Chapter 13
• Overview: more than 1/3 of all children suffer from a significant behavioural or
emotional disorder by 16; boys more vulnerable than girls; linked to major
stressors which have cumulative effect; 12.5% of children live below poverty line
in Canada
• Resilient children: many children who face major stressors not develop severe
psychological symptoms or disorders; at least one healthy, competent adult or
other high quality interactions with parents
• Temperament: child’s arousability and general mood; biological factor
implicated in development of many disorders; difficult temperaments consist of
sensitivity to stimulation, trouble calming oneself, negative mood and difficulty
adapting to new situations; can elicit more negative interactions from others
• Developmental psychology: study of childhood disorders; understand when
children’s behaviours cross from normal difficulties into abnormal problems;
understand impact of normal development on the form abnormal behaviours take
Behaviour disorders
• Attention-deficit/hyperactivity disorder: inattention, hyperactivity and
impulsivity; trouble controlling impulses, paying attention and organizing
behaviours to accomplish long-term goals; behaviour driven and disorganized
• Inattention symptoms
o Does not pay attention to details and makes careless mistakes
o Difficulty sustaining attention
o Does not seem to be listening when others talk
o Does not follow through on instructions or finish tasks
o Difficulty organizing behaviours
o Avoids activities that require sustained effort and attention
o Loses things frequently
o Is easily distracted
o Is forgetful
• Hyperactivity symptoms
o Fidgets with hands or feet and squirms in seat
o Leaves his or her seat when inappropriate
o Runs around or climbs excessively
o Has difficulty engaging in quiet activities
o Often acts as if “driven by a motor”
o Often talks excessively
• Impulsivity symptoms
o Blurts out responses while others are talking
o Has difficulty waiting his or her turn
o Often interrupts or intrudes on others
• Combined type: most common; presence of six or more of the symptoms of
inattention and six or more of the symptoms of hyperactivity-impulsivity • Predominantly inattentive type: six or more symptoms of inattention but fewer
than six symptoms of hyperactivity-impulsivity present; some argue certain
symptoms indicating a sluggish cognitive tempo, which include slow retrieval of
information from memory and slow processing of information, low levels of
alertness, drowsiness and daydreaming, should be considered
• Predominantly hyperactive-impulsive type: six or more symptoms of
hyperactivity-impulsivity but fewer than six symptoms of inattention
• Other difficulties: 20-25% have serious learning disabilities; poor relationships
with others; may also be diagnosed with conduct disorder; symptoms persist from
childhood into young adulthood for about ¾ of children; increased risk for ASPD,
substance abuse, marital problems
• Prevalence: only 1-7% of children develop; boys have a higher incidence for all
age groups but rates differ; higher prevalence for 6-8 year olds than 12-14 year
olds; boys have more disruptive behaviours which could lead to
underidentification in girls
• Biological contributors: formerly referred to as minimal brain damage; sufferers
differ from healthy kids on measures of neurological functioning and cerebral
blood flow; areas of brain most likely involved are frontal lobe, caudate nucleus
within basal ganglia, corpus callosum and pathways between structures; important
roles in deployment of attention, regulation of impulses and planning of complex
behaviour; dopamine most consistently implicated; remove allergen additives
from food
o Immaturity hypothesis: children with ADHD are neurologically
immature (brains slower in developing); unable to maintain attention and
control behaviour at an age-appropriate level; explain why symptoms
decline with age
o Genetic links: runs in families; between 10-35% of immediate family
members of children with ADHD are also likely to have the disorder;
ASPD, alcoholism and depression also run in these families; twin studies
and adoption studies also suggest genetic factors play a role; dopamine
transporter genes may be abnormal
o Prenatal and birth complications: maternal ingestion of large amounts
of nicotine or barbiturates during pregnancy, low birthweight, premature
delivery and difficult delivery, leading to oxygen deprivation; moderate to
severe drinking by mothers can lead to kinds of problems in inhibiting
behaviours seen in children with ADHD; also high concentrations of lead
• Psychological and social contributors: ADHD kids more likely to experience
frequent disruptions in childhood and have antisocial/criminal fathers and hostile
mothers who report lower parenting competence and satisfaction; child places
stress on home environment and creates more conflict; may need to reshape
family’s interactions to reduce symptoms
• Drug treatments: stimulants like Ritalin, Dexedrine and Adderall most common
treatment; decreases in demanding, disruptive and non-compliant behaviour and
