Chapter 13Developmental Disorders &

Cognitive Disorders

Nature of Developmental Psychopathology: An Overview

Normal vs. Abnormal Development

Developmental Psychopathology

– Study of how disorders arise and change with time

– Disruption of early skills can affect later development

DSM-IV TR has 43 different categories/types

Mental Health vs. Educational categories – IDEA 2004

IDEA 97 Categories - PL 105-17IDEA 97 Categories - PL 105-17IDEA 2004 – (Same)IDEA 2004 – (Same)

Individual Disabilities Education ActIndividual Disabilities Education Act

Blind or Visually Impaired Hearing impaired (includes

deaf) Orthopedic Other Health Impaired Mentally Retarded Specific Learning Disability Autism

Emotional Disturbance Speech & Language Impaired Traumatic Brain Injury Developmental Delay (DD) <

age 9 Needs special education

services

Kentucky Regulations - IDEA

Mental Disability (mild/functional)

Hearing impairments Communication Disorders Visual Impairment Emotional Behavioral

Disability Autism Deaf-Blind

Orthopedic/physically disabled Traumatic Brain Injury Other Health Impaired Specific Learning Disability Multiple Disabilities Developmental Delay (DD)

<age 9

Nature of Developmental Psychopathology: An Overview (continued)

Developmental Disorders

– Diagnosed first in infancy, childhood, or adolescence (43 diagnoses)

– Attention deficit hyperactivity disorder (ADHD)

– Learning disorders

– Autism

– Mental retardation

Attention Deficit HyperactivityDisorder (ADHD): An Overview

Nature of ADHD

– Central features – Inattention, overactivity, and impulsivity

– Associated with numerous impairments

Behavioral

Cognitive

Social and academic problems

Attention Deficit HyperactivityDisorder (ADHD): An Overview (continued)

DSM-IV-TR Symptom Types

– Inattentive type

– Hyperactive type

– Impulsive type

ADHD: Facts and Statistics

Prevalence

– Occurs in 6% of school-aged children

– Symptoms are usually present around age 3 or 4

– 68% of children with ADHD have problems as adults

ADHD: Facts and Statistics (continued)

Gender Differences

– Boys outnumber girls 4 to 1

Cultural Factors

Probability of ADHD diagnosis

– Greatest in the United States

The Causes of ADHD: Biological Contributions

Genetic Contributions

– ADHD seems to run in families

– DRD4, DAT1, and DRD5 genes have been implicated

The Causes of ADHD: Biological Contributions (continued)

Neurobiological Contributions

– Smaller brain volume

– Inactivity of the frontal cortex and basal ganglia

– Abnormal frontal lobe development and functioning

The Causes of ADHD: Biological Contributions (continued)

The Role of Toxins

– No evidence that allergens and food additives are causes

– Maternal smoking increases risk

The Causes of ADHD: Psychosocial Contributions

Psychosocial Factors

– Can influence the nature of ADHD

– ADHD children are often viewed negatively by others

– Constant negative feedback from peers and adults

– Peer rejection and resulting social isolation

– Such factors foster low self-esteem

Biological Treatment of ADHD

Goal of Biological Treatments

– To reduce impulsivity and hyperactivity and to improve attention

Stimulant Medications

– Reduce core symptoms in 70% of cases

– Examples include Ritalin, Dexedrine

Biological Treatment of ADHD (continued)

Other Medications With More Limited Efficacy

– Imipramine and Clonidine (antihypertensive)

Effects of Medications

– Improve compliance and decrease negative behaviors

– Do not affect learning and academic performance

– Benefits are not lasting following discontinuation

Behavioral and Combined Treatment of ADHD

Behavioral Treatment

– Reinforcement programs

To increase appropriate behaviors

Decrease inappropriate behaviors

– May also involve parent training

Behavioral and Combined Treatment of ADHD (continued)

Combined Bio-Psycho-Social Treatments

– Are highly recommended

– Superior to medication or behavioral treatments alone

Learning Disorders: An Overview

Scope of Learning Disorders

– Academic problems in reading, mathematics, and writing

– Performance substantially below expected levels

Learning Disorders: An Overview (continued)

