1 Disorders Common Among Children and Adolescentschapter fourteen Disorders Common Among Children and Adolescents

2 Childhood and AdolescenceChildren of all cultures typically experience some emotional and behavioral problems Adolescence can also be a difficult period Bullying ranks as a major problem in the minds of most youngsters, often a bigger problem than racism and peer pressure to try sex or alcohol At least one-fifth of all children and adolescents in North America also experience a diagnosable psychological disorder Worry, bedwetting, nightmares, temper tantrums, and restlessness are other problems experienced by many children. Physical and sexual changes, social and academic pressures, being bullied, personal doubts, and temptation cause many teenagers to feel anxious, confused, and depressed. Over one-quarter of students report being bullied frequently, and more than 70 percent report having been a victim at least once. Boys with disorders outnumber girls, even though most of the adult psychological disorders are more common in women.

3 Are Parents Aware of Their Children’s Stress?Figure 14-1 Not always, according to a large survey of parents and their children aged 8 to 17. For example, although 44 percent of the child respondents report that they worry about school, only 34 percent of the parent respondents believe that their children have that concern. (Munsey, 2010.)

4 Childhood Anxiety DisordersAnxiety is a normal and common part of childhood For some children, anxieties become long-lasting and overwhelming; they may be suffering from an anxiety disorder Although some of these disorders are similar to their adult counterparts, more often they differ from that of adult anxiety disorders Anxiety is a normal and common part of childhood Limited experiences Parental problems or inadequacies Genetic links to anxious temperament Some disorders of children Childhood anxiety disorders and childhood depression have adult counterparts. Elimination disorders usually disappear or radically change form by adulthood. Disorders that begin in birth or childhood and persist in stable forms into adult life Autism spectrum disorder and intellectual development disorder (previously called mental retardation) Since children have had fewer experiences than adults, their world is often new and scary. Children also may be affected greatly by parental problems and inadequacies. There also is genetic evidence that some children are prone to an anxious temperament. For some children, such anxieties become long-lasting and overwhelming; they may be suffering from an anxiety disorder. Surveys indicate that between 8 and 29 percent of all children and adolescents display an anxiety disorder.

5 School Bullying A particular concern among children and adolescents is that of being bullied Surveys throughout the world have revealed repeatedly that bullying ranks as a major problem in the minds of most young respondents, often a bigger problem than racism and peer pressure to try sex or alcohol. Much bullying takes place at school. Around two-thirds of all school bullying occurs in hallways, schoolyards, bathrooms, cafeterias, or buses. A full one-third occurs in classrooms while teachers are present (BSA, 2014). It is estimated that 40 percent of school bullying goes unreported (BSA, 2014). Features of School Antibullying Programs Increased supervision of students Delivery of consequences for bullying Schoolwide implementation of antibullying policies Cooperation among school staff, parents, and professionals across disciplines Identification of risk factors for bullying

6 Childhood Anxiety DisordersSEPARATION ANXIETY DISORDER Begins as early as the preschool years and is displayed by 4 percent of all children May further take the form of a SCHOOL PHOBIA or SCHOOL REFUSAL Common problem in which children fear going to school and often stay home for a long period Sufferers feel extreme anxiety, often panic, whenever they are separated from home or a parent. Oh, that first day!

7 Separation Anxiety DisorderDx Checklist Separation Anxiety Disorder Individual displays fear or anxiety concerning separation from attachment figures, anxiety that is unreasonable or excessive for his or her age group. Individual’s excessive anxiety features three or more of the following symptoms: Repeated separation-related upset Repeated loss-related concern Repeated fear of experiencing separation-caused events Repeated resistance to leaving home Repeated resistance to being alone Repeated resistance to sleepaways Repeated separation-focused nightmares Repeated separation-triggered physical symptoms. Individual’s symptoms last 4 or more weeks for children and at least 6 months for adults. Significant distress or impairment.

