Ch 13 (lesson 16): childhood disorders Flashcards

1
Q

disorders of Childhood

A
  • attention deficit disorder
  • conduct disorder
  • depression and anxiety disorders
  • learning disability
  • communication disorders
  • motor disorders
  • intellectual development disorder
  • autism spectrum disorder
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2
Q

Developmental psychopathology

A

area of psychopathology that studies disorders within context of normal child development

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3
Q

relationship btwn child and adult psychopathology

A
  • some disorders are unique to children
    • eg: separation anxiety disorder
  • some disorders are primarily childhood disorders, but may continue into adulthood
    • eg: adhd
  • some disorders are present in children and adults
    • eg: depression

symptoms can be quite different in adulthood than in childhood

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4
Q

DSM-5 childhood disorders- 2 chapters

A
  • Neurodevelopmental disorders
  • Disruptive, Impulse Control, and Conduct disorder
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5
Q

changes in DSM-5 from DSM-IV-TR

A
  • name changes
    • eg: mental retardation –> intellectual developmental disorder
  • DSM-5 combined some disorders
    • eg: autistic disorder, aspergers, childhood disintegrative disorder, and pervasive developmental disorder —> combined into autism spectrum disorder
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6
Q

the more prevalent childhood disorders are often divided into two domains:

A
  • Externalizing disorders (outward-directed behavior such as aggressive, noncompliant, over-active, impulsive)
  • Internalizing disorders (inward focused experiences/ behavior like depression, social withdrawel, anxiety)
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7
Q

Externalizing disorders

A

contains:

  • ADHD
  • conduct disorder
  • oppositional defiant disorder

characterized by:

  • outward-directed
    • aggressiveness
    • noncompliance
    • over-activity
    • impulsiveness
  • more common in boys
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8
Q

internalizing disorders

A

contains

  • childhood anxiety
  • mood disorders

characterized by

  • inward behaviors and experiences
    • depression
    • anxiety
    • social withdrawal
  • more common in girls
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9
Q

Attention Deficit/Hyperactivity Disorder

A

can include:

  • Excessive levels of activity (Hyperactivity)
    • fidgeting, squirming, running around when inappropriate, incessant talking
  • Distractibility + difficulty concentration
    • careless mistakes, cannot follow instructions, forgetful
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10
Q

DSM-5 criteria of AD/HD

A

either A or B:

  • A. 6+ manifestations of inattention at least 6 mo
    • eg: careless mistakes, not listening well, not following instructions, distraction, forgetful
  • B. 6+ manifestations of hyperactivity-impulsivity at least 6 mo
    • eg fidgeting, running about, “driven by a motor”, interrupting/intruding, incessant talking
  • some of the above present b4 age 12
  • present in 2+ settings
  • sig impairment
  • 17+, only 5 signs
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11
Q

ADHD presentation specifiers

A
  • predominantly inattentive
  • predominantly hyperactive-impulsive
  • combination of both presentations
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12
Q

ADHD or Conduct Disorder? (differential diagnosis)

A

adhd:

  • more off-task behavior, cog and achievement deficits

conduct disorder:

  • more aggressive, act out in most settings, antisocial parents, family hostility

if have both:

  • worst features of each manifest
  • most serious antisocial behavior
  • most likely rejected by peers
  • poorest academic acheivement
  • poorest prognosis
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13
Q

prevalence, gender differences, comorbidity, beyond childhood

A
  • comorbidity: anxiety + depression (30% adhd have)
  • prevalence- 3-7%, now 8-11%
  • more common in boys (maybe due to boys more externalized/ aggressive)
  • persistence beyond childhood:
    • 65%- 85% still exhibit symptoms
    • 60% adults continue to meet criteria in remission
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14
Q

girls w ADHD

A

Hinshaw et al- large diverse study on girls w adhd

  • girls tended to be combined or inattentive type

combined type had:

  • more disruptive behavior than inattentive type
  • more comorbid diagnoses of conduct disorder or oppositional defiant disorder than w/out ADHD
  • viewed more neg by peers than inattentive or w/out ADHD

Inattentive type:

  • viewed more neg than girls w/out ADHD
  • exhibit neurological deficits (poor planning, prob solving)
  • have symptoms of EDs and Substance abuse by adolescence
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15
Q

