Chapter 15 Disorders of Childhood and Adolescence (Neurodevelopmental Disorders)

Causal Factors in Anxiety Disorders

A number of causal factors have been emphasized in explanations of the childhood anxiety disorders. Although genetic factors have been thought to contribute to the development of anxiety disorders, particularly obsessive-compulsive disorder, in children (Nestadt et al., 2010), social and cultural factors are likely to be influential in resulting in anxiety disorders in children. For example, some research has reported an increased risk of anxiety and depression among immigrant Latino youth. Parental behavior and family stress in minority families have been particularly noted as potential influential factors in the origin of anxiety disorders in children; however, broader cultural factors are also important considerations. Anxious children often manifest an unusual constitutional sensitivity that makes them easily conditionable by aversive stimuli. For example, they may be readily upset by even small disappointments—a lost toy or an encounter with an overeager dog. They then have a harder time calming down, a fact that can result in a buildup and generalization of surplus fear reactions. The child can become anxious because of early illnesses, accidents, or losses that involved pain and discomfort. The traumatic effect of experiences such as hospitalizations makes such children feel insecure and inadequate. The traumatic nature of certain life changes such as moving away from friends and into a new situation can also have an intensely negative effect on a child's adjustment. Overanxious children often have the modeling effect of an overanxious and protective parent who sensitizes a child to the dangers and threats of the outside world. Often, the parent's overprotectiveness communicates a lack of confidence in the child's ability to cope, thus reinforcing the child's feelings of inadequacy Indifferent or detached parents (Chartier et al., 2001) or rejecting parents (Hudson & Rapee, 2001) also foster anxiety in their children. The child may not feel adequately supported in mastering essential competencies and in gaining a positive self-concept. Repeated experiences of failure stemming from poor learning skills may lead to subsequent patterns of anxiety or withdrawal in the face of "threatening" situations. Other children may perform adequately but may be overcritical of themselves and feel intensely anxious and devalued when they perceive themselves as failing to do well enough to earn their parents' love and respect. The role that social-environmental factors might play in the development of anxiety-based disorders, though important, is not clearly understood. A cross-cultural study of fears (Ollendick et al., 1996) found significant differences among American, Australian, Nigerian, and Chinese children and adolescents. These authors suggest that cultures that favor inhibition, compliance, and obedience appear to increase the levels of fear reported. In another study in the United States, Last and Perrin (1993) reported that there are some differences between African American and white children with respect to types of anxiety disorders. White children are more likely to present with school refusal than are African American children, who show more posttraumatic stress syndrome (PTSD) symptoms. This difference might result from differing patterns of referral for African American and white families, or it might reflect differing environmental stressors placed on the children. Several studies have also reported a strong association between exposure to violence and a reduced sense of security and psychological well-being. Children who experience a sense of diminished control over negative environmental factors may become more vulnerable to the development of anxiety than those children who achieve a sense of efficacy in managing stressful circumstances.

Learning disorders

Learning disorders are delays in cognitive development in the areas of language, speech, mathematical, or motor skills that are not necessarily due to any demonstrable physical or neurological defect. Of these types of problems, the best known and most widely researched are a variety of reading/writing difficulties known collectively as dyslexia. In dyslexia, the individual has problems in word recognition and reading comprehension; often he or she is markedly deficient in spelling and memory (Smith-Spark & Fisk, 2007) as well. On assessments of reading skill, these persons routinely omit, add, and distort words, and their reading is typically painfully slow. The diagnosis of learning disorders is restricted to those cases in which there is clear impairment in school performance or (if the person is not a student) in daily living activities—impairment not due to intellectual disability or to a pervasive developmental disorder such as autism. Skill deficits due to ADHD are coded under ADHD. This coding presents another diagnostic dilemma, however, because some investigators hold that an attention deficit is basic to many learning disorders; evidence for the latter view is equivocal (see Faraone et al., 1993). Children (and adults) with these disorders are more generally said to have a learning disorder. Significantly more boys than girls are diagnosed as having a learning disorder, but estimates of the extent of this gender discrepancy have varied widely from study to study. Prevalence estimates have shown that approximately 1 in 59, or 4.6 million people, in the United States Children with learning disorder are initially identified as such because of an apparent disparity between their expected academic achievement level and their actual academic performance in one or more school subjects such as math, spelling, writing, or reading. Typically, these children have overall IQs, family backgrounds, and exposure to cultural norms and symbols that are consistent with at least average achievement in school. They do not have obvious, crippling emotional problems, nor do they seem to be lacking in motivation, cooperativeness, or eagerness to please their teachers and parents—at least not at the outset of their formal education. Nevertheless, they fail, often abysmally and usually with a stubborn, puzzling persistence. The consequences of these encounters between children with learning disabilities and rigid school systems can be disastrous to these children's self-esteem and general psychological well-being, and research indicates that these effects do not necessarily dissipate after secondary schooling ends but continue to impact these individuals' career adjustments (Morris & Turnbull, 2007). Thus, even when learning disorder difficulties are no longer a significant impediment, an individual may bear, into maturity and beyond, the scars of many painful school-related episodes of failure.. But there is also a brighter side to this picture. High levels of general talent and of motivation to overcome the obstacle of a learning disorder sometimes produce a life of extraordinary achievement

DSM-5 Criteria for... Autism Spectrum Disorder

Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history (examples are illustrative, not exhaustive; see text): Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history (examples are illustrative, not exhaustive; see text): Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys or flipping objects, echolalia, idiosyncratic phrases). Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take same route or eat same food every day). Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests). Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). Symptoms must be present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities, or may be masked by learned strategies in later life). Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning. These disturbances are not better explained by intellectual disability (intellectual developmental disorder) or global developmental delay. Intellectual disability and autism spectrum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum disorder and intellectual disability, social communication should be below that expected for general developmental level. NOTE: Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger's disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder. Individuals who have marked deficits in social communication, but whose symptoms do not otherwise meet criteria for autism spectrum disorder, should be evaluated for social (pragmatic) communication disorder.

The Clinical Picture in Down Syndrome

A number of physical features are often found among children with Down syndrome, but few of these children have all of the characteristics commonly thought to typify this group. The eyes appear almond shaped, and the skin of the eyelids tends to be abnormally thick. The face and nose are often flat and broad, as is the back of the head. The tongue, which seems too large for the mouth, may show deep fissures. The iris of the eye is frequently speckled. The neck is often short and broad, as are the hands. The fingers are stubby, and the little finger is often more noticeably curved than the other fingers. Although facial surgery is sometimes tried to correct the more stigmatizing features, its success is often limited Parents' acceptance of their Down syndrome child is inversely related to their support of such surgery Death rates for children with Down syndrome have decreased dramatically in the past century. In 1919 the life expectancy at birth for such children was about 9 years; most of the deaths were due to gross physical problems, and a large proportion occurred in the first year of life. Thanks to antibiotics, surgical correction of lethal anatomical defects such as holes in the walls separating the heart's chambers, and better general medical care, many more of these children now live to adulthood (Hijii et al., 1997). Nevertheless, they appear as a group to experience an accelerated aging process (Hasegawa et al., 1997) and a decline in cognitive abilities (Thompson, 2003). One recent study reported that of those with Down syndrome who were age 60 and above, more than 50 percent had clinical evidence of dementia Despite their problems, children with Down syndrome are usually able to learn self-help skills, acceptable social behavior, and routine manual skills that enable them to be of assistance in a family or institutional setting (Brown et al., 2001). The traditional view has been that children with Down syndrome are unusually placid and affectionate. However, research has called into question the validity of this generalization (Pary, 2004). These children may indeed be very docile, but probably in no greater proportion than normal children; they may also be equally (or more) difficult in various areas. In general, the quality of a child's social relationships depends on both IQ level and a supportive home environment (Alderson, 2001). Adults with Down syndrome may manifest less maladaptive behavior than comparable persons with other types of learning disabilities Research has also suggested that the intellectual defect in Down syndrome may not be consistent across various abilities. Children with Down syndrome tend to remain relatively unimpaired in their appreciation of spatial relationships and in visual-motor coordination, although some evidence disputes this conclusion (Uecker et al., 1993). Research data are quite consistent in showing that their greatest deficits are in verbal and language-related skills (Azari et al., 1994). Because spatial functions are known to be partially localized in the right cerebral hemisphere, and language-related functions localized in the left cerebral hemisphere, some investigators speculate that the syndrome is especially crippling to the left hemisphere. Chromosomal abnormalities other than the trisomy of chromosome 21 may occasionally be involved in the etiology of Down syndrome. However, the extra version of chromosome 21 is present in at least 94 percent of cases. As we noted earlier, it may be significant that this is the same chromosome that has been implicated in research on Alzheimer's disease, especially given that persons with Down syndrome are at extremely high risk for Alzheimer's as they get into and beyond their late 30s The reason for the trisomy of chromosome 21 is not clear, and research continues to address the potential causes (Korbel et al., 2009), but the defect is probably related to cognitive deficit (Kahlem, 2006) and to parental age at conception. It has been known for many years that the incidence of Down syndrome increases (from the 20s on) with increasing age of the mother. A woman in her 20s has about 1 chance in 2,000 of conceiving a Down syndrome baby, whereas the risk for a woman in her 40s is 1 in 50 (Holvey & Talbott, 1972). As in the case of all birth defects, the risk of having a baby with Down syndrome also is high for very young mothers, whose reproductive systems have not yet fully matured. Research has indicated that the father's age at conception is also implicated in Down syndrome, with higher ages conferring greater risk

DSM-5 Criteria for... Attention-Deficit/Hyperactivity Disorder

A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): INATTENTION: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: NOTE: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate). Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked). Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines). Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers). Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). HYPERACTIVITY AND IMPULSIVITY: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: NOTE: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. Often fidgets with or taps hands or feet or squirms in seat. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place). Often runs about or climbs in situations where it is inappropriate. (NOTE: In adolescents or adults, may be limited to feeling restless.) Often unable to play or engage in leisure activities quietly. Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). Often talks excessively. Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation). Often has difficulty waiting his or her turn (e.g., while waiting in line). Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing). Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

DSM-5 Criteria for... Conduct Disorder

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: Aggression to People and Animals 1. Often bullies, threatens, or intimidates others. 2. Often initiates physical fights. 3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). 4. Has been physically cruel to people. 5. Has been physically cruel to animals. 6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). 7. Has forced someone into sexual activity. Destruction of Property 8. Has deliberately engaged in fire setting with the intention of causing serious damage. 9. Has deliberately destroyed others' property (other than by fire setting). Deceitfulness or Theft 10. Has broken into someone else's house, building, or car. 11. Often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others). 12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery). Serious Violations of Rules 13. Often stays out at night despite parental prohibitions, beginning before age 13 years. 14. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period. 15. Is often truant from school, beginning before age 13 years. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Tic Disorders