8 Treatments for Childhood Anxiety DisordersAround two-thirds of anxious children go untreated Therapies used Psychodynamic, behavioral, cognitive, cognitive-behavioral, family, and group therapies, separately or in combination, have been applied most often – each with some degree of success Drug therapy, often in combination with psychotherapy, has begun only recently to receive much research attention Psychodynamic therapists use play therapy as part of treatment Because children typically have difficulty recognizing and understanding their feelings and motives, many therapists, particularly psychodynamic therapists, use play therapy as part of treatment. Play therapy A treatment approach that helps children express their conflicts and feelings indirectly by drawing, playing with toys, and making up stories

9 Major Depressive DisorderTypically, very young children lack some of the cognitive skills that produce clinical depression Yet, depression in the young may be triggered by negative life events (particularly losses), major changes, rejection, or ongoing abuse Clinical depression is much more common among teenagers Suicidal thoughts and attempts are particularly common Before age 13: No gender difference By age 16: Girls twice as likely to be depressed Depression is often characterized by headaches, stomach pain, irritability, and a disinterest in toys and games. As many as 20 percent of adolescents experience at least one depressive episode during their teen years. While there is no difference between rates of depression in boys and girls before the age of 13, girls are twice as likely as boys to be depressed by the age of 16. One explanation for this gender shift that has received attention is teenage girls’ growing dissatisfaction with their bodies.

10 Separation and DepressionThis 3-year-old boy hugs his father as the soldier departs for deployment to Iraq Given research evidence that extended family separations often produce depression in children, clinical theorists have been particularly worried about the thousands of children from military families who were left behind during the wars in Afghanistan and Iraq

11 Major Depressive DisorderTreatment Recent research disputes the wisdom of using adult treatment for depression with children NIMH TADS data suggest that depressed teens respond less well to cognitive-behavioral therapy than adults Antidepressant drugs may be highly dangerous for some depressed children and teenagers For years, it was generally believed that childhood and teenage depression would respond well to the same treatments that have been of help to depressed adults – cognitive-behavioral therapy, and antidepressant drugs – and many studies indicated the effectiveness of such approaches. TADS findings Neither antidepressants alone nor cognitive-behavioral therapy alone was as effective for teenage depression as was a combination of antidepressants and cognitive-behavioral therapy. Antidepressants alone tended to be more helpful to depressed teens than cognitive-behavioral therapy alone. Cognitive-behavioral therapy alone was barely more helpful than placebo therapy.

12 What advice would you give to these parents?Parent Worries on the Rise Today’s parents worry about their children’s online experiences Safety Exposure to pornography or violence Bullying Who worries? African American, Hispanic American, and Asian American parents worry more than white American parents Urban and low-income parents have more anxiety about online bullying than suburban and rural parents Mothers, parents of daughters, and those politically conservative worry more than fathers and liberal parents What advice would you give to these parents?

13 Bipolar Disorder and Disruptive Mood Dysregulation DisorderSince the mid-1990s, clinical theorists recognized that many children display bipolar disorder Causes: Increase in prevalence or new diagnostic trend For decades, conventional clinical wisdom held that bipolar disorder is exclusively an adult mood disorder, whose earliest age of onset is the late teens. Most theorists believe that the growing numbers of children diagnosed with this disorder reflect not an increase in prevalence but a new diagnostic trend. Many clinical theorists believe the diagnosis is currently being overapplied to children and adolescents. They suggest the label has become a clinical “catchall” that is being applied to almost every explosive, aggressive child.

14 Bipolar Disorder and Disruptive Mood Dysregulation DisorderDSM-5 task force added this new category targeted for children with severe patterns of rage to rectify situation Especially important because of over-diagnosis and adult medication prescribed for children Dx Checklist Disruptive Mood Dysregulation Disorder For at least a year, individual repeatedly displays severe outbursts of temper that are extremely out of proportion to triggering situations and different from ones displayed by most other people of his or her age. The outbursts occur at least three times per week and are present in at least two settings (home, school, with peers). Individual repeatedly displays irritable or angry mood between the outbursts. Individual receives initial diagnosis between 6 and 18 years of age. Table 14-2 Concluded that childhood bipolar label has been over-applied This issue is particularly important because the current shift in diagnoses has been accompanied by an increase in the number of children who receive adult medications. Few of these drugs have been tested on and approved specifically for use in children.

15 Oppositional Defiant Disorder and Conduct DisorderOPPOSITIONAL DEFIANT DISORDER is characterized by extreme hostility and defiance Those with oppositional defiant disorder are argumentative and defiant, angry and irritable, and, in some cases, vindictive As many as 10 percent of children qualify for this diagnosis. Disorder is more common in boys than girls before puberty, but equal in both sexes after puberty.