Etiology of ADHD- Genetic factors

A
  • adoption and twin studies
    • heritability estimates 70-80%
  • two dopamine genes implicated *
    • DRD4 (dopamine receptor gene)
    • DAT1 (dopamine transporter gene)
    • *either gene assoc. w/ increased risk ONLY when prenatal maternal nicotine or alc use is present

not one single gene, many genes interacting w eachother and enviro

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16
Q

Etiology of ADHD- Neurobiological factors

A
  • Dopaminergic areas smaller in kids w ADHD
    • frontal lobes, caudate neucleus, globus pallidus
  • Poor performance on tests of frontal lobe function (exec functioning, impulsivity)
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17
Q

Etiology ADHD- Prenatal + Perinatal factors

A
  • Low birth weight
    • can be mitigated by later maternal warmth
  • maternal tobacco and alc use
    • exposure to tobacco in utero
    • may damage dopaminergic system resulting in behavioral disinhibition
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18
Q

etiology of ADHD- Enviornmental toxins

A
  • Limited evidence that food additives/ coloring may have small impact on hyperactive behavior
  • no evidence that refined sugar causes ADHD
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19
Q

Etiology of ADHD- parent-child relationships

A
  • parents give more commands/ have more neg interactions
  • family factors-
    • interact w genetic and neurobiological factors
    • contribute to or maintain ADHD behaviors, not cause them
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20
Q

treatment of ADHD- meds

A

Stimulants (ritalin, adderall, concerta, strattera)

  • reduce disruptive behavior
  • improve interactions
  • improve goal-directed behavior/ concentration
  • reduce aggression

side effects:

  • loss of appetite
  • weight
  • sleep probs
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21
Q

Treatment ADHD- meds plus behavioral treatment

A
  • slightly better than meds alone
  • improved social skills, meds alone don’t
  • 3 year followup found superior benefits of meds by themselves didn’t persist
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22
Q

treatment of ADHD- behavioral/ psych treatment

A

psych treatment:

  • parental training
  • change in classroom mgmt
  • behavior monitoring and reinforcement of approp. behavior
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23
Q

treatment of adhd- behavior treatment- classroom structure

A

supportive classroom structure:

  • brief assignments
  • immediate feedback
  • task-focused style
  • breaks for exercise
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24
Q

Conduct Disorder (CD)

