1. DISORDERS OF CHILDHOOD LECTURE OUTLINE Overview Externalizing disorders - Attention- deficit/Hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) Internalizing disorders – Separation anxiety disorder (SAD) Other disorders – tic disorders, elimination disorders Pervasive developmental disorder – including autism

2. DISORDERS OF CHILDHOOD OVERVIEW The DSM and childhood disorders Developmental psychopathology Risk and protective factors Special considerations in treating children Prevalence of childhood disorders

3. DISORDERS OF CHILDHOOD OVERVIEW Ontario Child Health Study (Offord et al., 1987) studied rates of 4 disorders (conduct disorder, hyperactivity, emotional disorders, somatization) for children 4-16 years of age 6-month prevalence rate for any disorder was 18% boys have higher rates of conduct disorders (8%) and hyperactivity (9%) than girls (3% for both)

4. DISORDERS OF CHILDHOOD OVERVIEW Ontario Child Health Study (Offord et al., 1987) girls have higher rates of emotional (14%) and somatization (11%) disorders than boys (8% & 5%) for boys, rates of conduct disorder increase with age, while rates of hyperactivity and emotional problems decrease for girls, rates of emotional problems increase with age

5. DISORDERS OF CHILDHOOD ADHD – History and background originally called MBD (minimal brain dysfunction), then Hyperkinetic Reaction of Childhood most common presenting problem in mental health clinics for children more common for boys than girls (3:1 to 5:1)

6. DISORDERS OF CHILDHOOD ADHD – Core features age-inappropriate levels of inattention (e.g., difficulty sustaining attention with school work, easily distracted) impulsivity (e.g., not waiting turn, blurting out answers) hyperactivity (fidgets, squirms, talks excessively)

7. DISORDERS OF CHILDHOOD ADHD - Subtypes Children can be diagnosed as ADHD combined type, predominantly inattentive, or predominantly impulsive-hyperactive Research by Virginia Douglas at McGill demonstrated that inability to sustain attention and control impulses, not higher activity levels, were key features of this disorder

8. DISORDERS OF CHILDHOOD ADHD and other disorders high rates of comorbidity with oppositional defiant disorder (80%), conduct disorder (40%), and antisocial personality disorder (25%) in adolescence also, high rates of comorbidity with learning disabilities assessed primarily with rating scales (e.g., Connors)

9. DISORDERS OF CHILDHOOD ADHD – Long-term prognosis Follow-up studies of children with ADHD show elevated rates of school problems, conduct disorders or antisocial personality, substance abuse, criminal behaviour But this long-term trend is observed mostly with aggression associated with ADHD

10. DISORDERS OF CHILDHOOD ADHD – Long-term prognosis Moreover, some children seem to outgrow ADHD (see figure 5.1 in text) at age 10, 250 cases per 1000 for ADHD in boys; drops to < 50 cases per 1000 by age 20 girls remain at low rates (75 cases per 1000) from ages 10 to 20

11. DISORDERS OF CHILDHOOD ADHD - Etiology likely some biological predisposition 30-50% heritability component food additives and sugar – no evidence that these are causal factors PET and MRI research suggests some brain abnormalities, such as reduced glucose metabolism

12. DISORDERS OF CHILDHOOD ADHD - Treatment stimulant medications – Ritalin, Dexedrine, Cylert reduced impulsiveness and hyperactivity and improved attention, but little evidence of improvement in academic achievement

13. DISORDERS OF CHILDHOOD ADHD - Treatment proliferation of medications for treatment of ADHD rates of use quadrupled in Canada from 1990 to 1995, then increased by 85% per year from 1996-98 (McCubbin & Cohen, 1999) concerns about side effects about use of stimulant medication

14. DISORDERS OF CHILDHOOD ADHD - Treatment behavioural management at home and school these strategies can also help, but appear less powerful and are more demanding of adults than medications combination of medication and behavioural treatment may be most beneficial

15. DISORDERS OF CHILDHOOD OPPOSITIONAL DEFIANT DISORDER (ODD) diagnosed when children behave in a negative, hostile, or defiant manner; related to problems in relationships and at school symptoms emerge before age 8 1 in 4 boys will go on to develop CD

