week 5 Flashcards
Childhood Disorders
Overview
General Diagnostic Skills
E.g., Differential Diagnosis
Neurodevelopmental Disorders
E.g., Autism Spectrum Disorder
Externalizing Disorders
E.g., Oppositional Defiant Disorder
Internalizing Disorders
E.g., Anxiety
General Diagnostic Skills
Developmental Psychopathology
Cannot know what is pathological in children and adolescents without knowing what is normal and healthy!
Cannot know what is going on without doing a differential diagnosis!
Abnormality as defined by deviation to normal function can be examined using the Childhood Milestones sheets
Differential Diagnosis
Differential diagnosis - differential diagnosis is the initial set of possible diagnoses you must consider before settling on a definitive diagnosis
“Just because something looks like a condition, does not mean it is”
Work along with other relevant specialists:
-GP, Paediatrician, Child Psychiatrist, Speech Pathologist, Occupational Therapist, Teachers
Neurodevelopmental Disorders
Intellectual Disability
Communication Disorders
Autism Spectrum Disorder
Attention-Deficit/Hyperactivity Disorder
Specific Learning Disorder
Motor Disorders
how many neurodevelopmental disorders?
6
DSM-V Neurodevelopmental Disorders
Group of related but different conditions varying from specific problems (e.g., planning) to global problems (e.g. social skills) with onset in the developmental period before the child enters grade school!
Neurodevelopmental Disorders
Intellectual Disability
DSM-V Neurodevelopmental Disorders1.Intellectual Disability
Intellectual disability (intellectual development disorder) – characterised by deficits in: -General mental abilities – reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience
Severity – mild, moderate, severe, profound ( DSM-V)
Global developmental delay – an individual fails to meet expected milestones in several areas of functioning
Differential diagnosis – does the individual have a genetic (Down Syndrome) or a medical condition (cerebral palsy)?
Neurodevelopmental Disorders
Communication Disorders
Communication disorders include:
- Language disorder
- Speech sound disorder
- Social (pragmatic) communication disorder
- All characterised by deficits in the development and use of language (spoken words, written words, sign language, pictures), speech (fluency, voice, articulation) and social communication (verbal or nonverbal that influences behaviour, ideas or attitudes).
- Childhood-onset fluency disorder (stuttering)
DSM-V Neurodevelopmental Disorders2. Communication Disorders
Differential diagnoses: nationality (language), hearing impairments, neurological disorders (epilepsy), selective mutism (based in anxiety), dysarthria (due to cerebral palsy), sensory deficits, medication, tourette’s disorder, social anxiety etc
Neurodevelopmental Disorders
Autism Spectrum Disorder
Autism Spectrum Disorder – characterised by persistent deficits:
- Social communication and social interaction across multiple contexts
- Requires presence of restricted, repetitive patterns of behaviour, interests or activities
Severity:
- Level 3 – requiring very substantial support
- Level 2 – requiring substantial support
- Level 1 – requiring support
Differential diagnosis – consider Rett Syndrome (neurodevelopmental disorder characterized by normal development and sudden loss of purposeful use of hands slowed brain growth problems walking, intellectual disability and more), selective mutism, language disorders, stereotypic movement disorder, ADHD, schizophrenia
– no diagnosis of Aspergers any longer (must meet Criteria for Autism Level 1)
Removal of Aspergers from DSM-V
Can I or my child retain the diagnosis of Asperger syndrome?
Many individuals may wish to retain their previous diagnosis as the label is considered part of their identity or may reflect a peer group with whom they identify. This is perfectly acceptable. A clinician can indicate both the DSM-5 diagnosis as well as the previous diagnosis, such as Asperger syndrome, in an individual’s clinical record.
The DSM-5 text states “ Individuals with a well-established DSM-IV diagnoses of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder”.
