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Chapter 13

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Chapter Outline DEVELOPMENTAL AND COGNITIVE DISORDERS I. Common Developmental Disorders A. Developmental psychopathology is the study of how disorders arise and change with time. In general, childhood is associated with significant developmental changes that follow a specific pattern. As a result, any disruption in the development of early skills will likely disrupt the development of later skills. B. The disorders covered in this chapter are usually diagnosed first in infancy, childhood, or adolescence and include attention deficit/hyperactivity disorder (ADHD), learning disorders, autism, and lastly mental retardation. C. Attention deficit/hyperactivity disorder 1. The primary characteristics of persons with attention deficit/hyperactivity disorder (ADHD) are inattention, overactivity, and impulsivity. Such persons start many tasks but rarely finish them, have trouble concentrating, and do not seem to pay attention when others speak. Children with ADHD are often described as fidgety in school, and often are unable to sit still for more than a few minutes. The textbook illustrates ADHD with the case of Danny. 2. The DSM-IV-TR differentiates two clusters of ADHD symptoms. a. The first cluster includes problems of inattention. b. The second cluster includes symptoms of hyperactivity and impulsivity. c. Either the first (inattention) or the second (hyperactivity and impulsivity) cluster must be present for the diagnosis of ADHD. 3. Inattention, hyperactivity, and/or impulsivity often result in other problems that are secondary to ADHD. Examples include poor academic performance, unpopularity and peer rejection, and low self-esteem resulting from frequent negative feedback by parents and teachers. 4. ADHD is estimated to occur in 4% to 12% of children who are 6 to 12 years of age, with boys outnumbering girls 4 to 1. Reasons for this large gender difference are unknown. Children with ADHD are first identified as different from their peers around age 3 or 4, and the symptoms of inattention, impulsivity, and/or hyperactivity become increasingly obvious during the school years. 68% of children with ADHD continue to have problems as adults, mostly with inattention. The ADHD label is more likely to be used for children in the United States than anywhere else. 5. The causes of ADHD have centered on genetics, brain damage, toxins and food additives, and maternal smoking. a. With regard to genetics, it has been known for some time that ADHD is more common in families with one person having the disorder, and such families display an increase in psychopathology in general, including conduct disorder, mood disorders, anxiety disorders, and substance abuse. More than one gene appears responsible for ADHD, leading researchers to consider possible subtypes of ADHD. i. Families with many persons with ADHD seem to have a very specific deficit in the region of chromosome number 20. ii. The gene for the D4 receptor — which appears involved in novelty-seeking behavior — appears more often in children with ADHD. iii. It is also suspected that the protein that assists with reuptake of dopamine is involved in ADHD. b. Brain damage has been implicated as a cause of ADHD for several decades as reflected in use of labels such as "minimal brain damage" or "minimal brain dysfunction." i. Relative inactivity of the frontal cortex and the basal ganglia have been associated with ADHD. ii. Other evidence suggests right hemisphere malfunction, and abnormal frontal lobe development and functioning. iii. Research has yet to unearth precise neurological mechanisms underlying the basic symptoms of ADHD. c. Toxins, such as allergens and food additives have been considered as possible causes of ADHD, though there is little evidence for this link. Yet, many families continue to put their children on fad diets (e.g., the Feingold Diet), despite the absence of evidence that such diets help. d. Maternal smoking during pregnancy results in a threefold increased probability having a child with ADHD. e. Psychological and social factors of ADHD also can influence the disorder itself. For instance, impulsive and hyperactive behavior can evoke negative responses by parents, teachers, and peers. Such responses, in turn, may foster a low-self image in ADHD children. 6. Treatment of ADHD has proceeded on two fronts: biological and psychosocial interventions. a. The goal of biological treatments is to reduce impulsivity and hyperactivity and to improve attention. i. Hundreds of studies have documented the effectiveness of stimulant medication in reducing the core symptoms of ADHD. Such medications include methylphenidate (Ritalin), d- amphetamine (Dexedrine), and pemoline (Cylert). Such medications are effective in 70% of cases. Cylert is discouraged from use on a regular basis due to the greater likelihood of negative side effects. Most common side effects include insomnia, drowsiness, and/or irritability. ii. Other drugs such as antidepressants (imipramine) and a drug used to treat high blood pressure (clonidine) appear to offer some therapeutic benefit. iii. All of these drugs seem to improve compliance and decrease negative behaviors in ADHD children, but they do not affect learning and academic performance. The beneficial effects do not last in the long term once drugs are discontinued. iv. The paradoxical effects of stimulant medication are the similar in children and adults with and without ADHD. Stimulant medications reinforce the brain’s ability to focus attention during problem-solving tasks. The theory