Disorders of Childhood

Number of children diagnosed/treated has increased over the years (ADHD diagnoses increased 41% 2003-2012)
Controversial medication treatment

Classification and Diagnosis of Childhood Disorders

Developmental psychopathology = focuses on the disorders of childhood within the context of lifespan development, enabling us to identify behaviours that are considered appropriate at one stage but not at another

Most childhood disorders fall under either: a) Neurodevelopmental disorders & b) Disruptive, impulse-control, and conduct disorders  Defined in 2 broad domains:

o Externalizing disorders = more outward-directed behaviours, such as aggressiveness, noncompliance, over-activity, and impulsiveness

Includes ADHD, conduct disorder, and oppositional defiant disorder o Internalizing disorders = more inward-focused experiences and behaviours, such as depression, social withdrawal, and anxiety
Childhood anxiety, and mood disorders

Attention-Deficit/Hyperactivity Disorder (ADHD)

DSM-5 Criteria

1) Either A or B:
- A) 6+ manifestations of inattention present for at least 6 months to a maladaptive degree and greater than what would be expected given a person’s developmental level (e.g. careless mistakes, not listening well, not following instructions, easily distracted, forgetful in daily activities)
- B) 6+ manifestations of hyperactivity-impulsivity present for at least 6 months to a maladaptive degree and greater than what would be expected given a person’s developmental level, e.g. fidgeting, running about inappropriately (in adults, restlessness), acting as if “driven by a motor”, interrupting or intruding, incessant talking
2) Several of the above present before age 12
3) Present in two or more settings
4) Significant impairment in social, academic, or occupational functioning
5) For people age 17 or older, only 5 signs of hyperactivity-impulsivity are needed to meet the diagnosis
Overestimate their ability to navigate social situations with peers
Vicious cycles – 3 domains: poor social skills, aggressive behaviour, overestimation of one’s social abilities – predict decline in these abilities at follow-up
Age of onset was changed from under 7 to under 12 & adults only need to show symptoms in 5 domains = more diagnoses

 3 specifiers:
- 1) Predominantly inattentive = children whose problems are primarily those of poor attention
  - More difficulty with focused attention or speed of information processing
  - Problems with DA and prefrontal cortex

o 2) Predominantly hyperactive-impulsive = children whose difficulties result primarily from hyperactive/impulsive behaviour

- 3) Combined = children who have both sets of problems ***majority
  - More likely to develop conduct problems & oppositional behaviour, be placed in special classes and have difficulties interacting with peers
- Frequently comorbid with conduct disorder *ADHD associated more with off-task behaviour in school, cognitive and achievement deficits, and a better long-term prognosis
- Also comorbid with anxiety and depression (30%), 15-30% have a learning disorder
- Hyperactive symptoms predict substance use
- 8-11% prevalence *increase could be due to factors other than increase in the actual disorder o Over diagnosis due to assessments that are too brief to properly judge & differing educational policies

3x as common in boys than girls ADHD in Adulthood

65-80% of children with ADHD still have symptoms associated with impairments in adolescence
Most adults with ADHD are employed and financially independent (generally lower SES)  15% still meet criteria at age 25, 60% still experience impairment from symptoms Etiology

Genetic Factors

Genetic component to ADHD, heritability estimate of 70-80%
Number of candidate genes found as suggested to causing ADHD *related to NTM DA (DRD4, DRD5,

DAT1) o Only associated with risk if have particular environmental factors **prenatal nicotine/alcohol use

SNAP-25 – gene that codes for protein that promotes plasticity of neuron synapses also associated with ADHD

Neurobiological Factors

Brain areas linked to DA may be different in structure/function/connectivity
Dopaminergic areas: caudate nucleus, globus pallidus, frontal lobes *smaller in kids with ADHD *less frontal activation
Perform poorer on neuropsychological tests requiring frontal lobes  Perinatal and Prenatal Factors:
- LBW is a predictor *less of an impact with maternal warmth  Environmental Toxins:
- Additives and artificial colours in foods upset that nervous system of children who are hyperactive
- View that refined sugar can cause ADHD is not supported by research
- Higher blood-lead levels may associate with hyperactivity symptoms and attention problems
- Maternal smoking *nicotine* may play a role in development of ADHD

