ADHD Diagnosis

15 disorders of childhood and adolescence (neurodevelopmental disorders)

learning objectives 15

·  15.1 How does maladaptive behavior appear in different life periods?

·  15.2 What are the common disorders of childhood?

·  15.3 Do anxiety and depression appear in children and adolescents?

·  15.4 What are some specific disorders that occur in childhood?

·  15.5 What are intellectual disabilities?

·  15.6 How can we plan better programs to help children and adolescents?

A Case of Adolescent Depression and Attempted Suicide Emily is 15-year-old girl from a middle-class Caucasian background who had a history of depression during her childhood. She had periods of low mood, poor self-esteem, and social withdrawal. She also had symptoms of anxiety and was very reluctant to leave her home. During her year in the seventh grade, she became so fearful of going to school that she missed so many days she had to repeat the grade. She currently is in the eighth grade and has, to this point, missed a great deal of school. Her family became very concerned over Emily’s low mood and isolation, so they enrolled her in an out-patient treatment program for depression, anxiety episodes, and eating disorders. Her depression continued, and she became more isolated, lonely, and depressed and would not leave her room even for meals. One day her grandmother found her in their car in the garage with the engine running in an effort to end her life. Emily was admitted into an inpatient treatment program following her serious suicide attempt.

There is a history of psychiatric problems, particularly mood disorders, in her family. Her mother has been hospitalized on three occasions for depression. Her maternal grandfather, now deceased, was hospitalized at one time following a manic depressive episode.

In the early phases of her hospitalization, Emily underwent an extensive psychological and psychiatric evaluation. She was administered a battery of tests, including the Minnesota Multiphasic Personality Inventory for Adolescents (MMPI-A). She was cooperative with the evaluation and provided the assessment staff with sufficient information regarding her mood and attitudes to assist in developing a treatment program.

Emily showed many symptoms of a mood disorder in which both depression and anxiety were prominent features. The psychological evaluation indicated that she was depressed, anxious, and felt unable to deal with the school stress that her condition prompted. Moreover, her physical appearance and eating behavior suggested the strong likelihood of anorexia nervosa. Emily showed an extreme degree of social introversion on several measures and acknowledged her reticence at engaging in social interactions. The assessment psychologist concluded that her personality characteristics of social withdrawal, isolation, and difficult interpersonal relationships would likely result in her having problems in establishing a therapeutic relationship. Her treatment program involved supportive cognitive therapy along with antidepressant medication.

Although she endorsed a broad range of anxiety symptoms, in her testing and in the intake interview she endorsed few items regarding suicidal ideation. This was not sufficient evidence to support a conclusion that she was at less risk for suicide; however, it could simply reflect her unwillingness to openly discuss her recent attempt. Her past behavior and low mood indicated a need to consider the possibility of further suicide attempts.

She remained in inpatient treatment for 3 weeks and was discharged with the summary that she had shown substantial improvement. She was, however, referred for further psychological treatment on an outpatient basis.

Source: Adapted from Williams & Butcher,  2011 , pp. 151–63.

Until the twentieth century, little account was taken of the special characteristics of psychopathology in children; maladaptive patterns considered relatively specific to childhood, such as autism, received virtually no attention at all. Only since the advent of the mental health movement and the availability of child guidance facilities at the beginning of the twentieth century have marked strides been made in assessing, treating, and understanding the maladaptive behavior patterns of children and adolescents.

The problems of childhood were initially seen simply as downward extensions of adult-oriented diagnoses. The prevailing view was one of children as “miniature adults.” But this view failed to recognize special problems, such as those associated with the developmental changes that normally take place in childhood or adolescence. Only relatively recently have clinicians come to realize that they cannot fully understand childhood disorders without taking these developmental processes into account. Today, even though great progress has been made in providing treatment for disturbed children, facilities are still inadequate to the task, and most children with mental health problems do not receive psychological attention.

The number of children affected by psychological problems is considerable. Research studies in several countries have provided estimates of childhood disorders. Roberts, Roberts, et al. ( 2007 ) found that 17.1 percent of adolescents in large metropolitan areas of the United States meet the criteria for one or more DSM diagnoses. Verhulst ( 1995 ) conducted an evaluation of the overall prevalence of childhood disorder based on 49 studies involving over 240,000 children across many countries and found the average rate to be 12.3 percent. In most studies, maladjustment is found more commonly among boys than among girls; however, for some diagnostic problems, such as eating disorders (see  Chapter 8 ), rates are higher for girls than for boys. The most prevalent disorders are attention-deficit/hyperactivity disorder (ADHD) (Ryan-Krause et al.,  2010 ) and separation anxiety disorders (Cartwright-Hatton et al.,  2006 ). Some subgroups of the population—for example, Native Americans—tend to have higher rates of mental disorders. One study reported that 23 percent of the Native American children rated in the sample met criteria for 1 of the 11 mental disorders in the survey and 9 percent met criteria for 2 or more of the disorders (Whitbeck et al.,  2006 ).

Maladaptive Behavior in Different Life Periods

Several behaviors that characterize maladjustment or emotional disturbance are relatively common in childhood. Because of the manner in which personality develops, the various steps in growth and development, and the differing stressors people face in childhood, adolescence, and adulthood, we would expect to find some differences in maladaptive behavior in these periods. The fields of developmental science (Hetherington,  1998 ) and, more specifically,  developmental psychopathology  (Kim-Cohen,  2007 ) are devoted to studying the origins and course of individual maladaptation in the context of normal growth processes.

It is important to view a child’s behavior in the context of normal childhood development (Silk et al.,  2000 ). We cannot consider a child’s behavior abnormal without determining whether the behavior in question is appropriate for the child’s age. For example, temper tantrums and eating inedible objects might be viewed as abnormal behavior at age 10 but not at age 2. Despite the somewhat distinctive characteristics of childhood disturbances at different ages, there is no sharp line of demarcation between the maladaptive behavior patterns of childhood and those of adolescence, or between those of adolescence and those of adulthood. Thus, although our focus in this chapter will be on the behavior disorders of children and adolescents, we will find some inevitable carryover into later life periods.

Varying Clinical Pictures

The clinical picture of childhood disorders tends to be distinct from the clinical picture of disorders in other life periods. Some of the emotional disturbances of childhood may be relatively short lived and less specific than those occurring in adulthood. However, some childhood disorders severely affect future development. One study found that individuals who had been hospitalized as child psychiatric patients (between the ages of 5 and 17) died early in life due to unnatural causes (about twice the rate of the general population) when followed up from 4 to 15 years later (Kuperman et al.,  1988 ). The suicide risk among some disturbed adolescents is long-lasting and requires careful follow-up and attention (Fortune et al.,  2007 ). Suicidal thoughts are not uncommon in children. Riesch and colleagues ( 2008 ) report that 18 percent of sixth graders have thoughts of killing themselves. Two other recent studies have reported rates for children under age 15. Dervic, Brent, and Oquendo ( 2008 ) report that international suicide rates are 3.1 per million. Hawton and Harriss ( 2008 ) report that the long-term risk of suicide is 1.1 percent, with girls more likely than boys to commit suicide. Both studies report that difficult family relationships are the leading cause of suicidal behavior. Being bullied by another child is another factor that has been found to be associated with risk of suicide (Rivers & Noret,  2010 ).

Special Psychological Vulnerabilities of Young Children

Young children are especially vulnerable to psychological problems (Ingram & Price,  2001 ). In evaluating the presence or extent of mental health problems in children and adolescents, one needs to consider the following:

·  • They do not have as complex and realistic a view of themselves and their world as they will have later; they have less self- understanding; and they have not yet developed a stable sense of identity or a clear understanding of what is expected of them and what resources they might have to deal with problems.

·  • Immediately perceived threats are tempered less by considerations of the past or future and thus tend to be seen as disproportionately important. As a result, children often have more difficulty than adults in coping with stressful events (Mash & Barkley,  2006 ). For example, children are at risk for posttraumatic stress disorder after a disaster, especially if the family atmosphere is troubled—a circumstance that adds additional stress to the problems resulting from the natural disaster (Menaghan,  2010 ).

·  • Children’s limited perspectives, as might be expected, lead them to use unrealistic concepts to explain events. For young children, suicide or violence against another person may be undertaken without any real understanding of the finality of death.

·  • Children also are more dependent on other people than are adults. Although in some ways this dependency serves as a buffer against other dangers because the adults around him or her might “protect” a child against stressors in the environment, it also makes the child highly vulnerable to experiences of rejection, disappointment, and failure if these adults, because of their own problems, ignore the child (Lengua,  2006 ).

·  • Children’s lack of experience in dealing with adversity can make manageable problems seem insurmountable (Scott et al.,  2010 ). On the other hand, although their inexperience and lack of self-sufficiency make them easily upset by problems that seem minor to the average adult, children typically recover more rapidly from their hurts.

The Classification of Childhood and Adolescent Disorders

Until the 1950s no formal, specific system was available for classifying the emotional or behavioral problems of children and adolescents. Kraepelin’s ( 1883 ) classic textbook on the classification of mental disorders did not include childhood disorders. In 1952, the first formal psychiatric nomenclature (DSM-I) was published, and childhood disorders were included. This system was quite limited and included only two childhood emotional disorders: childhood schizophrenia and adjustment reaction of childhood. In 1966, the Group for the Advancement of Psychiatry provided a classification system for children that was detailed and comprehensive. Thus, in the 1968 revision of the DSM (DSM-II), several additional categories were added. However, growing concern remained—both among clinicians attempting to diagnose and treat childhood problems and among researchers attempting to broaden our understanding of childhood psycho-pathology—that the then-current ways of viewing psychological disorders in children and adolescents were inappropriate and inaccurate for several reasons. The greatest problem was that the same classification system that had been developed for adults was used for childhood problems even though many childhood disorders, such as autism, learning disabilities, and school phobias, have no counterpart in adult psychopathology. The early systems also ignored the fact that in childhood disorders, environmental factors play an important part in the expression of symptoms—that is, symptoms are highly influenced by a family’s acceptance or rejection of the behavior. In addition, symptoms were not considered with respect to a child’s developmental level. Some of the problem behaviors might be considered age appropriate, and troubling behaviors might simply be behaviors that the child will eventually outgrow. In the most recent revision of the diagnostic and statistical manual (DSM-5), efforts were made to provide diagnostic classification that is consistent with current research and contemporary clinical practice.

in review

·  • Define developmental psychopathology.

·  • Discuss the special psychological vulnerabilities of children.

Common Disorders of Childhood

At present the DSM-5 provides diagnoses for a large number of childhood and adolescent disorders or Neurodevelopmental Disorders. In addition, several disorders, involving intellectual disability (formerly referred to as mental retardation) are included. Space limitations do not allow us to explore fully the mental disorders of childhood and adolescence included in the DSM system, so we have selected several disorders to illustrate the broad range of problems that can occur in childhood and adolescence. Some of these disorders are more transient than many of the abnormal behavior patterns of adulthood discussed in earlier chapters—and also perhaps more amenable to treatment while others have a likelihood of persistence.

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) , often referred to as hyperactivity, is characterized by difficulties that interfere with effective task-oriented behavior in children—particularly impulsivity, excessive or exaggerated motor activity, such as aimless or haphazard running or fidgeting, and difficulties in sustaining attention (Nigg et al.,  2005 ; see DSM-5 Criteria for Attention-Deficit/Hyperactivity Disorder). The diagnostic criteria for ADHD remained relatively unchanged for children and adolescents in DSM-5.

Children with ADHD are highly distractible and often fail to follow instructions or respond to demands placed on them (Wender,  2000 ). Perhaps as a result of their behavioral problems, children with ADHD are often lower in intelligence, usually about 7 to 15 IQ points below average (Barkley,  1997 ). Children with ADHD also tend to talk incessantly and to be socially intrusive and immature. Recent research has shown that many children with ADHD show deficits on neuropsychological testing that are related to poor academic functioning (Biederman et al.,  2004 ) Watch the Video Jimmy: Attention-Deficit/Hyperactivity Disorder on MyPsychLab .

Children with ADHD generally have many social problems because of their impulsivity and overactivity. Hyperactive children usually have great difficulty in getting along with their parents because they do not obey rules. Their behavior problems also result in their being viewed negatively by their peers (Hoza et al.,  2005 ). In general, however, hyperactive children are not anxious, even though their overactivity, restlessness, and distractibility are frequently interpreted as indications of anxiety. They usually do poorly in school and often show specific learning disabilities such as difficulties in reading or in learning other basic school subjects. Hyperactive children also pose behavior problems in the elementary grades. The case study on page 513 reveals a typical clinical picture.

The symptoms of ADHD are relatively common among children seen at mental health facilities in the United States, with from 3 to 7 percent reported in the DSM and 8 percent reported in a recent study in the United Kingdom (Alloway et al.,  2010 ). In fact, hyperactivity is the most frequently diagnosed mental health condition in children in the United States (Ryan-Krause et al.,  2010 ). The disorder occurs most frequently among preadolescent boys—it is six to nine times more prevalent among boys than among girls. ADHD occurs with the greatest frequency before age 8 and tends to become less frequent and to involve briefer episodes thereafter. ADHD has also been found to be comorbid with other disorders such as oppositional defiant disorder (ODD) (Staller,  2006 ), which we discuss later. Some residual effects, such as attention difficulties, may persist into adolescence or adulthood (Odell et al.,  1997 ). ADHD is found in other cultures (Bauermeister et al.,  2010 )—for example, one study of 1,573 children from 10 European countries reported that ADHD symptoms are similarly recognized across all countries studied and that the children are significantly impaired across a wide range of domains.

DSM-5 criteria for: Attention-Deficit/Hyperactivity Disorder

·  A. A persistent pattern of inattention and/or hyperactivityimpulsivity that interferes with functioning or development, as characterized by (1) and/or (2):

·  1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.

·  a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

·  b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

·  c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

·  d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).

·  e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

·  f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

·  g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

·  h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

·  i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

·  2 Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.

·  a. Often fidgets with or taps hands or feet or squirms in seat.

·  b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

·  c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)

·  d. Often unable to play or engage in leisure activities quietly.

·  e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).

·  f. Often talks excessively.

·  g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).

·  h. Often has difficulty waiting his or her turn (e.g., while waiting in line).

·  i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

·  B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

·  C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities).

·  D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning.

·  E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

CAUSAL FACTORS IN ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

The cause or causes of ADHD in children have been much debated. It still remains unclear to what extent the disorder results from environmental or biological factors (Carr et al.,  2006 ; Hinshaw et al.,  2007 ), and recent research points to both genetic (Sharp et al.,  2009 ; Ilott et al.,  2010 ) and social environmental precursors (Hechtman,  1996 ). Many researchers believe that biological factors such as genetic inheritance will turn out to be important precursors to the development of ADHD (Durston,  2003 ). But firm conclusions about any biological basis for ADHD must await further research.

Gina, a Student with Hyperactivity Gina was referred to a community clinic because of overactive, inattentive, and disruptive behavior. Her hyperactivity and uninhibited behavior caused problems for her teacher and for other students. She would impulsively hit other children, knock things off their desks, erase material on the blackboard, and damage books and other school property. She seemed to be in perpetual motion, talking, moving about, and darting from one area of the classroom to another. She demanded an inordinate amount of attention from her parents and her teacher, and she was intensely jealous of other children, including her own brother and sister. Despite her hyper-active behavior, inferior school performance, and other problems, she was considerably above average in intelligence. Nevertheless, she felt stupid and had a seriously devaluated self-image. Neurological tests revealed no significant organic brain disorder.

The search for psychological causes of ADHD has yielded similarly inconclusive results, although temperament and learning appear likely to be factors. One study suggested that family pathology, particularly parental personality, can be transmitted to children (Goos et al.,  2007 ), and another recent study found that prenatal alcohol exposure can increase the severity of problems in children with ADHD (Ware et al.,  2012 ). Currently, ADHD is considered to have multiple causes and effects (Hinshaw et al.,  1997 ). Whatever cause or causes are ultimately determined to be influential in ADHD, the mechanisms underlying the disorder need to be more clearly understood and explored. There is general agreement that processes operating in the brain are disinhibiting the child’s behavior (Nigg,  2001 ), and some research has found different EEG patterns occurring in children with ADHD than in children without ADHD (Barry et al.,  2003 ). At this time, however, theorists do not agree what those central nervous system processes are.

TREATMENTS AND OUTCOMES

Although the hyperactive syndrome was first described more than 100 years ago, disagreement over the most effective methods of treatment continues, especially regarding the use of drugs to calm a child with ADHD. Yet this approach to treating children with ADHD has great appeal in the medical community; one survey (Runnheim et al.,  1996 ) found that 40 percent of junior high school children and 15 percent of high school children with emotional and behavioral problems and ADHD are prescribed medication, mostly  Ritalin  (methylphenidate), an amphetamine. In fact, school nurses administer more daily medication for ADHD than for any other chronic health problem.

Interestingly, research has shown that amphetamines have a quieting effect on children—just the opposite of what we would expect from their effects on adults. For children with ADHD, such stimulant medication decreases overactivity and distractibility and, at the same time, increases their alertness (Konrad et al.,  2004 ). As a result, they are often able to function much better at school (Hazell,  2007 ; Pelham et al.,  2002 ).

Fava ( 1997 ) concludes that Ritalin can often lower the amount of aggressiveness in children with ADHD. In fact, many children whose behavior has not been acceptable in regular classes can function and progress in a relatively normal manner when they use such a drug. In a 5-year follow-up study, Charach, Ickowicz, and Schachar ( 2004 ) reported that children with ADHD on medication showed greater improvement in teacher-reported symptoms than nontreated children. The possible side effects of Ritalin, however, are numerous: decreased blood flow to the brain, which can result in impaired thinking ability and memory loss; disruption of growth hormone, leading to suppression of growth in the body and brain of the child; insomnia; psychotic symptoms; and others. Although amphetamines do not cure ADHD, they have reduced the behavioral symptoms in about one-half to two-thirds of the cases in which medication appears warranted.

Ritalin has been shown to be effective in the short-term treatment of ADHD (Goldstein,  2009 ; Spencer,  2004a ). There are newer variants of the drug, referred to as extended-release methylphenidate (Concerta), that have similar benefits but with available doses that may better suit an adolescent’s lifestyle (Mott & Leach,  2004 ; Spencer,  2004b ).

Three other medications for treating ADHD have received attention in recent years.  Pemoline  is chemically very different from Ritalin (Faigel & Heiligenstein,  1996 ); it exerts beneficial effects on classroom behavior by enhancing cognitive processing but has less adverse side effects (Bostic et al.,  2000 ; Pelham et al.,  2005 ).  Strattera  (atomoxetine), a noncontrolled treatment option that can be obtained readily, is an FDA-approved non-stimulant medication (FDA,  2002 ). This medication reduces the symptoms of ADHD (Friemoth,  2005 ), but its mode of operation is not well understood. The side effects for the drug are decreased appetite, nausea, vomiting, and fatigue. The development of jaundice has been reported, and the FDA ( 2004 ) has warned of the possibility of liver damage from using Strattera. Although Strattera has been shown to reduce some symptoms of ADHD, further research is needed to evaluate its effectiveness and potential side effects (Barton et al.,  2005 ). Another drug that reduces symptoms of impulsivity and hyperactivity in children with attention deficit/hyperactivity disorder is  Adderall . This medication is a combination of amphetamine and dextro-amphetamine; however, research has suggested that Adderall has no advantage or improvement in results over Ritalin or Strattera (Miller-Horn et al.,  2008 ).