that these medications produce a paradoxical effect is not supported. b. Behavioral interventions for ADHD involve reinforcement programs to increase appropriate sitting, work, and play. Other programs incorporate parent training. c. Most clinicians recommend a combination of biological and psychological approaches to treat short-term management issues and long-term concerns such as improving social skills and preventing and reversing academic decline. D. Learning disorders 1. Learning disorders cover problems related to academic performance in reading, mathematics, and writing. Performance across such domains is substantially below what would be expected given the person’s age, IQ, and education. The textbook illustrates a reading disorder with the case of Alice. a. DSM-IV-TR defines a reading disorder as a significant discrepancy between a person’s reading achievement and what would be expected for someone of the same age. i. DSM criteria require that the person read at a level significantly below that of a typical person of the same age, cognitive ability (as measured with an IQ test), and educational background. ii. The reading problem cannot be caused by a sensory deficit such a trouble with sight or hearing. b. Similarly, the DSM-IV-TR defines a mathematics disorder as achievement below expected levels in mathematics. c. The DSM-IV-TR disorder of written expression represents achievement below expected levels in writing. 2. Definitions of learning disorders vary greatly, making estimates of incidence and prevalence difficult. a. Conservatively, there is a 1% to 3% incidence of learning disorders in the United States, with increased frequency of such disorders in wealthier regions of the U.S. b. The prevalence rate of learning disorders is 10% to 15% among school age children. c. Reading difficulties are the most common learning disorder, affecting 5% to 15% of the general population. Mathematics disorder appears in 6% of the population. Girls and boys are equally likely to be diagnosed with reading disorder. d. About 32% of students with learning disabilities drop out of school, and employment rates for this group tend to be quite low. e. Most adults with learning disabilities report that their school experiences were generally negative, with such effects lasting beyond graduation. 3. Etiological theories of learning disorders include genetic, neurobiological, and environmental factors. a. Regarding genetics, reading disorders tend to run in families, and the concordance rate of reading disorders in identical twins is 100%. i. Reading disorder may be linked to genetic material on chromosome 6 and 15, but is likely influenced by several biological and psychosocial factors. b. Subtle forms of brain damage may be related to learning disabilities; though findings are somewhat mixed. 4. Treatment for learning disorders requires intense educational intervention and biological treatment and is typically restricted to those individuals who may also have ADHD. 5. Educational interventions focus on the following: a. Remediation of the underlying basic processing problems (e.g., teaching students visual and auditory perception skills). b. Improvement in cognitive skills through general instruction in listening, comprehension, and memory. c. Targeting behavioral skills needed to compensate for specific problems in reading, math, or written expression. d. Considerable research supports the usefulness of teaching behavioral skills as a means to improve academic skills. II. Pervasive Developmental Disorders A. All persons with pervasive developmental disorders have problems with language, socialization, and cognition. Pervasive means that the problems affect persons throughout their lives, and includes autistic disorder, Asperger’s syndrome, Rett’s disorder, childhood disintegrative disorder, and pervasive developmental disorder — not otherwise specified. The textbook focuses on autistic disorder. B. Autistic disorder, or autism, is a childhood disorder characterized by significant impairment in social interactions and communication and by restricted patterns of behavior, interest, and activities. The textbook illustrates autism with the case of Amy. 1. The DSM-IV-TR notes three major characteristics of autism: impairment in social interactions, impairment in communication, and restricted behavior, interests, and activities. a. Persons with autism do not develop the types expected social relationships expected for their age. Such problems are often more qualitative than quantitative. Such persons are not totally unaware of others, but they do not seem to enjoy meaningful relationships with others or have the ability to develop them. b. Persons with autism have severe problems with communication, with about 50% never acquiring useful speech. Some with speech engage in echolalia, and others are unable or unwilling to carry on conversations with others. c. Restricted patterns of behavior, interests, and activities are the most striking aspects of autism. Many persons with autism prefer that things remain the same; a phenomenon referred to as maintenance of sameness. Such persons may also spend countless hours engaging in stereotyped and ritualistic behaviors (e.g., spinning around in circles, biting their hands). Prevention of such rituals may result in a severe tantrum. 