Developmental and

Cognitive Disorders
Chapter 13

Perspectives on Developmental Disorders

Normal vs. Abnormal Development

Childhood is associated with significant developmental changes
Disruption of early skills will likely disrupt development of later skills

Developmental Disorders
Diagnosed first in infancy, childhood, or adolescence
Attention deficit hyperactivity disorder (ADHD)
Learning disorders
Autism
Mental retardation

Attention Deficit Hyperactivity Disorder (ADHD): An Overview

Nature of ADHD
Central features Inattention, overactivity, and impulsivity
Associated with behavioral, cognitive, social, and academic
problems

DSM-IV and DSM-IV-TR Symptom Clusters

Cluster 1 Symptoms of inattention
Cluster 2 Symptoms of hyperactivity and impulsivity cluster
Either cluster 1 or 2 must be present for a diagnosis

ADHD: Facts and Statistics

Prevalence
Occurs in 4%-12% of children who are 6 to 12 years of age
Symptoms are usually present around age 3 or 4
68% of children with ADHD have problems as adults

Gender Differences
Boys outnumber girls 4 to 1

Cultural Factors
Probability of ADHD diagnosis is greatest in the United States

ADHD: Biological Contributions

Genetic Contributions
ADHD runs in families
Familial ADHD may involve deficits on chromosome 20

Neurobiological Contributions: Brain Dysfunction and Damage

Inactivity of the frontal cortex and basal ganglia
Right hemisphere malfunction
Abnormal frontal lobe development and functioning
Yet to identify a precise neurobiological mechanism for ADHD

The Role of Toxins

Allergens and food additives do not appear to cause ADHD
Maternal smoking increases risk of having a child with ADHD

ADHD: Psychosocial Contributions

Psychosocial Factors Can Influence the Disorder Itself

Constant negative feedback from teachers, parents, and peers
Peer rejection and resulting social isolation
Such factors foster low self-image

Biological Treatment of ADHD

Goal of Biological Treatments

To reduce impulsivity/hyperactivity and to improve attention

Stimulant Medications
Reduce the core symptoms of ADHD in 70% of cases
Examples include Ritalin, Dexedrine

Effects of Medications
Improve compliance and decrease negative behaviors in many
children
Beneficial effects are not lasting following drug discontinuation
Negative side effects include insomnia, drowsiness, and irritability

Behavioral and Combined Treatment of ADHD

Behavioral Treatment
Involve reinforcement programs
Aim to increase appropriate behaviors and decrease inappropriate
behaviors
May also involve parent training

Combined Bio-Psycho-Social Treatments

Are highly recommended

Learning Disorders

Scope of Learning Disorders

Problems related to academic performance in reading, mathematics,
and writing
Performance is substantially below what would be expected

DSM-IV and DSM-IV-TR Reading Disorder

Discrepancy between actual and expected reading achievement
Reading is at a level significantly below that of a typical person of the
same age
Problem cannot be caused by sensory deficits (e.g., poor vision)

DSM-IV and DSM-IV-TR Mathematics Disorder

Achievement below expected performance in mathematics

DSM-IV and DSM-IV-TR Disorder of Written Expression

Achievement below expected performance in writing

Learning Disorders: Some Facts and Statistics

Incidence and Prevalence of Learning Disorders

1% to 3% incidence of learning disorders in the United States
Prevalence is highest in wealthier regions of the United States
Prevalence rate is 10% to 15% among school age children
Reading difficulties are the most common of the learning disorders
About 32% of students with learning disabilities drop out of school
School experience for such persons tends to be quite negative

Biological and Psychosocial Causes of Learning Disorders

Genetic and Neurobiological Contributions

Reading disorder runs in families, with 100% concordance rate for
identical twins
Evidence for subtle forms of brain damage is inconclusive
Overall, genetic and neurobiological contributions are unclear

Psychological and motivational factors seem to affect eventual outcome

Treatment of Learning Disorders

Requires Intense Educational Interventions

Remediation of basic processing problems (e.g., teaching visual
skills)
Efforts to improve of cognitive skills (e.g., instruction in listening)
Targeting behavioral skills to compensate for problem areas

Data Support Behavioral Educational Interventions for Learning

Disorders

Pervasive Developmental Disorders: An Overview

Nature of Pervasive Developmental Disorders

Problems occur in language, socialization, and cognition
Pervasive Means the problems span the persons entire life

Examples of Pervasive Developmental Disorders

Autistic disorder
Aspergers syndrome

Autistic Disorder

Autism
Significant impairment in social interactions and communication
Restricted patterns of behavior, interest, and activities