A tic is a persistent, intermittent muscle twitch or spasm, usually limited to a localized muscle group. The term is used broadly to include blinking the eye, twitching the mouth, licking the lips, shrugging the shoulders, clearing the throat, and grimacing, among other actions. Tic disorders are classified under motor disorders in DSM-5. Tics occur most frequently between the ages of 2 and 14 . In some instances, as in clearing the throat, an individual may be aware of the tic when it occurs, but usually he or she performs the act habitually and does not notice it. In fact, many individuals do not even realize they have a tic unless someone brings it to their attention. A cross-cultural examination of tics found a similar pattern in research and clinical case reports from other countries (Staley et al., 1997). Moreover, the age of onset (average 7 to 8 years old) and predominant gender (male) of cases were reported to be similar across cultures. A recent study on the prevalence of tic disorder in children and adolescents reported that the lifetime prevalence of tic disorders (TDs) is 2.6 percent for transient tic disorder (TTD), 3.7 percent for chronic tic disorder (CTD), and 0.6 percent for Tourette's disorder

Bilirubin encephalopathy

Abnormal levels of bilirubin (a toxic substance released by red cell destruction) in the blood; motor incoordination frequent Often, Rh (ABO) blood group incompatibility between mother and fetus

ADHD Beyond Adolescence

Although ADHD has long been thought of as a disorder that occurs only during childhood and adolescence, studies done in the United States and internationally suggest that approximately half of children with ADHD will continue to meet criteria in adulthood (Kessler, Green, et al., 2010; Lara et al., 2008). Interestingly, however, most cases of adult ADHD are characterized by symptoms of inattention (95 percent), whereas a much smaller percentage are characterized by hyperactivity (35 percent) (Kessler, Green, et al., 2010). It is estimated that approximately 4 percent of U.S. adults meet criteria for ADHD, with higher rates among those who are male, divorced, and unemployed The association with unemployment may be due to trouble finding work, but may also be the result of poor work performance or absenteeism. One recent study showed that those with ADHD miss significantly more days of work (approximately 22 more days each year) than those without ADHD.

Possibility of Using Parents as Change Agents

Although parents can, in some instances, help to create an environment that increases the risk of psychological disorders, on the flip side, they can be used as agents of positive change. Because the typical child therapist only sees the child for approximately 1 hour per week, whereas parents have access to their children the other 167 hours of the week, parents can be used as change agents by training them in techniques that enable them to modify their children's thoughts, feelings, and behaviors. Typically, such training focuses on helping the parents understand their child's psychological disorder and teaching them to reinforce adaptive behavior while withholding reinforcement for undesirable behavior. Many of the most effective treatments for children and adolescents rely heavily on such help from the child's parents or guardians.

Disruptive, Impulse-Control, and Conduct Disorder

Anxiety and depressive disorders often are referred to as "internalizing disorders" because the focus of the symptoms is on what is happening inside the person (i.e., abnormalities in their thoughts and feelings). In contrast, disorders characterized by symptoms focused outside the person, such as engagement in disruptive and impulsive behavior, often are referred to as "externalizing disorders." Two of the most common externalizing disorders are oppositional defiant disorder and conduct disorder. Of course, many children will act out from time to time, disobeying adults and getting into fights, and so it is important to distinguish normal acting out from the more severe and persistent behaviors that can occur in those with oppositional defiant disorder and conduct disorder. It also is important to differentiate between these disorders and illegal activity among youth. Juvenile delinquency is the legal term used to refer to violations of the law committed by minors. Although youth with externalizing disorders may break the law, breaking the law in itself does not signal the presence of one of these disorders.

Treatments and Outcomes

Approximately half of those with ODD (54 percent) and a third of those with CD (32 percent) have received treatment for their behavior problems (Merikangas, He, et al., 2011). Effective treatments for ODD and CD focus primarily on modifying the child's family and broader environment as a way of decreasing his or her problematic behavior

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is characterized by a persistent pattern of difficulties sustaining attention and/or impulsiveness and excessive or exaggerated motor activity. We all have had lapses in attention or periods of excess energy during childhood; however, in order to meet criteria for ADHD these problems have to be numerous, persistent, and causing impairment at home, school, or the workplace Perhaps due partially to their behavioral problems, children with ADHD often score approximately 7 to 15 points lower on intelligence quotient (IQ) tests (Barkley, 1997) and show deficits on neuropsychological testing that are related to poor academic functioning (Biederman et al., 2004). They often show specific learning disabilities such as difficulties in reading or learning other basic school subjects. Children and adolescents with ADHD also are at significantly higher risk of a range of school problems including suspension and repeating a grade, and these effects appear to be due in large part to disruptive behavior problems. In addition to academic problems, symptoms of ADHD also can lead to significant social impairment (see the following video on Jimmy). Hyperactive children often have great difficulty getting along with their parents because they often fail to obey rules. Their behavior problems also can result in their being viewed negatively by their peers. ADHD is fairly prevalent, occurring in approximately 9 percent of children and adolescents (Merikangas et al., 2010). Although it is not the most prevalent disorder among U.S. children and adolescents (specific phobia is seen in 19 percent of youth), it is the one that is most frequently diagnosed by health professionals (Ryan-Krause et al., 2010). The reason for this difference is that parents are much more likely to bring a child with ADHD in for treatment than they are a child with a less disruptive disorder such as specific phobia. The rate of ADHD is much higher in boys (13 percent) than in girls (4 percent) (Merikangas et al., 2010) and is commonly comorbid with other externalizing disorders such as ODD and CD. ADHD is seen in cultures all around the world. For example, one study of 1,573 children from 10 European countries reported that ADHD symptoms are similarly recognized across all countries studied and that the children have significant impairments across a wide range of domains

Causal Factors in Autism

Autism is a complex disorder and its precise causes are unknown. Twin and sibling studies have shown that there is a very strong heritable component in autism. For instance, 2 to 14 percent of siblings of children diagnosed with autism also have the disorder, and approximately 20 percent have some symptoms of the disorder Although there is a clear heritable component, the exact mode of genetic transmission is not yet understood. On one hand, recent research has shown that hundreds of different genes are associated with increased risk of autism, suggesting that there are many different paths to developing this disorder (Robinson et al., 2014; State & Šestan, 2012). On the other hand, research also has shown that the same genetic variants are associated with multiple disorders. For instance, some of the same genes that have been linked with an increased risk of autism also increase the risk of ADHD, schizophrenia, bipolar disorder, and depression Given the complexity of this picture, how will we ever know what causes autism? Researchers are pursuing several different avenues of research to try to answer this question. They are trying to determine what portion of the genetic risk is inherited (52 percent) and what portion is due to de novo genetic mutations (3 percent). De novo mutations are those that occur in the egg or sperm and are passed on to every cell in the child's body, despite not appearing in the parents' DNA. It seems that much of the risk for autism is indeed inherited from one's parents (Gaugler et al., 2014). However, a significant portion of risk also arises due to de novo mutations. This is important to know, because as we learn about factors that increase the likelihood of genetic mutations, we can take steps to try to decrease their occurrence. For instance, genetic mutations have been reported to occur at higher rates in the sperm of older men, and there is now converging evidence that older father age at a child's birth is associated with increased risk of autism

Autism Spectrum Disorder

Autism spectrum disorder (which we refer to as "autism") is a neurodevelopmental disorder that involves a wide range of problematic behaviors including deficits in language and perceptual and motor development; defective reality testing; and impairments in social communication. Autism was first described in 1943 (Kanner). It afflicts tens of thousands of American children from all socioeconomic levels and is seemingly on the increase—estimates range between 30 and 60 people in 10,000 (Fombonne, 2005). A recent study by the Centers for Disease Control and Prevention (Baio, 2014) reported that the rate of autism among children is about 1 in 68. This reported increase in autism in recent years is likely due to methodological differences between studies and changes in diagnostic practice and public and professional awareness in recent years rather than an increase in prevalence. Autism is usually identified before a child is 30 months of age and diagnostic stability over the childhood years is quite high. Lord and colleagues (2006) report that children diagnosed with autism by age 2 tend to be similarly diagnosed at age 9. Recent research suggests that early signs of problems with social communication can be detected in the first 6 months of an infant's life (Jones & Klin, 2014). When scanning the world around them, typically developing infants from 2 to 6 months of age focus increasingly on the face and especially the eyes of others. This focus allows infants to better understand those caring for them and helps facilitate later social interaction. In contrast, children later diagnosed with autism show a significant decline in their focus on the eyes of others from 2 to 6 months of age and this decline continues until 24 months—at which point it is approximately half the level of focus as that seen in typically developing children. In contrast, while their attention to other people's eyes decreases, infants later diagnosed with autism show a significant increase in their focus on inanimate objects, which is double the level of typically developing children by 24 months.

Need to Treat Parents as well as Children

Because many of the behavior disorders specific to childhood appear to grow out of pathogenic family interactions and result from having parents with psychiatric problems themselves (Johnson et al., 2000), it is often important for the parents, as well as their child, to receive treatment (Dishion & Stormshak, 2007). In some instances, in fact, the treatment program may focus on the parents entirely, as in the case of child abuse. Increasingly, then, the treatment of children has come to mean family therapy in which one or both parents, along with the child and siblings, may participate in all phases of the program. This is particularly important when the family situation has been identified as involving violence (Chaffin et al., 2004). Many therapists have discovered that fathers are particularly difficult to engage in the treatment process. Unfortunately, there are many barriers that prevent many families from initiating treatment or sticking with it once they start. Some of the most common barriers include concrete stressors or obstacles such as lack of transportation of child care, as well as the perception that treatment is not relevant or help and a poor relationship with one's therapist

Bipolar Disorder in Children and Adolescents: Is There an Epidemic?