2. Autism is relatively rare, occurring in about 2 to 20 persons for every 10,000 people. a. Autism is more prevalent in females for people with IQs under 35, where in the higher IQ range it is more prevalent in males. The reason for this difference is unknown. b. Autism occurs worldwide, and symptoms often develop before age 3. c. About 50% of persons with autism have IQs in the severe to profound range of mental retardation (i.e., IQ less than 50), about 25% test in the mild-to-moderate IQ range (i.e., IQ of 50 to 70), and the remaining 25% display abilities in the borderline-to-average range (i.e., IQ greater than 70). Better language skills and IQ test performance predicts better lifetime prognosis. 3. Historically, numerous etiologic theories have been proposed to explain autism. a. In the past, autism was viewed as the result of bad parenting. Such parents were thought to be perfectionistic, cold, and aloof. Later research has contradicted this view. b. Other theories focused on unusual speech patterns; namely the tendency to avoid first-person pronouns such as I and me and to use he and she instead. This led to the view that autism may reflect a lack of self-awareness. Later research shows that some people with autism do have self-awareness and that such awareness follows a developmental progression. c. The characteristic idiot savant is not a usual feature of autism. d. The phenomenon of echolalia (i.e., repeating a word or phrase spoken by another person) was believed to be an unusual characteristic of this disorder; however, this feature is also part of normal development. e. The primary characteristic that clearly distinguishes persons with autism from others is social deficiencies. 4. Biological dimensions of autism include the following: a. Medical conditions, such as congenital rubella (i.e. German measles), tuberous sclerosis, and difficulties during labor are not always associated with autism. b. Autism has a genetic component. Families with one child with autism have a 3% to 5% risk of having another child with the disorder. The exact genetic contribution is unknown. c. Neurobiological evidence of brain damage is derived from the observation that 3 of 4 people with autism have some level of mental retardation, and 30% to 75% display neurological abnormalities such as clumsiness or abnormal posture or gait. d. CAT and MRI scans show abnormalities of the cerebellum, including reduced size of this structure, among people with autism. This appears to be one of the most reliable findings of brain involvement in autism to date. C. Treatment for pervasive developmental disorders relies on a similar approach as used with ADHD. The textbook largely focuses on the treatment of autism. 1. Psychosocial treatments for autism include behavioral approaches that focus on skill building and treatment of problem behaviors. The behavioral approach is based on the early work of Charles Ferster and Ivar Lovaas. The basic premise is that people with autism can learn and can be taught skills. Targets for treatment include the following: a. Communication problems and problems with language are defining characteristics of autism. The basic procedure involves shaping and discrimination training to teach nonspeaking autistic children to imitate others verbally. Alternative methods might include nonverbal gestures and signs. b. Socialization deficits are profound in persons with autism, and yet limited progress has been achieved toward developing interventions that teach subtle social skills that are important for interactions with peers and others. c. Data suggest that early intervention is promising for children with autism. Autistic children placed in regular classrooms tend to do better than those placed in special education classes. 2. No biological or medical treatment exists to cure autism. In fact, medical interventions have limited success. 3. Integrated treatments, combining several approaches, are the preferred treatment of choice for people with pervasive developmental disorders. a. In children, such treatment involves school education combined with special psychological supports for problems with communication and socialization. b. Parents likewise need support. c. As children with autism grow older, intervention focuses on efforts to integrate such individuals into their communities. III. Mental Retardation A. Mental retardation (MR) is a disorder of childhood that involves below-average intellectual and adaptive functioning. Historically, persons with mental retardation have been devalued by societies and their treatment has been shameful. Manifestations of mental retardation are varied, with some individuals able to function well in society. Persons with mild-to-moderate impairments (i.e., the majority of persons with MR) can, with proper preparation, carry out most daily activities, whereas those with severe impairments need help to carry out basic living tasks and may, with proper training, achieve a degree of independence. Persons with MR experience impairments that affect most areas of functioning, with language and communication skills being the most obvious problem areas. The textbook illustrates mental retardation with the case of James. B. The DSM-IV and DSM-IV-TR codes MR on Axis II, indicating that it is a chronic condition and less amenable to treatment. DSM-IV-TR criteria for MR are arranged in three groups. 1. First a person must have significantly subaverage intellectual functioning as determined by one of several IQ tests with a somewhat arbitrary cutoff score set by the DSM-IV-TR at 70 or below. About 2% to 3% of the population score at or below this cutoff. 2. Second, concurrent deficits or impairments in adaptive functioning must be evident in at least two of the following areas: communication, self-care, home living, social and interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health, and/or safety. 