DSM-IV-TR Reading Disorder

– Discrepancy between actual and expected achievement

– Performance significantly below age or grade level

– Cannot be caused by sensory deficits

Learning Disorders: An Overview (continued)

DSM-IV-TR Mathematics Disorder

– Achievement below expected performance

DSM-IV-TR Disorder of Written Expression

– Achievement below expected performance in writing

Learning Disorders: Some Facts and Statistics

Prevalence of Learning Disorders

– 5-10% prevalence in the United States

– Highest in wealthier regions of the United States

– About 32% of these students drop out of school

– 5-15% prevalence for reading difficulties

– School experience tends to be generally negative

Fig. 13.1, p. 514

Biological and Psychosocial Causes of Learning Disorders

Genetic and Neurobiological Contributions

– Reading disorder runs in families

– 100% concordance rate for identical twins

– Evidence for subtle forms of brain damage is inconclusive

– Overall, contributions are unclear

Psychosocial Contributions are Largely Unknown

Treatment of Learning Disorders

Requires Intense Educational Interventions

– Remediation of basic processing problems

– Improvement of cognitive skills

– Targeting skills to compensate for problem areas

Data Support Behavioral Educational Interventions

Pervasive Developmental Disorders: An Overview

Nature of Pervasive Developmental Disorders

– Problems occur in Language, Socialization, and Cognition

– Pervasive – Problems span many life areas

Examples of Pervasive Developmental Disorders

– Autistic disorder

– Asperger’s syndrome

The Nature of Autistic Disorder: An Overview

Autism – Significant Impairments

– Social interactions and communication

– Restricted patterns of behavior, interest, and activities

The Nature of Autistic Disorder: An Overview (continued)

Three Central DSM-IV-TR Features of Autism

– Qualitative impairment of social interaction

– Problems in communication

50% never acquire useful speech

– Restricted patterns of behavior, interests, and activities

Autistic Disorder: Facts and Statistics

Prevalence and Features of Autism – 1 in every 500 births

– More prevalent in females with IQs below 35

– More prevalent in males with higher IQs

– Occurs worldwide

– Symptoms usually develop before 36 months of age

Autistic Disorder: Facts and Statistics (continued)

Autism and Intellectual Functioning

– 50% have IQs in the severe-to-profound range

– 25% test in the mild-to-moderate IQ range

– Remaining test in the borderline-to-average IQ range

Reliable indicators of good prognosis

– Language ability and IQ

Causes of Autism: Early and More Recent Contributions

Historical Views

– Bad parenting

– Unusual speech patterns

– Lack of self-awareness

– Echolalia

Causes of Autism: Early and More Recent Contributions (continued)

Current Understanding of Autism

– Medical conditions – Not always related with autism

– Genetic component is largely unclear

– Neurobiological evidence of brain damage

– Substantially reduced cerebellum size

Psychosocial Contributions Are Unclear

Asperger’s Disorder: Part of the Autistic Spectrum

The Nature of Asperger’s Disorder

– Show significant social impairments

– Restricted and repetitive stereotyped behaviors

– May be clumsy

– Often quite verbal

– No severe language and/or cognitive delays

Asperger’s Disorder: Part of the Autistic Spectrum (continued)

Prevalence of Asperger’s Disorder

– Often under diagnosed

– Affects about 1 to 36 persons per 10,000 people

Causes of Asperger’s Disorder Are Somewhat Unclear

Treatment of Pervasive DevelopmentalDisorders: Example of Autism

Psychosocial “Behavioral” Treatments

– Skill building

– Reduction of problem behaviors

– Target communication and language problems

– Address socialization deficits

– Early intervention is critical

Treatment of Pervasive DevelopmentalDisorders: Example of Autism (continued)

Biological and Medical Treatments Are Unavailable

Integrated Treatments: The Preferred Model

– Focus on children, their families, schools, and home

– Build in appropriate community and social support

Mental Retardation (MR): An Overview

Nature of Mental Retardation/Intellectual Disability (new term)

– Disorder of childhood

– Below-average intellectual and adaptive functioning

– Range of impairment varies greatly across persons

Mental Retardation (MR): An Overview (continued)

