary:
Produces growth
hormone
Regulates
Endocrine
system
Testes:
Thyroid:
Produces
thyroxingrowth/brain
development
metabolism
TestosteroneDifferentiation of male
reproductive system
and male sexual
maturation
Estrogen
Progesterone
Regulates menstrual
cycle
metabolism
Ovaries:
Adrenal Gland:
Stimulates
growth
Pubescence
Observing for Visual
Impairments
 Rubs eyes constantly
 Shuts or covers one eye, tilts head, or
thrusts head forward.
 Squints eyelids together or frowns
 Crossed eyes, inflamed or watery eyes
 Eyes itch, burn or feel scratchy
 Blurred vision, dizziness, headaches
Observing for Hearing
Impairments
 Frequent earaches/Sinus congestion
 Seasonal allergies
 Problems understanding spoken language.
 Inattention or lost in daydreaming.
 Often appears distracted or confused.
 Speech is loud.
 Turning head to hear.
 Frequent misunderstanding instructions.
Observing for Language
Impairments
 Articulation problems
 Fluency problems- abnormal rate and
rhythm (stuttering & cluttering)
 Phonology problems-construction of word
forms.
 Problems: listening, speaking, writing,
reading.
 Loudness/Quality/Pitch (disorders of
phonation/resonance
Observing for Social/Emotional
Impairments




Externalizing- Aggressive, acting out
Internalizing-Immature, Withdrawn Behavior
Encopresis/Enuresis
Self-stimulation: rocking, twirling, hand flapping,
staring
 Language Deviations: echolalia
 Cognitive Impairments
 Lacks of Daily Living Skills
 Self-Injurious Behaviors
Observing for Giftedness
 Exceptional Academic Achievement
 Exceptional Creativity
 Existence of Special Talents
 Insight-A qualitative difference in reasoning
and thinking.
 Abstract thought
 High task commitment
Alcoholism & Giftedness
“Higher childhood mental ability was
related to alcohol problems and higher
alcohol intake in adult life.” 2008
American Journal of Public Health
“For every 15 point increase in IQ there
was a 1.27 times increase for alcohol
abuse.
Gifted teens tend to be more adapt at
hiding their alcohol or drug abuse.
Alcoholism in professional women is
growing at exponential rates.
A Primer on Regional Brain Functioning
and Behavior
•NEURONS: Cell body- Axon, Synaptic bulb, Synapse,
Reuptake, Dendrite
•PREFRONTAL CORTEX: Executive
functioning,
neural braking, inhibition, gating, linking, (Dopaminergic)
•LIMBIC SYSTEM: Cingulate- shifting,
Hippocampus- memory, Amygdalarecognition of emotional affect.
(Serotonergic)
•BASAL GANGLIA: "idle speed",
(Noradrenergic)
•TEMPORAL: Memory, temper
Dopamine Effects
• Working Memory
• Shifting
• Cognitive Set
• Movement
• Motivation
• Too high dopamine may produce
tics (basal ganglia pushed too far)
111
Serotonin Effects
•
•
•
•
•
Response Inhibition- (Holding
back the action)
Mediates Mood Stabilization
Reduce obsessive/intrusive
thoughts (Ventromedial Cortex)
Reduce binges of (eating, sex,
drugs, etc.) *Assigning value to
stimulus. *Orbitofrontal Cortex
Integrates smell, touch, sight,
texture
112
What is ADHD?
“ADHD is a common neurobiological disorder affecting
5-7% of the school age population. 80% will persist into
adolescence and 50% into adulthood. It is characterized
by deficits in executive functioning including: inhibition
failure, working memory, sense of time, self-regulation of
affect/motivation/arousal resulting in impaired rulegoverned behavior.”
The Problem of Attention
 Old as Mankind- Attention is the heart of
self-control. It bridges time.
 Inattention and Impulsivity of childhood
connects excessive impropriety of
adulthood and feeds addictions.
 Attention rides on a genetic and
environmental substrate.
 To understand human weakness and
strength we must understand Attention.
114
Etiology Of ADHD
•Genetics: DRD2, D4RD, DAT-1 These gene patterns are
overrepresented. Twin studies-The concordance rate for ADHD
is 81% for MZ twins and 29% for DZ twins.
•Diminished arousal in the prefrontal cortex as demonstrated
through SPECT and PET scans.
•FMRI's have smaller right hemisphere plana temporal than
control group children.
