Disorders Usually 1st Diagnosed in Infancy, Childhood, & Adolescence

Core Concept of Diagnostic Group: Categorized by time of onset Predominantly disorders of abnormal development and maturation. Emphasis of disorders is on the inability of the individual to attain certain normal developmental milestones and the associated functions, capabilities, & behaviors.

10 Diagnostic Subgroups (DSM-IV-TR)

1) 2) 3) 4) 5) 6) 7) Mental Retardation Learning Disorders Motor Skills Disorders Communication Disorders Pervasive Developmental Disorders Attention Deficit and Disruptive Behavior Disorders Feeding & Eating Disorders of Infancy & Early Childhood 8) Tic Disorders 9) Elimination Disorders 10) Other Disorders of Infancy, Childhood, or Adolescence

Mental Retardation
Characteristics: IQ is significantly below average (< 70) Accompanied by deficits in adaptive functioning, e.g. communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, academic skills, work, leisure, health, safety Onset before age 18 years Coding: coded on axis II Code based on degree of severity, reflecting level of intellectual impairment: Mild Mental Retardation IQ from 50-55 to 70 Moderate Mental Retardation IQ from 35-40 to 50-55 Severe Mental Retardation IQ from 20-25 to 35-40 Profound Mental Retardation IQ below 20-25

Mental Retardation
Prevalence: 1-3% of population; 90% are mild MR Course: chronic Prognosis: variable, depending on IQ & level of impairment Gender differences: more prevalent for males (1.6 to 1); no gender differences for severe & profound MR Causes: genetic; chromosomal (Down syndrome, Fragile X syndrome, Lesch-Nyhan syndrome); environmental (deprivation, abuse, neglect); prenatal (exposure to disease, alcohol, drugs, chemicals, poor maternal nutrition); perinatal (difficulties during labor & delivery); postnatal (malnutrition, infections, & head injuries) Treatment: behavioral skills training; communication training; supported living and employment; mainstreaming

Learning Disorders
Characteristics: Inadequate development of specific academic skills, such as reading, writing, and math. Specific academic skills are substantially below expected for age, intelligence, and education Significantly interferes with aspects of life requiring those skills. Subtypes: Reading Disorder Mathematics Disorder Disorder of Written Expression Learning Disorder Not Otherwise Specified

Learning Disorders
Prevalence:
general population: 5-10% reading disorders: 5-15% math disorders: 6%

Racial: more common in black children Negative outcomes: negative school experiences; school drop-out; lower employment rates; lower educational & career goals Causes: genetics; structural & functional differences in the brain Treatment: educational interventions (processing skills; cognitive skills; behavioral skills)

Tic Disorder: Tourettes Disorder

Symptoms: characterized by multiple motor tics and one or more vocal tics (involuntary, sudden, rapid, nonrhythmic, stereotyped motor movements or vocalizations), which occur many times a day, nearly every day, or intermittently for more than a year. Common motor tics: eye-blinking, eye-rolling, spitting, flipping/twirling hair, rolling head around, bending/jumping, skin picking, shrugging/jerking shoulders, thrusting pelvic movements, tapping fingers/feet Common vocal tics: throat clearing, tongue-clicking, whistling, grunting, humming, hoots, howls, burps/belches, animal noises, repetition of ones own words, repetition of others words

Tourettes Disorder
Causes: genetic (32% have relatives with TD); abnormal metabolism of 5HT & D; brain processing problem (basal ganglia) Prevalence: decreases with age; 5-30 per 10,000 in childhood; 1-2 per 10,000 in adulthood Gender: 2-5x as common for males Onset: as early as 2 yrs; average age of onset is 6-7 yrs; typically develops by age 14 Course: severity, frequency, and disruptiveness of sx diminish during adolescence & adulthood Treatment: antipsychotics; antihypertensive medications; SSRIs; self-monitoring; relaxation training; habit reversal

Attention Deficit/Hyperactivity Disorder

Includes two major syndromes: 1) Inattention 2) Hyperactivity-Impulsivity Syndromes may occur independently or together, but usually some components of each are present. Symptoms begin before age 7 Symptoms cause some impairment in 2 or more settings.

