Week 12/2 ID Flashcards
Terminology
Historically, whatever term has been used to define this
condition has shifted to become an insult and offensive called the
“Euphemism treadmill” – terms intended to be neutral slowly acquire negative meanings
Do you know rainbow acronym for bipolar treatment ?
B be a good friend
Idiot, imbecile, moron were all once neutral terms used to describe individuals experiencing developmental delays
These terms were phased out in favour of
mental retardation (DSM-IV) Mental retardation is also now seen as offensive Advocates prefer intellectually disability or developmental disability DSM-5 uses the term “intellectual disability” or “intellectual development disorder”
Aside on person with x disorder :)
What is intelligence?
Composed of many sub-processes
Verbal ability
Spatial skills
Reasoning
Working memory and control of attention
Is iq (part of intelligence) stable?
Trait or state?
IQ stable but CAN change
Environment and testing situation
Core Features: DSM-5 for ID
Deficits in intellectual functioning including reasoning, problem solving, planning, abstract thinking, judgment as confirmed by both clinical assessment and individualized, standardized intelligence testing
IQ < 70 or equivalent assessment
Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility; functioning is limited in one more activities of daily life such as communication, social participation, and independent living, across multiple environments
Onset during developmental period
Subtypes by Degree of Impairment
Mild (IQ of 55 to 70)
applies to about 85% of persons with ID
typically not identified until elementary school years
overrepresentation of minority group / low SES members
Moderate (IQ of 40 to 54)
applies to about 10% of persons with ID
usually identified during preschool years
applies to many people with Down syndrome
Severe (IQ of 20 to 39)
applies to about 3%-4% of persons with ID
often associated with clear organic cause
usually identified at a very young age
Profound (IQ below 20 or 25)
applies to about 1%-2% of persons with ID
usually identified in infancy
almost always associated with clear organic cause and often co-occurs with severe medical conditions
Mild (IQ of 55 to 70)
applies to about 85% of persons with ID
typically not identified until elementary school years
overrepresentation of minority group / low SES members
Moderate (IQ of 40 to 54) characteristics
applies to about 10% of persons with ID
usually identified during preschool years
applies to many people with Down syndrome
Severe (IQ of 20 to 39)
applies to about 3%-4% of persons with ID
often associated with clear organic cause
usually identified at a very young age
Profound (IQ below 20 or 25)
applies to about 1%-2% of persons with ID
usually identified in infancy
almost always associated with clear organic cause and often co-occurs with severe medical conditions
Assessment of ID requires?
IQ
Adaptive Functioning
IQ Assessment
A series of tasks designed to assess different types of intelligence
Weschler Intelligence Scale for Children (WISC)
Children aged 6 to 17 years
Also a preschool version
IQ Assessment (training)
WISC is standardized (picture, block and matrix)
Procedures for administering the tasks on the WISC are highly
Where you are supposed to sit
How you are supposed to interact with the child, do not visa higher.
Norms for the WISC have been established, and they are?
Performance can be compared to other children of the same
age and gender
Average performance on the WISC is 100
Standard deviation is 15
Criticisms of IQ Tests
Test knowledge associated with the cultural majority
Focus on speed of processing
Children with behavior difficulties are likely to underperform
Good discriminate of Id down to 60.
Floor effect, 20-60 poor discrimination. Not good.
Assessment of Adaptive Functioning for ID
Vineland Adaptive Behavior Scales
Assesses children’s functioning in several domains
Vineland Adaptive Behavior Scales Assesses children’s functioning in several domains
Communication
Receptive
Listening
Following instructions
Expressive
Pointing when offered a choice
Uses phrases with a noun and a verb
Written
Recognizes own name
Prints more than 20 words from memory
Vineland living skills
Living Skills
Personal
Drinks from a cup
Asks to use toilet!
Puts shoes on correct feet
Domestic
Is careful using sharp objects
Is careful around hot objects
Community
Demonstrates understanding of function of telephone
Demonstrates understanding of function of a clock
Can identify pennies, nickels, dimes
Socialization of Vineland
Interpersonal Relationship
Looks at face of parent or caregiver
Shows two or more emotions
Demonstrates friendship seeking behavior with others of the same age
Play and Leisure Time
Responds when a caregiver is playful
Plays simple interaction games (peek-a-boo)
Shares toys or possession
Coping Skills
Controls angry feelings
Changes easily from one activity to the next
Vineland Adaptive Behavior Scales structure?
Semistructured Interview
Interviewer has a lot of latitude when asking questions
Differs from a structured interview where the interviewer is given a very specific set of a questions to ask
Excellent for building rapport as it is like having a conversation
Interview given a number of general questions (prompts) and a set of more specific probes if needed, clarifications and laddering. Wow efficient and satisfying.