•Environmental Toxins: (alcohol, drugs, tobacco)
•Pre/perinatal history (intraventricular bleeding, eclampsia,
toxemia, precipitous birth/low birth weight etc.)
•Diet, child-rearing, and common environmental toxins have
been effectively ruled out as providing credible explanations for
the etiology of ADHD.
DSM-IV CRITERIA
INATTENTION: Six or more (for six months) must be maladaptive
and inconsistent with the child’s developmental level.
(a) Often fails to give close attention to details or makes careless
mistakes
(b) Often has difficulty sustaining attention in tasks
(c) Often doesn’t listen when spoken to directly
(d) Often has difficulty organizing tasks and activities
(e) Often avoids, dislikes, or is reluctant to engage in tasks that
require sustained mental effort
(f) Often doesn’t follow through on instructions
(g) Often loses things
(h) Is often easily distracted
(i) Is often forgetful
DSM-IV Criteria, cont.,
Hyperactivity: Six or more for six months to a degree that is
maladaptive and inconsistent with the child’s developmental
level.
(A) Often fidgets with hands or feet or squirms in seat.
(B) Often leaves seat in which remaining seated is expected.
(C) Often runs about or climbs excessively in situations where
inappropriate.
(D) Often has difficulty playing or engaging in leisure activities
quietly.
(E) Is often “on the go” or acts as if “driven by a motor”.
(F) Often talks excessively.
DSM-IV- Criteria, cont.,
IMPULSIVITY:
(G) Often blurts out answers before the questions have been
completed.
(H) Often has difficulty awaiting turn.
(I)
Often interrupts or intrudes on others.
B. Some hyperactive-impulsive or inattentive symptoms that caused
impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more
settings.
D. There must be clear evidence of clinically significant impairment
in social, academic or occupational functioning.
E. Not better explained by PDD, or other disorders.
The stimulant/abuse controversy
“It is certainly true, for example, that some children with ADHD-many
of whom are taking stimulant medication or have taken it some time in
the past-become involved with substance abuse. It is even probable that
a higher percentage of children with ADHD experiment with illegal
substances than children who do not have ADHD. After all people with
this disorder are among the most impulsive in our society, and many
have been extremely unsuccessful in school and life in general. These
are the factors that can lead to drug abuse. In fact, the evidence
indicates that effective treatment of ADHD, which includes the use of
stimulants in many cases, improves self-esteem and makes substance
use less likely.
Likewise a sizable proportion of the inmates of juvenile detention
centers and prisons have a history of ADHD, and many of them have, at
one time or another, been treated with Ritalin. However, the probability
is that early treatment of these patients is more likely to prevent criminal
activity than lead to it.”
119
“We now have the first statistical
evidence that the treatment of ADHD
in childhood Is protective against
substance abuse in adolescence.”
Joseph Biederman, Professor of
Psychiatry at Harvard Medical School
and Chief of Pediatric
Psychopharmacology at
Massachusetts General Hospital
120
International Consensus Statement
January, 2002
1.
ADHD is recognized as a valid disorder by: The U.S. Surgeon
General, The American Medical Association, The American
Academy of Child and Adolescent Psychiatry, The American
Psychological Association, The American Academy of Pediatrics,
among others.
2.
ADHD is not a benign disorder. It can cause devastating
problems including interfering with educational attainment,
family functioning, social impairment, contributing to antisocial
activities, increased use of tobacco and drugs, increased teen
pregnancy, increased accident history, increased depression and
personality disorders.
3.
Neuro-imaging studies find metabolic differences. Twin studies
indicated genetic contribution. It is not the result of poor
parenting.
4.
The media has misled the public by distorting scientific evidence
about the disorder suggesting the disorder is not real or consists of
trivial affliction.
The debate continues…
Do children become addicted to stimulant medication?
The truth is that when stimulant medications are used to treat ADHD,
there is no evidence that patients develop any addictive syndrome.
Stimulant medication is a replacement that normalizes brain chemistry
based upon PET scans. They do not get “high”, nor do they need ever
increasing doses to achieve the same effect. Rather, the dose very often
remains the same or may even diminish as the child gets older. Children
on medications frequently skip the medication over the weekend or
holidays. These children are not pilfering medication or whining for
extra pills.
Some children may “rebound” when the medication is wearing off with
some increased irritability, but this is a minor side effect.
