Journal - 400 words - due in 24 hours

combs

11CH_Abnormal_Getzfeld.pdf

Home >Psychology homework help >Journal - 400 words - due in 24 hours

11 NeurodevelopmentalDisorders

Bowdenimages/iStock/Thinkstock

Chapter Objectives

After reading this chapter, you should be able to do the following:

• Explain how developmental psychology contributes to our understanding of psychological disorders among children and adolescents.

• Describe the main psychological disorders first observed in childhood and adolescence.

• Explain the effects of a childhood disorder on other family members.

• Describe how childhood and adolescent disorders can be treated.

get83787_11_c11_305-324.indd 305 2/16/18 4:49 PM

306

Understanding Developmental Psychopathology Section 11.1

11.1 Understanding Developmental Psychopathology It is stressful for any family when one member has a psychological disorder; it is especially stressful when the affected person is a child. Children are changing constantly. Unfortu- nately, because of disease, genetics, or traumatic experiences (to name just three possible factors), some children find the road to adulthood full of obstacles. Unless they are helped, such children are at risk for psychological disorders. In addition to the at-risk children, their parent(s) and/or caregivers are also at risk. To gain a better picture of children’s issues, and those of their caregivers, we will examine the members of the University Hospital Parent Sup- port Group. This group was organized by psychologist Stuart Berg. Its members are parents of children under treatment for psychological disorders. Let’s look at Part 1 of the support group’s case study.

Case Study: Support Group: Part 1

Parent Support Group Transcript DR. BERG: My name is Stuart Berg. I am a clinical psychologist working here at University Hospital. I want to welcome each of you to this first support group meeting. I know some of you, and I will look forward to meeting and working with all of you in the weeks to come. The goal of this support group is to help you help your children and yourselves. You are all here because you have a child in treatment and because you indicated an interest in mutual support. Although these meetings will be unstructured, they do have a goal—to help you cope with having a child who has a psychological disorder. Some of the issues we discuss will be practical: how to access government assistance programs, how to find a babysitter, how to get your child to the dentist. Because some parents whose children develop psychological disorders feel guilty and ashamed, as if they were the cause of their child’s problems, we will also try to educate ourselves about what causes psychological disorders in children and what we can do about them. Because this is our first meeting, I thought it might be a good idea to go around and have each of you introduce yourself to the others. Let’s begin on my left.

JOHN CHENEY: My name is John Cheney. I am a doctor, a radiologist, in this hospital. My son, Eddie, has autism. He is eight. I have no other children. I just couldn’t handle any more.

INGRID CHENEY: I am Ingrid Cheney, John’s wife. I do not work. My life is looking after Eddie.

PASQUALE ARMANTI: My name is Pasquale Armanti. I am a builder here in town. In fact, my company built this hospital. My wife, Francesca, couldn’t have children. We adopted Paolo when he was a baby. My life hasn’t been the same since. He has been in trouble since he could walk and nothing—

FRANCESCA ARMANTI (interrupting her husband): You are always picking on him. You never wanted Paolo. You always rejected him. Even when he was little, you spanked him—

PASQUALE ARMANTI (interrupting his wife): Lighten up! Listen to yourself. Who are you kidding? Paolo is out of control. He needs discipline.

DR. BERG: Perhaps we should get back to this later. Let’s move on.

KAREN BEASLEY: I’m Karen. Karen Beasley. I’m 19 years old. I’m here on my own because my boyfriend Eric left us a few months ago. It’s just me and Michelle now. Michelle is four, and she won’t talk. She won’t hug me or let me hug her. She just stays in her room. Sometimes she watches TV; other times she just cries. Sometimes she hurts herself by banging her head

(continued)

get83787_11_c11_305-324.indd 306 2/16/18 4:49 PM

307

Section 11.1 Understanding Developmental Psychopathology

Children who have oppositional defiant disorder are frequently in trouble at school, are argu- mentative and angry, and sometimes are vindictive. They may use temper tantrums to get their way (APA, 2013). According to the APA, they may deliberately ignore adult rules, argue repeatedly with adults, and feel a lot of anger and resentment. About 12% of children qualify for this diagnosis, with males slightly surpassing females in prevalence (Mash & Wolfe, 2016). Typically, the disorder presents by age eight (Mash & Wolfe, 2016).

Diagnosing psychological disorders in children is not easy because behavior that is appro- priate to one developmental stage may not be appropriate to another. For example, wetting the bed is considered normal in many 1-year-olds but not in a 10-year-old. To understand whether a child’s behavior is “abnormal,” we need to know what behaviors are “normal” for children at different stages of development. Studying abnormal behavior in its developmental context is the goal of the specialty area of clinical psychology known as developmental psy- chopathology (refer to Chapter 1 for a definition of psychopathology).

The goal of those working in this field is to identify, as early in life as possible, the risk fac- tors for psychological disorders, and much of the work in this field focuses on childhood temperament.

against the wall. But even when she is hurting herself, she won’t let me comfort her. I don’t have a job. I never finished high school. Lately I’ve become fat. I’m dieting, but it doesn’t help. I’ve been running, and even that doesn’t work. That’s me—a fat girl with no money, no boyfriend, and a kid who won’t talk.

CELIA BEROFSKY (to Karen): How did you get into this mess? A baby at 15, abandoned at 19. And what makes you think you are fat? You’re nothing but skin and bones.

KAREN BEASLEY: I am? But I feel fat.

DR. BERG (addressing Celia): Perhaps you can introduce yourself ?

CELIA BEROFSKY: I am Celia Berofsky, and this is my husband, Michael.

MICHAEL BEROFSKY: Hi.

CELIA BEROFSKY: My son Gordon won’t go to school. When we force him to go, he won’t talk to anyone. I know this is just a phase that he will grow out of. Michael thinks so, too. Our psychologist suggested that we come to this group, but I don’t think we will be members long.

DR. BERG: Thanks, everyone, that was good. Perhaps one of you could start off the discussion by telling us about your experiences and the problems you are encountering. Everyone should feel free to ask questions. Now, who wants to start?

PASQUALE ARMANTI: I’ll start. I am used to talking about Paolo. According to the psychologists at school and Dr. Gale, our private psychologist, Paolo has attention-deficit/ hyperactivity disorder. But this is not his only diagnosis. For a long time, they told me he had an oppositional defiant disorder, and he also supposedly has a conduct disorder. Once they suspected Tourette’s disorder. I wonder if anyone knows what is wrong with Paolo. Maybe he’s just a difficult kid.

See appendix for full case study.

