PSY 240 CH. 16
Disorders of Childhood andAdolescence
• Progress in child psychopathology has lagged behind adult psychopathology.
• Most children with problems do not receive psychological attention.
• 14% of Canadian children between the ages of 4-17 experience some sort of mental
Maladaptive Behaviour in Different Life Periods
• Developmental psychopathology: Field of psychology that focuses on determining what
is abnormal at any point in the developmental process by comparing and contrasting it
with normal and expected changes that occur.
• We can’t consider a behaviour abnormal unless it is not something that normally occurs
during development. The behaviour has to be abnormal for that child’s age group.
Varying Clinical Pictures
• Some emotional disturbances in childhood may be short-lived. Kids who are hospitalized
in early childhood for a psychiatric illness are more likely to die of unnatural causes
(mostly suicide) 4-15 years later.
Special Vulnerabilities of Young Children
• In evaluating the presence or extent of a disorder in a child, one needs to consider the
- Don’t have as complex a view of themselves yet. They are not as self-aware as adults.
- Immediately perceived threats tend to appear more important than any others, past or
- Achild has a limited perspective and will not be able to understand certain concepts.
- Children are more dependent on adults than are other people.
- Children don’t have experience dealing with problems, making current ones seem
impossible to get by.
The Classification of Childhood andAdolescent Disorders
• In the first DSM, there were only 2 childhood emotional disorders: childhood
schizophrenia and adjustment reaction of childhood.
• In the DSM II, the same method of classifying disorders was used in adults and children.
Common Disorders of Childhood
• There are many more disorders in the current issue of the DSM to classify a child’s
• Attention-deficit/hyperactivity disorder: Disorder of childhood characterized by
difficulties that interfere with task-oriented behaviour, such as impulsivity, excessive
motor activity, and difficulties in sustaining attention.
• Hyperactive children tend to have lower IQs, talk a lot, and be socially intrusive or
• They often have difficulty getting along with others due to their hyperactivity. • Often confused with anxiety.
Causal Factors in Attention-Deficit/Hyperactivity Disorder
• Unknown if it is more biological or environmental factors. The hypothesis is that it will
be mostly due to genetics.
• One study suggests that parental personality problems may lead toADHD.
Treatments and Outcomes
• Ritalin: Central nervous system stimulant often used to treat ADHD.
• Amphetamines in general have a quieting effect on children.
• Ritalin can also lower the child’s aggressiveness.
• Side effects: Decreased blood flow to the brain, disruption of growth hormone, insomnia,
• Ritalin is an effective short-term treatment helping 50%-66% of the children it is
• Strattera: A NE reuptake inhibitor and non-stimulant drug that is sometimes used to treat
• Side effects: Decreased appetite, nausea, vomiting, and fatigue. The development of
jaundice has also been reported.
• Further research needed to evaluate its effectiveness and safety.
• Ritalin is often abused, mostly by university students.
• One of the better treatments forADHD may be a combination of psychological
interventions and medications. Behavioural techniques include selective reinforcement
and family therapy.
• Medication is more effective than behavioural treatment, though both help reduce
ADHD Beyond Adolescence
• Many withADHD in childhood retain the disorder in adolescence. Some go on to
development aggressive of substance abuse behaviours.
• More research is needed to determine if these children go on to develop other disorders in
Oppositional Defiant Disorder and Conduct Disorder
• In both cases, antisocial behaviour is the focus.
• Oppositional defiant disorder is usually apparent by age 8 and conduct disorder by age 9.
• Juvenile delinquent (young offender): Formerly called ‘juvenile delinquent,’young
offenders are those individuals, typically between ages 12 and 16, who are judged to be
criminally responsible for an illegal act.
The Clinical Picture in Oppositional Defiant Disorder
• Oppositional defiant disorder: Childhood disorder that appears by the age of 6 and is
characterized by persistent acts of aggressive or antisocial behaviour that may or may
not be against the law.
• Oppositional defiant disorder is often a precursor for conduct disorder.
• Essential features: Recurrent pattern of negativistic, defiant, disobedient, and hostile
behaviour toward authority figures that persist for at least 6 months.
• Usually begins by age 8. • Virtually all cases of conduct disorder are from patients who first had oppositional defiant
• Risk factors: Family discord, socioeconomic disadvantage, and antisocial behaviours in
The Clinical Picture in Conduct Disorder
• Conduct disorder: Childhood and adolescent disorders that can appear by age 9 and are
marked by persistent acts of aggressive or antisocial behaviour that may or may not be
against the law.
• Essential symptomatic behaviours: Persistent, repetitive violation of rules and a disregard
for the rights of others.
• Characteristics: Overt or covert hostility, disobedience, physical and verbal
aggressiveness, quarrelsomeness, vengefulness, and destructiveness. Some engage in
cruelty to animals, bullying, vandalism, robbery, and even homicidal acts.