16 Oppositional Defiant Disorder and Conduct DisorderCONDUCT DISORDER is characterized as a severe problem; children repeatedly violate the basic rights of others Some clinical theorists believe there are actually several kinds of conduct disorder Overt-destructive Overt-nondestructive Covert-destructive Covert-nondestructive It may be that the different patterns have different causes They are often aggressive; may be physically cruel to people and animals; may steal from, threaten, or harm their victims, committing such crimes as shoplifting, forgery, mugging, and armed robbery. Children with a mild conduct disorder may improve over time, but severe cases frequently continue into adulthood and develop into antisocial personality disorder or other psychological problems. Usually begins between 7 and 15 years of age Involves as many as 10 percent of children, three-quarters of them boys May be mild or severe

17 Oppositional Defiant Disorder and Conduct DisorderRELATIONAL AGGRESSION is another pattern of aggression found in certain cases of conduct disorder in which individuals are socially isolated and primarily display social misdeeds JUVENILE DELINQUENCY occurs when children between the ages of 8 and 18 break the law Many children with conduct disorder are suspended from school, placed in foster homes, or incarcerated. When children between the ages of 8 and 18 break the law, the legal system often labels them juvenile delinquents. Boys are much more involved in juvenile crime than are girls, although rates for girls are on the increase. After steadily rising during the 1990s, the number of arrests of teenagers for serious crimes has fallen by one-third during the past decade. Relational aggression is more common among girls than boys; boys are much more involved in juvenile crime than are girls.

18 Conduct Disorder DX Checklist Conduct DisorderIndividual repeatedly behaves in ways that violate the rights of other people or ignores the norms or rules of society, beyond the violations displayed by most other people of his or her age. At least three of the following features are present over the past year (and at least one in the past 6 months): Frequent bullying or threatening of others Frequent provoking of physical fights Using dangerous weapons Physical cruelty to people Physical cruelty to animals Stealing during confrontations with a victim Forcing someone into sexual activity Fire-setting Deliberately destroying others’ property Breaking into a house, building, or car Frequent lying Stealing items of value under non-confrontational circumstances Frequent staying out beyond curfews, starting before the age of 13 Running away from home overnight at least twice Frequent truancy from school, starting before the age of 13. Significant impairment. Table 14-3

19 What Are the Causes of Conduct Disorder?Linked to genetic and biological factors, drug abuse, poverty, traumatic events, and exposure to violent peers or community violence Often tied to troubled parent-child relationships, inadequate parenting, family conflict, marital conflict, and family hostility

20 How Do Clinicians Treat Conduct Disorder?Sociocultural treatments Family interventions Parent-child interaction therapy Video modeling Parent management training Residential treatment in community and programs at school Treatment foster care Institutionalization Juvenile training centers Because aggressive behaviors become more locked in with age, treatments for conduct disorder are generally most effective with children younger than 13. A number of interventions have been developed but none of them alone is the answer for this difficult problem. Today’s clinicians are increasingly combining several approaches into a wide-ranging treatment program. Given the importance of family factors in conduct disorder, therapists often use family interventions. One such approach is parent-child interaction therapy. When children reach school age, therapists often use a family intervention called parent management training. These treatments often have achieved a measure of success. Other sociocultural approaches, such as residential treatment in the community and programs at school, have also helped some children improve. One such approach is treatment foster care. In contrast to these other approaches, institutionalization in juvenile training centers has not met with much success and may, in fact, strengthen delinquent behavior.

21 How Do Clinicians Treat Conduct Disorder?CHILD-FOCUSED TREATMENTS focus primarily on the child with conduct disorder, particularly cognitive-behavioral interventions Problem-solving skills training Anger Coping and Coping Power Program Stimulant drug therapy Prevention Early prevention programs In problem-solving skills training, therapists combine modeling, practice, role-playing, and systematic rewards. Another child-focused approach, the Anger Coping and Coping Power Program, has children participate in group sessions that teach them to manage their anger more effectively. Studies indicate that these approaches do reduce aggressive behaviors and prevent substance use in adolescence. Recently, drug therapy with stimulant drugs has been tried. It may be that the greatest hope for reducing the problem of conduct disorder lies in prevention programs that begin in early childhood. These programs try to change unfavorable social conditions before a conduct disorder is able to develop. All such approaches work best when they educate and involve the family.

22 Elimination DisordersChildren with elimination disorders repeatedly urinate or pass feces in their clothes, in bed, or on the floor These symptoms are not caused by physical illness or medications Information for image The Bedwetter Outrageous comedian Sarah Silverman holds up a copy of her best selling 2010 book The Bedwetter. In this memoir, she writes extensively about her childhood experiences with enuresis and other emotional difficulties—always with a blend of self-revelation, pain, and humor. Enuresis A childhood disorder marked by repeated bed-wetting or wetting of one’s clothes. Encopresis A childhood disorder characterized by repeatedly defecating in inappropriate places, such as one’s clothing.