Case Study: Support Group: Part 1 (continued)

get83787_11_c11_305-324.indd 307 2/16/18 4:49 PM

308

Section 11.1 Understanding Developmental Psychopathology

Temperament and Behavior All children display a characteristic temperament (Sayal, Heron, Maughan, Rowe, & Ramchan- dani, 2013). Easy children have regular patterns of elimination, eating, and sleeping. They adapt readily to new environments, and, even when they are distressed, their emotional reac- tions are usually mild. Slow-to-warm-up children take longer to adapt to new situations than easy children, but they eventually adjust. Like easy children, their emotional reactions are mild. Difficult children are another matter. They are slow to adapt to new situations, and they have intense, usually negative, emotional reactions (such as tantrums).

Difficult children are at risk for developing psychological disorders later in childhood and as adults (Sayal et al., 2013). They are particularly prone to develop “acting out” or externalizing disorders, which involve behaviors that annoy or threaten others (Sayal et al., 2013). Of course, not all diffi- cult children develop psychological disor- ders, nor do all easy and slow-to-warm-up children avoid them. Some members of the latter groups will develop internalizing disorders, such as depression and anxiety, in which symptoms are directed inward. Whether children develop a psychological

disorder depends on the fit between their temperaments and their environments (Sayal et al., 2013).

As an introduction to developmental psychopathology, we will look briefly at elimination disorders.

Elimination Disorders In the DSM–5, elimination disorders are included in their own chapter rather than in the chapter on neurodevelopmental disorders (American Psychiatric Association [APA], 2013), but since these disorders occur during childhood, we will discuss them here. Researchers of all theoretical orientations agree that elimination disorders are most likely to occur when toilet training is harsh or inconsistent, especially when a child is resistant. “Difficult” children, especially those with conduct disorders (described later in this chapter) and those who are in psychiatric institutions or in sheltered care, have a particularly hard time with toilet training (Mash & Wolfe, 2016; Park et al., 2013).

Children who do not toilet train successfully by the usual age (or developmental level, if they have an intellectual disability) are diagnosed as having enuresis (poor control of urination), encopresis (poor control of defecation), or, in rare cases, both. Enuresis typically occurs at night (nocturnal enuresis), but it can occur during the day (diurnal enuresis). Children must be at least 5 years old to be diagnosed with enuresis. About 10% of children between the ages

Ziggy_mars/iStock/Thinkstock There are three types of temperament in chil- dren: easy, slow-to-warm-up, and difficult.

get83787_11_c11_305-324.indd 308 2/16/18 4:49 PM

309

Section 11.2 Conduct Disorder

of 5 and 16 are bed-wetters, but as the child ages the problem becomes less common (Fri- man, 2008). More recent data note the prevalence as between 5% to 10% among 5-year-olds, 3% to 5% among 10-year-olds, and 1% among children aged 15 years or older (APA, 2013). Encopresis is diagnosed when a child is older than four years, or developmentally equivalent to four years old, and affects about 1% of five-year-olds (APA, 2013). It is often the cause of chronic constipation that is unrelated to medical or functional causes (Olaru et al., 2016).

Elimination disorders occur more often in boys than in girls and seem to run in families (APA, 2013). Although this implicates biology in their etiology, elimination disorders are also linked to stressful life situations such as a parent’s death (Johnson et al., 2006). Behavioral therapy is usually successful for enuresis and may help encopresis. It is frequently supplemented with cognitive therapy and antidepressants. Sometimes desmopressin (DDAVP), an antidiuretic, is given to treat enuresis (Mash & Wolfe, 2016).

11.2 Conduct Disorder Many children have mild temper tantrums and can be argumentative. Although this sort of behavior rarely presents a serious interpersonal problem, children who commit violent acts of aggression, such as hitting, biting, and kicking, may develop a conduct disorder. Learning the difference between aggression, which harms others, and assertiveness, which is neces- sary for effective functioning in society, is an important part of growing up. (See the appendix to read Part 2 of the parent support group case study.)

The main DSM–5 diagnostic criteria for conduct disorder also apply to antisocial personal- ity disorder. The main difference between the two disorders is age. In theory, an adult may be given the diagnosis of conduct disorder, but in practice, antisocial personality disorder is used for individuals over age 18, whereas conduct disorder is applied to people under 18. The DSM–5 distinguishes three conduct disorder subtypes: childhood-onset (before age 10); adolescent-onset (for those who are older than age 10 when the characteristic behaviors first appear); and unspecified onset, when criteria are met to diagnose conduct disorder (but it is unclear if the onset of the first symptom was before or after age 10). Three severity speci- fiers may also be applied: mild (behavior causes little harm), moderate (stealing, but little violence), and severe (when the person displays many criterion behaviors and causes consid- erable harm to others).

In community settings, conduct disorder is more common among boys (14.1%) than girls (3.8%), but the ratio is more equal in clinical settings (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). Higher estimates may include children who live in threatening, high-crime neighborhoods and engage in aggressive antisocial behavior as part of gangs. For most such children, antisocial behavior may not be a sign of a psychological disorder but simply a way of life. There is consistent evidence of a genetic basis for conduct disorder (Silberg, Moore, & Rut- ter, 2015). Precisely what is inherited that causes conduct disorder remains unclear though. One theory is that people with conduct disorder are chronically underaroused. To make up for this, they are always seeking excitement. When their environment lacks socially accept- able opportunities for excitement, they may turn to antisocial behaviors (Mann et al., 2017).

get83787_11_c11_305-324.indd 309 2/16/18 4:49 PM

310

Section 11.2 Conduct Disorder

Although genetics may predispose children to conduct disorders, it is not the whole story. The concordance rate for conduct disorders among identical twins is less than 100%, so environ- ment must also play a role. One place to look for environmental influence is in faulty family relationships. Studies have consistently focused on parent-child relationships, conflict and hostility within the family, and marital problems between parents as causes of conduct disor- der (Silberg et al., 2015). However, these troublesome family interactions could just as easily be the result of having a child with a conduct disorder.

In addition to family dynamics, some theo- rists attribute conduct disorders to drug abuse and social factors such as poverty and exposure to community violence and aggressive and criminal peers and models (Mash & Wolfe, 2016). Still, others empha- size how extra parental and teacher atten- tion can reinforce antisocial behavior (Ahmadi-Kashani & Hechtman, 2014). Of course, parental neglect, exposure to anti- social models, and the reinforcement of antisocial behavior are not mutually exclu- sive; many children experience all three (Ahmadi-Kashani & Hechtman, 2014). Whatever the cause(s) of conduct disorders, the outlook is poor for those whose disor- der is first diagnosed in childhood (Mash & Wolfe, 2016). Many such children go on to be diagnosed with antisocial personality disorder (Mash & Wolfe, 2016). The relationship between age of onset and prognosis is similar for both sexes, although females are less likely than males to develop antisocial personality disorder as adults (Black, 2015).

