Disorders of Childhood

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• Disorders of Childhood

I. Classification and Diagnosis of Childhood Disorders

Classification and Diagnosis of
Childhood Disorders
• Developmental psychopathology
• Studies disorders within context of normal child
development
• Relationship between child and adult psychopathology
• Some disorders are unique to children

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• e.g., elimination disorders
• Some disorders are primarily childhood disorders, but
may continue into adulthood
• e.g., attention-deficit/hyperactivity disorder
• Some disorders are present in children and adults
• e.g., depression
Classification and Diagnosis of
Childhood Disorders
• DSM-5 splits childhood disorders into two chapters:
• Neurodevelopmental Disorders
• Disruptive, Impulse Control, and Conduct Disorder

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• DSM-5 has new names for disorders
• e.g., mental retardation will now be called intellectual
developmental disorder

• DSM-5 combines some disorders

• Autistic disorder, Asperger’s disorder, and pervasive
developmental disorder not otherwise specified combined into
Autism Spectrum Disorder
Figure
Organization of
Childhood
Disorders in
DSM-IV-TR and
DSM-5

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Table Diagnoses of Childhood Disorders: Likely
Changes for DSM-5
Classification and Diagnosis of
Childhood Disorders
• Externalizing disorders
• Characterized by outward-directed behaviors
• Noncompliance, aggressiveness, overactivity, impulsiveness
• Includes attention-deficit/hyperactivity disorder, conduct

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disorder, and oppositional defiant disorder.
• More common in boys
• Internalizing disorders
• Characterized by inward-focused behaviors
• Depression, anxiety, social withdrawal
• Includes childhood anxiety and mood disorders
• More common in girls
Attention Deficit/Hyperactivity Disorder
• Excessive levels of activity
• Fidgeting, squirming, running around when inappropriate,
incessant talking
• Distractibility and difficulty concentrating

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• Makes careless mistakes, cannot follow instructions,
forgetful
Proposed DSM-5 Criteria for
Attention-Deficit/Hyperactivity Disorder
• Either A or B:
A. Six or more 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. Six or more manifestations of hyperactivity-impulsivity present for at least 6 months to a maladaptive

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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
• Some of the above present before age 12
• Present in two or more settings, e.g., at home, school, or work
• Significant impairment in social, academic, or occupational functioning
• For people age 17 or older, only four signs of inattention and/or four signs of hyperactivity-impulsivity are
required to meet the diagnosis.
Attention Deficit/Hyperactivity Disorder
• Three subcategories in DSM-IV-TR
1. Predominantly inattentive type
2. Predominantly hyperactive-impulsive type
3. Combined type
• Differential diagnosis
• ADHD or Conduct Disorder?
• ADHD
• More off-task behavior, cognitive and achievement deficits
• Conduct Disorder
• More aggressive, act out in most settings, antisocial parents,
family hostility
 Attention Deficit/Hyperactivity Disorder
• ADHD often comorbid with
anxiety and depression
• Prevalence estimates 3 to
7% worldwide
• More common in boys

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than girls
• Symptoms persist beyond
childhood
• Numerous longitudinal
studies show 65 to 80% still
exhibit symptoms
• 60% of adults continue to
meet criteria for ADHD in
remission
Girls with Attention Deficit/Hyperactivity
Disorder
• Hinshaw et al. (2006) large, ethnically diverse study of girls
• Combined type had:
• More disruptive behaviors than inattentive type
• More comorbid diagnoses of conduct disorder or oppositional defiant disorder
than girls without ADHD

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• Viewed more negatively by peers than inattentive type or girls without ADHD
• Inattentive type
• Viewed more negatively by peers than girls without ADHD
• Girls with ADHD more likely to:
• Be anxious and depressed
• Exhibit neurological deficits (e.g., poor planning, problem-solving)
• Have symptoms of eating disorder and substance abuse by adolescence
Etiology of ADHD
• Genetic factors
• Adoption and twin studies
• Heritability estimates as high as 70 to 80%
• Two dopamine genes implicated
• DRD4

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• Dopamine receptor gene
• DAT1
• Dopamine transporter gene
• Mixed support for this gene
• Either gene associated with increased risk only when prenatal maternal nicotine or
alcohol use is present
• Neurobiological factors
• Dopaminergic areas smaller in children with ADHD
• Frontal lobes, caudate nucleus, globus pallidus
• Poor performance on tests of frontal lobe function
Etiology of ADHD
• Perinatal and prenatal factors
• Low birth weight
• Can be mitigated by later maternal warmth
• Maternal tobacco and alcohol use