Although the short-term pharmacological effect of stimulants on the symptoms of hyperactive children is well established, their long-term effects are not well known (Safer,  1997a ). Carlson and Bunner ( 1993 ) reported that studies of achievement over long periods of time failed to show that the medication has beneficial effects. The pharmacological similarity of Ritalin and cocaine, for example, has caused some investigators to be concerned about its use in the treatment of ADHD (Volkow et al.,  1995 ). There have also been some reported recreational uses of Ritalin, particularly among college students. Kapner ( 2003 ) described several surveys in which Ritalin was reportedly abused on college campuses. In one survey, 16 percent of students at one university reported using Ritalin, and in another study 1.5 percent of the population surveyed reported using Ritalin for recreational purposes within the past 30 days. Some college students share the prescription medications of friends as a means of obtaining a “high” (Chutko et al.,  2010 ).

Some authorities prefer using psychological interventions in conjunction with medications (Mariani & Levin,  2007 ). The behavioral intervention techniques that have been developed for ADHD include selective reinforcement in the classroom (DuPaul et al.,  1998 ) and family therapy (Everett & Everett,  2001 ). Another effective approach to treating children with ADHD involves the use of behavior therapy techniques featuring positive reinforcement and the structuring of learning materials and tasks in a way that minimizes error and maximizes immediate feedback and success (Frazier & Merrill,  1998 ). An example is providing a boy with ADHD immediate praise for stopping to think through a task he has been assigned before he starts to do it. The use of behavioral treatment methods for ADHD has reportedly been quite successful, at least for short-term gains.

The use of psychosocial treatment of ADHD has also shown positive results (Pelham & Fabiano,  2008 ; Corcoran,  2011 ). Van Lier and colleagues ( 2004 ) conducted a school-based behavioral intervention program using positive reinforcement aimed at preventing disruptive behavior in elementary school children. They found this program to be effective with children with ADHD with different levels of disorder but most effective with children at lower or intermediate levels.

It is important to recognize that gender differences, as noted above, are found in ADHD, with the disorder being more prominent among boys than girls and the symptoms appraised differently. Recent concerns have been expressed over the possibility that treatment of females with symptoms of ADHD might not be provided because they are more often diagnosed as “predominantly inattentive” than boys. Rucklidge ( 2010 ) points out that females are less likely to be referred to treatment than males with ADHD although treatments appear to be equally effective for both genders. She points out that future research should be attentive to gender differences in the disorder and further examine potential differences that might occur in treatment and outcomes.

ADHD BEYOND ADOLESCENCE

A number of changes were made to the diagnostic criteria of ADHD in the development of DSM-5 in order to expand the diagnoses “across the life span.” Although the diagnostic criteria were not substantially changed for ADHD in DSM-5, some adjustments as to age level of the appearance of symptoms were modified to allow the diagnosis in adult years.

Some researchers have reported that many children with ADHD retain symptoms and behavior into early adulthood. Kessler, Adler, and colleagues ( 2006 ) reported a prevalence rate of 4.4 percent in adult patients. Many children with ADHD go on to have other psychological problems such as overly aggressive behavior or substance abuse in their late teens and early adulthood (Barkley et al.,  2004 ). For example, Carroll and Rounsaville ( 1993 ) found that 34.6 percent of treatment-seeking cocaine abusers in their study had met the criteria for ADHD when they were children. In a 30-year follow-up study of hyperactive boys with conduct problems, Satterfield and colleagues ( 2007 ) reported that such boys are at substantial increased risk for adult criminality. Biederman and colleagues ( 2010 ) conducted an 11-year follow-up study of girls with ADHD and found that girls with ADHD were at high risk for antisocial, addictive, mood, anxiety, and eating disorders. In another recent study, college students with ADHD have been shown to exhibit more on-the-job difficulties than peers without ADHD (Shifrin et al.,  2010 ). In a recent follow-up study of children with ADHD, Klein and colleagues ( 2012 ) reported that compared with peers without ADHD, those with ADHD displayed dysfunction in multiple domains as adults. Educational and occupational attainment was significantly compromised, leading to a relative economic disadvantage.

More  longitudinal research  is clearly needed before we can conclude that children with ADHD go on to develop similar or other problems in adulthood. Mannuzza, Klein, and Moulton ( 2003 ) reported that estimates of the numbers of children with ADHD who will experience symptoms of ADHD in adulthood are likely to vary considerably. However, some of the research cited suggests that a significant percentage of adolescents continue to have problems in later life, and many continue to obtain treatment for ADHD (Doyle,  2006 ) or for other disorders such as major depression or bipolar disorder in their adult years (Klassen et al.,  2010 ).

research CLOSE-UP: Longitudinal Research

Longitudinal research involves studying and collecting baseline information on a specific group of interest (patients with a given disorder, high-risk children, etc.) and then following up with them at a future date (e.g., 1, 5, or even 20 years later) to determine the changes that have occurred over the intervening period.

Disruptive, Impulse-Control, and Conduct Disorder

The next group of disorders involves a child’s or an adolescent’s relationship to social norms and rules of conduct. In both oppositional defiant disorder and conduct disorder, aggressive or antisocial behavior is the focus. As we will see, oppositional defiant disorder is usually apparent by about age 8, and conduct disorder tends to be seen by age 9. These disorders are closely linked (Thomas,  2010 ). However, it is important to distinguish between persistent antisocial acts—such as setting fires, where the rights of others are violated—and the less serious pranks often carried out by normal children and adolescents. Also, oppositional defiant disorder and conduct disorder involve misdeeds that may or may not be against the law;  juvenile delinquency  is the legal term used to refer to violations of the law committed by minors. (See the Unresolved Issues section at the end of this chapter.)

THE CLINICAL PICTURE IN OPPOSITIONAL DEFIANT DISORDER

An important precursor of the antisocial behavior seen in children who develop conduct disorder is often what is now called  oppositional defiant disorder (ODD)  and categorized under Disruptive, Impulse-Control, and Conduct Disorders in DSM-5. The criteria for ODD were changed in DSM-5 somewhat from the DSM-IV disorder. The ODD disorder is now grouped into three subtypes: angry/irritable mood, argumentative/defiant behavior and vindictiveness. Moreover, a severity rating has been included as an indicator of severity. The essential feature is a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months. This disorder usually begins by the age of 8, whereas full-blown conduct disorders typically begin from middle childhood through adolescence. The lifetime prevalence of ODD as reported in a national sample of adult respondents was relatively high: 11.2 percent for boys and 9.2 percent for girls (Nock et al.,  2007 ). Prospective studies have found a developmental sequence from oppositional defiant disorder to conduct disorder, with common risk factors for both conditions (Hinshaw,  1994 ). That is, virtually all cases of conduct disorder are preceded developmentally by oppositional defiant disorder, but not all children with oppositional defiant disorder go on to develop conduct disorder within a 3-year period (Lahey et al.,  2000 ). The risk factors for both include family discord, socioeconomic disadvantage, and antisocial behavior in the parents.

DSM-5 criteria for: Conduct Disorder

·  A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months:

Aggression to People and Animals

·  1. Often bullies, threatens, or intimidates others.

·  2. Often initiates physical fights.

·  3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).

·  4. Has been physically cruel to people.

·  5. Has been physically cruel to animals.

·  6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).

·  7. Has forced someone into sexual activity.

Destruction of Property

·  8. Has deliberately engaged in fire setting with the intention of causing serious damage.

·  9. Has deliberately destroyed others’ property (other than by fire setting).

Deceitfulness or Theft

·  10. Has broken into someone else’s house, building, or car.

·  11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).

·  12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

Serious Violations of Rules

·  13. Often stays out at night despite parental prohibitions, beginning before age 13 years.

·  14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period.

·  15. Is often truant from school, beginning before age 13 years.

·  B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

·  C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

THE CLINICAL PICTURE IN CONDUCT DISORDER

The essential symptomatic behavior in  conduct disorder  and ODD involves a persistent, repetitive violation of rules and a disregard for the rights of others and is essentially the same as in DSM-IV. Children with conduct disorder show a deficit in social behavior (Happe & Frith,  1996 ; see DSM Criteria for Conduct Disorder). In general, they manifest such characteristics as overt or covert hostility, disobedience, physical and verbal aggressiveness, quarrelsomeness, vengefulness, and destructiveness. Lying, solitary stealing, and temper tantrums are common. Such children tend to be sexually uninhibited and inclined toward sexual aggressiveness. Some may engage in cruelty to animals (Becker et al.,  2004 ), bullying (Coolidge et al.,  2004 ), firesetting (Becker et al.,  2004 ; Slavkin & Fineman,  2000 ; Stickle & Blechman,  2002 ), vandalism, robbery, and even ho-micidal acts. Children and adolescents with conduct disorder are also frequently comorbid for other disorders such as substance-abuse disorder (Goldstein et al.,  2006 ) or depressive symptoms (O’Connor et al.,  1998 ). Zoccolillo, Meyers, and Assiter ( 1997 ) found that conduct disorder is a risk factor for unwed pregnancy and substance abuse in teenage girls. Goldstein and colleagues ( 2006 ) report that early-onset conduct disorder is highly associated with later development of antisocial personality disorder (see  Chapter 8 ); Fergusson, Hor-wood, and Ridder ( 2007 ) and Yang and colleagues ( 2007 ) found that conduct disorder in childhood and adolescence is generally related to later substance use, abuse, and dependence.

CAUSAL FACTORS IN OPPOSITIONAL DISORDER AND CONDUCT DISORDER

Understanding of the factors associated with the development of conduct problems in childhood has increased tremendously in the past 20 years. Several factors will be covered in the sections that follow.

A Self-Perpetuating Cycle Evidence has accumulated that a genetic predisposition (Simonoff,  2001 ) leading to low verbal intelligence, mild neuropsychological problems, and difficult temperament can set the stage for early-onset conduct disorder. Baker and colleagues ( 2007 ) reported strong heritable effects of conduct problems and antisocal behavior across ethnically and economically diverse samples. The child’s difficult temperament may lead to an insecure attachment because parents find it hard to engage in the good parenting that would promote a secure attachment. In addition, the low verbal intelligence and mild neuropsychological deficits that have been documented in many of these children—some of which may involve deficiencies in self-control functions such as sustaining attention, planning, self-monitoring, and inhibiting unsuccessful or impulsive behaviors—may help set the stage for a lifelong course of difficulties. In attempting to explain why the relatively mild neuropsychological deficits typically seen can have such pervasive effects, Moffitt and Lynam ( 1994 ) provided the following scenario: A preschooler has problems understanding language and tends to resist his mother’s efforts to read to him. This deficit then delays the child’s readiness for school. When he does enter school, the typically busy curriculum does not allow teachers to focus their attention on students at his low readiness level. Over time, and after a few years of school failure, the child will be chronologically older than his classmates, setting the stage for social rejection. At some point, the child might be placed into remedial programs that contain other pupils who have similar behavioral disorders as well as learning disabilities. This involvement with conduct-disordered peers exposes him to delinquent behaviors that he adopts in order to gain acceptance.

Hostility and aggressive behavior have been found to play a role in the development of conduct disorder. Children who develop this disorder early in childhood are at special risk for problems later in life.

Age of Onset and Links to Antisocial Personality Disorder Children who develop conduct disorder at an earlier age are much more likely to develop psychopathy or antisocial personality disorder as adults than are adolescents who develop conduct disorder suddenly in adolescence (Copeland et al.,  2007 ). The link between conduct disorder and antisocial personality is stronger among lower-socioeconomic-class children (Lahey et al.,  2005 ). It is the pervasiveness of the problems first associated with oppositional defiant disorder and then with conduct disorder that forms the pattern associated with an adult diagnosis of psychopathy or antisocial personality. Although only about 25 to 40 percent of cases of early-onset conduct disorder go on to develop adult antisocial personality disorder, over 80 percent of boys with early-onset conduct disorder do continue to have multiple problems of social dysfunction (in friendships, intimate relationships, and vocational activities) even if they do not meet all the criteria for antisocial personality disorder. By contrast, most individuals who develop conduct disorder in adolescence do not go on to become adult psychopaths or antisocial personalities but instead have problems limited to the adolescent years. These adolescent-onset cases also do not share the same set of risk factors that the child-onset cases have, including low verbal intelligence, neuropsychological deficits, and impulsivity and attentional problems.

Psychosocial Factors In addition to the genetic or constitutional liabilities that may predispose a person to develop conduct disorder and adult psychopathy and antisocial personality, Kazdin ( 1995 ) underscored the importance of family and social context factors as causal variables. Children who are aggressive and socially unskilled are often rejected by their peers, and such rejection can lead to a spiraling sequence of social interactions with peers that exacerbates the tendency toward antisocial behavior (Freidenfelt & Klinteberg,  2007 ). Severe conduct problems can lead to other mental health problems as well. Mason and colleagues ( 2004 ) found that children who report higher levels of conduct problems are nearly four times more likely to experience a depressive episode in early adulthood.

This socially rejected subgroup of aggressive children is also at the highest risk for adolescent delinquency and probably for adult antisocial personality. In addition, parents and teachers may react to aggressive children with strong negative affect such as anger (Capaldi & Patterson,  1994 ), and they may in turn reject these aggressive children. The combination of rejection by parents, peers, and teachers leads these children to become isolated and alienated. Not surprisingly, they often turn to deviant peer groups for companionship, at which point a good deal of imitation of the antisocial behavior of their deviant peer models may occur.

Investigators generally seem to agree that the family setting of a child with conduct disorder is typically characterized by ineffective parenting, rejection, harsh and inconsistent discipline, and parental neglect (Frick,  1998 ). Frequently, the parents have an unstable marital relationship, are emotionally disturbed or sociopathic, and do not provide the child with consistent guidance, acceptance, or affection. Even if the family is intact, a child in a conflict-charged home feels overtly rejected. For example, Rutter and Quinton ( 1984 ) concluded that family discord and hostility are the primary factors defining the relationship between disturbed parents and disturbed children; this is particularly true with respect to the development of conduct disorders in children and adolescents. Such discord and hostility contribute to poor and ineffective parenting skills, especially ineffective discipline and supervision. These children are “trained” in antisocial behavior by the family—directly via coercive interchanges and indirectly via lack of monitoring and consistent discipline (Capaldi & Patterson,  1994 ). This all too often leads to association with deviant peers and the opportunity for further learning of antisocial behavior.

Ineffective parenting, harsh and inconsistent discipline, parental neglect, and marital discord can all contribute to oppositional defiant disorder (ODD) and conduct disorders. So can poverty and parental stress and depression.

In addition to these familial factors, a number of broader psychosocial and sociocultural variables increase the probability that a child will develop conduct disorder and, later, adult psychopathy or antisocial personality disorder (Granic & Patterson,  2006 ) or depressive disorder (Boylan et al.,  2010 ). Low socioeconomic status, poor neighborhoods, parental stress, and depression all appear to increase the likelihood that a child will become enmeshed in this cycle (Schonberg & Shaw,  2007 ).

TREATMENTS AND OUTCOMES

By and large, our society tends to take a punitive, rather than a rehabilitative, attitude toward an antisocial, aggressive youth. Thus the emphasis is on punishment and on “teaching the child a lesson.” Such treatment, however, seems to intensify rather than correct the behavior. Treatment for oppositional defiant disorder and conduct disorder tends to focus on the dysfunctional family patterns described above and on finding ways to alter the child’s aggressive or otherwise maladaptive behaviors (Behan & Carr,  2000 ; Milne et al.,  2001 ).

The Cohesive Family Model Therapy for a child with conduct disorder is likely to be ineffective unless some way can be found to modify the child’s environment. One interesting and often effective treatment strategy with conduct disorder is the cohesive family model (Granic & Patterson,  2006 ; Patterson et al.,  1998 ). In this family-group-oriented approach, parents of children with conduct disorder are viewed as lacking in parenting skills and as behaving in inconsistent ways, thereby reinforcing inappropriate behavior and failing to socialize their children. Children learn to escape or avoid parental criticism by escalating their negative behavior. This tactic, in turn, increases their parents’ aversive interactions and criticism. The child observes the increased anger in his or her parents and models this aggressive pattern. The parental attention to the child’s negative, aggressive behavior actually serves to reinforce that behavior instead of suppressing it. Viewing conduct problems as emerging from such interactions places the treatment focus squarely on the interaction between the child and the parents (Patterson et al.,  1991 ).

Obtaining treatment cooperation from parents who are themselves in conflict with each other is difficult. Often, an over-burdened parent who is separated or divorced and working simply does not have the resources, the time, or the inclination to learn and practice a more adequate parental role (Clarke-Stewart et al.,  2000 ). In more extreme cases, the circumstances may call for a child to be removed from the home and placed in a foster home or institution, with the expectation of a later return to the home if intervening therapy with the parent or parents appears to justify it (Hahn et al.,  2005 ).

Unfortunately, children who are removed to new environments often interpret this removal as further rejection not only by their parents but by society as well. Unless the changed environment offers a warm, kindly, and accepting yet consistent and firm setting, such children are likely to make little progress (see Pumariega,  2007 ).

Behavioral and Biologically Based Treatments The effectiveness of behavior therapy techniques and biologically based treatments has made the outlook brighter for children with conduct disorder (Kazdin & Weisz,  2003 ). A recent study of treating depression and oppositional defiant behavior with the antidepressant medication, fluoxetine (Prozac), and cognitive behavior therapy found a reduction in oppositionality over those not receiving the medication (Jacobs et al.,  2010 ).

Teaching control techniques to the parents of such children is particularly important so that they can function as therapists in reinforcing desirable behavior and modifying the environmental conditions that have been reinforcing maladaptive behavior in their children. The changes brought about when parents consistently accept and reward their child’s positive behavior and stop focusing on the negative behavior may finally change their perception of and feelings toward the child, leading to the basic acceptance that the child has so badly needed.

Although effective tactics for behavioral management can be taught to parents, they often have difficulty carrying out treatment plans. If this is the case, other techniques, such as family therapy or parental counseling, are used to ensure that the parent or person responsible for the child’s discipline is sufficiently assertive to follow through on the program.

in review

·  • Describe two common anxiety disorders found in children and adolescents.

·  • Distinguish among conduct disorder, oppositional defiant disorder, and juvenile delinquency.

Anxiety and Depression in Children and Adolescents

Anxiety Disorders of Childhood and Adolescence

In modern society, no one is totally insulated from anxiety-producing events or situations, and the experience of traumatic events can predispose children to develop anxiety disorders (Shevlin et al.,  2007 ). Most children are vulnerable to fears and uncertainties as a normal part of growing up, and children can get generalized panic disorder just as adults do. Children with anxiety disorders, however, are more extreme in their behavior than those experiencing “normal” anxiety. These children appear to share many of the following characteristics: oversensitivity, unrealistic fears, shyness and timidity, pervasive feelings of inadequacy, sleep disturbances, and fear of school (Goodyer,  2000 ). Children diagnosed as suffering from an anxiety disorder typically attempt to cope with their fears by becoming overly dependent on others for support and help. In the DSM-5, anxiety disorders of childhood and adolescence are classified similarly to anxiety disorders in adults (Albano et al.,  1996 ). Research has shown that anxiety disorders are often comorbid with depressive disorders (Kendall et al.,  2010 ; O’Neil et al.,  2010 ) or may be influential in later depression (Silberg et al.,  2001 ); children who have these comorbid conditions often have significantly more symptoms than children who have anxiety disorders without depression (Masi et al.,  2000 ).

