disorders of childhood lecture outline overview externalizing disorders - attention-...

DISORDERS OF CHILDHOOD

LECTURE OUTLINE

• Overview

• Externalizing disorders - Attention-deficit/Hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD)

• Internalizing disorders – Separation anxiety disorder (SAD)

• Other disorders – tic disorders, elimination disorders

• Pervasive developmental disorder – including autism


OVERVIEW

• The DSM and childhood disorders

• Developmental psychopathology

• Risk and protective factors

• Special considerations in treating children

• Prevalence of childhood disorders


OVERVIEW

Ontario Child Health Study (Offord et al., 1987)

• studied rates of 4 disorders (conduct disorder, hyperactivity, emotional disorders, somatization) for children 4-16 years of age

• 6-month prevalence rate for any disorder was 18%

• boys have higher rates of conduct disorders (8%) and hyperactivity (9%) than girls (3% for both)


OVERVIEW

Ontario Child Health Study (Offord et al., 1987)

• girls have higher rates of emotional (14%) and somatization (11%) disorders than boys (8% & 5%)

• for boys, rates of conduct disorder increase with age, while rates of hyperactivity and emotional problems decrease

• for girls, rates of emotional problems increase with age


ADHD – History and background

• originally called MBD (minimal brain dysfunction), then Hyperkinetic Reaction of Childhood

• most common presenting problem in mental health clinics for children

• more common for boys than girls (3:1 to 5:1)


ADHD – Core features

• age-inappropriate levels of inattention (e.g., difficulty sustaining attention with school work, easily distracted)

• impulsivity (e.g., not waiting turn, blurting out answers)

• hyperactivity (fidgets, squirms, talks excessively)


ADHD - Subtypes

• Children can be diagnosed as ADHD combined type, predominantly inattentive, or predominantly impulsive-hyperactive

• Research by Virginia Douglas at McGill demonstrated that inability to sustain attention and control impulses, not higher activity levels, were key features of this disorder


ADHD and other disorders

• high rates of comorbidity with oppositional defiant disorder (80%), conduct disorder (40%), and antisocial personality disorder (25%) in adolescence

• also, high rates of comorbidity with learning disabilities

• assessed primarily with rating scales (e.g., Connors)


ADHD – Long-term prognosis

• Follow-up studies of children with ADHD show elevated rates of school problems, conduct disorders or antisocial personality, substance abuse, criminal behaviour

• But this long-term trend is observed mostly with aggression associated with ADHD


ADHD – Long-term prognosis

• Moreover, some children seem to outgrow ADHD (see figure 5.1 in text)

• at age 10, 250 cases per 1000 for ADHD in boys; drops to < 50 cases per 1000 by age 20

• girls remain at low rates (75 cases per 1000) from ages 10 to 20


ADHD - Etiology

• likely some biological predisposition

• 30-50% heritability component

• food additives and sugar – no evidence that these are causal factors

• PET and MRI research suggests some brain abnormalities, such as reduced glucose metabolism


ADHD - Treatment

• stimulant medications – Ritalin, Dexedrine, Cylert

• reduced impulsiveness and hyperactivity and improved attention, but little evidence of improvement in academic achievement


ADHD - Treatment

• proliferation of medications for treatment of ADHD

• rates of use quadrupled in Canada from 1990 to 1995, then increased by 85% per year from 1996-98 (McCubbin & Cohen, 1999)

• concerns about side effects about use of stimulant medication


ADHD - Treatment

• behavioural management at home and school

• these strategies can also help, but appear less powerful and are more demanding of adults than medications

• combination of medication and behavioural treatment may be most beneficial


OPPOSITIONAL DEFIANT DISORDER (ODD)

• diagnosed when children behave in a negative, hostile, or defiant manner; related to problems in relationships and at school

• symptoms emerge before age 8

• 1 in 4 boys will go on to develop CD


CONDUCT DISORDER (CD)

• “repetitive and persistent pattern of conduct in which the basic rights of others and major age-appropriate societal norms or rules are violated”

• aggression is a major concern; also property destruction, lying, theft, rule violation