Three Central DSM-IV and DSM-IV-TR Features of Autism

Problems in socialization and social function
Problems in communication 50% never acquire useful speech
Restricted patterns of behavior, interests, and activities

Autistic Disorder: Facts and Statistics

Prevalence and Features of Autism

Affects 2 to 20 persons for every 10,000 people
More prevalent in females with IQs below 35, and in males with
higher IQs
Autism occurs worldwide
Symptoms usually develop before 36 months of age

Autism and Intellectual Functioning

50% have IQs in the severe-to-profound range of mental retardation
25% test in the mild-to-moderate IQ range (i.e., IQ of 50 to 70)
Remaining people display abilities in the borderline-to-average IQ
range
Better language skills and IQ test performance predicts better
lifetime prognosis

Causes of Autism: Early and More Recent Contributions

Historical Views
Bad parenting
Unusual speech patterns
Lack of self-awareness
Echolalia

Current Understanding of Autism

Medical conditions Not always associated with autism
Autism has a genetic component that is largely unclear
Neurobiological evidence for brain damage Link with mental
retardation
Cerebellum size Substantially reduced in persons with autism

Treatment of Pervasive Developmental Disorders

Psychosocial Behavioral Treatments

Skill building and treatment of problem behaviors
Communication and language problems
Address socialization deficits
Early intervention is critical

Biological and Medical Treatments Are Unavailable

Integrated Treatments: The Preferred Model

Focus on children, their families, parents, schools, and the home
Build in appropriate community and social support

Mental Retardation (MR)

Nature of Mental Retardation

Disorder of childhood
Below-average intellectual and adaptive functioning
Range of impairment varies greatly across persons

Mental Retardation and the DSM-IV and DSM-IV-TR

Significantly subaverage intellectual functioning (IQ below 70)
Concurrent deficits or impairments two or more areas of adaptive
functioning
MR must be evident before the person is 18 years of age

DSM-IV and DSM-IV-TR Levels of Mental Retardation (MR)

Mild MR
Includes persons with an IQ score between 50 or 55 and 70

Moderate MR
Includes persons in the IQ range of 35-40 to 50-55

Severe MR
Includes people with IQs ranging from 20-25 up to 35-40

Profound MR
Includes people with IQ scores below 20-25

Other Classification Systems for Mental Retardation (MR)

American Association of Mental Retardation (AAMR)

Defines MR based on levels of assistance required
Examples of levels include intermittent, limited, extensive, or
pervasive assistance

Classification of MR in Educational Systems

Educable mental retardation (i.e., IQ of 50 to approximately 70-75)
Trainable mental retardation (i.e., IQ of 30 to 50)
Severe mental retardation (i.e., IQ below 30)

Mental Retardation (MR): Some Facts and Statistics

Prevalence
About 1% to 3% of the general population
90% of MR persons are labeled with mild mental retardation

Gender Differences
MR occurs more often in males, male-to-female ratio of about 1.6:1

Course of MR
Tends to be chronic, but prognosis varies greatly from person to
person

Mental Retardation (MR): Biological Contributions

Genetic Research
MR involves multiple genes, and at times single genes

Chromosomal Abnormalities and Other Forms of MR

Down syndrome Trisomy 21
Fragile X syndrome Abnormality on X chromosome

Maternal Age and Risk of Having a Downs Baby

Nearly 75% of cases cannot be attributed to any known biological

cause

Mental Retardation (MR): Psychosocial Contributions

Cultural-Familial Retardation
Believed to cause about 75% of MR cases and is the least
understood
Associated with mild levels of retardation on IQ tests and good
adaptive skills

Cultural-Familial Retardation: Difference vs. Developmental Views

Difference view Mild MR is a matter of degree and kind
Developmental view Mild MR reflects a slowing or delay of normal
development

Treatment of Mental Retardation (MR)

Parallels Treatment of Pervasive Developmental Disorders

Teach needed skills to foster productivity and independence
Educational and behavioral management
Living and self-care skills via task analysis
Communication training Often most challenging treatment target!
Community and supportive interventions

Persons with MR Can Benefit from Such Interventions

Summary of Developmental Disorders

Developmental Psychopathology and Normal and Abnormal Development

Attention Deficit Hyperactivity Disorder

Deficits in inattention, hyperactivity, or impulsivity
Disrupt academic and social functioning

Learning Disorders
All share deficits in performance below expectations for IQ and school
preparation

Pervasive Developmental Disorder

All share deficits in language, socialization, and cognition

Mental Retardation
Subaverage IQ, deficits in adaptive functioning, onset before age 18
Prevention and Early Intervention Are Critical for Developmental Disorders

