Chapter 11 (Lecture - Ch 9 in textbook)

Question 1

Neurodevelopmental Disorders

Answer 1

Neurodevelopmental disorders include:
- fetal alcohol spectrum disorders (FASD)
- intellectual disorders
- motor disorders (Tourette syndrome)
- communication disorders
- genetically determined disorders (down and Williams syndrome)
- conditions associated with traumatic and congenital brain injuries (cerebral palsy)

There is a wide variation in the symptoms and severity associated with these disorders

Question 2

Autism Spectrum Disorder (ASD)

Answer 2

• characterised by persistent deficits in social communication and social interaction across multiple contexts including deficits in social reciprocity, nonverbal communicative behaviours used for social interaction, and skills in developing, maintaining and understanding relationships
• presence of restricted, repetitive patterns of behaviour, interest, or activities
• many previously diagnosed with Asperger’s disorder would now receive a diagnosis of autism spectrum disorder without language or intellectual impairment

Question 3

neurodevelopmental disorders share 2 key features

Answer 3

1. a neurological dysfunction that affects the capacity of the individual for intellectual, social, and (sometimes) physical development
2. individuals diagnosed with these disorders may struggle to fit in and be fully included in society

Focus on being biological in nature and posing challenges to social functioning and educational achievement

Question 4

ADHD

Answer 4

• characterised by inattentive, hyperactive, impulsive behaviours
• stereotypically: a boy who has difficulty sitting well, being organised, concentrating, resisting impulses, and who may be aggressive
• often first noticed at school, where these behaviours are a deemed “problematic”
• once referred for assessment, the DSM-5 checklist is used to see if the child meets criteria for diagnosis (6/18 symptoms, consistently for 6 months)
• many of the listed criterion are normal childhood behaviours - it is the frequency and social impact of them that leads to diagnosis

Question 5

ADHD symptoms and checklist

Answer 5

clinicians uses the DSM-5 checklist to make the diagnosis, the child must have presented 6 out of 18 symptoms consistently over a period of 6 months

These symptoms include when a child has:
- difficulty waiting their turn
- often talks excessively
- often fails to give close attention to details or make mistakes
- often does not follow through on instructions and fails to finish schoolwork or workplace duties

While these sorts of symptoms may be problematic (leading to impairment or hindering performance), it is easy to see how they can be interpreted subjectively, perhaps leading to over-diagnosis of the disorder

Also:
- these symptoms are evident among adults when they are stressed, anxious, or short of time
- many high functioning and very effective people may display these symptoms
- context specific nature is evident: one view of ADHD is that specific people (children) do not adequately “fit” with expectations in classrooms and behaviour is deemed a “problem”

Question 6

ADHD criticisms

Answer 6

Key criticism: diagnositc criteria may be explained by immaturity (has not yet reached a particular level of development) - the youngest children in a school cohort are more likely to be diagnosed with ADHD, and even more likely to be prescribed medication (unable to “fit” with expectations and context)
- estimated that approximately 1.1 million children received an inappropriate diagnosis and over 800,000 received stimulant medication due only to relative maturity -illustrating the importance of this “immaturity” or development view
- another critique points out that a regimented classroom setting may lead to misbehaviour for some children who then would be more likely to be diagnosed, compared to children in a more active, flexible, and hands-on environment (contextual influence on diagnosis)

Question 7

ADHD global prevalence

Answer 7

5% in children
2.5% in adults

Question 8

Autism

Answer 8

• difficulty understanding the need to be social and managing social interactions is an essential feature of autism
• evolutionary perspective: social relations are the core of our success and survival, so autism may have brought some advantages for individuals as well
• this visibility and perceived prevalence of autism may have risen as society became increasingly urban and complex- became an important concept in the 1940s

Question 9

Autism - clinical perspective

Answer 9

People with autism struggle to manage social life and social expectations
- core symptoms of autism: difficulties with reciprocal social interaction and communication, as well as repetitive, stereotypical routines and behaviours and associated sensory symptoms
There is no biological marker for autism; it can not be observed or diagnosed with a brain scan, it is not clear what causes it

Question 10

High prevalence of childhood mental disorders - ADHD and Autism

Answer 10

2. ADHD 3.7 prevalence
3. Autism Spectrum disorder 0.4 prevalence

Question 11

ADHD DSM-5 diagnosis

Answer 11

3 components: must feature at least 1:
1. inattention
2. hyperactivity
3. impulsivity
- in the DSM-5 its 2 they focus on: inattention and hyperactivity-impulsivity (they combine 2 and 3)