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• Environmental toxins
• Limited evidence that food additives or food coloring can have
a small impact on hyperactive behavior
• No evidence that refined sugar causes ADHD
• Nicotine from maternal smoking
• Exposure to tobacco in utero associated with ADHD
symptoms
• May damage dopaminergic system resulting in behavioral
Etiology of ADHD

• Parent-child relationship
• Parents give more commands and have more
negative interactions
• Family factors

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• Interact with genetic and neurobiological factors
• Contribute to or maintain ADHD behaviors but do
not cause them
Treatment of ADHD

• Stimulant medications (Ritalin, Adderall, Concerta, Strattera)

• Reduce disruptive behavior
• Improve interactions with parents, teachers, peers
• Improve goal-directed behavior and concentration

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• Reduce aggression
• Side effects
• Loss of appetite, weight, sleep problems
• Medication plus behavioral treatment
• Slightly better than meds alone
• Improved social skills whereas meds alone did not
• Three-year follow-up found superior benefits of meds did not persist
Treatment of ADHD
• Psychological treatment
• Parental training
• Change in classroom management
• Behavior monitoring and reinforcement of appropriate behavior
• Supportive classroom structure

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• Brief assignments
• Immediate feedback
• Task-focused style
• Breaks for exercise
Conduct Disorder (CD)
• Pattern of engaging in behaviors that violate social
norms, the rights of others, and are often illegal
• Aggression
• Cruelty towards other people or animals

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• Damaging property
• Lying
• Stealing
• Vandalism
• Often accompanied by viciousness, callousness, and lack of
remorse
Oppositional Defiant Disorder (ODD)

• ODD behaviors do not meet criteria for CD (especially extreme

physical aggressiveness) but child displays pattern of defiant
behavior
• Argumentative

..
• Loses temper
• Lack of compliance
• Deliberately aggravates others
• Hostile, vindictive, spiteful, or touchy
• Blames others for their problems
• Comorbid with ADHD, learning and communication disorders
• Disruptive behavior of ODD more deliberate than ADHD
• Most often diagnosed in boys but may be as prevalent in girls
Proposed DSM-5 Criteria for
Conduct Disorder
• Repetitive and persistent behavior pattern that violates the basic rights of others or conventional social

norms as manifested by the presence of three or more of the following in the previous 12 months and

at least one of them in the previous 6 months:

A. Aggression to people and animals, e.g., bullying, initiating physical fights, physically cruel to people

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or animals, forcing someone into sexual activity

B. Destruction of property, e.g., fire-setting, vandalism

C. Deceitfulness or theft, e.g., breaking into another’s house or car, conning, shoplifting

D. Serious violation of rules, e.g., staying out at night before age 13 in defiance of parental rules,

truancy before age 13

• Significant impairment in social, academic, or occupational functioning

Conduct Disorder
• Substance abuse common
• Unclear whether it precedes or is concomitant with
disorder
• Comorbid with anxiety and depression
• Comorbidity rates vary from 15 to 45%
• CD precedes anxiety and depression
• Prevalence
• Boys
• 4 to 16%
• Girls
• 1.2 to 9%
Figure : Arrest Rates Across Ages for Homicide, Forcible Rape,
Robber, Aggravated Assault, and Auto Theft
Conduct Disorder (CD)
• Two distinct CD types (Moffitt, 1993)
1. Life-course-persistent pattern of antisocial behavior
• 10 – 15x more common in boys than girls
2. Adolescence-limited
• Maturity gap between physical maturation and rewarding adult behaviors
• Follow-up longitudinal studies of life-course-persistent type show

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more severe problems into early adulthood including:
• Academic underachievement
• Neuropsychological deficits
• ADHD
• Family psychopathology
• Poorer physical health
• Lower SES
• Violent behaviors
Figure : Etiology of Conduct Disorder
 Etiology of Conduct Disorder (CD)

• Genetic factors
• Heritability likely plays a part
• Twin study data show mixed results
• Adoption studies focused on criminal behavior, not conduct disorder
• Meta-analysis of twin and adoption studies suggest 40 – 50% of antisocial
behavior is heritable
• Genetics a stronger influence when behaviors begin in childhood rather than
adolescence
• Genetics and environment interact
• Abuse as a child PLUS low MAOA activity most likely to develop CD
 Etiology of Conduct Disorder (CD)
• Neurobiological factors
• Poor verbal skills
• Difficulty with executive functioning
• Low IQ
• Lower levels of resting skin conductance and heart rate suggest
lower arousal levels
• Psychological factors
• Deficient moral development, especially lack of remorse
• Modeling and reinforcement of aggressive behavior
• Harsh and inconsistent parenting
• Lack of parental monitoring
• Cognitive bias: Neutral acts by others perceived as hostile
Figure :
Dodge’s Cognitive Theory of Aggression

