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Childhood Disorders

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on 25 October 2012

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Transcript of Childhood Disorders

Childhood and Adolescent Disorders Considerations when diagnosing children
Who is the referral source?
What is the presenting problem?
Who are the primary informants?
Teachers Mental Retardation
Significantly below average general intellectual functioning.
Measured using IQ or its equivalent using standardized tests.
WISC-3, Stanford-Binet-4 Diagnostic Criteria
Mild Mental Retardation
IQ of 50-55 to 70
Moderate Mental Retardation
IQ of 35-40 to 50-55
Severe Mental Retardation
IQ of 20-25 to 35-40
Profound Mental Retardation
IQ below 20-25 Mild Mental Retardation
85% of people with disorder
Academic skills up to 6th grade
Unskilled or semiskilled work under supervision Moderate Mental Retardation
10% of people with disorder
Academic skills up to 2nd grade
Unskilled work under supervision Severe Mental Retardation
3-4% of people with disorder
Limited communication skills Profound Mental Retardation
Usually neurologically based 1% prevalence rate
High comorbidity with other mental disorders Diagnostic Criteria
IQ below 70 on IQ testing
Deficits in adaptive functioning in two areas:
Communication, self-care, home living, interpersonal skills, use of community resources, self-direction, academics, work, health, safety
Onset must be before 18 years Autistic Disorders Pervasive Developmental Disorder NOS Pervasive Developmental Disorders
Severe & pervasive impairment in the following developmental areas:
Social interaction, communication, presence of stereotyped behavior, interests, and activities Diagnostic Criteria
Six of the following items with at least two from impairment in social interaction Impairment in social interaction
Use of multiple non-verbals (eye contact, facial expression)
Failure to develop peer relationships
Lack of spontaneous social interaction
Lack of social/emotional responss Impairment in communication
Delay in spoken language development
If language is present, impairment in conversational ability
Stereotyped and repetitive use of language
Lack of make-believe play Restricted repetitive and stereotyped patterns fo behaviors, interests, and activities
Preoccupation with interests abnormal in intensity or focus
Inflexible routines or rituals
Stereotyped or repetitive mannerisms
Persistent preoccupation with parts of objects Abnormal functioning in social interaction, language, or symbolic/imaginative play before age 3 Remember, prior to 3 years old.
Best prognosis is developed langauge skills and IQ level Often children with autism will appear unresponsive to parents early in life, parents will sometimes believe child is deaf. Asperger's Disorder Impairment in at least two of the following areas:
Use of multiple non-verbals (eye contact, facial expression)
Failure to develop peer relationships
Lack of spontaneous social interaction
Lack of social/emotional responses Restricted repetitive and stereotyped patterns fo behaviors, interests, and activities
Preoccupation with interests abnormal in intensity or focus
Inflexible routines or rituals
Stereotyped or repetitive mannerisms
Persistent preoccupation with parts of objects Disturbances cause significant impairment in social, occupational, other important areas No language delays
No cognitive or adaptive delays Atypical autisms that do not fit other categories
late age of onset
subthreshold symptomolgy Mental retardation prominent in autistic disorder but not Asperger's disorder.
Asperger's disorder highly comorbid with ADHD and depression Conduct Disorder Aggression to people and animals

1. often bullies, threatens, or intimidates others

2. often initiates physical fights

3. has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)

4. has been physically cruel to people

5. has been physically cruel to animals

6. has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)

7. has forced someone into sexual activity

Destruction of property

8. has deliberately engaged in fire setting with the intention of causing serious damage

9. has deliberately destroyed others’ property (other than by fire setting)

Deceitfulness or theft

10. has broken into someone else’s house, building, or car

11. often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)

12. has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)

Serious violations of rules
13. often stays out at night despite parental prohibitions, beginning before age 13 years . (In adults, often violates rules of family life, e.g., neglects basic needs of a child.)

14. has run away from home overnight at least twice while living in parental or parental surrogate home, or once without returning for a lengthy period. (In adults, often violates major societal norms, e.g., rulings of the court or conditions of parole/probation or rules of a public agency or residential setting.)

15. is often truant from school, beginning before age 13 years. (In adults or adolescents not in school, often violates rules of the workplace, e.g., chronic work absenteeism without acceptable reason.)

