Types of Childhood and Adolescence Disorders (7, but 4 main ones)

1. Internalizing Disorders
2. Externalizing Disorders
3. Pervasive developmental disorders
4. Cognitive disorders
5. Tic disorders
6. Feeding disorders
7. Elimination disorders
Internalizing disorder examples
1. separation anxiety disorder
2. other anxiety disorders (phobia, panic, PTSD, OCD)
3. Mood disorders
4. Somatization
5. Eating disorders
Externalizing disorder examples
1. ADHD
2. Conduct disorder
3. Oppositional Defiant Disorder
4. Substance use
Pervasive development disorder examples
1. Rhett's
2. Childhood disintegrative disorder
3. Asperger's
4. Autism
Cognitive disorder examples
1. Learning disorders
2. Motor skill disorders
3. Communication disorders
4. Mental retardation
Other examples
1. Tic disorders
2. Feeding disorders
3. Elimination disorders
Internalizing Disorders (definition)
Similar to those experienced by adults
BUT not exactly the same
More somatic and behavioral symptoms (less cognitive)
Some disorders are unique to childhood (e.g., separation anxiety disorder)

Differences in treatment
Play therapy
Sessions w/parents
Interalizing Disorders - differences between kids and adults
Kids - more somatic/behavioral symptoms (less cognitive)

Treatment - kids have play therapy and sessions with parents

What disorder is unique to childhood?
separation anxiety disorder
Bipolar Disorder in Children?
+ used to be considered an "adult" mood disorder
+ But 40-fold increase in number of cases from 1994 to 2003
+ Controversial...many children do not display "true mania"
+ Treated with powerful mood stabilizers and antipsychotics
+ DSM-V - disruptive mood dysregulation disorder?
How might the DSM-V classify bipolar disorder in children?
disruptive mood dysregulation disorder
Why is classifying bipolar disorder in children controversial?
1. Many children do not display true mania
2. Treated with powerful medications (mood stabilizers and antipsychotics)
ADHD (Attention Deficit Hyperactive Disorder) - two groups
A. 6 symptoms of inattention (persisting for at least 6 months) - 66 devil child
1. failure to pay attention to detail/careless mistakes
2. difficulty sustaining attention
3. failure to listen
4. failure to finish work
5. difficulty with organization
6. avoidance/dislike of tasks with mental effort
7. Loss of items
8. Easily distracted
9. Forgetfulness

B. 6 symptoms of hyperactivity/impulsivity for 6 months

1. fidgeting/squirming
2. wandering from seat
3. running about/climbing when inappropriate
4. difficulty being quiet
5. frequent on the go activity (driven by a motor)
6. excessive talking
7. blurting out answers
8. difficulty waiting for turn
9. interrupts others
Subtypes of ADHD
1. Combined types (6+ symptoms of inattention and 6+ of hyperactivity/impusivity)
2. Predominantly inattentive type (6+ symptoms of inattention and less than 6 of hyperactivity)
3. Predominantly hyperactive impulsive
ADHD Statistics
4-9% of schoolchildren
70% are boys
80% receive treatment
Lessening of symptoms into adolescence

Difficult to assess -- observations across contexts (parent, teacher, etc.)

Controversies around ADHD
Epidemic?
Overdiagnosis or underdiagnosis?
Adult ADHD?
Childhood ADHD actually bipolar disorder?
Causes of ADHD
1. Genetics
2. Dopamine dysregulation
3. Disrupted functioning of frontal lobes, caudate nucleus, corpus callosum
4. Prenatal and birth complications
5. Family environment
ADHD Pharmacological Treatments
1. Stimulants (Ritalin, Adderall - 2.2 million children in the US take stimulants)
2. Drugs that affect norepinephrine (Clonidine, guanfacine, atomoxetine)
3. Antidepressants
Most effective treatment for ADHD
combination therapy
579 children with ADHA - 8yo
14 months treatment

Four conditions:
1. Routine community care (control)
- 25% improved
2. Behavioral therapy only
-35% improved
3. Stimulants only
-55% improved
4. Behavior therapy + stimulants
-70% improved
Are we overmedicating children?
Long-term safety and effectiveness of drugs still to be fully determined