Neurodevelopmental Disorders
Motor Disorders
Motor Disorder – include:
Developmental Co-ordination Disorder - clumsiness and slowness or inaccuracy of performance of motor skills
Stereotypic Movement Disorder – purposeless motor behaviour (hand shaking or waving, body rocking, head banging, self-biting)
Tic Disorders – tourettes disorder (vocal tics), persistent(chronic) motor or vocal tic disorder
Differential diagnosis – cerebral palsy, autism, ADHD, OCD, genetic conditions (Huntington’s disease), encephalitis etc
Neurodevelopmental Disorders
Specific Learning Disorder
Specific Learning Disorder – is defined by specific deficits in an individuals’ ability to perceive or process information efficiently and accurately. Impairments include:
- Reading – accuracy, fluency, comprehension
- Written expression – spelling, grammar, clarity, organisation
- Mathematics – number sense, memorisation, calculation, reasoning
- Specify: Mild, Moderate, Severe
- Differential diagnosis – normal variations in academic abilities, vision impairment, hearing impairment, ADHD, etc
Externalizing Disorders
Behaviour problems directed toward external world
Characterised by failure to control behaviour according to the expectations of others
The most commonly diagnosed childhood disorders
ADHD, oppositional defiant disorder (ODD), conduct disorder (CD)
DSM-V Neurodevelopmental/Externalising Disorders1. ADHD
ADHD(considered neurodevelopmental (1 of the 6))
Attention-Deficit Hyperactivity Disorder – is defined by impairing levels of:
–Inattention and disorganisation – inability to stay on task, seeming not to listen, and loosing materials
–And/or hyperactivity-impulsivity – over-activity, fidgeting, inability to stay seated, inability to wait
Differential diagnosis – oppositional defiant disorder, intermittent explosive disorder, depression, bipolar disorder, reactive attachment disorder, learning disorder, substance use
Attention-Deficit Hyperactivity Disorder (ADHD)
criterion
(innattention)
`A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:
Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:
Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
Often has trouble holding attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
Often has trouble organizing tasks and activities.
Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
Is often easily distracted
Is often forgetful in daily activities.
Attention Deficit Hyperactivity Disorder (ADHD)
HYPERACTIVITY AND IMPULSIVITY:
HYPERACTIVITY AND IMPULSIVITY: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
Often fidgets with or taps hands or feet, or squirms in seat.
Often leaves seat in situations when remaining seated is expected.
Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
Often unable to play or take part in leisure activities quietly.
Is often “on the go” acting as if “driven by a motor”.
Often talks excessively.
Often blurts out an answer before a question has been completed.
Often has trouble waiting his/her turn.
Often interrupts or intrudes on others (e.g., butts into conversations or games)
ADHD - Types
Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
1) Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
2) Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
3) Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.
Because symptoms can change over time, the presentation may change over time as well
Attention Deficit Hyperactivity Disorder (ADHD)
diagnosis decision making
Deciding if a child has ADHD is a several-step process. There is no single test to diagnose ADHD, and many other problems, like anxiety, depression, and certain types of learning disabilities, can have similar symptoms.
Treatment of ADHD
Pharmacotherapy
Stimulant medications. 1991 – 1995 the number of 15-19 yr olds treated with Ritalin jumped 311% in USA
Methylphenidate (Ritalin) & Dextroamphetamine - Increase availability of dopamine
Short term effectiveness – long term outcomes questionable
Medication targets hyper-activity and impulsivity, more so than inattention
Side effects – decreased appetite, increased HR, sleeping difficulties, retarded growth
Treatment of ADHD
behaviour management
Behaviour Management - Behavioural Family Intervention (been around since the 60’s), Triple P (Sanders, 1999), Incredible Years (Webster-Stratton, 1990)
- Parent training in behaviour management strongest evidence base
- Increasing desirable behaviour and reducing noncompliance
- Training in contingency management – rewards & consequences – token economies
- Quiet time, time out, planned ignoring
- Parental expectations, appropriate commands, consistency & routine
- Child problem solving, social skills, & learning to self-soothe
- School accommodations and teacher use of attention & praise
Behaviour Management (potentially with added medication) is without a doubt the most long-term effective treatment to date!
