Is he mentally ill?

Vascular dementia—multi-infarct dementia

• Vascular dementia—multi-infarct dementia

• Similar clinical picture to Alzheimer's
• Series of infarcts destroy neurons over expanding brain regions
• After 50; more common in men
• About 19% of all dementia cases
• Vulnerable to death from stroke
• Mood disorders more common than in AD
• Can manage cerebral arteriosclerosis to some extent

Creutzfeld-Jakob Disease—slow acting virus that may live in the body for years; then rapid course

• Creutzfeld-Jakob Disease—slow acting virus that may live in the body for years; then rapid course

• Dementia from HIV-1 infection

• HIV can result in destruction of brain cells
• May lead to psychotic phenomena
• Damage may occur throughout brain, but tends to be localized in subcortical regions
• 30-60% of untreated pts with HIV will develop AIDS-related dementia; with current antiviral tx, rate reduces to 20%

Central feature is strikingly disturbed memory or amnesia

• Central feature is strikingly disturbed memory or amnesia

• Immediate recall and memory for remote events is usually preserved

• Short term memory is typically very impaired

• Confabulation is common

• Overall cognitive functioning is relatively intact

• Korsakoff’s Syndrome—follows severe alcohol abuse

• May also be caused by head trauma, stroke, surgery in the temporal lobe, hypoxia
• Depending on cause, may abate wholly or partially

Affects more than 2 million per year

• Affects more than 2 million per year

• Most common cause—MVA, followed by falls, assaults, sports injuries

• Men 15-24 are at greatest risk

• Three types of head injury—closed, penetrating, skull fractures

• Immediate acute reactions—unconscious, disruption of circulatory, metabolic, and neurotransmitter regulation

• Retrograde and anterograde amnesia are common

• Person typically passes through stupor and confusion on way to recovering clear consciousness

• Coma may occur

• Treatment—prompt medical attention is required

• Mild concussions improve quickly
• Minority—personality change
• Severe injury—poor prognosis
• 24% of TBI develop post-traumatic epilepsy, presumably because of the growth of scar tissue

Take a developmental perspective

• Take a developmental perspective

• Tasks a child should be handling and see how they’re doing
• All of this is culturally related.
• Often an attempt to adapt to negative circumstances.

• Issues in working with children:

• 1) Limited capacity to understand in children
• 2) More difficulty coping as cannot put problems into perspective of a past and future
• 3) Use unrealistic concepts to explain things (don’t understand death, etc)
• 4) Dependent on others for help

• Adultomorphism

• 1/5 children has a disorder that disrupts functioning. 1/10 has a disorder that severely impairs functioning.

• Loosely categorized into externalizing and internalizing.

Inattention—doesn’t pay attention/makes careless mistakes

• Inattention—doesn’t pay attention/makes careless mistakes

• Doesn’t listen when spoken to
• Doesn’t follow through on instructions
• Difficulty getting organized
• Avoids things that require concentration

• Hyperactive

• Fidgets
• Can’t stay seated
• Runs or climbs excessively/inappropriately
• Can’t play quietly
• On the go/driven by a motor

• Girls tend to have PI, boys PH or C; 2-3X more common in boys (not 6-9x as text says)

• Other issues: 7-15 points lower IQ

• Social problems
• Emotional competence
• Those with PI are more likely to have internalizing problems, LD, slow pace of problem solving

• Prevalence is 3-5% of school aged kids

• 50-70% continue to have problems into adolescence and adulthood; less hyperactivity with age

• Poorer prognosis when comorbid with CD

• As adults—more car accidents, higher risk of substance abuse

Causes: Multiple biological and psychological causes.

• Causes: Multiple biological and psychological causes.

• Frontal lobe deficits
• Runs in families
• Mothers report more stress; negative parenting
• Not caused by diet, additives

• Treatments: 70-80% on stimulants improve

• Side effects: decreased appetite, insomnia, abdominal pain, headaches, crying spells, stunts growth—drug holidays. Don’t improve social skills or academics.
• Behavior modification
• Combination most effective
• Social skills training, cognitive-behavioral effective after sx under control

Typically kids 3-7

• Typically kids 3-7

• Poor control of emotions

• Noncompliant

• Argumentative with parents and teachers

• Conflicts with peers

• Tantrums

• Problem with ODD: some sx are very common

• Majority of kids with ODD will go on to show conduct problems.

• Risk factors: family discord, low SES, antisocial beh. in parents

More serious behavior problems

• More serious behavior problems

• Repetitive, persistent problems with behaviors that are potentially harmful to

• child, others, or property

• Sx—physical fights, weapons, stealing with or without confrontation, fires, sexual aggression, truancy, lying, running away overnight, breaking into house, bldg or car, bullying, cruelty to animals or people

• Demographics vary greatly. More common in boys. Boys have more aggressive subtypes. Girls tend toward less confrontational sx.

