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Lecture 10

PSY240H1 Lecture 10: Neurodevelopmental Disorders & Legal + Ethics Issues

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University of Toronto St. George
Christine Burton

When we talk about Neurodevelopmental Disorders (ex. ADHD, Autism), we denote “developmental” to mean that it occurs and is diagnosed during a developmental period (aka while you’re living with your parents such as infancy and up). It’s not necessarily “disorders of childhood”. “Neuro” denotes that there is a presumed neurological basis (not for sure though, but presumed). Neurodevelopmental disorders commonly co-occur (ex. ASD and ID often go together, ADHD and specific learning disorder). Something to keep in mind: Assessing and diagnosing children requires a lot of experience (in fact, psychopathology in children is its own area of expertise). The reason for this is because kids (independent of everyone else) are very complex as they are still developing psychologically and so we need to be careful about what to consider clinically relevant (Kids do a lot of weird things for a reason that may not be indicative of a disorder ex. her chicken nugget story). Another reason is because we need to compare what the kids are presenting to what is developmentally normal. ADHD See DSM (slides 10-12)  Notes: ADHD can be diagnosed in adults as long as it started/happened in childhood. If it only started/happened in adulthood then it’s “other specified attention disorder”. ADHD is sometimes over-diagnosed. For it to be properly diagnosed it must actually be interfering with functioning (see criteria D). Ex: My kids performance in school doesn’t match his IQ (due to the ADHD). Informant reports are used to see if these symptoms are present in more than one setting (see criteria C). Note that ADHD is a disorder about regulating attention (directing attention to something important) NOT about an inability to focus. Notes on specifiers: Combined is 50-75% of people, Predominantly inattentive is 20-30% (and this one specifically is more common in girls), Predominantly hyperactive is 15%. Prevalence is 5-6% in children, 2-3% in adults. Sex ratio is more male (estimates between 2:1 and 4:1). Very low birth rate is a risk factor as well as being exposed to toxins in utero or right after birth (but we don’t know if this is a causality). These stats are common across cultures. Associated Features: Mood lability/irritability, low frustration tolerance. In early adulthood there is an elevated suicide attempt risk (especially if comorbid with mood, substance disorders). Course is often stable through adolescence (some have declining course associated with development of antisocial behaviour). Most often identified in early school years. Hyperactivity symptoms often most noticeable in preschool age (adolescence and later: motor hyperactivity more likely to be replaced by feelings of restlessness/impatience, fidgetiness. As well, with age the inattention features become more prominent). Functional consequences of ADHD: Reduced academic performance, reduced occupational performance, interpersonal conflict, rates of unemployment due to looking for job options with flexible deadlines which are not common jobs, higher rates of conduct disorder, antisocial PD, substance use disorders, incarceration rates (these higher rates more so in boys), rates of injury, traffic violations and accidents. URRICI Other functional consequences: Others may interpret lack of focus/attention to detail as reflecting laziness or lack of care, higher rates of teasing and bullying (due to the hyperactivity symptoms) as well as peer rejection/neglect (due to the inattention), Can affect self-esteem and social skills development. Treatment: Drug treatment using stimulants such as Methylphenidate and Ritalin (side note: the use of stimulants for ADHD was an accident since it was originally used for headaches but they notice patients were calmer). It seems paradoxical to use stimulants but when combined with behaviour interventions it has good efficacy (70% of treated children get reduction in symptoms in that they now have increased attention and/or reduced disruptive behaviour. They see improvements in academic performance and social connections). The cons of this drug treatment: May increase risk of later substance use issues, we’re unsure about the long-term effects of drug therapy, there’s a lot of over-prescription if these drugs, side effects such as low appetite and sleep issues. Lastly, some kids don’t respond specifically in terms of gains in academic functioning. Psychosocial options: Usually involves doing CBT on parents to train them. First educate them about ADHD. Then, increase positive acknowledgement (teach them to not criticize the child) of child’s behaviours and implement reward-based systems. Learn to communicate requests/expectations clearly and help the child meet them. Implement costs for minor rule violations, time outs for majors. Ethical Practice Controlled acts are specific actions performed by someone in the process of administrating health care. They are identified and outlined in the Regulated Health Professionals Act (ex. what they are and who specifically can perform them – clinical psychologist can diagnose and administer psychotherapy). Controlled acts include: diagnosing people, administering psychotherapy (talk therapy), prescribing medications, performing invasive procedures. (note: I think the way it works is this: You have the Regulated Health Professionals Act which outlines the controlled acts but then each regulated health profession has its own individual act with more details of the job generally termed as “[health profession] Act” as well as its own college) Nursing is a regulated health profession (Nursing Act and College Nurses Ontario). Ontario nurses can, under appropriate circumstances for example: “Administer a substance by injection or inhalation”, “Put an instrument, hand or finger beyond the opening of the urethra (catheter)”, “Put an instrument, hand or finger into an artificial opening into the body”. The professional regulatory body (aka College) resulting from an Act then develops registration requirements (ex. what degrees needed, must be in good standing with the college, etc.) and standards of practice. For example: The Psychotherapy Act  This established the College of Registered Psychotherapists of Ontario (CRPO) (can’t diagnose, only talk therapy). To legally call yourself a psychotherapist you must be registered in good standing with the CRPO. Clinical psychologists are also regulated health professions. They are governed by the College of Psychologists of Ontario (CPO). These colleges protect the public interest NOT the worker’s protection; that is what a union is for. They protect public interest by keeping the professions accountable for their competence and ensure ethical practice. Therefore, anything bad a professional does (such as break a standard of practice) the college would be most concerned with the safety of the public (not the worker). CPO Standard of Practice The standard of practice written by a college (ex. CPO) provides ethical guidelines for different aspects of conduct with patients. Three examples of the CPO standard of practice: 1. Practicing within boundaries of one’s competence (this is a construct in health care). a. The person must demonstrate that: They are authorized in the area of practice (ex. forensic) and that they are authorized to deal with a certain client population (ex. children, adolescents; a person can have multiple populations). b. They require supervision until competence is established. If one wishes to expand area of competence, they need to inform the college they’re interested in doing so. The college will tell them to find a supervisor, study a certain
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