• several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years
• several inattentive or hyper-impulsive symptoms are present in two or more settings (home, school, work, etc)
• there is clear evidence that the symptoms interfere with, or reduce the quality of social, academic, or occupational functioning
• 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)

Question 12

3 types of ADHD and 3 severity levels

Answer 12

3 Types:
1. combined
2. predominantly inattentive
3. predominantly hyperactive/impulsive

3 Severity levels:
1. mild (w/ minor impairments)
2. moderate
3. severe

Question 13

Culture-related diagnostic issues for ADHD

Answer 13

Positivist view tells us ADHD “exists everywhere” (not just North America), but:

• differences in ADHD prevalence rates across regions appear attributable mainly to different diagnostic and methodological practices
• cultural variation in attitudes toward or interpretation of children’s behaviours (some people think that’s just how kids act)
• clinical identification rates in the US for African Americans and Latino populations tend to be lower than white populations
• informant symptom ratings may be influenced by cultural group of the child and informant

Question 14

Gender-related diagnostic issues for ADHD

Answer 14

• ADHD is more frequent in males than in females in the general population
• ratio 2:1 in children
• ratio 1.6:1 in adults
• females more likely to display inattentive presentation

Question 15

Functional consequences of ADHD

Answer 15

• associated with reduced school performance and academic attainment, social rejection, in children
• in adults, poorer occupational performance, attainment, attendance, and higher probability of unemployment and elevated interpersonal conflict
• children w ADHD are significantly more likely than other kids to develop conduct disorder in adolescence and antisocial personality disorder in adulthood which then increases likelihood for substance use disorders and incarceration
• people w ADHD are more likely to be injured
• traffic accidents and violations are more frequent in drivers with ADHD
• may be an elevated likelihood of obesity among individuals with ADHD
• ADHD often interpreted by others as laziness, irresponsibility, or failure to cooperate
• family and friend relationships may be negative

Question 16

Autism Spectrum Disorder - DSM-5 diagnosis

Answer 16

Criteria A: Persistent deficits in:
- social emotional reciprocity
- non-verbal social interactions
- relationships: developing, maintaining, and understanding
Criteria B: at least 2/4 (currently or previously)
- repetitive motor movements
- insistence on sameness/inflexibility
- restricted interests and fixation
- hyper or hypo- reactivity to sensory stimuli
C: appear early
D: difficulty, impairment
E: ruling out other conditions/causes of symptoms
Specifications: with/without accompanying conditions, or associated with medical condition, or other “disorder”

Question 17

Autism Spectrum Disorder - Level 1 severity (lowest severity)

Answer 17

Requiring Support

Social communication:
- without support, social communications causes noticeable impairments
- difficulty initiating social interactions
- atypical responses to social overtures of others
- may have decreased interest in social interactions

Restricted, repetitive behaviours:
- inflexibility of behaviour causes significant interference with functioning in one or more contexts
- difficulty switching between activities
- problems of organisation and planning

Question 18

Autism Spectrum Disorder - Level 2 Severity

Answer 18

Requiring substantial support

Social communication:
- deficits in verbal and non-verbal social communication skills
- social impairments apparent even with supports in place
- limited initiation of social interaction
- reduced or abnormal responses to social overtures with others

Restricted, repetitive behaviours:
- inflexibility of behaviour, difficult of coping with change, or other restricted/repetitive behaviours appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of context
- distress and/or difficulty changing focus on action

Question 19

Autism Spectrum Disorder - Level 3 Severity (most severe)

Answer 19

Requiring very substantial support

Social communication:
- severe deficits in verbal and nonverbal social communication skills cause severe impairment in functioning
- very limited initiation of social interactions
- minimal responses to social overtures for others

Restricted, repetitive behaviours:
- inflexibility of behaviour
- extreme difficulty coping with change
- great distress/difficulty changing focus or action

Question 20

Allie Jaynes - her experience of ADHD

Question 21

Toby and Rosie TEDx

Question 22

Emergence of ADHD and Autism

Answer 22

1957: Terms “hyperkinetic impulse disorder” and “hyperkinetic behaviour syndrome” were coined.
- They described a child with a short attention span, who was impulsive (consistent with the current description of ADHD)