• Prognosis factors

• Childhood onset vs. adolescence-limited
• Degree of callous-unemotional traits
• Big three sx: fires, cruelty to animals, cruelty to people
• Socialized vs. unsocialized

• Early onset is linked to APD (25-40%)

• Even if not APD, often associated with life problems such as divorce, joblessness, and abusive parenting

Biological

• Biological

• Danish adoption study—parent history of criminality and % of kids convicted of conduct offense

• Bio

• Yes No

• Adop yes 25 14

• No 20 13

• Generally lower levels of adrenaline—low arousal

• Psychosocial causes—

• Gerald Patterson—coercive cycles—kid is obnoxious until parent relents; parents engage in negative parenting
• Parents of CD kids more likely to behave in ways that encourage development of coercive styles; criticize more, issue more commands
• Adverse environmental factors make it harder to use positive child rearing skills—substance abuse, marital distress, violence, poverty, social isolation, death of a family member
• Self-perpetuating—deviancy training
• Difficult temperament leads to poor attachment

• Hostile attribution bias

Society picks punitive rather than treatment based approaches but…

• Society picks punitive rather than treatment based approaches but…

• Must be multimodal

• Need to address family issues

• Behavioral programs

• All most effective at young ages

SAD—characterized by worry that caregiver will get hurt/child hurt if not with caregiver

• SAD—characterized by worry that caregiver will get hurt/child hurt if not with caregiver

• Normal in young kids—not a disorder until past normal period, generally 6-9
• School avoidance present in ¾
• Often have specific phobias as well
• May be acute onset following big life changes; may wax and wane
• More common in girls

• Generalized Anxiety Disorder

• Pervasive diffuse worry
• 95% worry all the time
• ½ meet MDD criteria
• Seems to be chronic

Selective mutism—

• Selective mutism—

• Persistent failure to speak in specific social situations
• Can speak and understand language
• Rare, most common at school entry
• More common in families where taciturn behavior is prominent
• Stress and family environmental factors

• Phobias—simple—consider in context of kids’ normal fears

• Fears can be adaptive, but can become phobias
• Unusual age of onset
• Intensity
• Persistence of fear
• Type of fear—rational or not
• Morris and Kratchowill (1989)
• Toddlers—separation, animals, dark
• Preschool—strangers, bodily harm, toddler fears
• School age-being alone, imaginary beings, violence, death, dark, injury, storms, teasing
• Teens—peer rejection, achievement, family problems, war, poverty, AIDS

Causal factors in anxiety disorders:

• Causal factors in anxiety disorders:

• Modeling of anxious parents
• Indifferent or detached parent may instill insecurity
• Temperament
• Cultural factors
• Genetic link—anxiety in parents predicts anxiety in kids

• Treatment:

• Meds—common, not yet well established. Possibly prozac
• Behavior therapy—focused on assertiveness training and desensitization
• Cognitive-behavioral tx

Adult criteria are used, but there are limitations in this

• Adult criteria are used, but there are limitations in this

• Kids are less adept at expressing the cognitive symptoms
• Childhood depression is not factor analytically distinct from anxiety
• Ability to feel and express shame and guilt does not emerge until age 7 or so
• Many more somatic complaints in kids
• Social withdrawal is common, but this looks different in children—not able to choose to stay home
• Irritability is common instead of overtly depressed mood
• Hallucinations are more common in children than adults
• Wt. issues may be failure to make expected gains instead of wt. loss

• Younger kids—depression is more common in boys or equal in boys and girls

• By adolescence—more common in girls

• Prevalence==.4-2.5% in children, 4-8.3% for adolescents

Causal factors

• Causal factors

• Genetic component –higher risk if parent is depressed
• Early exposure to traumatic events, including death of a parent
• Parent-child interaction in transmission of depressed affect
• Cognitive—global, internal, stable

• Treatments—

• Antidepressants are not well established. Some studies show no effect, others show a moderate effect. Concern about side effects and suicidal thoughts.
• Suicide appraisal is important—longitudinal study of 8-13 yo who were depressed found that 1/3 made suicide attempts in the next 7 yrs.
• Perhaps 7%-1/10 of all teens make a suicide attempt

• Cognitive behavioral techniques are effective

75 outcome studies

• 75 outcome studies

• Average outcome for a treated child was 2/3 of an SD better than untreated kids

• Beh>nonbeh

• Play or non-play did not matter

• Parents or no parents did not matter

• Experience, education and sex of therapist did not matter

• Greatest improvements for specific problems, global issues like self-esteem and social adjustment improved less

Group of severely disabling conditions

• Group of severely disabling conditions

• Result of structural differences in the brain

• Examples include Asperger’s and Autism

• Prevalence unclear, but increasing, maybe 3.2% of clinic cases

Three primary features: noncommunicative speech, social isolation, need for sameness

• Three primary features: noncommunicative speech, social isolation, need for sameness

• Appears as early as 1 yr to 18 months when kid are not making eye contact

• Social deficit-do not want physical contact, do not show affection

• Self-stimulation—stereotyped movements

• Panic if routine is changed

• Intellectual ability—have thought that most have IQs in MR range. New studies questions whether this is so or whether it is an artifact of testing.