3. The third criterion is age of onset. MR must be evident before the person is 18 years of age. This age criterion rules out the diagnosis of MR for adults who suffer brain trauma or forms of dementia. C. MR is largely defined by society and most classification systems (including the DSM-IV- TR) identify four levels of MR. 1. Mild MR includes persons with an IQ score between 50 or 55 and 70. 2. Moderate MR includes persons in the IQ range of 35-40 up to 50-55. 3. Severe MR includes people with IQs ranging from 20-25 up to 35-40. 4. Profound MR covers people with IQ scores below 20-25. D. The most controversial change in the American Association of Mental Retardation (AAMR) definition of MR is its description of different levels of this disorder, based on the level of assistance people need (i.e., intermittent, limited, extensive, or pervasive assistance). The AAMR system identified the role of needed supports in determining level of functioning, whereas the DSM-IV-TR implies that the ability of the person is the sole determining factor of an MR diagnosis. E. An additional classification method used in education systems to identify abilities of persons with MR relies on three categories. Built into this system is the negative assumption that certain individuals cannot benefit from certain types of training. This system, and the potential stigma of the DSM, led to the AAMR categorization of needed supports. 1. Educable mental retardation (i.e., IQ of 50 to approximately 70-75). 2. Trainable mental retardation (i.e., IQ of 30 to 50). 3. Severe mental retardation (i.e., IQ below 30). F. About 90% of persons with MR get the label mild mental retardation, and persons with any form of MR represent about 1% to 3% of the general population. The course of MR is chronic; however, prognosis varies greatly. MR occurs more often in males, with a male- to-female ratio being about 6:1, at least in cases of mild MR. G. Etiologic research has identified hundreds of known causes of MR, including environmental (e.g., abuse, deprivation), prenatal (e.g., exposure to disease, drugs, poor nutrition), perinatal (e.g., difficulties during labor and delivery) and postnatal (e.g., infections, head injury). Despite the range of known causes, nearly 75% of cases cannot be attributed to any known cause or are thought to result from a combination of social and environmental influences. 1. Genetic research suggests that multiple gene influences are involved in MR. A portion of people with severe MR have identifiable single-gene disorders, involving dominant, recessive, or X-linked genes. Only a few dominant genes result in MR, but can produce conditions related to MR (e.g., tuberous sclerosis, phenylketonuria). Lesch-Nyhan syndrome is an X-linked disorder found only in males characterized by MR, signs of cerebral palsy (i.e., spasticity or tightening of the muscles), and self-injurious behavior. 2. Several chromosomal aberrations resulting in MR have been identified. a. For example, Down syndrome is caused by an extra 21 chromosome and is sometimes referred to as trisomy 21. This condition is caused by the failure of cell division (i.e., nondisjunction) on chromosome 21, resulting in one cell with one copy that dies and one cell with three copies that divide to create a person with Down syndrome. Down syndrome is associated with characteristic facial features, congenital heart malformations, and dementia of the Alzheimer’s type in all adults with Down syndrome past the age of 40. Incidence of Down syndrome increases with the maternal age and risk of this condition can be detected via amniocentesis. b. Fragile X syndrome is a second common chromosomally related cause of MR, related to an abnormality on the X chromosome. This condition primarily affects males because they do not have a second X chromosome with a normal gene to balance out the mutation. Female carriers of fragile X syndrome commonly display mild-to-severe learning disabilities. Males with fragile X show moderate-to-severe levels of MR, higher rates of hyperactivity, short attention spans, gaze avoidance, and perseverative speech. Physical characteristics include large ears, testicles, and head circumference. About 1 of every 2,000 males is born with fragile X syndrome. 3. Psychological and social factors that are thought to contribute to MR include the following: a. Cultural-familial retardation is believed to cause about 75% of MR cases and is the least understood. Persons with this form of MR tend to score in the mild MR range on IQ tests and have good adaptive skills. Their MR is thought to result from a combination of psychosocial and biological influences, such as abuse, neglect, and social deprivation. According to the difference view, persons with cultural-familial retardation have a limited subset of deficits (e.g., attentional or memory problems) of those with severe forms of MR and are, therefore, more like persons with severe MR but different from people without MR. The developmental view conceptualizes mild MR in persons with cultural- familial retardation as a difference in the rate and ultimate ceiling of an otherwise normal developmental sequence. This later view suggests that such children proceed through normal development, but at a slower pace. Support for both views is mixed. H. Treatment for MR parallels treatment of persons with pervasive developmental disorders and attempts to teach such persons skills they need to become more productive and independent. Biological treatment for MR is not a viable option. 1. For mild MR, interventions are similar to those used for learning disorders, and include identification of learning deficits, assis
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