DSM-IV-TR criteria

– Significantly sub-average intellectual functioning

– Deficits or impairments in present adaptive functioning

– Must be evident before the person is 18 years of age

DSM-IV-TR Levels of Mental Retardation (MR)

Mild MR/ID

– IQ score between 50 or 55 and 70

Moderate MR/ID

– IQ range of 35-40 to 50-55

Severe MR/ID

– IQs ranging from 20-25 up to 35-40

Profound MR/ID

– IQ scores below 20-25

Other Classification Systems for Mental Retardation (MR)

American Association of Mental Retardation (AAMR)

– Defines MR based on levels of assistance required

– Levels of assistance

Intermittent, limited, extensive, pervasive

Other Classification Systems for Mental Retardation (MR) (continued)

Classification of MR/ID in Educational Systems

– Educable (IQ of 50 to 70-75)

– Trainable (IQ of 30 to 50)

– Severe (IQ below 30)

Implications of Different MR/ID Classification Systems

Mental Retardation (MR)/Intellectual Disabilities (ID): Some Facts and Statistics

Prevalence

– About 1-3% of the general population

– 90% are labeled with mild mental retardation

Mental Retardation (MR): Some Facts and Statistics (continued)

Gender Differences

– MR occurs more often in males

– Male-to-female ratio of about 1.6:1

Course of MR

– Tends to be chronic

– Prognosis varies greatly from person to person

Causes of Mental Retardation (MR):Biological Contributions

Hundreds of known causes

– Environmental – Deprivation, abuse

– Prenatal – Exposure to disease or a drug / toxin

– Perinatal – Difficulties during labor

– Postnatal – Head injury

Causes of Mental Retardation (MR):Biological Contributions (continued)

Genetic Research

– Multiple genes, and at times single genes

Chromosomal Abnormalities

– Down syndrome and Fragile X syndrome

Maternal Age and Risk of Having a Down’s Baby

Nearly 75% of Cases Have No Known Cause

Causes of Mental Retardation (MR):Psychosocial Contributions

Cultural-Familial Retardation

– Believed to cause about 75% of MR cases

– Is the least understood

– Associated with

Mild levels of retardation on IQ tests

Good adaptive skills

Causes of Mental Retardation (MR):Psychosocial Contributions (continued)

Difference vs. Developmental Views

– Difference view - Kind and degree of impairment

– Developmental view – Rate of developmental delay

Treatment of Mental Retardation (MR)

Parallels Treatment of Pervasive Developmental Disorders

Teach Needed Skills

– To foster productivity

– To foster independence

– Educational and behavioral management

– Living and self-care skills via task analysis

– Communication training – Often most challenging

Treatment of Mental Retardation (MR) (continued)

Community and Supportive Interventions

– Persons with MR can benefit from such interventions

Summary of Developmental Disorders

Developmental Psychopathology

Attention Deficit Hyperactivity Disorder

– Deficits in attention, hyperactivity, or impulsivity

Learning Disorders

– Deficits in performance below expectations

Summary of Developmental Disorders (continued)

Pervasive Developmental Disorder

– All share deficits in language, socialization, and cognition

Mental Retardation

– Sub-average IQ, deficits in adaptive functioning

– Onset before age 18

Prevention and Early Intervention Are Critical

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Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence 

New additions Posttraumatic Stress Disorder in Preschool Children   Temper Dysregulation Disorder with Dysphoria   Callous and Unemotional Specifier for Conduct Disorder   Learning Disabilities   Non-Suicidal Self Injury   Non-Suicidal Self Injury Not Otherwise Specified   Language Impairment Late Language Emergence   Specific Language Impairment   Social Communication Disorder   Voice Disorder

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence 

Reclassification Pica: Move to Eating Disorders Rumination Disorder: Move to Eating Disorders Feeding Disorder of Infancy or Early Childhood: Move to

Eating Disorders; Renamed Avoidant/Restrictive Food Intake Disorder

Separation Anxiety Disorder: Moved to Anxiety Disorders

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence 

Disorders to be removed Expressive Language Disorder Mixed Receptive-Expressive Language Disorder Communication Disorder Not Otherwise Specified Rett's Disorder