Children with conduct disorders may also have learning disorders such as a specific learning disorder with impairment in reading, often called dyslexia (APA, 2013; Erford, Bardhoshi, Ross, Gunther & Duncan, 2017). More than one third of boys and one half of girls with conduct disorder also display attention-deficit/hyperactivity disorder, or ADHD, which is described in the next section (Waschbusch, 2002). It is possible that these learning disorders may be one of the causes of conduct disorders. Specifically, children who continuously fail at school may feel humiliated because other children ridicule them. To win respect and ease the pain of repeated failure, such children may act out. While trying to control this disorderly behavior, teachers may inadvertently reinforce it by giving disruptive children extra attention. Eventu- ally, antisocial behavior becomes a well-rewarded habit. Although this hypothesis is plau- sible, keep in mind that it is based on a correlation between conduct and specific learning disorders. It is equally possible that the causal mechanism goes the other way around. Con- duct disorders may cause specific learning disorders, perhaps by interfering with study time. It is also possible that conduct and learning disorders both result from the same cause. For example, both may result from distractibility—the main symptom of ADHD.

Olga_sweet/iStock/Thinkstock Learning disorders may be a direct cause of conduct disorder. Children who fail at school may experience a sense of humiliation and act out as a response.

get83787_11_c11_305-324.indd 310 2/16/18 4:49 PM

311

Section 11.3 Attention-Deficit/Hyperactivity Disorder (ADHD)

11.3 Attention-Deficit/Hyperactivity Disorder (ADHD) Attention-deficit/hyperactivity disorder (ADHD) is a psychological disorder that typically begins in childhood. It is characterized by long spells of inattention, hyperactivity, and/or impulsivity. It can be difficult to properly diagnose and assess (Müller et al., 2011). The notion for the disorder originated with the work of Alfred Strauss and his colleagues (see Strauss & Kephart, 1955). Their goal was to identify childhood behaviors that could be used to diagnose brain damage in ambiguous cases (when there were no clear-cut signs of neurological impair- ment). Because children with brain damage were often very active, they argued that hyper- activity (a term they did not define) is a sign that a child is brain damaged. To get around the problem that hyperactive children did not show any hard signs of brain damage, the concept of minimal brain damage (or dysfunction) was introduced (Strother, 1973). These children were said to be hyperactive, impulsive, distractible, and emotionally unstable. They had short attention spans, perceptual-motor deficits, poor coordination, and learning disorders.

Despite the many attempts to refine these criteria, the DSM–5 diagnostic criteria remain problematic. For instance, clinicians do not know how much fidgeting is “excessive” for chil- dren at different stages of development. Moreover, children behave differently depending on the context. Some children have attentional problems at school, whereas at home they sit and watch television for hours. Because norms are unavailable for many attentional behaviors and because behavior depends on context, parents, teachers, and clinicians often fail to agree about which children suffer from ADHD (Müller et al., 2011).

According to the Centers for Disease Control and Prevention, ADHD is more common among boys (13.2%) than girls (5.6%). This may reflect a genuine sex difference or a social bias. That is, girls may not be diagnosed with ADHD because they rarely cause the discipline problems that lead to teacher intervention. This may also be because girls tend to present with more inattention than boys, who typically present with more hyperactive and/or impulsive symp- toms (Mash & Wolfe, 2016). Although the gender difference in ADHD prevalence may provide clues to its etiology, until recently many studies included only boys (Skogli, Teicher, Ander- sen, Hovik, & Øie, 2013). The DSM–IV (APA, 1994) field trials established that the inclusion of a “predominantly inattentive” subtype might identify substantially more girls affected by ADHD (Skogli et al., 2013).

Because ADHD counts as a disability, it qualifies children for special treatment under the Americans With Disabilities Act (1990, 2008). Parents may actually want their children to be diagnosed with ADHD if this means they will receive special services in school.

Lead poisoning, brain damage, birth defects, food additives, and too much sugar in the diet have all been blamed at one time for “causing” ADHD, but none of these supposed causes has found strong empirical support (Riley, Carson-DeWitt, & Knight, 2016). There is evidence that the problem runs in families. Children whose parents have ADHD are more likely to develop it (APA, 1994, 2000, 2013). Among monozygotic twins, when one twin is diagnosed with ADHD, the other is more likely to receive the same diagnosis than if he or she were a dizygotic twin (Riley et al., 2016). Although these data suggest that inheritance contributes to ADHD, even for identical twins, the concordance rate is less than 100%. In other words, genetics produces a disposition to ADHD, but environmental factors also play a role. Most research efforts have gone into treatment, specifically the use of stimulant drugs to control the symptoms of ADHD.

get83787_11_c11_305-324.indd 311 2/16/18 4:49 PM

312

Section 11.4 Tourette’s Disorder

The most commonly used stimulants are methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and a mixture of several amphetamines (Adderall). Stimulants can have dra- matic effects. After only a few doses, children who are constantly on the go calm down and focus their attention. Because stimulants produce a dramatic calming effect in children with ADHD, some writers have argued that a “paradoxical” calming response to stimulant drugs is diagnostic all by itself. In other words, if stimulant drugs lead to less hyperactivity and dis- tractibility, then the child probably has ADHD. In reality, the response of people with ADHD is not paradoxical; it is not even unusual. Stimulants improve everyone’s ability to concen- trate (Hoffman, 2009; Procyshyn, Bezchlibnyk-Butler, & Jeffries, 2017). However, despite the effects of methylphenidate on attention and behavior, it is not clear whether the drug improves academic achievement (Hale et al., 2011). It does decrease the core symptoms of ADHD and makes children more manageable (Riley et al., 2016).

A drawback to the use of stimulants is the likelihood of unpleasant side effects, although for most people they are not severe (Procyshyn et al., 2017; Riley et al., 2016). Side effects include sleeplessness, irritability, loss of appetite, and growth retardation. Taking drugs may also affect a child’s self-concept. Children may learn to externalize responsibility for their behavior (“I can’t control myself, so I must take medicine”). Externalizing responsibility could make children less responsive to learning self-control (Molina & Musich, 2016). Skepticism about stimulant treatment has almost as long a history as stimulant treatment itself (Hoff- man, 2009). In practice, the appropriate treatment for ADHD is not an either-or choice. Many children with ADHD receive a combination of stimulants, cognitive therapy, and behavioral therapy, as well as various forms of special education (Hoffman, 2009).

