PSYC 300
Chapter 15 - Disorders of Childhood and Neurodevelopment
15.1 The Mental Health Crisis Among Children and Adolescents
- There is growing evidence of an alarming epidemic of mental health issues among younger people in
Canada and elsewhere.
Estimated in Canada, 14% of children aged 4 -17 years (more than 800,000 children) have
clinically important disorders that cause significant distress and impairment at home, school, and
in the community (anxiety disorders most prevalent)
Concerns have been raised suggesting levels of symptoms of anxiety and depression are
increasing among girls, while staying relatively stable among boys
- Flett and Hewitt (2013) advanced argument that current statistics may underestimate the number of
children and adolescents who need treatment.
1. There are many young people who do not meet thresholds for various diagnoses but nevertheless
experience significant distress and impairment.
o While an official diagnosis is not warranted, the cost of suffering requires intervention.
2. Due to self-presentational concerns and related concerns about shame and stigma, many young
people are “flying under the radar” and hide their distress behind a mask or facade.
o This trend results in suicides or attempted suicides that occur “without warning” by
young people who appeared on surface to be highly functioning.
- There is a crisis in Canada young people do not have timely access to mental health services
Child and adolescent mental health services are inadequate in Canada
Wait-list times are considered unacceptable often exacerbated when a young person lives in a
more remote area of Canada that is underserviced
o Or live in a densely populated areas where resources are outstripped by the demand.
Too many children and youth who need treatment do not receive any form, or eventually receive
some kind of treatment that was needed much sooner.
- National initiative TRAM introduced in 2013.
TRAM partnership in Transformational Research in Adolescent Mental Health
Goal establish a national network focused on adolescent mental health.
Initiative developed to increase early detection of mental health problems and earlier access of
children and adolescents to treatment.
Had led to ACCESS Canada pan-Canadian research network focused on enhancing early
identification of disorders and improved access to appropriate treatment.
SUMMARY
- There is a mental health crisis among children and adolescents
- Prevalence of disorders and difficulties in gaining timely access to qualified treatment providers.
- Estimates suggest about 1 in 6 children and adolescents have some form of diagnosable disorder
suggested that estimates may be underestimated due to tendency for some young people to hide their
distress and experience significant distress and impairment
Even if characteristics may not meet diagnostic criteria.
15.2 Classification of Childhood Disorders
- Conceptualizations of psychopathology and other adjustment problems among children and adolescents
have to consider what is ‘normal’ for a particular age.
Diagnosis for a child who lies on the floor kicking and screaming when they don't get their way
must consider whether the child is 2 or 7.
- The field of developmental psychopathology involves disorders of childhood within the context of normal
lifespan development enables us to identify behaviours that are appropriate at one stage but considered
disturbed at another.
, Basic theme “because all psychopathology can be conceived as a distortion, disturbance, or
degeneration of normal functioning, if one wishes to comprehend psychopathology more fully,
then one must understand the normal functioning with which psychopathology is compared”
Approach is consistent with a biopsychosocial paradigm, a multiple levels of analysis
perspective, and an interdisciplinary approach.
- Issue surrounding what is ‘normal’ for a child controversial DSM-5 inclusion of disruptive mood
dysregulation disorder (“the temper tantrum disorder”).
Severe recurrent temper outbursts qualify as a disorder only if the temper outbursts occur 3 or
more times a week and if they are inconsistent with the child's developmental level
Diagnosticians may vary in their subjective perception of what is appropriate at a certain
developmental level/stage.
- When adjustment problems do exist, they can reflect externalizing or internalizing problems
Externalizing problems: overt and visible behavioural and maladjustment problems and
symptoms that are expressed (typically reflect anger, impulsivity, and conduct disorder)
Internalizing problems: emotional symptoms primarily experienced inside the person and not as
noticeable, such as anxiety and depression (directed toward the self and not overtly expressed)
- Children and adolescents may have externalized symptoms, internalized symptoms, or both (e.g., the
angry, depressed child who acts out).
- A related distinction involves undercontrolled behaviours vs. overcontrolled behaviours.
