ICL 3.2: Recognizing and Treating Childhood Disorders 2

Question 1

is ADHD a short term or long term disorder?

Answer 1

long term

ADHD begins in childhood, but it often lasts into adulthood

ADHD occurs in an estimated 3 to 5 percent of preschool and school-age children

Question 2

is ADHD more common in boys or girls?

Answer 2

more common in boys than girls 3:1

higher rates in boys may be related to boys higher vulnerability to prenatal and perinatal injury

Question 3

what is the cause of ADHD?

Answer 3

uncertain

it may be due to prenatal toxic exposure, prematurity and obstetric complications, or prenatal insult to the fetal nervous system

genes related to dopamine receiving special attention; mutation in dopamine transporter gene present in 55% of ADHD patients –> dopamine allows us to regulate emotional responses and take action to achieve specific rewards and it’s responsible for feelings of pleasure and reward – scientists have observed that lower levels of dopamine are associated with symptoms of ADHD

Question 4

is ADHD heritable?

Answer 4

the heritability of ADHD is substantial, with ADHD elevated significantly in 1st degree relatives of individuals with ADHD

“the rate at which the disorder is inherited, about 75 percent, is similar to the rate at which children’s height is inherited”

Question 5

what are the brain-based differences seen in an ADHD patient?

Answer 5

1. prefrontal cortex = inhibition, executive functions- abstract planning, organization
2. PET scan = differences/lower cerebral blood flow and metabolic rates in the frontal lobe which leads to the frontal lobes not adequately performing their inhibitory mechanisms on lower structure = disinhibition
3. MRI = often prefrontal cortex, basal ganglia, and/or cerebellum are either reduced in size or have asymmetry

Question 6

what is the role of your executive function?

Answer 6

it’s you’re capacity for self-control that allows for goal-directed problem solving and persistence!

it’s responsible for:

1. inhibit behavior/ stop what you are doing
2. nonverbal working memory – hold images in mind to guide behavior and remember steps needed; hindsight; foresight
3. verbal working memory; self-guidance; talking to self
4. affect regulation; control of strong emotions
5. planning and problem-solving

people with ADHD have a problem doing these things!

Question 7

what are the frequently seen comorbid problems in pre-school children with ADHD?

Answer 7

1. temper tantrums
2. aggressive behavior
3. fearless behavior
4. accidental injury
5. noncompliance
6. sleep disturbance

Question 8

what are the frequently seen comorbid problems in school-aged children and adolescence with ADHD?

Answer 8

1. cognitively effortful work is very difficult *
2. difficulty in peer relationships
3. noncompliant behavior
4. high levels of disorganization
5. poorly organized approaches to school and work
6. failure to complete independent academic work
7. risky behaviors
8. adolescence and adulthood: Internal sense of restlessness rather than gross motor activity

Question 9

how do you treat ADHD?

Answer 9

medications for ADHD are well established and effective for most

stimulants are the gold standard treatment like methylphenidate and amphetamines

Question 10

what happens when people aren’t treated for ADHD?

Answer 10

1/3 have tolerable outcomes: they have sx into adulthood but learn to work around them

1/3 had moderately poor outcomes: school difficulties and underperformance relative to ability, work problems, substance overuse

1/3 have bad outcomes: psychopathology, criminal activity, incarceration, serious drug problems

Question 11

what is the first line of treatment for ADHD in younger children?

Answer 11

parent training/behavior management

modify the environment, make expectations clear and consistent –> arrange the environment such that reinforcing activities immediately follow effortful ones

reinforcement of on-task, compliant, organized, self-controlled behavior should be frequent, consistent and contingent

individual psychotherapy can be used to address self-control issues, social skills and related issues, anger management, etc.

with older children and teens you can do combined treatment of PTBM with meds

Question 12

what are the 2 main disruptive behavior disorders?

Answer 12

1. oppositional-defiant disorder

2. conduct disorder

Question 13

what is oppositional-defiant disorder?

Answer 13

1. social cognitive deficits
2. cannot generate multiple plausible solutions to problems
3. attribute hostile intent to others –> aggressive behavior
4. beliefs/attitudes favorable to verbal and physical aggression (it’s okay to yell, argue, fight if I don’t get my way)

children learn to get their way and escape parental criticism by escalating negative behavior – the only way the parent can get the child to listen is to yell and become violent – the child observes the parent’s aggression and then they do the same thing so it’s a vicious cycle

Question 14

what are common characteristics of of the parents whose kids have oppositional-defiant disorder?

Answer 14

parents of children with ODD/CD are more likely to exhibit:

1. fewer positive behaviors
2. more violent disciplinary techniques
3. more criticism
4. more permissiveness
5. less supervision/monitoring of child’s behavior
6. more reinforcement of inappropriate behaviors
7. negative reinforcement leads to more oppositional/coercive behaviors
8. ignoring or punishment of positive behaviors

Question 15

what are 2 of the predictive factors of a child developing oppositional-defiant disorder?

Answer 15

1. constitutional-temperamental factors “difficult” child –> child’s behavior is not socially rewarding to the parent –> less positive parent/child interactions, more negative parent/child interactions –> more difficult child behaviors
2. less-than-perfect parenting skills –> less positive parent/child interactions, more negative parent/child interactions –> “difficult” child behaviors –> responding with abuse, overly punitive manner –> more difficult child behaviors

Question 16

how do you treat oppositional-defiant disorder?