23 Enuresis ENURESIS is characterized by repeated involuntary or intentional bedwetting or wetting of one’s clothes Typically occurs at night during sleep but may also occur during the day May be triggered by a stressful event Must be at least 5 years of age to receive this diagnosis Prevalence Decreases with age Often involves a close relative who has had or will have the same disorder Corrects without treatment in most cases Most cases of enuresis correct themselves without treatment. Therapy, particularly behavioral therapy, can speed up the process.

24 Enuresis Theories Psychodynamic theorists explain it as a symptom of broader anxiety and underlying conflicts Family theorists point to disturbed family interactions Behaviorists often view it as the result of improper, unrealistic, or coercive toilet training Biological theorists suspect a small bladder capacity or weak bladder muscles Research has not favored one explanation for the disorder over others.

25 Enuresis Causes Psychodynamic theorists explain it as a symptom of broader anxiety and underlying conflicts Family theorists point to disturbed family interactions Behaviorists often view it as the result of improper, unrealistic, or coercive toilet training Biological theorists suspect a small bladder capacity or weak bladder muscles Research has not favored one explanation for the disorder over others.

26 Encopresis ENCOPRESIS is characterized by repeatedly defecating in one’s clothing; less common than enuresis and less well researched The problem Is usually involuntary Seldom occurs during sleep Starts after the age of 4 Is more common in boys than girls Causes intense social problems, shame, and embarrassment The problem Is usually involuntary Seldom occurs during sleep Starts after the age of 4 Is more common in boys than girls Causes intense social problems, shame, and embarrassment

27 Encopresis Causes Common treatmentsStress, constipation, improper toilet training, or a combination of all three Common treatments Behavioral and medical approaches, or combinations of the two Family therapy

28 Child Abuse Some researchers believe that physical abuse and neglect are the leading causes of death among young children Same rate of physical abuse for boys and girls Most often parents with myriad of psychological challenges Victims may suffer immediate and long-term psychological effects Forms Psychological and sexual abuse Therapies Parent support groups and training Prevention programs Early detection programs At least 5 percent of children in the United States are physically abused each year (Mash & Wolfe, 2015). Surveys suggest that 1 of every 10 children is the victim of severe violence, such as being kicked, bitten, hit, beaten, or threatened with a knife or a gun. Clinical investigators have learned that abusive parents often have poor impulse control, low self-esteem, higher levels of depression, and weak parenting skills. In some cases, they are dealing with stressors such as marital discord or unemployment. PSYCHOLOGICAL ABUSE may include severe rejection, excessive discipline, scapegoating and ridicule, isolation, and refusal to provide help for a child with psychological problems. CHILD SEXUAL ABUSE, the use of a child for gratification of adult sexual desires, may occur outside or within the home.

29 Neurodevelopmental DisorderATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) is characterized by great difficulty attending to tasks, behaving overactively and impulsively, or both About half the children with ADHD also have learning or communication problems Disorder usually persists through childhood, but many children show a lessening of symptoms as they move into mid-adolescence Gender and age differences seen The primary symptoms of ADHD may feed into one another, but in many cases one of the symptoms stands out more than the other. ADHD is a difficult disorder to assess. Ideally, the child’s behavior should be observed in several environmental settings, because symptoms must be present across multiple settings for a diagnosis. It also is important to obtain reports of the child’s symptoms from their parents and teachers. Many more also have: Poor school performance Difficulty interacting with other children Misbehavior, often serious Mood or anxiety problems Onset and prevalence Disorder usually persists through childhood, but many children show a lessening of symptoms as they move into mid-adolescence. Around 4-9 percent of schoolchildren display ADHD, as many as 70 percent of them boys. Between 35 percent and 60 percent continue to have ADHD as adults. Race seems to come into play with regard to ADHD. A number of studies indicate that African American and Hispanic American children with significant attention and activity problems are less likely than white American children to be assessed for ADHD, receive an ADHD diagnosis, or undergo treatment for the disorder. Those who do receive a diagnosis are less likely than white children to be treated with the interventions that seem to be of most help, including the promising (but more expensive) long-acting stimulant drugs. In part, racial differences in diagnosis and treatment are tied to economic factors. Some clinical theorists further believe that social bias and stereotyping may contribute to the racial differences seen in diagnosis and treatment. While many of today’s clinical theorists correctly alert us that ADHD may be generally overdiagnosed and overtreated, it is important that they also recognize that children from certain segments of society may, in fact, be underdiagnosed and undertreated.