At the same time, they do provide symptom reduction

Oppositional Defiant Disorder (ODD) - need 4 symptoms
Pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, and characterized
by four or more of the following:
1. Loses temper
2. Argues
3. Refuses to follow rules/requests
4. Deliberately annoys others
5. Blames others
6. Easily annoyed
7. Angry
8. Spiteful/vindictive (holds a grudge)
Conduct Disorder (CD)
[bad conduct -- violating rules]
Persistent pattern of behavior violating basic rights of others and societal rules, manifested by
three or more symptoms in the following classes:
1. Aggression to people and animals
2. Destruction of property
3. Deceitfulness or theft
4. Serious violation of rules
Aggression Symptoms
1. Bullies, threatens, intimidates other people
2. Often initiates physical fights
3. Uses weapons that can cause serious harm
4. Has stolen while confronting a victim
5. Physically cruel to people/animals
6. Forced someone into sexual activity
Property Destruction Symptoms
1. Sets fires w/the intention of causing serious damage
2. Deliberately destroys property of another person
Violation of Rules Symptoms
1. Stays out at night (in spite of parents' rules), starting before the age of 13
2. Has run away from home overnight at least twice
3. Has run away from home once but for an extended period of time
4. Often truant from school, starting before the age of 13
Subtypes of Conduct Disorder
1. Life-course persistent (develops early in childhood, more likely to continue having problems
into adulthood)

2. Adolescent limited (onset in adolescence; LESS likely to have problems into adulthood)
Distinctions between Oppositional Defiant Disorder and Conduct Disorder
1. ODD milder than CD (Oppositional mild)
2. ODD has earlier onset (Oppositional early)

3. Subset of children with ODD go on to meet criteria for CD (about 43% of boys 9-13yrs with
ODD meet CD over next three years)

4. If a child meets criteria for CD, they CANNOT be diagnosed with ODD
Gender Differences in Conduct Disorder
+ Boys 3x as likely to be diagnosed as girls
+ Boys with CD more aggressive than girls with CD
+ Girls' antisocial behavior manifested differently? Relational aggression? (often verbal, indirect,
involves character defamation)
Comorbidity of CD
Boys - 20% ADHD, 45% Anxiety, 35% Depression, 45% Alcohol Dependence, 40% Marijuana
dependence
(Boys = anxiety, alcohol, marijuana, depression)
Girls - 70% Anxiety, 70% Depression, 30% Alcohol Dpendence, 27% Marijuana Dependence
(Girls - Anxiety, depression, alcohol, marijuana)
Negative Outcomes Associated with ODD and CD
+ History of ODD/CD present in 25-60% adults w/mental disorders

+ 75-85% chronically unemployed, engaged in impulsive, aggressive behavior

+30-40% will be diagnosed with antisocial personality disorder as adults

What percentage of adults have mental disorders who also have a history of ODD/CD?
25-60%
Outcomes of Boys with CD at Age 21
Those with CD:
1. Crime (1.0)
2. Violence (0.8)
3. Jail (0.63)
4. Alcohol Dependence (0.62)
5. Unemployment (0.62)
6. Welfare (0.4)
7. Physical Abuse Perpetrator (0.15)
Family and Environment Risk Factors for CD/ODD
1. Chaotic/disrupted family environments
2. Low SES (Socioeconomic Status) - Costello
3. Parenting practices (lack of involvement, harsh, physical abuse, severe neglect)
4. Exposure to deviant peers (deviants child tends to associate with deviant peers, escalating
behavioral problems)
Costello experiment and SES
+ Costello (2003) - natural experiment with 1420 kids in rural NC; casino opened, leading to
increase in income for many families,
+ decrease in rates of ODD/CD after casino opened
+ Parental supervision improved
Biological Perspective on CD/ODD
1. Brain circuitry
2. Neurotoxins
3. Low arousal to punishment and rewards (low cortisol in response to stress)
4. High serotonin (linked to violent crimes)
5. High testosterone
6. Genetics/family history
Gene and Environment
Genes may predispose to specific disorders or more generally to a resilient or vulnerable
temperament

Environment can enhance resiliency / worsen vulnerability

Child Maltreatment Interacts with Genes
Percentage with Low MAOA activity and SEVERE maltreatment - 80% CD
(with high MAOA activity - only 40%)
Behavioral Therapy for CD/ODD
1. Problem Solving Skills Therapy (PSST)
2. Parent Management Training (PMT)
Problem Solving Skills Therapy (PSST)
Problem Solving Skills Therapy (PSST)
(Alan Kazdin)
Child uses the following steps to engage in better social problem solving

What am I supposed to do?