Behavioral therapy has been well researched and appears to be quite effective in treating ADHD, especially when combined with stimulants (Riley et al., 2016) Typically, behavioral therapy will focus on training teachers and parents to reward attention and self-control in the child or pupil; this is often done while using a token economy system. Research has also revealed that combined stimulant and behavior modification treatment will eventually lead to lower levels of medication required (Hale et al., 2011). In sum, research indicates that stimulants, either alone or with behavior modification therapy, are the most effective treatment approaches for ADHD. (See the appendix to read Part 3 of the parent support group case study.)

11.4 Tourette’s Disorder Tourette’s disorder is characterized by strange utterances (swearing, barking) and multiple motor tics (sudden repetitive but irregular movements). The DSM–5 also includes other tic disorders (chronic motor or vocal tic disorders, provisional tic disorder) that have some, but not all, of the symptoms of Tourette’s disorder. Unlike those for many psychiatric diagnoses, the criteria for Tourette’s disorder have hardly changed from Tourette’s original description. The criteria include vocal and motor tics that are generally chronic (although tic-free periods can occur).

Like most childhood disorders, Tourette’s disorder occurs more often in boys than in girls (Amiri, Fakhari, Golmirzaei, Mohammadpoorasl, & Abdi, 2012; APA, 2013). It begins with facial tics, usually blinking or sniffing. In serious cases, it progresses to neck and shoulder jerking, head banging, arm flinging, and other peculiar movements. Sometimes, the tics are self-destructive (head banging, for instance). Odd verbalizations are always part of the

get83787_11_c11_305-324.indd 312 2/16/18 4:49 PM

313

Section 11.4 Tourette’s Disorder

disorder. People with Tourette’s may sniff, bark, or, in some cases, shout obscenities (a symp- tom known as coprolalia; APA, 2013). As already noted, tics come and go, and old ones are replaced by new ones (Ludolph, Roessner, Münchau, & Müller-Vahl, 2012).

People with Tourette’s disorder can consciously inhibit their tics for brief periods, although this requires considerable effort. Because they can inhibit their symptoms at least part of the time and because their tics disappear during sleep, people with Tourette’s were long consid- ered to have a psychological disorder (Shapiro, Shapiro, Bruun, & Sweet, 1978). Symptoms such as coprolalia were explained as either displaced aggression or the expression of poorly “defended” id impulses. Psychotherapy designed to uncover the unconscious conflicts caus- ing Tourette’s disorder did not meet with much success (Shapiro, Shapiro, Young, & Fein- berg, 1998), and attention shifted to the neurochemistry of the illness (Ludolph et al., 2012). The discovery that small doses of haloperidol (Haldol), a dopamine-suppressing drug used to treat schizophrenia, suppresses Tourette’s symptoms in many people has led to the hypoth- esis that those with Tourette’s may have an excess of dopamine (Ludolph et al., 2012). Further evidence for this hypothesis comes from the finding that drugs that increase dopamine levels, such as L-dopa (which is used in the treatment of Parkinson’s disease), tend to increase the severity of tics.

An important finding is that Tourette’s disorder seems to be a genetically transmitted domi- nant trait (Prakash, Singh, Bhat, Srivastava, & Gupta, 2015). This is why people with Tourette’s disorder often have relatives who also have tic disorders (Prakash et al., 2015). They also have a high frequency of relatives with obsessive-compulsive disorder and ADHD, and many people with Tourette’s disorder have these other disorders as well (Prakash et al., 2015). Several writers have remarked on the substantial similarities between people with Tourette’s disorder and people who stutter (Abwender et al., 1998; Pauls, Leckman, & Cohen, 1993). Both have facial tics and odd grimaces, particularly when they are in emotionally arousing situations, and both may be helped by haloperidol, risperidone (Risperdal), and ziprasidone (Geodon) (Budman, 2014; Procyshyn et al., 2017). Coprolalia, surely the most peculiar symp- tom of Tourette’s disorder, has also been noted among patients with aphasia and schizo- phrenia (Lenneberg, 1967). It has been noted that stress worsens coprolalia and the other symptoms of Tourette’s disorder. In other words, Tourette’s disorder, like practically all other psychological disorders, has both a genetic-physiological and a psychological component.

Estimates are that Tourette’s disorder occurs in 0.3% of children aged 6–17 years in the United States. In addition, about 0.6% children meet criteria for Tourette’s, suggesting that the disorder is underdiagnosed (Cologonari & Rockmore, 2017). Every time a television show or magazine article discusses Tourette’s, many people with Tourette’s symptoms consult their doctors. Some of these people say that they have suffered from the symptoms all of their lives without knowing that their condition had a name.

Haloperidol remains the most common treatment for Tourette’s syndrome. Unfortunately, people often discontinue treatment because of the drug’s side effects, which, ironically, include a movement disorder similar to Parkinson’s. Other side effects include tardive dys- kinesia (involuntary movements of the tongue, face, mouth, or jaw), and grogginess, blurred vision, and dry mouth (Vallerand & Sanoski, 2017). For those who need treatment in addition to drugs (or who reject drugs because of their side effects), behavior therapy and cognitive- behavioral therapy have been used to help people relax and to deal with the interpersonal and social problems caused by having a tic disorder (Cologonari & Rockmore, 2017). See the accompanying Highlight.

get83787_11_c11_305-324.indd 313 2/16/18 4:49 PM

314

Section 11.5 Separation Anxiety Disorder

11.5 Separation Anxiety Disorder Separation anxiety disorder appears in the anxiety disorders chapter in the DSM–5, but because it is the most common anxiety disorder in children younger than age 12 years (APA, 2013), we will discuss it here. The disorder is characterized by devel- opmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached. Consider the case of 10-year-old Gordon Berofsky. At home, playing com- puter games, Gordon seems to be a normal boy, but he has significant problems. He typ- ically refuses to attend school, and when he does, he will not talk to his bus driver, the other children, or his teachers. Gordon has been seen by two psychologists and a psy- chiatrist and has received several diagnoses, as his mother relates in Part 4 of the support group case study (see the appendix).