A
  • pattern of engaging in behaviors that violate social norms/ rights of others/ often illegal
    • aggression
    • cruelty towards ppl/animals
    • damaging property
    • lying
    • stealing
    • vandalism
  • oft w viciousness, callousness, lack of remourse
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Oppositional Defiant Disorder (ODD)
- ODD behaviors don't meet criteria for CD (esp extreme physical aggressiveness) but displays pattern of defiant behavior - argumentative - loses temper - lack of compliance - deliberately aggravates others - Hostile, vindictive, spiteful, or touchy - blames thers - comorbid w ADHD, learning and communication disorders - disruptive behavior of ODD more deliberate than ADHD - Most often diagnosed in boys, but may be as prevalent in girls - 8.3% prevalence
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Intermittent explosive disorder (IED)
- recurrent verbal or physical aggressive outbursts that are fare out of proportion - diff from conduct disorder, because the outburts are impulsive, not preplanned
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DSM-5 criteria for Conduct disorder
- repetitive and persistent behavior pattern that violates basic rights of others/ social norms - 3+ in the last 12 mo, atleast 1 in last 6 mo - A. aggression to ppl or animals - B. destruction of property - C. deceitfulness or theft - D. serious violation of rules - significant impairment is social, academic, occupational func. - includes a "limited prosocial emotions" diagnostic specifier for kids w callous, unemotional traits
28
Conduct disorder, comorbidity
- substance abuse common - unclear whether in precedes or is concomitant - Comorbid w anxiety and depression - 14-45% - CD precedes anxiety and depression (but phobias and social anxiety precedes it)
29
Prevalence of conduct disorder
- 7% preschool children exhibit symptoms - boys 4-16% - girls 1.2-9%
30
Conduct disorder-2 types
- 1. Life-course-persistent pattern of antisocial behavior - 10-15x more likely in boys - 2. Adolescence-limited - maturity gap btwn physical maturation and rewarding adult behaviors follow up longitudinal studies of life-course-persistent type show more severe probs into adulthood including: - academic underacheivement - neurophyscological - ADHD - family psychopathology - poorer physical health - lower SES - violent behaviors
31
Etiology of Conduct disorder- factors
- social factors - psychological factors - neurobiological factors interaction between all three to develop conduct disorder
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Etiology of CD- Genetic factors
- Heritability likely plays a part - twin study mixed results - genetics played role in rule-breaking behavior in wealthy areas, not as much in poor areas - adoption studies focused on criminal behavior, not conduct disorder - meta-analysis of twin + adopt studies suggest 40-50% heritability of antisocial behavior - genetics stronger influence when behaviors begin in childhood (rather than adolescence) - genetics and environment- - abuse as child PLUS low MAOA activity most likely to develop CD
33
Etiology of CD- Neurobiological factors
- poor verbal skills - difficulty w executive functioning - Low IQ - Lower levels of resting skin conductance and heart rate-- suggests lower arousal levels (less anxious of doing bad/getting caught) txtbook adds - those w callous/ unemotional traits: deficits in regions that support emotion, especially empathy - amygdala, ventral striatum, prefrontal cortex
34
Etiology of CD- Psych factors
- deficient moral development, lack of remorse - modeling and reinforcement of aggressive behavior - harsh and inconsistent parenting - lack of parental monitoring - Cognitive bias: neutral acts by others perceived as hostile
35
dodge's cognitive theory of aggression- CD
---> ambiguous act interp. as hostile --> aggression toward others --> retaliation from others --> further angry aggression towards others -->
36
Etiology of CD: Peers, Sociocultural
- Peer influences associated w CD - Rejection by peers - Affiliation w deviant peers -Sociocultural factors - poverty - urban enviro - higher rates of delinq. acts among PoC males linked to living in poorer neighborhoods rather than race txtbook adds- - social selection view: kids w CD choose to be assoc. w likeminded peers, thus cont. antisocial behavior - social influence view: being around devient peers helps initiate antisocial behavior both correct
37
treatment of Conduct disorder- Family Interventions
Family Interventions - Family check-ups (FCU) assoc. w less disruptive behavior - Parental mgmt training (PMT) - teach parents to reward prosocial behavior - positive reinforcement for pos behaviors, time-out and loss of privileges for aggressive or antisocial behavior
38
treatment of Conduct disorder- Multisystemic therapy (MST)
Multisystemic therapy (MST) - Deliver intensive community-based services - incorporates behavioral, cog, family-systems, and case-mgmt techniques - emphasizes individual and family strenghs - identifying social context for the conduct prob - using present-focused and action-oriented interventions - interventions that require daily/weekly efforts by family members treatment is provided in homes, schools, local recreational centers to maximize chances that improvement will carry into the daily lives of children/their familiies
39
treatment of Conduct disorder- prevention program
types- Head start, Fast Track goal: to prevent conduct disorder before it develops - Fast track- impressive reductions in later psychopathology w brief intervention
40
Depression and Anxiety in children/adolescents- Comorbidity
- often co-occur w ADHD and CD - also co-occur w eachother - early research suggested depression and anxiety can be distinguished from each other the same way as in adults - depression: high neg affect, low pos affect - anxiety: high neg affect but not low levels of pos affect - more recent research calls this into question