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Etiology of Conduct Disorder (CD)

• Peer influences associated with CD

• Rejection by peers
• Affiliation with deviant peers
• Sociocultural factors

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• Poverty
• Urban environment
• Higher rates of delinquent acts among African
American males linked to living in poorer
neighborhoods rather than race
Treatment of Conduct Disorder

• Family interventions
• Family check-ups (FCU) associated with less
disruptive behavior
• Parental management train (PMT)

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• Teach parents to reward prosocial behavior
• Multisystemic therapy
• Deliver intensive community-based services
Figure : Multisystemic Treatment of CD
Depression and Anxiety in Children and
Adolescents
• Commonly co-occur with ADHD and CD
• Also co-occur with each other
• Early research suggested that depression and anxiety could be
distinguished from each other in the same way they are in adults:

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• Depression – high negative affect, low positive affect
• Anxiety – high negative affect but not low levels of positive affect
• More recent research calls this finding into question
Depression in Children and Adolescents
• Symptoms common to children, • Symptoms specific to children and
adolescents
adolescents, and adults
• Higher rates of suicide attempts and guilt
• Depressed mood • Lower rates of
• Inability to experience pleasure • Early morning awakening
• Fatigue • Early morning depression

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• Problems concentrating • Loss of appetite
• Weight loss
• Suicidal ideation

• Prevalence
• 1% of preschoolers
• 2 – 3% of school-age children
• 6% of girls and 4% of boys during
adolescence
Etiology of Depression in
Children and Adolescents
• Genetic factors
• Early adversity and negative life events
• Family and relationship factors
• A parent who is depressed

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• Parental rejection only modestly associated with depression
• Children with depression and their parents interact in negative ways
• Less warmth
• More hostility
• Cognitive distortions and negative attributional style
• Stable attributional style
• Develops by early adolescence
• By middle school, attributional style serves as a cognitive diathesis for depression
 Treatment of Depression in
Children and Adolescents
 Medications
• SSRIs more effective than tricyclics
• Meta-analysis showed medications most effective for anxiety other than OCD
• Less effective for depression and OCD

• Concerns about medications

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• Side effects including diarrhea, nausea, sleep problems, and agitation
• Possibility of increased risk of suicide attempts

• Interpersonal psychotherapy (IPT)

• Focuses on peer pressures, transition to adulthood, and issues related to independence

• CBT
• More effective for Caucasian adolescents, those with pretreatment, good coping skills, and recurrent depression

• Psychotherapy generally only modestly effective with children and adolescents

• CBT no better than non-CBT therapies
Anxiety in Children and Adolescents
• Fears and worries common in childhood
• Anxiety disorder
• More severe and persistent worry
• Must interfere with functioning
• Most childhood fears disappear but adults with anxiety disorders

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report feeling anxious as children
• “I’ve always been this way”
• Prevalence
• 3-5% of children and adolescents are diagnosed with anxiety disorder
Anxiety Disorders in Children
 Separation Anxiety Disorder
• Worry about parental or personal safety when away from parents
• Typically first observed when child begins school

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 Social Anxiety Disorder
• Extremely shy and quiet
• May exhibit selective mutism
• Refusal to speak in unfamiliar social setting
• Prevalence
• 1% of children and adolescents
• Etiology
• Overestimation of threat
• Underestimation of coping ability
• Poor social skills
 PTSD
• Exposure to trauma
• Chronic physical or sexual abuse
• Community violence
• Natural disasters
• Symptom categories
• Flashbacks, nightmares, intrusive thoughts
• Avoidance
• Negative cognitions and moods
• Hyperarousal and vigilance
• Some symptoms may differ from adults
• May exhibit agitation instead of fear or hopelessness
OCD
• Prevalence 1 to 4%
• Symptoms similar to those in adults
• Most common obsessions:
• Contamination from dirt and germs

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• Aggression
• Thoughts about sex and religion more common in adolescence
• OCD more common in boys than girls
Etiology of Anxiety Disorders

• Genetics
• Heritability estimates from 29 – 50%
• Genetics plays a stronger role in separation anxiety in context of more negative life
events

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• Parenting plays a small role in anxiety disorders
• Only 4% of variance
• Emotion regulation and attachment problems also play a role
• Perception of lack of acceptance by peers a factor in social phobia
• Risk factors for PTSD include:
• Family stress and coping style
• Past experience with trauma
Treatment of Anxiety Disorders in
Childhood and Adolescence
• Exposure to feared object
• Reward approach behavior
• CBT Kendall’s Coping Cat program
• Shows to be effective in two randomized clinical trials