Reactive Attachment Disorder of Infancy or Early Childhood: Division into Reactive Attachment Disorder of Infancy or Early Childhood & Disinhibited Social Engagement Disorder

Disorder of Written Expression and Learning Disorder Not Otherwise Specified: Subsumed under Learning Disorder

Childhood Disintegrative Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder: Subsumed under Autistic Disorder (Autism Spectrum Disorder)

ADHD

A.   Either (1) and/or (2) 1.  Inattention 2.  Hyperactivity and Impulsivity

B.   Several noticeable inattentive or hyperactive-impulsive symptoms were present by age 12.

C.   The symptoms are apparent in two or more settings (e.g., at home, school or work, with friends or relatives, or in other activities).

D.   There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.

E.   The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

Specifiers: Combined, Predominately Inattentive, Predominately

Hyperactive/Impulsive, Inattentive (Restrictive)

Communication & Learning Disorders

Phonological Disorder: Renamed to Speech Sound Disorder Stuttering: Renamed to Childhood Onset Fluency Disorder Reading Disorder: Renamed to Dyslexia Mathematics Disorder: Renamed to Dyscalculia

Mental Retardation

Mental Retardation: Renamed Intellectual Disability Mental Retardation, Severity Unspecified: Renamed to

Intellectual or Global Developmental Delay Not Further Specified

Autistic (Autism Spectrum) Disorder

Autistic Disorder: Renamed Autism Spectrum Disorder Must meet criteria A, B, C, and D

A. Persistent deficits in social communication and social interaction across contexts

B. Restricted, repetitive patterns of behavior, interests, or activities

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

Tic Disorders

Tic Disorders Tourette’s Disorder Chronic Motor or Vocal Tic Disorder Transient Tic Disorder Tic Disorder NOS

All proposed to be classified as Neurodevelopmental Disorders

Medical Conditions Related to Delirium

Medical Conditions

– Drug intoxication, poisons, withdrawal from drugs

– Infections

– Head injury and several forms of brain trauma

– Sleep deprivation, immobility, and excessive stress

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Nature of Cognitive Disorders: An Overview

Perspectives on Cognitive Disorders

– Affect learning, memory, and consciousness

– Most develop later in life

Nature of Cognitive Disorders: An Overview (continued)

Three Classes of Cognitive Disorders

– Delirium – Temporary confusion and disorientation

– Dementia – Marked by broad cognitive deterioration

– Amnestic disorders – Memory dysfunctions

Nature of Cognitive Disorders: An Overview (continued)

Shifting DSM Perspectives

– From “organic” mental disorders to “cognitive” disorders

– Broad impairments in cognitive functioning

– Profound changes in behavior and personality

Delirium: An Overview

Nature of Delirium

– Central features – Impaired consciousness and cognition

– Develops rapidly over several hours or days

– Appear confused, disoriented, and inattentive

– Marked memory and language deficits

Delirium: An Overview (continued)

Facts and Statistics

– Affects 10% to 30% of persons in acute care facilities

– Most prevalent in older adults

Those undergoing medical procedures

AIDS patients and cancer patients

– Full recovery often occurs within several weeks

Medical Conditions Related to Delirium (continued)

DSM-IV-TR Subtypes of Delirium

– Delirium due to a general medical condition

– Substance-induced delirium

– Delirium due to multiple etiologies

– Delirium not otherwise specified

Treatment and Prevention of Delirium

Treatment

– Attention to precipitating medical problems

– Psychosocial interventions include reassurance

Focus on coping strategies

Inclusion of patients in treatment decisions

Treatment and Prevention of Delirium (continued)

Prevention

– Address proper medical care for illnesses

– Address proper use and adherence to therapeutic drugs

Dementia: An Overview

Nature of Dementia

– Gradual deterioration of brain functioning

– Deterioration in judgment and memory

– Deterioration in language / advanced cognitive processes

– Has many causes and may be irreversible

Dementia: Initial and Later Stages

Initial Stages

– Memory and visuospatial skills impairments

– Agnosia – Inability to recognize and name objects

– Facial agnosia – Inability to recognize familiar faces

– Other symptoms

Delusions, apathy, depression, agitation, aggression

Dementia: Initial and Later Stages (continued)