Stimulant medications have remained a first line treatment of ADHD
since the 1940’s with no evidence of serious side effects. Why then does
the controversy continue? ADHD children have long-lasting and
profound problems. To blame stimulant medication for the problems of
ADHD children is like blaming insulin for the long-term sequelae of
diabetes. (Thomas Spencer, M.D., Harvard Medical School)
122
COMORBIDITY AND ADHD
TIC D.
C.D.
ADHD
O.D.D.
Aggres.
Behavioral Inhibition
 Stop, Delay, Think, Analysis, Synthesis,
Act. Hindsight/Forethought/ Time
Awareness/ Self-awareness
Reasoning/Create Rules/ (Inhibiting a
Prepotent Response)
 Stop an ongoing response. *Interrupt
 Interference Control
A New Theory of ADHD
DEFICITS IN:
 INTERNALIZED SPEECH
 EMOTIONAL CONTROL
 WORKING MEMORY
 CREATIVE PROBLEM-SOLVING
COMORBIDITY AND ADD
Depress
OCD
ADD
Anxiety
L.D.
WORKING MEMORY
 Holding events in mind.
 Retrospective functioning




(hindsight)
Prospective functioning
(forethought)
Sense of time
Imitation of complex
behavioral sequences
Self-awareness
Identified Deficits by Research
Poor Persistence of Effort
Perseveration of Responding- (Inflexibility)
Impaired Behavioral Inhibition
Deficits in Performance, not in knowledge or skill
Planning, Sequencing, time conceptualization
Greater Variability in work performance
Less mature self-directed speech
Less efficient mental calculation
Reading comprehension
Differential Diagnosis
Tourette
Learning Fragile X
Syndrome Disability
OCD
Low IQ
TBI
PDD/Auti Anxiety
Social Anxiety
sm/Asp.
Disorder/ADD
ICD-NOS Depression/ A&D
Dysthymia Abuse
Physical
Illness(Mono)
PTSD
Personality
Disorders
Conduct
Disorder
ODD
Implications For Understanding
ADHD
It is more commonly a trait, than a pathology.
It interferes with “free-will”.
It is a disorder of performance, not lack of skill.
It requires long spans of time to become fully evident to others.
It creates great stress on the family. The family will look
dysfunctional, but improves when the child is absent.
It is contextually dependent.
It becomes more complex over time due to the development of comorbid conditions such as ODD, CD, SA, LD, etc.
It may not be a disadvantage in every situation.
Evaluating for ADHD
 Clinical history:
 Genetic co-morbidity
 Screen for other
neurological,
psychological
disorders
 Age of onset
 Severity of symptoms
 Setting
 DSM-IV criteria
 A brief measure of




intellect- working
memory,
Rating scales.
Achievement.
Rule-out…odd, PDD,
Tourettes, adjustment, etc.
*TOVA, WCS, FD may
give false positives or
false negatives.
Effects on the Family
 Increased marital tension.
A. More disagreements.
B. More supervision is required.
C. More criticism by family members.
D. More difficult to get babysitters.
Negative Parental Feelings Associated
with Parenting the ADHD Child
Frustration
Guilt
Shame
Fatigue
Anger
Helpless
Denial
Grief
Fear
Isolation
Exhaustion Loneliness
Confusion
Sadness
Anxiety
Worried
Parenting Principles for the
ADHD Child
 Practice Forgiveness
 Keep a Disability Perspective
 Use Positive Reinforcement
 Make Rules External
 Vacation Away From Your Child
 Join a Support Group
 Increase the Immediacy of Consequences
 Stay Away from Unproven Treatments
Parenting Principles, Cont.,
 Choose your fights carefully
 Don’t neglect your spouse and other
children.
 Modify expectations
 Grieve your loss of normalcy.
 Use token systems
 Learn about medication
 Become an advocate for your child.
Educational Management





Allow some restlessness.
Be animated, theatrical.
Create compliance opportunities.
Increase prompting and cueing.
Have access to rewards several times a day.
Increase immediacy of consequences/Reward
throughout the task.
 Increase frequency of consequences
 More frequent changes in consequences
 Maintain a disability perspective
 Don’t use multiple commands
Educational Management
 Use token systems.
 3 step command- Command-count 5,
Warning-Count 5 (Raise voice), Time-out
 After time-out reward next good behavior.
 Use occasional exercise periods.