I have to look at all my possibilities
I have to consider the consequences
I have to make a choice
"I did a good job" or "I made a mistake"
Parent Management Training (PMT)
Parent Management Training (PMT)

Parents learn to identify, define, and observe problem behaviors from a behavioral perspective

Taught to use positive reinforcement, prompting, shaping, mild punishment, negotiation, and
contingency contracting

Techniques modeled by therapist and practiced by parent in session

Behavioral Therapy Outcomes
Behavioral problems decrease in all cases
Decreases from atoung 70% to 60%
Fastest decrease in combined PSST+PMT (lowest in the end too)
PSST (Problem Solving) - second quickest decrease
PMT - takes a bit longer but same effect
Pharmacology for CD/ODD
1. Antidepressants (SSRIs)
2. Neuroleptics
3. Stimulants
4. Mood Stabilizers

Mixed Results
Pervasive Developmental Disorders: Autism Spectrum
1. Rhett's disorder
Normal development through first 5 months, then losses of skills
2. Childhood disintegrative disorder
Normal development thorough first 2 years, then losses for function
3. Asperger's disorder
Deficits in social interactions and activities, but NOT in language or communication
4. Autistic disorder
Deficits in social interaction, communication, activities, and interests
Rhett's Disorder
+ Characterized by normal development until a certain point
+ Loss of previously acquired skills, such as language
+ Severe motor difficulties and trouble interacting w/others
+ Thought to be genetic
+ No language impairments, according to chart...? (difference from childhood)
+ Hypotonia/microephaly/seizures
+ Mutation of X chromosome
+ 1 in 12,500
Childhood Disintegrative Disorder
Normal development until age 2 - 10; then loss of acquired skills
Language
Social skills
Self care
Control over bowel & bladder
Play skills
Motor skills
+ Seizures
+ Regression at under 2 years
+ 1 in 50,000
Asperger's Disorder (2 impairment in social interaction & 1 repetitive behavior)
Qualitative impairment in social interaction, as manifested by at least 2 of the following:
1. 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
2. failure to develop peer relationships appropriate to developmental level
3. a lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
(e.g., by a lack of showing, bringing, or pointing out objects of interest to other people)
4. lack of social or emotional reciprocity

Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested
by at least 1of the following:
1. encompassing preoccupation with one or more stereotyped and restricted patterns of interest
that is abnormal either in intensity or focus
2. apparently inflexible adherence to specific, nonfunctional routines or rituals
3. stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or
complex whole-body movements)
4. persistent preoccupation with parts of objects

+ Average IQ
+ 1 in 3,000
Autistic Disorder (6 total of impaired social interaction & communication; repetitive behavior)
A total of at least 6 of the following
Impairment in social interaction, as manifested by at least 2 of the following
1. Marked impairment in the use of multiple nonverbal behaviors (e.g., eye contact)
2. Failure to develop peer relationships appropriately
3. Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people
4. Lack of social or emotional reciprocity

Impairment in communication, as manifested by at least 1 of the following

1. Delay in, or total lack of, development of spoken language
2. In individuals w/ adequate speech, marked impairment in the ability to start/sustain a
conversation
3. Stereotyped and repetitive use of language, or idiosyncratic language
4. Lack of varied, spontaneous make-believe play or social imitative play

Restrictive repetitive and stereotyped patterns of behavior, interest, and activities, as manifested
by at least 1 of the following
1. Abnormal preoccupation w/one or more stereotyped and restricted patterns of interest
2. Inflexible adherence to specific nonfunctional routines or rituals
3. Stereotyped and repetitive motor mannerisms (e.g., finger flapping)
4. Persistent preoccupation w/parts of objects

+ Sensory problems/Seizures
+ Average to below average IQ
+ 1-2 in 1000
Autism Spectrum Statistics
Steady increase in prevalence
+ 1 in 600 children and perhaps as many as 1 in 150
+ No reliable diagnosis until age 3
+ YET, treatment can be very effective if begun early enough
Eye Tracking Studies
Klin et al. (2003)
15 males w/autism and 15 healthy controls
Researchers coded fixations on mouth, eyes, body, and objects
+++ Best predictor of autism was eye region fixation time (vew low by comparison; higher
fixation percentage on mouth and body)
Range of Functioning
Some individuals do poorly in tests of intelligence; others do very well

Some individuals become independent adults; others do not

Causes of Autistic Disorders
1. Psychodynamic perspective: "refrigerator parents" (cold and closed off?)
2. Social and environmental stress
3. Failure to develop theory of mind
4. Genetics
5. Neurocircuitry
+ Abnormal development of the cerebellum +Increased brain volume, structural abnormalities in
limbic system, brain stem nuclei
Can Vaccines Cause Autism Spectrum Disorders?
Initial study showing association with MMR vaccine and autism retracted by the Lancet in 2010
Psychosocial Treatment for Autism
1. CBT approach
+ Skills training
+ Operant conditioning to teach speech, social skills, self-help
2. Communication training
+ Augmentative communication systems
3. Parent training
4. Community integration
Pharmacology for Autism
1. SSRIs reduce repetitive behaviors, aggression, depression, anxiety, and improve social
interactions

2. Antipsychotics reduce compulsive behavior and improve self-control

3. Naltrexone reduces hyperactivity

4. Stimulants improve attention