Undercontrolled behaviour is characterized by excess, including extreme aggressiveness.
Children who are overcontrolled may seem docile, passive, & emotionally inhibited or restricted.
Children and adolescents may exhibit symptoms from both extremes.
- Distinction between externalizing and internalizing problems is reflected in the top problems found
among adolescents.
- Widely used measure Child Behavior Checklist
Shows that undercontrolled and overcontrolled behaviours are abundant.
CBCL lists over 100 problems that children may experience across multiple areas (e.g., social
problems, attention problems, thought problems, conduct problems).
There are parent and teacher rating versions of the CBCL as well as a youth self-report version.
The pervasive pressure that young people experience is clearly evident
o Analyses of self-reports and parent ratings showed that feeling a pressure to be perfect
was among the top 10 problems listed both by youths and parents.
o Pressure to be perfect is linked with anxiety and depression.
- Reflect disorders involving undercontrolled behaviours (e.g., conduct disorders, ADHD)
- Disorders that primarily involve overcontrolled behaviours (e.g., anxiety, depression).
Important to recognize a substantial proportion of children and adolescents diagnosed with
undercontrolled disorders also have problems with anxiety and depression.
o Illustrated by work in the field of autism spectrum disorder that focuses on autistic
children who suffer from comorbid anxiety.
- Key finding in boys early-onset, undercontrol problems (e.g. ASD), and conduct disorders are
consistently found more often among boys
- Key findings in girls adolescent-onset, overcontrol problems found in girls across various cultures
SUMMARY
- Disorders among children and adolescents are differentiated in terms of whether they reflect
undercontrolled behaviours (i.e., unable to restrain maladaptive tendencies) or overcontrolled behaviours
(i.e., constrained behaviours that typically reflect anxiety or depression).
- Primary difficulty is determining whether behaviour expressed by children is typical and a reflection of
the child's developmental stage or whether it is atypical (clinical)
15.3 Disorders of Undercontrolled Behaviour
,Attention-Deficit/Hyperactivity Disorder
- ADHD: attention-deficit hyperactivity disorder; disorder in children marked by difficulties in focusing on
task at hand, inappropriate fidgeting, anti-social behaviour, and excessive non–goal-directed behaviour.
- Two general categories of undercontrolled behaviour differentiated: ADHD and conduct disorder.
- The term “hyperactive” is familiar to most people, especially parents and teachers.
Child who is constantly in motion, tapping fingers, jiggling legs, poking others for no apparent
reason, talking out of turn, and fidgeting is often called hyperactive.
Children also have difficulty concentrating on the task at hand for an appropriate period of time.
Current diagnostic term is attention-deficit/hyperactivity disorder (ADHD).
- Virginia Douglas 1970s Psychology professor at McGill University, key role in refining understanding
of ADHD and symptoms.
Hyperactive children used to be identified as having “minimal brain damage” or “minimal brain
dysfunction” apparent similarities between hyperactive behaviours and behaviours expressed
by certain children with brain damage.
Brain damage could not be detected more emphasis placed on hyperactivity disorder came to
be known as “hyperactive child syndrome” and “hyperkinetic reaction of childhood.”
Douglas (1972) credited with being the first researcher to note attentional problems in
ADHD.
- Children with ADHD have particular difficulty controlling their activity in situations that call for sitting
still (e.g. classroom, mealtimes, tests)
Appear unable to stop moving or talking when asked to be quiet.
Disorganized, erratic, tactless, obstinate, and bossy.
Activities and movements seem haphazard.
o Smash their toys and exhaust their family and teachers.
ADHD children have difficulty in adjusting to a typical classroom environment.
- Children often have problems in social interactions with peers and confronted with peer rejection and
social isolation
Behaviour is often aggressive and annoying to others.
Tend to miss subtle social cues noticing when friends are tired of their constant energy.
Frequently misinterpret wishes and intentions of their peers
Make inadvertent social mistakes reacting aggressively because they assume that a neutral
action by a peer was meant to be aggressive.
o Cognitive misattributions are also found in some children with conduct disorder.