• Theory of mind deficits

• Less time in symbolic play

• Not the same as schizophrenia

• 4x more common in boys

• About 5% of autistics are savants—isolated skills of great talent with no known cause or training

Not caused parents actions (refrigerator mothers—retreat in autistic fortress)

• Not caused parents actions (refrigerator mothers—retreat in autistic fortress)

• Not caused by vaccines. Multiple big studies.

• Precise cause is unknown.

• Based on twin studies, 80-90% is based on genetic factors.

• Fragile X in 8% of autistic males.

• Increased frequency of pre and perinatal complications

• Many brain abnormalities

Poor prognosis

• Poor prognosis

• No medications—

• Behavioral tx work best

• Eliminate self-injurious behavior
• Social skills training
• Development of language skills
• Hard to find reinforcers
• Don’t like change
• Self-stimulation interferes with teaching
• Difficulty generalizing learning
• Lovaas—highly positive results
• Intensive, in home
• 47% achieved normal intellectual functioning

Disorders of receptive and expressive language and reading, writing, mathematics

• Disorders of receptive and expressive language and reading, writing, mathematics

• Two groups are highly comorbid
• All are more common in boys
• Look for discrepancy between expected and actual achievement

• Reading disorder

• Word recognition, reading comprehension
• Typically spelling too
• Difficulty with oral reading—either omit or add
• Phonological awareness!
• 2-8% of kids (5% sounds about right)

• Mathematics disorder

• Difficulty with variety of skills including coding written problems into math symbols; perceptual organization skills like recognizing symbols
• Less common than reading, maybe 1% of kids

• Written expression

• Impairment of ability to write words, spelling, grammar, punctuation, ,handwriting
• Write less complex and less interesting essays
• <1% of kids
• Less research on this

Receptive-expressive language disorder

• Receptive-expressive language disorder

• Trouble producing and understanding spoken language
• Those with receptive may appear deaf

• Phonological disorder

• Able to comprehend and use substantial vocabulary, but actual sounds are disturbed.
• Later acquired speech sounds are more difficult—r, sh, th, f, z, l, ch, j
• May need speech therapy
• May recover

Causes

• Causes

• Genetically influenced
• Neurological deficits

• Treatment

• Instruction on listening, speaking, reading, and writing skills in a logical, sequential manner.
• Hands on instruction.
• Time in seat on task. Not discovery-based.

• Long term

• Some deficits continue to adulthood.
• Lower occupational attainment than would be expected.
• Cover for deficits by listening to news instead of reading, etc.

Significantly subaverage intellectual functioning

• Significantly subaverage intellectual functioning

• Deficits in adaptive functioning

• Occurring prior to age 18

• Intelligence testing—2 sds below

• About 2.5% of population in theory, 5% in practice

• Adaptive functioning

• Problem—what is adaptive in some places isn’t in others

• Time of onset—can’t occur from an accident later in life

• Dx often in infancy or before birth

• Mild cases most often dx’d in school—no obvious phys or neuro manifestations

• Only about 25% have known organic cause.

• Most mild cases have no known cause

Mild—50/55 to 70 AKA EMI

• Mild—50/55 to 70 AKA EMI

• 85% of ID pop
• By late teens can learn to about 6th grade level
• Unskilled jobs or sheltered workshops
• May marry, have kids
• Often no brain pathology, just kids with parents with low SES, low IQ

• Moderate—35/40 to 50/55 AKA TMI

• 10% of ID pop
• May have phys defects that hinder fine motor skills (pencils) and gross motor (running, climbing) skills
• Learn to about 2nd grade level
• Learn some self-care skills
• Partial independent living—group homes

• Severe—20/25 to 35/40

• 3-4% of ID pop
• Limited sensorimotor control. Some congenital physical abnormalities
• May be friendly, but can communicate only at a concrete level

• Profound—IQ below 20/25

• 1-2% of ID pop
• Require total supervision and often nursing care
• High mortality in childhood
• Can improve skills with training

All ID have deficits to some degree in

• All ID have deficits to some degree in

• Communication
• Academics
• Sensorimotor skills
• Self-help
• Vocational skills

• Etiology

• Lack of exposure to reading materials; poor parenting
• Down syndrome (1/1000 births). Most < 50.
• PKU 1/14000
• FAS
• Infectious diseases (German measles, syphilis) prenatally
• Prematurity
• Malnutrition
• Accidents
• Radiation in pregnancy
• Lead poisoning
• Anoxia

Treatment

• Treatment

• Families are satisfied with choice of institutionalization or not
• Community-oriented care has positives for adolescents
• Mainstreaming vs. self-contained---
• Children do well in mainstreaming—modest gains in social skills
• No particular academic advantage (except for mild MR who may not have rec’d enough attn in self-contained room)
• Other children are not harmed by ID kids in room

Child’s inability to seek assistance

• Child’s inability to seek assistance

• Parental consent is needed except for mature/emancipated minors, emergencies, court order

• Risk factors for kids

• Need to address family issues

• Placement issues

• Juvenile detention
• Boot camps
• Deviancy training