30 Attention-Deficit/Hyperactivity DisorderDx Checklist Attention-Deficit/Hyperactivity Disorder Individual presents one or both of the following patterns: For 6 months or more, individual frequently displays at least six of the following symptoms of inattention, to a degree that is maladaptive and beyond that shown by most similarly aged persons: • Unable to properly attend to details, or frequently makes careless errors • Finds it hard to maintain attention • Fails to listen when spoken to by others • Fails to carry out instructions and finish work • Disorganized • Dislikes or avoids mentally effortful work • Loses items that are needed for successful work • Easily distracted by irrelevant stimuli • Forgets to do many everyday activities. For 6 months or more, individual frequently displays at least six of the following symptoms of hyperactivity and impulsivity, to a degree that is maladaptive and beyond that shown by most similarly aged persons: • Fidgets, taps hands or feet, or squirms • Inappropriately wanders from seat • Inappropriately runs or climbs • Unable to play quietly • In constant motion • Talks excessively • Interrupts questioners during discussions • Unable to wait for turn • Barges in on others’ activities or conversations. Individual displayed some of the symptoms before 12 years of age. Individual shows symptoms in more than one setting. Individual experiences impaired functioning. Table 14-5

31 What Are the Causes of ADHD?Several interacting causes Biological theorist Abnormal dopamine activity Abnormalities in frontal-striatal regions of the brain Sociocultural theorists ADHD symptoms and a diagnosis of ADHD may themselves create interpersonal problems and produce additional symptoms in the child

32 How Is ADHD Treated? Treatment Most commonly applied approachesAbout 80 percent of all children and adolescents with ADHD receive treatment Heated disagreement about the most effective treatment for ADHD Most commonly applied approaches Drug therapy (Methylphenidate/Ritalin) Behavioral therapy Combination Diagnostic interviews, rating scales, and psychological test About 80 percent of all children and adolescents with ADHD receive treatment. There is, however, heated disagreement about the most effective treatment for ADHD. The most commonly applied approaches are drug therapy, behavioral therapy, or a combination. Millions of children and adults with ADHD are currently treated with methylphenidate (Ritalin), a stimulant drug that has been available for decades. It is estimated that 2.2 million children in the United States, 3 percent of all school children, take Ritalin or other stimulant drugs for ADHD. However, many clinicians worry about the possible long-term effects of the drugs and others question the applicability of study findings to minority children. Other clinicians worry that the drugs are being prescribed for children who do not actually suffer from ADHD. On the positive side, Ritalin is apparently very helpful for those who do have the disorder and most studies indicate that it is safe. Behavioral therapy has been applied in many cases of ADHD. Parents and teachers learn how to apply operant conditioning techniques to change behavior. These treatments have often been helpful, especially when combined with drug therapy.

33 Multicultural Factors and ADHDRacial differences exist among children with significant attention and activity problems who are or are not assessed, diagnosed, or treated for ADHD Economic disadvantage Social bias and racial stereotyping What conclusions can you draw from this information? African American and Hispanic American children with significant attention and activity problems are less likely than white American children to be assessed, diagnosed, or treated for ADHD. Children from racial minorities are less likely than white American children to be treated with stimulant drugs or a combination of stimulants and behavioral therapy—the interventions that seem to be of most help to those with ADHD.

34 Behavioral InterventionEducational programs use behavioral principles that clearly spell out targeted behaviors and program rewards and systematically reinforce appropriate behaviors. Such programs can be particularly helpful for children with ADHD.

35 Long-Term Disorders That Begin in ChildhoodAUTISM SPECTRUM DISORDER is characterized by lack of responsiveness and social reciprocity, communication problems, wide range of highly rigid and repetitive behaviors, interests, and activities Individuals with autism may also exhibit unusual, rigid, and repetitive motor movements or self-stimulatory or self-injurious behaviors, and hyperreactivity or hypo-reactivity The individual’s lack of responsiveness and social reciprocity—extreme aloofness, lack of interest in other people, low empathy, and inability to share attention with others—has long been considered a central feature of autism. Communication problems take various forms. One common speech peculiarity is echolalia, the exact echoing of phrases spoken by others. Another is pronominal reversal, or confusion of pronouns. Individuals with this disorder also display a range of highly rigid and very repetitive behaviors, interests, and activities. This has been called a perseveration of sameness. Many sufferers become strongly attached to particular objects – plastic lids, rubber bands, buttons, water – and may collect, carry, or play with them constantly. The motor movements of people with this disorder may be unusual. Often called “self-stimulatory” behaviors; may include jumping, arm flapping, and making faces Some individuals with the disorder may also engage in self-injurious behaviors. Children may at times seem overstimulated and/or understimulated by their environments.