Highlight: Living With a Special Needs Child

According to Autism Speaks (http://www.autismspeaks.org), it costs about $60,000 per year to raise a child with autism spectrum disorder. Presently there is no cure. One question to consider is whether you think you could raise a child with autism spectrum disorder, Tourette’s, or some other neurodevelopmental disorder. This might seem like an unfair question, but it is one that anyone contemplating future parenthood needs to be considered, especially since there is no prenatal test for autism spectrum disorder. Do you think you can answer this question honestly?

Even for those who think that $60,000 a year doesn’t seem like a lot, keep in mind that this is an average, and it doesn’t take into account the extra time and energy required to raise a child with special needs. One parent may need to give up a successful career to take care of the child. Sometimes one or both parents are just not able to handle the special needs. Although some disorders respond well to therapy and/or medication, autism spectrum disorder is one that, in general, does not respond as well. There is no medication specifically to treat autism spectrum disorder (though we will discuss risperidone as an adjunct therapy later in this chapter).

Child-rearing is not easy, and raising a special needs child requires a lot of extra care and effort. Being honest with yourself is crucial to ensuring that a special needs child can receive proper care.

Exactostock-1527/SuperStock Children suffering from separation anxiety experience severe distress at the thought of separating from home or close family members. Younger children typically encounter a mild uneasiness about separation or attending school, yet if the symptoms occur to a greater degree, they may be diagnosed with early-onset separation anxiety disorder.

get83787_11_c11_305-324.indd 314 2/16/18 4:50 PM

http://www.autismspeaks.org

315

Section 11.6 Autism Spectrum Disorder

It is important to take into account developmental level when considering a diagnosis of sep- aration anxiety disorder. It is normal for young children to be more uneasy about separation than older children. It is unclear whether a relationship exists between separation anxiety disorder in children and the development of panic disorders in adolescence and adults, but studies have shown a poor prognosis; many children who have separation anxiety go on to develop adult anxiety disorders (Cooper-Vince, Emmert-Aronson, Pincus & Comer, 2013).

As school is children’s primary social venue, it is not surprising that the school context is a significant source of distress for children and adolescents with separation anxiety disorder (Cooper-Vince et al., 2013). It seems to occur equally often in boys and girls and is most likely to occur at transition points—entry to elementary school or at the beginning of junior or senior high school. Children who refuse to go to school need not have difficulty with school- work. Some may fear evaluation; others fear mixing with new children and may suffer from a social phobia or avoidant personality disorder. Some school refusers may fear bullying or ridicule. However, for children like Gordon, the term school phobia is misleading. It is not the fear of school that motivates Gordon to stay home; it is the fear of separation from his mother. Gordon’s physical symptoms are an excuse to avoid school. Children like Gordon are different from truants, who skip school without their parents’ knowledge to do something they like better, such as go to the beach or a ball game (Haight, Kearney, Hendron, & Schafer, 2011). Gordon skips school to stay home, and his parents know all about it.

There are many possible causes for separation anxiety. In some cases, a child may have expe- rienced separation from his or her parents through death or, more often, divorce. In other cases, separation anxiety may arise from overprotectiveness. Parents who worry excessively about harm coming to their child once the child is outside of their immediate purview com- municate their anxiety to their child, who learns to fear separation. Children are likelier to have an anxiety disorder if a parent has one (Hughes, Furr, Sood, Barmish, & Kendall, 2009).

Staying home is reinforcing because it not only reduces anxiety but also offers secondary rewards, such as maternal attention. Refusal to go to school and separation anxiety disorder make a dangerous combination. Children who show both signs may develop other anxiety disorders (Cooper-Vince et al., 2013).

11.6 Autism Spectrum Disorder

Autism spectrum disorder is the most seri- ous psychopathological condition occurring in childhood. It is marked by poor interper- sonal relationships and communication skills, and repetitive/stereotyped behavior. At one time, this disorder was referred to as child- hood schizophrenia, but it is now clear that it is different from schizophrenia. It is not asso- ciated with hallucinations or delusions, and the children do not develop schizophrenia when they grow up. Previously classified in

KatarzyynaBialasiewicz/iStock/Thinkstock Autism spectrum disorder is character- ized by poor social interactions, impaired communication, and odd motor behaviors. Parents notice unusual behavior before age three and often report their child’s lack of responsiveness.

get83787_11_c11_305-324.indd 315 2/16/18 4:50 PM

316

Section 11.6 Autism Spectrum Disorder

the DSM–IV–TR as pervasive developmental disorders, autism spectrum disorder now consti- tutes a separate category of psychological disorder in the DSM–5 (APA, 2013). Autism is now classified on a spectrum, ranging from some impairment to severe impairment. Table 11.1 summarizes the diagnostic criteria for the disorder.

Not every child with autism spectrum disorder (also referred to as autism throughout the remainder of the chapter) has an intellectual disability. Percentages of children with autism and an intellectual disability have been estimated to range from 25% to 80%; one researcher claimed that this prevalence is overstated (Edelson, 2006). The association between intellec- tual disabilities and autism is not the result of common causes; rather, the presence of both makes it more likely that both disorders will be diagnosed (Skuse, 2007).

John and Ingrid Cheney were both 27 years old when their son, Eddie, was born. Neither John nor Ingrid knows of any mental illness in their families, although Ingrid’s brother had a devel- opmental language disorder as a child. As you can see from Part 5 of the parent support group case study, Eddie’s problems became apparent early in life, and his behavior reflects almost all of the diagnostic criteria for autism spectrum disorder (see the appendix).

Diagnosis The DSM–5 notes that symptoms of autism spectrum disorder typically are noticed from ages 12 to 24 months, but they may be seen earlier than 12 months if the symptoms are severe, or after 24 months if the symptoms are more subtle (APA, 2013). Autistic behaviors are so unusual that most parents notice something is “wrong” well before the child reaches age two. The first sign is the child’s lack of responsiveness. Eddie was typical. He did not form a nor- mal parental attachment. He never anticipated being picked up by his mother, and when he was hugged, he did not hug back. Leo Kanner’s descriptions emphasized this aspect of autism (Kanner, 1943). In fact, the term autism comes from the Greek word for “self.” Kanner believed that autistic children are alone within themselves, unable to relate to others. Eddie’s failure to respond to his name or to other sounds gave his parents the impression that he was deaf. When they realized that he could hear, they interpreted his “deafness” as indifference. This impression was reinforced by his avoidance of eye contact—he looked through people rather than at them—and his insensitivity to pain.