- Children with ADHD can know socially correct actions in hypothetical situations but be unable to
translate their knowledge and appropriate behaviour into real-life social interactions
Despite deficits, some evidence suggests boys with ADHD may have illusory biases that makes
them overestimate the quality of their social behaviours
- About 15-30% of children with ADHD have a learning disability
Children diagnosed with ADHD and mathematical and reading disorders are more severely
impaired and attain lower IQ, language, and academic scores relative to those with ADHD alone
Approximately 25% of children with ADHD exhibit comorbidity with anxiety
- ADHD diagnosis does not properly apply to youngsters who are rambunctious, active, or slightly
distractible in early school years most children are that way.
Diagnosis is reserved for truly extreme and persistent cases.
- Symptoms of ADHD are varied some primarily have poor attention while others have difficulties due
to hyperactive-impulsive behaviour (most children have both sets of symptoms)
- Evidence indicates two sets of symptoms may not emerge at the same time hyperactivity-impulsivity
contributing to subsequent emergence over time of inattentiveness
- Children with both attentional problems and hyperactivity are more likely to develop conduct problems
and oppositional behaviour
Placed in special classes for behaviour-disordered children, and have peer difficulties
, Children with ADHD typically use long-term support from public sector services, with high rates
of contact with schools, educational professionals, and the criminal justice system
- Prevalence of ADHD difficult to establish varied definitions of disorder over time and in populations
Estimated worldwide-pooled prevalence was 5.29%
Generally believed disorder is more common in boys than girls
o Sex difference may be overestimated
o Boys are more likely to be referred to clinics higher likelihood of aggressive and
anti-social behaviour
ADHD girls, relative to ADHD boys and control participants, have significantly greater
impairment on a wide range of measures
- Overall prevalence of adult ADHD is 4.4%
- Expression of ADHD in adults vs. children has more emphasis placed on inattention symptoms and less
emphasis on impulsivity and hyperactivity
Studies of ADHD in adulthood suggest affective, anxiety, substance abuse, and anti-social
disorders are common comorbidities
Most adults with ADHD are employed and financially independent, individuals generally reach
a lower socio-economic level and change jobs more frequently
Family and marital functioning was impaired in families with an ADHD adult
Study of adult women with ADHD (Toronto) found impairments in social functioning,
reduced self-esteem, elevated stress, and a self-blaming attributional style
Biological Theories of ADHD
- Search for causes of ADHD is complicated by heterogeneity of children given diagnosis
No single risk factor explains ADHD
- Evidence for the role of genetic factors cautioned future research will likely highlight the role of early
experiences, including prenatal events that influence genetic expression.
Increasing attention will be given to possible role of environmental causality and role of the gene
by environment interaction.
- Current neurological research will only be meaningful if there is an expanded focus that reflects cultural
variations and rapid changes in social factors and technology use by children and adolescents.
ADHD is similar around the world evidence of universality
ADHD was previously under-represented in African-American children vs. Caucasian children
Nigg (2012) highlights need for more work on phenotype for ADHD symptoms to assess
whether structure is dimensional or categorical.
Genetic Factors
- Research suggests a genetic predisposition to ADHD
Estimates heritability at approximately 75%
- ADHD is viewed as having one of the most heritable phenotypes
Cross-Disorder Group of Psychiatric Genomics Consortium (2013) examined several specific
genetic variations that apply to all five disorders
Found ADHD involves single-nucleotide polymorphisms in regions on chromosomes 3p21 and
10q24, and in two calcium subunits: CACNA1C and CANB2
How does the same genetic vulnerability develop into ADHD instead of another disorder?
- Some insights have emerged from a study of genetic effects in adult ADHD initial indications are that
the gene BAIAP2 is implicated in ADHD susceptibility among adults
- Research on genetic risk factors has yielded only small effect sizes
- Some studies point to differences in brain function and structure
Evidence implicates frontal striatal circuitry, reductions in volume throughout cerebrum and
cerebellum, and delays found in cortical maturation.
Hypothesis is that ADHD is due to a dopamine deficit.