41
Symptoms of Depression shared by children, adolescents, and adults
- depressed mood - inability to experience pleasure - fatigue - probs concentrating - suicidal ideation
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Symptoms of Depression specific to children and adolescents
- higher rates of suicide attempts - higher rates of guilt - lower rates of - early morning awakening - early morning depression - loss of appetite - weight loss
43
prevalence of depression in children/ adolescents
- 1% preschoolers - 2-3% under 12 - 15.9% adolescent girls, 7.7% adolescent boys
44
Etiology of Depression- Genetic factors
- Having depressed parents = 4x increase in risk of developing depression in childhood - there are risks of this involving genes and the environment - gene-enviro interaction- ppl w short allele of serotonin transporter gene AND sig interpersonal stressful life events more likely to have depressive episode -interpersonal factor esp. important in adolescent girls
45
Etiology of Depression- Early adversity/ life events
kids w depression (15-20) more likely to have experienced early adversity and neg life events
46
Etiology of Depression- Family and relationship factors
- a parent who is depressed - parental rejection modestly assoc. w depression - children w depression and their parents interact in negative ways - less warmth - more hostility
47
Etiology of depression- Cog distortions and neg attributional style
- cog distortions and neg attributional style, hopelessness theory - stable attributional style - develops by early adolescence - by 8th/9th grade attributional style serves as cog diathesis for depression
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Etiology of Depression- Brain factors
- HPA axis and release of cortisol - cortisol levels on awakening predicted onset of of MDD - cortisol in depressed ppl assoc. w smaller hippocampus volume - grew more slowly btwn early + mid adolescents for those who developed depression
49
treatment of depression- meds
- SSRIs more effective than tricyclics - Meta-analysis show medications most effective for anxiety other than OCD - less effective for depression and OCD Concerns abt meds: - side effects including diarrhea, nausea, sleep probs, agitation - possibility of increased risk of suicide attempts
50
treatment of depression- psychotherapy
- IPT (interpersonal therapy) - Focuses on peer pressures, transition to adulthood, and issues related to independence - CBT - More effective for white adolescents, those w good coping skills already, and those w recurrent depression -Psychotherapy generally only modestly effective w kids and adolescents - CBT no better than other therapies
51
treatment of depression- two types of preventative interventions
- selective prevention programs - target kids based on family and enviro risk factors - universal prevention programs - targeted towards large groups, provide info about depression
52
Anxiety in Children and Adolescents
- Anxiety disorder - more severe and persistent worry - must interfere w functioning - most childhood fears disappear but adults w anxiety disorders report feeling anxious as children - unlike adults, kids don't need to regard their anxiety/ fear as unreasonablw - 3-5% prevalence
53
Separation Anxiety Disorder
- worry about parental or personal safety when away from parents - typically observed when child begins school - associated w development of other internalizing and externalizing disorders later
54
social anxiety disorder
- extremely shy and quiet - selective mutism - refusal to speak in unfamiliar social setting - 1% prevalence - Etiology - often overestimation of threat - underestimation of coping ability - poor social skills
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PTSD
- Exposure to trauma - chronic physical or sexual abuse - community violence - natural disasters - symptom categories - flashbacks, nightmares, intrusice thoughts - avoidance - neg cognitions and moods - hyperarousal and vigilance differ from adults: - may exhibit agitation instead of fear/hopelessness
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OCD
- prevalence 1-4%, more common in boys - symptoms similar to those in adults - most common obsessions: - contamination from dirt/germs - aggression - thoughts about sex/religion (more common in adolescence)
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Etiology of anxiety disorders- Genetics
- Heritability 29-50% - Genetics play stronger role in separation anxiety in context of more neg life events
58
Etiology of anxiety disorder- parenting, attachment, etc
- parenting plays small role - 4% variance - parental control and overprotectiveness more so than parental rejection - emotion regulation and attachment probs also play a role - overestimate danger, underestimate ability to cope - perception of lack of acceptance/ being bullied risk factor in anxiety and social phobia
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etiology of anxiety disorders- PTSD
- family stress and coping style - past experience w trauma - parent reactions to trauma can help lessen child's distress
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treatment of Anxiety Disorders - Exposure
- Exposure to feared object - reward approach behavior CBT Kendall's Coping Cat - shows to be effective in two randomized clinical trials - 7-13 - Cognitive restructuring - develop new ways to think about fears - Psychoeducation - Modeling and exposure - skills training and practice - relapse prevention - family involved in treatment txtbook: Coping Cat focuses on: - confrontation of fears - development of new ways to think about fears - exposure to feared situations - relapse prevention
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treatment of anxiety- OCD
- CBT + Zoloft
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Specific Learning Disorder (Learning Disability?- slide show)