 Teach “Think-aloud” approach
 Sit child close to teachers desk
 Act Don’t Yak!
 Stop repeating your commands
 Avoid lengthy reasoning over misbehavior.
 Have child pre-state goals or rules.
 “Turtle Technique”
“The evidence for drug efficacy and the side
effects are so benign, that to refuse medication
for the child with ADHD is tantamount to
malpractice.”
John Werry, M.D.
Professor Emeritus of Child
Psychiatry
REWARD DEFICIENCY SYNDROME
1. 1954 James Olds discovered the ability to produce a
reward sensation by activation of the mesolimibic
dopamine pathways. (the medial hypothalamus)
2. Gerald McLearn produced an in-bred mouse (the C57)
strain that bred true for a preference for alcohol,
suggesting that alcoholism could have a genetic basis.
3. Dopaminergic and opiodergic reward pathways are
critical for survival. They provide pleasure drives for
eating, love and reproduction. These pathways can be
reached by ‘unnatural rewards’ such as alcohol,
cocaine, nicotine, and other drugs, and by compulsive
activities such as sex, gambling, and eating. Activation
of these pathways produce an agents addictive
properties.
139
4. The primary neurotransmitter for reward is dopamine,
however norepinephrine, serotonin, GABA, Cannabinoid,
and Opioid neurons modify metabolism.
5. Dopamine influences mood and affect along with
inhibition and executive functioning thus influencing
motivation.
6. Heroin increases the neuronal firing rate of dopamine
cells. Cocaine inhibits the reuptake of dopamine.
Combined these two drugs produce even more intensive
dopamine activation. (speed-ball)
7. Repeated drug use produces neuroadaptive changes
causing normal rewards to lose their motivational
significance. (motivational toxicity)/ Sensitization occurs.
140
The effects of a dopamine agonist on recovery for the
A2/A2 as compared to the A1/A1
141
Types Of Medications
STIMULANTS- Ritalin, Dexedrine, Adderall, Metadate, Concerta,
Focalin, Vyvanse, Daytrana, Methylyn, etc. (Enhance dopamine release
and concentration in the synapse.) Improves inhibition, attention, memory
storage and retrieval, time management, self-regulation of affect, improved
internalization of speech, fine-motor control, improved reasoning.
ANTIHYPERTENSIVES- Clonidine, Tenex (reduces arousal, improves
sleep, improves frustration tolerance, decreases aggression)
ANTICONVULSANTS-Tegretol, Depakote (may reduce aggression)
ANTIDEPRESSANTS: (Tricyclics)- Tofranil, Norpramine (may improve
self-regulation of affect)
(SSRI’s)- Prozac, Celexa, Paxil, Zoloft, Effexor (May improve inhibition
and control of affect)
NEUROLEPTICS: Risperdal, Zyprexa, (may improve reality orientation,
decrease aggression)
Medication In Special
Populations
SUBSTANCE ABUSE: Stimulant mediation use decreases rather than
increases the risk for drug abuse in adolescence and adulthood. Stimulant
medication may even reduce the risk of relapse of substance abusers after
treatment.
CONDUCT DISORDER: Symptom severity appeared reduced in the shortterm.
MINORITIES: African-Americans are 2.5 times less likely to receive
methylphenidate than Caucasian youths.
HEAD INJURY: MPH appears to be an effective treatment for post TBI
cognitive and behavioral sequelae in the brain injured child. Speed of mental
processing appears improved while motor speed is unaffected.
TOURETTES: Both anti-hypertensive and stimulants have been used
successfully in the treatment of Tourette’s.
Diagnostic Criteria for
Oppositional Defiant Disorder
A. A pattern of negativistic, hostile, and defiant behavior lasting at least
six months, during which four (or more) of the following are present.
1. Often loses temper
2. Often argues with adults
3.often actively defies or refuses to comply with adults’ requests or rules.
4.Often deliberately annoys people.
5. Often blames others for his or her mistakes or misbehavior.
6. Is often touchy or easily annoyed by others
7. Is often angry and resentful
8. Is often spiteful or vindictive.
Diag. Criteria for ODD Cont.,
B. The disturbance in behavior causes clinically significant
impairment in social, academic, or occupational functioning.
C. The behaviors do not occur exclusively during the course
of Psychotic or Mood Disorder.
D. Criteria are not met for Conduct Disorder, and if the
individual is 18 years or older, criteria are not met for
Antisocial Personality Disorder.