• poor interpersonal skills and peer rejection


Diagnostic issues in ODD & CD

• more common in boys (2:1)

• many boys with ODD do not develop CD

• minority of those with CD don’t develop antisocial personality disorder

• CD linked with ADHD and substance abuse


Etiology of ODD & CD

• subclinical neurological signs

• temperament

• inter-generational patterns

• marital conflict, divorce, abuse

• attachment problems

• parenting


Long-term development of ODD & CD

• form of behaviour changes over time – from overt to covert

• severity and frequency of problems best predictors of who will continue to have problems in the future

• many children do improve over time


Treatment of ODD & CD

Coercive process – Gerry Patterson

• parents behaviour impacts on child; child’s behaviour impacts on adult

• in families of children with ODD or CD, parents lack child management skills and often end up in coercive interactions that sprial out of control and are self-perpetuating

DISORDERS OF CHILDHOOD Treatment of ODD & CDParents’ impact on child

Brother Brother and and sister at sister at playplay

Children play Children play cooperativelycooperatively

Parent Parent ignores ignores childrenchildren

Extinction of Extinction of cooperative cooperative playplay

Brother Brother and and sister at sister at playplay

Children fightChildren fight Parent Parent criticizes criticizes or scolds or scolds childrenchildren

Positive Positive reinforcement reinforcement for fightingfor fighting

DISORDERS OF CHILDHOOD Treatment of ODD & CDChilds’ impact on parent

Children Children fightfight

Parent Parent criticizes criticizes or scoldsor scolds

Children stop Children stop fighting fighting (temporarily)(temporarily)

Negative Negative reinforcement reinforcement for criticism or for criticism or scoldingscolding


Patterson’s parent training for ODD & CD

Defining and pinpointing behaviour

• “I want Johnny to be a good student”

• “I want Johnny to stop being aggressive”

• “I want Johnny to stop hitting his peers”


Patterson’s parent training for ODD & CD

Focusing on the positive – alternative, incompatible behaviours

• yelling

• whining

• interrupting

• non-compliance


Patterson’s parent training – key focus is on obtaining compliance from child

• commands vs. requests

• positive reinforcement (praise)

• extinction (ignoring)

• punishment (timeout)


Community Parent Education Program (COPE) for ODD & CD – Cunningham et al.

(1993)

• parent training in schools and community centres

• school-based intervention


Other treatments for ODD & CD

• Problem-solving skills training

• Family therapy – multisystemic therapy

• the earlier the treatment, the better long-term prognosis


Separation Anxiety Disorder

• only SAD remains in DSM-IV as an anxiety disorder unique to childhood

• distress upon being separated from a parent or fears that parent will be harmed

• average age of onset is 9

• typically occurs after a major stressor


SAD – Diagnosis and assessment

• severe and excessive anxiety when faced with separation from a parent

• also related to mood problems, school refusal, somatic complaints

• need for multi-dimensional assessment


SAD – Long-term development

• social withdrawal, poor school performance

• not much known about long-term course if left untreated, possibly related to adult anxiety disorders such as agoraphobia and panic disorder


SAD – Etiology

• strong heritability component, concordance for anxiety disorders is 3 times higher in MZ than DZ twins

• temperament – behavioural inhibition (shyness, vigilance, avoidance)

• insecure attachment


SAD – Treatment

• cognitive-behaviour therapy

• play therapy

• medication

• overall, shy and anxious children respond well to treatment, again early treatment is needed

• SAD is far less researched than the externalizing disorders


Other disorders

• tic disorders – Tourette syndrome, responds well to anti-psychotic medication Haldol

• elimination disorders – enuresis and encopresis, Mowrer bell and pad treatment based on classical conditioning


SUMMARY

• childhood disorders have high prevalence (OCHS)

• externalizing disorders (ADHD, ODD, CD) have received the most attention because of negative impacts on others and their damaging long-term impacts

• less well understood are internalizing disorders, such as SAD

disorders of childhood lecture outline overview externalizing disorders - attention-...

Documents

disorders tic disorders

emotional disorders

adhd slide

disorder slide

age slide

rates of hyperactivity

autism slide

connors slide