Chapter Outline (See related pages) Introduction Disorders of childhood and adolescence include wide range of problems Involve failure to pass developmental milestone on time Involve disruption of developmentally acquired skill Some are psychological disorders that normally have onset prior to adulthood Disorders may have no counterpart in adult psychopathology Deciding what is abnormal more difficult in childhood and adolescence Disorders differ in course and outcome from adult psychological disorders Most children do not think of themselves as having treatable psychological disorders Issues in Child Psychopathology Prevalence One out of every five children and adolescents has moderate or severe psychological disorder Admission rates begin to increase at age six or seven Psychological disturbances more common in boys than in girls Classification and Diagnosis Classified as syndromes Empirical method groups together pre-adult problems that occur together in same children or age group Disruptive behavior disorders Disorders of emotional distress Habit disorders Learning and communication disorders Most of DSM-IV and DSM-IV-TR diagnostic categories can be grouped under four headings Disruptive behavior disorders Disorders of emotional distress Habit disorders Learning and communication disorders Children change rapidly Children may not fit neatly into one category Long-Term Consequences Stability is one type of predictability; antisocial behavior is stable Continuity of developmental adaptation leads to other different disorders Reactivity to particular stressors relates to disorders creating stresses Some childhood disorders do predict adult disorders often indirectly Some children and adolescents respond well to treatment Disruptive Behavior Disorders Disruptive behavior disorders involve poorly controlled, impulsive, acting-out behavior in situations in which self-control is expected Attention Deficit Hyperactivity Disorder Attention deficit hyperactivity disorder (ADHD) involves short attention span and hyperactivity More common in boys than girls; 3Ð5% of elementary school children said to have ADHD Some believe that it is too readily applied to children who are difficult to control Symptoms affect every area of child's functioning Behavior often distinguished less by its excessiveness than by its haphazard quality Activity seems purposeless and disorganized Affects child's academic progress ADHD children tend to have poor social adjustment DSM-IV-TR divides syndrome into three subtypes Predominantly inattentive type Predominantly hyperactive/impulsive type Combined type; most ADHD children more likely to have wide range of problems Most ADHD children still show the disorder in adolescence Many ADHD children will develop antisocial behavior Cognitive problems tend to persist into adolescence Conduct Disorder Conduct disorder (CD) characterized by indifference to rights of others, reckless behavior, and cruel behavior Aggression against people or animals Destruction of property Deceitfulness or theft Serious violation of rules One of most common syndromes of childhood and adolescence; estimated prevalence 4-16%; boys outnumber girls Age of onset important Childhood-onset with at least one symptom before age 10; usually male; physically aggressive; have few friends; more likely to develop antisocial personality disorder Adolescent-onset with no symptoms before age 10; less aggressive, have friends Many with conduct disorders commit serious crimes Many children come from disorganized and unhappy families, leading to poor prognosis Groups at Risk for Disruptive Behavior Disorders Gender is strongest risk factor for disruptive behavior disorders Boys outnumber girls nine to one in ADHD Boys outnumber girls in conduct disorders Gender difference subject to recent debate May be due to artifact of reporting May be due to differential socialization May be due to difference of seriousness of crimes Socioeconomic factors such as correlates of poverty play role in conduct disorders Disorders of Emotional Distress Disorders of emotional distress are internalizing disorders whereby conflict is turned inward Diagnosis is difficult when child lacks verbal and conceptual skills; must rely on child's behavior Anxiety Disorders Separation Anxiety Disorder Separation anxiety is intense fear and distress upon separation from parents or caregivers Seen in almost all children; peaks at about 12 months In some it persists into school years; disappears and reappears triggered by stress characterizes separation anxiety disorder Child may have fears of horrible things happening while separated from parents Parent-child conflicts common and exacerbate disorder Estimated prevalence is 4-13% of children and adolescents Social Phobia Social phobia is fear of social or performance situations in which embarrassment may occur Most children grow out of fear of strangers by age two and a half; children with social phobia do not Social phobia may not generalize to all social situations Children with social phobia are often well adjusted at home and have normal relationships with parents At school, child is withdrawn, interfering with academic progress and social relationships Generalized Anxiety Disorder (GAD) In generalized anxiety disorder child experiences anticipatory anxiety, doubting his/her own capabilities Family dynamics may play role Anxiety tends to breed failure, which brings on the very problems child was anticipating, creating vicious cycle Childhood Depression Parents and teacher often fail to notice depression in children Childhood depression resembles adult depression Symptoms of depression are often expressed differently by children than by adults Prevalence is 2-5%; adolescents may be more