ASSOCIATED FEATURES: Depressed mood, Learning
Problems, Hyperactivity, Addiction
What Do You Believe Discipline
Is?
 Influencing
 Controlling
 Training, coaching
 Correcting
 Tutoring, guiding
 Governing
 Informing, preparing
 Punishing, rebuking
 Familiarizing,
 Reproving, containing
 Enlightening
 Restraining, managing
 Encouraging
 Supervising
 Harnessing
Diagnostic Criteria for Conduct
Disorder
A. A repetitive and persistent pattern of behavior in which
the basic rights of others or major age-appropriate
societal norms or rules are violated, as manifested by the
presence of three (or more) of the following criteria in
the past 12 months, with at least one criterion present in
the past six months.
AGGRESSION TO PEOPLE AND ANIMALS
1. Often bullies, threatens, or intimidates others
2. Often initiates fights
3. Has used a weapon that can cause serious physical
147
harm.
C.D. Criteria Cont.,
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim.
7. Has forced someone into sexual activity.
DESTRUCTION OF PROPERTY
8. Has deliberately engaged in fire-setting with the intention of
causing serious damage.
9. Has deliberately destroyed others’ property
DECEITFULNESS OR THEFT
10. Has broken into someone else’s house, building, or car.
11. Often lies to obtain goods 148
or favors or to avoid obligations
Conduct Disorder
TYPE ONE
TYPE TWO
 Uncontrolled
 Derives
affective
aggression
 Generalized
anxiety
 Depression
 Worried
 Frustrated
 Reactive
reinforcement from
aggressive acts.
 Predatory
 Unexcited when
engaging in
aggressive acts.
Deliberate
 More likely to
progress
to
antisocial
149
Best Practice for Conduct
Disorder
 Treat the co-morbid disorder (ADHD, SUD,
M.R.)
 Family interventions- Treat parental pathology
 Individual & Group psychotherapy.
 Psychopharmacology
 Other: juvenile justice, social services, community
resources, out of home placement, school
interventions, independent living skills.
150
Why are kids so angry today?
Major
Losses
Mistreatment
Abuse
Lack of
Opportunity
Devaluation
Crushed
Dreams
Pain
Discrimin
ation
Mental
Illness
Lack of
guidance
Violence in
the Media
Loss of
Family of
Origin
Relocation
Increasing
Demands
Victims of
Bullying
Loss of
Community
Increased
Academic
access to
Demands
drugs/alcohol
Parents out
of touch
with reality
Fear
Loss of
Childhood/In
nocence
Loss of
emotional
Support
Adult Roles
Loss of
Religious
Guidance
Lack of
Boundaries
Character
Education
is lacking
Lack of
time with
responsible
adults
Lack of
access to
medical/ment
al health
professionals
151
Work
Demands
Neglect
EXPLANATIONS FOR DEFIANCE
Co-Morbid Problem such as ADHD
Bad Role Models
Frustration/Stress
Neglect/Social Skill Deficits
Mood Disturbance/Temperament
Maltreatment/Abuse-Pain
Ineffective Discipline/Inconsistent
Grief & Loss
Low Cognitive Functioning
Brain Injury
*Other mental health disorders
To Restrain or Not?
 The problem with
 The problem of not
restraint is it risks
injury to the client or
staff.
restraining is it risks
injury to the client or
staff.
153
“There is no national standard for
the use of seclusion and restraint.
Thus, there is considerable
variability including potentially
dangerous and unsafe practices.”
154
Agree or Disagree? (1)
 Restraints keep people safe.
 Staff know how to recognize potentially violent
situations
 Restraints are therapeutic.
 Seclusion encourages self-control.
 Most who have been restrained see it as a helpful
experience.
 There are national standards for restraining
children.
 Seclusion and restraint reflect treatment failure.
155
Agree or Disagree?
 There is no such thing as “the right way” to
intervene. If you believe there is a “right way”,
what is it?
 There is such a thing as “the wrong way” to
intervene. If there is a wrong way to intervene,
what is it?
 You can be following protocol and procedure and
still be wrong.
 If you don’t follow protocol and procedure, it is
guaranteed you are wrong.
156
Potential Effects of Reinforcers
in Behavioral Interventions







Student Reinforcers
Sense of Empowerment
Peer Attention
Anxiety Reduction
Victim Image
Peer Sympathy
Escape from boredom
Opportunity to be
aggressive.