Anxiety disorders are common among children. In a recent review of the epidemiological studies of anxiety in children, Pine and Klein ( 2010 ) conclude that the prevalence for any anxiety disorder accompanied by impairment appears to be about 5 to 10 percent. For example, 9.7 percent of children in one community-based school sample clearly met diagnostic criteria for an anxiety-based disorder (Dadds et al.,  1997 ). There is a greater preponderance of anxiety-based disorder in girls than in boys (Lewinsohn et al., 1998). And, among adolescents, Goodwin and Gotlib ( 2004b ) reported that panic attacks occurred in 3.3 percent of a large community-based epidemiological study.

SEPARATION ANXIETY DISORDER

Separation anxiety disorder , classified under Anxiety Disorders in DSM-5, is the most common of the childhood anxiety disorders, reportedly occurring in 2 to 41 percent of children in past population health studies (Cartwright-Hatton et al.,  2006 ). Children with separation anxiety disorder exhibit unrealistic fears, oversensitivity, self-consciousness, nightmares, and chronic anxiety. They lack self-confidence, are apprehensive in new situations, and tend to be immature for their age. Such children are described by their parents as shy, sensitive, nervous, submissive, easily discouraged, worried, and frequently moved to tears. Typically, they are overly dependent, particularly on their parents. The essential feature in the clinical picture of this disorder is excessive anxiety about separation from major attachment figures, such as their mother, and from familiar home surroundings (Bernstein & Layne,  2006 ). In many cases, a clear psychosocial stressor can be identified, such as the death of a relative or a pet. The case study below illustrates the clinical picture in this disorder.

DSM-5 criteria for: Separation Anxiety Disorder

·  A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following:

·  1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures.

·  2. Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death.

·  3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure.

·  4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation.

·  5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings.

·  6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure.

·  7. Repeated nightmares involving the theme of separation.

·  8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.

·  B. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults.

·  C. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning.

·  D. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

Johnny’s Severe Separation Anxiety Johnny was a highly sensitive 6-year-old who suffered from numerous fears, nightmares, and chronic anxiety. He was terrified of being separated from his mother, even for a brief period. When his mother tried to enroll him in kindergarten, he became so upset when she left the room that the principal arranged for her to remain in the classroom. After 2 weeks, however, this arrangement had to be discontinued, and Johnny had to be withdrawn from kindergarten because his mother could not leave him even for a few minutes. Later, when his mother attempted to enroll him in the first grade, Johnny manifested the same intense anxiety and unwillingness to be separated from her. At the suggestion of the school counselor, Johnny’s mother brought him to a community clinic for assistance with the problem. The therapist who initially saw Johnny and his mother was wearing a white clinic jacket, which led to a severe panic reaction on Johnny’s part. His mother had to hold him to keep him from running away, and he did not settle down until the therapist removed his jacket. Johnny’s mother explained that he was terrified of doctors and that it was almost impossible to get him to a physician even when he was sick.

When children with separation anxiety disorder are actually separated from their attachment figures, they typically become preoccupied with morbid fears, such as the worry that their parents are going to become ill or die.

When children with separation anxiety disorder are actually separated from their attachment figures, they typically become preoccupied with morbid fears, such as the worry that their parents are going to become ill or die. They cling helplessly to adults, have difficulty sleeping, and become intensely demanding. Separation anxiety is more common in girls (Bernstein & Layne,  2006 ), and the disorder is not very stable over time (Poulton et al.,  2001 ). One study, for example, reported that 44 percent of youngsters showed recovery at a 4-year follow-up (Cantwell & Baker,  1989 ). However, some children go on to exhibit school refusal problems (a fear of leaving home and parents to attend school) and continue to have subsequent adjustment difficulties. A disproportionate number of children with separation anxiety disorder also experience a high number of other anxiety-based disorders such as phobia and obsessive-compulsive disorder (Egger et al.,  2003 ; Kearney et al.,  2003 ).

CAUSAL FACTORS IN ANXIETY DISORDERS

A number of causal factors have been emphasized in explanations of the childhood anxiety disorders. Although genetic factors have been thought to contribute to the development of anxiety disorders, particularly obsessive-compulsive disorder, in children (Nestadt et al.,  2010 ), social and cultural factors are likely to be influential in resulting in anxiety disorders in children. For example, Potochnick and Perreira ( 2010 ) found an increased risk of anxiety and depression among immigrant Latino youth. Parental behavior and family stress in minority families have been particularly noted as potential influential factors in the origin of anxiety disorders in children; however, broader cultural factors are also important considerations.

Anxious children often manifest an unusual constitutional sensitivity that makes them easily conditionable by aversive stimuli. For example, they may be readily upset by even small disappointments—a lost toy or an encounter with an overeager dog. They then have a harder time calming down, a fact that can result in a build-up and generalization of surplus fear reactions.

The child can become anxious because of early illnesses, accidents, or losses that involved pain and discomfort. The traumatic effect of experiences such as hospitalizations makes such children feel insecure and inadequate. The traumatic nature of certain life changes such as moving away from friends and into a new situation can also have an intensely negative effect on a child’s adjustment.

Overanxious children often have the modeling effect of an overanxious and protective parent who sensitizes a child to the dangers and threats of the outside world. Often, the parent’s overprotectiveness communicates a lack of confidence in the child’s ability to cope, thus reinforcing the child’s feelings of inadequacy (Woodruff-Borden et al.,  2002 ).

Indifferent or detached parents (Chartier et al.,  2001 ) or rejecting parents (Hudson & Rapee,  2001 ) also foster anxiety in their children. The child may not feel adequately supported in mastering essential competencies and in gaining a positive self-concept. Repeated experiences of failure stemming from poor learning skills may lead to subsequent patterns of anxiety or withdrawal in the face of “threatening” situations. Other children may perform adequately but may be overcritical of themselves and feel intensely anxious and devalued when they perceive themselves as failing to do well enough to earn their parents’ love and respect.

The role that social-environmental factors might play in the development of anxiety-based disorders, though important, is not clearly understood. A cross-cultural study of fears (Ollendick et al.,  1996 ) found significant differences among American, Australian, Nigerian, and Chinese children and adolescents. These authors suggest that cultures that favor inhibition, compliance, and obedience appear to increase the levels of fear reported. In another study in the United States, Last and Perrin ( 1993 ) reported that there are some differences between African American and white children with respect to types of anxiety disorders. White children are more likely to present with school refusal than are African American children, who show more PTSD symptoms. This difference might result from differing patterns of referral for African American and white families, or it might reflect differing environmental stressors placed on the children. Several studies have also reported a strong association between exposure to violence and a reduced sense of security and psychological well-being (Cooley-Quille et al.,  2001 ). Children who experience a sense of diminished control over negative environmental factors may become more vulnerable to the development of anxiety than those children who achieve a sense of efficacy in managing stressful circumstances.

TREATMENTS AND OUTCOMES

The anxiety disorders of childhood occasionally continue into adolescence and young adulthood, leading first to maladaptive avoidance behavior and later to increasingly idiosyncratic thinking and behavior or an inability to “fit in” with a peer group. Typically, however, this is not the case. As affected children grow and have wider interactions in school and in activities with peers, they often benefit from experiences such as making friends and succeeding at given tasks. Teachers who are aware of the needs of both overanxious and shy, withdrawn children are often able to ensure that they will have successful experiences that help alleviate their anxiety.

Biologically Based Treatments Psychopharmacological treatment of anxiety disorders in children and adolescents is becoming more common today (Vitiello & Waslick,  2010 ). Birmaher and colleagues ( 2003 ) evaluated the efficacy of using fluoxetine in the treatment of a variety of anxiety-based disorders and found the medication useful. However, the cautious use of medications with anxiety-based disorders involves obtaining diagnostic clarity since these conditions often coexist with other disorders.

Psychological Treatment Behavior therapy procedures, sometimes used in school settings, often help anxious children (Mash & Barkley,  2006 ). Such procedures include assertiveness training to provide help with mastering essential competencies and desensitization to reduce anxious behavior. Kendall and colleagues have reported the successful use of manual-based cognitive-behavioral treatment (well-defined procedures using positive reinforcement to enhance coping strategies to deal with fears) for children with anxiety disorders (Chu & Kendall,  2004 ). Behavioral treatment approaches such as desensitization must be explicitly tailored to a child’s particular problem, and in vivo methods (using real-life situations graded in terms of the anxiety they arouse) tend to be more effective than having the child “imagine” situations. Svensson, Larsson, and Oest ( 2002 ) reported successful treatment of phobic children using brief exposure.

Cognitive behavioral therapy has been shown to be highly effective at reducing anxiety symptoms in young children (Legerstee et al.,  2010 ; Hirshfeld-Becker et al.,  2010 ). An interesting and effective cognitive-behavioral anxiety prevention and treatment study was implemented in Australia. In an effort to identify and reduce anxiousness in young adolescents, Dadds and colleagues ( 1997 ) identified 314 children who met the criteria for an anxiety disorder out of a sample of 1,786 children 7 to 14 years old in a school system in Brisbane, Australia. They contacted the parents of these anxious children to engage them in the treatment intervention, and the parents of 128 of the children agreed to participate. The treatment intervention involved holding group sessions with the children in which they were taught to recognize their anxious feelings and deal with them more effectively than they otherwise would have. In addition, the parents were taught behavioral management procedures to deal more effectively with their child’s behavior. Six months after therapy was completed, significant anxiety reduction was shown for the treatment group compared with an untreated control sample.

Childhood Depression and Bipolar Disorder

Childhood depression includes behaviors such as withdrawal, crying, avoidance of eye contact, physical complaints, poor appetite, and even aggressive behavior and in some cases suicide (Pfeffer,  1996a ,  1996b ). One epidemiological study (Cohen et al.,  1998 ) reported an association between somatic illness and childhood depressive illness, suggesting that there may be some common etiologic factors.

In the past, childhood depression has been classified according to essentially the same DSM diagnostic criteria used for adults. However, research on the neurobiological correlates and treatment responses of children, adolescents, and adults has shown clear differences in hormonal levels and in the response to treatment (Kaufman et al.,  2001 ). Gaffrey and colleagues ( 2011 ) recently reported an fMRI study indicating that depressed preschoolers exhibit a significant positive relationship between depression severity and right amygdala activity when viewing facial expressions of negative affect.

Childhood depression includes behaviors such as withdrawal, crying, avoiding eye contact, physical complaints, poor appetite, and in some extreme cases, aggressive behavior and suicide.

Future neuroimaging studies are needed to explore these differences further. One modification used for diagnosing depression in children is that irritability is often found as a major symptom and can be substituted for depressed mood, as seen in the following case.

The Unhappy Child Joey is a 10-year-old boy whose mother and teacher have shared their concerns about his irritability and temper tantrums displayed both at home and at school. With little provocation, he bursts into tears and yells and throws objects. In class he seems to have difficulty concentrating and seems easily distracted. Increasingly shunned by his peers, he plays by himself at recess, and at home he spends most of his time in his room watching TV. His mother notes that he has been sleeping poorly and has gained 10 pounds over the past couple of months from constant snacking. A consultation with the school psychologist has ruled out learning disabilities and attention-deficit disorder; instead, she says, he is a deeply unhappy child who expresses feelings of worthlessness and hopelessness—and even a wish that he would die. These experiences probably began about 6 months ago when his father, divorced from Joey’s mother for several years, remarried and moved to another town, with the result that he spends far less time with Joey.

Source: Adapted from Hammen & Rudolph,  1996 , pp. 153–54.

Depression in children and adolescents occurs with high frequency. The overall prevalence rates are as follows: under age 13, 2.8 percent; ages 13 to 18, 5.6 percent (girls, 5.9 percent; boys, 4.6 percent). These rates have been generally consistent over the past 30 years (Costello et al.,  2006 ). Lewinsohn and colleagues ( 1993 ) report that 7.1 percent of the adolescents surveyed reported having attempted suicide in the past; in another epidemiological study, Lewinsohn, Rohde, and Seeley ( 1994 ) point out that 1.7 percent of adolescents between 14 and 18 had made a suicide attempt.

There is an increased use of bipolar diagnosis among children and adolescents in the United States (see Developments in Research, p. 523). Moreno and colleagues ( 2007 ) reported that the estimated annual number of youth office-based visits with a diagnosis of bipolar disorder increased from 25 (1994–1995) to 1,003 (2002–2003) visits per 100,000 population, as did adult visits, with the majority of visits by males (66.5). A high percentage of these adolescents received a comorbid diagnosis, frequently ADHD.

CAUSAL FACTORS IN CHILDHOOD DEPRESSION

The causal factors implicated in the childhood anxiety disorders are pertinent to the depressive disorders as well.

Biological Factors There appears to be an association between parental depression and behavioral and mood problems in children (Halligan et al.,  2007 ; Hammen et al.,  2004 ). Children of parents with major depression are more impaired, receive more psychological treatment, and have more psychological diagnoses than children of parents with no psychological disorders (Kramer et al.,  1998 ). This is particularly the case when the parent’s depression affects the child through less-than-optimal interactions (Carter et al.,  2001 ). A controlled study of family history and onset of depression found that children from mood-disordered families had significantly higher rates of depression than those from nondisordered families (Kovacs et al.,  1997 ). The suicide attempt rate has also been shown to be higher for children of depressed parents (7.8 percent) than for the offspring of control parents (Weissman et al.,  1992 ).

Other biological factors might also make children vulnerable to psychological problems like depression. These factors include biological changes in the neonate as a result of alcohol intake by the mother during pregnancy, as prenatal exposure to alcohol is related to depression in children. M. J. O’Connor’s ( 2001 ) study of children exposed to alcohol in utero reveals a continuity between alcohol use by the mother and infant negative affect and early childhood depression symptoms. (See Developments in Research, p. 373 for a discussion of fetal alcohol syndrome.)

Learning Factors Learning maladaptive behaviors appears to be important in childhood depressive disorders, and there are likely to be learning or cultural factors in the expression of depression. Stewart, Kennard and colleagues ( 2004 ) reported that depression symptoms and hopelessness are higher in Hong Kong than in the United States. In addition, a number of studies have indicated that children’s exposure to early traumatic events can increase their risk for the development of depression. Children who have experienced past stressful events are susceptible to states of depression that make them vulnerable to suicidal thinking under stress (Silberg et al.,  1999 ). Intense or persistent sensitization of the central nervous system in response to severe stress might induce hyperreactivity and alteration of the neurotransmitter system, leaving these children vulnerable to later depression (Heim & Nemeroff,  2001 ). A recent study by Olino and colleagues ( 2010 ) found that temperamental emotionality was associated with having a depressed parent. Children who are exposed to negative parental behavior or negative emotional states may develop depressed affect themselves (Herman-Stahl & Peterson,  1999 ). For example, childhood depression has been found to be more common in divorced families (Palosaari & Laippala,  1996 ).

Mothers who are depressed may transmit their depression to their children by their lack of responsiveness to the children as a result of their own depression (Bagner et al.,  2010 ). Unfortunately, depression among mothers is all too common. Exhaustion, marital distress as a result of the arrival of children in a couple’s lives, delivery complications, and the difficulties of particular babies may all play a part.

One important area of research is focusing on the role of the mother–child interaction in the transmission of depressed affect. Specifically, investigators have been evaluating the possibility that mothers who are depressed transfer their low mood to their infants through their interactions with them (Jackson & Huang,  2000 ). Depression among mothers is not uncommon and can result from several sources, such as financial or marital problems. One study found that parenting problems and depressed mood in mothers are associated with depression in children (Oldehinkel et al.,  2007 ).

Depressed mothers do not respond effectively to their children (Goldsmith & Rogoff,  1997 ), and they tend to be less sensitively attuned to, and more negative toward, their infants than nondepressed mothers. Other research has shown that negative (depressed) affect and constricted mood on the part of a mother, which shows up as unresponsive facial expressions and irritable behavior, can produce similar responses in her infant (Tronick & Cohn,  1989 ). Interestingly, the negative impact of depressed mothers’ interaction style has also been studied at the physiological level. Infants have been reported to exhibit greater frontal brain electrical activity during the expression of negative emotionality by their mothers (Dawson et al.,  1997 ). Although many of these studies have implicated the mother–child relationship in development of the disorder, depression in fathers has also been related to depression in children (Jacob & Johnson,  2001 ).

developments in RESEARCH: Bipolar Disorder in Children and Adolescents: Is There an Epidemic?

Bipolar disorder is often characterized by extreme mood swings and aggressive, irritable behavior (Braaten,  2011 ). Until recent years it was thought to largely be a disorder occurring in adulthood. But in the late 1990s, many psychiatrists began applying the diagnosis to children and adolescents and prescribing bipolar medication for their treatment (see Geller & DelBello,  2008 ). In DSM-5, the diagnosis of childhood depression has been modified as a means of preventing the over-diagnosis of bipolar disorder in children. A new diagnosis, disruptive mood regulation disorder, has been included for children at or under age 18 who exhibit persistent irritability and frequent of lack behavioral control. Bipolar disorder is often comorbid with other disorders such as ADHD (Klassen et al.,  2010 ). Is there an epidemic of depression and bipolar disorder among children and adolescents?

As described in  Chapter 7 , bipolar disorders differ from uni-polar mood disorders by the presence of manic or hypomanic symptoms. A person who experiences a manic episode has a markedly elevated, euphoric, and expansive mood that is often interrupted by occasional outbursts of intense irritability or even violence. In order to meet DSM-5 diagnostic criteria, these extreme moods must persist for at least a week. In addition, three or more additional symptoms must occur in the same time period. There must also be significant impairment of life or social functioning. Hospitalization is often necessary during manic episodes. In about two-thirds of cases, the manic episodes either immediately precede or immediately follow a depressive episode; in other cases, the manic and depressive episodes are separated by intervals of relatively normal functioning. Bipolar disorder occurs equally in males and females and usually starts in adolescence and young adulthood. The likelihood of a full recovery from bipolar disorder is low even with the use of mood-stabilizing medications such as lithium because bipolar disorder is typically a recurrent condition that continues into adulthood.

The DSM-5 provides criteria to define bipolar disorder in children that are based on how the disorder typically appears in adults; however, there is not a specific childhood or adolescent bipolar condition in the present DSM manual. The diagnostic criteria for bipolar disorder have not changed over the past decade (McClellan et al.,  2007 ), even though there is an increased use of the diagnosis among children and adolescents in the United States, as noted by recent news media reports (Carey,  2007 ) as well as recent research surveys.

The question of overdiagnosis of bipolar disorder in children has emerged, in part, because of the increased use of antidepressant prescriptions for children and adolescents. For example, Harris ( 2005 ) points out that during a recent 3-month period in the child assessment unit at Cambridge Hospital in Massachusetts, a quarter of the children ages 3 to 13 years who were in her care had been given a diagnosis of bipolar disorder by their outpatient clinicians and were receiving mood stabilizers or antipsychotics. Another quarter were believed to have bipolar disorder by their parents, who requested that appropriate medications be started. A number of authorities, however, have questioned the extreme increase in the use of bipolar diagnoses for children and adolescents and the more extensive use of medications for treating bipolar disorder among young people.

Does the increased rate of bipolar diagnosis for young people result from changes in practice in which clinicians are using the diagnosis more? Or, are younger people acquiring the disorder more commonly? Or, are practitioners now recognizing more patients with the disorder that they had “missed” in the past? Many experts theorize that the increase reflects the fact that doctors are more aggressively applying the diagnosis to children, not an indication that the incidence of the disorder has increased. Blader and Carlson ( 2007 ) point out that the growth in the rate of bipolar disorder–diagnosed discharges might reflect a “progressive rebranding” of the same clinical phenomena for which hospitalized children previously received different diagnoses such as ADHD. Basing their conclusions on data from the National Hospital Discharge Survey, Blader and Carlson reported that the rate of bipolar diagnoses jumped from 10.0 percent to 34.1 percent for all pediatric psychiatric discharges during the study period, and it rose from 10.2 percent to 25.9 percent in adolescents. They concluded that the rate for discharge diagnosis of bipolar disorder in children has increased by 25 percent annually.