Attention Deficit/Hyperactivity Disorder

Inattention: 6+ of the following for 6+ months Often fails to give close attention to details Often makes careless mistakes in school, work, etc. Often has difficulty sustaining attention Often doesnt seem to listen when spoken to directly Often doesnt follow instructions Often fails to finish schoolwork, chores, or work duties Has difficulty organizing tasks & activities Avoids or dislikes tasks requiring sustained mental effort Often loses things Is easily distracted by extraneous stimuli Is forgetful in daily activities

Attention Deficit/Hyperactivity Disorder

Hyperactivity-Impulsivity 6+ of following for 6+ months Hyperactivity: Fidgets with hands or feet; squirms in seat Difficulty staying in seat Excessive running, climbing, or restlessness Difficulty playing or engaging in leisure activities quietly Often on the go; acts as if driven by a motor Often talks excessively Impulsivity: Often blurts out statements Impatient; difficulty awaiting turn Often interrupts or intrudes on others

Attention Deficit/Hyperactivity Disorder

Subtypes: AD/HD, Predominantly Inattentive Type AD/HD, Predominantly Hyperactive-Impulsive Type AD/HD, Combined Type AD/HD, Not Otherwise Specified Onset: 3-4 years old Age: 68% have ongoing sx in adulthood; inattentive subtype is more common in adolescents and adults Gender: ratios of males to females range from 2:1 to 9:1; Combined and Hyperactive Subtypes are much more common in males than females Prevalence: up to 3-7% of school-age children

ADHD: Associated Features

Academic deficits School-related problems Peer rejection Low frustration tolerance Tantrums Poor self-esteem Mood swings Bossiness Stubbornness Accidents Driving difficulties speeding, accidents

ADHD: Diagnostic Considerations

Difficulty of distinguishing normal activity from hyperactivity and normal distractibility from attention deficit distractibility. Need to evaluate behavior in terms of whats normal for others of same gender, age, developmental level, cultural background. Behaviors must occur in multiple settings. Behaviors must cause clinically significant impairment. Symptoms must have been present and caused impairment by age 7. Combined and Hyperactive Subtypes are less likely to be missed.

ADHD: Contributing Factors

Genetics: increased incidence of ADHD & psychopathology in families & relatives Prenatal factors: inadequate oxygen; drug exposure; maternal smoking Neurotransmitters: inadequate availability of dopamine; NE, 5HT, GABA also implicated Brain abnormalities: frontal cortex, basal ganglia, & cerebellar vermis are smaller Exposure to toxins: allergens, food additives Parenting: negative attempts to control their behavior; intrusive, over-bearing parenting

Attention Deficit/Hyperactivity Disorder

Treatments: Medication stimulants, Strattera (SNRI), Wellbutrin Psychoeducation & bibliotherapy Skills-based training time management, organizational skills, study skills, problemsolving, social skills

Conduct Disorder
Repetitive, persistent pattern of behavior in which the basic rights of others or major societal norms or rules are violated. 3 or more of the following are present in the past 12 months, and at least one of the following is present in the past 6 months. 1) Aggression to people and animals 2) Destruction of property 3) Deceitfulness or theft 4) Serious violations of rules

Conduct Disorder
1) Aggression to People and Animals: Bullying, threats, intimidation Physical fights Use of weapons Physical cruelty to people Physical cruelty to animals Mugging, purse snatching, extortion, armed robbery Forced sexual activity

Conduct Disorder
2) Destruction of Property: Deliberate fire-setting Deliberate destruction of others property 3) Deceitfulness or Theft Breaking & entering Lying; conning Stealing; shoplifting; forgery 4) Serious Violations of Rules Breaking curfew prior to age 13 School truancy prior to age 13 Running away from home

Conduct Disorder
Subtypes: Conduct Disorder, Childhood Onset onset of at least 1 criterion prior to age 10 Conduct Disorder, Adolescent Onset absence of any criteria prior to 10 Conduct Disorder, Unspecified Onset age of onset is unknown Specifiers: Mild few, if any, conduct problems in excess of those required to make dx; cause only minor harm to others Moderate number of conduct problems and effect on others are in the intermediate range Severe many conduct problems in excess of those required to make dx; cause considerable harm to others