157
Staff Reinforcers
Ends the Acting out
Restores safe
environment.
Sense of empowerment.
Peer Recognition
Retribution-Frustrationelicited aggression
Important Considerations before
Seclusion and Restraint
 Consider the cognitive age of the child, not
merely the chronological age.
 Consider the sexual development of the child
and staff supervision or intervention.
 Consider medical diagnosis (particularly
cardiac, epilepsy, brain injury, asthma, etc.)
 Consider substance or medication issues.
 Consider mental health diagnosis.
 Are staff CPR trained? Is safety equipment
available? (ventilation bag & mask?)
 Has each child been screened for
appropriateness or hazards to restraint?
158
What happens next….?
 If a child dies while in or following a restraint?
 If a limb is dislocated, a broken rib punctures a
lung, a concussion occurs from falling on a
concrete floor, an asthma attack from dust in the
carpet) *Could the staff quickly determine if these
have occurred and how would they respond?
 If a staff member is seriously or critically injured
or is killed during a restraint?
159
Disorders Associated With Rage
or Aggression
Oppositional Defiant
Disorder
Conduct Disorder
Intermittent Explosive
Disorder
Impulse Control
Disorder-NOS
Bi-Polar Disorder
Disorders of delirium
Traumatic Brain Injury
Substance Abuse
Disorders
Reactive Attachment
Disorder
Mental Retardation
Personality Disorders
160
Helping the Explosive Child
1. Use “No” sparingly. Choose your battles wisely.
2. Ignoring will likely make the child worse.
3. Ask, “Why can’t my child think his way through
frustration.” Complexity increases with age. Seek a
thorough evaluation.
4. Therapy should involving learning new strategies and
PRACTICING new strategies experientially.
5. Most children with severe anger problems have a comorbid disorder that must be treated simultaneously.
6. Multiple disciplines (Psychological, Educational, Medical,
must communicate with each other.)
Helping the Explosive Child, Cont.,
7. Learn about medication management. Be especially aware of
serious side effects of antipsychotics and anti-seizure
medications.
8. Do not protect your child from appropriate consequences and
use his diagnosis as an excuse for irresponsible behavior.
Holding the child accountable is essential to change!
9. Seek an experienced and skilled clinician. Complexity
increases over the development of the child. Seek to correctly
identify etiology.
10. Are the behaviors related to a character disorder, neurological
disorder, or psychological disorder?
Helping the Explosive Child., Cont.
11. Remember, remorse doesn’t keep an angry-impulsive child
from being impulsive. Be aware that the angry-impulsive child
is at greater risk of suicide than the depressed child.
12. Assess lethality towards family members as well as suicidal
behavior. Are behaviors threatening and predatory? Does this
child belong in the household?
13. Rule-out brain injury: Look carefully at the neurological
history of the child. Children with evidence of brain injury
have 5 times the number of serious behavior disorders and
generally require medication for stability.
14. Provide a predictable, organized, warm environment.
Reducing Aggressive Behavior in
Children
 Use storytelling that
 Assist parents in
emphasizes nonaggressive solutions.
 Praise students for
non-aggressive
solutions for difficult
problems.
 Model non-aggressive
behavior.
developing behavior
plans and reducing
corporal punishment.
 Daily character
development:
“forgiveness,
compassion,
understanding,
tolerance, etc.
De-escalation Techniques
 Communicate with
 Become aware of
calmness and clarity.
 Do not challenge,
threaten, or demand
compliance!
 Approach at an angle
and identify a path of
escape
 Avoid a threatening
posture
obstacles or dangers.
 Listen accurately and
restate/reflect. Show
compassion and
understanding.
 Do not become
argumentative,
insulting, demeaning,
inciting, or
intimidating.
De-escalation cont.,
 Keep hands free and in a
non-threatening manner.
 Maintain good eye
contact, but do not stare.
 Seek to redirect or change
the setting to a more safe
setting.
 If attacked or threatenedmake others immediately
aware.
 Follow your gut feeling




about when to get help.
Use the person’s name.
Avoid body contact. Do
not touch for reassurance!
If possible give him and
you a path of escape.
Move outside an office
into a common area.
Seek to involve others in
decision making and deescalation.
The Child’s Response To
Divorce
 Emotional distress, sadness, anger
 Regression- 6 months to 1 year
 After the initial disequilibrium there is a 2-3
year adjustment period.