Bipolar disorder is characterized by extreme mood swings and aggressive, irritable behavior (Braaten, 2011). Historically, bipolar disorder has been conceptualized as an adult disorder; however, starting in the mid-1990s, psychiatrists began applying the diagnosis to children and adolescents and prescribing bipolar medication for their treatment There are several potential explanations for this increase. It could reflect a true increase in the disorder in young people. Or, it could be that the rate of bipolar disorder was always high but unrecognized, and with increased awareness practitioners are now recognizing more patients with the disorder that they had "missed" in the past. A third possibility is that clinicians are using the bipolar diagnosis more liberally now than in the past and are erroneously increasing the application of the diagnosis to a wide range of behavior problems, for example, attention-deficit/hyperactivity disorder (ADHD). Many experts support this last possibility. For instance, children and adolescents diagnosed with bipolar disorder are much more likely than adults with such diagnoses to be male (67 percent versus 32 percent) and to have a comorbid diagnosis of ADHD (32 percent versus 3 percent) Longitudinal research studies (those in which assessments are done repeatedly over some period of time) that follow children and adolescents diagnosed with bipolar disorder into adulthood have documented that many of these children continue to meet criteria for this disorder in adulthood, suggesting that in many cases the diagnosis is being validly applied to youth

The Impact of Child Abuse on Psychological Disorders

Child abuse and neglect continue to be enormous concerns around the world. Approximately 1 percent of children in the United States are the victims of documented cases of child abuse or neglect each year. Most of these cases involve child neglect (78 percent), whereas 18 percent involve physical abuse and 9 percent involve sexual abuse (U.S. Department of Health and Human Services, 2013). Unfortunately, most abuse and neglect goes undocumented, so the actual rates of occurrence are much higher. In a recent nationally representative survey of U.S. adolescents, 4 percent reported being physically abused and 4 percent reported being sexually abused (McLaughlin, Green, et al., 2012). Cross-national studies indicate that approximately 8 percent of people report being physically abused during childhood and 2 percent report being the victim of sexual abuse (Kessler, McLaughlin, et al., 2010). In extreme cases, the abuse and neglect of children can lead to death. Beyond the direct and intentional killing of a child (known as filicide), abuse and neglect can increase the risk of death via inadequate health care or poor parental supervision (Sidebotham et al., 2014). Most cases of child abuse and neglect are not lethal, but they can still have an enormous impact on the development of psychopathology. Children who experience physical or sexual abuse show a doubling in the risk of developing a range of different psychological disorders (McLaughlin, Green, et al., 2012) as well as a doubling in the risk of suicidal behavior (Bruffaerts et al., 2010). Moreover, this elevated risk of psychopathology and suicidal behavior is seen in cultures all around the globe and extends across the life span (Bruffaerts et al., 2010; Kessler, McLaughlin, et al., 2010), suggesting that events that occur during childhood can have a broad and long-lasting impact. Indeed, children who have been abused also show long-term adjustment problems such as difficulties adjusting to college (Elliott et al., 2009) and within intimate relationships later in life (Friesen et al., 2010). Of course, not all instances of abuse lead to psychopathology, and many people who experience abuse go on to lead happy and healthy lives (Rind et al., 1998). In some cases, those who suffered through abuse seek treatment, which often aims at addressing potential problems with social adjustment and interpersonal skills that may have been affected or hindered by the abuse. Treatment can be especially effective if it is targeted to the specific needs of the affected child (Harvey & Taylor, 2010).

Childhood Depression and Bipolar Disorder

Childhood depression, like depression in adults, is characterized by symptoms of sadness, withdrawal, crying, poor sleep and appetite, and in some cases thoughts of suicide or suicide attempts. In the past, childhood depression was classified according to essentially the same DSM diagnostic criteria used for adults. One modification used for diagnosing depression in children is that irritability is often found as a major symptom and can be substituted for depressed mood. Depression in children and adolescents occurs with high frequency. Approximately 12 percent of children and adolescents meet criteria for major depression at some point in their lives, with higher rates in girls (16 percent) than boys (8 percent) (Merikangas et al., 2010). These rates have been generally consistent during the past several decades (Costello et al., 2006). Although depression can occur in children, the rates are low during childhood but increase dramatically during adolescence. Bipolar disorder occurs less frequently (3 percent of boys and girls), but it can be diagnosed in children and adolescents (Merikangas et al., 2010). An increased use of bipolar diagnosis has been noted among children and adolescents in the United States. A high percentage of these adolescents received a comorbid diagnosis, frequently attention-deficit/hyperactivity disorder.

Vulnerabilities that Place Children at Risk for Developing Emotional Problems

Children and youth who experience or are exposed to violence are at increased risk for developing psychological disorders (Seifert, 2003). In addition, many families provide an undesirable environment for their growing children (Ammerman et al., 1998). Studies have shown that up to a fourth of American children may be living in inadequate homes and that approximately 8 percent of youth in the United States report spending at least one night in a shelter, public place, or abandoned building (Ringwalt et al., 1998). Another study revealed that 23 percent of newly homeless men in New York City report a history of out-of-home care as children (Susser et al., 1993). Parental substance abuse also has been found to be associated with the vulnerability of children to the development of psychological disorders High-risk behaviors or difficult life conditions need to be recognized and taken into consideration (Harrington & Clark, 1998). For example, there are a number of behaviors such as engaging in sexual acts or delinquency and using alcohol or drugs that might place young people at greater risk for developing emotional problems. Moreover, physical or sexual abuse, parental divorce, family turbulence, and homelessness can place young people at great risk for emotional distress and subsequent maladaptive behavior (Cauce et al., 2000; Spataro et al., 2004) (see the World Around Us box). For example, children from homes with harsh discipline and physical abuse are more likely to be aggressive and to have conduct disorder than those from homes with less harsh discipline and from nonabusing families

Age of Onset and Links to Antisocial Personality Disorder

Children who develop CD at an earlier age are much more likely to develop psychopathy or antisocial personality disorder as adults than are adolescents who develop CD suddenly in adolescence (Copeland et al., 2007). The link between CD and antisocial personality is stronger among lower-socioeconomic-class children (Lahey et al., 2005). It is the pervasiveness of the problems first associated with ODD and then with CD that forms the pattern associated with an adult diagnosis of psychopathy or antisocial personality. Although only about 25 to 40 percent of cases of early-onset CD go on to develop adult antisocial personality disorder, over 80 percent of boys with early-onset CD continue to have multiple problems of social dysfunction (in friendships, intimate relationships, and vocational activities) even if they do not meet all the criteria for antisocial personality disorder. By contrast, most individuals who develop CD in adolescence do not go on to become adult psychopaths or antisocial personalities but instead have problems limited to the adolescent years. These adolescent-onset cases also do not share the same set of risk factors that the child-onset cases have, including low verbal intelligence, neuropsychological deficits, and impulsivity and attentional problems.

The Clinical Picture in Autistic Spectrum Disorder

Children with autism show varying degrees of impairments and capabilities. A cardinal and typical sign is that a child seems apart or aloof from others, even in the earliest stages of life (Hillman et al., 2007). Mothers often remember such babies as not being cuddly, not reaching out when being picked up, not smiling or looking at them while being fed, and not appearing to notice the comings and goings of other people. Children with autism often do not show any need for affection or contact with others. Several studies, however, have questioned the traditional view that children with autism are emotionally flat. These studies have shown that children with autism do express emotions and should not be considered as lacking emotional reactions (Jones et al., 2001). Instead, some have characterized the seeming inability of children with autism to respond to others as a lack of social understanding—a deficit in the ability to attend to social cues from others. Indeed, neuroimaging studies have revealed that children with autism show decreased activity in the medial prefrontal cortex, a region associated with understanding the mental states of others, but increased activation in the ventral occipitotemporal regions involved in object perception Additionally, children with autism show deficits in attention and in locating and orienting to sounds in their environment (Hillman et al., 2007). These children often show an aversion to auditory stimuli, crying even at the sound of a parent's voice. The pattern is not always consistent, however; children with autism may at one moment be severely agitated or panicked by a very soft sound and at another time be totally oblivious to a loud noise. Children with autism do not effectively learn by imitation (Smith & Bryson, 1994). This dysfunction might explain their characteristic absence or severely limited use of speech. If speech is present, it is almost never used to communicate except in the most rudimentary fashion, such as by saying "yes" in answer to a question or by the use of echolalia—the parrot-like repetition of a few words. Whereas the echoing of parents' verbal behavior is found to a small degree in normal children as they experiment with their ability to produce articulate speech, persistent echolalia is found in about 75 percent of children with autism Self-stimulation is often characteristic of children with autism. It usually takes the form of such repetitive movements as head banging, spinning, and rocking, which may continue by the hour. Many children with autism become preoccupied with and form strong attachments to unusual objects such as rocks, light switches, or keys. When their preoccupation with the object is disturbed—for example, by its removal or by attempts to substitute something in its place—or when anything familiar in the environment is altered even slightly, these children may have a violent temper tantrum or a crying spell that continues until the familiar situation is restored. Thus children with autism are often said to be "obsessed with the maintenance of sameness."

Psychological Treatment

Cognitive-behavior therapy (CBT) has been shown to be highly effective at reducing anxiety symptoms in young children (Hirshfeld-Becker et al., 2010; Legerstee et al., 2010). Kendall and colleagues have pioneered the use of CBT for child anxiety using positive reinforcement to enhance coping strategies to deal with fears. Using this approach, the clinician tailors the treatment to a child's particular problem, and exposure to the anxiety-provoking stimuli is an especially important component of this approach. An interesting and effective cognitive-behavioral anxiety prevention and treatment study was implemented in Australia. In an effort to identify and reduce anxiousness in young adolescents, Dadds and colleagues (1997) identified 314 children who met the criteria for an anxiety disorder out of a sample of 1,786 children 7 to 14 years old in a school system in Brisbane, Australia. They contacted the parents of these anxious children to engage them in the treatment intervention, and the parents of 128 of the children agreed to participate. The treatment intervention involved holding group sessions with the children in which they were taught to recognize their anxious feelings and deal with them more effectively than they otherwise would have. In addition, the parents were taught behavioral management procedures to deal more effectively with their child's behavior. Six months after therapy was completed, significant anxiety reduction was shown for the treatment group compared with an untreated control sample.

Conduct Disorder

Conduct disorder (CD) is characterized by a persistent, repetitive violation of rules and a disregard for the rights of others (see the DSM criteria box for CD). CD has a median age of onset of 12 years (meaning half of those who ever develop this disorder have it by age 12) and a lifetime prevalence of 10 percent (Nock et al., 2006). Like ODD, CD is more common among boys (12 percent) than girls (7 percent). Because the combination of any 3 of the 15 symptoms listed in the DSM criteria box can lead to a diagnosis of CD, there is a great deal of variability in the clinical presentation of this disorder. Statistical analyses that examine how symptoms cluster together have revealed the presence of five common subtypes of CD, with each made up of children engaging primarily in (1) rule violations (26 percent of those with CD), (2) deceit/theft (13 percent), (3) aggressive behavior (3 percent), (4) severe forms of subtypes 1 and 2 (29 percent), and (5) a combination of subtypes 1, 2, and 3 (29 percent) Children and adolescents with CD are also frequently comorbid for other disorders such as substance abuse disorder (Goldstein et al., 2006) or depressive symptoms (O'Connor et al., 1998). CD significantly increases the risk of pregnancy and substance abuse in teenage girls (Zoccolillo et al., 1997) and of the later development of antisocial personality disorder and a range of other disorders (Goldstein et al., 2006). One study that followed more than 1,000 children for many years into adulthood revealed that between 25 and 60 percent of people who have a mental disorder during adulthood had a history of CD and/or ODD during childhood or adolescence

Tay-Sachs disease

Hypertonicity, listlessness, blindness, progressive spastic paralysis, and convulsions (death by the third year) Disorder of lipoid metabolism, carried by a single recessive gene

Causal Factors in ODD and CD-A Self-Perpetuating Cycle

Evidence has accumulated that a genetic predisposition leading to low verbal intelligence, mild neuropsychological problems, and difficult temperament can set the stage for early-onset CD (Simonoff, 2001). Researchers also have found strong heritable effects of conduct problems and antisocial behavior across ethnically and economically diverse samples (Baker et al., 2007). The child's difficult temperament may lead to an insecure attachment because parents find it hard to engage in the good parenting that would promote a secure attachment. In addition, the low verbal intelligence and mild neuropsychological deficits that have been documented in many of these children—some of which may involve deficiencies in self-control functions such as sustaining attention, planning, self-monitoring, and inhibiting unsuccessful or impulsive behaviors—may help set the stage for a lifelong course of difficulties. In attempting to explain why the relatively mild neuropsychological deficits typically seen can have such pervasive effects, Moffitt and Lynam (1994) provided the following scenario: A preschooler has problems understanding language and tends to resist his mother's efforts to read to him. This deficit then delays the child's readiness for school. When he does enter school, the typically busy curriculum does not allow teachers to focus their attention on students at his low readiness level. Over time, and after a few years of school failure, the child will be chronologically older than his classmates, setting the stage for social rejection. At some point, the child might be placed into remedial programs that contain other pupils who have similar behavioral disorders as well as learning disabilities. This involvement with conduct-disordered peers exposes him to delinquent behaviors that he adopts in order to gain acceptance.