- Evidence of inadequate development in specific area of academic, language, speech, or motor skills - not due to intellectual disability, autism, physical disorder, or deficient educational opportunities - usually average or above avg intelligence - often identified and treated in school - reading disorders more common in boys
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DSM-5 criteria for Specific learning disorder
- Difficulties in learning basic academic skills (reading, math, or writing) inconsistent w age/ schooling/intelligence - persists atleast 6 mo - sig intereference w academic achievement or activities
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specifiers of Specific Learning Disorder
- Reading impairment (Dyslexia) (5-15%) - written expression impairment - math impairment (dyscalculia)
65
Communication DIsorders
- Speech Sound disorder (formerly phonological disorder) - Childhood-onset Fluency Disorder (formerly stuttering) - Social (pragmatic) communication Disordr -Language Disorder
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Speech Sound Disorder
formerly phonological disorder - correct comprehension and sufficient vocabulary use - unclear speech and improper articulation
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Childhood-onset fluency Disorder (stuttering)
Disturbance in verbal fluency characterized by one or more of the following speech patterns: - frequent repetitions or prolongation of sounds - long pauses btwn words - substituting easy words for thos that are difficult to articulate - repeating whole words
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Social (pragmatic) communication disorder
- persistent difficulty with verbal + non-verbal communication - limits effective communication, social relationships, academic achievement, or occupational performance - not explained by low cog ability - must be present in early childhood
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language disorder
- Persistent deficits in comprehension production of language - substantially below age level - beginning in early development period, not due to other disorders/ conditions
70
Motor Disoders
- Developmental Coordination Disorder (fka motor skills disorder - Marked impairment in dev. of motor coord
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- repetitive, seemingly purposeless, oftem rhythimical motor behavior - interferes w normal activities - onset in "early dev. periods"
Sterotypic Movement Disorder
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Involves one or more vocal and multiple motor tics (sudden rapid movement/vocalization) - onset before 18
tourrette's Disorder
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at least on motor or vocal tic, not both - must be present for > 1 year - onset before 18
Persistent (chronic) motor or vocal tic disorder
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one or more motor and or vocal tics, present < 1 year - onset before 18
provisional tic disorder
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tic disorder symptoms causeing distress/ impairment but not meeting other criteria
Other Specified tic disorder or "Unspecified tic disorder", if reason is unspecified
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Etiology of Dyslexia- Genetic Factors
- Evidence from family and twin studies show heritable component - genes for dyslexia are genes associated w typical reading abilities (generalist genes)
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Etiology of Dyslexia- Problems in language processing
- deficient PHONOLOGICAL AWARENESS - inadequate left temporal, parietal, occipital activation - phonological awareness : includes perceiving spoken language and its relation to printed words, detedcting syllables, recognizing rhyme - difficulties in speech perception - difficulties in analysis of sounds and their relationship to printed words - difficulty recognizing rhyme and alliteration - problems naming familiar objects rapidly - delays learning syntactic rules
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Parts of brain implicated in dyslexia
- frontal lobe - temporal lobe - parietal - sometimes occipital too
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Etiology of Dyscalculia- Genetic and biological
- Evidence from twin studies suggest common genetic factors underlie both reading and math defecits - intraparietal sulcus implicated - has different cog deficits from dyslexia - kids w only dyscalculia don't have deficits in phonological awareness
80
treatment of reading/writing disorder
- mulitsensory instruction in listening, speaking, writing skills - readiness skills in younger kids in preparation for learning to read - phonics instruction
81
treatment of communication disorders
- fast forWard - computer games and audiotapes that slow speech sounds
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Intellectual Disability (Intellectual Developmental Disorder?)
- fka mental retardation in DSM-IV-TR - not preferred due to stigma - followed the guidelines of American Association on Intellectual and Developmental Disabilities AAIDD definition of Intellectual Disability: - characterized by sig limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual , social and practical adaptive skills - began before 18 - Five assumptions Essential to the App. of the definition - 1. limitations in func considered w/in context of community enviro typical of person's age/peers/culture - 2. valid assess. considers cult. and linguistic diversity as well as differences in communication/sensory/motor/ behavioral factors - 3. w/in indvl limitations coexist w strengths - 4. purpose of describing limitations is to develop profile of needed supports - 5. w aprop. personalized supoorts over sustained period, life func of person w intellec. disability generally will improve
83
Intellectual Disability- DSM-5