36 What Are the Causes of Autism Spectrum Disorder?Sociocultural causes: Family dysfunction and social stress Psychological causes: Central perceptual or cognitive disturbance or limitations Theory of mind “Mind-blindness” Biological causes: Brain abnormalities Examination of relatives keeps suggesting a genetic factor in the disorder Prenatal difficulties or birth complications Specific biological abnormalities No proven MMR vaccine link Sociocultural explanations are now seen as having been overemphasized. Sociocultural causes Theorists initially thought that family dysfunction and social stress were the primary causes of this disorder. Kanner argued that particular personality characteristics of parents created an unfavorable climate for development – “refrigerator parents.” These claims had enormous influence on the public’s image, as well as on the self-image, of parents, but research totally failed to support this model. Some clinicians have proposed a high degree of social and environmental stress as a factor, a theory also unsupported by research. One theory holds that individuals fail to develop a theory of mind – an awareness that other people base their behaviors on their own beliefs, intentions, and other mental states, not on information they have no way of knowing. Repeated studies have shown that people with autism spectrum disorder have this kind of “mind-blindness.” It has been theorized that early biological problems prevented proper cognitive development. Biological causes While a detailed biological explanation for autism has not yet been developed, promising leads have been uncovered. Examination of relatives keeps suggesting a genetic factor in the disorder. Prevalence rates are higher among siblings and highest among identical twins. Some studies have linked autism spectrum disorder to prenatal difficulties or birth complications. Researchers have also identified specific biological abnormalities that may contribute to the disorder, particularly in the cerebellum.

37 How Do Clinicians and Educators Treat Autism Spectrum Disorder?Treatments Cognitive-behavioral therapy Communication training Parent training Community integration Cognitive-behavioral therapy Treatment can help people with autism spectrum disorder adapt better to their environment, although no known treatment totally reverses the autistic pattern. Education and training in special education classes and programs (LEAP) Therapies are ideally applied when they are started early in the children’s lives. Communication training Even with treatment, half of people with autism spectrum disorder remain speechless. Other forms of communication taught Sign language and simultaneous communication Augmentative communication systems Child-initiated interactions Parent training Today’s treatment programs involve parents in a variety of ways. Behavioral programs train parents to apply behavioral techniques at home. Individual therapy and support groups help parents deal with their own emotions and needs. Community integration Many of today’s school-based and home-based programs for autism teach self-help and self-­management, as well as living, social, and work skills. In addition, greater numbers of group homes and sheltered workshops are available for teens and young adults with autism spectrum disorder. These programs help individuals become a part of their community and also reduce the concerns of aging parents.

38 A Special Kind of Talent A savant is a person with a major mental disorder or intellectual handicap who has some spectacular ability Common skills Calendar calculating, musical skill, reproduction in art media Theories of savant skills Special forms of cognitive functioning Positive side to certain cognitive deficits Often these abilities are remarkable only in light of the handicap, but sometimes they are remarkable by any standard.

39 Intellectual Development DisorderThe term “mental retardation” has been replaced by INTELLECTUAL DEVELOPMENT DISORDER (DSM-5) As many as 3 of every 100 persons meets the criteria for this diagnosis Around three-fifths of them are male and the vast majority display a mild level of the disorder Dx Checklist Intellectual Disability Individual displays deficient intellectual functioning in areas such as reasoning, problem-solving, planning, abstract thinking, judgment, academic learning, and learning from experience. The deficits are reflected by clinical assessment and intelligence tests. Individual displays deficient adaptive functioning in at least one area of daily life, such as communication, social involvement, or personal independence, across home, school, work, or community settings. The limitations extend beyond those displayed by most other persons of his or her age and necessitate ongoing support at school, work, or independent living. The deficits begin during the developmental period (before the age of 18). People receive a diagnosis of intellectual development disorder (IDD) when they display general intellectual functioning that is well below average, in combination with poor adaptive behavior. IQ must be 70 or lower. The person must have difficulty in such areas as communication, home living, self-direction, work, or safety.

