Developmental and Cognitive Disorders

1. Developmental and Cognitive Disorders Chapter 13

2. What are developmental disorders? • Disorders that usually first appear in childhood or adolescence (onset) • Note: most of these conditions persist into adulthood

5. ICA D/O • As you answer the questions below, you will be better able to choose between the four categories introduced earlier. • 1. Is the predominant sx an impairment of learning or intellectual function? • 2. Is the predominant sx abnormal motor activity? • 3. Is the predominant sx socially inappropriate or self injurious behavior? • 4. Is the predominant sx an impairment in the ability to communicate or exchange meaningful information?

6. Perspectives on Developmental Disorders • Normal vs. Abnormal Development • Developmental Psychopathology • Study of how disorders arise and change with time • Childhood is associated with significant developmental changes • Disruption of early skills will likely disrupt development of later skills

7. Outline • Common developmental disorders (ADHD & Learning Disorders) • Pervasive Developmental disorders (autism) • Mental Retardation • Cognitive Disorders (dementia)

8. Attention Deficit Hyperactivity Disorder (ADHD): An Overview • Nature of ADHD • Central features – Inattention, overactivity, and impulsivity • Difficulty w sustained attn (can’t finish games, watch TV) • Constant motion, fidgeting • Blurt out answers, act without thinking • Associated with behavioral, cognitive, social, and academic problems

9. Attention Deficit Hyperactivity Disorder (ADHD): An Overview • DSM-IV and DSM-IV-TR Symptom Clusters • Cluster 1 – Symptoms of inattention • Cluster 2 – Symptoms of hyperactivity and impulsivity cluster • Either cluster 1 or 2 must be present for a diagnosis

10. ADHD: Facts and Statistics • Prevalence • Occurs in 4%-12% of children who are 6 to 12 years of age • Symptoms are usually present around age 3 or 4 • 68% of children with ADHD have problems as adults • Impulsive component decreases over time • Gender Differences • Boys outnumber girls 4 to 1

11. ADHD: Overdiagnosis? • Cultural Factors • Probability of ADHD diagnosis is greatest in the United States • Studies show more school-aged kids on stimulants than prevalence of Dx • College-aged people often present for assessment when academic problems emerge

12. ADHD: Biological Contributions • Genetic Contributions • ADHD runs in families • Some studies suggest High heritability • Familial ADHD may involve deficits on chromosome 20 • The D4 receptor gene is more common in ADHD children (dopamine dysregulation?)

13. ADHD: Biological Contributions • Neurobiological Contributions: Brain Dysfunction and Damage • Used to be called “minimal brain dysfunction” • Inactivity of the frontal cortex and basal ganglia • Right hemisphere malfunction • Abnormal frontal lobe development and functioning • Yet to identify a precise neurobiological mechanism for ADHD

14. ADHD: Biological Contributions • The Role of Toxins • Allergens and food additives do not appear to cause ADHD • Maternal smoking increases risk of having a child with ADHD

15. ADHD: Psychosocial Contributions • Psychosocial Factors appear to Influence (not cause) the Disorder • Constant negative feedback from teachers, parents, and peers • Peer rejection and resulting social isolation • Such factors foster low self-image

16. Biological Treatment of ADHD • Goal of Biological Treatments • To reduce impulsivity/hyperactivity and to improve attention • Stimulant Medications • Reduce the core symptoms of ADHD in 70% of cases • Examples include Ritalin, Dexedrine, Cylert • Other Medications • Imipramine and Clonidine (antihypertensive) have some efficacy

17. Biological Treatment of ADHD • Effects of Medications • Improve compliance and decrease negative behaviors in many children • Not clear that academic performance or social skills are improved in the long-term • Beneficial effects are not lasting following drug discontinuation • Negative side effects include insomnia, drowsiness, and irritability

18. Behavioral and Combined Treatment of ADHD • Behavioral Treatment • Involve reinforcement programs • Aim to increase appropriate behaviors and decrease inappropriate behaviors • May also involve parent training • Combined Bio-Psycho-Social Treatments • Are highly recommended - it appears however that long-term psychosocial Tx is necessary to maintain gains

19. Learning Disorders • Scope of Learning Disorders • Problems related to academic performance in reading, mathematics, and writing • Performance is substantially below what would be expected (IQ - Ach discrepancy) • DSM-IV and DSM-IV-TR Reading, Mathematics, Written Expression Disorders • Performance is at a level significantly below that of a typical person of the same age • Problem cannot be caused by sensory deficits (e.g., poor vision)

20. Learning Disorders: Some Facts and Statistics • Incidence and Prevalence of Learning Disorders • 1% to 3% incidence of learning disorders in the United States • Prevalence is highest in wealthier regions of the United States • Prevalence rate is 10% to 15% among school age children • Reading difficulties are the most common of the learning disorders • School experience for such persons tends to be quite negative • About 32% of students with learning disabilities drop out of school