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

Subtypes based on age at onset:
Conduct Disorder, Childhood-Onset Type: onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years

Conduct Disorder, Adolescent-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to age 10 years

Conduct Disorder, Unspecified Onset: age at onset is not known DSM-V Changes Attention Deficit Hyperactivity Disorder Diagnostic Criteria

IA. Six or more of the following signs of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

Does not pay close attention to details or makes careless mistakes.
trouble keeping attention on tasks or play activities.
Does not seem to listen when spoken to.
Does not follow instructions and fails to finish schoolwork, chores.
Trouble organizing activities.
Avoids, dislikes or refuses to do things that take a lot of mental effort for a long period of time.
Loses things needed for tasks and activities.
Easily distracted.
Forgetful in daily activities. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
ADHD Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months
ADHD, Predominantly Hyperactive-Impulsive Type: if criterion 1B is met but criterion 1A is not met for the past six months. Adult ADHD
Between 33-60% of children with ADHD may continue to have ADHD symptoms as adults. Most commonly diagnosed disorder in children.
3-7% prevalence rate in children. Children with ADHD often have reduced brain volume.
Especially in left-sided prefrontal cortex.
Suggests that ADHD symptoms of inattention, hyperactivity, and impulsivity reflect problems in the frontal lobe.
Delayed development of frontal cortex and temporal lobe, responsible for ability to control and focus thinking.
Faster development of motor cortex. Oppositional Defiant Disorder Behavioral Treatments 37% of children with ADHD do not receive their high school diplomas.
Often receive special education services.a 1. Loses temper
2. Argues with adults.
3. Actively refuses to comply with adult's requests or rules.
4. Performs actions to deliberately annoy others.
5. Blames others for his/her own mistakes.
6. Spiteful or seeks revenge
7. Touchy or easily annoyed by others.
8. Angry and resentful of others. Unsure what the mechanisms are behind autism.
It appears highly complex, much like intellectual disability, it involves multiple underlying problems. Available approaches include applied behavior analysis (ABA), developmental models, structured teaching, speech and language therapy, social skills therapy, and occupational therapy. Physical aggression often appears early in childhood for most children.
Often peaks around preschool age.
Problem if high levels persist into middle childhood & may become violent.
Verbal aggression appears later in life.
If a young child has high verbal aggression that merits clinical attention also. Interpersonal Aggression The most frequent reasons for youth referral to mental health services are:
Aggressive behaviors,
Acting out behaviors,
Or other disruptive behavior patterns.
These types of behaviors are referred to as “antisocial behaviors”. Delinquency Aggression can be instrumental (goal-directed) or hostile (intended to inflict pain).
Instrumental aggression is normal in toddlers. Aggression Motive Two types of interpersonal aggression:
Verbal (threatening, name calling, taunting, swearing)
Physical (bullying, fighting, assaulting) Subtypes of Aggression & ASB Aggressive and antisocial behaviors that include infliction of pain, denial of rights of others and other status offenses.

Judged as CD if actions are persistent and impairing. Conduct Disorder Externalizing Behaviors
Impulsive and overactive (ADHD)
Aggressive and antisocial (ADD & CD)
Internalizing Behaviors
Dysphoric and withdrawn
Somaticizing Child & Adolescent Problem Behaviors Age-inappropriate and persistent display of angry, defiant, irritable and oppositional behaviors.

There are some behaviors that are age-appropriate such as a three year old refusing to share his/her toys, go to bed, etc. Oppositional Defiant Disorder (ODD) Direct versus indirect/relational (“getting even” through a third party, damaging reputations via rumors, ostracization).
Relational aggression is attempt to inflict harm upon another person by manipulating and damaging social relationships.
Leads to loneliness, social isolation, depression and peer rejection. Aggression Forms Also aggression can be proactive (bullying, threatening) or reactive (retaliatory).
Very different underlying thoughts underlie these aggression types. Aggression Motive Overt versus covert (nonaggressive or hidden behaviors such as lying, stealing, substance abuse, truancy, property damage.
Most individuals with CD engage in both but have different etiologies and prognosis. Overt vs Covert Aggression Antidepressants - Prozac, Luvox, Zoloft, Anafranil
Used to treat symptoms of autism in children older than age of seven.

Antipsychotics (old) -Haldol, Thorazine
Reduce intensity of dopamine in the brain to control behavioral problems.

Antipsychotics (new) - Risperidone, Zyprexa, Geodon
Reduces aggression and self-injury among children with autism with few side effects.