Cognitive Disorders: An Overview

Perspectives on Cognitive Disorders

Affect cognitive processes such as learning, memory, and consciousness
Most develop later in life

Three Classes of Cognitive Disorders

Delirium Often temporary confusion and disorientation
Dementia Degenerative condition marked by broad cognitive deterioration
Amnestic disorders Memory dysfunctions caused by disease, drugs, or
toxins

Shifting DSM Perspectives

From organic mental disorders to cognitive disorders
Broad impairments in memory, attention, perception, and thinking
Profound changes in behavior and personality

Delirium

Nature of Delirium
Central features Impaired consciousness and cognition
Impairments develop rapidly over several hours or days
Examples include confusion, disorientation, attention, memory, and
language deficits

Facts and Statistics

Affects 10% to 30% of persons in acute care facilities
Most prevalent in older adults, AIDS patients, and medical patients
Full recovery often occurs within several weeks

Medical Conditions Related to Delirium

Medical Conditions
Drug intoxication, poisons, withdrawal from drugs
Infections, head injury, and several forms of brain trauma
Sleep deprivation, immobility, and excessive stress

DSM-IV and DSM-IV Subtypes of Delirium

Delirium due to a general medical condition
Substance-induced delirium
Delirium due to multiple etiologies
Delirium not otherwise specified

Treatment and Prevention of Delirium

Treatment
Attention to precipitating medical problems
Psychosocial interventions include reassurance, coping strategies

Prevention
Address proper medical care for illnesses
Address proper use and adherence to therapeutic drugs

Dementia

Nature of Dementia
Gradual deterioration of brain functioning
Affects judgment, memory, language, and advanced cognitive processes
Dementia has many causes and may be reversible or irreversible

Progression of Dementia: Initial Stages

Memory impairment, visuospatial skills deficits
Agnosia Inability to recognize and name objects (most common symptom)
Facial agnosia Inability to recognize familiar faces
Other symptoms Delusions, depression, agitation, aggression, and apathy

Progression of Dementia: Later Stages

Cognitive functioning continues to deteriorate
Person requires almost total support to carry out day-to-day activities
Death results from inactivity combined with onset of other illnesses

Dementia: Facts and Statistics

Onset and Prevalence

Can occur at any age, but most common in the elderly
Affects 1% of those between 65-74 years of age
Affects over 10% of persons 85 years and older
47% of adults over the age of 85 have dementia of the Alzheimers type

Incidence of Dementia
Affects 2.3% of those 75-79 years of age and 8.5% of persons 85 and
older
Rates of new cases appear to double with every 5 years of age

Gender and Sociocultural Factors

Dementia occurs equally in men and women
Dementia occurs equally across educational level and social class

DSM-IV and DSM-IV-TR Classes of Dementia

Dementia of the Alzheimers type

Vascular Dementia

Dementia Due to Other General Medical Conditions

Substance-Induced Persisting Dementia

Dementia Due to Multiple Etiologies

Dementia Not Otherwise Specified

Dementia of the Alzheimers Type

DSM-IV-TR Criteria and Clinical Features

Multiple cognitive deficits that develop gradually and steadily
Predominant impairment in memory, orientation, judgment, and
reasoning
Can include agitation, confusion, depression, anxiety, or
combativeness
Symptoms are usually more pronounced at the end of the day

Range of Cognitive Deficits

Aphasia Difficulty with language
Apraxia Impaired motor functioning
Agnosia Failure to recognize objects
Difficulties with planning, organizing, sequencing, or abstracting
information
Impairments have a marked negative impact on social and
occupational functioning

An Autopsy Is Required for a Definitive Diagnosis

Alzheimers Disease: Some Facts and Statistics

Nature and Progression of the Disease

Deterioration is slow during the early and later stages, but rapid
during middle stages
Average survival time is about 8 years
Onset usually occurs in the 60s or 70s, but may occur earlier

Prevalence of Alzheimers Disease

Affects about 4 million Americans and many more worldwide
Prevalence is greater in poorly educated persons and women
Prevalence rates are low in some ethnic groups (e.g., Japanese,
Nigerian, Amish)

Vascular Dementia

Nature of Vascular Dementia

Progressive brain disorder caused by blockage or damage to blood
vessels
Second leading cause of dementia next to Alzheimers
Onset is often sudden (e.g., stroke)
Patterns of impairment are variable, and most require formal care in
later stages