- Intellectual deficit of 2 or more std deviation in IQ below the avg score for age + culture- typically below 70 - sig deficits in adaptive func relative to age + culture in 1+ area: - communication - social participation - work or school - independence and home/community - requiring need for support at school/work/ind. life - onset during development
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Intellectual disability- Dsm-5 changes
- explicit recog that IQ score consirdered w/in cultural context - adaptive func also assessed/ considered w/in age/culture - no longer distinguish mild, mod, severe ID based on IQ scores alone
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Etiology of Intellectual Disability- neurobiological factors
- Down syndrome - chromosomal trisomy 21- extra copy of chromosome 21 ( 47 instead of 46) - Fragile-X syndrome - mutation in fMR1 gene on X chromosome - Recessive-gene disease - Phenylketonuria (PKU) - Maternal infectious disease, esp during 1st trimester - cytomegalovirus, toxoplasmosis, rubella, herpes simplex, HIV, syphilis - lead/mercury poisoning
86
Treatment of Intellectual Disability- residential, behavioral
- Residential treatment - small- med sized community residences - Behavioral treatments - language, social, motor skills training - method of successive approximation (shaping) to teach basic self-care skills for severe cases (holding a spoon, toilet) - applied behavioral analysis- applying behavioral learning theory to learn new skills - Cognitive treatments - problem-solving strategies - computer-assisted instruction
87
Autism Spectrum Disorder- DSM-5 vs IV-TR
- DSM-5 combines multiple diagnoses into Autism Spectrum disorder: - Autistic disorder - Aspergers Disorder - pervasive developmental disorder not otherwise specified - childhood disintegrative disorder - research didn't support distinctive categories - share similar clinical features- vary only in severity - DSM_5 includes clinical specifiers relating to severity and extent of language impairment
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`DSM-5 criteria for Autism spectrum disorder
total of 6+ items from A, B, and C below w at least 2 from A, 1 each from B and C A. Deficits in Social communication/interactions: - deficits in nonverbal behavior (eye contact, facial expression, body lang) - deficits in dev of peer relationships - deficits in social/emotional reciprocity (not approaching others, not having back-and-forth, reduced sharing of interests/emotions) B. Restricted, repetitive behavior patterns/interests/activities - stereotyped or repetitive speech motor movements, use of objects - excessive adherence to routines, rituals in verbal/nonverbal behavior, resistance to change - v restricted interests abnormal in focus, such as parts of objects - hyper or hypo-reactivity to sensory input or unusual interest in sensory enviro C. onset in early childhood D. symptoms limit and impair functioning
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characteristics of autism
- profound problems w social world - theory of mind - communication deficits - repetitive and ritualistic acts
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autism - profound problems w social world
- rarely approached by others, may look through people - problems in joint attention - pay attention to different parts of face- neglect eye contact - this likely contributes to difficulties in perceiving emotion in other people
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autism- theory of mind
theory of mind - understanding that other people have different desires, beliefs, intentions, emotions - crucial for understanding and successfully engaging in social interaction - typically develops btwn 2.5-5 yrs - children w ASD seem not to achieve this developmental milestone- atleast to same degree
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autism-communication deficits
- kids w ASD have evidence of early language disturbances - Echolalia: immediate or delayed repetition of what was heard - pronoun reversal - literal use of words
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ASD- repetitive and ritualistic acts
- extremely upset when routine altered - engage in obsessional play - engage in ritualistic body movements - become attached to inanimate objects
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ASD- comorbidity, prevalence, prognosis
Comorbidity: - IQ> 70 common - kids w intellectual disability score poorly on all parts of IQ test, ASD score poorly on subtests related to language, tasks requiring abstract thought, symbolism, sequential logic - anxiety - specific learning disorder prevalence - 1/110 kids - found in all SES, ethnic, racial groups - diagnosis of ASD remarkably stable prognosis - kids w higher IQ who learn to speak b4 6 have best outcomes
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Etiology of ASD- genetic
- heritability: .80 - twin studies: 47-90% for MZ twins, 0-20% for DZ - genetic flaw- deletion of chromosome 16
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Etiology ASD- Neurobiological factors
- Brain size - although normal size at birth, brains of autistic adults/kids are bigger than normal - pruning of neurons not occurring -"overgrown" areas include frontal, temporal, cerebellar - linked to language, social, emotional func. -abnormally sized amygdalae predicted more difficulty in social behavior/communication
97
Treatment of ASD
- Psych treatments more promising than drugs - Earlier treatment = better outcomes Behavioral treatments: - Intensive Operant Conditioning (dramatic, encouraging results) - using reinforces to teach kids appropriate responses, motor behavior etc. - Parent training and education - Pivotal Response Treatment - focus on increasing motivation and responsiveness rather than on discrete behaviors - Joint Attention Intervention and symbolic play used to improve attention and expressive skills
98
treatment for ASD- meds
Haloperidol (Haldol) - antipsychotic - reduces aggression and motor behavior - doesn't improve language and interpersonal relationships