Anti-convulsants - Tegretol< lamictal, topamax, Depakote
1 in 4 persons with autism have seizures, thus anti-convulsants help to reduce the amount of seizures.

Stimulants – Ritalin
Stimulants are drugs that are used for the treatment of autism symptoms to control and treat the autistic tendencies of inattention and hyperactivity. DSM-IV assumes that attention deficits are:
1. A distinct, differentiated condition.
2. Reliably measured using objective, behavioral measures.
3. Resulting from biological abnormalities. II. Some signs that cause impairment were present before age 7 years.

III. Some impairment from the signs is present in two or more settings (such as at school/work and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning.

V. The signs do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The signs are not better accounted for by another mental disorder (such as Mood Disorder, Anxiety Disorder, Dissociative Identity Disorder, or a Personality Disorder). IB. Six or more of the following signs of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:


Fidgets with hands or feet or cannot sit still.
Often gets up from seat when supposed to be seated.
Runs about or climbs when not appropriate.
has trouble playing or enjoying leisure activities quietly.
Often "on the go" or acts as if "driven by a motor"
Talks excessively

Blurts out answers before questions have been finished.
Trouble waiting one's turn.
Interrupts or intrudes on others. Twin studies suggest that ADHD is highly heritable.
About half of children referred for ADHD treatment also have ODD or CD.
Especially for Combined or Hyperactive-Impulsive types
Children with ADHD typically obtain less schooling than peers and less vocational achievement. Diagnostic Criteria
Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, manifested by three (or more) of the following in the past 12 months, with a least one in the past 6 months. Caused by both genetic and environmental factors.
May often misinterpret the intentions of others as hostile or threatening.
Often see poor frustration tolerance, irritability, temper and impulsivity.
Associated with earlier sexual and risk-taking behaviors, and alcohol and drug use.
Higher than typical rates of suicidal ideation and suicide. Diagnostic Criteria

Pattern of negativistic, hostile, defiant behavior (often towards authority) in which 4 (or more) of the following are present over 6 months: 2-16% prevalence rate.
More common in families that use inconsistent or neglectful child-rearing practices.
ODD behaviors are often positively reinforced by parents accidentally and thus increased. Child Behavior Checklist: 6-18
(Achenbach, 2001) Completed by parents or caregiver.
120 questions on behavior or emotional behaviors over past six months.
Uses 3-point Likert scale (0=not true, 2=very true) Stimulant medications are treatment of choice.
Not recommended for preschool children, long-term effects are unknown. Behavioral techniques can be applied to treat autism-spectrum disorders, ADHD, and behavioral problems. One of the primary factors that develops and maintains problematic behaviors is reinforcement of unwanted behaviors.
One of the most powerful reinforcers that children receive is attention (positive or negative).
Many parents attempt to correct negative behaviors with attention or punishment, creating a cycle of negative interactions.
Positive reinforcement and praise for appropriate behaviors teaches and strengthens bond between child and caregiver. Differential Reinforcement of Other Behaviors To qualify, must have displayed at least 2 of the following characteristics persistently over at least 12 months and in multiple relationships and settings.
Reflect person's typical pattern of interpersonal and emotional functioning over this period. Conduct Disorder with a Callous-Unemotional Presentation 1. Lack of remorse or guilt
Blames others, not admit being wrong, only expresses remorse when caught.
2. Callous-lack of empathy
Cold and uncaring.
3. Unconcerned about performance.
Not concerned about poor performance at school, work, or other activities.
4. Shallow or deficient affect.
Feelings appear shallow, insincere, superficial. A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following:

1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back and forth conversation through reduced sharing of interests, emotions, and affect and response to total lack of initiation of social interaction,

2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated- verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits in understanding and use of nonverbal communication, to total lack of facial expression or gestures.

3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people

B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following:

1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).

2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or extreme distress at small changes).

3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).

4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling or touching of objects, fascination with lights or spinning objects).

C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities)

D. Symptoms together limit and impair everyday functioning. Autism Spectrum Disorder
Must meet A, B, C, & D criteria Autism is common set of behaviors ; thus one category adapted to individual.
Use clinical specifiers (e.g., severity, verbal abilities and others) and associated features (e.g., known genetic disorders, epilepsy, intellectual disability and others.)
two domains instead of three
1) Social/communication deficits
2) Fixated interests and repetitive behaviors
language problems are not universal in autism, thus it is not enough to base diagnosis on this.
Subdomain examples given for different ages to help diagnosis.
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