Family Factors

Parent-child relationship interacts with neurobiological factors to contribute to ADHD symptoms  Many parents of ADHD children have ADHD themselves

Treatment

Stimulant Medications

Examples: methylphenidate, Ritalin – prescribed since 1960s, others: Adderall, Concerta, Strattera
80% of ADHD patients take stimulants, includes 10% of all adolescent boys
Drugs reduce disruptive behaviours and impulsivity and improve ability to focus attention
Short-term improvements in goal0directed activity, classroom behaviour, social interactions with parents/teachers/peers, reductions in aggressiveness and impulsivity in 75%
Drugs interact with DA system
Combined treatment of medication and therapy is superior, followed by medication alone o Combined treatment also didn’t require as high a dose of Ritalin & more social skills improvement
Medication more effective for children with ADHD
Stimulant side effects: loss of appetite, weight loss, stomach pain, sleep problems, cardiovascular risks

Psychological Treatment

Parent training & changes in classroom management
Children’s behaviour monitored at home and school, reinforced for behaving appropriately
Point system and daily report cards
Focus: improving academic work, completing household tasks, learning specific social skills  May be as effective as Ritalin Conduct Disorder
Intermittent explosive disorder (IED) = recurrent verbal or physical aggressive outbursts that are far out of proportion of the circumstances o Aggression is impulsive and not preplanned toward other people
Oppositional defiant disorder (ODD) = child does not meet criteria for conduct disorder, most especially, extreme physical aggressiveness, but exhibits such behaviours as losing his/her temper, arguing with adults, repeated refusing to comply with requests from adults, deliberately doing things to annoy others, and being angry, spiteful, touchy or vindictive o ODD and ADHD frequently occur together *different since defiant behaviours not thought to arise from attentional deficits or impulsiveness
- Children with ODD are more deliberate

DSM-5 Criteria:

1) Repetitive and persistent behaviour pattern that violates the basic rights of others or conventional social norms as manifested by he presence of 3+ of the following in the previous 12 months and at least one of them in the previous 6 months:
- Aggression to people and animals (e.g. bullying, initiating physical fights, physical cruelty to people or animals, forcing someone into a sexual activity)
- Destruction of property (e.g. fie-setting, vandalism) o C. Deceitfulness or theft (e.g. breaking into another’s house or car, conning, shoplifting) o D. Serious violation of rules (e.g. staying out at night before age 13 in defiance of parental rules, truancy before age 13)
2) Significant impairment in social, academic, or occupational functioning
3-4x as common in boys than girls
Behaviour marked by: callousness, viciousness, and lack of remorse
Limited prosocial emotions – diagnostic specifier for children who have callous and unemotional traits
- Lack of remorse/empathy/guilt and shallow emotions
- Traits associated with more severe course, more cognitive deficits, more antisocial behaviour, poorer response to treatment
Often comorbid with substance abuse and internalizing disorders (15-45% comorbidity with anxiety/depression) o Conduct disorder tends to precede anxiety/depression *except specific phobias and social anxiety
7% of preschoolers exhibit symptoms *important to assess early, not just manifestations of typical developmentally disruptive behaviours  2 courses:
- Life-course-persistent pattern of antisocial behaviour, begin to show conduct problems by age 3 and continue to commit serious transgression into adulthood
- Adolescent-limited – typical childhoods, high levels of antisocial behaviour during adolescence, typical, non-problematic adulthood
  - Result of maturity gap between adolescent physical maturation and opportunity to assume adult responsibilities and obtain rewards usually accorded such behaviour
  - Continue to have substance use, impulsivity, crime and mental health problems in mid 20s
- 6-9.5% prevalence, more common in boys
- Incidence and prevalence of serious law breaking peak at age 17, drop in young adulthood Etiology