 The divorce interferes with the child’s
ability to inhibit anger/aggression. It serves
as a stimulus for catharsis.
The Influence/Impact of Divorce
 Separating or
 Children feel helpless
divorcing adults are
significantly
distressed.
 Children are exposed
to unhappy, possibly
depressed or anxious
parents.
and frightened and
often view unhappy
scenes.
 Parents are consumed
with their own
emotional reactions
and often neglect the
child’s reactions
Parental Conflict During Divorce
 High conflict between parents exacerbate
the child’s emotional problems.
 Children should not be witness to displays
(including phone calls) of name-calling,
yelling, threatening, or other aggressive
behavior.
Divorce and the school-age child
 Resents the strict schedule often imposed upon
him.
 The visitation schedule often disrupts the child’s
developmental and social needs.
 The child of divorce often resents the loss of
control over their lives compared to their peers.
 There is often a downward economic shift after
divorce. The child often doesn’t fully understand
this and resentments increase towards both
parents.
Post-Divorce Issues
 Parents must agree on issues of transition
arrangements
 School choices
 Access to information
 Discussion regarding relocations.
 Vacations and holidays
 Significant others/Remarriage
 Both parents should agree upon disciplinary plans
and behavior management.
Additional Concerns with
Divorce
 Depends upon the parents ability to
demonstrate self-control.
 Visitation is often irregular.
 The relationship with the father changes
significantly. The father often begins dating
or remarriage.
 There is often geographical isolation.
Post-Divorce Issues -Cont.,
 Fathers assist in valuing her femininity.
 Low feminine self-esteem resulting in more
negative attitudes towards self and conflicts
with her father.
 Early childhood divorce is linked to
oppositional behavior, anxiety, and
hyperactivity.
Mother Custody
 84% of children reside with their mother.
 Most divorced women work full time.
 Placement in day-care facilities often result in
increased illnesses the first year.
 There is often less affection, more coercion, less
communication, and less consistency in control
and monitoring.
 Children are often expected to “mature faster” and
take on greater responsibility for self.
Joint Custody
 It encourages the active involvement of
both parents.
 Encourages child support payments because
of this involvement.
 Provides relief from child care for both
parents, thus improving quality of life.
Emotionality in Preschool
Children
 They may be fearful or anxious.
 They have emotional meltdowns.
 Become aware of where they have been,
how they were treated, where they are, and
where they are going.
 Low Frustration Tolerance
 Difficulty Delaying Gratification
 Generally impulsive
Assessing for Child Maltreatment
Aggression Clinging
Behavior
Social
Somatic
Withdrawal Complaints
NonEnuresis/En Affective
Compliance copresis
Symptoms
Overeating/
Undereating
Sleep
Poor
Disturbance Hygiene
Sexual
Acting out
Inadequate
Dress
The Effects of Fatherlessness
 71% of high school
 85% of all youths in
dropouts come from
fatherless homes.
 80% of rapists come from
fatherless homes.
 85% of children with
behavioral disorders come
from fatherless homes.
 90% of homeless and
runaway children come
from fatherless homes.
prison are from
fatherless homes.
 70% of youths
identified delinquent
are from fatherless
homes.
Children from a fatherless home
are:
 5 times more likely to commit suicide.
 32 times more likely to run away.
 20 times more likely to have behavioral disorders.
 14 times more likely to commit rape.
 10 times more likely to abuse chemical
substances.
 9 times more likely to end up in state custody
 20 times more likely to end up in prison.
Psychological Maltreatment
TERRORIZING SPURNING:
Threatening to
Verbal Battery;
kill or abandon the
child. Exposing the Calling Names
child to violence
Humiliation
ISOLATING:
WITHHOLDING
CARE
Physical health,
education,
behavioral, etc.
EMOTIONAL
NEGLECT:
EXPLOITING
Exposure to
pornography,
modeling and
teaching criminal
behavior.
Refusing family
interaction.
Locking the child up
for an extended period
of time.
Refusing affection,
absence of love,
caring.
Munchausen’s Syndrome by
Proxy
 *Frequent unexplained illnesses in child.
 *Excessive trips to E.R. or physician.
 *Child may appear overmedicated.
 *Parent may act appropriately around
others.
 *Parentally induced symptoms.
Thank you for your
attendance here today!
For questions please contact me at
willbeyerlpe@gmail.com
Or 731-217-1358 or 731-660-2850