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• For childern between 7 and 13 years old
• Cognitive restructuring
• Develop new ways to think about fears
• Psychoeducation
• Modeling and exposure
• Skills training and practice
• Relapse prevention
• Family involved in treatment
Learning Disability
• Evidence of inadequate development in a
specific area of academic, language, speech or
motor skills
• e.g., arithmetic or reading

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• Not due to mental retardation, autism, physical
disorder, or lack of educational opportunity
• Individual usually of average or above average
intelligence
Learning Disability
• DSM has 3 categories:
• Learning disorders
• Communication disorders
• Motor skills disorder
• Often identified and treated in school

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• Reading disorders more common in boys
• Proposed DSM-5 Criteria for Learning Disorder:
• Difficulties in learning basic academic skills (reading, mathematics, or writing)
inconsistent with person’s age, schooling, and intelligence
• Significant interference with academic achievement or activities of daily living
Table : Learning, Communication, and Motor
Disorders Likely to Be in DSM-5
Table : Learning, Communication, and Motor
Disorders Likely to Be in DSM-5

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Etiology of Learning Disabilities: Dyslexia
• Genetic factors
• Evidence from family and twin studies
• Genes are those associated with typical reading abilities (generalist
genes)
• Problems in language processing
• Speech perception
• Analysis of sounds and their relationship to printed words
• Difficulty recognizing rhyme and alliteration
• Problems naming familiar objects rapidly
• Delays learning syntactic rules
• Deficient phonological awareness
• Inadequate left temporal, parietal, occipital activation
Figure : Areas of the Brain Implicated in Dyslexia: Frontal,
Parietal, and Temporal Lobes

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Etiology of Learning Disabilities: Dyscalculia
• Genetic and biological factors
• Evidence from twin studies suggest common
genetic factors underlie both reading and math
deficits

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• Intraparietal sulcus implicated
• Has different cognitive deficits from dyslexia
• Children with only dyscalculia do not have deficits
in phonological awareness
Treatment of Learning Disabilities
• Reading and writing disorders
• Multisensory instruction in listening, speaking, and
writing skills
• Readiness skills in younger children as preparation for
learning to read
• Phonics instruction
• Communication disorders
• Fast For Word
• Involves computer games and audiotapes that slow
speech sounds
 Intellectual Developmental Disorder
• Formerly known as Mental Retardation in DSM-IV-TR
• Not preferred due to stigma
• Followed the guidelines of the American Association on Intellectual and Developmental
Disabilities (AAIDD)
• The AAIDD Definition of Intellectual Disability:
• Intellectual disability is characterized by significant limitations both in intellectual functioning

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and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills
• This disability begins before age 18
• Five Assumptions Essential to the Application of the Definition
1. Limitations in present functioning must be considered within the context of community environments
typical of the individual’s age, peers, and culture
2. Valid assessment considers cultural and linguistic diversity as well as differences in communication,
sensory, motor, and behavioral factors
3. Within an individual, limitations often coexist with strengths
4. An important purpose of describing limitations is to develop profile of needed supports
5. With appropriate personalized supports over a sustained period, the life functioning of the person with
intellectual disability generally will improve
Intellectual Developmental Disorder
• DSM-5 criteria:
• Intellectual deficit of 2 or more standard deviations in IQ below the average score for a person’s age
and cultural group, which is typically an IQ score less than 70
• Significant deficits in adaptive functioning relative to the person’s age and cultural group in one or
more of the following areas: communication, social participation, work or school, independence at

.
home or in the community, requiring the need for support at school, work, or independent life
• Onset before age 18

• DSM-5 changes:
• There is explicit recognition that an IQ score must be considered within the cultural context of a
person
• Adaptive functioning must also be assessed and considered within the person’s age and cultural group
• No longer distinguish among mild, moderate, and severe ID based on IQ scores alone
Etiology of Intellectual Developmental Disorder:
Neurological Factors
• Down syndrome
• Chromosomal trisomy 21: an extra copy of chromosome 21
• 47 instead of 46 chromosomes
• Fragile-X syndrome
• Mutation in the fMRI gene on the X chromosome

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• Recessive-gene disease
• Phenylketonuria (PKU)
• Maternal infectious disease, especially during first trimester
• Cytomegalovirus, toxoplasmosis, rubella, herpes simplex, HIV, and
syphilis
• Lead or mercury poisoning
Treatment of
Intellectual Developmental Disorder
• Residential treatment
• Small to medium-sized community residences
• Behavioral treatments
• Language, social, and motor skills training
• Method of successive approximation to teach basic self-care skills in
severely retarded