vulnerable than younger children Studies suggest that depressed children are at risk for mood disorders as much as depressed adults Groups at Risk for Disorders of Emotional Distress Girls more likely to develop separation anxiety disorder, social phobia, and generalized anxiety disorder Young boys more vulnerable to depression Teenage girls more likely to develop disorders of emotional distress Eating Disorders Anorexia Nervosa Anorexia nervosa is severe restriction of food intake caused by fear of weight gain Most cases are female between ages of 12 and 18 Anorexia nervosa is physically dangerous Most dramatic sign of anorexia is emaciation; DSM-IV-TR criterion is body weight less than 85% of what is normal for age and height of patient Other criteria are intense fear of becoming fat, unrealistic body image, and amenorrhea There are two behavioral patterns Restricting type refuses to eat Binge-eating/purging type eats and then purges Most anorexics have normal appetites, at least in early stages of disorder May become preoccupied with food Collect cookbooks and prepare elaborate meals for others Fear of obesity most typical feature of anorexia Some see disorder as way of avoiding an adult sexual role and pregnancy Some view disorder as daughter's weapon against her parents, suggesting disturbed family relationships Bulimia Nervosa Bulimia nervosa characterized by uncontrolled binge eating plus compensation Base their self-esteem on body shape Binge often triggered by stress or unhappiness Bulimia resembles anorexia with regard to onset and gender difference Childhood Obesity Rate of obesity in children and adolescence is 20% Excess weight can contribute to physical disorders and can have psychological consequences Teasing by peers Especially acute for girls Obesity is due to combination of physiological and psychological factors Family routine plays role in childhood obesity Balance of physical exercise versus television watching Diet Groups at Risk for Eating Disorders Girls at greater risk for anorexia and bulimia Cultural ideals of female attractiveness have contributed to problem Increase in occurrence may be due to increased awareness and reporting of disorders Risk for eating disorders spreading to pre-teenage group Many girls have only partial syndromes Efforts to identify at-risk girls to prevent full-syndrome eating disorders from developing Elimination Disorders Enuresis Disorder Enuresis is lack of bladder control past age at which such control is usual Daytime wetting is less common and may be sign of more serious psychological problems Clinician decides age that separates normal accidents from enuresis DSM-IV-TR specifies minimum age of 5 years Wetting must occur at least twice a week Suffering serious distress or impaired functioning Rate of enuresis at age 5 is 7% for boys and 3% for girls; at age 10, 3% for boys and 2% for girls Enuresis may be of two types Primary enuresis occurs when child has never achieved bladder control and may last into middle childhood; may have organic abnormality Secondary enuresis occurs when child achieves bladder control and loses it, usually due to stress Most enuretic children are not emotionally disturbed; emotional problem may be result of disorder Enuresis may cause social problems Bed-wetting almost always clears up Encopresis Disorder Encopresis is lack of bowel control May occur with enuresis, which it resembles Can be classified as primary or secondary More common in boys than girls Child experiences mockery and wrath from parents Encopresis has prevalence of 1% Typically occurs as part of larger disorder such as disruptive behavior disorder or part of severe family problems Childhood Sleep Disorders Insomnia Most common response to stress in early childhood is insomnia Insomnia is usually in form of difficulty falling asleep or staying asleep Child does not decide if problem needs treatment; parents often see it as attention-getting behavior Sleeping problem may have physiological cause, but most often related to worry Nightmares and Night Terrors Nightmares occur more frequently in childhood than in later years Shows no particular physiological arousal May or may not be awakened by dream Usually able to describe dream in detail Occurs during REM sleeps Less prevalent but more disturbing are sleep terrors Child shows intense physiological arousal Very hard to comfort Has no memory of episode next morning Terrors occur during first few hours of sleep in non-REM sleep Sleepwalking (Sonambulism) Sleepwalking is more common in young Child falls asleep but about two hours later performs complex action Eyes are open and child does not bump into things Event can last 15 seconds to 30 minutes Child usually returns to bed Not acting out dreams Occurs during non-REM sleep Usually not a serious problem Learning and Communication Disorders Learning Disorders (LD) Learning disorders involves person's skill in one of three areas substantially below what would be expected for age, education, and intelligence of person and interferes with adjustment Reading disorder Disorder of written expression Mathematics disorder Occurrence is 5-15%, with majority of them boys About 25% of children with conduct disorders, ADHD, and depression also have learning disorders Various medical conditions involve learning disorders Many cases of learning disorders involve distortions of visual and auditory perception Struggle to distinguish sounds of different words or make associations between words they hear Perceptual problems usually occur in more than one sense system Some children also show disturbances in memory and other cognitive functions Difficulties with sequential thinking and organizing thoughts May be related to attention deficits Children often do