Conduct Disorder
Etiology: genetics; decreased arousal; low levels of 5HT; neurological deficits Prevalence: 2-9% of nonclinical population; up to 1/31/2 of child mental health referrals; 87-91% of incarcerated juveniles Gender Differences: mostly males Onset: as early as preschool Prognosis: poor; 2/3rds of cases develop into Antisocial Personality Disorder Treatment: parent management training; communitybased interventions (group homes, wilderness programs; therapeutic boarding schools); CBT (social skills, problem solving, cognitive restructuring)

Oppositional Defiant Disorder

Pattern of negativistic, hostile, and defiant behavior for at lease 6 months. At least 4 of the following are present:
Often loses temper Often argues with adults Often actively defies or refuses to comply with adults requests or rules Often deliberately annoys others Often blames others for own mistakes or misbehavior Is often touchy or easily annoyed by others Is often angry or resentful Is often spiteful or vindictive

Absence of behavior that violate the rights of others

Oppositional Defiant Disorder

Prevalence: 1-6% Gender differences: more prevalent for males prior to puberty; ratio evens out after puberty Prognosis: relatively persistent some of the behaviors persist into adulthood, others are outgrown; higher divorce rate, employment difficulties, and drug/alcohol abuse for those with ODD Causes: marital conflict; family discord; inconsistent parenting; overly lenient or rigid parent; coercive or aversive parent-child interactions; genetics Treatment: parent training; family therapy; behavioral therapy (anger management, social skills training, problem solving, frustration tolerance); cognitive interventions to reduce negativity

Separation Anxiety Disorder

At least 4 weeks of inappropriate or excessive anxiety about separation from home or major attachment figures, as evidenced by at least 3 of the following: excessive anxiety regarding separation excessive fears of losing major attachment figures nightmares involving the theme of separation refusal to go to school refusal to be alone or without major attachment figures refusal to sleep away from home or attachment figures repeated physical complaints when separation occurs or is anticipated Onset prior to age 18

Pervasive Developmental Disorders

Characterized by: A broad-based impairment or a loss of functions expected for childs age. Includes 3 components: 1) Impairment in social interactions/relationships 2) Impairment in communication/language 3) Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities

Autistic Disorder
Abnormal functioning in at least one of the following areas, with onset prior to 3:
1) Social interaction 2) Language and communication 3) Symbolic, imaginative play

Qualitative impairment in social interaction and relationship development Qualitative impairment in communication, language, and conversation skills Restricted, repetitive, stereotyped patterns of behavior, interests, activities.

Autism
Mental retardation: 75-80%; 50% are profoundly or severely MR; 25% are moderately MR; 25% borderline to average IQ Gender differences: higher IQ more prevalent among males; IQ < 35 more prevalent among females Prevalence: 1 in 500 births Onset: first apparent in infancy & toddlerhood Course: chronic; life-long impairment; 50% never acquire speech Causes: abnormalities in brain structure and function (5HT synthesis, cerebellum); genetics Treatments: intensive behavioral Tx focusing on improving communication, social and daily living skills and reducing problem behaviors; early intervention programs; applied behavior analysis; parent training; mainstreaming for education; community interventions (supportive living arrangements & work settings)

Aspergers Disorder
Qualitative impairment in social interaction and relationship development Restricted, repetitive, and stereotyped patterns of behavior, interests, and activities But lack any clinically significant delay in language or cognitive development

Aspergers Syndrome
What you see: Anxious, excessive desire for sameness Preoccupation with stereotyped, repetitive activities Obsess about objects Limited interests Cant relate to others Cant read emotions Cant understand social cues Social isolation, socially inept Average IQ scores Motor clumsiness Poor coordination

Aspergers Syndrome
Gender: up to 4x as common for males Prevalence: up to 5x as common as Autism Onset: later onset than Autism Course: chronic, life-long Etiology: genetics; brain abnormalities (limbic system, 5HT & D systems, right hemisphere)

Aspergers Syndrome: Treatments

Behavioral treatments/skills building: interventions targeting problem behaviors, problem solving, social skills, communication skills, empathy-building, daily living skills School-based interventions: mainstreaming; tutoring; special aides; multiple modalities for presenting information Psychotherapy to address accompanying psychiatric disorders, such as depression and anxiety Medications: antidepressants, antipsychotics