16. DISORDERS OF CHILDHOOD CONDUCT DISORDER (CD) “repetitive and persistent pattern of conduct in which the basic rights of others and major age-appropriate societal norms or rules are violated” aggression is a major concern; also property destruction, lying, theft, rule violation poor interpersonal skills and peer rejection

17. DISORDERS OF CHILDHOOD Diagnostic issues in ODD & CD more common in boys (2:1) many boys with ODD do not develop CD minority of those with CD don’t develop antisocial personality disorder CD linked with ADHD and substance abuse

18. DISORDERS OF CHILDHOOD Etiology of ODD & CD subclinical neurological signs temperament inter-generational patterns marital conflict, divorce, abuse attachment problems parenting

19. DISORDERS OF CHILDHOOD Long-term development of ODD & CD form of behaviour changes over time – from overt to covert severity and frequency of problems best predictors of who will continue to have problems in the future many children do improve over time

20. DISORDERS OF CHILDHOOD Treatment of ODD & CD Coercive process – Gerry Patterson parents behaviour impacts on child; child’s behaviour impacts on adult in families of children with ODD or CD, parents lack child management skills and often end up in coercive interactions that sprial out of control and are self- perpetuating

21. DISORDERS OF CHILDHOOD Treatment of ODD & CD Parents’ impact on child Brother and sister at play Children play cooperatively Parent ignores children Extinction of cooperative play Brother and sister at play Children fight Parent criticizes or scolds children Positive reinforcement for fighting

22. DISORDERS OF CHILDHOOD Treatment of ODD & CD Childs’ impact on parent Children fight Parent criticizes or scolds Children stop fighting (temporarily) Negative reinforcement for criticism or scolding

23. DISORDERS OF CHILDHOOD Patterson’s parent training for ODD & CD Defining and pinpointing behaviour “I want Johnny to be a good student” “I want Johnny to stop being aggressive” “I want Johnny to stop hitting his peers”

24. DISORDERS OF CHILDHOOD Patterson’s parent training for ODD & CD Focusing on the positive – alternative, incompatible behaviours yelling whining interrupting non-compliance

25. DISORDERS OF CHILDHOOD Patterson’s parent training – key focus is on obtaining compliance from child commands vs. requests positive reinforcement (praise) extinction (ignoring) punishment (timeout)

26. DISORDERS OF CHILDHOOD Community Parent Education Program (COPE) for ODD & CD – Cunningham et al. (1993) parent training in schools and community centres school-based intervention

27. DISORDERS OF CHILDHOOD Other treatments for ODD & CD Problem-solving skills training Family therapy – multisystemic therapy the earlier the treatment, the better long- term prognosis

28. DISORDERS OF CHILDHOOD Separation Anxiety Disorder only SAD remains in DSM-IV as an anxiety disorder unique to childhood distress upon being separated from a parent or fears that parent will be harmed average age of onset is 9 typically occurs after a major stressor

29. DISORDERS OF CHILDHOOD SAD – Diagnosis and assessment severe and excessive anxiety when faced with separation from a parent also related to mood problems, school refusal, somatic complaints need for multi-dimensional assessment

30. DISORDERS OF CHILDHOOD SAD – Long-term development social withdrawal, poor school performance not much known about long-term course if left untreated, possibly related to adult anxiety disorders such as agoraphobia and panic disorder

31. DISORDERS OF CHILDHOOD SAD – Etiology strong heritability component, concordance for anxiety disorders is 3 times higher in MZ than DZ twins temperament – behavioural inhibition (shyness, vigilance, avoidance) insecure attachment

32. DISORDERS OF CHILDHOOD SAD – Treatment cognitive-behaviour therapy play therapy medication overall, shy and anxious children respond well to treatment, again early treatment is needed SAD is far less researched than the externalizing disorders

33. DISORDERS OF CHILDHOOD Other disorders tic disorders – Tourette syndrome, responds well to anti-psychotic medication Haldol elimination disorders – enuresis and encopresis, Mowrer bell and pad treatment based on classical conditioning

34. DISORDERS OF CHILDHOOD SUMMARY childhood disorders have high prevalence (OCHS) externalizing disorders (ADHD, ODD, CD) have received the most attention because of negative impacts on others and their damaging long-term impacts less well understood are internalizing disorders, such as SAD