Externalizing Disorders
Oppositional and Conduct Disorders
- Oppositional Defiant Disorder – angry/irritable mood (e.g., is resentful); argumentative/defiant behaviour (e.g., blames others); or vindictiveness
- Conduct Disorder – pattern of behaviour where basic rights of others are violated. Examples: aggression to animals or people, destruction of property, deceitfulness or theft, serious violations of rules
- –is a strong predictor of adult criminal behaviour
Differential diagnosis: adjustment disorder, depression ADHD, anxiety, intellectual impairment
Note: There is also something called Intermittent Explosive Disorder – recurrent behavioural outbursts (verbal aggression & destruction to property
Internalizing Disorders
Anxiety
OCD
Trauma
Depression
Disruptive, Impulse-Control, and Conduct Disorders
Classification of Internalizing Disorders
Internalising disorder:
- -Psychological / emotional problems directed inward
- -Involve the child’s internal world – thoughts, feelings
Internalizing Disorders
OCD
Obsessive-Compulsive Disorder
Obsessions – “sticky” thoughts (children speak differently to adults…>)
Compulsions – checking, repetitive behaviours
Skin picking
Hair pulling
Hoarding
PANDAS– pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (post-infection autoimmune disorder) characterised by the sudden onset of obsessions, compulsions, tics
Controversial diagnosis
Internalizing Disorders
Trauma and Stress
Reactive Attachment Disorder – inhibited and emotionally withdrawn behaviour toward adult caregiver + social & emotional disturbance
Disinhibited Social Engagement Disorder – a child actively approaches and interacts with unfamiliar adults
Differential diagnosis – autism, depression, intellectual impairment
Internalizing Disorders
Depression
Children may experience significant and persistent irritability rather than sadness
Poor agreement between parents and children – generally
Developmental variation in presentation
- Under 2 – unresponsiveness to caregivers
- Preschoolers – sad expression & social withdrawal
- School – somatic complaints, awareness of sadness
- Youth – full-blown depression, suicidal ideation and intent
Internalizing Disorders
Anxiety
Anxiety Disorders
–Separation anxiety – excessive distress when anticipating or experiencing separation from home or major attachment figures
Selective Mutism – consistent failure to speak in social situations (this is most likely an avoidance strategy used to avoid speaking in public – i.e., social phobia)
Specific phobia – marked anxiety about a specific object (needles, blood, insects)
Social anxiety – fear of scrutiny of others, worry of humiliation or embarrassment
Generalised anxiety – excessive anxiety and worry about a number of events or activities
In children, the fear of anxiety may be expressed as crying, tantrums, freezing, clinging, shrinking or failing to speak in social situations
Normal Developmental Fears and link to anxiety an adulthood
Infancy – strangers, loud noises
Early childhood – separation, monsters, darkness
Middle childhood – real-world dangers, injury, new challenges
Adolescence – social status, performance, health
NORMAL FEARS can lead to ANXIETY DISORDERS
Fear of Thunder – Avoid – Problem Fixed
Fear of negative social evaluation – Avoid – Problem Fixed
Fear of negative evaluation at work place – Avoid – Problem Fixed
DSM-V Other Disorders 1. Elimination Disorders
Elimination Disorders – involve the inappropriate elimination of urine or faeces
- Enuresis – repeated voiding of urine into inappropriate places (into bed or clothes) – during day or night or both
- Encopresis – repeated passage of faeces into inappropriate places (into clothing or floor) – may involve constipation and/or overflow incontinence
^^ likely to go away with time
(But what are the costs of waiting for spontaneous remittance? How would you feel, think, behave if wetting yourself at 12?)
Differential diagnosis – medical conditions (diabetes, urinary tract infection), medicine, stress, diarrhoea etc.
Other Disorders
Elimination Disorders
Feeding and Eating Disorders
Developmental Psychopathology
Disorders are defined by syndrome’s (collection of symptoms) versus individual symptoms (remember lecture 1?)
Balance between risk and protective factors important in predicting outcomes (See DSM-V – provides information on this)
Risk – things that can make the situation worse (alcoholic parents, parents with mental health difficulties,)
Protective factors – anything that reduces the situationfrom becoming worse (social support, healthy coping)
Example: child with learning disorder and father can’tread and mum is not interested in child (risks to situation)
Other issues - school refusal
School Refusal
- “difficulty attending school associated with emotional distress, especially anxiety and depression” King & Bernstein (2001)
- “child-motivated refusal to attend school or difficulties remaining in school for the entire day” (Kearney & Silverman, 1996)
Fears: - Separation from parents -Tests, academic performance, -school work -Bullying, social concerns -Specific classes/teachers -New school/transition Bullying and Cyberbullying
DSM-V Other Disorders 2. Feeding & Eating Disorders
Pica– involves eating non-nutritive, non-food substances (soap, paper, hair)
Rumination Disorder – repeated regurgitation of food (re-chew, re-swallow or spit out)
Differential diagnosis – autism, schizophrenia, Kleine-Levin Syndrome (neurological disorder), intellectual impairment
For children, it can be due to neglect, lack of supervision, developmental delay, lack of stimulation, stressful life situations
Internalizing Disorders–
Trauma & Stress-Related Disorders
Post-Traumatic Stress Disorder – exposure to actual or threatened death, serious injury or sexual violence
Acute Stress Disorder - exposure to actual or threatened death, serious injury or sexual violation (symptoms last 3 days to 1 month)
Adjustment Disorder - begins within 3 months and lasts up to six (going to school, leaving a parent, grief and loss)
Differential diagnosis – autism, depression, intellectual impairment
Causes of Internalising Disorders
Genetic predisposition Conditioning & Trauma & Learning --Modelling ---Reinforcement --Stressful / traumatic events Family Factors Cognitive factors --Thinking style --Explanatory style