• Risk factor for negative adult outcomes: crime, substance-use disorders, relationship
issues, and mental health problems.
Causal Factors in Oppositional Disorder and Conduct Disorder
• ASelf-Perpetuating Cycle
- Genetic predisposition leading to low verbal intelligence, mild neuropsychological
problems, and difficult temperament can set the stage for early onset conduct
- Child’s difficult temperament Insecure attachment to parent because parents find it
hard to engage in good parenting to promote a health attachment.
- Low verbal intelligence and/or mild neuropsychological deficits have been
documented in these children.
- Deficits can lead to a child being placed in a class with other ‘delinquent peers’where
the child can be exposed to delinquent behaviours.
• Age of Onset and Links toAntisocial Personality Disorder
- Children who develop conduct disorder at an early age are much more likely to
develop psychopathy or antisocial personality disorder as adults.
- 25-40% with early onset conduct disorder go on to develop antisocial personality
disorder. 80% of those with early onset conduct disorder still have difficulties in
social functioning, but do not meet the criteria for antisocial personality disorder.
- Those who develop conduct disorder late in adolescence mostly do not go on to
develop antisocial personality disorder.
• Environmental factors
- Children who are aggressive are often rejected by their peers and never fully grasp
how to interact with other people.
- These children can be rejected by their parents (bad attachment style) their peers (too
aggressive), and their teacher (bad in-class attitude). This rejection can lead to the
child feeling alienated and isolated. They will often turn to the deviant peer groups
then for companionship.
- Family discord and hostility were the primary factors defining the relationship
between disturbed parents and disturbed children.
- Other environmental factors increasing risk of developing conduct disorder: low
socioeconomic status, poor neighbourhoods, parental stress, and depression. Treatments and Outcomes
• Our society tends to focus on punishing rather than rehabilitating troubled youth.
• This tends to intensify rather than correct the behaviour.
• Treatment focuses on helping the dysfunctional family and on finding ways to alter
• The Cohesive Family Model
- The child’s environment needs to be modified.
- The parental attention a child receives from behaving badly actually serves to
reinforce that behaviour instead of suppressing it.
• Behavioural Techniques
- Teaching control techniques to the parents of children with the disorder is important.
- Changes occur when the parents consistently reward and accept their child’s positive
behaviour and stop focusing on the negative.
- Interventions with teachers is also helpful.
- If teachers and parents have difficulties carrying out the treatment, family therapy or
parental counselling is often used.
Anxiety Disorders of Childhood and Adolescence
• Children with anxiety disorders tend to be more extreme in their behaviours than those
experiencing normal anxiety.
• Characteristics: oversensitivity, unrealistic fears, shyness and timidity, pervasive feelings
of inadequacy, sleep disturbances, and fear of school.
• Children diagnosed with anxiety disorder typically attempt to cope by being overly
dependent on others for support.
• Often comorbid with depression.
• 6.4% between 5-17 years have an anxiety disorder.
• Greater numbers among girls than boys.
Separation Anxiety Disorder
• Separation anxiety disorder: Childhood disorder characterized by unrealistic fears,
oversensitivity, self-consciousness, nightmares, and chronic anxiety.
• 2-4% of children have this type. It is responsible for 50% of anxiety disorders of those
that come into clinics. More common in girls.
• Often lack self-confidence, are apprehensive in new situations, and are immature for their
• They tend to be described as shy, sensitive, nervous, submission, easily discouraged,
worried, and frequently moved to tears.
• Essential feature: Excessive anxiety over separation from major attachment figures and
from familiar home settings.
• Often there is a clear psychological stressor.
• When they are separated, they often feel as though a person is in danger of dying.
• Many children will get better.
• Selective mutism: Condition that involves the persistent failure to speak in specific social
situations and interferes with educational or social adjustment.
• Common for them to have a diagnosis of developmental disorder/delay. • Only be diagnosed when the child can actually speak the language but chooses not to.
Must persist for a month and not be limited to school.
• Biological and learning factors have been cited as possible causal factors.
• SSRIs are used as treatment as well as MAO inhibitors. Family-based psychological
treatment is another commonly used therapeutic approach.
Causal Factors in Anxiety Disorders
• Parental behaviour has been particularly noted. Cultural factors are also important.
• Tend to be have an unusual sensitivity that makes them easily conditionable by aversive
• Causes include early illness, accidents, or losses that involved pain and discomfort. These
can make them feel insecure of inadequate.
• Overanxious children often have a modelling effect of an overanxious and protective
• Indifferent or detached parents also foster anxiety in children.
• Social-environment factors are important though not well understood.
• Achild’s lack of control over situations in their environment such as violence may
experience more feelings of anxiety.