40 Assessing IntelligenceEducators and clinicians administer intelligence tests to measure intellectual functioning These tests consist of a variety of questions and tasks that rely on different aspects of intelligence An individual’s overall test score, or INTELLIGENCE QUOTIENT (IQ), is thought to indicate general intellectual ability Some people may receive an inaccurate diagnosis partly because of test inadequacies, cultural differences, discomfort with the testing situation, or the bias of a tester Having difficulty in one or two of these subtests or areas of functioning does not necessarily reflect low intelligence. Some people may receive the inaccurate diagnosis partly because of test inadequacies, cultural differences, discomfort with the testing situation, or the bias of a tester. Many theorists have questioned whether IQ tests are valid or socioculturally unbiased. If IQ tests do not always measure intelligence accurately and objectively, then the diagnosis of intellectual developmental disorder may also be biased.

41 Assessing Adaptive FunctioningDiagnosticians Cannot rely solely on a cutoff IQ score of 70 to determine whether a person suffers from IDD Should observe the functioning of each individual in his or her everyday environment, taking both the person’s background and the community standards into account

42 What Are the Features of Intellectual Developmental Disorder?Learning very slowly Difficulty in attention, short term memory, planning, and language Institutionalization may increase these limitations The most consistent feature of IDD is that the person learns very slowly.

43 READING AND ‘RITING AND ‘RITHMETICSPECIFIC LEARNING DISORDER -- Significant difficulties in the acquisition of reading, writing, arithmetic, or mathematical reasoning skills LANGUAGE DISORDER -- Persistent difficulties acquiring, using, or comprehending spoken or written language DEVELOPMENTAL COORDINATION DISORDER --Coordinated motor activities performed at a level well below that of others of his or her age Limited research has linked these various disorders to genetic defects, birth injuries, lead poisoning, inappropriate diet, sensory or perceptual dysfunction, and poor teaching Some of the disorders respond to special treatment approaches. Various disorders often disappear before adulthood, even without any treatment.

44 What Are the Features of Intellectual Developmental Disorder?Traditionally, four levels of intellectual developmental disorder have been distinguished Mild (IQ 50–70) Moderate (IQ 35–49) Severe (IQ 20–34) Profound (IQ below 20) Mild IDD Some 80 to 85 percent of all people with intellectual developmental disorder fall into the category of mild IDD (IQ 50–70). This is sometimes called the “educable” level because the individuals can benefit from schooling. Intellectual performance seems to improve with age. Their jobs tend to be unskilled or semiskilled. Research has linked mild IDD mainly to sociocultural and psychological causes, particularly: Poor and unstimulating environments Inadequate parent-child interactions Insufficient early learning experiences Some biological factors may also be operating Mothers’ moderate drinking Drug use Malnutrition during pregnancy Moderate and Severe IDD Approximately 10 percent of persons with intellectual developmental disorder function at a level of moderate IDD (IQ 35–49). They can care for themselves, benefit from vocational training, and can work in unskilled or semiskilled jobs. Approximately 3 to 4 percent of persons with intellectual developmental disorder display severe IDD (IQ 20–34). They usually require careful supervision and can perform only basic work tasks. They are rarely able to live independently. Profound IDD About 1 to 2 percent of persons with intellectual developmental disorder fall into the category of profound IDD (IQ below 20). With training they may learn or improve basic skills but they need a very structured environment. Severe and profound levels of intellectual developmental disorder often appear as part of larger syndromes that include severe physical handicaps.

45 What Are the Causes of Intellectual Developmental Disorder?Primary causes of mild IDD Environmental Biological factors may be operating in some cases Primary causes of moderate, severe, and profound IDD Biological People who function at these levels are also greatly affected by their family and social environments

46 What Are the Biological Causes of Intellectual Developmental Disorder?Chromosomal causes DOWN SYNDROME is the most common chromosomal disorder cause of IDD FRAGILE X SYNDROME is the second most common chromosomal cause Metabolic causes PHENYLKETONURIA (PKU) TAY-SACHS DISEASE Prenatal and birth-related causes CRETINISM FETAL ALCOHOL SYNDROME (FAS) Prenatal maternal infections ANOXIA Chromosomal causes The most common chromosomal disorder leading to intellectual developmental disorder is DOWN SYNDROME. Fewer than 1 of every 1000 live births result in Down syndrome, but this rate increases greatly when the mother’s age is over 35. Several types of chromosomal abnormalities may cause Down syndrome, but the most common is TRISOMY 21. FRAGILE X SYNDROME is the second most common chromosomal cause of IDD. Metabolic causes Body’s breakdown or production of chemicals is disturbed. Intelligence and development are typically caused by the pairing of two defective recessive genes, one from each parent. Examples PHENYLKETONURIA (PKU) TAY-SACHS DISEASE Prenatal and birth-related causes As a fetus develops, major physical problems in the pregnant mother can threaten the child’s healthy development. Low iodine may lead to CRETINISM Alcohol use may lead to FETAL ALCOHOL SYNDROME (FAS). Certain maternal infections during pregnancy (e.g., RUBELLA, SYPHILIS) may cause childhood problems including IDD. Birth complications, such as a prolonged period without oxygen (ANOXIA), can also lead to problems in intellectual functioning.