21. Figure 13.1 Half of school children classified as disabled have learning disabilities. Twenty years ago the proportion was 50% lower

22. Biological and Psychosocial Causes of Learning Disorders • Genetic and Neurobiological Contributions • Reading disorder runs in families, with 100% concordance rate for identical twins • Evidence for subtle forms of brain damage is inconclusive • Overall, genetic and neurobiological contributions are unclear • Psychological and motivational factors seem to affect eventual outcome

23. Treatment of Learning Disorders • Medications not typically used • Requires Intense Educational Interventions • Remediation of basic processing problems (e.g., teaching visual skills) • Efforts to improve of cognitive skills (e.g., instruction in listening) • Targeting behavioral skills to compensate for problem areas • Data Support Behavioral Educational Interventions for Learning Disorders

24. Pervasive Developmental Disorders • PDD is an umbrella term • severe and pervasive impairments in several areas of development: reciprocal social interaction skills, communication skills, presence of stereotyped behavior, interests, and activities • Symptoms are on a continuum • 5 PDD’s: autistic disorder, Asperger’s disorder, Rett’s disorder, Childhood Disintegrative Disorder, PDD/NOS (distinctions among these not particularly clear)

25. Autistic Disorder • Approximately 10 cases per 10,000 individuals • More common in males (4-5:1) • Impairment in Social Interactions • Impairment in Communication • Restricted, Repetitive and Stereotyped Behaviors, Interests, and Activities • Onset of delays prior to age 3 years

26. Autistic Disorder (cont.) Qualitative Impairment in Social Interaction (needs at least 2) • marked impairment in the use of nonverbal behaviors • Failure to develop peer relationships appropriate to developmental level • A lack of spontaneous seeking to share enjoyment, interests, or achievements • lack of social or emotional reciprocity

27. Autistic Disorder (cont.) Qualitative impairment in Communication (needs a lest one) • delay or total lack of development of spoken language (no compensation) • marked impairment in the ability to initiate or sustain a conversation with others in individuals that can speak • stereotyped and repetitive use of language or idiosyncratic language • lack of carried , spontaneous make-believe play or social imitative play appropriate to developmental level.

28. Autistic Disorder (cont.) Restricted, Repetitive and Stereotyped Behaviors, Interests, and Activities (needs at least one) • encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus • apparently inflexible adherence to specific, nonfunctional routines or rituals • stereotyped mannerisms • persistent preoccupation with parts of objects

29. Other issues related to autism • Sensory issues (e.g., high threshold for pain, oversensitivity to sounds, fascination with touch or smell) • Abnormalities in mood and affect • Feeding issues (limited diet, pica) • Behavior difficulties (SIB, Tantrums, short attention span, hyperactivity, sleep problems)

30. Phenomenology of Autism • 20/20 Video • What is it like to be autistic?

31. Autism and Intellectual Functioning • 75% of individuals have mental retardation • 50% have IQs in the severe-to-profound range of mental retardation • 25% test in the mild-to-moderate IQ range (i.e., IQ of 50 to 70) • Remaining people display abilities in the borderline-to-average IQ range • Better language skills and IQ test performance predicts better lifetime prognosis

32. Etiology of Autism • Psychosocial Contributions Are Unclear • Autism has a genetic component that is largely unclear • Neurobiological evidence for brain damage – Link with mental retardation • Cerebellum size – Substantially reduced in persons with autism

33. Asperger’s Disorder • Qualitative impairment in social interaction • Restrictive Repetitive and stereotyped patterns of behavior, interest, and activities • Disturbance causes clinically significant impairment • no clinically significant general delay in language • no clinically significant delay in cognitive or adaptive functioning

34. Rett’s Disorder • Only reported in females • Apparent normal pre and perinatal development • Normal head circumference at birth • Deceleration of head growth between 5 and 48 months • Loss of hand skills between 5 and 30 months with development of stereotyped hand movement, loss of social engagement, poorly coordinated gait or trunk movements, severely impaired expressive and receptive language development with severe psychomotor retardation • Severe or Profound MR

35. Applied Behavior Analysis • Breaks down autism into separate behavioral problems and attempts to treat as many of these problems as possible. • By far the most well documented treatment approach with hundreds of studies on behavioral treatment for children with autism. • Goal is remediation (recovery) from the disorder to the point that children are indistinguishable from their peers.