Chapter 15 - Disorders of Childhood and Neurodevelopment
15.1 The Mental Health Crisis Among Children and Adolescents
- There is growing evidence of an alarming epidemic of mental health issues among younger people in
Canada and elsewhere.
Estimated in Canada, 14% of children aged 4 -17 years (more than 800,000 children) have
clinically important disorders that cause significant distress and impairment at home, school, and
in the community (anxiety disorders most prevalent)
Concerns have been raised suggesting levels of symptoms of anxiety and depression are
increasing among girls, while staying relatively stable among boys
- Flett and Hewitt (2013) advanced argument that current statistics may underestimate the number of
children and adolescents who need treatment.
1. There are many young people who do not meet thresholds for various diagnoses but nevertheless
experience significant distress and impairment.
o While an official diagnosis is not warranted, the cost of suffering requires intervention.
2. Due to self-presentational concerns and related concerns about shame and stigma, many young
people are “flying under the radar” and hide their distress behind a mask or facade.
o This trend results in suicides or attempted suicides that occur “without warning” by
young people who appeared on surface to be highly functioning.
- There is a crisis in Canada young people do not have timely access to mental health services
Child and adolescent mental health services are inadequate in Canada
Wait-list times are considered unacceptable often exacerbated when a young person lives in a
more remote area of Canada that is underserviced
o Or live in a densely populated areas where resources are outstripped by the demand.
Too many children and youth who need treatment do not receive any form, or eventually receive
some kind of treatment that was needed much sooner.
- National initiative TRAM introduced in 2013.
TRAM partnership in Transformational Research in Adolescent Mental Health
Goal establish a national network focused on adolescent mental health.
Initiative developed to increase early detection of mental health problems and earlier access of
children and adolescents to treatment.
Had led to ACCESS Canada pan-Canadian research network focused on enhancing early
identification of disorders and improved access to appropriate treatment.
SUMMARY
- There is a mental health crisis among children and adolescents
- Prevalence of disorders and difficulties in gaining timely access to qualified treatment providers.
- Estimates suggest about 1 in 6 children and adolescents have some form of diagnosable disorder
suggested that estimates may be underestimated due to tendency for some young people to hide their
distress and experience significant distress and impairment
Even if characteristics may not meet diagnostic criteria.
15.2 Classification of Childhood Disorders
- Conceptualizations of psychopathology and other adjustment problems among children and adolescents
have to consider what is ‘normal’ for a particular age.
Diagnosis for a child who lies on the floor kicking and screaming when they don't get their way
must consider whether the child is 2 or 7.
- The field of developmental psychopathology involves disorders of childhood within the context of normal
lifespan development enables us to identify behaviours that are appropriate at one stage but considered
disturbed at another.
, Basic theme “because all psychopathology can be conceived as a distortion, disturbance, or
degeneration of normal functioning, if one wishes to comprehend psychopathology more fully,
then one must understand the normal functioning with which psychopathology is compared”
Approach is consistent with a biopsychosocial paradigm, a multiple levels of analysis
perspective, and an interdisciplinary approach.
- Issue surrounding what is ‘normal’ for a child controversial DSM-5 inclusion of disruptive mood
dysregulation disorder (“the temper tantrum disorder”).
Severe recurrent temper outbursts qualify as a disorder only if the temper outbursts occur 3 or
more times a week and if they are inconsistent with the child's developmental level
Diagnosticians may vary in their subjective perception of what is appropriate at a certain
developmental level/stage.
- When adjustment problems do exist, they can reflect externalizing or internalizing problems
Externalizing problems: overt and visible behavioural and maladjustment problems and
symptoms that are expressed (typically reflect anger, impulsivity, and conduct disorder)
Internalizing problems: emotional symptoms primarily experienced inside the person and not as
noticeable, such as anxiety and depression (directed toward the self and not overtly expressed)
- Children and adolescents may have externalized symptoms, internalized symptoms, or both (e.g., the
angry, depressed child who acts out).
- A related distinction involves undercontrolled behaviours vs. overcontrolled behaviours.