The reported increase in depression and bipolar disorder among children and adolescents has, however, been questioned by some studies. For example, using published rates of admission in epidemiological research in the United Kingdom, Costello, Erkanli, and Angold ( 2006 ) report different results. They conducted a meta-analysis of 26 epidemiological studies on children born between 1965 and 1996 that included nearly 60,000 interviews that allowed for a diagnosis of depression and concluded that there is not an increased prevalence of adolescent depression over the past 30 years.

Several authorities have advised caution in the use of bipolar diagnoses in children and adolescents. Harris ( 2005 ) points out that child and adolescent psychiatrists must demand tighter criteria and higher quality of evidence in regard to juvenile bipolar disorder in order to ensure diagnostic accuracy and also integrate these criteria into case formulations that lead to an effective treatment plan. One concern resulting from possible inaccurate diagnoses of bipolar disorder is that psychiatrists might overprescribe medications used in the treatment of bipolar disorder (NIMH,  2007 ).

Considerable evidence has accumulated that depressive symptoms are positively correlated with the tendency to attribute positive events to external, specific, and unstable causes and negative events to internal, global, and stable causes (Klein et al.,  2008 ); with fatalistic thinking (Roberts et al.,  2000 ); and with feelings of helplessness (Kistner et al.,  2001 ). For example, the child may respond to peer rejection or teasing by concluding that he or she has some internal flaw.

TREATMENTS AND OUTCOMES

The view that childhood and adolescent depression is like adult depression has prompted researchers to treat children displaying mood disorders—particularly adolescents who are viewed as suicidal (Greenhill & Waslick,  1997 )—with medications that have worked with adults. Research on the effectiveness of antidepressant medications with children is both limited (Emslie & Mayes,  2001 ) and contradictory at best, and some studies have found antidepressants to be only moderately helpful (Wagner & Ambrosini,  2001 ). Some studies using fluoxetine (Prozac) with depressed adolescents have shown the drug to be more effective than a placebo (DeVane & Sallee,  1996 ; Emslie et al.,  1997 ), and other research has shown fluoxetine to be effective in the treatment of depression when administered as part of cognitive-behavioral therapy (Treatment for Adolescents with Depression Study [TADS] Team, U.S.,  2004 ), although complete remission of symptoms was seldom obtained. Anti-depressant medications may also have some undesirable side effects (nausea, headaches, nervousness, insomnia, and even seizures) in children and adolescents. Four accidental deaths from a drug called desipramine have been reported (Campbell & Cueva,  1995 ).

Emslie, Croarkin, and Mayes ( 2010 ) recently pointed out that antidepressants are among the most widely used drugs in treating children and adolescents for a variety of disorders, with significant increases over the past 20 years. Primarily, antidepressants are used for the same disorders as in adults (i.e., depression, anxiety).

Depressed mood has come to be viewed as an important risk factor in suicide among children and adolescents. About 7 to 10 percent of adolescents report having made at least one suicide attempt (Safer,  1997b ). Children who attempt suicide are at greater risk for subsequent suicidal episodes than are non-attempters, particularly within the first 2 years after their initial attempt (Pfeffer et al.,  1994 ), and some research has suggested that antidepressant medication treatment in children and adolescents is associated with an increased risk of suicide (Olfson et al.,  2006 ). Among the childhood disorders, depression especially merits aggressive treatment. Recent attention is being paid to the increased potential of suicidal ideation and behavior in children and adolescents who are taking SSRIs for their depression (Whittington et al.,  2004 ), and some risk of suicide for those taking the medication has been noted (Couzin,  2004 ). The extent to which these medications represent an additional threat of suicide is being investigated.

An important facet of psychological therapy with children, whether for depression or anxiety or other disorders, is providing a supportive emotional environment in which they can learn more adaptive coping strategies and more effective emotional expression (see Gillham et al.,  2006 ). Older children and adolescents often benefit from a positive therapeutic relationship in which they can discuss their feelings openly (Harvey & Taylor,  2010 ). Younger children and those with less developed verbal skills may benefit from play therapy. Play therapy has been found to be an effective psychological treatment with children (Schaefer,  2010 ; Steele et al.,  2007 ), particularly using a developmentally appropriate and skill-based approach (Reddy & Atamanoff,  2006 ). As a treatment technique, play therapy emerged out of efforts to apply psychodynamic therapy to children. Through their play, children often express their feelings, fears, and emotions in a direct and uncensored fashion, providing a clinician with a clearer picture of problems and feelings (Perry & Landreth,  2001 ). Research has shown that play therapy is as effective as other types of treatment such as behavior therapy at engaging children in expressing problems. In one study, in which play therapy was integrated into an 8-week intervention program to treat children with conduct disorder, the subjects showed significant gains at a 2-year follow-up (McDonald et al.,  1997 ).

The predominant approach for treating depression in children and adolescents over the past few years has been the combined use of medication and psychotherapy (Skaer et al.,  2000 ). Controlled studies of psychological treatment with depressed adolescents have shown significantly reduced symptoms with cognitive-behavioral therapy (Horowitz et al.,  2007 ; Mash & Barkley,  2006 ). Short-term residential treatment can also be effective with depressed children (Leichtman,  2006 ). A recent longitudinal follow-up study of adolescents who had been treated for depression showed that effective treatment can reduce the recurrence of depression (Beevers et al.,  2007 ).

in review

·  • How do the symptoms of childhood depression compare to those seen in adult depression?

·  • Describe the symptoms of ADHD.

·  • Identify four common symptom disorders that can arise in childhood.

Elimination Disorders (Enuresis, Encopresis), Sleepwalking, and Tics

The childhood disorders we will deal with in this section—“elimination disorders” (enuresis and encopresis), sleepwalking, and tics—typically involve a single outstanding symptom rather than a pervasive maladaptive pattern. These disorders are essentially the same in DSM-5 as in DM-IV-TR.

Enuresis

The term  enuresis  refers to the habitual involuntary discharge of urine, usually at night, after the age of expected continence (age 5). In DSM-5, functional enuresis is described as bed-wetting that is not organically caused and classified under elimination disorders. Children who have primary functional enuresis have never been continent; children who have secondary functional enuresis have been continent for at least a year but have regressed.

Enuresis may vary in frequency, from nightly occurrence to occasional instances when a child is under considerable stress or is unduly tired. It has been estimated that some 4 to 5 million children and adolescents in the United States suffer from the inconvenience and embarrassment of this disorder. Estimates of the prevalence of enuresis reported in DSM IV are 5 to 10 percent among 5-year-olds, 3 to 5 percent among 10-year-olds, and 1.1 percent among children age 15 or older. An epidemiological study in China reported a 4.3 percent prevalence, with a significantly higher percentage of boys than girls (Liu et al.,  2000 ).

Enuresis may result from a variety of organic conditions, such as disturbed cerebral control of the bladder (Goin,  1998 ), neurological dysfunction, other medical factors such as medication side effects (Took & Buck,  1996 ), or having a small functional bladder capacity and a weak urethral sphincter (Dahl,  1992 ). One group of researchers reported that 11 percent of their enuretic patients had disorders of the urinary tract (Watanabe et al.,  1994 ). However, most investigators have pointed to a number of other possible causal factors: (1) faulty learning, resulting in the failure to acquire inhibition of reflexive bladder emptying; (2) personal immaturity, associated with or stemming from emotional problems; (3) disturbed family interactions, particularly those that lead to sustained anxiety, hostility, or both; and (4) stressful events (Haug Schnabel,  1992 ). For example, a child may regress to bed-wetting when a new baby enters the family and becomes the center of attention.

Medical treatment of enuresis typically centers on using medications such as the antidepressant drug imipramine. The mechanism underlying the action of the drug is unclear, but it may simply lessen the deepest stages of sleep to light sleep, enabling the child to recognize bodily needs more effectively (Dahl,  1992 ). An intranasal desmopressin (DDAVP) has also been used to help children manage urine more effectively (Rahm et al.,  2010 ). This medication, a hormone replacement, apparently increases urine concentration, decreases urine volume, and therefore reduces the need to urinate. The use of this medication to treat enuretic children is no panacea, however. Disadvantages of its use include its high cost and the fact that it is effective only with a small subset of enuretic children, and then only temporarily. Bath and colleagues ( 1996 ) reported that treatment with desmopressin was disappointing but conclude that this treatment has some utility as a way to enable children to stay dry for brief periods of time—for example, at a camp or on a holiday. Moffatt ( 1997 ) suggested that DDAVP has an important place in treating nocturnal enuresis in youngsters who have not responded well to behavioral treatment methods. It is good to remember that medications by themselves do not cure enuresis and that there is frequent relapse when the drug is discontinued or the child habituates to the medication (Dahl,  1992 ).

When combined with medication such as desmopressin, a urine alarm (shown here) can be very effective in treating enuresis. The child sleeps with a wetness detector, which is wired to a battery-operated alarm in his or her undergarment. Through conditioning, the child comes to associate bladder tension with awakening.

Conditioning procedures have proved to be highly effective treatment for enuresis (Friman et al.,  2008 ). Mowrer and Mowrer ( 1938 ), in their classic research that is still relevant today, introduced a procedure in which a child sleeps on a pad that is wired to a battery-operated bell. At the first few drops of urine, the bell is set off, thus awakening the child. Through conditioning, the child comes to associate bladder tension with awakening. Some evidence suggests that a biobehavioral approach—that is, using the urine alarm along with desmopressin—is most effective (Mellon & McGrath,  2000 ).

With or without treatment, the incidence of enuresis tends to decrease significantly with age, but many experts still believe that enuresis should be treated in childhood because there is presently no way to identify which children will remain enuretic into adulthood (Goin,  1998 ). In an evaluation of research on the treatment of bed-wetting, Houts, Berman, and Abramson ( 1994 ) concluded that treated children are more improved at follow-up than nontreated children. They also found that learning-based procedures are more effective than medications.

Encopresis

The term  encopresis  describes a symptom disorder of children who have not learned appropriate toileting for bowel movements after age 4. This condition, classified under elimination disorders, in DSM-5, is less common than enuresis; however, DSM-based estimates are that about 1 percent of 5-year-olds have encopresis. A study of 102 cases of encopretic children yielded the following list of characteristics: The average age of children with encopresis was 7, with a range of ages 4 to 13. About one-third of encopretic children were also enuretic, and a large sex difference was found, with about six times more boys than girls in the sample. Many of the children soiled their clothing when they were under stress. A common time was in the late afternoon after school; few children actually had this problem at school. Most of the children reported that they did not know when they needed to have a bowel movement or were too shy to use the bathrooms at school.

Many encopretic children suffer from constipation, so an important element in the diagnosis is a physical examination to determine whether physiological factors are contributing to the disorder. The treatment of encopresis usually involves both medical and psychological aspects. Several studies of the use of conditioning procedures with encopretic children have reported moderate treatment success; that is, no additional incidents occurred within 6 months following treatment (Friman et al.,  2008 ). However, research has shown that a minority of children (11 to 20 percent) do not respond to learning-based treatment approaches (Keeley et al.,  2009 ).

Sleepwalking

The onset of  sleepwalking disorder  is usually between the ages of 6 and 12. The disorder is classified in parasomnias in DSM-5. The symptoms of sleepwalking disorder involve repeated episodes in which a person leaves his or her bed and walks around without being conscious of the experience or remembering it later.

The incidence of sleepwalking reported for children in the DSM is high for one episode—between 10 and 30 percent is relatively common—and girls are more likely to experience sleepwalking than boys (Mahendran et al.,  2006 ). The incidence for repeated episodes is usually low—from 1 to 5 percent. Children subject to this problem usually go to sleep in a normal manner but arise during the second or third hour of sleep. They may walk to another room of the house or even outside, and they may engage in complex activities. Finally, they return to bed and in the morning remember nothing that had taken place. While moving about, sleepwalkers’ eyes are partially or fully open; they avoid obstacles, listen when spoken to, and ordinarily respond to commands, such as to return to bed. Shaking them will usually awaken sleepwalkers, and they will be surprised and perplexed at finding themselves in an unexpected place. Sleepwalking takes place during NREM (non–rapid eye movement) sleep, and sleepwalking episodes usually last only a few minutes (Plazzi et al.,  2005 ). The causes of sleepwalking—a condition of arousal in which the subject arises from deep sleep, even displaying long, complex behavior including leaving the bed and walking, with memory impairment of the event—are not fully understood.

Little attention has been devoted to the treatment of sleepwalking. Clement ( 1970 ), however, reported on the treatment of a 7-year-old boy through behavior therapy. During treatment, the therapist learned that just before each sleepwalking episode, the boy had a nightmare about being chased by “a big black bug.” After his nightmare began, he perspired freely, moaned and talked in his sleep, tossed and turned, and finally got up and walked through the house. He did not remember the sleepwalking episode when he awoke the next morning. Assessment data revealed no neurological or other medical problems and indicated that he was of normal intelligence. He was, however, found to be a very anxious, guilt-ridden little boy who avoided performing assertive and aggressive behaviors appropriate to his age and sex (p. 23). The therapist focused treatment on having the boy’s mother awaken him each time he showed signs of an impending episode. After washing his face with cold water and making sure he was fully awake, the mother would return him to bed, where he was to hit and tear up a picture of the big black bug. (At the start of the treatment program, he had made several of these drawings.)

Eventually, the nightmare was associated with awakening, and he learned to wake up on most occasions when he was having a bad dream. Thus the basic behavior therapy followed in this case was the same as that used in the conditioning treatment for enuresis, where a waking response is elicited by an intense stimulus just as urination is beginning and becomes associated with, and eventually prevents, nocturnal bed-wetting.

Tic Disorders

A  tic  is a persistent, intermittent muscle twitch or spasm, usually limited to a localized muscle group. The term is used broadly to include blinking the eye, twitching the mouth, licking the lips, shrugging the shoulders, twisting the neck, clearing the throat, blowing the nose, and grimacing, among other actions. Tic disorders are classified under motor disorders in DSM-5. Tics occur most frequently between the ages of 2 and 14 (Evans et al.,  1996 ). In some instances, as in clearing the throat, an individual may be aware of the tic when it occurs, but usually he or she performs the act habitually and does not notice it. In fact, many individuals do not even realize they have a tic unless someone brings it to their attention. A cross-cultural examination of tics found a similar pattern in research and clinical case reports from other countries (Staley et al.,  1997 ). Moreover, the age of onset (average 7 to 8 years) and predominant gender (male) of cases were reported to be similar across cultures (Turan & Senol,  2000 ). A recent study on the prevalence of tic disorder in children and adolescents conducted by Stefanoff and colleagues ( 2008 ) reported that tic disorders are common among school-children. They found that the lifetime prevalence of tic disorders (TD) is 2.6 percent for transient tic disorder (TTD), 3.7 percent for chronic tic disorder (CTD), and 0.6 percent for Tourette disorder (TD).

The psychological impact that tics can have on an adolescent is illustrated in the following case.

The Adolescent Who Wanted to Be a Teacher An adolescent who had wanted very much to be a teacher told the school counselor that he was thinking of giving up his plans. When asked why, he explained that several friends had told him that he had a persistent twitching of the mouth muscles when he answered questions in class. He had been unaware of this muscle twitch and, even after being told about it, could not tell when it took place. However, he became acutely self-conscious and was reluctant to answer questions or enter into class discussions. As a result, his general level of tension increased, and so did the frequency of the tic, which now became apparent even when he was talking to his friends. Thus a vicious circle had been established. Fortunately, the tic proved amenable to treatment by conditioning and assertiveness training.

Tourette’s disorder , classified as a motor disorder in DSM-5, is an extreme tic disorder involving multiple motor and vocal patterns. This disorder typically involves uncontrollable head movements with accompanying sounds such as grunts, clicks, yelps, sniffs, or words. Some, possibly most, tics are preceded by an urge or sensation that seems to be relieved by execution of the tic. Tics are thus often difficult to differentiate from compulsions, and they are sometimes referred to as “compulsive tics” (Jankovic,  1997 ). An epidemiological study in Sweden reported the prevalence of Tourette’s disorder in children and adolescents to be about 0.56 percent (Khalifa & von Knorring,  2004 ). About one-third of individuals with Tourette’s disorder manifest coprolalia, which is a complex vocal tic that involves the uttering of obscenities. Some people with Tourette’s disorder also experience explosive outbursts (Budman et al.,  2000 ). The average age of onset for Tourette’s disorder is 7, and most cases have an onset before age 14. The disorder frequently persists into adulthood, and it is about three times more frequent among males than among females. Although the exact cause of Tourette’s disorder is undetermined, evidence suggests an organic basis (Margolis et al.,  2006 ). There are many types of tics, and many of them appear to be associated with the presence of other psychological disorders (Cardona et al.,  1997 ), particularly obsessive-compulsive disorder (OCD). Most tics, however, do not have an organic basis but stem from psychological causes such as self-consciousness or tension in social situations, and they are usually associated with severe behavioral problems (Rosenberg et al.,  1995 ). As in the case of the adolescent boy previously described, an individual’s awareness of the tic often increases tension and the occurrence of the tic.

Among medications, neuroleptics are the most predictably effective tic-suppressing drugs (Kurlan,  1997 ). Clonazepam, clonidine, and tiapride have all shown effectiveness in reducing motor tics; however, tiapride has shown the greatest decrease in the intensity and frequency of tics (Drtikova et al.,  1996 ). Campbell and Cueva ( 1995 ) reported that both haloperidol and pimozide reduced the severity of tics by about 65 percent but that haloperidol seemed the more effective of the two medications. Gilbert and colleagues ( 2004 ) reported that risperidone outperformed pimozide in tic suppression.

Most people suffering from tic disorders do not receive treatment for their symptoms (Cook & Blacher,  2007 ); however, behavioral intervention techniques have been used successfully in treating tics (Woods & Miltenberger,  2001 ). One successful program, habit reversal treatment or HRT, involves several sequential elements, beginning with awareness training, relaxation training, and the development of incompatible responses, and then progressing to cognitive therapy and modification of the individual’s overall style of action (Chang, Piacentina, & Walkup,  2007 ). Finally, perfectionist expectations about self-image (which are often found in children and adolescents with tics) are addressed through cognitive restructuring. Because children with Tourette’s disorder can have substantial family adjustment (Wilkinson et al.,  2001 ) and school adjustment problems (Nolan & Gadow,  1997 ), interventions should be designed to aid their adjustment and to modify the reactions of peers to them. School psychologists can play an effective part in the social adjustment of the child with Tourette’s disorder (Walter & Carter,  1997 ) by applying behavioral intervention strategies that help arrange the child’s environment to be more accepting of such unusual behaviors.

in review

·  • What is functional enuresis? Describe a traditional and highly effective treatment for enuresis.

·  • What is encropresis? Is this condition more common among boys or girls?

·  • What is somnambulism?

Neurodevelopmental Disorders

The  neurodevelopmental disorders  are a group of severely disabling conditions that are among the most difficult to understand and treat. They make up about 3.2 percent of cases seen in inpatient settings (Sverd et al.,  1995 ). They are considered to be the result of some structural differences in the brain that are usually evident at birth or become apparent as the child begins to develop (Siegel,  1996 ). There is fairly good diagnostic agreement in the determination of neuro developmental disorders in children whether one follows the DSM-5 or the ICD-10 (the International Classification of Disease, published by the World Health Organization), which have slightly different criteria for some disorders. Several Neurodevelopmental disorders are covered in DSM-5—for example, autism spectrum disorder, one of the most severe and puzzling disorders occurring in early childhood. (See Goldstein et al.,  2009 , for a comprehensive discussion of the assessment of developmental disorders.)