increases in positive mood, goal direction and interactions; may work by
increasing dopamine level in synapses by enhancing release and inhibiting
reuptake; side effects include higher frequency of tics, insomnia, edginess, GI upset and reduced appetite; 20% increase in Ritalin referrals since 1997; greater
use due to increase in recognition of the disorder and treatment seeking for
children with ADHD OR inappropriate overuse of drugs; other drugs include
clonidine and guanfacine (affect norepinephrine) which reduce tics and increase
cognitive performance; atomexetine also approved; antidepressants also
prescribed which reduce depression and have some positive effects on cognitive
performance (esp. bupropion); only produces short term gains
• Behavioural training programs: longer term gains can be had by combining
stimulant therapy with behaviour therapy (68% in one study, meds second) that
focuses on reinforcing attentive, goal directed and prosocial behaviours and
extinguishing impulse and hyperactive behaviours; improve functioning for
family and child; teach behavioural methods to promote positive and extinguish
maladaptive behaviours; focus on parents’ own psychological problems and
impairments in parenting skills
• Conduct disorder: serious transgressions of societal norms for behaviour and
chronic patterns of unconcern for basic rights of others
• Symptoms: bullying, threatening or intimidating others, initiates physical fights,
uses weapons in fights, engages in theft and burglary, is physically abusive to
people and animals, forces others into sexual activity, lies and breaks promises
often, violates parents’ rules about staying out at night, runs away from home, sets
fires deliberately, vandalizes and destroys property, often skips school
• Prevalence: 5.5% of kids aged 4-16 years meet diagnosis in Ontario; high cost to
society; trouble conforming to norms into adolescence and adulthood; as
adolescents, about ½ engage in criminal behaviour and drug abuse; chronic
unemployment, unstable personal relationships and aggression and violent in
adulthood
• Oppositional defiant disorder: less severe pattern of chronic misbehaviour;
frequently lose temper or have tantrums, argue with adults, defy requests and
rules, deliberately annoy others, blame others for own mistakes, easily annoyed,
angry and resentful and spiteful or vindictive; do NOT destroy property, show
pattern of theft/deceit or show aggression to people/animals
• Prevalence: symptoms begin very early in life (toddler and preschool years);
some seem to outgrow behaviours by late childhood or early adolescence; a subset
go on to develop CD; boys three times more likely to be diagnosed with both and
to be more physically aggressive; girls more likely to be indirect and verbal and
alienate, ostracize and defame others
• Biological contributors: runs in families; parents with antisocial personalities,
alcohol abuse, depression; heritable; 82% of variability in CD due to genetic
factors; fundamental neurological deficits in frontal lobes, brain systems involved
in planning and controlling behaviour (frequently co-occurs with ADHD);
exposure to neurotoxins and drugs while in womb/pre-school years; often signs of
trouble in diagnosed children, even in infancy; more difficult temperament; high
serotonin levels in men or testosterone in those with deviant peers; more difficulty
learning from punishments/rewards because are less physiologically aroused;
unusually low levels of cortisol • Social contributors: more frequent in children in lower socioeconomic classes
and rural areas; downward social drift (parents are antisocial) versus causal role of
poverty; quality of parenting received related to whether one develops the full
syndrome; if parents are abusive, neglectful or uninvolved delinquency results;
more severe punishments for boys may account for higher rates; deviant peer
groups or relationships with those with disturbances encourage delinquent acts;
biological/family factors can coincide; neuropsychological problems associated
with antisocial behaviours linked to maternal drug use
• Cognitive contributors: process information about social interactions in ways
that promote aggressive reactions; narrow range of responses and assumptions;
negative ramifications will contribute to assumptions world is against child;
changing thinking patterns can change tendencies to act aggressively
• Drug therapies: meds have not proved consistently helpful; SSRIs can reduce
irritable and agitated behaviours; neuroleptics and stimulant drugs suppress
aggressive behaviour; mood stabilizers like lithium and anticonvulsants might be
effective for aggressive conduct disorder
• Psychological and social therapies: derived from social learning theory; focus
on changing ways of interpreting interactions, teaching them to consider
perspectives of others; use self-talk to control impulses and use more adaptive
ways of solving conflicts than aggression; try to involve parents
• CBT: first step to teach kids to recognize situations that trigger anger (observation
in natural settings); analyze thoughts and consider alternate interpretations; next