Undercontrolled behaviour is characterized by excess, including extreme aggressiveness.
Children who are overcontrolled may seem docile, passive, & emotionally inhibited or restricted.
Children and adolescents may exhibit symptoms from both extremes.
- Distinction between externalizing and internalizing problems is reflected in the top problems found
among adolescents.
- Widely used measure Child Behavior Checklist
Shows that undercontrolled and overcontrolled behaviours are abundant.
CBCL lists over 100 problems that children may experience across multiple areas (e.g., social
problems, attention problems, thought problems, conduct problems).
There are parent and teacher rating versions of the CBCL as well as a youth self-report version.
The pervasive pressure that young people experience is clearly evident
o Analyses of self-reports and parent ratings showed that feeling a pressure to be perfect
was among the top 10 problems listed both by youths and parents.
o Pressure to be perfect is linked with anxiety and depression.
- Reflect disorders involving undercontrolled behaviours (e.g., conduct disorders, ADHD)
- Disorders that primarily involve overcontrolled behaviours (e.g., anxiety, depression).
Important to recognize a substantial proportion of children and adolescents diagnosed with
undercontrolled disorders also have problems with anxiety and depression.
o Illustrated by work in the field of autism spectrum disorder that focuses on autistic
children who suffer from comorbid anxiety.
- Key finding in boys early-onset, undercontrol problems (e.g. ASD), and conduct disorders are
consistently found more often among boys
- Key findings in girls adolescent-onset, overcontrol problems found in girls across various cultures
SUMMARY
- Disorders among children and adolescents are differentiated in terms of whether they reflect
undercontrolled behaviours (i.e., unable to restrain maladaptive tendencies) or overcontrolled behaviours
(i.e., constrained behaviours that typically reflect anxiety or depression).
- Primary difficulty is determining whether behaviour expressed by children is typical and a reflection of
the child's developmental stage or whether it is atypical (clinical)
15.3 Disorders of Undercontrolled Behaviour
,Attention-Deficit/Hyperactivity Disorder
- ADHD: attention-deficit hyperactivity disorder; disorder in children marked by difficulties in focusing on
task at hand, inappropriate fidgeting, anti-social behaviour, and excessive non–goal-directed behaviour.
- Two general categories of undercontrolled behaviour differentiated: ADHD and conduct disorder.
- The term “hyperactive” is familiar to most people, especially parents and teachers.
Child who is constantly in motion, tapping fingers, jiggling legs, poking others for no apparent
reason, talking out of turn, and fidgeting is often called hyperactive.
Children also have difficulty concentrating on the task at hand for an appropriate period of time.
Current diagnostic term is attention-deficit/hyperactivity disorder (ADHD).
- Virginia Douglas 1970s Psychology professor at McGill University, key role in refining understanding
of ADHD and symptoms.
Hyperactive children used to be identified as having “minimal brain damage” or “minimal brain
dysfunction” apparent similarities between hyperactive behaviours and behaviours expressed
by certain children with brain damage.
Brain damage could not be detected more emphasis placed on hyperactivity disorder came to
be known as “hyperactive child syndrome” and “hyperkinetic reaction of childhood.”
Douglas (1972) credited with being the first researcher to note attentional problems in
ADHD.
- Children with ADHD have particular difficulty controlling their activity in situations that call for sitting
still (e.g. classroom, mealtimes, tests)
Appear unable to stop moving or talking when asked to be quiet.
Disorganized, erratic, tactless, obstinate, and bossy.
Activities and movements seem haphazard.
o Smash their toys and exhaust their family and teachers.
ADHD children have difficulty in adjusting to a typical classroom environment.
- Children often have problems in social interactions with peers and confronted with peer rejection and
social isolation
Behaviour is often aggressive and annoying to others.
Tend to miss subtle social cues noticing when friends are tired of their constant energy.
Frequently misinterpret wishes and intentions of their peers
Make inadvertent social mistakes reacting aggressively because they assume that a neutral
action by a peer was meant to be aggressive.
o Cognitive misattributions are also found in some children with conduct disorder.