Autism Spectrum Disorder

One of the most disabling of the childhood disorders is autistic disorder, which is often referred to as autism, childhood autism (Schopler et al.,  2001 ), or, in the DSM-5, autism spectrum disorder. It is a developmental disorder that involves a wide range of problematic behaviors including deficits in language and perceptual and motor development; defective reality testing; and an inability to function in social situations. The following case illustrates some of the behaviors that may be seen in a child with autism.

The Need for Routine Mathew is 5 years old. When spoken to, he turns his head away. Sometimes he mumbles unintelligibly. He is neither toilet trained nor able to feed himself. He actively resists being touched. He dislikes sounds and is uncommunicative. He cannot relate to others and avoids looking anyone in the eye. He often engages in routine manipulative activities such as dropping an object, picking it up, and dropping it again. He shows a pathological need for sameness. While seated, he often rocks back and forth in a rhythmic motion for hours. Any change in routine is highly upsetting to him.

Autism in infancy and childhood was first described by Kanner ( 1943 ). It afflicts tens of thousands of American children from all socioeconomic levels and is seemingly on the increase—estimates range between 30 and 60 people in 10,000 (Fombonne,  2005 ). A recent study by the Centers for Disease Control and Prevention (CDC,  2013 ) reported that the rate of autism among children is about 1 in 50. This reported increase in autism in recent years is likely due to methodological differences between studies and changes in diagnostic practice and public and professional awareness in recent years rather than an increase in prevalence (Williams et al.,  2005 ). Autism is usually identified before a child is 30 months of age and may be suspected in the early weeks of life. Diagnostic stability over the childhood years is quite high for autism. Lord and colleagues ( 2006 ) report that children diagnosed with autism by age 2 tend to be similarly diagnosed at age 9. One study found that autistic behavior such as lack of empathy, inattention to others, and inability to imitate is shown as early as 20 months (Charman et al.,  1997 ).

THE CLINICAL PICTURE IN AUTISTIC SPECTRUM DISORDER

Children with autism show varying degrees of impairments and capabilities. In this section, we will discuss some of the behaviors that may be evident in autism. A cardinal and typical sign is that a child seems apart or aloof from others, even in the earliest stages of life (Hillman & Snyder,  2007 ). Mothers often remember such babies as never being cuddly, never reaching out when being picked up, never smiling or looking at them while being fed, and never appearing to notice the comings and goings of other people.

DSM-5 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, not exhaustive; see text):

·  1. Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of 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.

·  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, not exhaustive; see text):

·  1. Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, 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, fixated 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).

·  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.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

A Social Deficit Typically, children with autism do not show any need for affection or contact with anyone, and they usually do not even seem to know or care who their parents are. Several studies, however, have questioned the traditional view that autistic children are emotionally flat. These studies (Capps et al.,  1993 ) have shown that children with autism do express emotions and should not be considered as lacking emotional reactions (Jones et al.,  2001 ). Instead, Sigman ( 1996 ) has characterized the seeming inability of children with autism to respond to others as a lack of social understanding—a deficit in the ability to attend to social cues from others. The child with autism is thought to have a “mind blindness,” an inability to take the attitude of others or to “see” things as others do. For example, a child with autism appears limited in the ability to understand where another person is pointing. Additionally, children with autism show deficits in attention and in locating and orienting to sounds in their environment (Hillman & Snyder,  2007 ).

The lack of social interaction among children with autism has been well described. A behavioral observation study by Lord and Magill-Evans ( 1995 ) noted that the youngsters with autism engaged in fewer social interactions than other children; however, this study also made the important observation that the children with autism did not play—particularly, did not show spontaneous play. In fact, much of the time, nothing was going on.

Encopresis is common (Siegel,  2003 ) among children with autism. Radford and Anderson ( 2003 ) point out that relatively little of the clinical descriptive literature on children with autism addresses the problem of toilet training. They note that failing to cooperate in toilet training is a common problem and one that creates added difficulty for parents of children with autism, and they provide practical advice and training guidelines for dealing with this problem behavior. In addition, a high prevalence of sleep problems has been reported for children with autism (Williams et al.,  2004 ).

An Absence of Speech Children with autism do not effectively learn by imitation (Smith & Bryson,  1994 ). This dysfunction might explain their characteristic absence or severely limited use of speech. If speech is present, it is almost never used to communicate except in the most rudimentary fashion, such as by saying “yes” in answer to a question or by the use of  echolalia —the parrot-like repetition of a few words. Whereas the echoing of parents’ verbal behavior is found to a small degree in normal children as they experiment with their ability to produce articulate speech, persistent echolalia is found in about 75 percent of autistic children (Prizant,  1983 ).

Self-Stimulation Self-stimulation is often characteristic of children with autism. It usually takes the form of such repetitive movements as head banging, spinning, and rocking, which may continue by the hour. Other bizarre repetitive behaviors are typical.

Children with autism seem to actively arrange the environment on their own terms in an effort to exclude or limit variety and intervention from other people, preferring instead a limited and solitary routine. These children often show an active aversion to auditory stimuli, crying even at the sound of a parent’s voice. The pattern is not always consistent, however; children with autism may at one moment be severely agitated or panicked by a very soft sound and at another time be totally oblivious to a loud noise.

Intellectual Ability Compared with the performance of other groups of children on cognitive or intellectual tasks, children with autism often show marked impairment. For example, children with autism are significantly impaired on memory tasks when compared with both normal children and children with intellectual disability. They show a particular deficit in representing mental states—that is, they appear to have deficits in social reasoning but can manipulate objects. Carpentieri and Morgan ( 1996 ) found that the cognitive impairment in children with autism is reflected in their greater impairment in adaptive behaviors than is seen in mentally retarded children without autism.

Some children with autism are quite skilled at fitting objects together; thus their performance on puzzles or form boards may be average or above. Even in the manipulation of objects, however, difficulty with meaning is apparent. For example, when pictures are to be arranged in an order that tells a story, children with autism show a marked deficiency in performance. Moreover, adolescents with autism, even those who are functioning well, have difficulty with symbolic tasks such as pantomime—in which they are asked to recall motor actions to imitate tasks (e.g., ironing) with imagined objects—in spite of the fact that they might perform the task well with real objects (Hillman & Snyder,  2007 ).

Maintaining Sameness Many children with autism become preoccupied with and form strong attachments to unusual objects such as rocks, light switches, or keys. In some instances, the object is so large or bizarre that merely carrying it around interferes with other activities. When their preoccupation with the object is disturbed—for example, by its removal or by attempts to substitute something in its place—or when anything familiar in the environment is altered even slightly, these children may have a violent temper tantrum or a crying spell that continues until the familiar situation is restored. Thus children with autism are often said to be “obsessed with the maintenance of sameness.” Watch the Video Xavier: Autismon MyPsychLab.

CAUSAL FACTORS IN AUTISM

The precise cause or causes of autism are unknown, although most investigators agree that a fundamental disturbance of the central nervous system is involved (Girgis et al.,  2007 ; Volker & Lopata,  2008 ). Many investigators believe that autism begins with some type of inborn defect that impairs an infant’s perceptual-cognitive function-ing—the ability to process incoming stimuli and to relate to the world. Recent MRI research suggests that abnormalities in the brain anatomy may contribute to the brain metabolic differences and behavioral phenotype in autism (McAlonan et al.,  2005 ). Whatever the physiological mechanisms or brain structures involved, evidence has accumulated that defective genes or damage from radiation or other conditions during prenatal development may play a significant role in the etiologic picture (Nicolson & Szatmari,  2003 ; Waterhouse & Fein,  1997 ). Evidence for a genetic contribution to autism comes from examining the risk for autism in the siblings of autistic children (Levy et al.,  2009 ; Mazefsky et al.,  2008 ). The best estimates are that in families with one child with autism there is a 3 to 5 percent risk of a sibling having autism as well. Although this figure may seem low in an absolute sense, it is in fact extremely high, given the frequency of autism in the population. The most extensive autism genetics research project recently reported that tiny, rare variations in genes increase the risk of autism spectrum disorder (Autism Genome Project,  2007 ). These results suggest that components of the brain’s glutamate neurotransmitter system are involved in autism. Thus, autism seemingly results from faulty wiring in the early stages of development. That is, glutamate increases neuronal activity and plays an important role in wiring the brain during early development. Smoller and colleagues (2013) recently conducted a study analyzing genetic factors in mental disorders in 33,332 cases and 27,888 controls of European ancestry. They concluded that five disorders: autism spectrum disorders, schizophrenia, ADHD, bipolar disorder, and recurrent major depressive disorder shared a genetic basis.

Nevertheless, the exact mode of genetic transmission is not yet understood, but it seems likely that relatives may also show an increased risk for other cognitive and social deficits that are milder in form than true autism (Smalley,  1991 ).

TREATMENTS AND OUTCOMES OF AUTISM

The treatment prognosis for autistic disorder is poor, and because of the severity of their problems, those diagnosed with autism are often insufficiently treated (Moldin & Rubenstein,  2006 ). Moreover, because of the typically poor response to treatment, children with autism are often subjected to a range of fads and “novel” approaches that turn out to be equally ineffective.

Medical Treatment  In the past, the use of medications to treat children with autism has not proved effective. The drugs most often used in the treatment of autism are antidepressants (21.7 percent), antipsychotic medication (16.8 percent), and stimulants (13.9 percent; Handen & Lubetsky,  2005 ); but the data on their effectiveness do not support their use unless a child’s behavior is unmanageable by other means (Sloman,  1991 ). If irritability and aggressiveness are present, the medical management of a case might involve the use of medications to lower the level of aggression (Fava,  1997 ). Although there are no sure-fire medications approved for this purpose, the drug clomipramine has had some beneficial effects (see the discussion by Erickson et al.,  2007 ). However, no currently available medication reduces the symptoms of autism enough to encourage its general use. We will thus direct our attention to a variety of psychological procedures that have been more successful in treating children with autism.

Behavioral Treatment  Behavior therapy in an institutional setting has been used successfully in the elimination of self-injurious behavior, the mastery of the fundamentals of social behavior, and the development of some language skills (Charlop-Christie et al.,  1998 ). The late Ivar Lovaas (1987), a pioneer in behavioral treatment of children with autism, reported highly positive results from a long-term experimental treatment program. The intervention developed by Lovaas and colleagues is very intensive and is usually conducted in the children’s homes rather than in a clinical setting. The children are usually immersed in a one-to-one teaching situation for most of their waking hours over several years. The intervention is based on both discrimination-training strategies (reinforcement) and contingent aversive techniques (punishment). The treatment plan typically enlists parents in the process and emphasizes teaching children to learn from and interact with “normal” peers in real-world situations. Of the treated children in the study by Lovaas and colleagues, 47 percent achieved normal intellectual functioning, and another 40 percent attained the mildly retarded level. In comparison, only 2 percent of the untreated control children achieved normal functioning, and 45 percent attained mildly retarded functioning. These remarkable results did, however, require a considerable staffing effort, with well-qualified therapists working with each child at least 40 hours per week for 2 years.

Some studies show that intensive behavioral treatment of children with autism, requiring a significant investment of time and energy on the part of therapist and parents, can bring about improvement, particularly if this treatment continues at home rather than in an institution.

Some of the other impressive results with children with autism have also been obtained in projects that involve parents, with treatment in the home (Siegel,  2003 ). Treatment contracts with parents specify the desired behavior changes in their child and spell out the explicit techniques for bringing about these changes. Such “contracting” acknowledges the value of the parents as potential agents of change (Huynen et al.,  1996 ). See Developments in Practice below for an example of the use of technology to improve autistic behavior.

The Effectiveness of Treatment It is too early to draw conclusions about the effectiveness of newer treatment methods or the degree of improvement they actually accomplish, although reports of effective behavioral intervention in some areas, such as attention skills, have been noted (Martins & Harris,  2006 ). The prognosis for children with autism, particularly for children showing symptoms before the age of 2, is poor. Commonly, the long-term results of autism treatments have been unfavorable. A great deal of attention has thus been given to high-functioning children with autism (children who meet the criteria for autism yet develop functional speech).

One important factor limiting treatment success is the difficulty that children with autism have in generalizing behavior outside the treatment context. Children with severe developmental disabilities do not transfer skills across situations very well. Consequently, learning behavior in one situation does not appear to help them meet challenges in others.

In spite of a few remarkable cases of dramatic success, the overall prognosis for children with autism remains guarded. Less than one-fourth of the children who receive treatment attain even marginal adjustment in later life. Even with intensive, long-term care in a clinical facility, where gratifying improvements in specific behaviors may be brought about, children with autism are a long way from becoming normal.

developments in PRACTICE: Can Virtual Reality Video Games Improve Treatment of Children with Neurodevelopmental Disorders?

Many children and adolescents with learning disabilities or neurodevelopmental disorders, like other children today, are readily drawn to computer video games and will spend long hours at machines. The potential value of video media and virtual reality games at engaging and training young people appears to be great. These approaches have shown considerable promise in interesting and motivating children who might have cognitive processing impairments (Ecalle et al.,  2010 ). Even though many of these children have problems in social relationships, deficits in attention, and often volatile and disruptive behaviors they can readily become engrossed in the world of virtual reality (see informative discussion by Durkin,  2010 ). Recent projects in developmental psychology in Japan have incorporated the use of computer-based media technology for influencing young people, including those with disabilities, to learn and experience new ways of functioning (Shwalb et al.,  2005 ). For example, Nakamura, Iwabuchi, and Sakai ( 2005 ) report an intervention using cell phone calls to promote a qualitative change in communication behavior in a boy with autism.

Although video games as a medium for teaching life skills are recognized as having potential for the development of effective treatments (Cartreine et al.,  2010 ), a successful treatment requires more than its value as entertainment or time consumption. It is not necessarily a productive goal for a child with autism to just sit and stare in front of a TV screen and watch the same program all day as often happens. The treatment benefit needs to be more carefully considered. Programs for treatment or education require specifically tailored strategies to obtain the most effective results. Machines can only perform as they are programmed to do. Thus appropriate behavioral change strategies need to be developed and studied for particular applications. The effectiveness of behavior modification approaches using computer technology for children with developmental disorders has not been widely demonstrated or even explored for many problem areas. It takes considerable research and development, along with extensive programming skills, to address particular problems that can change behavior. At this time, the psychological knowledge and research base lingers behind the expanding developments in technical equipment.

The video and virtual reality game phenomena that have attracted many young people’s interest have also prompted some unanswered questions. This approach to education and treatment has come under criticism and raised potential concerns over its use. For example, there is concern that this approach has a strong potential for “addiction” to virtual reality games that could potentially adversely influence a child’s development (Pies,  2009 ). Questions have also been raised about the need for further considerations as to possible ethical issues, involving such factors as identity, equity, and confidentiality, that face instructors and therapists who use online teaching or therapy (Anderson & Simpson, 2007).

Although the available and acceptable use of computer-based learning methods show promise, there are professional issues and program research limitations that need to be more fully explored before the full potential of this methodology is reached.

Parenting children with autism can be trying and stressful (Dunn et al.,  2001 ) and can be very financially stressful for families. Parents of children with autism often find themselves in the extremely frustrating situation of trying to understand their child, providing day-to-day care, and searching for possible educational resources for their child in the present health and educational environment. An informative book on the topic of autism is The World of the Autistic Child (Siegel,  1996 , 2007). Siegel discusses the impact that having a child with autism can have on the family—both parents and siblings—and describes ways of dealing with the problems that can arise, including the possible need of psychological treatment for other family members. The book is a particularly valuable guide to accessing the resources available for educating and treating children with autism and negotiating the confusing educational environment. Whether to seek residential placement, clearly a necessity in some situations and families, is also an important decision that parents of many children with autism must address.

in review

·  What is known about the causes and treatments of autistic disorder?

Specific Learning Disorders

The inadequate development found in  learning disorders , a term that refers to delayed development, may be manifested in language, speech, mathematical, or motor skills, and it is not necessarily due to any demonstrable physical or neurological defect. Of these types of problems, the best known and most widely researched are a variety of reading/writing difficulties known collectively as  dyslexia . In dyslexia, the individual manifests problems in word recognition and reading comprehension; often he or she is markedly deficient in spelling and memory (Smith-Spark & Fisk,  2007 ) as well. On assessments of reading skill, these persons routinely omit, add, and distort words, and their reading is typically painfully slow.

The diagnosis of learning disorders is restricted to those cases in which there is clear impairment in school performance or (if the person is not a student) in daily living activities—impairment not due to intellectual disability or to a pervasive developmental disorder such as autism. Skill deficits due to attention-deficit/hyperactivity disorder are coded under that diagnosis. This coding presents another diagnostic dilemma, however, because some investigators hold that an attention deficit is basic to many learning disorders; evidence for the latter view is equivocal (see Faraone et al.,  1993 ). Children (and adults) with these disorders are more generally said to be learning disordered. Significantly more boys than girls are diagnosed as learning disabled, but estimates of the extent of this gender discrepancy have varied widely from study to study. Prevalence estimates have shown that approximately 1 in 59, or 4.6 million people, in the United States (National Institutes of Mental Health,  2007 ) are learning disabled.

Children with learning disorders can experience deep emotional tension under normal learning circumstances.

Children with learning disorder are initially identified as such because of an apparent disparity between their expected academic achievement level and their actual academic performance in one or more school subjects such as math, spelling, writing, or reading. Typically, these children have overall IQs, family backgrounds, and exposure to cultural norms and symbols that are consistent with at least average achievement in school. They do not have obvious, crippling emotional problems, nor do they seem to be lacking in motivation, cooperativeness, or eagerness to please their teachers and parents—at least not at the outset of their formal education. Nevertheless, they fail, often abysmally and usually with a stubborn, puzzling persistence.

The consequences of these encounters between children with learning disabilities and rigid school systems can be disastrous to these children’s self-esteem and general psychological well-being, and research indicates that these effects do not necessarily dissipate after secondary schooling ends but impact their career adjustment (Morris & Turnbull,  2007 ). Thus even when learning disorder difficulties are no longer a significant impediment, an individual may bear, into maturity and beyond, the scars of many painful school-related episodes of failure.

But there is also a brighter side to this picture. High levels of general talent and of motivation to overcome the obstacle of a learning disorder sometimes produce a life of extraordinary achievement. Sir Winston Churchill, British statesman, author, and inspiring World War II leader, is said to have been dyslexic as a child. The same attribution is made to Woodrow Wilson, former university professor and president of the United States, and to Nelson Rockefeller, former governor of New York and vice president of the United States. Such examples remind us that the “bad luck” and personal adversity of having a learning disorder need not be uniformly limiting; quite the contrary.

Causal Factors in Learning Disorder

Probably the most widely held view of the causes of specific learning disorders is that they are the products of subtle central nervous system impairments. In particular, these disabilities are thought to result from some sort of immaturity, deficiency, or dysregulation limited to those brain functions that supposedly mediate, for normal children, the cognitive skills that learning disorder children cannot efficiently acquire. For example, many researchers believe that language-related learning disorders such as dyslexia are associated with a failure of the brain to develop in a normally asymmetrical manner with respect to the right and left hemispheres. Specifically, portions of the left hemisphere, where language function is normally mediated, for unknown reasons appear to remain relatively underdeveloped in many dyslexic individuals (Beaton,  1997 ). Recent work with functional magnetic resonance imaging (see  Chapter 4 ) has suggested that dyslexic individuals have a deficiency of physiological activation in the cerebellum (Richards et al.,  2005 ).

