Chapter 22.  Childhood Disorders, Part 1.

Slide 1: Time to think

Slide 2:  Why is work with children and teens fun?

Slide 3: Why is work with children and teens challenging?

• What is "normal" behavior?
• Some problems are "normal" at some points and abnormal at others.
• Others are healthy -- even when they drive adults crazy!
• Child depression may or may not look like adult depression.
• Is this a "bad" child or a "sad" child?
• Problems with self-reports
• They are not good self-observers.
• They may only be able to identify two or three emotions.
• They are often less insightful about their inner experience -- & adults aren't all that good!!!

Slide 4: Major Depressive Episode

(1) Depressed mood most of the day
(2) Markedly diminished interest or pleasure
(3) Significant weight loss or gain when not dieting
(4) Insomnia or hypersomnia nearly every day
(5) Psychomotor agitation or retardation
(6) Fatigue or loss of energy nearly every day
(7) Feelings of worthlessness or excessive guilt
(8) Diminished ability to think or concentrate
(9) Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide
      attempt or a specific plan for committing suicide

Slide 5.Time to think

Slide 6. Some facts

• Little social interest
• Odd, deficient or absent verbal and nonverbal communication
• Stereotyped activities and interests

Slide 7. Prevalence & co-morbidity

• about 2-20 per 10,000
• about 22 per 10,000 have some symptoms of autism & severe social impairment

• About 25% have seizures
• About 50% have little or no speech
• About 75% have IQs lower than 70

Slide 8. Autistic Disorder (APA, 2000)

(a) marked impairment in the use of multiple nonverbal behaviors such as eye to eye gaze, facial expression, body postures, and gestures to regulate social interaction
(b) failure to develop peer relationships appropriate to developmental level
(c) a lack of spontaneous seeking to share enjoyment, interests of achievements with other people
(d) lack of social or emotional reciprocity

(a)     delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
(b)     in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
(c)     stereotyped or repetitive use of language or idiosyncratic language
(d)    Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level    

(a) Encompassing preoccupation with 1+ stereotyped and restricted patterns of interest that is abnormal either in intensity or focus
(b)Apparently inflexible adherence to specific, nonfunctional routines or rituals
(c) Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements
(d)Persistent preoccupation with parts of objects 

Temple Grandin's (1995) story: Social relationships
Social interactions that come naturally to most people can be daunting for people with autism.  As a child, I was like an animal that had no instincts to guide me; I just had to learn by trial and error.  I was always observing, trying to work out the best way to behave, but I never fit in.  I had to think about every social interaction.  When other students swooned over the Beatles, I called their reaction an ISP -- interesting sociological phenomenon.  I was a scientist trying to figure out the ways of the natives.  I wanted to participate, but did not know how. (p. 132)

Temple Grandin's (1995) story: Touch
From as far back as I can remember, I always hated to be hugged.  I wanted to experience the good feelings of being hugged, but it was just too overwhelming.  It was like a great, all-engulfing tidal wave of stimulation and I reacted like a wild animal.  Being touched triggered flight; it flipped my circuit breaker.  I was overloaded and would have to escape, often by jerking away suddenly. (p. 62)

Slide 5.Pronoun reversal

Parent: What are you doing, Johnny?
Johnny: He's here.
Parent: Are you having a good time?
Johnny: He knows it.
(Davison, Neale, & Kring, 2004)

Slide 6.Echolalia

Child (wanting cookie): Do you want a cookie?

May not understand meaning of words, but has learned that this sentence is associated with getting a cookie.
(Davison, Neale, & Kring, 2004)

Temple Grandin's (1995) story: Emotions
My emotions are simpler than those of most people.  I don't know what complex emotion in a human relationship is.  I only understand simple emotions, such as fear, anger, happiness, and sadness.  I cry during sad movies, and sometimes I cry when I see something that really moves me.  But complex emotional relationships are beyond my comprehension (p. 89)

Grandin with Atwood: Repetitive behaviors
One of the things I used to do was dribble sand through my hands and watch the sand, studying each little particle like a scientist looking at it under a microscope. When I did that I could tune the whole world out. You know, I think itÕs OK for an autistic kid to do a little bit of that, because itÕs calming.
    But if they do it all day, theyÕre not going to develop.
                                                                http://www.tonyattwood.com/interview.htm

Slide 7. Causes

• Not attributable to parenting. Parenting problems due to stress of raising child with autism.
• Genetics?
• 36% Concordance for MZ twins; 0% for DZ twins (Folstein & Rutter, 1977)
• 2 - 9% of sibs -- 100-200 times prevalence in general population (APA, 2000)
• Brain injury?
• In 12 of 17 discordant twin pairs, twin with autism had a birth complication  (Folstein & Rutter, 1977)
• About 25% have seizures  (Dawson & Castelloe, 1992)
  

Slide 8. Treatments

• Drugs can make it easier to participate in society, but do not change core of problems
• SSRIs can reduce repetitive behaviors and aggression, improve social interactions.
• Stimulants can increase attention
• Behavior therapy in home and school to:
• Decrease self-injurious and inappropriate behaviors
• Teach speech, social skills
• This treatment can make marked difference in helping child meet age-appropriate norms

Slide 9. Prognosis

• Generally poor, but best when:
• IQ is higher
• When verbal skills are present before age 6
• When adults: (Ratey, Grandin & Miller, 1992)
• About 25% can live independently, with some social impairment
• 25% can function in supportive environment
• Sometimes significant intellectual success for people with Asperger's disorder:
• Did Albert Einstein have Asperger's or high-functioning autism??? (Perner, 2001)

Slide 10.