Later Stages

– Cognitive functioning continues to deteriorate

– Total support is needed to carry out day-to-day activities

– Death due to inactivity and onset of other illnesses

Dementia: Facts and Statistics

Onset and Prevalence

– Can occur at any age, but most common in the elderly

– Affects 1% of those between 65-74 years of age

– Affects over 10% of persons 85 years and older

Dementia: Facts and Statistics (continued)

Incidence of Dementia

– Affects 2.3% of those 75-79 years of age

– Affects 8.5% of those 85 and older

– Rates seem to double with every 5 years of age

Dementia: Facts and Statistics (continued)

Gender and Sociocultural Factors

– Occurs equally in men and women

– Occurs equally across educational level and social class

DSM-IV-TR Classes of Dementia

Dementia of the Alzheimer’s type

Vascular Dementia

Dementia Due to Other General Medical Conditions

Substance-Induced Persisting Dementia

Dementia Due to Multiple Etiologies

Dementia Not Otherwise Specified

Dementia of the Alzheimer’s Type: An Overview

DSM-IV-TR Criteria and Clinical Features

– Multiple cognitive deficits

– Develop gradually and steadily

– Memory, orientation, judgment, and reasoning deficits

– Additional symptoms may include

Agitation, confusion, or combativeness

Depression and/or anxiety

– “Sundowner syndrome”

Dementia of the Alzheimer’s Type: Extent of Deficits

Range of Cognitive Deficits

– Aphasia – Difficulty with language

– Apraxia – Impaired motor functioning

– Agnosia – Failure to recognize objects

Dementia of the Alzheimer’s Type: Extent of Deficits (continued)

– Difficulties with

Planning

Organizing

Sequencing

Abstracting information

– Negative impact on social and occupational functioning

An Autopsy Is Required for a Definitive Diagnosis

Alzheimer’s Disease: Some Facts and Statistics

Nature and Progression of the Disease

– Deterioration is slow during the early and later stages

– Deterioration is rapid during middle stages

– Average survival time is about 8 years

– Onset usually occurs in the 60s or 70s

Alzheimer’s Disease: Some Facts and Statistics (continued)

Prevalence of Alzheimer’s Disease

– About 4 million Americans and many more worldwide

– Prevalence greater in

Poorly educated persons and females

– Prevalence rates are low in some ethnic groups

10 Warning Signs of Alzheimer’s Disease

1. Memory loss that disrupts daily life 2. challenging in planning or solving problems 3. Difficulty completing familiar tasks 4. Confusion as to time and place 5. Trouble understanding visual images and spatial

relationships 6. New problems with words in speaking and writing 7. Misplacing things and losing the ability to retrace steps 8. Decreased or poor judgment 9. Withdrawal from work or social activities 10. Change in mood or personality

See – www.alz.org

Vascular Dementia: An Overview

Nature of Vascular Dementia

– Caused by blockage or damage to blood vessels

– Second leading cause of dementia next to Alzheimer’s

– Onset is often sudden (e.g., stroke)

– Patterns of impairment are variable

– Most require formal care in later stages

Vascular Dementia: An Overview (continued)

DSM-IV-TR Criteria and Incidence

– Cognitive disturbances – Identical to dementia

– Obvious neurological signs of brain tissue damage

– Incidence is about 4.7% of men and 3.8% of women

Other Causes of Dementia:HIV

HIV

– Causes neurological impairments and dementia

– Cognitive slowness, impaired attention, and forgetfulness

– Apathy and social withdrawal

Other Causes of Dementia:Head Trauma

Head Trauma – Accidents are leading cause

– Memory loss is the most common symptom

Other Causes of Dementia:Parkinson’s Disease

Parkinson’s Disease – Degenerative brain disorder

– Affects about 1 out of 1,000 people worldwide

– Motor problems – Central feature of this disorder

Caused by damage to dopamine pathways

– Impairments appear similar to sub-cortical dementia

Other Causes of Dementia:Huntington’s

Huntington’s Disease

– Genetic autosomal dominant disorder

– Manifests initially as chorea, usually later in life

– About 20-80% display dementia

– Dementia also follows a subcortical pattern

Other Causes of Dementia:Pick’s Disease

Pick’s Disease

– Rare neurological condition

– Produces a cortical dementia like Alzheimer’s

– Also occurs later in life (around 40s or 50s)