Some investigators believe that the various forms of learning disorder, or the vulnerability to develop them, may be genetically transmitted. This issue seems not to have been studied with the same intensity or methodological rigor as in other disorders, but identification of a gene region for dyslexia on chromosome 6 has been reported (Schulte-Koerne,  2001 ). Although it would be somewhat surprising if a single gene were identified as the causal factor in all cases of reading disorder, the hypothesis of a genetic contribution to at least the dyslexic form of learning disorder seems promising. One twin study of mathematics disability has also turned up evidence of some genetic contribution to this form of learning disorder (Alarcon et al.,  1997 ).

Treatments and Outcomes

Because we do not yet have a confident grasp of what is “wrong” with the average learning disordered child, it is important to have a clear assessment of their problems and abilities (Mapou,  2009 ) so that successful treatment can be implemented. We have had limited success in treating many of these children. Many informal and single-case reports claim success with various treatment approaches, but direct instruction strategies often do not succeed in transforming these children’s abilities (Gettinger & Koscik,  2001 ), and there are few well-designed and well-executed outcome studies on specific treatments for learning disorders.

We have only limited data on the long-term, adult adjustments of people who grew up with the personal, academic, and social problems that learning disorder generally entails. Two studies of college students with learning disorder (Gregg & Hoy,  1989 ) suggest that as a group they continue to have problems—academic, personal, and social—into the postsecondary education years. In a community survey of learning disorder adults, Khan, Cowan, and Roy, ( 1997 ) found that some 50 percent of them had personality abnormalities. Cato and Rice ( 1982 ) extracted from the available literature a lengthy list of problems experienced by the typical learning disorder adult. These include—in addition to expected difficulties with self-confidence—continuing problems with deficits in the ordinary skills such as math that these people had trouble with as children. The authors do note, however, that there are considerable individual differences in these outcomes and that some adults with learning disorder are able to manage very well.

DSM-5 THINKING CRITICALLY about DSM-5: Changes to the Diagnostic System are Nominal for Some Disorders

Along with the addition of new diagnostic categories, such as gambling disorder and hoarding disorder, and the revision of other earlier diagnostic criteria resulting in disorders such as disruptive mood dysregulation disorder, there have been changes to some existing categories that are largely nominal in order to make the terminology more appropriate with contemporary language use and/or consistent with forthcoming International Classification of Diseases system (ICD-11) to be published in 2015.

Several reasons are provided for renaming of some diagnostic categories. For example, the term mental retardation was used in describing individuals with intellectual impairment in previous editions of the DSM. However, the term “Mental Retardation” has come to be unacceptable in contemporary use and is considered to be derogatory by many. The new term, “intellectual disability” to replace the term mental retardation has come into more common use in the last decades by professionals, by the lay public and various advocacy groups. As noted by the DSM-5 committee, a U.S. legal statue (Public Law 111-256 or Rosa’s Law) has replaced the term mental retardation with intellectual disability. At the Second Session of the 111 Congress of the United States in 2010 the following resolution was passed:

·  (b) INDIVIDUALS WITH DISABILITIES EDUCATION ACT—

·  (1) SECTION 601(c) (12)(C) of the Individuals with Disabilities Education Act (20 U.S.C. 1400(c) (12)(C) is amended by striking “having mental retardation” and inserting “having intellectual disabilities.”

Although, some practitioners (being accustomed to prior terminology) may have “translation” difficulties as they proceed with new language in DSM-5 the behaviors and symptoms that make up the problem areas being described are essentially familiar ones.

Intellectual Disability

Intellectual disability  (intellectual developmental disorder) is characterized by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract-thinking, judgment, academic learning, and learning from experience (APA  2013 , p. 31). For the diagnosis to apply, these problems must begin before the age of 18. Intellectual disability is thus defined in terms of level of performance as well as intelligence. The definition says nothing about causal factors, which may be primarily biological, psychosocial, sociocultural, or a combination of these. By definition, any functional equivalent of Intellectual disability that has its onset after age 17 must be considered a dementia rather than intellectual disability. The distinction is an important one because the psychological situation of a person who acquires a pronounced impairment of intellectual functioning after attaining maturity is vastly different from that of a person whose intellectual resources were below normal throughout all or most of his or her development.

Intellectual disability occurs among children throughout the world (Fryers,  2000 ). In its most severe forms, it is a source of great hardship to parents as well as an economic and social burden on a community. The point prevalence rate of diagnosed intellectual disability in the United States is estimated to be about 1 percent, which would indicate a population estimate of some 2.6 million people. In fact, however, prevalence is extremely difficult to pin down because definitions of intellectual disability vary considerably (Roeleveld et al.,  1997 ). Most states have laws providing that persons with IQs below 70 who show socially incompetent or persistently problematic behavior can be classified as “mentally retarded” and, if judged otherwise unmanageable, may be placed in an institution. Informally, IQ scores between about 70 and 90 are often referred to as “borderline” or (in the upper part of the range) as “dull-normal.”

Initial diagnoses of intellectual disability occur very frequently at ages 5 to 6 (around the time that schooling begins for most children), peak at age 15, and drop off sharply after that. For the most part, these patterns in age of first diagnosis reflect changes in life demands. During early childhood, individuals with only a mild degree of intellectual impairment, who constitute the vast majority of the mentally retarded, often appear to be normal. Their subaverage intellectual functioning becomes apparent only when difficulties with schoolwork lead to a diagnostic evaluation. When adequate facilities are available for their education, children in this group can usually master essential school skills and achieve a satisfactory level of socially adaptive behavior. Following the school years, they usually make a more or less acceptable adjustment in the community and thus lose the identity of being mentally retarded.

Individuals with mild intellectual disability constitute the largest number of those categorized as mentally retarded. With help, a great majority of these individuals can adjust socially, master simple academic and occupational skills, and become self-supporting citizens.

Levels of Intellectual Disability

The various levels of intellectual disability are described in greater detail in the following sections.

MILD INTELLECTUAL DISABILITY

Individuals with mild intellectual disability constitute by far the largest number of those diagnosed with intellectual disability Within the educational context, people in this group are considered educable, and their intellectual levels as adults are comparable to those of average 8-to 11-year-old children. Statements such as the latter, however, should not be taken too literally. An adult with mild disability with a mental age of, say, 10 (that is, his or her intelligence test performance is at the level of the average 10-year-old) may not in fact be comparable to the average 10-year-old in information-processing ability or speed (Weiss et al.,  1986 ). On the other hand, he or she will normally have had far more experience in living, which would tend to raise the measured intelligence scores.

The social adjustment of people with mild intellectual disability often approximates that of adolescents, although they tend to lack normal adolescents’ imagination, inventiveness, and judgment. Ordinarily, they do not show signs of brain pathology or other physical anomalies, but often they require some measure of supervision because of their limited abilities to foresee the consequences of their actions. With early diagnosis, parental assistance, and special educational programs, the great majority of borderline and individuals with mild intellectual disability can adjust socially, master simple academic and occupational skills, and become self-supporting citizens (Maclean,  1997 ).

TABLE 15.1 Disability Severity and IQ Ranges

Diagnosed level of Intellectual disability	Corresponding IQ Range
Mild disability	50–55 to approximately 70
Moderate disability	35–40 to 50–55
Severe disability	20–25 to 35–40
Profound disability	below 20–25

MODERATE INTELLECTUAL DISABILITY

Individuals with moderate intellectual disability are likely to fall in the educational category of trainable, which means that they are presumed able to master certain routine skills such as cooking or minor janitorial work if provided specialized instruction in these activities. In adult life, individuals with moderate intellectual disability attain intellectual levels similar to those of average 4- to 7-year-old children. Although some can be taught to read and write a little and may manage to achieve a fair command of spoken language, their rate of learning is slow, and their level of conceptualizing is extremely limited. They usually appear clumsy and ungainly, and they suffer from bodily deformities and poor motor coordination. Some individuals with moderate intellectual disability are hostile and aggressive; more typically, they are affable and nonthreatening. In general, with early diagnosis, parental help, and adequate opportunities for training, most individuals with moderate intellectual disability can achieve partial independence in daily self-care, acceptable behavior, and economic sustenance in a family or other sheltered environment.

SEVERE INTELLECTUAL DISABILITY

In individuals with severe intellectual disability, motor and speech development are severely retarded and sensory defects and motor handicaps are common. They can develop limited levels of personal hygiene and self-help skills, which somewhat lessen their dependency, but they are always dependent on others for care. However, many profit to some extent from training and can perform simple occupational tasks under supervision.

PROFOUND INTELLECTUAL DISABILITY

Most individuals with profound intellectual disability are severely deficient in adaptive behavior and unable to master any but the simplest tasks. Useful speech, if it develops at all, is rudimentary. Severe physical deformities, central nervous system pathology, and retarded growth are typical; convulsive seizures, mutism, deafness, and other physical anomalies are also common. These individuals must remain in custodial care all their lives. They tend, however, to have poor health and low resistance to disease and thus a short life expectancy. Severe and profound cases of intellectual disability can usually be readily diagnosed in infancy because of the presence of obvious physical malformations, grossly delayed development (e.g., in taking solid food), and other obvious symptoms of abnormality. These individuals show a marked impairment of overall intellectual functioning.

Causal Factors in Intellectual Disability

Some cases of intellectual disability occur in association with known organic brain pathology (Kaski,  2000 ). In these cases, retardation is virtually always at least moderate, and it is often severe. Profound retardation, which fortunately is rare, always includes obvious organic impairment. Organically caused retardation is, in essential respects, similar to dementia, except for the different history of prior functioning. In this section, we will consider five biological conditions that may lead to intellectual disability, noting some of the possible interrelationships among them. Then we will review some of the major clinical types of intellectual disability associated with these organic causes.

GENETIC-CHROMOSOMAL FACTORS

Intellectual disability, especially mild disability, tends to run in families. Poverty and sociocultural deprivation, however, also tend to run in families, and with early and continued exposure to such conditions, even the inheritance of average intellectual potential may not prevent subaverage intellectual functioning.

Genetic-chromosomal factors play a much clearer role in the etiology of relatively infrequent but more severe types of intellectual disability such as Down syndrome and a heritable condition known as fragile X (Huber & Tamminga,  2007 ; Schwarte,  2008 ). The gene responsible for fragile X syndrome (FMR-1) was identified in 1991 (Verkerk et al.,  1991 ). In such conditions, genetic aberrations are responsible for metabolic alterations that adversely affect the brain’s development. Genetic defects leading to metabolic alterations may, of course, involve many other developmental anomalies besides intellectual disability—for example, autism (Wassink et al.,  2001 ). In general, intellectual disability associated with known genetic-chromosomal defects is moderate to severe.

INFECTIONS AND TOXIC AGENTS

Intellectual disability may be associated with a wide range of conditions due to infection such as viral encephalitis or genital herpes (Kaski,  2000 ). If a pregnant woman is infected with syphilis or HIV-1 or if she gets German measles, her child may suffer brain damage.

A number of toxic agents such as carbon monoxide and lead may cause brain damage during fetal development or after birth (Kaski,  2000 ). In rare instances, immunological agents such as antitetanus serum or typhoid vaccine may lead to brain damage. Similarly, if taken by a pregnant woman, certain drugs, including an excess of alcohol (West et al.,  1998 ), may lead to congenital malformations. And an overdose of drugs administered to an infant may result in toxicity and cause brain damage. In rare cases, brain damage results from incompatibility in blood types between mother and fetus. Fortunately, early diagnosis and blood transfusions can minimize the effects of such incompatibility.

TRAUMA (PHYSICAL INJURY)

Physical injury at birth can result in intellectual disability (Kaski,  2000 ). Although the fetus is normally well protected by its fluid-filled placenta during gestation, and although its skull resists delivery stressors, accidents do happen during delivery and after birth. Difficulties in labor due to malposition of the fetus or other complications may irreparably damage the infant’s brain. Bleeding within the brain is probably the most common result of such birth trauma. Hypoxia—lack of sufficient oxygen to the brain stemming from delayed breathing or other causes—is another type of birth trauma that may damage the brain.

IONIZING RADIATION

In recent decades, a good deal of scientific attention has been focused on the damaging effects of ionizing radiation on sex cells and other bodily cells and tissues. Radiation may act directly on the fertilized ovum or may produce gene mutations in the sex cells of either or both parents, which may lead to defective offspring. Sources of harmful radiation were once limited primarily to high-energy X rays used in medicine for diagnosis and therapy, but the list has grown to include nuclear weapons testing and leakages at nuclear power plants, among others.

MALNUTRITION AND OTHER BIOLOGICAL FACTORS

It was long thought that dietary deficiencies in protein and other essential nutrients during early development of the fetus could do irreversible physical and mental damage. However, it is currently believed that this assumption of a direct causal link may have been oversimplified. Ricciuti ( 1993 ) cited growing evidence that malnutrition may affect mental development more indirectly by altering a child’s responsiveness, curiosity, and motivation to learn. According to this hypothesis, these losses would then lead to a relative retardation of intellectual facility. The implication here is that at least some malnutrition-associated intellectual deficit is a special case of psychosocial deprivation, which is also involved in retardation outcomes, as described below.

A limited number of cases of intellectual disability are clearly associated with organic brain pathology. In some instances—particularly of the severe and profound types—the specific causes are uncertain or unknown, although extensive brain pathology is evident.

Organic Retardation Syndromes

Intellectual disability stemming primarily from biological causes can be classified into several recognizable clinical types (Murphy et al.,  1998 ), of which Down syndrome, phenylketonuria (PKU), and cranial anomalies will be discussed here.  Table 15.2  presents information on several other well-known forms.

DOWN SYNDROME

First described by Langdon Down in 1866,  Down syndrome  is the best known of the clinical conditions associated with moderate and severe intellectual disability. The prevalence of Down syndrome has been reported to be 5.9 per 10,000 of the general population (Cooper, Smiley, et al.,  2009 ). It is a condition that creates irreversible limitations on survivability, intellectual achievement, and competence in managing life tasks (Bittles et al.,  2007 ; Patterson & Lott,  2008 ) and is associated with health problems in later life such as pneumonia and other respiratory infections. The availability of amniocentesis and chorionic villus sampling in expectant mothers has made it possible to detect in utero the extra genetic material involved in Down syndrome, which is most often the trisomy of chromosome 21, yielding 47 rather than the normal 46 chromosomes (see  Figure 15.1 ).

TABLE 15.2 Other Disorders Sometimes Associated with Intellectual Disability

Clinical Type	Symptoms	Causes
No. 18 trisomy syndrome	Peculiar pattern of multiple congenital anomalies, the most common being low-set malformed ears, flexion of fingers, small jaw, and heart defects	Autosomal anomaly of chromosome 18
Tay-Sachs disease	Hypertonicity, listlessness, blindness, progressive spastic paralysis, and convulsions (death by the third year)	Disorder of lipoid metabolism, carried by a single recessive gene
Turner’s syndrome	In females only; webbing of neck, increased carrying angle of forearm, and sexual infantilism; intellectual disability may occur but is infrequent	Sex chromosome anomaly (XO)
Klinefelter’s syndrome	In males only; features vary from case to case, the only constant finding being the presence of small testes after puberty	Sex chromosome anomaly (XXY)
Niemann-Pick’s disease	Onset usually in infancy, with loss of weight, dehydration, and progressive paralysis	Disorder of lipoid metabolism
Bilirubin encephalopathy	Abnormal levels of bilirubin (a toxic substance released by red cell destruction) in the blood; motor incoordination frequent	Often, Rh (ABO) blood group incompatibility between mother and fetus
Rubella, congenital	Visual difficulties most common, with cataracts and retinal problems often occurring together, and with deafness and anomalies in the valves and septa of the heart	The mother’s contraction of rubella (German measles) during the first few months of her pregnancy

Source: Based on American Psychiatric Association ( 2013 ); Harris ( 2006 ).

Physical features found among children with Down syndrome include almond-shaped eyes, abnormally thick skin on the eyelids, and a face and nose that are often flat and broad. The tongue may seem too big for the mouth and may show deep fissures. The iris of the eye is frequently speckled. The neck is often short and broad, as are the hands. The fingers are stubby, and the little finger is often more noticeably curved than the other fingers.

The Clinical Picture in Down Syndrome A number of physical features are often found among children with Down syndrome, but few of these children have all of the characteristics commonly thought to typify this group. The eyes appear almond-shaped, and the skin of the eyelids tends to be abnormally thick. The face and nose are often flat and broad, as is the back of the head. The tongue, which seems too large for the mouth, may show deep fissures. The iris of the eye is frequently speckled. The neck is often short and broad, as are the hands. The fingers are stubby, and the little finger is often more noticeably curved than the other fingers. Although facial surgery is sometimes tried to correct the more stigmatizing features, its success is often limited (Roizen,  2007 ). Also, parents’ acceptance of their Down syndrome child is inversely related to their support of such surgery (Katz et al.,  1997 ).

FIGURE 15.1 Trisomy of Chromosome 21 in Down Syndrome This is a reproduction (karyotype) of the chromosomes of a female patient with Down syndrome. Note the triple (rather than the normal paired) representation at chromosome 21.

Source: Reproduced with permission by Custom Medical Stock Photo, Inc.

There are special medical problems with Down syndrome children that require careful medical attention and examinations (Tyrer et al.,  2007 ). Death rates for children with Down syndrome have, however, decreased dramatically in the past century. In 1919 the life expectancy at birth for such children was about 9 years; most of the deaths were due to gross physical problems, and a large proportion occurred in the first year of life. Thanks to antibiotics, surgical correction of lethal anatomical defects such as holes in the walls separating the heart’s chambers, and better general medical care, many more of these children now live to adulthood (Hijii et al.,  1997 ). Nevertheless, they appear as a group to experience an accelerated aging process (Hasegawa et al.,  1997 ) and a decline in cognitive abilities (Thompson,  2003 ). One recent study reported that of those with Down syndrome who were age 60 and above, a little more than 50 percent had clinical evidence of dementia (Margallo et al.,  2007 ).

Despite their problems, children with Down syndrome are usually able to learn self-help skills, acceptable social behavior, and routine manual skills that enable them to be of assistance in a family or institutional setting (Brown et al.,  2001 ). The traditional view has been that children with Down syndrome are unusually placid and affectionate. However, research has called into question the validity of this generalization (Pary,  2004 ). These children may indeed be very docile, but probably in no greater proportion than normal children; they may also be equally (or more) difficult in various areas. In general, the quality of a child’s social relationships depends on both IQ level and a supportive home environment (Alderson,  2001 ). Adults with Down syndrome may manifest less maladaptive behavior than comparable persons with other types of learning disabilities (Collacott et al.,  1998 ).

Today many more Down syndrome children are living to adulthood than in the past and are able to learn self-help, social, and manual skills. It is not unusual for Down syndrome children to be mainstreamed to some extent with unimpaired children, such as this boy (center, with glasses). Children with Down syndrome tend to remain relatively unimpaired in their appreciation of spatial relationships and visual-motor coordination; they show their greatest deficits in verbal and language-related skills.

Research has also suggested that the intellectual defect in Down syndrome may not be consistent across various abilities. Children with Down syndrome tend to remain relatively unimpaired in their appreciation of spatial relationships and in visual-motor coordination, although some evidence disputes this conclusion (Uecker et al.,  1993 ). Research data are quite consistent in showing that their greatest deficits are in verbal and language-related skills (Azari et al.,  1994 ; Silverstein et al.,  1982 ). Because spatial functions are known to be partially localized in the right cerebral hemisphere, and language-related functions localized in the left cerebral hemisphere, some investigators speculate that the syndrome is especially crippling to the left hemisphere.