About 50% of people with autism spectrum disorder never develop intelligible speech or are silent (Sachdeva & Dutta, 2012). The remainder learn to produce words, but they have dif- ficulty using them to communicate (Neff & Teska, 2016). Instead, their speech is like Eddie’s, mere parroting of what they have heard others say (a symptom called echolalia). Although the DSM–5 emphasizes the communication disorder, most people with autism spectrum disorder also have a cognitive deficit (McLuckey & Therivel, 2016).

Ingenious experiments have shown that people with autism spectrum disorder are unable to see the world from another person’s point of view (Sachdeva & Dutta, 2012). This is referred to as theory of mind (Golan & Baron-Cohen, 2006; Slaughter, 2017). Although people with intellectual disabilities may have similar difficulties (Sachdeva & Dutta, 2012), people with autism spectrum disorder do poorly on “mind-reading” tasks, even when they have good lan- guage skills and high IQs. For people with autism spectrum disorder who do not have intel- lectual and language impairment, their difficulty is not with perception but with inferring

get83787_11_c11_305-324.indd 316 2/16/18 4:51 PM

317

Section 11.6 Autism Spectrum Disorder

Table 11.1 DSM–5 diagnostic criteria for autism spectrum disorder

A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative): 1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and

failure or normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

Specify current severity based on social communication impairments and restricted, repetitive patterns of behavior.

B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative): 1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes,

lining up toys or flipping objects, echolalia, idiosyncratic phrases). 2. Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal

behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day).

3. Highly restricted, fixed interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).

4. Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement).

Specify current severity based on social communication impairments and restricted, repetitive patterns of behavior.

C. Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life).

D. Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning.

E. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level.

Note: Individuals with a well-established DSM–IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.

Specify if: With or without accompanying intellectual impairment With or without accompanying language impairment Associated with a known medical or genetic condition or environmental factor Associated with another neurodevelopmental, mental, or behavioral disorder With catatonia

get83787_11_c11_305-324.indd 317 2/16/18 4:51 PM

318

Section 11.6 Autism Spectrum Disorder

mental states (Autism Society of America, 2006; Baron-Cohen, Jolliffe, Mortimore, & Robert- son, 1997; Sachdeva & Dutta, 2012).

Kanner believed that the avoidance of change was an important sign of autism. Kanner’s autistic children insisted on keeping objects in their accustomed place and in maintaining routines. Any change might result in a catastrophic reaction (an intense temper tantrum). Stereotyped body movements (such as rocking, whirling, and hand waving) are also common in autism.

Epidemiology and Course Kanner considered autism to be a rare disorder; however, the latest available figures reveal that it occurs in 1 out of 110 children (CDC, 2009). More recent data indicate that about 1% of the population has an autism spectrum disorder (APA, 2013). Put into numbers, autism spectrum disorder now affects 1 in 68 children and 1 in 42 boys (Autism Speaks, 2017).

Etiology Although everything from smothering mothers to perceptual defects to viruses to childhood vaccinations has been implicated by one theorist or another as a potential cause of autism spectrum disorder, there is still no generally agreed-on etiological theory (Sachdeva & Dutta, 2012). There are some notable trends, however. For a long time, theories that implicated parental behavior were dominant. Child psychoanalysts blamed autism partly on “refrigera- tor” parents who behave in a cold, detached manner toward their children (Kanner, 1943, 1954) or described autism as a defense against a destructive maternal environment (Bettel- heim, 1967). Some behaviorists also held similar views. For example, Ferster (1961) claimed that the home environment of children with autism spectrum disorder failed to reinforce proper social behavior.

However, because there is no evidence that the parents of children with autism spectrum disorder differ from other parents in personality or child-rearing practices (Koegel, Schreib- man, O’Neill, & Burke, 1983), blame-the-parent theories have largely disappeared. There is no reason for parents, whose lives have already been made more trying by having a child with an autism spectrum disorder, to also feel guilty for having caused their child’s problems.

Parental behavior may not cause autism spectrum disorder, but something must. The sex ratio (many more boys than girls), the remarkable similarity of one child to another, and physical signs all suggest that biology is a good place to look for etiological explanations. In several studies from the 1980s and 1990s that used a strict definition of autism, a 69% to 95% concordance was demonstrated in monozygotic twins, whereas the chance in dizygotic twins was only 0% to 24% (Verhoeven, Egger, & Feenstra, 2011). The contribution of the hereditary components is estimated to be about 90% (El-Fishawy & State, 2010). The male- female ratio is approximately 5:1 (Baio, 2014). Cognitive and language disorders also appear with greater than average frequency among the relatives of people with an autism spectrum disorder (Constantino, Zhang, Frazier, Abbacchi, & Law, 2010). It is likely that no single gene causes autism; it takes many genes acting together. At one time or another, practically every

get83787_11_c11_305-324.indd 318 2/16/18 4:51 PM

319

Section 11.6 Autism Spectrum Disorder

chromosome has been implicated in the genesis of autism spectrum disorder (El-Fishawy & State, 2010), yet we still are unsure which genes are actually responsible (McLuckey, 2016).

There have been reports of monozygotic twins in which only one had autism spectrum disor- der (Wong et al., 2014). Given their identical inheritance, some other factor(s) must interact with genetics to produce the disorder (McLuckey, 2016). One possibility is that autism spec- trum disorder is the result of an unlucky conjunction—a genetic predisposition to develop cognitive and language disorders combined with exposure to an environmental trigger. Pos- sible candidates for this trigger include toxins, viruses, birth trauma, and a variety of illnesses (Modabbernia, Velthorst, & Reichenberg, 2017). As yet, definitive triggers have not been iden- tified; most have proved to be dead ends. Attempts to link an increased prevalence of autism to rates of vaccination have also been unsuccessful. As reported in a 2013 study from The Journal of Pediatrics, “The notion that the measles, mumps, rubella (MMR) vaccine, or any other vaccine or vaccine constituent, may cause autism is a hypothesis with little supporting evidence” (DeStefano, Price, & Weintraub, 2013, p. 836).

In the past, researchers have enlisted every conceivable blood test, hormonal assay, neuro- psychological test, and imaging technique to shed light on the pathology underlying autism spectrum disorder (Dawson, Meltzoff, Osterling, & Rinaldi, 1998; Hashimoto et al., 1998; Lin- coln, Courchesne, Allen, Hanson, & Ene, 1998; Piven & O’Leary, 1997); however, it is gener-

ally agreed upon that neurobiological causes are the main etiological factors in autism spectrum disorder (Sachdeva & Dutta, 2012). Although these research- ers have produced intriguing findings—including an association between the mild form of autism spectrum disorder (formerly called Asperger’s) and Tourette’s disorder (Neff & Teska, 2016)—there is still no agreement on the neurological defects that cause the symptoms and signs of autism spectrum disorder. All we can conclude at present is that peo- ple with autism spectrum disorder probably have a congenital vulnerability that combines with a trig- ger, resulting in an inability to form normal human attachments and, in people with more severe forms of autism, a language disability as well.