Genetic Factors

Some genetic factors of conduct disorder are shared with other disorders (ADHD, depression) others are specific to CD
Criminal and antisocial behaviour is accounted for both by genetic and environmental factors
40-50% of antisocial behaviour is heritable
Aggressive behaviour is more heritable than other delinquent behaviour
Age of onset is related to heritability
MAOA gene – located on the X chromosome, releases MAO enzyme which metabolizes NTMs (DA, 5-

HT, NE) o Maltreated children with low MAOA activity more likely to develop conduct disorder

Brain Function, Autonomic Nervous System, and Neuropsychological Factors  Deficits in brain regions supporting emotions **empathetic responses o Difficulty perceiving distress and happiness on others, no difficulty perceiving anger

Reduced amygdala and prefrontal cortex activation
Do not learn to associate behaviour with reward/punishment as easily as others (amygdala/ventral striatum)
ANS abnormalities associated with antisocial behaviour in adolescents o Low levels of resting skin conductance and heart rate *lower arousal o May not fear punishment as much
Poor verbal skills, problems with executive functioning, problems with memory  IQ 1 SD lower if developed at early age *not due to low SES or school failure

Psychological Factors

Deficient in moral awareness, lacking remorse for wrongdoings *prominent in antisocial personality disorder and psychopathy
Interpret ambiguous acts as hostile intent (e.g. being bumped in line)

Peer Influences

1) Acceptance or rejection by peers o Rejection by peers is causally related to aggressive behaviour *specifically in combination with ADHD
- Can predict later aggressive behaviour
2) Affiliation with deviant peers o Increases likelihood of delinquent behaviour

Treatment

Family Intervention

Intervening early has an impact
Family checkup treatment (FCU) = 3 meetings to get to know, assess, and provide feedback to parents regarding their children and parenting practices
Parent management training (PMT) = parents are taught to modify their response to their children so that prosocial rather than antisocial behaviour is consistently rewarded o Parents taught to use positive reinforcement, and time-outs and loss of privileges o Most efficacious intervention

Multisystemic Treatment (MST)

= Delivering intensive and comprehensive therapy services in the community, targeting the adolescent, the family, the school, and in some cases, the peer group
Conduct problems influenced by multiple factors
Incorporates behavioural, cognitive, family-systems and case management techniques  Emphasizes individual family strengths Prevention Programs
Fast Track – designed to help children academically, socially, and behaviourally, focusing on areas that are problematic in CD including peer-relationships, aggressive and disruptive behaviour, social information processing, and parent-child relationships o Treatment for 10 years, more intensive in years 1-5
- Benefits dwindled as children got older

III. Depression and Anxiety in Children and Adolescents

A) Depression

Ages 7-17 show following same symptoms as adults:
- Depressed mood, inability to experience pleasure, fatigue, concentration problems, suicidal ideation
Show more guilt, lower rates of early-morning wakefulness, early-morning depression, loss of appetite & weight loss
Recurrent symptoms
Occurs in 2-3% of school-aged children under age 13
By adolescence, rate rises to from 6-16% for girls and 4-7% for boys (2x as common among adolescent girls) o Less gender differences in symptoms *no gender difference until adolescence  Comorbid with anxiety
Role of genetic factors (with depressed parent, have 4x risk of developing depression)
Gene-environment interactions predict onset: short-allele of serotonin gene & interpersonal stress
Interpersonal factors especially important in predicting depression in girls
Early adversity predicts depression for ages 15-20 or rejection by parents
Cortisol in people with depression is associated with small volume of hippocampus
Cognitive distortions and negative attributional style (consistent with Beck’s theory and hopelessness theory)
Attributional style doesn’t appear to be stable until early adolescence *does not predict child depression  Treatment:
- Treatment for Adolescents with Depression Study (TADS) – efficacy of antidepressants

(Prozac)