Down Syndrome

First described by Langdon Down in 1866, Down syndrome is the best known of the clinical conditions associated with moderate and severe intellectual disability. The prevalence of Down syndrome has been reported to be 5.9 per 10,000 of the general population (Cooper et al., 2009). It is a condition that creates irreversible limitations on intellectual achievement, competence in managing life tasks, and survivability It also is associated with health problems in later life such as pneumonia and other respiratory infections. The availability of amniocentesis and chorionic villus sampling in expectant mothers has made it possible to detect in utero the extra genetic material involved in Down syndrome, which is most often the trisomy of chromosome 21, yielding 47 rather than the normal 46 chromosomes.

Behavioral Treatment

For many years, it was generally accepted that there is no effective way to treat people diagnosed with autism. However, in 1987, Ivar Lovaas (1987) reported that an intensive behavioral intervention administered via one-on-one meetings with the child for over 40 hours per week for 2 years resulted in extremely positive results. The intervention was based on both discrimination-training strategies (reinforcement) and contingent aversive techniques (punishment). The treatment plan typically enlists parents in the process and emphasizes teaching children to learn from and interact with "normal" peers in real-world situations. Of the treated children in the study by Lovaas and colleagues, 47 percent achieved normal intellectual and educational functioning, compared with only 2 percent of children in the untreated control condition. More recent versions of this intensive behavioral approach have continued to demonstrate success. Geraldine Dawson and colleagues (2010) recently showed that toddlers (18-30 months old) with autism who were randomly assigned to receive the Early Start Denver Model (ESDM) intervention showed significant improvements in IQ (an average of a 17-point increase), language, and adaptive behavior as well as a decrease in symptoms of autism. The ESDM intervention involves more than 20 hours per week of intensive behavioral work with the child and parent(s) focused on interpersonal exchanges, verbal and nonverbal communication, and adult sensitivity to children's cues. Children receiving the ESDM intervention also showed greater cortical activation when viewing other people's faces (compared to objects), which in turn was correlated with greater improvements in the children's social communication

Turner's syndrome

In females only; webbing of neck, increased carrying angle of forearm, and sexual infantilism; intellectual disability may occur but is infrequent Sex chromosome anomaly (XO)

Klinefelter's syndrome

In males only; features vary from case to case, the only constant finding being the presence of small testes after puberty Sex chromosome anomaly (XXY)

Phenylketonuria

In phenylketonuria (PKU), a baby appears normal at birth but lacks a liver enzyme needed to break down phenylalanine, an amino acid found in many foods. The genetic error results in intellectual disability only when significant quantities of phenylalanine are ingested, which is virtually certain to occur if the child's condition remains undiagnosed (Grodin & Laurie, 2000). This disorder, which occurs in about 1 in 12,000 births (Deb & Ahmed, 2000), is reversible (Embury et al., 2007); however, if it is not detected and treated, the amount of phenylalanine in the blood increases and eventually produces brain damage. The disorder usually becomes apparent between 6 and 12 months after birth, although symptoms such as vomiting, a peculiar odor, infantile eczema, and seizures may occur during the early weeks of life. Often, the first symptoms noticed are signs of intellectual disability, which may be moderate to severe, depending on the degree to which the disease has progressed. Lack of motor coordination and other neurological problems caused by the brain damage are also common, and often the eyes, skin, and hair of untreated patients with PKU are very pale The early detection of PKU by examining urine for the presence of phenylpyruvic acid is routine in developed countries, and dietary treatment (such as the elimination of phenylalanine-containing foods such as diet soda or turkey) and related procedures can be used to prevent the disorder (Sullivan & Chang, 1999). With early detection and treatment—preferably before an infant is 6 months old—the deterioration process can usually be arrested so that levels of intellectual functioning may range from borderline to normal. A few children suffer intellectual disability despite restricted phenylalanine intake and other preventive efforts, however. Dietary restriction in late-diagnosed PKU may improve the clinical picture somewhat, but there is no real substitute for early detection and prompt intervention For a baby to inherit PKU, both parents must carry the recessive gene. Thus, when one child in a family is discovered to have PKU, it is especially critical that other children in the family be screened as well. Also, a pregnant mother with PKU whose risk status has been successfully addressed by early dietary intervention may damage her at-risk fetus unless she maintains rigorous control of phenylalanine intake.

Ionizing Radiation

In recent decades, a good deal of scientific attention has focused on the damaging effects of ionizing radiation on sex cells and other bodily cells and tissues. Radiation may act directly on the fertilized ovum or may produce gene mutations in the sex cells of either or both parents, which may lead to intellectual disability among offspring. Sources of harmful radiation were once limited primarily to high-energy X-rays used in medicine for diagnosis and therapy, but the list has grown to include nuclear weapons testing and leakages at nuclear power plants, among others.

Macrocephaly

In the rare condition known as macrocephaly ("large-headedness"), for example, there is an increase in the size and weight of the brain, an enlargement of the skull, visual impairment, convulsions, and other neurological symptoms resulting from the abnormal growth of glial cells that form the supporting structure for brain tissue.

Moderate Intellectual Disability

Individuals with moderate intellectual disability have IQ scores ranging between 35-40 and 50-55 and, even in adulthood, attain intellectual levels similar to those of average 4- to 7-year-old children. Although some can be taught to read and write a little and may manage to achieve a fair command of spoken language, their rate of learning is slow, and their level of conceptualizing is extremely limited. They usually appear clumsy and ungainly and suffer from bodily deformities and poor motor coordination. In general, with early diagnosis, parental help, and adequate opportunities for training, most individuals with moderate intellectual disability can achieve partial independence in daily self-care, acceptable behavior, and economic sustenance in a family or other sheltered environment. Many also can master routine skills such as cooking or minor janitorial work if provided specialized instruction in these activities.

Severe Intellectual Disability

Individuals with severe intellectual disability have IQ scores ranging from 20-25 to 35-40 and commonly suffer from impaired speech development, sensory defects, and motor handicaps. They can develop limited levels of personal hygiene and self-help skills, which somewhat lessen their dependency, but they are always dependent on others for care. However, many profit to some extent from training and can perform simple occupational tasks under supervision.

Intellectual Disability

Intellectual disability (also called intellectual developmental disorder) is characterized by deficits in general mental abilities, such as reasoning, problem solving, planning, abstract thinking, judgment, academic learning, and learning from experience (APA, 2013, p. 31). Intellectual disability is defined in terms of both intelligence and level of performance, and for the diagnosis to apply these problems must begin before the age of 18. By definition, any functional equivalent of intellectual disability that has its onset after age 17 is considered to be "dementia" rather than intellectual disability. The distinction is an important one because the psychological situation of a person who acquires a pronounced impairment of intellectual functioning after attaining maturity is vastly different from that of a person whose intellectual resources were below normal throughout all or most of his or her development. Intellectual disability occurs among children throughout the world (Fryers, 2000). In its most severe forms, it is a source of great hardship to parents as well as an economic and social burden on a community. The prevalence of diagnosed intellectual disability in the United States is estimated to be about 1 percent, which would indicate a population estimate of some 2.6 million people. However, prevalence is extremely difficult to pin down because definitions of intellectual disability vary considerably (Roeleveld et al., 1997). Most states have laws providing that persons with IQs below 70 who show socially incompetent or persistently problematic behavior can be classified as "mentally retarded" and, if judged otherwise unmanageable, may be placed in an institution. Initial diagnoses of intellectual disability most frequently occur at ages 5 to 6 (around the time that schooling begins for most children), peak at age 15, and drop off sharply after that. For the most part, these patterns in age of first diagnosis reflect changes in life demands. During early childhood, individuals with only a mild degree of intellectual impairment, who constitute the vast majority of those with intellectual disability, often appear to be normal. Their below-average intellectual functioning becomes apparent only when difficulties with schoolwork lead to a diagnostic evaluation. When adequate facilities are available for their education, children in this group can usually master essential school skills and achieve a satisfactory level of socially adaptive behavior. Following the school years, they usually make a more or less acceptable adjustment in the community and thus lose the identity of having an intellectual disability.

Infections and Toxic Agents

Intellectual disability also can result from a wide range of conditions due to infection, such as viral encephalitis or genital herpes (Kaski, 2000). If a pregnant woman is infected with syphilis or HIV-1 or if she gets German measles, her child may suffer brain damage as a result. A number of toxic agents such as carbon monoxide and lead may cause brain damage during fetal development or after birth (Kaski, 2000). Similarly, if taken by a pregnant woman, certain drugs, including an excess of alcohol (West et al., 1998), may lead to congenital malformations. And an overdose of drugs administered to an infant may result in toxicity and cause brain damage. In rare cases, brain damage results from incompatibility in blood types between mother and fetus. Fortunately, early diagnosis and blood transfusions can minimize the effects of such incompatibility.

Genetic-Chromosomal Factors

Intellectual disability, especially mild disability, tends to run in families. Poverty and sociocultural deprivation, however, also tend to run in families. Early and continued exposure to such conditions, even the inheritance of average intellectual potential, may not prevent below-average intellectual functioning. Genetic-chromosomal factors play a much clearer role in the etiology of relatively infrequent but more severe types of intellectual disability such as Down syndrome and a heritable condition known as fragile X (Huber & Tamminga, 2007; Schwarte, 2008). The gene responsible for fragile X syndrome (FMR-1) was identified in 1991 (Verkerk et al., 1991). In such conditions, genetic aberrations are responsible for metabolic alterations that adversely affect the brain's development. Genetic defects leading to metabolic alterations may also involve many other developmental anomalies besides intellectual disability (e.g., autism) (Wassink et al., 2001). Intellectual disability associated with known genetic-chromosomal defects tends to be moderate to severe in nature.