poorly in school and experience low self-esteem and low motivation Are at risk for dropping out of school Tend to have employment problems Groups at Risk for Learning Disorders Boys are more likely than girls to develop learning disorders Reading disorder occurs at equal rates in both boys and girls Socioeconomic factors operate as well Standardized tests may discriminate against certain groups In the past, disproportionately higher numbers of White middle-class children diagnosed as having learning disorder In the past, disproportionately higher numbers of African-American children diagnosed as mentally retarded There is much variability in learning disorders Children with same symptoms have different underlying disorders Same disorders may produce different symptoms in different children Learning disorders can be attributed to wide range of causes Approaches to treatment extremely varied Communication Disorders Delayed Speech and other Gaps in Communication Prolonged delay in speech may be early sign of problem Problems with articulation as in enunciation Difficulties with expressive language in putting thoughts into words Difficulties with receptive language in understanding language of others Most serious and longer-lasting Can be disastrous for a child in school Special education usually necessary Stuttering Interruption of fluent speech through blocked, prolonged, or repeated words, syllables, or sounds is called stuttering Hesitant speech is most common Persistent stuttering occurs in 1% of population and is more common among boys Many children outgrow stuttering Organic theories have been proposed; problem with physical articulation of sounds in mouth and larynx Stuttering is probably psychogenic, with parents creating anxiety that disturbs their speech, making them even more anxious Disorders of Childhood and Adolescence: Theory and Therapy Psychodynamic Perspective Conflict and Regression Childhood developmental disorders stem from id/impulses and prohibitions from parents and superego Encopresis can be interpreted as a disguised expression of hostility Enuresis interpreted as sign of regression Anorexia viewed as regression Ego psychologists view anorexia as related to adolescent's drive for autonomy Play Therapy Best treatment is one that allows patient to bring to surface and work through unconscious conflicts Play therapy allows child to draw and play with toys Toys used for expressing aggression Dolls and puppets for play-acting family conflicts Therapists interact with parents as well Specific approach varies from therapist to therapist The Behavioral Perspective Inappropriate Learning Childhood disorders stem from inadequate learning or inappropriate learning Inadequate learning is a failure to learn relevant cues for performing desired behaviors Inappropriate learning refers to reinforcement of undesirable behavior Relearning Behavior therapists use entire behavioral repertoire to replace child's maladaptive responses with adaptive responses Classical conditioning used to treat nocturnal enuresis Anxiety disorders can be treated using systematic desensitization Modeling can be useful in treatment of phobias Operant conditioning has been successful in treatment of ADHD Token economy has been used for certain behavior disorders Cognitive Perspective Negative Cognitions in Children Problem behaviors in children stem from negative beliefs, faulty attributions, poor problem solving, and other cognitive factors Real trigger in depression is cognitive factors not events Changing Children's Cognitions Goal of cognitive therapy in ADHD is to teach how to modify their impulsiveness through self-control skills and reflective problem solving by using self-instructional training Self-instructional training works well for specific tasks Skills learned from self-instructional training may not generalize if not carefully reinforced Attribution retaining involves teaching children to make attributions that are less internal, less stable, and less global Usefulness of cognitive therapy depends greatly on age of child Cognitive therapy often combined with behavioral strategies The Interpersonal Perspective Child plays a critical role in family, and child's disorder reflects a disturbance in family Family psychopathology underlies many childhood disorders and must be addressed if child's problems are to be relieved Anorexia has been treated successfully through family therapy Girls' families tend to be overprotective, rigid, and superficially close Family therapy lunch sessions used where girl is instructed that she has won over her parents and told that she must eat to live The Sociocultural Perspective Cultural patterns shape the child's disorder There are cultural differences in expression of symptoms among American and Thai children To identify cause of disorders, the culture as well as the individual should be considered Risk for conduct disorders correlated strongly with poverty-related factors To address disorders, society must address those factors Anorexia and bulimia may be influenced by culture The Neurosciences Perspective Childhood and adolescent disorders may have biological component Anorexia involves both biological and psychological causes Anorexics are hungry Psychological factors override hunger ADHD seems most likely to have biological basis Most ADHD children have paradoxical response to amphetamines Amphetamines given to normal people cause them to act like hyperactive children Three-fourths of ADHD children benefit from stimulants There are side effects of Ritalin Academic performance usually does not improve and child must continue to be taught skills Potential for abuse Drugs must be prescribed with caution
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