Interviewer checks off items on a list as they obtain the information
Prevalence of ID
Low income and minority.
1% to 403% prevalence.
Ses differences only apparent for less severe.
Not for severe,
Effects slightly more males than females.
Etiology of ID.
Organic causes
Chromosome,me
Genetic
Neurobiological.
Associated with moderate to severe/profound,
Do not see more in
Prevalence (All subtypes)
Prevalence
Community prevalence estimates range from 1% to 3%
Cultural and contextual differences More prevalent in lower SES groups
More prevalent in minority groups
Differences only apparent for less severe ID
Gender differences
Slightly more males than females
Etiology
Organic
includes chromosome abnormalities, single gene conditions,
and neurobiological influences
tend to be moderate, severe, and profound cases Prevalence comparable across SES groups
Cultural / Familial
Does not have a clear cause
Includes family history of intellectual disability, economic deprivation, inadequate child care, poor nutrition, and parental psychopathology
tend to be mild cases (most cases!)
Higher rates in lower SES and minority group
Specific Organic Syndromes for ID
Chromosomal abnormalities
Most common cause of severe MR
Fragile-X syndrome (X chromosome, inherited)
Down syndrome (chromosome 21, most cases are random event)
Prader-Willi and Angelman (chromosome 15, most cases are random events) need to eat
Single-gene problems
Phenylketonuria (PKU; inherited), special diet needed
Cannot metabolize amino acid phenylalanine, rising levels are toxic and impact intellectual development
Neurobiological injury
Prenatal (e.g., Fetal Alcohol Syndrome)
Perinatal (e.g., anoxia at birth)
Postnatal (e.g., head injury)
Summary of Causes of ID
note mr mental retardation = ID
Genetic factors
General heritability of intelligence is approximately 50%
Rare conditions associated with ID also inherited
Neurobiological influences
Prenatal, perinatal, and postnatal injury
Environmental influences
deprivation of physical and emotional care, social stimulation, and early learning environment
Prevention of ID
Available test for Down’s syndrome, other specific single-gene
EthicL issue
Prenatal care
Reduce prenatal neurobiological injury
Increase gestation time
Plan for uncomplicated delivery
Early childhood care and education prevention strategy for ID?
Safe and stimulating environments
Safe
Lead paint
Stimulating
Educational programs
Major focus on speech and communication
Early intervention (preschool) optimal brain is growing
Educational enrichment for low-SES youth
Rich vs poor kids exposure to words
Rich get considerably more,
45m vs 10 over 3y
No tv or radio
Low ses lower vocab
Carolina Abecedarian Project
Low-income families
Four cohorts of children recruited from 1972 and
1977
Randomly assigned as infants to receive a full-time educational intervention at a project-run childcare center OR to be cared for at home or in another child care center
Offered enriched environments from infancy through preschool (lasted 5 years)
Individualized educational program
Focus on language
Games
findings
By age two, children who are receiving the program have higher test scores than children in control group, and these differences were maintained over time
IQ scores
Mathematics and reading achievement scores
Their scores stay higher over a prolonged period of time – still saw differences at 21 years of age
A larger percentage of children in the intervention group went to colle
Treatment
Behavioral Treatments
Family Strategies
Residential Care
Preschools good for
Learning for low ses,
Immunology for high ses and low ses
Cost benefit, like Mst, for abecedarian
Earn more contribute more,m
Is expensive, but more than regain in your investment.
Residential Treatment
Serious and dangerous behaviors such that the child requires full-time supervision
Intensive treatment programs
Full or part-time
Research has shown that family involvement is critical
Home visits, parental involvement
Family-Oriented Strategies
Individual services are more effective when the family is involved
Parent-management training
Parents serving as behavior therapists
Skill acquisition, rather than problem behavior reduction
Behavioral Treatment
I’d
Shaping procedure
Rewarding successive approximations
Receive a reward when you imitate the sound made by the speech therapist
Once that sound is mastered, only receive a reward for the next sound on the list
Modeling behavior you want to see
Break into component parts
Rewards for behaviors you want to see, consequences for behaviors you do not want to see
Social skills
Self-injurious behaviors and pica
Behavioral Treatment I’d
Basic principles of behavioral treatment
Positively or negatively reinforce behaviors you want to see
Administer consequences or remove rewards for behaviors you do not want to see
Start small break it down, like just touching spoon rewarded first, working to getting it to the mouth
Treatment
For ID
Behavioral Treatments Family Strategies
Residential Care
Two ways to approach prevention of psychopathology
Prevention
Can we stop children’s mental health problems before they
start?