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• e.g., holding a spoon, toileting
• Applied behavioral analysis
• Cognitive treatments
• Problem-solving strategies
• Computer-assisted instruction
Autism Spectrum Disorder
• DSM-5 combines multiple diagnoses into one: Autism Spectrum Disorder
• Autistic disorder, Asperger’s disorder, pervasive developmental disorder not
otherwise specified, and childhood disintegrative disorder
• Research did not support distinctive categories

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• Share similar clinical features; vary only in severity
• DSM-5 includes different clinical specifiers relating to severity and the
extent of language impairment
 Proposed DSM-5 Criteria for
Autism Spectrum Disorder
A total of six or more items from A, B, and C below, with at least two from A and one each from B and C:

A. Deficits in social communication and social interactions as manifested by all of the following:

• Deficits in nonverbal behaviors such as eye contact, facial expression, body language

• Deficit in development of peer relationships appropriate to developmental level

• Deficits in social or emotional reciprocity such as not approaching others, not having a back-and-forth

© 2012 John Wiley & Sons, Inc.

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• conversation, reduced sharing of interests and emotions
B. Restricted, repetitive behavior patterns, interests, or activities manifested by at least two of the following:

• Stereotyped or repetitive speech, motor movements, or use of objects

• Excessive adherence to routines, rituals in verbal or nonverbal behavior, or extreme resistance to
change
• Very restricted interests that are abnormal in focus, such as preoccupation with parts of objects

• Hyper- or hypo-reactivity to sensory input or unusual interest in sensory environment, such as

fascination with lights or spinning objects
C. Onset in early childhood
D. Symptoms limit and impair functioning
 Autism Spectrum Disorder
• Profound problems with the social world
• Rarely approach others, may look through people
• Problems in joint attention
• Pay attention to different parts of faces than do people without autism; focus on
mouth, neglect eye region
• This neglect likely contributes to difficulties in perceiving emotion in other people

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• Theory of mind
• Understanding that other people have different desires, beliefs, intentions, and
emotions
• Crucial for understanding and successfully engaging in social interactions
• Typically develops between 2½ and 5 years of age
• Children with ASD seem not to achieve this developmental milestone
 Autism Spectrum Disorder
• Communication deficits
• Children with ASD evidence early language disturbances
• Echolalia: immediate or delayed repeating of what was heard
• Pronoun reversal: refer to themselves as “he” or “she”
• Literal use of words
• Repetitive and ritualistic acts
• Become extremely upset when routine is altered
• Engage in obsessional play
• Engage in ritualistic body movements
• Become attached to inanimate objects (e.g., keys, rocks)
 Autism Spectrum Disorder
• Comorbidity
• IQ < 70 is common
• Children with intellectual developmental disorder score poorly on all parts of an IQ test;
children with ASD score poorly on those subtests related to language, such as tasks
requiring abstract thought, symbolism, or sequential logic
• Prevalence

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• 1 out of 110 children
• Found in all SES, ethnic, and racial groups
• Diagnosis of ASD is remarkably stable
• Prognosis
• Children with higher IQs who learn to speak before age six have the best outcomes
Etiology of Autistic Spectrum Disorder
• Genetic factors
• heritability estimates of around .80
• Twin studies
• 47 to 90% concordance rates for MZ twins; 0-

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20% for DZ twins
• Genetic flaw
• Deletion on chromosome 16
Etiology of Autistic Spectrum Disorder
• Neurobiological factors
• Brain size
• Although normal size at birth, brains of autistic adults
and children are larger than normal
• Pruning of neurons may not be occurring
• “Overgrown” areas include the frontal, temporal, and
cerebellar, which have been linked with language, social,
and emotional functions
• Abnormally sized amygdalae predicted more difficulties in
social behavior and communication
Treatment of
Autistic Spectrum Disorder
• Psychological treatments more promising than drugs
• Earlier treatment associate with better outcomes
• Intensive operant conditioning (Lovaas, 1987)
• Dramatic and encouraging results
• Parent training and education

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• Pivotal response treatment (Koegel et al., 2003)
• Focus on increasing child’s motivation and responsiveness rather than on discrete
behaviors
• Joint attention intervention and symbolic play used to improve attention and
expressive skills
• Medication used to treat problem behaviors
• Haloperidol (Haldol)
• Antipsychotic
• Reduces aggression and stereotyped motor behavior
• Does not improve language and interpersonal relationships