– Little is known about what causes this disease

Other Dementias: Creutzfeldt-Jakob Disease

Creutzfeldt-Jakob Disease

– Affects 1 out of 1,000,000 persons

– Linked to mad cow disease

Other Dementias: Substance-Induced Dementia

Substance-Induced Persisting Dementia

– Results from drug use in combination with poor diet

– Several drugs can lead to symptoms of dementia

– Resulting brain damage may be permanent

Other Dementias: Substance-Induced Dementia (continued)

– Dementia is similar to that of Alzheimer’s

– Deficits may include

Aphasia, apraxia, agnosia

Disturbed executive functioning

Causes of Dementia: The Example of Alzheimer’s Disease

Early and Largely Unsupported Views

– Implicated aluminum and smoking

Causes of Dementia: The Example of Alzheimer’s Disease (continued)

Current Neurobiological Findings

– Neurofibrillary tangles

– Amyloid plaques

– The role of deterministic genes

Beta-amyloid precursor gene

Presenilin-1 and Presenilin-2 genes

– The role of susceptibility genes - ApoE4 gene

– Brains of Alzheimer’s patients tend to atrophy

Causes of Dementia: The Example ofAlzheimer’s Disease (continued)

Current Neurobiological Findings

– Multiple genes are involved in Alzheimer’s disease

– Chromosomes 21, 19, 14, 12, 1

– Chromosome 14

Associated with early onset Alzheimer’s

– Chromosome 19

Associated with a late onset Alzheimer’s

The Contributions of Psychosocial Factors in Dementia

Psychosocial Factors

– Do not cause dementia directly

– May influence onset and course

– Lifestyle factors – Drug use, diet, exercise, stress

The Contributions of Psychosocial Factors in Dementia (continued)

– Cultural factors

Risk for certain conditions vary by ethnicity and class

– Psychosocial factors

Educational attainment

Coping skills

Social support

Medical and Psychosocial Treatment of Dementia

Medical Treatment: Best if Enacted Early

– Few exist for most types of dementias

– Most attempt to slow progression of deterioration

– Do not stop progression of dementia

Medical and Psychosocial Treatment of Dementia (continued)

Psychosocial Treatments - Aims

– To enhance lives of patients and their families

– To teach compensatory skills

– To use memory enhancement devices, if needed

– Psychosocial interventions appear to focus on caregivers

Prevention of Dementia

Reducing Risk of Dementia in Older Adults

– Estrogen-replacement therapy

– Proper treatment of cardiovascular diseases

– Use of anti-inflammatory medications

Other Targets of Prevention Efforts

– Increasing safety behaviors to reduce head trauma

– Reducing exposure to neurotoxins and use of drugs

Amnestic Disorder: An Overview

Nature of Amnestic Disorder

– Circumscribed loss of memory

– Inability to transfer information into long-term memory

– No loss of other high-level cognitive functions

Amnestic Disorder: An Overview (continued)

Causes May Include

– Medical conditions, head trauma, or long-term drug use

DSM-IV-TR Criteria

– Inability to

Learn new information or recall learned information

– Significant impairment in functioning

Amnestic Disorder: An Overview (continued)

The Example of Wernicke-Korsakoff Syndrome

– Damage to the thalamus

– Thiamine (Vitamin B-1) deficiency

– Resulting from stroke or chronic heavy alcohol use

Prevention

– Use of thiamine supplements with heavy drinkers

Research on Amnestic Disorders Is Scant

Summary of Cognitive Disorders

Cognitive Disorders Span a Range of Deficits

– Affect attention, memory, language, and motor behavior

– Causes include

Medical conditions

Drug use

Environmental factors

Summary of Cognitive Disorders (continued)

Most Result in Progressive Deterioration of Functioning

Few Treatments Exist to Reverse Damage and Deficits

Table 13.1, p. 540

Table 13.2, p. 543

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