Identify risk factors and target those
Identify high risk populations and intervene before problems
start?
Notes on dissemination
Risk factors identified in class for children to de. Psychopathology.
Poverty
Child Abuse
Parental Psychopatholog
Poverty evidence correlate
W Low SES is a risk factor for many psychological problems
Particularly behavioral problems
Casino study
So change poverty change behvairour problems?
Recall that there is evidence that low SES causes behavior problems
If we change conditions associated with poverty, can we change behavior problems?
Neighborhood
Violence, deviant peers, few adult role models, poorer schools
Moving to Opportunity (MTO)
Operated from 1994 to 1998
Baltimore, Boston, Chicago, Los Angeles, and New
Eligible families with children living in:
public housing
high-poverty neighborhoods (poverty rate >= 40%)
MTO: Random Assignment
4608 eligible families in public housing
Low-Poverty Voucher Group (LPV)
(N = 1,800)
Section 8 Group (S8)
(N = 1,350)
Control Group (C) (N = 1,400)
Offered restricted Section 8 voucher + mobility counseling
Offered conventional Section 8 voucher
No voucher, existing programs
47% used voucher to move
(N = 864)
68% used voucher to move
(N = 918)
Selected Characteristics of Sample
22 percent of household heads were employed at baseline
87 percent single-parent female-headed households
Baltimore and Chicago samples are almost 100 percent African-American
LA, and NY are roughly 50 percent African- American, 50 percent Hispanic.
About 20 percent of the sample in Boston is nh- white or Asian
Outcomes: Interim (4 to 7 years) of MTO STUDY
Neighborhoodoutcomes
Assignment to either of the MTO mobility groups led participating adults to feel safer and more satisfied with their housing and neighborhoods.
Improved outcomes for female youth
Low poverty voucher group – less psychological distress, fewer behavior problems
Section 8 group – less depression
Both moving groups – less GAD
Deleterious effects on male youth risky behavior
Low poverty voucher group – More likely to be arrested
MTO had no detectable effects on the math and reading achievement of children
MTO
Final analyses are underway
Suggests benefits for girls
Neighborhood wealth can effect children in different ways
Access to more resources might be helpful
But, makes them aware of their relative deprivation
Safety may mean different things to boys and girls
Feel less threat of sexual assault.
Child Abuse
Risk factor for many types of disorders Conduct problems
Can we reduce incidence of child abuse?
Nurse-Family Partnership Program (NFP; David Olds)
Support for mothers “at risk”
Low income
Single
Young (under age 19)
Treatment model
Structured home visits
Education and social support
High intensity during pregnancy
High intensity immediately post-pregnancy (6 weeks)
Lower intensity through age 2 1⁄2
NFP Target Outcomes
Pregnancy
reduce Smoking and substance use
Premature births reduce, instead full term.
Caregiving, abuse
Neglect (e.g., accidents)
Maternal “life course”
Education and employment, life planning I guess
Number and spacing of additional births
Long-term youth behavior
NFP Elmira Outcomes
Participants
– 400 pregnant women
– 62% unmarried
– 47% younger than 19
– 61% “working poor”
– 89% Caucasian
Design
– Random assignment 3 groups
– “Usual services” (e.g., developmental screening)
– NFP – two groups – one receiving visitation during pregnancy only and the second receiving visitation both during and after pregnancy
Pregnancy outcomes
– 25% less smoking
– Fewer infections
– Fewer pre-term deliveries
Dysfunctional caregiving
– 27% fewer ER visits
– 56% fewer accidents
– 80% less abuse (verified)
– Effects strongest for women with least resources
Mom income was moderator, worse off biggest effects
NFP outcomes later on 15yr later
Less likely to run away, arrested, or convicted.
Significant later improvement too!
NFP Outcomes
Significant effects on pregnancy outcomes, parental behavior
Also saw effects on children’s behavior 15 years later
Shows importance of early intervention for kids
MacMillan et al. 2005
In Olds’ program, women are visited during pregnancy
Can a similar program when children are older stop child abuse?
MacMillan et al. designed a nurse-home visitation program targeting stopping recurrence of child abuse
MacMillan et al. 2005
Families recruited from child protection agencies
Physical abuse/neglect had occurred in the previous
three months
Child was still living with families
MacMillan et al. 2005
Families randomly assigned to the treatment group or the control group
Control group:
Standard services provided by child protection agency
E.g., Follow up by social workers, education
Treatment group
Standard services
Home visits (1.5 hours) by a public-health nurse every week for six months, then every two weeks for six months, and then monthly for twelve months
Nurse visits focused on family support, parent education, and helping families get services needed (e.g., special education, employment services)
Goal was to reduce stressors and increase support
MacMillan et al. 2005
Primary outcome was reports of child abuse/neglect made to CPA
Research assistants went through CPA records and identified cases of abuse or neglect
Found that the intervention had no effect
No differences between intervention and control group
Were not seeing lower rates of recurrence in the intervention group
Incidences in the intervention group were as severe as incidences in the control group
Suggests once involved with cap, hard to change things.