36. UCLA Young Autism Project (Lovaas) • Intensive one-on-one training for app. 40 hours a week. • Training prg carried out in homes, school, community • commences at age no older than 46 months • 1st phase, focuses on teaching compliance, simple imitation, appropriate play, suppress self-stimulation and non-compliant behavior • 2nd phase teaching expressive skills, early abstract language, social play with peers • Third phase teaching expression of emotions, functional academics and more complex cognitive abilities (e.g., cause-to-effect relationships)

37. UCLA Young Autism Project - study design • Initial 2 year treatment • N = 59 children • 3 groups: (a) Experimental group (N=19) - 40 hours a week of treatment for 2 years Control group # 1 (N=19) - 10 hours of treatment for 2 years on average Control group #2 (N=21) - No treatment provided by UCLA • Blind Evaluations pre & post treatment

38. UCLA Young Autism Project pre-treatment Exp GroupControl Group # 1 Treatment: 40 hrs/week 10 hrs/week Pre Treatment Measures: Age at Dx 32 months 34 months Age @ Beg. trt 35 months 40 months IQ 53 46

39. UCLA Young Autism Project pre-treatment Exp GrControl Group # 1 (N=19) (N=19) Mute 58% 47% Reject Adults 63% 42% Not Toilet Trained 68% 63% Gross Inattention 89% 74% Tantrums 89% 79% Absent Toy Play 53% 63% Self Stimulation 95% 89% Absent Peer Play 100% 100%

40. UCLA Young Autism Project- Results • Blind evaluation: pre treatment & 2 years later (Age 6-7) • Experimental Group Results: • ** Average IQ Gain = 20 points • ** 9/19 (47%) Completed first grade in regular class • ** IQ Gain for these 9 subjects = 37 points • 8/19 (42%) Continued in a learning disabled class • 2/19 (11%) Severe MR / autistic classroom • Control Group Results: Group # 1 Group # 2 • IQ no significant changes • Completed first grade in regular class: 0/19 ( 0%) 1/21 (5%) • Continued in a learning disabled class: 8/19 (42%) 10/21 (48%) • Continued in a Severe MR Class: 11/19 (58%) 10/21 (48%)

41. UCLA Young Autism Project- Results1993 Follow Up Study Results • Blind Evaluations of the 9 children in the “Best Outcome” Group • Age at follow up evaluation - 13 years old. • IQ gains remained. • Normal functioning on tests of: • emotional functioning; • social functioning; • intellectual functioning. • 8/9 (88%) Remained in typical classrooms. • 1/9 was in an LD classroom.

42. Autism - Pharmacotherapy • No known effective medications

43. Mental Retardation • Nature of Mental Retardation • Disorder of childhood • Below-average intellectual and adaptive functioning • Range of impairment varies greatly across persons • Mental Retardation and the DSM-IV and DSM-IV-TR • Significantly subaverage intellectual functioning (IQ below 70 - about 2-3% of the population) • Concurrent deficits or impairments two or more areas of adaptive functioning • MR must be evident before the person is 18 years of age

44. Levels of MR • Mild MR • Includes persons with an IQ score between 50 or 55 and 70 (often can lead independent lives) • Moderate MR • Includes persons in the IQ range of 35-40 to 50-55 • Severe MR • Includes people with IQs ranging from 20-25 up to 35-40 • Profound MR • Includes people with IQ scores below 20-25 (typically require complete assistance)

45. Other Classification Systems for Mental Retardation (MR) • American Association of Mental Retardation (AAMR) • Defines MR based on levels of assistance required • Examples of levels include intermittent, limited, extensive, or pervasive assistance • Not that widely adopted • Classification of MR in Educational Systems • Based on whether person is “Educable” • Stigmatizing system

46. Mental Retardation (MR): Some Facts and Statistics • Prevalence • About 1% to 3% of the general population • 90% of MR persons are labeled with mild mental retardation • Gender Differences • MR occurs more often in males, male-to-female ratio of about 1.6:1 • Course of MR • Tends to be chronic, but prognosis varies greatly from person to person

47. Mental Retardation (MR): Psychosocial Contributions • Cultural-Familial Retardation • Believed to cause about 75% of MR cases and is the least understood • Believed to result from combination of biological (low IQ) and social factors • Neglect, abuse, poor nutrition • Associated with mild levels of retardation on IQ tests and good adaptive skills • Lower end of distribution but probably distinct etiology from those w clear organic causes

48. Mental Retardation (MR): Biological Contributions • Genetic Research • MR involves multiple genes, and at times single genes • Chromosomal Abnormalities and Other Forms of MR • Down syndrome – Trisomy 21 • Fragile X syndrome – Abnormality on X chromosome • Maternal Age and Risk of Having a Down’s Baby • Nearly 75% of cases cannot be attributed to any known biological cause

49. Specific genetic syndromes associated with MR • Down Syndrome • Fragile X syndrome

50. Down Syndrome