Answer 16

parent training!!

1. change reinforcement schedule for child’s behavior
2. teach parents to attend to child’s positive behavior and qualities
3. teach parent to lower aggression and maladaptive coping in their own life

this leads to lower noncompliance in child, improved sibling behavior, and improved parental attitudes towards children

Question 17

what is conduct disorder?

Answer 17

a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated

ex. fire setting, breaking into peoples houses, stealing items, staying out all night, running away from home, etc.

Question 18

children with conduct disorder are at a higher risk for what problems as children/adolescents?

Answer 18

as children and adolescents, they’re at higher risk for:

1. rejection from peers
2. abuse
3. school dropout
4. delinquency/early legal involvement
5. ODD patients have a higher risk for conduct disorder

Question 19

children with conduct disorder are at a higher risk for what problems as adults?

Answer 19

1. alcoholism/drug abuse
2. depression
3. adult crime
4. antisocial personality disorder
5. marital problems

Question 20

how do you treat oppositional-defiant disorder?

Answer 20

1. parent training/behavior management**
2. although not technically an evidence-based treatment for ODD, some youths also need social skills training to address peer relationships or cognitive behavioral therapy (CBT) to address anger/irritability, anxiety or depression
3. multimodal treatments

there are no meds for ODD

Question 21

how do you treat conduct disorder?

Answer 21

1. multisystemic therapy*
2. functional family therapy*
3. individual therapy has limited potential but can be used to address social problem solving, anger management, and comorbid disorders
4. medication can sometimes help with explosive aggression

Question 22

what is multisystemic therapy?

Answer 22

used to treat conduct disorder:

1. school, family and community resources
2. clearly state and enforce behavioral expectations,
3. reinforcement of good behavior, and consequences for misbehavior.
4. remedy abuse, neglect/lack of supervision, family violence/conflict

all of this together leads to reduced re-arrest, violent crime arrest and out of home placements

Question 23

what is functional family therapy?

Answer 23

used to treat conduct disorder:

1. engagement and motivation: why change, what are the benefits of treatment, picture what “better” would look like
2. evaluate and change family behaviors that maintain adolescents’ delinquent behavior
3. improve effective parenting skills
4. modify dysfunctional family communication
5. train family members to negotiate/compromise/problem-solve
6. establish behavioral rules and monitor closely, use reinforcement and response-cost techniques
7. address community contexts and relationships that promote/inhibit behavior problems

all of this leads to reduced re-arrest, improved family interactions, reduced sibling involvement in the juvenile system

Question 24

how do you treat nocturnal enuresis?

Answer 24

1. fluid restriction before bedtime
2. encourage the child to go to the bathroom before bedtime
3. positive reinforcement; praise and reinforce the child on dry mornings
4. avoid punishments
5. schedule wakings during the night

if all of this is unsuccessful you can do pad buzzers or medications

treat this before diurnal enuresis

can’t diagnose till 5 years old and if proper toilet training has been attempted

Question 25

how do you treat diurnal enuresis?

Answer 25

1. education of bladder functioning and fluid intake
2. promotion of regular voiding intervals whether they need to or not
3. behavior management
4. pelvic muscle training if indicated

Question 26

what is encopresis?

Answer 26

the soiling of underwear with stool by children who are past the age of toilet training

can be diagnosed after 4 years old or equivalent developmental level

most cases involve constipation, some kids avoid bowel movements, maybe a past sexual assault may all cause this

Question 27

how do you treat encopresis?

Answer 27

1. clean-out-period = clearing the colon of retained, impacted stool
2. behavioral reinforcement of toileting behavior or production of stool
3. use effective toilet training techniques, regular trips to the toilet

Question 28

what is a tic?

Answer 28

a sudden rapid, recurrent nonrhythmic motor movement or vocalization

ex. Teret’s disorder = both motor and vocal tics

Question 29

what is CBIT?

Answer 29

CBIT = comprehensive behavioral intervention for tics

teach the patient to become aware of the sensations/feelings/urges felt prior to tics

teach and reinforce “competing response” to be used when the patient notices the urge to tic or notices doing the tic itself

functional interventions

medications should be considered for moderate - severe tics causing severe impairment in quality of life

Question 30

which medications can be used to treat tics?

Answer 30

haloperidol and pimozide

however, most clinicians use atypical antipsychotics before these agents like risperdone and clonidine

Question 31

what are the 3 types of ADHD?

Answer 31

1. inattentive
2. hyperactive/impulsive
3. combined type

just because someone has these symptoms though doesn’t mean they have ADHD; there must be impairment in functioning and the impairment must be inconsistent with developmental level compared to other kids that age

Question 32

what is the limited time horizon?

Answer 32

if you don’t have ADHD, you’re probably thinking about/learning from things you learned 2 weeks ago – you’re also planning for the thing you need to do next week or 2 weeks from now etc. = broad time horizon

however, if you have ADHD, that thing that happened even a few days ago is no longer effecting your behavior and that thing that’s happening this weekend isn’t on your mind and you’re not planning for it = limited time horizon

reinforcers are what help put things in an ADHDs kid’s time horizon – give one step directions for what to do now and then give a reinforcement right after that thing is done