- Children with ADHD can know socially correct actions in hypothetical situations but be unable to
translate their knowledge and appropriate behaviour into real-life social interactions
Despite deficits, some evidence suggests boys with ADHD may have illusory biases that makes
them overestimate the quality of their social behaviours
- About 15-30% of children with ADHD have a learning disability
Children diagnosed with ADHD and mathematical and reading disorders are more severely
impaired and attain lower IQ, language, and academic scores relative to those with ADHD alone
Approximately 25% of children with ADHD exhibit comorbidity with anxiety
- ADHD diagnosis does not properly apply to youngsters who are rambunctious, active, or slightly
distractible in early school years most children are that way.
Diagnosis is reserved for truly extreme and persistent cases.
- Symptoms of ADHD are varied some primarily have poor attention while others have difficulties due
to hyperactive-impulsive behaviour (most children have both sets of symptoms)
- Evidence indicates two sets of symptoms may not emerge at the same time hyperactivity-impulsivity
contributing to subsequent emergence over time of inattentiveness
- Children with both attentional problems and hyperactivity are more likely to develop conduct problems
and oppositional behaviour
Placed in special classes for behaviour-disordered children, and have peer difficulties
, Children with ADHD typically use long-term support from public sector services, with high rates
of contact with schools, educational professionals, and the criminal justice system
- Prevalence of ADHD difficult to establish varied definitions of disorder over time and in populations
Estimated worldwide-pooled prevalence was 5.29%
Generally believed disorder is more common in boys than girls
o Sex difference may be overestimated
o Boys are more likely to be referred to clinics higher likelihood of aggressive and
anti-social behaviour
ADHD girls, relative to ADHD boys and control participants, have significantly greater
impairment on a wide range of measures
- Overall prevalence of adult ADHD is 4.4%
- Expression of ADHD in adults vs. children has more emphasis placed on inattention symptoms and less
emphasis on impulsivity and hyperactivity
Studies of ADHD in adulthood suggest affective, anxiety, substance abuse, and anti-social
disorders are common comorbidities
Most adults with ADHD are employed and financially independent, individuals generally reach
a lower socio-economic level and change jobs more frequently
Family and marital functioning was impaired in families with an ADHD adult
Study of adult women with ADHD (Toronto) found impairments in social functioning,
reduced self-esteem, elevated stress, and a self-blaming attributional style
Biological Theories of ADHD
- Search for causes of ADHD is complicated by heterogeneity of children given diagnosis
No single risk factor explains ADHD
- Evidence for the role of genetic factors cautioned future research will likely highlight the role of early
experiences, including prenatal events that influence genetic expression.
Increasing attention will be given to possible role of environmental causality and role of the gene
by environment interaction.
- Current neurological research will only be meaningful if there is an expanded focus that reflects cultural
variations and rapid changes in social factors and technology use by children and adolescents.
ADHD is similar around the world evidence of universality
ADHD was previously under-represented in African-American children vs. Caucasian children
Nigg (2012) highlights need for more work on phenotype for ADHD symptoms to assess
whether structure is dimensional or categorical.
Genetic Factors
- Research suggests a genetic predisposition to ADHD
Estimates heritability at approximately 75%
- ADHD is viewed as having one of the most heritable phenotypes
Cross-Disorder Group of Psychiatric Genomics Consortium (2013) examined several specific
genetic variations that apply to all five disorders
Found ADHD involves single-nucleotide polymorphisms in regions on chromosomes 3p21 and
10q24, and in two calcium subunits: CACNA1C and CANB2
How does the same genetic vulnerability develop into ADHD instead of another disorder?
- Some insights have emerged from a study of genetic effects in adult ADHD initial indications are that
the gene BAIAP2 is implicated in ADHD susceptibility among adults
- Research on genetic risk factors has yielded only small effect sizes
- Some studies point to differences in brain function and structure
Evidence implicates frontal striatal circuitry, reductions in volume throughout cerebrum and
cerebellum, and delays found in cortical maturation.
Hypothesis is that ADHD is due to a dopamine deficit.