Treatments and Outcomes for adhd

Interestingly, research has shown that stimulants have a quieting effect on children—just the opposite of what we would expect from their effects on adults. For children with ADHD, stimulant medication decreases overactivity and distractibility and, at the same time, increases their alertness (Konrad et al., 2004). As a result, they are often able to function much better at school Ritalin also seems to lower the amount of aggressiveness in children with ADHD (Fava, 1997). In fact, many children whose behavior has not been acceptable in regular classes can function and progress in a relatively normal manner when they use such a drug. In a 5-year follow-up study, Charach, Ickowicz, and Schachar (2004) reported that children with ADHD on medication showed greater improvement in teacher-reported symptoms than nontreated children. The possible side effects of Ritalin, however, are numerous: decreased blood flow to the brain, which can result in impaired thinking ability and memory loss; disruption of growth hormone, leading to suppression of growth in the body and brain of the child; insomnia; psychotic symptoms; and others. Although amphetamines do not cure ADHD, they have reduced the behavioral symptoms in about one-half to two-thirds of the cases in which medication appears warranted. Newer variants of the drug, referred to as extended-release methylphenidate (Concerta), have similar benefits and are available in doses that may better suit an adolescent's lifestyle Three other medications for treating ADHD have received attention in recent years. Pemoline is chemically very different from Ritalin (Faigel & Heiligenstein, 1996); it exerts beneficial effects on classroom behavior by enhancing cognitive processing and has fewer adverse side effects than Ritalin (Bostic et al., 2000; Pelham et al., 2005). Strattera (atomoxetine), a noncontrolled treatment option that can be obtained readily, is a U.S. Food and Drug Administration (FDA)-approved nonstimulant medication (FDA, 2002). Side effects include decreased appetite, nausea, vomiting, and fatigue. The development of jaundice has been reported, and the FDA (2004) has warned of the possibility of liver damage from using Strattera. Another drug that reduces symptoms of impulsivity and hyperactivity in children with ADHD is Adderall. This medication is a combination of amphetamine and dextroamphetamine; however, research has suggested that Adderall provides no advantage or improvement in results over Ritalin or Strattera (Miller-Horn et al., 2008). Although the short-term pharmacological effect of stimulants on the symptoms of hyperactive children is well established, their long-term effects are not well known

Malnutrition and Other Biological Factors

It was long thought that dietary deficiencies in protein and other essential nutrients during early development of the fetus could do irreversible physical and mental damage. However, it is currently believed that this assumption of a direct causal link may have been oversimplified. Ricciuti (1993) cited growing evidence that malnutrition may affect mental development more indirectly by altering a child's responsiveness, curiosity, and motivation to learn, which would in turn lead to intellectual disability. The implication here is that at least some malnutrition-associated intellectual deficit is a special case of psychosocial deprivation, which is also involved in disability-related outcomes, as described below.

Treatments and Outcomes for depression/bipolar

More than one-third (38 percent) of children and adolescents with depression or bipolar disorder receive mental health treatment (Merikangas, He, et al., 2011). The view that childhood and adolescent depression is like adult depression has prompted researchers to treat children displaying mood disorder with medications that have worked with adults. Antidepressants are among the most widely used drugs in treating child and adolescent mental disorders. Unfortunately, research on the effectiveness of antidepressant medications with children has been mixed. Some studies of adolescents with depression have suggested that antidepressants such as fluoxetine (Prozac) are more effective than a placebo. On the other hand, in addition to having some undesirable somatic side effects (nausea, headaches, nervousness, insomnia, and even seizures) in children and adolescents, some research has suggested that antidepressant medication treatment in children and adolescents is associated with an increased risk of suicidal thoughts and behaviors Psychological treatments have proven effective in the treatment of depression in children and adolescents. Controlled studies of psychological treatment of adolescents with depression have shown significantly reduced symptoms with the use of CBT (Spirito et al., 2011). Comprehensive meta-analytic studies that examine the overall effectiveness of psychological treatments for child and adolescent depression reveal that such interventions are effective, especially in the short term, and that such treatments also seem to decrease anxiety symptoms (although not behavior problems) in children receiving them. Longitudinal follow-up studies of adolescents who have been treated for depression have shown that effective treatment can reduce the recurrence of depression.

Anxiety Disorders of Childhood and Adolescence

Most children are vulnerable to fear, uncertainty, and anxiety as a normal part of growing up. During childhood, many of us feared things like heights, thunder, the dark, clowns, and so on. Such fears are a normal part of human development, are not considered to be pathological in most cases, and are outgrown over time. However, in some cases the experience of fear and anxiety are so extreme, persistent, impairing, and beyond what would be expected developmentally that the child is determined to have an anxiety disorder. Anxiety disorders of childhood and adolescence are classified similarly to anxiety disorders in adults, and as in adulthood are often comorbid with depressive disorders Anxiety disorders are the most common mental disorder among children and adolescents, occurring at some point in the lifetime of approximately 32 percent of U.S. youth (Merikangas et al., 2010). They occur at higher rates among girls (38 percent) than boys (26 percent), and most commonly take the form of specific phobias (19 percent), social phobia (9 percent), separation anxiety disorder (8 percent), and posttraumatic stress disorder (5 percent)

The Child's Inability to Seek Assistance

Most children with psychological disorders who need assistance are not in a position to ask for help themselves or to transport themselves to and from child treatment clinics. Thus, unlike an adult, who can usually seek help, a child is dependent, primarily on his or her parents. Adults should realize when a child needs professional help and take the initiative in obtaining it. Often, however, adults are unaware of the problems or neglect this responsibility. The law identifies four areas in which treatment without parental consent is permitted: (1) in the case of mature minors (those considered capable of making decisions about themselves); (2) in the case of emancipated minors (those living independently, away from their parents); (3) in emergency situations; and (4) in situations in which a court orders treatment. Many children, of course, come to the attention of treatment agencies as a consequence of school referrals, delinquent acts, abuse by parents, or as a result of family custody court cases.

Problem of Placing a Child Outside the Family

Most communities have juvenile facilities that, day or night, will provide protective care and custody for young victims of abuse, neglect, and related conditions. Depending on the home situation and the special needs of the child, he or she will later either be returned to his or her parents or placed elsewhere. In the latter instance, four types of facilities are commonly relied on: (1) foster homes, (2) private institutions for the care of children such as group homes, (3) county or state institutions, and (4) the homes of relatives. At any one time, more than half a million children are living in foster care facilities, many of whom have been abused or neglected (Minnis et al., 2006). The quality of a child's new home is, of course, a crucial determinant of whether the child's problems will be alleviated or made worse, and there is evidence to suggest that foster home placement has more positive effects than group home placement (Buckley & Zimmermann, 2003; Groza et al., 2003). Efforts are usually made to screen the placement facilities and maintain contact with the situation through follow-up visits, but even so, there have been cases of mistreatment in the new home (Dubner & Motta, 1999; Wilson et al., 2000). In cases of child abuse, child abandonment, or a serious childhood behavior problem that parents cannot control, it had often been assumed that the only feasible action was to take the child out of the home and find a temporary substitute. With such a child's own home so obviously inadequate, the hope was that a more stable outside placement would be better for the child. But when children are taken from their homes and placed in an institution or in a series of foster homes, they may feel rejected by their own parents, unwanted by their new caretakers, rootless, constantly insecure, lonely, and bitter. Not surprisingly, children and adolescents in foster homes tend to require more mental health services than do other children (dos Reis et al., 2001). Accordingly, the trend today is toward permanent planning. First, every effort is made to hold a family together and to give the parents the support and guidance they need for adequate childrearing. If this is impossible, then efforts are made to free the child legally for adoption and to find an adoptive home as soon as possible. This, of course, means that the public agencies need specially trained staffs with reasonable caseloads and access to resources that they and their clients may need.

Profound Intellectual Disability

Most individuals with profound intellectual disability have IQ scores below 20-25 and are severely deficient in adaptive behavior and unable to master any but the simplest tasks. Useful speech, if it develops at all, is rudimentary. Severe physical deformities, CNS pathology, and retarded growth are typical; convulsive seizures, mutism, deafness, and other physical anomalies are also common. These individuals must remain in custodial care all their lives. Unfortunately, they also tend to have poor health and low resistance to disease and thus a short life expectancy. Severe and profound cases of intellectual disability can usually be readily diagnosed in infancy because of the presence of obvious physical malformations, grossly delayed development (e.g., in taking solid food), and other obvious symptoms of abnormality. These individuals show a marked impairment of overall intellectual functioning.

%/onset age of adolescent mental health disorders

Nationally representative surveys designed specifically to estimate the prevalence of mental disorders among children and adolescents reveal that they occur quite frequently. Approximately half (49.5 percent) of children and adolescents meet criteria for at least one mental disorder by the age of 18 years (see Figure 15.1) (Merikangas et al., 2010). Anxiety disorders have the earliest onset (typically beginning around age 6), followed by behavior disorders (age 11), mood disorders (age 13), and substance use disorders (age 15) (Merikangas et al., 2010). Suicidal thoughts and behaviors are rare in children, but increase dramatically starting around age 12 (Nock et al., 2013). Approximately 12 percent of adolescents report having suicidal thoughts by the time they are 18 years old, and 4 percent report having made a suicide attempt (Nock et al., 2013). Given the prevalence and seriousness of these problems, efforts are being made to better understand disorders of childhood and adolescence.

Neurodevelopmental Disorders

Neurodevelopmental disorders are a group of conditions characterized by an early onset and persistent course that are believed to be the result of disruptions to normal brain development (Andrews et al., 2009; Insel, 2014). Neurodevelopmental disorders are different from anxiety and depression in that they must have their onset during childhood. These disorders differ from ODD and CD in that they are believed to be the result of significant delays or disruptions in brain development that persist into adulthood (with a few exceptions discussed below). Although neurodevelopmental disorders are heterogeneous in nature, they often overlap and share common risk factors.