taught to use self-talk to avoid negative reactions; teach adaptive problem solving
skills; try to teach parents to reinforce positive behaviours and discourage
aggressive ones; treatments are effective but relapse is common if parents have
issues; booster sessions of additional therapy help avoid relapse; have most long-
term positive effects if therapy begins early in disturbed child’s life
• Separation anxiety disorder: emotional disorder specific to childhood; children
show much more than usual anxiety when separated from caregivers; can
continue into childhood and adolescence; may refuse to go to school, can’t sleep
at night, have nightmares with themes of separation, exaggerated fears, avoid
activities; many children go through short episodes of a few days of these
symptoms after traumatic events
• Diagnosis: symptoms for at least four weeks and impairment of daily functioning;
excessive distress when separate from home or caregivers or when anticipating
separation, persistent and excessive worry about losing or harm coming to
caregivers, persistent reluctance or refusal to go to school/elsewhere, excessive
fear of being alone, reluctance to sleep without caregivers near by, repeated
nightmares involving fears of separation, repeated complaints of physical
symptoms where separation occurs
• Prevalence: about 3% of children under 11 suffer SAD; more common in girls
than boys; can recur frequently throughout childhood and adolescence; more
likely to have psychiatric problems as adults, live at home and be unmarried
• Biological contributors: family histories of anxiety and depressive disorders;
heritable, but more so in girls than boys; some children born high in behavioural inhibition (kind of temperament) and are shy, fearful and introverted; avoid novel
situations and are excessively aroused when exposed to unfamiliar situations;
abnormalities on gene regulating CRH (important role in stress response); parents
prone to anxiety disorder and panic attacks
• Psychological and sociological contributors: can learn to be anxious from
parents, as an understandable response to an environment or following a traumatic
event; parents can be overprotective and model anxious reactions to separation;
close-knit families do not encourage developmentally appropriate levels of
independence; insecurely attached kids who are behaviourally inhibited and have
anxious parents are particularly at risk
• Treatments: CBT most often used; develop new coping skills and challenge
cognitions that feed anxiety; relaxation exercises and challenge fears of
separation; increase separation from parents as therapy progresses; teach parents
to model non-anxious reactions; effective in short term and can maintain effects in
long-term; can use antidepressants (benzodiazepines), stimulants and
antihistamines; SSRIs most frequently used and shown to be effective in reducing
anxiety symptoms; in 2000, province mandated screening and outcome
measurement for children’s mental health organizations (well-validated clinical
tools to detect at risk kids and monitor clinical outcomes)
• Elimination disorders: involve uncontrolled wetting and defecation far beyond
age (four) at which children usually gain control over these functions
• Enuresis: unintended urination at least two times a week for three months; child
over five years of age; most wet only at night; 15-20% of five year olds wet the
bed at least once per months; by adolescence, prevalence decreases to 1-2%;
• Causes: about 75% of children with enuresis have biological relatives with the
disorder; inherited unusually small bladder or lower bladder threshold for
involuntary voiding; 5-10% of kids have urinary tract infections; psychodynamic
and family systems theorists say its due to conflicts and anxiety caused by
disruptions and dysfunction in family; behaviourists say its lax or inappropriate
toilet training (lack of bladder control)
• Treatment: tricyclics often prescribed but have dangerous side effects and
overdose can be fatal; increases in norepinephrine can help with bladder control;
about half of kids treated with imipramine show reductions in wetness but up to
95% relapse when its discontinued; synthetic antidiuretic dormone has emerged as
drug of choice as it concentrated urine and releases its output from kidney to
bladder; reduces wetting but relapse is common
o Bell and pad method: pad with sensory device to detect urine is placed
under sleeping child; if child wets, bell rings and wakens child; use
classical conditioning to teach child when to wake up and urinate; 70%
cured in four weeks
• Encopresis: repeated defecation into clothing or onto floor; rarer than enuresis; at
least one such event a month for at least three months; must be at least four years
old; fewer than 1% of children can be diagnosed; more common in boys; usually
begins after one or more episodes of severe constipation; can result from
environmental factors (withholding of bowel movements for some reason), genetic predisposition toward decreased bowl motility, food intolerance or certain
medication; constipation can cause distention of the colon, decreasing the child’s
More
Less