You note that he was quiet and well-behaved in your office during your hour long interview.  His mother was very nervous and reprimanded him frequently and somewhat inappropriately during the interview.  She admitted that their house is frequently "in an uproar" and that she and her partner are recently separated, but attributed the uproar to Bobby.  Bobby has no major health problems, although he does have a history of allergies.
 

Slide 11. Attention-Deficit/Hyperactivity Disorder (APA, 1994)

A. Either (1) or (2):

(1) symptoms of inattention to a degree that is maladaptive and inconsistent with developmental level (6 +, 6 mo.+):

 a.  often fails to give close attention to details or makes careless mistakes in schoolwork, work,     or other activities;
 b.  often has difficulty sustaining attention in tasks or play activities;
 c.  often does not seem to listen when spoken to directly;
 d. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions);
 e.  often has difficulty organizing tasks and activities;
 f.  often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework);
 g.  often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools);
 h.  is often easily distracted by extraneous stimuli;
 i.  is often forgetful in daily activities:  OR

(2) symptoms of hyperactivity-impulsivity to a degree that is maladaptive and inconsistent with developmental level (6+, 6 mo. +):
hyperactivity;

 a.  often fidgets with hands or feet or squirms in seat;
 b.  often leaves seat in classroom or in other situations in which  remaining seated is expected;
 c.  often runs about or climbs excessively in situations in which it  is inappropriate (in adolescents or adults, may be limited to  subjective feelings of restlessness);
 d.  often has difficulty playing or engaging in leisure activities   quietly;
 e.  often "on the go" or often acts as if "driven by a motor";
 f.  often talks excessively:

impulsivity;

 g.  often blurts out answers before questions have been   completed;
 h.  often has difficulty awaiting turn;
 i.  often interrupts or intrudes on others (e.g., butts into   conversations & games)

B.  Some symptoms present before 7 y.o.
C. Impairment in 2+ settings is present
D.  causes significant impairment in social, academic, occupational functioning
E.  does not occur exclusively during course of Pervasive Developmental Disorder, Schizophrenia, or other Psychotic disorder and not better accounted for by other disorder.
p. 363

Slide 12. Gender and age differences in diagnosis with ADHD (Cohen, 1993)

Slide 13. Changes in positive behavior when on Ritalin or placebo (Pellham, 1993)

Slide 14. Changes in negative behavior when on Ritalin or placebo (Pellham, 1993)

Slide 15. Treatment of ADHD

• 80% (S), 50% (A) moderately improved
• Mild to moderate side effects
• High relapse rate

• About 40%  moderately improved
• Low to moderate relapse rate

• Somewhat more effective than either alone
• Lower relapse rate than medicine alone

Slide 16. Oppositional defiant disorder, cont. (APA, 1994)

A. A pattern of negativistic, hostile, & defiant behavior (4+, at least 6 mos.):

 1. often loses temper;
 2. often argues with adults;
 3. often actively defies or refuses to comply with   adults' requests/rules;
 4. often deliberately annoys people;
 5. often blames others for own mistakes/misbehavior;
 6. often touchy or easily annoyed by others;
 7. often angry/resentful; often spiteful or vindictive.

B. Causes significant impairment in social, academic, occupational functioning
C. Behaviors do not occur exclusively during course of Psychotic or Mood disorder.
D. If 18 years or older, does not meet criteria for Antisocial P.D.
p. 361

Slide 17. Gender and age differences in diagnosis with ODD (Cohen, 1993)

Slide 18. Mental retardation (Axis II) (APA, 1994)

A. Significantly subaverage intellectual functioning (IQ of 70 or less, or judgment of subaverage intellectual functioning for infants);
B.  concurrent deficits or impairments in present adaptive functioning (i.e. the person's effectiveness in meeting the standards expected for his or her age by his or her cultural group) (2+):  communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and safety;
C. onset is before age 18 years.   p. 330

Slide 19. Mental retardation (Axis II) APA, 1994

mild -- IQ of 50-55 to 70
moderate -- IQ of 35-40 to 50-55
severe -- IQ of 20-25 to 35-40
profound -- IQ below 20-25

Slide 20. Goals of treatment

Improve social and adaptive living skills
Increase independence in living

Slide 21. Reading disorder (APA, 1994)

A. Reading achievement, as measured by individually administered standardized tests of reading accuracy or comprehension, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education;
B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g. writing grammatically correct sentences and organized paragraphs);
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.

Slide 22. Mathematical disorder (APA, 1994)

A. Mathematical ability, as measured by individually administered standardized tests, is substantially below that expected given the person's chronological age, measured intelligence, and age-appropriate education.
B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g. writing grammatically correct sentences and organized paragraphs);
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.

Slide 23. Disorder of written expression (APA, 1994)

A. Writing skills, as measured by individually administered standardized tests (or functional assessments of writing skills), are substantially below those expected given the person's chronological age, measured intelligence, and age-appropriate education.
B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require the composition of written texts (e.g. writing grammatically correct sentences and organized paragraphs);
C. If a sensory deficit is present, the difficulties in writing skills are in excess of those usually associated with it.

Last modified March 17, 2003.