The Classification of Childhood and Adolescent Disorders

No formal system for classifying the emotional or behavioral problems of children and adolescents was available until the publication of the DSM-I in 1952 (see the timeline below). Initially, the section on childhood disorders was quite limited and included only two disorders: childhood schizophrenia and adjustment reaction of childhood. In 1966, the Group for the Advancement of Psychiatry provided a classification system for children that was detailed and comprehensive. Thus, in the 1968 revision of the DSM (DSM-II), several additional categories were added. However, growing concern remained—both among clinicians attempting to diagnose and treat childhood problems and among researchers attempting to broaden our understanding of childhood psychopathology—that the then-current ways of viewing psychological disorders in children and adolescents were inappropriate and inaccurate for several reasons. The greatest problem was that the same classification system that had been developed for adults was used for childhood problems even though many childhood disorders, such as autism, learning disabilities, and school phobias, have no counterpart in adult psychopathology. The early systems also ignored the fact that in childhood disorders, environmental factors play an important part in the expression of symptoms—that is, symptoms are highly influenced by a family's acceptance or rejection of the behavior. In addition, symptoms were not considered with respect to a child's developmental level. Some behaviors that the DSM defined as problematic could be considered to be age-appropriate ones that would eventually be outgrown (e.g., fears, temper tantrums). All of these concerns are fully addressed in the DSM-5. The DSM-5 includes diagnoses for a large number of childhood and adolescent disorders. We don't have the space to review them all in this chapter, so we have selected several disorders that illustrate the broad range of problems that can occur in childhood and adolescence. We focus first on disorders that you learned about earlier in this book that can occur among children as well (e.g., anxiety and depression) and then turn our attention to disorders that always have their onset during childhood or adolescence such as oppositional defiant disorder, conduct disorder, and neurodevelopmental disorders.

Psychological Treatments

One interesting and often effective treatment strategy with CD is the cohesive family model (Granic & Patterson, 2006; Patterson et al., 1998). In this family-group-oriented approach, ODD and CD are conceptualized as being reinforced and maintained by ineffective parenting practices. For instance, parents can inadvertently reinforce inappropriate behavior such as in the example in the prior section in which the child learned to escape or avoid parental commands by escalating her negative behavior (whining). This tactic, in turn, increases parents' aversive interactions and criticism. The child observes the increased anger in his or her parents and models this aggressive pattern. The parental attention to the child's negative, aggressive behavior actually serves to reinforce that behavior instead of suppressing it. Viewing conduct problems as emerging from such interactions places the treatment focus squarely on the interaction between the child and the parents Fortunately, during the past several decades, researchers have developed psychological treatments that have been shown to significantly decrease CD and ODD. Alan Kazdin, a pioneer in the development and evaluation of treatments for child conduct problems, has shown through a series of many studies that standard talk therapies are not effective in treating CD and ODD. However, two psychological approaches that target some of the key risk factors mentioned above do have a positive effect. Parent management training, an approach in which the clinician teaches the parents how to effectively prompt and reinforce prosocial behaviors while ignoring aggressive or antisocial behaviors, has been shown to be quite effective. In addition, a separate approach in which the clinician meets with the child to teach social problem-solving skills (such as how to generate and perform more adaptive responses to others) also has proven effective. The combination of these two approaches is especially effective at decreasing child conduct problems, with effects lasting well after treatment has ended Given that prior research has identified many different risk factors for CD, researchers and clinicians can use this information to identify which children are at high risk of developing CD and can test prevention programs designed to decrease the likelihood of conduct problems. For instance, the Fast Track Prevention Program identified 891 first graders determined to be at high risk for developing CD and randomly assigned half of them to receive 10 years of prevention services that included training parents in effective behavior management procedures, social skills training for the children, and academic tutoring. The results showed that children assigned to the intervention were significantly less likely to develop CD (20 percent) compared to children in the control condition (42 percent)

Niemann-Pick's disease

Onset usually in infancy, with loss of weight, dehydration, and progressive paralysis Disorder of lipoid metabolism

Oppositional Defiant Disorder

Oppositional defiant disorder (ODD) is characterized by a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least 6 months. ODD is grouped into three subtypes: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. This disorder usually begins by the age of 8 and has a lifetime prevalence of 10 percent, with a slightly higher rate among boys (11 percent) than girls (9 percent) (Nock et al., 2007). Prospective studies have found a developmental sequence from ODD to conduct disorder, with common risk factors for both conditions (Hinshaw, 1994). That is, virtually all cases of conduct disorder are preceded developmentally by ODD, but not all children with ODD go on to develop conduct disorder within a 3-year period (Lahey et al., 2000). The risk factors for both include family discord, socioeconomic disadvantage, and antisocial behavior in the parents.

Treatment Facilities and Methods

Parents of children with intellectual disability often find that childrearing is a significant challenge (Glidden & Schoolcraft, 2007). For example, recent research has shown that learning disability is associated with a higher incidence of mental health problems (Cooper & van der Speck, 2009). One decision that the parents of a child with an intellectual disability must make is whether to place the child in an institution (Gath, 2000). Most authorities agree that this should be considered as a last resort, in light of the unfavorable outcomes normally experienced—particularly in regard to the erosion of self-care skills. In general, children who are institutionalized fall into two groups: (1) those who, in infancy and childhood, manifest severe intellectual disability and associated physical impairment and who enter an institution at an early age; and (2) those who have no physical impairments but show relatively mild intellectual disability and a failure to adjust socially in adolescence, eventually being institutionalized chiefly because of delinquency or other problem behavior. In these cases, social incompetence is the main factor in the decision. The families of patients in the first group come from all socioeconomic levels, whereas a significantly higher percentage of the families of those in the second group come from lower educational and occupational strata. In these cases, social incompetence is the main factor in the decision. The families of patients in the first group come from all socioeconomic levels, whereas a significantly higher percentage of the families of those in the second group come from lower educational and occupational strata. This neglect is especially tragic in view of the ways that exist to help people with intellectual disability. For example, classes for individuals with mild intellectual disability, which usually emphasize reading and other basic school subjects, budgeting and money matters, and developing of occupational skills, have succeeded in helping many people become independent, productive community members. Classes for those with moderate and severe intellectual disability usually have more limited objectives, but they emphasize the development of self-care and other skills—for example, toilet habits (Wilder et al., 1997)—that enable individuals to function adequately and to be of assistance in either a family (e.g., Heller et al., 1997) or an institutional setting. Just mastering toilet training and learning to eat and dress properly may mean the difference between remaining at home or in a community residence or being institutionalized. Currently, approximately 129,000 people with intellectual disability and other related conditions are receiving intermediate care, although many are not institutionalized. This is considerably less than the number of residents in treatment 40 years ago. These developments reflect both the new optimism that has come to prevail and, in many instances, new laws and judicial decisions upholding the rights of people with intellectual disabilities and their families. A notable example is Public Law 94-142, passed by Congress in 1975 and since modified several times (see Hayden, 1998). This statute, termed the Education for All Handicapped Children Act, asserts the right of people with intellectual disabilities to be educated at public expense in the least restrictive environment possible. During the 1970s, there was a rapid increase in alternative forms of care for individuals with intellectual disability. These included the use of decentralized regional facilities for short-term evaluation and training, small private hospitals specializing in rehabilitative techniques, group homes or halfway houses integrated into the local community, nursing homes for the elderly with intellectual disability, the placement of children with severe intellectual disability in more enriched foster-home environments, varied forms of support to the family for own-home care, and employment services (Conley, 2003). The past 25 years have seen a marked enhancement in alternative modes of life for individuals with intellectual disability, rendering obsolete (and often leading to the closing of) many public institutions formerly devoted exclusively to this type of care.

No. 18 trisomy syndrome

Peculiar pattern of multiple congenital anomalies, the most common being low-set malformed ears, flexion of fingers, small jaw, and heart defects

Trauma (Physical Injury)

Physical injury at birth can result in intellectual disability (Kaski, 2000). Although the fetus is normally well protected by its fluid-filled placenta during gestation, and although its skull resists delivery stressors, accidents that affect development can occur during delivery and after birth. Difficulties in labor due to malposition of the fetus or other complications may irreparably damage the infant's brain. Bleeding within the brain is probably the most common result of such birth trauma. Hypoxia—lack of sufficient oxygen to the brain stemming from delayed breathing or other causes—is another type of birth trauma that may damage the brain

Causal Factors in Learning Disorder

Probably the most widely held view of the causes of specific learning disorders is that they are the products of subtle CNS impairments. In particular, these disabilities are thought to result from some sort of immaturity, deficiency, or dysregulation limited to those brain functions that supposedly mediate, for normal children, the cognitive skills that children with learning disorders cannot efficiently acquire. For example, many researchers believe that language-related learning disorders such as dyslexia are associated with a failure of the brain to develop in a normally asymmetrical manner with respect to the right and left hemispheres. Specifically, portions of the left hemisphere, where language function is normally mediated, for unknown reasons appear to remain relatively underdeveloped in many people with dyslexia Some investigators believe that the various forms of learning disorder, or the vulnerability to develop them, may be genetically transmitted. This issue seems not to have been studied with the same intensity or methodological rigor as in other disorders, but identification of a gene region for dyslexia on chromosome 6 has been reported (Schulte-Koerne, 2001). Although it would be somewhat surprising if a single gene were identified as the causal factor in all cases of reading disorder, the hypothesis of a genetic contribution to at least the dyslexic form of learning disorder seems promising. One twin study of mathematics disability has also turned up evidence of some genetic contribution to this form of learning disorder.

Biologically Based Treatments

Psychopharmacological treatment of anxiety disorders in children and adolescents is becoming more common today (Vitiello & Waslick, 2010). In general, the same medications used to treat adult anxiety disorders are used in the treatment of these disorders among children and adolescents. The most commonly used medications are benzodiazepines, which rapidly inhibit the central nervous system (CNS), providing a calming effect, and selective serotonin reuptake inhibitors, which increase the availability of serotonin over time

Value of Intervening Before Problems Become Acute

Rather than waiting until children at risk develop acute psychological problems, psychologists increasingly are attempting to intervene before development has been seriously distorted (Schroeder & Gordon, 2002). As described in the Stress and Physical and Mental Health chapter, one type of early intervention has been developed in response to the special vulnerability children experience in the wake of a disaster or trauma such as a hurricane, accident, hostage-taking, or shooting (Shaw, 2003). Children and adolescents often require considerable support and attention to deal with such traumatic events, which are all too frequent in today's world. Individual and small-group psychological therapy might be implemented for victims of trauma (Cohen et al., 2006); support programs might operate through school-based interventions (Klingman, 1993); or community-based programs might be implemented to reduce the posttraumatic symptoms. Early intervention has the double goal of reducing the stressors in a child's life and strengthening the child's coping mechanisms. It can often reduce the incidence and intensity of later maladjustment, thus averting problems for both the individuals concerned and the broader society.