• developments in US education transformed classrooms in the early primary years from more experiential environments to places where students were expected to sit quietly - this was difficult for some students
• Ritalin, still used in the treatment of ADHD, was used as a treatment
• the rate of diagnosis of ADHD varies considerably internationally as well as regionally within countries
• Notably - Finland (w high educational outcome indicators) and the UK have lower rates of diagnosis

Question 23

Case Study - A Rose by Any Other Name

Answer 23

• hyperkinetic impulsive disorder was the term coined by Eric Denhoff and Maurice Laufer in 1957
• hyperkinesis or hyperactivity were other terms, and the DSM-II (1968) used the term “hyperkinetic reaction of childhood (or adolescence)”
• DSM-III (1980) introduced the term “attention-deficit disorder with or without hyperactivity” or ADD/ADD-HD
• DSM-III was revised in 1987 - the term ADHD finally came into being - then rates of the disorder began to reach epidemic proportions, first in the US and later globally

Question 24

Social and Political Developments

Answer 24

WWII: importance of psychiatry due to interest in keeping soldiers mentally healthy enough to fight
- leading to more prestige in psychiatry and the foundation of the National Institute of Mental Health in the US (1949)
The rise of biological and social psychology
- development of new drugs placed focus on biology and the brain as key to mental health
- Ritalin marketed as a new wonder drug
Demographic trend: Baby boomer generation, more children in schools (overwhelming system) with unique experiences (TV, processed foods, automobile transport, suburban existence)
- also start of gradual movement to eliminate corporal punishment

Question 25

Education Reform

Answer 25

Sputnik
- Americans were losing the “brain race”
- the child-centred, hands-on, flexible approach to children’s education was not suited to produce the types of scientists and engineers needed to win the space race
- schools and flexible learning styles were framed as “letting down” the nation in a time of great danger

GI Bill: helped created the expectation that post secondary education was necessary for success

National Defence Education Act (1958)
- classrooms were transformed from active spaces of learning to static spaces (learning by book instead of through example/practice)
- provided funding for guidance counsellors who served as intermediary between the educational and medical sphere, identifying children who struggled in these states spaces

Question 26

Treatment Debates - ADHD

Answer 26

Stimulant drugs are the primary treatment for ADHD - Ritalin was the first approved for use in children for treatment of ADHD (1950s), though other stimulants were used earlier (small scale)
- Ritalin became popular quickly, but doesn’t work at all for about 20% of patients - may not be as efficacious as projected
- some question the ethics of prescribing stimulants to children
- Ritalin is widely available on the illicit market, often misused and diverted, particular in college/university settings

Question 27

Study Question: is methylphenidate beneficial or harmful for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents?

Answer 27

• the results of meta-analysis suggest that methylphenidate may improve teacher reported ADHD symptoms, teacher reported general behaviour, and parent reported quality of life among children and adolescents with a diagnosis of ADHD
• the low quality of the underpinning evidence means that the magnitude of the effects is uncertain
• within the short follow up periods, there is some evidence that methylphenidate is associated with increased risk of non-serious adverse events, such as sleep problems and decreased appetite, but no evidence that it increases the risk of serious adverse events

Question 28

ADHD Treatment Debates - side effects, etc.

Answer 28

• side effects of ADHD drugs include insomnia, stunted growth, anorexia, bed-wetting, irritability, hallucinations, depression, and cardiovascular problems
• rather than questioning whether the medications should be sued at all - parents were advised to enact treatment interruptions (“drug holidays” from ADHD medications during school breaks), or consider prescriptions of additional medications to counter side effects (antidepressants, growth hormones)
• pharmaceutical companies fund most drug research, so there is little incentive to search for negative effects of medications, and potential conflicts of interest in relation to research
• importantly, there have been no studies of effects of stimulants on brain growth and development (although widely used at young ages) - but physical growth has been examined

Question 29

Alternative treatment for ADHD include

Answer 29

• dietary approaches
• education interventions
• CBT, neurofeedback, mind body therapy
• holistic approaches

Drugs are usually the frontline response in treatment, but perhaps should be the last resort given developmental processes and unknown impact on brain growth

Consider that ADHD is now managed as a lifelong condition, most other conditions which require maintenance medication for children are life threatening (epilepsy, diabetes, cancer, post organ transplant)