DSM-IV and DSM-IV Criteria and Incidence

Cognitive disturbances are identical to dementia
Unlike Alzheimers, obvious neurological signs of brain tissue
damage occur
Incidence is believed to be about 4.7% or men and 3.8% of women

Dementia Due to HIV Disease

Overview and Clinical Features

HIV causes neurological impairments and dementia
Cognitive slowness, impaired attention, forgetfulness, and
clumsiness
Repetitive movements (e.g., tremors/leg weakness), apathy, and
social withdrawal

Progression of HIV-Related Cognitive Impairments

Tend to occur during the later stages of HIV infection
Impairments are observed in 29% to 87% of people with AIDS
Subcortical dementia Refers to deficits that affect inner brain
regions
Aphasia is uncommon in subcortical dementia, but anxiety and
depression occur

Other Causes of Dementia: Head Trauma and Parkinsons Disease

Head Trauma
Accidents are leading causes of such cognitive impairments
Memory loss is the most common symptom

Parkinsons Disease
Degenerative brain disorder
Affects about 1 out of 1,000 people worldwide
Motor problems are characteristic of this disorder
Damage to dopamine pathways is believed to cause motor
problems
Pattern of impairments are similar to subcortical dementia

Other Causes of Dementia: Huntingtons and Picks Disease

Huntingtons Disease
Genetic autosomal dominant disorder (i.e., chromosome 4)
Manifests initially as chorea, usually later in life (around 40s or 50s)
About 20% to 80% of persons go on to display dementia of the
subcortical pattern

Picks Disease
Rare neurological condition that produces a cortical dementia like
Alzheimers
Also occurs later in life (around 40s or 50s)
Little is known about what causes this disease

Other Dementias: Creutzfeldt-Jakob Disease and Substance-Induced

Dementia

Creutzfeldt-Jakob Disease
Affects 1 out of 1,000,000 persons
Linked to mad cow disease

Substance-Induced Persisting Dementia

Results from drug use in combination with poor diet
Examples include alcohol, inhalants, and sedative, hypnotic, and
anxiolytic drugs
Resulting brain damage may be permanent
Dementia is similar to that of Alzheimers
Deficits may include aphasia, apraxia, agnosia, or disturbed
executive functioning

Causes of Dementia: The Example of Alzheimers Disease

Early and Largely Unsupported Views: The Example of Smoking

Current Neurobiological Findings

Neurofibrillary tangles Occur in all brains of Alzheimers patients
Amyloid plaques Accumulate excessively in brains of Alzheimers
patients
Brains of Alzheimers patients tend to atrophy

Current Neurobiological Findings

Multiple genes are involved in Alzheimers disease (chromosomes
21, 19, 14, 12, 1)
Chromosome 14 Associated with early onset Alzheimers
Chromosome 19 Associated with a late onset Alzheimers

The Contributions of Psychosocial Factors in Dementia

Do not cause dementia directly, but may influence onset and course

Lifestyle factors Drug use, diet, exercise, stress

Cultural factors Risk for certain diseases and accidents vary by

ethnicity and class

Psychosocial factors Educational attainment, coping skills, social

support

Medical and Psychosocial Treatment of Dementia

Medical Treatment: Best if Enacted Early

Few medical treatments exist for most types of dementia
Most medical treatments attempt to slow progression of deterioration
Examples include glial cell-derived neurotrophic factor, Cognex,
vitamin E, aspirin
Medical treatments do not stop progression of dementia

Psychosocial Treatments
Focus on enhancing the lives of dementia patients and their
families/caregivers
Teach adaptive skills
Use memory enhancement prosthetic devices (e.g., memory wallet)
Main emphasis of psychosocial interventions appears to be on the
caregivers

Prevention of Dementia

Reducing Risk of Dementia in Older Adults Via

Estrogen-replacement therapy Reduces risk of Alzheimers
dementia in women
Proper treatment of cardiovascular diseases
Use of anti-inflammatory medications

Other Targets of Prevention Efforts

Increasing safety behaviors to reduce head trauma
Reducing exposure to neurotoxins and use of drugs

Amnestic Disorder

Nature of Amnestic Disorder

Inability to transfer information from short-term memory into longterm memory
Often results from medical conditions, head trauma, or long-term
drug use

DSM-IV and DSM-IV-TR Criteria for Amnestic Disorder

Cover the inability to learn new information
Inability to recall previously learned information
Memory disturbance causes significant impairment in functioning

The Example of Wernicke-Korsakoff Syndrome

Caused by thalamic damage resulting from stroke or chronic heavy
alcohol use
Attempt to restore thiamine deficiency in the case of chronic alcohol
abuse

Research on Amnestic Disorders Is Scant