Separation Anxiety Disorder

Separation anxiety disorder, classified under anxiety disorders in DSM-5, is characterized by excessive anxiety about separation from major attachment figures, such as mothers, and from familiar home surroundings (Bernstein & Layne, 2006). Children with separation anxiety disorder often lack self-confidence, are apprehensive in new situations, and tend to be immature for their age. Such children are described by their parents as shy, sensitive, nervous, submissive, easily discouraged, worried, and frequently moved to tears. In many cases, a clear psychosocial stressor can be identified, such as the death of a relative or a pet. The case study below illustrates the clinical picture in this disorder. When children with separation anxiety disorder are actually separated from their attachment figures, they typically become preoccupied with morbid fears, such as the worry that their parents are going to become ill or die. They cling helplessly to adults, have difficulty sleeping, and become intensely demanding. Separation anxiety is slightly more common in girls (9 percent) than boys (6 percent). In many children with separation anxiety disorder, the disorder will go away on its own over time (Cantwell & Baker, 1989). However, some children go on to exhibit school refusal problems (a fear of leaving home and parents to attend school) and continue to have subsequent adjustment difficulties. A disproportionate number of children with separation anxiety disorder also experience a high number of other anxiety-based disorders such as phobia and obsessive-compulsive disorder

Causal Factors in Intellectual Disability

Some cases of intellectual disability occur in association with known organic brain pathology (Kaski, 2000). In these cases, the level of disability is virtually always at least moderate, and it is often severe. Profound intellectual disability, which fortunately is rare, always includes obvious organic impairment. In this section, we consider five biological conditions that may lead to intellectual disability, noting some of the possible interrelationships among them. Then we review some of the major clinical types of intellectual disability associated with these organic causes.

Mild Intellectual Disability

Tests of human intelligence produce IQ scores that have an average of 100 and a standard deviation of 15. That means that most people (95 percent) receive a score somewhere between 70 and 130. Individuals with mild intellectual disability have IQ scores ranging from 50-55 to approximately 70 (i.e., more than two standard deviations below the mean) and constitute by far the largest number of those diagnosed with this condition (see Table 15.1). Within the educational context, people in this group are considered educable, and their intellectual levels as adults are comparable to those of average 8- to 11-year-old children. Statements such as the latter, however, should not be taken too literally. An adult with mild disability with a mental age of, say, 10 (that is, his or her intelligence test performance is at the level of the average 10-year-old) may not in fact be comparable to the average 10-year-old in information-processing ability or speed (Weiss et al., 1986). On the other hand, he or she will normally have had far more experience in living, which would tend to raise the measured intelligence scores. The social adjustment of people with mild intellectual disability often approximates that of adolescents, although they tend to lack normal adolescents' imagination, inventiveness, and judgment. Ordinarily, they do not show signs of brain pathology or other physical anomalies, but often they require some measure of supervision because of their limited abilities to foresee the consequences of their actions. With early diagnosis, parental assistance, and special educational programs, the great majority of individuals with mild intellectual disability can adjust socially, master simple academic and occupational skills, and become self-supporting citizens

Elimination Disorders

The childhood disorders we deal with in this section—"elimination disorders" (enuresis and encopresis)—involve a single outstanding symptom rather than a pervasive maladaptive pattern.

Microcephaly

The condition known as microcephaly ("small-headedness") is defined by a head circumference that is more than three standard deviations below that of children of the same age and sex and is caused by decreased growth of the cerebral cortex during infancy (as skull size during infancy is determined by brain growth) (Woods, 2004). Primary microcephaly refers to decreased brain growth during pregnancy, and secondary microcephaly refers to decreased brain growth during infancy. Children with microcephaly fall within the moderate, severe, and profound categories of intellectual disability and most show little language development and are extremely limited in mental capacity. A recent review of nearly 700 cases of microcephaly revealed that the cause of the condition was identified in approximately 60 percent of cases (von der Hagen et al., 2014). Approximately half of these were caused by genetic factors, 45 percent were the result of brain damage in utero (e.g., due to factors such as maternal disease or birth complications), and 3 percent were caused by brain damage after birth. It is important to note that the cause of microcephaly is completely unknown in about 40 percent of cases, and so much additional research is needed to better understand this condition.

Hydrocephaly

The condition referred to as hydrocephaly is a relatively rare disorder in which the accumulation of an abnormal amount of cerebrospinal fluid within the cranium causes damage to the brain tissues and enlargement of the skull (Materro et al., 2001). In congenital cases, the head either is already enlarged at birth or begins to enlarge soon thereafter, presumably as a result of a disturbance in the formation, absorption, or circulation of the cerebrospinal fluid. The disorder can also arise in infancy or early childhood following the development of a brain tumor, subdural hematoma, meningitis, or other conditions. In these cases, the condition appears to result from a blockage of the cerebrospinal pathways and an accumulation of fluid in certain brain areas. The clinical picture in hydrocephaly depends on the extent of neural damage, which in turn depends on the age at onset and the duration and severity of the disorder. In chronic cases, the chief symptom is the gradual enlargement of the upper part of the head out of proportion to the face and the rest of the body. Although the expansion of the skull helps minimize destructive pressure on the brain, serious brain damage occurs nonetheless. This damage leads to intellectual impairment and to such other effects as convulsions and impairment or loss of sight and hearing. The degree of intellectual impairment varies, being severe or profound in advanced cases. Hydrocephaly can be treated by a procedure in which shunting devices are inserted to drain cerebrospinal fluid. With early diagnosis and treatment, this condition can usually be arrested before severe brain damage has occurred (Duinkerke et al., 2004). Even with significant brain damage, carefully planned and early interventions that take into account both strengths and weaknesses in intellectual functioning may minimize disability

Negative Life Events and Learning Factors-causal factors

The experience of negative life events and the learning of maladaptive behaviors appear to be important in childhood depressive disorders. A number of studies have indicated that children's exposure to early traumatic events can increase their risk for the development of depression. Children who have experienced past stressful events are susceptible to states of depression that make them vulnerable to suicidal thinking under stress (Silberg et al., 1999). Intense or persistent sensitization of the central nervous system in response to severe stress might induce hyperreactivity and alteration of the neurotransmitter system, leaving these children vulnerable to later depression Children who are exposed to negative parental behavior or negative emotional states may develop depressed affects themselves (Herman-Stahl & Peterson, 1999). Investigators have been evaluating the possibility that mothers who are depressed transfer their low mood to their infants through their interactions with them. Depression among mothers is not uncommon and can result from several sources, such as financial or marital problems. One study found that parenting problems and depressed mood in mothers are associated with depression in children Mothers with depression often do not respond effectively to their children (Goldsmith & Rogoff, 1997) and tend to be less attuned to, and more negative toward, their infants than nondepressed mothers. Other research has shown that negative (depressed) affect and constricted mood on the part of a mother, which shows up as unresponsive facial expressions and irritable behavior, can produce similar responses in her infant. Interestingly, the negative impact of depressed mothers' interaction style has also been studied at the physiological level. Infants have been reported to exhibit greater frontal brain electrical activity during the expression of negative emotionality by their mothers (Dawson et al., 1997). Although many of these studies have implicated the mother-child relationship in development of the disorder, depression in fathers has also been related to depression in children.

developmental psychopathology

The field of developmental psychopathology 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. How do we determine which behaviors that occur during childhood and adolescence are abnormal or pathological? In short, it is important that we view a child's behavior in the context of normal childhood development. We cannot consider a child's behavior abnormal without determining whether the behavior in question is appropriate for the child's age. For example, eating marbles and having temper tantrums are to be expected in a 2-year-old, but would be abnormal in someone who is 17 years old. It is important to note that there is no sharp line of demarcation between the maladaptive behavior patterns of childhood and those of adolescence (i.e., no precise age at which temper tantrums are now considered officially "abnormal"), or between those of adolescence and those of adulthood. Thus, although our focus in this chapter will be on the behavior disorders of children and adolescents, we will find some inevitable carryover into later life periods.

Causal Factors in Attention-Deficit/Hyperactivity Disorder

The specific causes of ADHD have been widely debated. As with most disorders, available evidence points to both genetic (Ilott et al., 2010; Sharp et al., 2009) and social-environmental factors (e.g., prenatal alcohol exposure; Ware et al., 2012). But how do genetic variations and social-environmental events produce the particular constellation of symptoms of ADHD that we see in children and adults? Research on the neurobiology of ADHD suggests that the answer may lie, at least in part, in the way that the brain develops in those with ADHD. Children with ADHD have smaller total brain volumes than those without ADHD (Castellanos et al., 2002), and their brains appear to mature approximately 3 years more slowly than those without ADHD. Interestingly, these maturational delays are most prominent in prefrontal brain regions involved in attention and impulsiveness. Findings like these are exciting steps toward understanding this disorder, but questions remain about how and why these differences arise. Answering these questions will likely lead not just to better understanding, but to the development of more effective treatments.

Encopresis

The term encopresis describes a symptom disorder of children who have not learned appropriate toileting for bowel movements after age 4. This condition, classified under elimination disorders in DSM-5, is less common than enuresis; however, DSM-based estimates are that about 1 percent of 5-year-olds have encopresis. A study of 102 cases of children with encopresis yielded the following list of characteristics: The average age of children with encopresis was 7, with a range of ages 4 to 13. About one-third of children with encopresis were also enuretic, and a large sex difference was found, with about six times more boys than girls in the sample. Many of the children soiled their clothing when they were under stress. A common time was in the late afternoon after school; few children actually had this problem at school. Most of the children reported that they did not know when they needed to have a bowel movement or were too shy to use the bathrooms at school. Many children with encopresis suffer from constipation, so an important element in the diagnosis is a physical examination to determine whether physiological factors are contributing to the disorder. The treatment of encopresis usually involves both medical and psychological aspects. Several studies of the use of conditioning procedures with children with encopresis have reported moderate treatment success; that is, no additional incidents occurred within 6 months following treatment (Friman et al., 2008). However, research has shown that a minority of children (11 to 20 percent) do not respond to learning-based treatment approaches

Enuresis

The term enuresis refers to the habitual involuntary discharge of urine, usually at night, after the age of expected continence (age 5). In the DSM-5, functional enuresis is an elimination disorder described as bed-wetting that is not organically caused. Children who have primary functional enuresis have never been continent; children who have secondary functional enuresis have been continent for at least a year but have regressed. Estimates of the prevalence of enuresis reported in the DSM-5 are 5 to 10 percent among 5-year-olds, 3 to 5 percent among 10-year-olds, and 1.1 percent among children ages 15 or older. Enuresis may result from a variety of organic conditions, such as disturbed cerebral control of the bladder (Goin, 1998), neurological dysfunction, other medical factors such as medication side effects (Took & Buck, 1996), or having a small functional bladder capacity and a weak urethral sphincter (Dahl, 1992). One group of researchers reported that 11 percent of their patients with enuresis had disorders of the urinary tract (Watanabe et al., 1994). However, most investigators have pointed to a number of other possible causal factors: (1) faulty learning, resulting in the failure to acquire inhibition of reflexive bladder emptying; (2) personal immaturity, associated with or stemming from emotional problems; (3) disturbed family interactions, particularly those that lead to sustained anxiety, hostility, or both; and (4) stressful events Conditioning procedures have proved to be highly effective treatment for enuresis (Friman et al., 2008). Mowrer and Mowrer (1938), in their classic research that is still relevant today, introduced a bell-and-pad procedure in which a child sleeps on a pad that is wired to a battery-operated bell. At the first few drops of urine, the bell is set off, thus awakening the child. Through conditioning, the child comes to associate bladder tension with awakening. Medical treatment of enuresis typically centers on using medications such as the antidepressant drug imipramine. The mechanism underlying the action of the drug is unclear, but it may simply lessen the deepest stages of sleep to light sleep, enabling the child to recognize bodily needs more effectively (Dahl, 1992). An intranasal desmopressin (DDAVP) has also been used to help children manage urine more effectively. This medication, a hormone replacement, apparently increases urine concentration, decreases urine volume, and therefore reduces the need to urinate. The use of this medication to treat children with enuresis is no panacea, however. Disadvantages of its use include its high cost and the fact that it is effective only with a small subset of children with enuresis, and then only temporarily. This medication, a hormone replacement, apparently increases urine concentration, decreases urine volume, and therefore reduces the need to urinate. The use of this medication to treat children with enuresis is no panacea, however. Disadvantages of its use include its high cost and the fact that it is effective only with a small subset of children with enuresis, and then only temporarily. With or without treatment, the incidence of enuresis tends to decrease significantly with age, but many experts still believe that enuresis should be treated in childhood because there is currently no way to identify which children will remain enuretic into adulthood (Goin, 1998). In an evaluation of research on the treatment of bed-wetting, Houts, Berman, and Abramson (1994) concluded that treated children are more improved at follow-up than nontreated children. They also found that learning-based procedures are more effective than medications.