Prevention necessary. Think olds group.
MacMillan et al. 2005
Findings suggest that once a family is involved with Child Protective Services
it may be hard to help
Importance of intervening before the problem starts
Parental Psychopathology
Parental psychopathology associated with a number of problematic outcomes in childhood
Disorders often “run in families” Genetics
Environment
Includes depression,
Parental Depression
Primary prevention (i.e., targeting children in general) has
not been very effective
Programs targeting high-risk samples
Children of parents with depression are at higher risk for developing a depressive disorder
Group CBT (Clarke et al. 1995)
Coping with Stress course
15, 45 minute group sessions
Taught cognitive techniques
E.g., identifying and challenging negative thoughts
Reduce negative thoughts before sub-clinical symptoms become more significant
Can we:
Reduce symptoms?
Prevent depressive episodes?
Clark et al. 2001
Initial recruitment letters sent by physicians to parents with depression and teenage children (N = 3374)
Youth categorized as subsyndromal and agreed to randomization (N = 94)
Usual Care (N = 49)
Clark et al. 2001
Youth in experimental group less likely to experience a depressive episode than youth in control group
At 16 months, 90% of youth in experimental group remained non-depressed, compared with 70% in control group
But at two years converge almost, may need booster sessions!
Garber et al. 2009
Generalizability
Basically the same intervention
Slight format changes
8 weekly 90 minute sessions
6 monthly continuation sessions
316 adolescents in 4 sites
Randomized to CBT intervention or usual care
Results replicated?
Rate of depressive episodes lower for the intervention group
Symptoms declined at a greater rate for youth in intervention group
Demonstrates that this intervention can be delivered by clinicians other than those who designed the intervention!
Summary: Prevention
Prevention programs can have a significant impact, even many years after the intervention takes place, think abcedarian and aba autism too.
Demonstrates importance of sound theoretical model and understanding of more basic processes
Dissemination
Many youth will experience significant mental health problems
We have treatments of demonstrated efficacy for a number of these issues
What do we know about treating psychological disorders in youth?
Disorder
Evidence-Based Psychosocial Treatments
ADHD
Behavior therapy – peer interventions, classroom management, parent training
ODD and CD
Anger control training (e.g., Anger Coping Program), parent management training, MST
Anorexia/Bulimia
Family therapy (AN); CBT (Bulimia)
Anxiety
CBT, trauma-focused CBT (PTSD)
Depression
CBT, Interpersonal therapy (not discussed in class)
Autism
ABA (Lovaas’ Method)
KNOW THIS,
Treatment Efficacy versus Effectiveness
Treatments have demonstrated efficacy
Efficacy: Can this treatment work?
Tested in RCTs
Patients recruited for studies who often do not represent “real world” presentation
Therapists who are highly trained to administer an intervention
Different conditions then we see in practice
Effectiveness
Does this treatment work? In rel world
Tested in the “real world”
Patients and therapists
Far less evidence about effectiveness relative to efficacy
Are Evidence-Based Interventions Being Used in Usual Care?
Not widely
Treatment in community is much more eclectic and
based upon therapist’s personal preferences E.g., Weersing & Weisz 2002
Therapists in community-mental health clinic report using more psychodynamic techniques during treatment of depression than cognitive and behavioral techniques
Why Not?
Efficacy versus effectiveness
Concerns about treatments in the real world
Complex case presentations
Rapport
Manuals too inflexible
The Critical Issue in Youth Mental Health
Bridging the gap between research and practice
Disseminating evidence-based treatments and
assessments
Recall that evidence-based assessments (e.g., structured and semi-structured interviews) perform better than unstructured interviews
Will be significant advantages to incorporating those in treatment
The Critical Issue in Mental Health
Is evidence-based practice associated with greater improvement in treatment?
Weersing & Weisz 2002
Includes tads
Plotting deprsion meta.
EBT versus Usual Care
Weisz et al. (2006)
Meta-analysis
Studies comparing evidence-based treatments to treatment as usual (usual care)
E.g., MST versus care as usual
Found that children receiving EBTs did better!
Note that differences were not due to symptom severity or co-morbidity
Conclusions of the course
Many youth will experience psychological problems
Basic research is ongoing to try to understand
etiology and maintenance of those problems
Apply research to developing more effective interventions
Dissemination of evidence-based interventions