Combined treatment of Prozac with CBT most effective, more than either alone
Similar relapse rates for all 3 treatment groups o Side effects: nausea, diarrhea, sleep problems, agitation, suicidality concerns o Girls more likely to relapse than boys, especially with comorbid anxiety (both genders) o CBT in school setting is more effective than family/supportive therapy o CBT most effective for Caucasian adolescents, those with good coping skills  Prevention: o Selective – target particular youth based on family risk factors, environmental factors, or personal factors
More effective

Universal – targeted toward large groups, typically in schools, seek to provide education and information about depression B) Anxiety

Common fears that get outgrown: fear of the dark, imaginary creatures, fear of being separated from parents
Reported more often in girls than boys
In order to meet criteria, functioning must be impaired *don’t need to regard fear as excessive/unreasonable
3-5% prevalence in children/adolescents *specific phobias and social anxiety disorder are most common
Separation anxiety disorder:
- Characterized by constant worry that some harm will befall their parents or themselves when they are away from their parents
- Often first observed when children begin school
- 1) Excessive anxiety that is not developmentally appropriate about being away from people to whom one is attached, with at least 3 symptoms that last for at least 4 weeks
  - Repeated & excessive distress when separated, excessive worry that something bad will happen to an attachment figure, refusal/reluctance to go to school/work/elsewhere, refusal/reluctance to sleep away from home, nightmares about separation from attachment figure, repeated physical complaints when separated from attachment figure
- Changes: moved into anxiety chapter, age of onset prior to 18 was removed **can be diagnosed in an adult
Social Anxiety Disorder: 1-7% prevalence, higher rates in adolescents *care more what others think of them
5% meet criteria for PTSD o 4 categories of symptoms for children older than 6:
- 1) Intrusively re-experiencing the traumatic event (nightmares, flashbacks, intrusive thoughts)
- 2) Avoiding trauma-related situations or information and experiencing a general numbing of responses (detachment)
- 3) Negative changes in cognitions or mood related to traumatic event
- 4) Increased arousal and reactivity, which can include irritability, sleep problems and hypervigilance
- Separate criteria for younger than 6 *presented in more developmentally appropriate ways
OCD prevalence: from less than 1-4%, similar symptoms as in adulthood o Common obsessions in children: dirt/contamination, aggression, Adolescence: sex, religion o More common in boys as children, more common in women as adults  Etiology:
- Heritability estimate of 29-50% o Parenting practices parental control and overprotectiveness, more than parental rejection o Social anxiety: over-estimate danger in many situations, under-estimate ability to cope
  - Anxiety interferes with social interactions, avoid social situations
  - Behavioural inhibition is an important risk factor o PTSD:
  - Requires exposure to trauma (experienced or witnessed)
  - Risk factors: level of family stress, coping styles of family, past experiences with trauma  Treatment:
- Major treatment focus is exposure *modified for children by including more modeling and more reinforcement
- CBT is effective: Coping Cat – focuses on confrontation of fears, development of new ways to think about fears, exposure to feared situations and relapse prevention
  - Effective short-term and long-term o Family CBT more effective than individual CBT when both parents have anxiety disorder, and both are more effective than psychoeducation
- Combination of CBT and medication (Sertraline *Zoloft) more effective than either alone

*results are more immediate o Group therapy effective for social anxiety disorder

For OCD, CBT more effective than medication, and combination *unless severe, then combination is best
Other methods: bibliotherapy and computer-assisted therapy
- Bibliotherapy – parents given written materials and are the therapist with their children
Reduces anxiety, but not as effective as CBT Autism Spectrum Disorder
Not formally included in DSM until 3^rd edition, rates have been rising
4 categories from DSM-IV-TR are combined into autism spectrum disorder (ASD) o 1) Autistic disorder, 2) Asperger’s disorder, 3) Pervasive developmental disorder not otherwise specified, 4) Childhood disintegrative disorder
All shared similar clinical features and etiologies, only varied in severity
DSM-5 – different clinical specifiers relating to severity and extent of language impairment

Social and Emotional Disturbances

Rarely approach others, look through/past people, turn their backs on others, few initiate play, usually unresponsive when being approached