Chromosomal abnormalities other than the trisomy of chromosome 21 may occasionally be involved in the etiology of Down syndrome. However, the extra version of chromosome 21 is present in at least 94 percent of cases. As we noted earlier, it may be significant that this is the same chromosome that has been implicated in research on Alzheimer’s disease, especially given that persons with Down syndrome are at extremely high risk for Alzheimer’s as they get into and beyond their late 30s (Prasher & Kirshnan,  1993 ).

The reason for the trisomy of chromosome 21 is not clear, and research continues to address the potential causes (Korbel et al.,  2009 ), but the defect seems definitely related to cognitive deficit (Kahlem,  2006 ) and to parental age at conception. It has been known for many years that the incidence of Down syndrome increases on an accelerating slope (from the 20s on) with increasing age of the mother. A woman in her 20s has about 1 chance in 2,000 of conceiving a Down syndrome baby, whereas the risk for a woman in her 40s is 1 in 50 (Holvey & Talbott,  1972 ). As in the case of all birth defects, the risk of having a Down syndrome baby is also high for very young mothers, whose reproductive systems have not yet fully matured. Research has also indicated that the father’s age at conception is implicated in Down syndrome, particularly at higher ages (Stene et al.,  1981 ).

Thus it seems that advancing age in either parent increases the risk of the trisomy 21 anomaly, although the effect of maternal age is greater. It is not yet clear how aging produces this effect. A reasonable guess is that aging is related to cumulative exposure to varied environmental hazards such as radiation that might have adverse effects on the processes involved in zygote formation or development.

PHENYLKETONURIA

In  phenylketonuria (PKU) , a baby appears normal at birth but lacks a liver enzyme needed to break down phenylalanine, an amino acid found in many foods. The genetic error results in intellectual disability only when significant quantities of phenylalanine are ingested, which is virtually certain to occur if the child’s condition remains undiagnosed (Grodin & Laurie,  2000 ). This disorder occurs in about 1 in 12,000 births (Deb & Ahmed,  2000 ). This condition is reversible (Embury et al.,  2007 ); however, if the condition is not detected and treated, the amount of phenylalanine in the blood increases and eventually produces brain damage.

The disorder usually becomes apparent between 6 and 12 months after birth, although such symptoms as vomiting, a peculiar odor, infantile eczema, and seizures may occur during the early weeks of life. Often, the first symptoms noticed are signs of intellectual disability, which may be moderate to severe, depending on the degree to which the disease has progressed. Lack of motor coordination and other neurological problems caused by the brain damage are also common, and often the eyes, skin, and hair of untreated PKU patients are very pale (Dyer,  1999 ).

The early detection of PKU by examining urine for the presence of phenylpyruvic acid is routine in developed countries, and dietary treatment (such as the elimination of phenylalanine-containing foods such as diet soda or turkey) and related procedures can be used to prevent the disorder (Sullivan & Chang,  1999 ). With early detection and treatment—preferably before an infant is 6 months old—the deterioration process can usually be arrested so that levels of intellectual functioning may range from borderline to normal. A few children suffer intellectual disability despite restricted phenylalanine intake and other preventive efforts, however. Dietary restriction in late-diagnosed PKU may improve the clinical picture somewhat, but there is no real substitute for early detection and prompt intervention (Pavone et al.,  1993 ).

It appears that for a baby to inherit PKU, both parents must carry the recessive gene. Thus, when one child in a family is discovered to have PKU, it is especially critical that other children in the family be screened as well. Also, a pregnant PKU mother whose risk status has been successfully addressed by early dietary intervention may damage her at-risk fetus unless she maintains rigorous control of phenylalanine intake.

Patients with PKU are typically advised to follow a restricted diet over their life span in order to prevent cognitive impairment. Some investigators have reported mild deficits in cognitive functioning even with long-term treatment (White et al.,  2002 ). However, other research has found little support for the hypothesis that deficits will occur even with dietary restrictions (Channon et al.,  2004 ).

CRANIAL ANOMALIES

Intellectual disability is associated with a number of conditions that involve alterations in head size and shape and for which the causal factors have not been definitely established (Carr et al.,  2007 ). In the rare condition known as  macrocephaly  (large-headedness), for example, there is an increase in the size and weight of the brain, an enlargement of the skull, visual impairment, convulsions, and other neurological symptoms resulting from the abnormal growth of glial cells that form the supporting structure for brain tissue.

Microcephaly  The term  microcephaly  means “small-headedness.” This condition is associated with a type of intellectual disability resulting from impaired development of the brain and a consequent failure of the cranium to attain normal size.

The most obvious characteristic of microcephaly is a small head, the circumference of which rarely exceeds 17 inches, compared with the normal size of approximately 22 inches. Penrose ( 1963 ) also describes children with microcephaly as being invariably short in stature but having relatively normal musculature and sex organs. Beyond these characteristics, they differ considerably from one another in appearance, although there is a tendency for the skull to be cone-shaped, with a receding chin and forehead. Children with microcephaly fall within the moderate, severe, and profound categories of intellectual disability but most show little language development and are extremely limited in mental capacity.

Microcephaly may result from a wide range of factors that impair brain development, including intrauterine infections and pelvic irradiation during the mother’s early months of pregnancy. Miller ( 1970 ) noted a number of cases of microcephaly in Hiroshima and Nagasaki that apparently resulted from the atomic bomb explosions during World War II. The role of genetic factors is not clear, although there is speculation that a single recessive gene is involved in a primary, inherited form of the disorder (Robinson & Robinson,  1976 ). Treatment is ineffective once faulty development has occurred; at present, preventive measures focus on the avoidance of infection and radiation during pregnancy.

Hydrocephaly  The condition referred to as  hydrocephaly  is a relatively rare disorder in which the accumulation of an abnormal amount of cerebrospinal fluid within the cranium causes damage to the brain tissues and enlargement of the skull (Materro et al.,  2001 ). In congenital cases, the head either is already enlarged at birth or begins to enlarge soon thereafter, presumably as a result of a disturbance in the formation, absorption, or circulation of the cerebrospinal fluid. The disorder can also arise in infancy or early childhood following the development of a brain tumor, subdural hematoma, meningitis, or other conditions. In these cases, the condition appears to result from a blockage of the cerebrospinal pathways and an accumulation of fluid in certain brain areas.

The clinical picture in hydrocephaly depends on the extent of neural damage, which in turn depends on the age at onset and the duration and severity of the disorder. In chronic cases, the chief symptom is the gradual enlargement of the upper part of the head out of proportion to the face and the rest of the body. While the expansion of the skull helps minimize destructive pressure on the brain, serious brain damage occurs nonetheless. This damage leads to intellectual impairment and to such other effects as convulsions and impairment or loss of sight and hearing. The degree of intellectual impairment varies, being severe or profound in advanced cases.

Hydrocephaly can be treated by a procedure in which shunting devices are inserted to drain cerebrospinal fluid. With early diagnosis and treatment, this condition can usually be arrested before severe brain damage has occurred (Duinkerke et al.,  2004 ). Even with significant brain damage, carefully planned and early interventions that take into account both strengths and weaknesses in intellectual functioning may minimize disability (Baron & Goldberger,  1993 ).

Treatments, Outcomes, and Prevention

A number of programs have demonstrated that significant changes in the adaptive capacity of children with intellectual disability are possible through special education and other rehabilitative measures (Berney,  2000 ). The degree of change that can be expected is related, of course, to the individual’s particular situation and level of intellectual disability.

TREATMENT FACILITIES AND METHODS

Parents of children with intellectual disability often find that childrearing is a very difficult challenge (Glidden & Schoolcraft,  2007 ). For example, recent research has shown that learning disability is associated with a higher incidence of mental health problems (Cooper & van der Speck,  2009 ). One decision that the parents of a intellectual disabled child must make is whether to place the child in an institution (Gath,  2000 ). Most authorities agree that this should be considered as a last resort, in light of the unfavorable outcomes normally experienced—particularly in regard to the erosion of self-care skills (Lynch et al.,  1997 ). In general, children who are institutionalized fall into two groups: (1) those who, in infancy and childhood, manifest severe intellectual disability and associated physical impairment and who enter an institution at an early age; and (2) those who have no physical impairments but show relatively mild intellectual disability and a failure to adjust socially in adolescence, eventually being institutionalized chiefly because of delinquency or other problem behavior (see Stattin & Klackenberg-Larsson,  1993 ). In these cases, social incompetence is the main factor in the decision. The families of patients in the first group come from all socioeconomic levels, whereas a significantly higher percentage of the families of those in the second group come from lower educational and occupational strata.

Long-term institutional care is linked with behavioral and emotional problems (Yang et al.,  2007 ). The effect of being institutionalized in adolescence depends heavily on the institution’s facilities as well as on individual factors because great care must be taken in assessing the residents’ needs and in the recruitment of staff personnel (Petronko et al.,  1994 ). For the many teenagers with intellectual disability whose families are not in a position to help them achieve a satisfactory adjustment, community-oriented residential care seems a particularly effective alternative (Alexander et al.,  1985 ). Unfortunately, many neighborhoods resist the location of such facilities within their confines and reject integration of residents into the local society (Short & Johnston,  1997 ).

For individuals with intellectual disability who do not require institutionalization, educational and training facilities have historically been woefully inadequate. It still appears that a very substantial proportion of individuals with intellectual disability in the United States never get access to services appropriate to their specific needs (Luckasson et al.,  1992 ).

This neglect is especially tragic in view of the ways that exist to help these people. For example, classes for individuals with mild intellectual disability, which usually emphasize reading and other basic school subjects, budgeting and money matters, and developing of occupational skills, have succeeded in helping many people become independent, productive community members. Classes for those with moderate and severe intellectual disability usually have more limited objectives, but they emphasize the development of self-care and other skills—e.g., toilet habits (Wilder et al.,  1997 )—that enable individuals to function adequately and to be of assistance in either a family (e.g., Heller et al.,  1997 ) or an institutional setting. Just mastering toilet training and learning to eat and dress properly may mean the difference between remaining at home or in a community residence and being institutionalized.

Today, there are approximately 129,000 people with intellectual disability and other related conditions who receive intermediate care although many are not institutionalized. This is considerably less than the number of residents in treatment 40 years ago. These developments reflect both the new optimism that has come to prevail and, in many instances, new laws and judicial decisions upholding the rights of retarded people and their families. A notable example is Public Law 94–142, passed by Congress in 1975 and since modified several times (see Hayden,  1998 ). This statute, termed the Education for All Handicapped Children Act, asserts the right of intellectually disabled people to be educated at public expense in the least restrictive environment possible.

During the 1970s, there was a rapid increase in alternative forms of care for individuals with intellectual disability (Tyor & Bell,  1984 ). These included the use of decentralized regional facilities for short-term evaluation and training, small private hospitals specializing in rehabilitative techniques, group homes or halfway houses integrated into the local community, nursing homes for the elderly with intellectual disability, the placement of children with severe intellectual disability in more enriched foster-home environments, varied forms of support to the family for own-home care, and employment services (Conley,  2003 ). The past 25 years have seen a marked enhancement in alternative modes of life for individuals with intellectual disability, rendering obsolete (and often leading to the closing of) many public institutions formerly devoted exclusively to this type of care.

EDUCATION AND INCLUSION PROGRAMMING

Typically, educational and training procedures involve mapping out target areas of improvement such as personal grooming, social behavior, basic academic skills, and (for retarded adults) simple occupational skills (see Shif,  2006 ). Within each area, specific skills are divided into simple components that can be learned and reinforced before more complex behaviors are required. Behavior modification that builds on a step-by-step progression can bring retarded individuals repeated experiences of success and lead to substantial progress even in severely impaired individuals (Mash & Barkley,  2006 ).

For children with mild intellectual disability, the question of what schooling is best is likely to challenge both parents and school officials. Many such children fare better when they attend regular classes for much of the day. Of course, this type of approach—often called  mainstreaming  or “inclusion programming”—requires careful planning, a high level of teacher skill, and facilitative teacher attitudes (Wehman,  2003 ).

in review

·  Compare and contrast mild, moderate, severe, and profound intellectual disability.

·  Describe five biological conditions that may lead to intellectual disability.

·  • Describe some of the physical characteristics of children born with Down syndrome. What is its cause?

·  • What is the cause of and the preventive treatment for phenylketonuria (PKU)?

·  • Describe rehabilitation approaches to intellectual disability.

Planning Better Programs To Help Children and Adolescents

In our earlier discussion of several disorders of childhood and adolescence, we noted the wide range of treatment procedures available as well as the marked differences in outcomes. In concluding this chapter, we will discuss certain special factors associated with the treatment of children and adolescents that can affect the success of an intervention.

Special Factors Associated With Treatment of Children and Adolescents

Mental health treatment, psychotherapy, and behavior therapy have been found to be as effective with children and adolescents as with adults (Kazdin & Weisz,  2003 ), but treatments conducted in laboratory-controlled studies are more effective than “real-world” treatment situations (Weisz et al.,  1995 ). There are a number of special factors to consider in relation to treatment for children and adolescents, as follows:

THE CHILD’S INABILITY TO SEEK ASSISTANCE

Most emotionally disturbed children who need assistance are not in a position to ask for help themselves or to transport themselves to and from child-treatment clinics. Thus, unlike an adult, who can usually seek help, a child is dependent, primarily on his or her parents. Adults should realize when a child needs professional help and take the initiative in obtaining it. Often, however, adults are unaware of the problems or neglect this responsibility.

The law identifies four areas in which treatment without parental consent is permitted: (1) in the case of mature minors (those considered capable of making decisions about themselves); (2) in the case of emancipated minors (those living independently, away from their parents); (3) in emergency situations; and (4) in situations in which a court orders treatment. Many children, of course, come to the attention of treatment agencies as a consequence of school referrals, delinquent acts, abuse by parents, or as a result of family custody court cases.

VULNERABILITIES THAT PLACE CHILDREN AT RISK FOR DEVELOPING EMOTIONAL PROBLEMS

Children and youth who experience or are exposed to violence are at increased risk for developing psychological disorders (Seifert,  2003 ). In addition, many families provide an undesirable environment for their growing children (Ammerman et al.,  1998 ). Studies have shown that up to a fourth of American children may be living in inadequate homes and that 7.6 percent of American youth have reported spending at least one night in a shelter, public place, or abandoned building (Ringwalt et al.,  1998 ). Another epidemiological study (Susser et al.,  1993 ) reveals that 23 percent of newly homeless men in New York City reported a history of out-of-home care as children. Parental substance abuse has also been found to be associated with the vulnerability of children to develop psychological disorders (Bijttebier & Goethals,  2006 ).

High-risk behaviors or difficult life conditions need to be recognized and taken into consideration (Harrington & Clark,  1998 ). For example, there are a number of behaviors such as engaging in sexual acts or delinquency and using alcohol or drugs that might place young people at great risk for developing later emotional problems. Moreover, physical or sexual abuse, parental divorce, family turbulence, and homelessness (Cauce et al.,  2000 ; Spataro et al.,  2004 ) can place young people at great risk for emotional distress and subsequent maladaptive behavior (see The World Around Us on p. 542). Dodge and colleagues ( 1997 ) found that children from homes with harsh discipline and physical abuse, for example, were more likely to be aggressive and conduct disordered than those from homes with less harsh discipline and from nonabusing families.

NEED FOR TREATING PARENTS AS WELL AS CHILDREN

Because many of the behavior disorders specific to childhood appear to grow out of pathogenic family interactions and result from having parents with psychiatric problems themselves (Johnson et al.,  2000 ), it is often important for the parents, as well as their child, to receive treatment (Dishion & Stormshak,  2007 ). In some instances, in fact, the treatment program may focus on the parents entirely, as in the case of child abuse.

Increasingly, then, the treatment of children has come to mean family therapy in which one or both parents, along with the child and siblings, may participate in all phases of the program. This is particularly important when the family situation has been identified as involving violence (Chaffin et al.,  2004 ). Many therapists have discovered that fathers are particularly difficult to engage in the treatment process. For working parents and for parents who basically reject the affected child, such treatment may be hard to arrange (Gaudin,  1993 ), especially in the case of poorer families who lack transportation and money. Thus both parental and economic factors help determine which emotionally disturbed children will receive assistance.

POSSIBILITY OF USING PARENTS AS CHANGE AGENTS

In essence, parents can be used as change agents by training them in techniques that enable them to help their child. Typically, such training focuses on helping the parents understand their child’s behavior disorder and teaching them to reinforce adaptive behavior while withholding reinforcement for undesirable behavior. Encouraging results have been obtained with parents who care about their children and want to help them (Garza et al.,  2007 ). Kazdin, Holland, and Crowley ( 1997 ) described a number of barriers to parental involvement in treatment that result in dropout from therapy. For example, coming from a disadvantaged background, having parents who are antisocial, or having parents who are under great stress tends to result in premature termination of treatment. Research on parental adherence to clinical recommendations has shown that many of the treatment suggestions made during evaluations are not followed by caregivers. However, one recent study by Dreyer and colleagues ( 2010 ) found that 81 percent of the recommendations from an ADHD evaluation were followed up.

the WORLD around us: The Impact of Child Abuse on Psychological Adjustment

Children who are physically or sexually abused show problems in social adjustment (Macmillan,  2010 ) and are particularly likely to feel that the outcomes of events are determined by external factors beyond their own control (Kinzl & Biebl,  1992 ; Toth et al.,  1992 ). They are also more likely to experience depressive symptoms (Bushnell et al.,  1992 ; Emery & Laumann-Billings,  1998 ). As a result, abused children are dramatically less likely to assume personal responsibility for themselves, and they generally demonstrate less interpersonal sensitivity than control children. Children who have been abused have been shown to have long-term adjustment problems, for example, in adjustment to college (Elliott,  2009 ) and adjustment in intimate relationships later in life (Friesen et al.,  2010 ). Moreover, child abuse and neglect may initiate a chain of violence. Child abuse is also associated with delinquent and criminal behavior when the victim grows up. Maxfield and Widom ( 1996 ), in a follow-up study of 908 people who were abused as children, found that their arrest rate for nontraffic offenses was significantly higher than that of a control sample of people who had not been abused as children.

Child abuse is an increasing concern in the United States (Crosson-Tower,  2002 ). A survey of reported incidents of child abuse in this country found that such reports increased 1.7 percent in 1995, the total number of incidents exceeding 3.1 million; an estimated 1,215 children were killed in 1995 in child abuse incidents (National Committee to Prevent Child Abuse,  1996 ). The excessive use of alcohol or drugs in a family appears to increase the risk of violent death in the home (Rivera et al.,  1997 ). Some evidence suggests that boys are more often physically abused than girls. It is clear that many children brought to the attention of legal agencies for abuse have been abused before. Moreover, the significantly higher rates among psychiatric inpatients of having been abused as children suggest that such maltreatment plays a causal role in the development of severe psychopathology (Read,  1997 ).

When the abuse involves a sexual component such as incest or rape, the long-range consequences can be profound (Paolucci et al.,  2001 ). Adults who were sexually abused as children often show serious psychological symptoms such as a tendency to use dissociative defense mechanisms to excess, excessive preoccupation with bodily functions, lowered self-esteem (Nash et al.,  1993 ), or a tendency to disengage as a means of handling stress (Coffey et al.,  1996 ).