Biological Factors-Causal

There appears to be an association between parental depression and behavioral and mood problems in children (Halligan et al., 2007; Hammen et al., 2004). Children of parents with major depression are more impaired, receive more psychological treatment, and have more psychological diagnoses than children of parents with no psychological disorders. This is particularly the case when the parent's depression affects the child through less-than-optimal interactions. A controlled study of family history and onset of depression found that children from mood-disordered families had significantly higher rates of depression than those from nondisordered families. The suicide attempt rate has also been shown to be higher for children of parents with depression (7.8 percent) than for the offspring of nondepressed parents Other biological factors might also make children vulnerable to psychological problems like depression. These factors include biological changes in the neonate as a result of alcohol intake by the mother during pregnancy, because prenatal exposure to alcohol is related to depression in children. M. J. O'Connor's (2001) study of children exposed to alcohol in utero reveals a continuity between alcohol use by the mother and infant negative affect and early childhood depression symptoms.

Child Advocacy Programs

There are over 74 million people under age 18 in the United States (U.S. Census Bureau, 2009). Children who encounter mental health problems are at substantial risk for adjustment problems in later life (Smith & Smith, 2010). Unfortunately, both treatment and preventive programs for our society's children remain inadequate for dealing with the extent of psychological problems among children and adolescents. In the United States, one approach that has evolved in recent years is mental health child advocacy. Advocacy programs attempt to help children or others receive services that they need but often are unable to obtain for themselves. In some cases, advocacy seeks to better conditions for underserved populations by changing the system (Pithouse & Crowley, 2007). Federal programs offering services for children are fragmented in that different agencies serve different needs; thus, no government agency is charged with considering the whole child and planning comprehensively for children who need help. Consequently, child advocacy is often frustrating and difficult to implement. Outside the federal government, advocacy efforts for children have until recently been supported largely by legal and special-interest citizen's groups such as the Children's Defense Fund, a public interest organization based in Washington, D.C. Mental health professionals were typically not involved. Today, however, there is greater interdisciplinary involvement in attempts to provide effective advocacy programs for children (Carlson, 2001; Singer & Singer, 2000).

Family Therapy as a Means of Helping Children

To address a child's problems, it is often necessary to alter pathological family interaction patterns that produce or serve to maintain the child's behavior problems (Mash & Barkley, 2006). Several family therapy approaches have been developed (Prout & Brown, 2007) that differ in some important ways—for example, in terms of how the family is defined (whether to include extended family members); what the treatment process will focus on (whether communications between the family members or the aberrant behavior of the problem family members is the focus); and what procedures will be used in treatment (analyzing and interpreting hidden messages in the family communications or altering the reward and punishment contingencies through behavioral assessment and reinforcement). But whatever their differences, all family therapies view a child's problems, at least in part, as an outgrowth of pathological interaction patterns within the family, and they attempt to bring about positive change in family members through analysis and modification of the deviant family patterns

Tourette's disorder

Tourette's disorder, classified as a motor disorder in the neurodevelopmental disorders section of DSM-5, is an extreme tic disorder involving multiple motor and vocal patterns. This disorder typically involves uncontrollable head movements with accompanying sounds such as grunts, clicks, yelps, sniffs, or words. Some, possibly most, tics are preceded by an urge or sensation that seems to be relieved by execution of the tic. Tics are thus often difficult to differentiate from compulsions, and they are sometimes referred to as "compulsive tics" (Jankovic, 1997). An epidemiological study in Sweden reported the prevalence of Tourette's disorder in children and adolescents to be about 0.5 percent Approximately one-third of individuals with Tourette's disorder manifest coprolalia, which is a complex vocal tic that involves the uttering of obscenities. Some people with Tourette's disorder also experience explosive outbursts (Budman et al., 2000). The average age of onset for Tourette's disorder is 7, and most cases have an onset before age 14. The disorder frequently persists into adulthood, and it is about three times more frequent among males than among females. Although the exact cause of Tourette's disorder is undetermined, evidence suggests a strong biological basis (Margolis et al., 2006). There are many types of tics, and many of them appear to be associated with the presence of other psychological disorders, particularly obsessive-compulsive disorder (OCD). Most tics, however, do not have a purely biological basis but stem from psychological causes such as self-consciousness or tension in social situations, and they are usually associated with severe behavioral problems. As in the case of the adolescent boy previously described, an individual's awareness of the tic often increases tension and the occurrence of the tic. Behavioral interventions also have been used to effectively treat tics (Woods & Miltenberger, 2001). One successful program, habit reversal training or HRT, involves several sequential elements, beginning with awareness training, relaxation training, and the development of incompatible responses, and then progressing to cognitive therapy and modification of the individual's overall style of action. Because children with Tourette's disorder can have substantial family adjustment (Wilkinson et al., 2001) and school adjustment problems (Nolan & Gadow, 1997), interventions should be designed to aid their adjustment and to modify the reactions of peers to them. School psychologists can play an effective part in the social adjustment of the child with Tourette's disorder by applying behavioral intervention strategies that help arrange the child's environment to be more accepting of such unusual behaviors. Among medications, neuroleptics are the most predictably effective tic-suppressing drugs (Kurlan, 1997). Clonazepam, clonidine, and tiapride have all shown effectiveness in reducing motor tics; however, tiapride has shown the greatest decrease in the intensity and frequency of tics (Drtikova et al., 1996). Campbell and Cueva (1995) reported that both haloperidol and pimozide reduced the severity of tics by about 65 percent but that haloperidol seemed the more effective of the two medications.

Education and Inclusion Programming

Typically, educational and training procedures involve mapping out target areas of improvement such as personal grooming, social behavior, basic academic skills, and simple occupational skills (see Shif, 2006). Within each area, specific skills are divided into simple components that can be learned and reinforced before more complex behaviors are required. Behavior modification that builds on a step-by-step progression can bring those with intellectual disability repeated experiences of success and lead to substantial progress even in individuals with severe impairments (Mash & Barkley, 2006). For children with mild intellectual disability, the question of what schooling is best is likely to challenge both parents and school officials. Many such children fare better when they attend regular classes for much of the day. Of course, this type of approach—often called mainstreaming or "inclusion programming"—requires careful planning, a high level of teacher skill, and facilitative teacher attitudes (Wehman, 2003).

Rubella, congenital

Visual difficulties most common, with cataracts and retinal problems often occurring together, and with deafness and anomalies in the valves and septa of the heart Visual difficulties most common, with cataracts and retinal problems often occurring together, and with deafness and anomalies in the valves and septa of the heart

Psychological Vulnerabilities of Young Children

Young children are especially vulnerable to psychological problems (Ingram & Price, 2001). In evaluating the presence or extent of mental health problems in children and adolescents, one needs to consider the following: They do not have as complex and realistic a view of themselves and their world as they will have later, and they have not yet developed a stable sense of identity or a clear understanding of what is expected of them and what resources they might have to deal with problems. Immediately perceived threats are tempered less by considerations of the past or future and thus tend to be seen as disproportionately important. As a result, children often have more difficulty than adults in coping with stressful events (Mash & Barkley, 2006). Children's lack of experience in dealing with adversity can make manageable problems seem insurmountable (Scott et al., 2010). For instance, one of the authors of this book thought the world would literally end when he didn't attend his junior prom. (Spoiler alert: It did not.) Children also are more dependent on other people than are adults. Although in some ways this dependency serves as a buffer against other dangers because the adults around him or her might "protect" a child against stressors in the environment, it also makes the child highly vulnerable to abuse or neglect by others.

Psychosocial Factors of CDD

n addition to the genetic or constitutional liabilities that may predispose a person to develop CD and adult psychopathy and antisocial personality, family and social context factors also seem to exert a strong influence (Kazdin, 1995). Children who are aggressive and socially unskilled are often rejected by their peers, and such rejection can lead to a spiraling sequence of social interactions with peers that exacerbates the tendency toward antisocial behavior Severe conduct problems can lead to other mental health problems as well. For instance, children who report higher levels of conduct problems are nearly four times more likely to experience a depressive episode in early adulthood This socially rejected subgroup of aggressive children is also at the highest risk for adolescent delinquency. In addition, parents and teachers may react to aggressive children with strong negative affect such as anger (Capaldi & Patterson, 1994), and they may in turn reject these aggressive children. The combination of rejection by parents, peers, and teachers leads these children to become isolated and alienated. Not surprisingly, they often turn to deviant peer groups for companionship, at which point a good deal of imitation of the antisocial behavior of their deviant peer models may occur. Investigators generally seem to agree that the family setting of a child with CD is typically characterized by rejection, harsh and inconsistent discipline, and parental neglect (Frick, 1998). There is some evidence that parental behavior can inadvertently "train" antisocial behavior in children—directly via coercive interchanges (e.g., mother asks child to get ready for bed → child starts whining → whining annoys mother so she walks away and lets her stay awake: here the child learns that if she whines she gets her way, whereas the mother learns that if she backs off the child stops whining; both behaviors are reinforced and the child has "learned" to misbehave) and indirectly via lack of monitoring and consistent discipline (Capaldi & Patterson, 1994). This all too often leads to association with deviant peers and the opportunity for further learning of antisocial behavior. In addition to these familial factors, a number of broader psychosocial and sociocultural variables increase the probability that a child will develop CD and, later, adult psychopathy or antisocial personality disorder (Granic & Patterson, 2006) or depressive disorder (Boylan et al., 2010). Low socioeconomic status, poor neighborhoods, parental stress, and depression all appear to increase the likelihood that a child will become enmeshed in this cycle