47 What Are the Causes of Intellectual Developmental Disorder?Childhood problems Injuries and accidents Poisoning, serious head injury, excessive exposure to X-rays, and excessive use of certain chemicals, minerals, and/or drugs Undiagnosed or untreated infections MENINGITIS ENCEPHALITIS After birth, particularly up to age 6, certain injuries and accidents can affect intellectual functioning. Examples include poisoning, serious head injury, excessive exposure to X-rays, and excessive use of certain chemicals, minerals, and/or drugs (e.g., lead paint). Certain infections, such as MENINGITIS and ENCEPHALITIS, can lead to IDD if they are not diagnosed and treated in time.

48 Interventions for People with IDDThe quality of life attained by people with IDD depends largely on sociocultural factors Intervention programs try to provide comfortable and stimulating residences, social and economic opportunities, and a proper education

49 Interventions for People with IDDWhat is the proper residence? Until recently: State schools and public institutions; basic care, but inadequate During the 1960s and 1970s: Deinstitutionalization movement; created some challenges Reforms since deinstitutionalization: Small institutions and other community residences Group homes, halfway houses, local branches of larger institutions, independent residences Today: Family home or community residence Until recently, parents of children with IDD would send them to live in public institutions – state schools – as early as possible. These overcrowded institutions provided basic care, but residents were neglected, often abused, and isolated from society. During the 1960s and 1970s, the public became more aware of these sorry conditions and, as part of the broader deinstitutionalization movement, demanded that many people be released from these schools. People with IDD faced challenges by deinstitutionalization similar to people with schizophrenia. Since deinstitutionalization, reforms have led to the creation of small institutions and other community residences that teach self-sufficiency, devote more time to patient care, and offer education and medical services. Residences include group homes, halfway houses, local branches of larger institutions, and independent residences. These programs follow the principle of normalization; they try to provide living conditions similar to those enjoyed by the rest of society. Today the vast majority of children with intellectual developmental disorder live at home rather than in an institution. Most people with IDD, including almost all with mild IDD, now spend their adult lives either in the family home or in a community residence.

50 Interventions for People with IDDWhich educational programs work best? Early intervention Special education versus mainstream classrooms Special education Mainstreaming Teacher preparedness Operant conditioning Token economy programs Because early intervention seems to offer such great promise, educational programs for individuals with IDD may begin during the earliest years. At issue are special education versus mainstream classrooms. In special education, children with IDD are grouped together in a separate, specially designed educational program. Mainstreaming places them in regular classes with students from the general school population. Neither approach seems consistently superior. Teacher preparedness is a factor that plays into decisions about mainstreaming. Many teachers use operant conditioning principles to improve the self-help, communication, social skills, and academic skills of individuals with IDD. Many schools also employ token economy programs.

51 Interventions for People with IDDWhen is therapy needed? Presence of emotional and behavioral problems Around 30 percent or more have a diagnosable psychological disorder other than IDD Some suffer from low self-esteem, interpersonal problems, and adjustment difficulties These problems are helped to some degree by individual or group therapy Psychotropic medication is sometimes prescribed Like anyone else, people with intellectual developmental disorder sometimes experience emotional and behavioral problems. Around 30 percent or more have a diagnosable psychological disorder other than IDD. Some suffer from low self-esteem, interpersonal problems, and adjustment difficulties. These problems are helped to some degree by individual or group therapy. Psychotropic medication is sometimes prescribed.

52 Interventions for People with IDDHow can opportunities for personal, social, and occupational growth be increased? Opportunities to feel effective and competent to move forward in life Opportunities that allow growth and choices when possible Programs and support related to socializing, sex, and marriage Work in sheltered workshops and job training programs available Socializing, sex, and marriage are difficult issues for people with IDD and their families. With proper training and practice, individuals with IDD can learn to use contraceptives and carry out responsible family planning. National advocacy organizations and a number of clinicians offer guidance in these matters. Some have developed dating skills programs. Adults with IDD need the financial security and personal satisfaction that comes from holding a job. Many can work in sheltered workshops, but there are too few training programs available. Additional programs are needed so that more people with IDD may achieve their full potential, as workers and as human beings.