Treatment Children with autism spectrum disorder have been subjected to just about every known psychological and medical treatment. For decades, psychoana- lytically oriented psychotherapists labored to bring insight into autism spectrum disorder. However, whereas there are some psychodynamic views of the disorder (Duckham & Yann, 2016), most psy- chologists agree that behavior modification, par- ent education and training, and communication

Dorling Kindersley/Thinkstock Researchers have attempted several methods to teach spoken language to children with autism spectrum disorder, including conditioning trials that proved to be ineffective. Although autistic children may be somewhat limited by their abilities, the use of sign language has been a more effective way to teach communication skills.

get83787_11_c11_305-324.indd 319 2/16/18 4:51 PM

320

Section 11.6 Autism Spectrum Disorder

training are the most helpful treatment methods (Teicher et al., 2008). None of these treat- ments can cure autism spectrum disorder, although effective early interventions may help to improve the quality of life of sufferers and their families (Sachdeva & Dutta, 2012). In addi- tion, antipsychotic medications such as risperidone (Risperdal) can be used to control the behavioral outbursts that often accompany autism spectrum disorder (Ellerbeck, Smith, & Courtemanche, 2014; Procyshyn et al., 2017; Virani et al., 2009).

A continuing problem for clinicians, and for the families of people with autism spectrum disorder, is the false hope given by well-meaning amateurs and outright charlatans (see the accompanying Highlight). Consider, for example, the Cheneys’ experience with an approach called facilitated communication (also called supportive typing), which they describe in Part 6 of the support group case study (see the appendix).

The Cheneys’ experience is not unusual. Facilitated communication is based on the notion that there is a person trapped inside the individual with autism spectrum disorder. These trapped people have lots to say, and it takes a facilitator to allow them to say it.

Despite a total lack of empirical support, facilitated communication was widely applied, not only to individuals with communication disorders, but also to help people recover suppos- edly lost memories of child abuse. However, research has confirmed that it is not the person being facilitated whose thoughts are being communicated but the facilitator’s (Schlosser et al., 2014).

Highlight: A Different Look at Autism Spectrum Disorder Treatments and Etiologies

Of all of the disorders and disabilities discussed in this book, none seem to have produced as many false etiological explanations and treatments as autism spectrum disorder. We have discussed the scientific fact that vaccines do not cause autism spectrum disorder, yet that has not stopped discredited researcher Andrew Wakefield from continuing to espouse this view, even though it was based on his fraudulent research. Many others continue to embrace this view as well in spite of the overwhelming evidence to the contrary. Autism spectrum disorder has also been linked to refrigerator mothers, discussed earlier, another fraudulent claim that puts unnecessary blame on the mother. Facilitated communication, discussed in the text, has been proven to have no scientific efficacy (APA, 1994; Mostert, 2001). These are just a few examples.

Do you believe that these false etiologies and treatments are limited to autism spectrum disorder and if so, why might that be? What is it about autism spectrum disorder that makes it so ripe for inaccurate, unsupported, or fraudulent etiologies and treatments? One theory is that parents of special needs children will latch onto any explanation, no matter how improbable or fantastic, that might bring comfort and a sense of closure. Autism spectrum disorder is particularly heartbreaking as parents see their child gradually manifest the disorder.

Although fraudulent theories and treatments will no doubt continue to surface, parents of special needs children have to understand that their child’s condition is not their fault, nor the fault of childhood vaccines, and that for some disorders, treatment modalities are often not successful.

get83787_11_c11_305-324.indd 320 2/16/18 4:51 PM

321

Section 11.6 Autism Spectrum Disorder

Behavior Training Techniques People with autism spectrum disorder, and their families, can be helped to lead higher qual- ity lives. They may be taught useful communication and survival skills, and those who care for them may benefit from learning useful coping skills. Using a combination of behavior modification, behaviorally based special education, and speech therapy, children can be toilet trained (Wenger, 2017), taught to play games (Odluyurt, 2013), and helped to acquire aca- demic skills (Koegel, Singh, & Koegel, 2010). This should not imply that behavioral treatment can work miracles (Sachdeva & Dutta, 2012). Sometimes, the techniques fail.

If, as the research suggests, the problems faced by people with autism spectrum disorder in forming attachments, engaging in social relations, and conducting normal conversations are partly because they lack a “theory of mind,” perhaps they would benefit from being explicitly taught how to empathize with the feelings and thoughts of others, as well as how to prop- erly perceive and interpret social cues (Golan & Baron-Cohen, 2006; Slaughter, 2017). The research in this area is still too new to interpret accurately.

Drug Therapy In addition to behavioral treatments, at one time or another just about every drug, vitamin, and herb has been administered to children with autism spectrum disorder (Höfer, Hoffmann, & Bachmann, 2017). However, there are currently no drugs, vitamins, or herbal treatments that cure autism spectrum disorder, although some of these items may alleviate symptoms (such as sleeplessness). See the accompanying Highlight.

Behavioral treatments, sometimes combined with drugs, have made it possible for some chil- dren with autism spectrum disorder to learn much-needed skills and have led to significant improvements in their social behavior. However, progress comes at great cost to their fami- lies. Having a child with an autism spectrum disorder affects every aspect of life and often leads to the parents not focusing on their own emotional needs and other issues. Therapy and support groups for these parents are available and often helpful (Neff & Teska, 2016).

Highlight: Atypical Antipsychotic Medications and Autism Spectrum Disorder

Did you know that atypical antipsychotic agents, sometimes called second-generation antipsychotic medications, are used widely for the treatment of irritable and aggressive behaviors in children with autism spectrum disorder (Elvins & Green, 2010). In October 2006, the FDA approved the use of risperidone (Risperdal) in children and adolescents aged 5–16 years who have symptoms of irritability associated with autism (Yan, 2007). Currently no agents are approved by the American Academy of Pediatrics for prescription in children younger than five years of age because of a lack of scientific evidence of efficacy and safety (Sharma & Shaw, 2012). Side effects tend to be rare; however, an exception is rapid weight gain, which is common and can create significant health problems. Sharma and Shaw (2012) conclude that for most children with autism and irritable and aggressive behavior, risperidone is an effective psychopharmacological treatment.