Treatments and Outcomes
• Most kids get help through interaction with peers in school, so the disorder does not
persist. Few have anxiety disorders that continue into adolescence and young adulthood.
• Biologically Based Treatments
- Psychopharmacological treatments becoming more common. Examples are fluoxetine
• Psychological Treatment
- CBT has been effective. Treatments include exposure-based strategies, reinforcement
for confronting feared situations, cognitive techniques for changing negative self-talk,
relaxation training, and assertiveness training.
- Group and individual treatment are equally effective.
• Childhood depression behaviours: withdrawing, crying, avoidance of eye contact,
physical complaints, poor appetite, and even aggressive behaviour and in some cases
• Often use same criteria to classify the disorder for children and adults.
• Point prevalence is estimated to be 0.4-25% for children and 4-8.3% for adults.
• Lifetime prevalence for adolescents is 25-20%.
• Before adolescence, rates are higher in boys; during adolescence, it is 2x as high in girls
Causal Factors in Childhood Depression
• Biological Factors
- Association between parental depression and mood problems in children.
- Suicide rate is higher for children of parents with mood disorders.
- Learning may be a causal factor.
- Vasopressin implicated in childhood depression. - Other biological factors may make children more vulnerable to psychological
• Psychological Factors
- History of stressful life events is important in childhood depressive disorders.
- Children exposed to negative parental behaviour may develop depression themselves.
- Studies looking into if a depressed mother affects the child by her interactions with
- Infants have been reported to exhibit greater frontal brain activity during expression
of negative emotionality by their mothers.
- Recent study suggests that depression in both the mother and the father is associated
with maladjustment in children.
- Depressed people tend to reason that positive events were caused by the environment
and negative events were caused by themselves.
Treatments and Outcomes
• Often treated the same way adults are. Though pharmacological treatments don’t appear
to be very helpful most times.
• Prozac has shown the most consistent positive results for children.
• Side effects are common with medication.
• 7-10% of adolescents report having made at least one suicide attempt.
• 1-3% on medication have had worsening of suicidal thoughts.
• CBT has been effective in adolescents.
• Predominant treatment is a combined approach of drugs and CBT.
Symptom Disorders: Enuresis, Encopresis, Sleepwalking, and Tics
• Elimination disorders include enuresis and encopresis.
• Enuresis: Bed wetting; involuntary discharge of urine after the expected age of expected
continence (age 5).
• Primary functional enuresis is used to describe children who have never been continent.
Secondary functional enuresis is used to describe children who have been continent for at
least a year and then regressed.
• 5-10% in 5 year olds, 3-5% among 10 year olds, and 1.1% of children aged 15 and
• Higher in boys than girls. And the percentage of boys diminishes more slowly in age
compared to girls.
• Can result from organic conditions such as disturbed cerebral control of the bladder,
neurological dysfunction, or other medical factors.
• Possible causal factors: 1) faulty learning, resulting in the failure to acquire inhibition or
reflexive bladder emptying, 2) personal immaturity, associated with emotional problems,
3) disturbed family interactions, particularly those leading to anxiety, hostility, or both,
and 4) stressful events.
• Medical treatments involve antidepressants such as imipramine, atomoxetine (NE
reuptake inhibitor), and an intranasal desmopressin (DDAVP, ahormone replacement).
• DDAVP is a short-term treatment, most effective for a child going to camp or on a
holiday. • Conditioned treatments are most effective.
• Child sleeps on a pad that is wired to a bell. It rings when the child wets the bed waking
• With or without treatment, enuresis numbers decrease with age.
• Encopresis: Disorder in children who have not learned appropriate toileting for bowel
movements by age 4.
• 1% of 5 year olds have encopresis.
• Characteristics:Average age is 7, 1/3 also have enuresis, 6x as many boys as girls.
Many children soiled their clothes when they were under stress.
• Many children with encopresis suffer from constipation.
• Treatments are usually medical and psychological. Psychological treatments have
• Sleepwalking disorder: Disorder of childhood that involves repeated episodes of leaving
the bed and walking around without being conscious of the experience or remembering it
• Onset between ages of 6-12.
• Incidence of repeated episodes is low.
• Incidents usually only last a few minutes.
• Causes are unknown. It does not take place during REM.
• Appears to be related to some anxiety causing situation.
• Treatment included the mother waking a child before an episode, and having them face
whatever the anxiety causing event was. Waking the child leads to them associating the
awakening with the nightmares that they were having.
• Tic: Persistent, intermittent muscle twitch or spasm, usually limited to a localized muscle
group, often the facial muscles.
• Most often occur between 2-14.
• The tic is performed habitually and the person is usually initially unaware of it.
• More common in males.
• Tourette’s syndrome: Extreme tic disorder involving uncontrollable multiple motor and
• The tic appears to reliev