Question 30

The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder

Answer 30

Highlights:
- ADHD occurs in 5.9% of youth and 2.5% of adults
- most cases of ADHD are caused by the combined effects of many genetic and environmental risks
- there are small differences in the brain between people with and without ADHD
- untreated ADHD can lead to many adverse outcomes
- ADHD costs society hundreds of billions of dollars each year, worldwide

• claims current idea of ADHD was first described in 1775, supporting the positivist universal view
• risk for comorbid health conditions
• increased risk of health and social problems among people living with ADHD, partially due to impaired functioning
• medications used to manage ADHD symptoms are deemed “safe and effective”, although presence of adverse effects are noted
• emphasises positive effect of medications on ADHD-related difficulties and other outcomes
• stimulants deemed most effective but potential for misuse
• A very large group of scientists have produced this consensus statement, which is a social process involving specific actors and a particular cultural orientation toward the condition - similar to committee processes producing the DSM
• A neurological perspective and positivist orientation, rather than constructivist view
• These scientists are “in the business of ADHD” or using a neurodevelopmental and biological perspective, subscribing to a particular view of etiology and specific research methods (likely non are from a social science background or employing a critical perspective)
• some of the authors may receive funding from the Pharma industry and companies for their research, and some may have under-recognised or undeclared conflicts of interest

Question 31

Treatment Debates - Autism

Answer 31

• there is no medication specifically for autism, although Pharma companies are searching
• medications used to treat other conditions are sometimes prescribed to relieve some of the symptoms and behaviours of autism (stimulants, SSRI antidepressants, antipsychotic medications)
• there is limited evidence supporting non-pharmacological interventions such as applied behaviour analysis, and other psychological interventions
• some interventions have been harmful (chelation and secretin therapies) or are suspected to be useless or harmful (facilitated communication)

Question 32

The neurodiversity movement

Answer 32

The neurodiversity movement argues that autism, and other mental illnesses are not “pathologies”, but instead are part of the normal spectrum of human experience and behaviour

It is argued that these conditions should not be “cured” as they can be a positive part of a person’s identity and experience-encouraging pride in “neurodivergent” identities (not less or limited, just “different”)

Proponents believe its more beneficial to help people with neurodevelopmental conditions adapt to an often inflexible society - and especially to make the world more accommodating to diverse people

Question 33

The Neurodiversity movement - Critiques

Answer 33

• Assumes (without adequate evidence or any doubt) that autism is truly a neurological issue: individuals understand themselves as simply “wired differently”
• can be seen as an oversimplification or reductionist- casting experiences as homogenous and overlooking diversity
• most members of the movement tend to be “high-functioning” and successful - it may ignore the needs of people who are less able to participate, for instance, those who are non-verbal
• nonetheless, this movement challenges out notions of normalcy, development, and mental illness- and draws attention to social conditions and social context

Question 34

Applied behaviour analysis (ABA) definition

Answer 34

A scientific discipline that aims to address behaviours that are challenging for individuals with autism, such as social skills or hygiene. ABA is a controversial practice as some believe it can be harmful or eliminate neurodiversity

Question 35

Neurodiversity movement definition

Answer 35

a movement that encourages society to view autism, as well as other neurological or psychiatric conditions, as variations of “normal”

Question 36

pathologization defintion

Answer 36

in psychiatry, the process by which behaviours that were previously understood as normal become categorised as symptoms or indicators of deviance or dysfunction

Question 37

Which of the following is NOT a key concern related to widespread prescribing of stimulants to treat ADHD among children and youth?
1. Potential for dependence, and misuse/diversion of medications
2. Problems with physical growth among children prescribed stimulants
3. Disease mongering or pathologizing “difficult” behavior
4. Documented problems with brain growth and development among children prescribed stimulants

Answer 37

4. Documented problems with brain growth and development among children prescribed stimulants

Question 38

Which of these is not a key ADHD symptom? 1. Difficulty waiting one’s turn
2. Excessive talking
3. Inattention to details
4. Difficulty sleeping

Answer 38

4. Difficulty sleeping

Question 39

Which psychiatric disorder does the chapter note to be clearly documented as “real” in medical terms? (e.g., there is an evident bio- marker)
1. Schizophrenia
2. Bipolar Disorder
3. Dementia
4. ADHD
5. Autism

Answer 39

3. Dementia