(continued)

get83787_11_c11_305-324.indd 321 2/16/18 4:51 PM

322

Chapter Summary

Understanding Developmental Psychopathology • Because differences in temperament are noticeable from the first day of life, before

the environment can exert any effect, they are most likely biologically based. • Whether children develop a psychological disorder depends on the fit between their

temperaments and their environments. • Children who fail to achieve toilet training by the usual age (or developmental level,

if they have an intellectual disability) are diagnosed as having enuresis (poor control of urination) or encopresis (poor control of defecation).

• Both disorders occur more often in boys than in girls and seem to run in families. • There also appear to be environmental influences; for example, the disorders are

linked to child abuse. • Behavior therapy is effective for enuresis and may also help encopresis.

Conduct Disorder • Conduct disorders are relatively common, share many of the features of antisocial

personality disorder, and affect boys more often than girls. • Childhood-onset disorders have worse outcomes than disorders that begin later. • Parental neglect and exposure to antisocial models are particularly important etio-

logical factors in conduct disorders.

Attention-Deficit/Hyperactivity Disorder • Children with attention-deficit/hyperactivity disorder (ADHD) are impulsive and

distractible (mainly at school, but sometimes at home as well). Many are also hyperactive.

There are some important aspects to consider here. First and foremost, a medication that was initially approved to treat psychotic disorders in adults has been approved to treat behavioral issues (irritability) in children with autism spectrum disorder. Therefore, it is possible that a child with autism could be taking a potent antipsychotic medication . . . at age five! If you were the child’s parent, how would you feel about this? In addition, risperidone does not treat autism spectrum disorder, just the irritability that sometimes goes with it. Does it make sense for a very young child to take this drug? That is, do the benefits outweigh the risks? Finally, what does it say about the helping professions that there seems to be a medication to treat, or to help to treat, most psychiatric conditions? Are these advances, or are we moving backward, masking the underlying causes and conditions with endless, perhaps unnecessary medications? Think about this as you conclude your reading of this chapter.

Highlight: Atypical Antipsychotic Medications and Autism Spectrum Disorder (continued)

get83787_11_c11_305-324.indd 322 2/16/18 4:51 PM

323

Chapter Summary

• ADHD is more common among boys than girls. • Once a disorder only of children, ADHD is now being identified in adults as well. • Many environmental factors have been blamed for ADHD at one time or another, but

its cause remains unclear. • Although many different drugs have been used to treat ADHD, stimulant drugs are

the most common treatment. • Cognitive-behavioral treatments can help many people with ADHD to focus their

attention and change their behavior.

Tourette’s Disorder • Tourette’s disorder is characterized by sudden movements, strange utterances

(swearing, barking), and multiple motor tics (sudden repetitive but irregular movements).

• The DSM–5 also identifies other tic disorders (chronic motor or vocal tic disorder, provisional tic disorder) that share some of the symptoms of Tourette’s disorder.

• Tic disorders affect boys more often than girls. • The discovery that small doses of haloperidol, a dopamine-suppressing drug used

to treat schizophrenia, suppress Tourette’s symptoms in many people has led to the hypothesis that Tourette’s patients may have an excess of the chemical dopamine.

• There is also evidence that Tourette’s disorder is inherited.

Separation Anxiety Disorder • Developmentally inappropriate separation anxiety can lead to a refusal to attend

school and may presage adult anxiety disorders. • Separation anxiety may also be associated with social phobia, avoidant personality

disorder, and nightmares.

Autism Spectrum Disorder • Autism spectrum disorder is the most serious psychopathological condition occur-

ring in childhood. • Autism spectrum disorders are marked by poor interpersonal relationships, dis-

torted thinking, defective perception, and inappropriate affect. • In addition to poor attachments and communication problems, children with autism

spectrum disorder also lack a “theory of mind.” • Most people with these disorders have an intellectual disability. • These disorders have been blamed on everything from smothering mothers to per-

ceptual defects to viruses.

Critical Thinking Questions

1. The text discusses the hypothesis that elimination disorders are a result of child abuse. Discuss how you would go about researching this hypothesis.

2. Suppose that you are a research assistant and your research indicates that conduct disorder is in fact more prevalent in girls than in boys. This finding goes against what previous research has shown. Discuss some possible reasons for your new finding.

get83787_11_c11_305-324.indd 323 2/16/18 4:51 PM

324

Chapter Summary

Key Terms attention-deficit/hyperactivity disorder (ADHD) Children with ADHD are impul- sive and distractible (mainly at school, but sometimes at home as well); many are also hyperactive.

autism spectrum disorder A disorder that typically is noticed from ages 12 to 24 months, but symptoms may be seen earlier than 12 months if the symptoms are severe, or after 24 months if the symptoms are sub- tler. It is marked by poor social interactions, impaired communication, and odd motor behaviors.

conduct disorder A repetitive and persis- tent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated.

elimination disorder A disorder marked by poor bladder or bowel control; often associated with child abuse.

encopresis Poor control of defecation.

enuresis Poor control of urination.

externalizing disorders Disorders that involve behaviors that annoy or threaten others; often referred to as “acting out.”

internalizing disorders Disorders such as depression and anxiety, in which symptoms are directed inward.

oppositional defiant disorder A disorder marked by children who are frequently in trouble at school, and who may use temper tantrums to get their way.

separation anxiety disorder Developmen- tally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached.

Tourette’s disorder A disorder character- ized by strange utterances (swearing, bark- ing) and multiple motor tics (sudden repeti- tive but irregular movements).

3. The most common treatment modality for ADHD is stimulant use. Discuss this treat- ment and your views on giving medications to young children.

4. Facilitated communication was once a popular form of treatment for autism spec- trum disorder in the United States and in Canada. Some people still believe in its efficacy. Imagine that you are a clinician and have begun working with a mother who has a child with autism. She has read about facilitated communication and regardless of the research still believes in its efficacy. She is convinced that it works and that her daughter is “trapped inside, waiting to come out.” Discuss how you would explain to this mother that this method does not work and is not supported by research. In addition, discuss what emotions you might see from the mother as you talk to her.

5. Suppose you were asked to sit on a panel with some experts who believe that vac- cines cause autism, and that people with Tourette’s are “faking” the illness to gain attention. These experts also believe that autism can also be caused by having a refrigerator mother. Discuss how, in a professional manner, you would respond on the panel to the experts’ claims.

get83787_11_c11_305-324.indd 324 2/16/18 4:51 PM