The role of sexual abuse in causing psychological problems has been the subject of several longitudinal studies. A large percentage of sexually abused children experience intense psychological symptoms following the incident (for example, the 74 percent reported by Bentovim et al.,  1987 ). At follow-up, however, the improvement often seems dramatic (Bentovim et al.,  1987 ; Conte et al.,  1986 ). Several investigators have conceptualized the residual symptoms of sexual abuse as a type of posttraumatic stress disorder (PTSD) because the symptoms experienced are similar—for example, nightmares, flashbacks, sleep problems, and feelings of estrangement (Donaldson & Gardner,  1985 ; Koltek et al.,  1998 ).

Child abuse all too frequently produces maladaptive social behavior in its victims (Winton & Mara,  2001 ). The treatment of abused children thus needs to address their problems of inadequate social adjustment, depression, and poor interpersonal skills. However, treatment can be effective if the therapy is targeted to specific needs of the child (Harvey & Taylor,  2010 ).

PROBLEM OF PLACING A CHILD OUTSIDE THE FAMILY

Most communities have juvenile facilities that, day or night, will provide protective care and custody for young victims of unfit homes, abandonment, abuse, neglect, and related conditions. Depending on the home situation and the special needs of the child, he or she will later be either returned to his or her parents or placed elsewhere. In the latter instance, four types of facilities are commonly relied on: (1) foster homes, (2) private institutions for the care of children such as group homes, (3) county or state institutions, and (4) the homes of relatives. At any one time, more than half a million children are living in foster-care facilities, many of whom have been abused or neglected (Minnis et al.,  2006 ).

The quality of a child’s new home is, of course, a crucial determinant of whether the child’s problems will be alleviated or made worse, and there is evidence to suggest that foster-home placement has more positive effects than group-home placement (Buckley & Zimmermann,  2003 ; Groza et al.,  2003 ). Efforts are usually made to screen the placement facilities and maintain contact with the situation through follow-up visits, but even so, there have been cases of mistreatment in the new home (Dubner & Motta,  1999 ; Wilson et al.,  2000 ). In cases of child abuse, child abandonment, or a serious childhood behavior problem that parents cannot control, it had often been assumed that the only feasible action was to take the child out of the home and find a temporary substitute. With such a child’s own home so obviously inadequate, the hope was that a more stable outside placement would be better for the child. But when children are taken from their homes and placed in an institution (which promptly tries to change them) or in a series of foster homes (where they obviously do not really belong), they are likely to feel rejected by their own parents, unwanted by their new caretakers, rootless, constantly insecure, lonely, and bitter. Not surprisingly, children and adolescents in foster homes tend to require more mental health services than do other children (dos Reis et al.,  2001 ).

Accordingly, the trend today is toward permanent planning. First, every effort is made to hold a family together and to give the parents the support and guidance they need for adequate childrearing. If this is impossible, then efforts are made to free the child legally for adoption and to find an adoptive home as soon as possible. This, of course, means that the public agencies need specially trained staffs with reasonable caseloads and access to resources that they and their clients may need.

VALUE OF INTERVENING BEFORE PROBLEMS BECOME ACUTE

Over the last 25 years, a primary concern of many researchers and clinicians has been to identify and provide early help for children who are at special risk (Athey et al.,  1997 ). Rather than waiting until these children develop acute psychological problems that may require therapy or major changes in living arrangements, psychologists are attempting to identify conditions in the children’s lives that seem likely to bring about or maintain behavior problems and, where such conditions exist, to intervene before development has been seriously distorted (Schroeder & Gordon,  2002 ). An example of this approach is provided in the work of Steele and Forehand ( 1997 ). These investigators found that children of parents who had a chronic medical condition (the fathers were diagnosed as having hemophilia, and many were HIV positive) were vulnerable to developing internalizing problems and avoidant behavior, particularly when the parent–child relationship was weak. These symptoms in the child were associated with depression in the parent. The investigators concluded that clinicians may be able to reduce the impact of parental chronic illness by strengthening the parent–child relationship and decreasing the child’s use of avoidant strategies.

As described in  Chapter 5 , another type of early intervention has been developed in response to the special vulnerability children experience in the wake of a disaster or trauma such as a hurricane, accident, hostage-taking, or shooting (Shaw,  2003 ). Children and adolescents often require considerable support and attention to deal with such traumatic events, which are all too frequent in today’s world. Individual and small-group psychological therapy might be implemented for victims of trauma (Cohen et al.,  2006 ); support programs might operate through school-based interventions (Klingman,  1993 ); or community-based programs might be implemented to reduce the posttraumatic symptoms.

Early intervention has the double goal of reducing the stress-ors in a child’s life and strengthening the child’s coping mechanisms. It can often reduce the incidence and intensity of later maladjustment, thus averting problems for both the individuals concerned and the broader society. It is apparent that children’s needs can be met only if adequate preventive and treatment facilities exist and are available to the children who need assistance.

Family Therapy as a Means of Helping Children

To address a child’s problems, it is often necessary to alter pathological family interaction patterns that produce or serve to maintain the child’s behavior problems (Mash & Barkley,  2006 ). Several family therapy approaches have been developed (Prout & Brown,  2007 ) that differ in some important ways—for example, in terms of how the family is defined (whether to include extended family members); what the treatment process will focus on (whether communications between the family members or the aberrant behavior of the problem family members is the focus); and what procedures are used in treatment (analyzing and interpreting hidden messages in the family communications or altering the reward and punishment contingencies through behavioral assessment and reinforcement). But whatever their differences, all family therapies view a child’s problems, at least in part, as an outgrowth of pathological interaction patterns within the family, and they attempt to bring about positive change in family members through analysis and modification of the deviant family patterns (Everett & Everett,  2001 ).

Treatment outcome research strongly supports the effectiveness of family therapy in improving disruptive family relationships and promoting a more positive atmosphere for children (Shadish et al.,  1993 ).

Child Advocacy Programs

Today there are over 74 million people under age 18 in the United States (U. S. Bureau of the Census,  2009 ). Children who encounter mental health problems are at substantial risk for adjustment problems in later life (Smith & Smith,  2010 ). Unfortunately, both treatment and preventive programs for our society’s children remain inadequate for dealing with the extent of psychological problems among children and adolescents. In 1989 the United Nations General Assembly adopted the U.N. Convention on the Rights of the Child, which provides a detailed definition of the rights of children in political, economic, social, and cultural areas. This international recognition of the rights of children can potentially have a great impact in promoting the humane treatment of children. However, implementing those high ideals on a practical level is difficult at best.

In the United States, one approach that has evolved in recent years is mental health child advocacy. Advocacy programs attempt to help children or others receive services that they need but often are unable to obtain for themselves. In some cases, advocacy seeks to better conditions for underserved populations by changing the system (Pithouse & Crowley,  2007 ). Federal programs offering services for children are fragmented in that different agencies serve different needs; thus no government agency is charged with considering the whole child and planning comprehensively for children who need help. Consequently, child advocacy is often frustrating and difficult to implement.

Outside the federal government, advocacy efforts for children have until recently been supported largely by legal and special-interest citizen’s groups such as the Children’s Defense Fund, a public interest organization based in Washington, DC. Mental health professionals were typically not involved. Today, however, there is greater interdisciplinary involvement in attempts to provide effective advocacy programs for children (Carlson,  2001 ; Singer & Singer,  2000 ).

Although such programs have made important local gains toward bettering conditions for children with mental disabilities, a great deal of confusion, inconsistency, and uncertainty still persist in the advocacy movement as a whole (Beeman & Edleson,  2000 ), and there is still a need to improve the accountability of mental health services for children. In addition, the tendency at both federal and state levels has for some time been to cut back on funds for social services. Even so, some important steps have been taken toward child advocacy, and new efforts to identify and help high-risk children have been made (National Advisory Mental Health Council,  2007 ). If the direction and momentum of these efforts can be maintained and if sufficient financial support for them can be procured, the psychological environment for children could substantially improve.

in review

·  • What special factors must be considered in providing treatment for children and adolescents?

·  • Why is therapeutic intervention a more complicated process with children than with adults?

UNRESOLVED issues: Can Society Deal with Delinquent Behavior?

One of the most troublesome and widespread problems in childhood and adolescence is delinquent behavior, especially that involving juvenile violence (Popma,  2007 ). This behavior includes such acts as destruction of property, violence against other people, and various behaviors contrary to the needs and rights of others and in violation of society’s laws. The term juvenile delinquency is a legal one that refers to illegal acts committed by individuals between the ages of 8 and 18 (depending on state law). It is not recognized in the DSM as a disorder. The actual incidence of juvenile delinquency is difficult to determine because many delinquent acts are not reported. However, some data are available:

·  • Of the more than 2 million young people who go through the juvenile courts each year in the United States, about a million and a half are there for delinquent acts. About one in five adolescents entering the juvenile justice system suffers from a mental health condition (Phillippi & DePrato,  2010 ).

·  • In 2008, there were over 2.1 million juveniles arrested in the United States, which accounts for about 16 percent of all violent crime arrests; 1,740 juveniles were murder victims (about 11 percent of all murders) (Puzzanchera,  2009 ).

·  • A high prevalence of mental health problems has been found among adolescents in juvenile justice populations (Vermeiren et al.,  2006 ). A significant research literature shows that adolescents detained in adult correctional facilities have a high rate of suicide or are likely to commit more crimes when they are released (Bath & Billick,  2010 ).

·  • Although most juvenile crime is committed by males, the rate has also risen for females. Female delinquents are commonly apprehended for drug use, sex offenses, running away from home, and incorrigibility.

·  • Both the incidence and the severity of delinquent behavior are disproportionately high for lower-class adolescents (Puzzanchera,  2009 ) with the violent crime arrest rate five times greater for African Americans than whites.

CAUSAL FACTORS

Only a small group of “continuous” delinquents actually evolve from oppositional defiant behavior to conduct disorder and then to adult antisocial personality; most people who engage in delinquent acts as adolescents do not follow this path (Moffitt, 1993a). The individuals who show adolescence-limited delinquency are thought to do so as a result of social mimicry. As they mature, they lose their motivation for delinquency and gain rewards for more socially acceptable behavior. Several key variables seem to play a part in the genesis of delinquency. They fall into the general categories of personal pathology, pathogenic family patterns, and undesirable peer relationships.

Personal Pathology

Genetic Determinants Although the research on genetic determinants of antisocial behavior is far from conclusive, some evidence suggests possible hereditary contributions to criminality (Bailey  2000 ).

More than 2 million children a year go through the juvenile justice system for committing delinquent acts.

Brain Damage and Learning Disability  In a distinct minority of delinquency cases (an estimated 1 percent or less), brain pathology results in lowered inhibitory controls and a tendency toward episodes of violent behavior. Such adolescents are often hyperactive, impulsive, emotionally unstable, and unable to inhibit themselves when strongly stimulated.

Psychological Disorders Some delinquent acts appear to be directly associated with behavior disorders such as hyperactivity (Freidenfelt & Klinteberg,  2007 ). One study reported that over half of delinquents show evidence of mental disorders and 14 percent are judged to have mental disorder with substantial impairment that requires a highly restrictive environment (Shelton,  2001 ).

Antisocial Traits Many habitual delinquents appear to share the traits typical of antisocial personalities (Bailey,  2000 ). They are impulsive, defiant, resentful, devoid of feelings of remorse or guilt, incapable of establishing and maintaining close interpersonal ties, and seemingly unable to profit from experience.

Drug Abuse  Many delinquent acts—particularly theft, prostitution, and assault—are directly associated with alcohol or drug use (Leukefeld et al.,  1998 ). Most adolescents who abuse hard drugs such as heroin are forced to steal to maintain their habit. In the case of female addicts, theft may be combined with or replaced by prostitution as a means of obtaining money.

Pathogenic Family Patterns Of the various family patterns that have been implicated in contributing to juvenile delinquency, the following appear to be the most important.

Parental Absence or Family Conflict Delinquency appears to be much more common among youths from homes in which parents have separated or divorced than among those from homes in which a parent has died, suggesting that parental conflict may be a key element in causing delinquency.

Parental Rejection and Faulty Discipline In many cases, one or both parents reject a child. When the father is the rejecting parent, it is difficult for a boy to identify with him and use him as a model for his own development. However, the detrimental effects of parental rejection and inconsistent discipline are by no means attributable only to fathers. Adolescents who experience alienation from both parents have been found to be more prone to delinquent behavior (Leas & Mellor,  2000 ).

Undesirable Peer Relationships

Delinquency tends to be an experience shared by a cultural group (O’Donnell,  2004 ). In a classic study, Haney and Gold ( 1973 ) found that about two-thirds of delinquent acts are committed in association with one or two other people, and most of the remainder involve three or four others. Usually the offender and the companion or companions are of the same sex. Interestingly, girls are more likely than boys to have a constant friend or companion in delinquency.

Broad social conditions may also tend to produce or support delinquency (Ward & Laughlin,  2003 ). An adolescent’s developmental level can have a great deal of influence over how effectively he or she engages with the justice system and resolves his or her problems (Kraus & Pope,  2010 ). Interrelated factors that appear to be of key importance include alienation and rebellion, social rejection, and the psychological support afforded by membership in a delinquent gang. Gang activity remains a widespread problem across the United States, with prevalence rates remaining significantly elevated in 2008 compared with numbers in the early 2000s (U.S. Department of Justice, Office of Justice Programs, 2010). Every state and every large city has a gang problem, and gangs are cropping up in small rural towns across the United States as well. The problem of gang membership is most prevalent in lower-SES areas and more common among ethnic minority adolescents (48 percent are African Americans; 43 percent are Hispanic Americans) than among Caucasians. Although young people join gangs for many reasons, most members appear to feel inadequate in and rejected by the larger society. About 1 percent of youth ages 10 to 17 are gang members (Snyder & Sickmund, 2006). One study (Yoder et al.,  2003 ) found that a significant number of homeless youth (32 percent of the sample) become gang members. Gang membership gives them a sense of belonging and a means of gaining some measure of status and approval.

DEALING WITH DELINQUENCY

If juvenile institutions have adequate facilities and personnel, they can be of great help to youth who need to be removed from aversive environments (see Scott,  2010 , for a comprehensive overview). These institutions can give adolescents a chance to learn about themselves and their world, to further their education and develop needed skills, and to find purpose and meaning in their lives. In such settings, young people may also have the opportunity to receive psychological counseling and group therapy. The use of “boot camps” (juvenile facilities designed along the lines of army-style basic training) has received some support as a means of intervening in the delinquency process (Weis & Toolis,  2008 ), although some of the early programs were highly criticized as being both overly harsh and noneffective in bringing about positive change. One early study reported that youth in boot camps viewed their environment as more positive and therapeutic than did those enrolled in traditional programs and that they showed less antisocial behavior at the end of the training (MacKenzie et al.,  2001 ). However, the harsh, punitive programs favored by many “law and order” politicians (as noted by the Washington State Institute for Public Policy,  1995 ,  1998 ) often fail because they do not bring about the necessary behavioral changes through reinforcing alternative behaviors (Huey & Henggeler,  2001 ). The value of the boot camp as a behavioral change approach for young delinquents remains to be determined by research.

Behavior therapy techniques based on the assumption that delinquent behavior is learned, maintained, and changed according to the same principles as other learned behavior have shown promise in the rehabilitation of juvenile offenders who require institutionalization (Ammerman & Hersen,  1997 ). Counseling with parents and related environmental changes are generally of vital importance in a total rehabilitation program (Farrington,  2010 ), but it is often difficult to get parents involved with incarcerated delinquents.

15 summary

·  15.1 How does maladaptive behavior appear in different life periods?

·  • Children once were viewed as “miniature adults.” It was not until the second half of the twentieth century that a diagnostic classification system focused clearly on the special problems of children.

·  • In this chapter, the DSM-5 classification system is followed in order to provide clinical descriptions of a wide range of childhood behavior problems.

·  15.2 What are the common disorders of childhood?

·  • Attention-deficit/hyperactivity disorder is one of the more common behavior problems of childhood. In this disorder, the child shows impulsive, overactive behavior that interferes with his or her ability to accomplish tasks.

·  • The major approaches to treating children with ADHD have been medication and behavior therapy. Using medications such as amphetamines with children is somewhat controversial. Behavior therapy, particularly cognitive-behavioral methods, has shown a great deal of promise in modifying the behavior of children with hyperactivity.

·  • In conduct disorder, a child engages in persistent aggressive or antisocial acts. The possible causes of conduct disorder or delinquent behavior include biological factors, personal pathology, family patterns, and peer relationships.

·  15.3 Do anxiety and depression appear in children and adolescents?

·  • Children who suffer from anxiety or depressive disorders typically do not cause trouble for others through their aggressive conduct. Rather, they are fearful, shy, withdrawn, and insecure and have difficulty adapting to outside demands.

·  • The anxiety disorders may be characterized by extreme anxiety, withdrawal, or avoidance behavior. A likely cause is early family relationships that generate anxiety and prevent the child from developing more adaptive coping skills.

·  15.4 What are some specific disorders that occur in childhood?

·  • Several other disorders of childhood involve behavior problems characterized by a single outstanding symptom rather than pervasive maladaptive patterns. The symptoms may involve enuresis, encopresis, sleepwalking, or tics.

·  15.5 What are intellectual disabilities?

·  • Specific learning disorders are those in which failure of mastery is limited to circumscribed areas, chiefly involving academic skills such as reading. General cognitive ability may be normal or superior.

·  • Affected children are commonly described as learning disabled (LD). Some localized defect in brain development is often considered the primary cause of the disorder. Learning disorders create great turmoil and frustration in victims, their families, schools, and professional helpers.

·  • When serious organic brain impairment occurs before the age of 18, the cognitive and behavioral deficits experienced are referred to as intellectual disability. Relatively common forms of such intellectual disability, which in these cases is normally at least moderate in severity, include Down syndrome, phenylketonuria (PKU), and certain cranial anomalies.

·  • This organic type of mental deficit accounts for only some 25 percent of all cases of intellectual disability.

·  • In children with autism spectrum disorders, extreme maladaptive behavior occurs during the early years and prevents affected children from developing psychologically.

·  • It has not been possible to normalize the behavior of children with autism through treatment, but newer instructional and behavior modification techniques have been helpful in improving the functioning of less severely impaired children with autism.

·  15.6 How can we plan better programs to help children and adolescents?

·  • We reviewed a number of potential causes for the disorders of childhood and adolescence. Although genetic predisposition appears to be important in several disorders, parental psychopathology, family disruption, and stressful circumstances (such as parental death or desertion and child abuse) can also contribute.

·  • There are special problems, and special opportunities, involved in treating childhood disorders. The need for preventive and treatment programs for children is always growing, and in recent years child advocacy has become effective in some states. Unfortunately, the financing and resources necessary for such services are not always readily available, and the future of programs for improving psychological environments for children remains uncertain.

key terms

·  Adderall  514

·  attention-deficit/hyperactivity disorder (ADHD)  511

·  autism spectrum disorder  527

·  conduct disorder  516

·  developmental psychopathology  510

·  Down syndrome  536

·  dyslexia  532

·  echolalia  529

·  encopresis  525

·  enuresis  525

·  hydrocephaly  539

·  intellectual disability  534

·  juvenile delinquency  515

·  learning disorders  532

·  macrocephaly  539

·  mainstreaming  540

·  microcephaly  539

·  neurodevelopmental disorders  527

·  oppositional defiant disorder (oDD)  515

·  Pemoline  513

·  phenylketonuria (PKu)  538

·  ritalin  513

·  separation anxiety disorder  518

·  sleepwalking disorder  526

·  Strattera  513

·  tic  526

·  Tourette’s disorder  527