Chapter 13 Developmental and Cognitive Disorders Nature of

Chapter 13 Developmental and Cognitive Disorders

Nature of Developmental Psychopathology: An Overview • Normal vs. abnormal development • Developmental psychopathology – Study of how disorders arise and change with time – Disruption of early skills can affect later development

Nature of Developmental Psychopathology: An Overview • Developmental disorders – Diagnosed first in infancy, childhood, or adolescence – Attention deficit hyperactivity disorder (ADHD) – Learning disorders – Autism – Mental retardation

Attention Deficit Hyperactivity Disorder (ADHD) • Nature of ADHD – Central features – inattention, overactivity, and impulsivity – Associated with numerous impairments • Behavioral • Cognitive • Social and academic problems

Attention Deficit Hyperactivity Disorder (ADHD) • DSM-IV-TR symptom types – Inattentive type – Hyperactive type – Impulsive type

ADHD: Facts and Statistics • Prevalence – Occurs in 3% - 7% of school-aged children – Symptoms are usually present around age three or four – Children with ADHD have problems as adults • Gender differences – Boys outnumber girls 3: 1 • Cultural factors • Probability of ADHD diagnosis – Greatest in the United States

The Causes of ADHD: Biological Contributions • Genetic contributions – ADHD seems to run in families – DAT 1 - gene have been implicated

The Causes of ADHD: Biological Contributions • Neurobiological contributions – Smaller brain volume – Inactivity of the frontal cortex and basal ganglia – Abnormal frontal lobe development and functioning

The Causes of ADHD: Biological Contributions (continued) • The role of toxins – No evidence that allergens and food additives are causes – Maternal smoking increases risk

The Causes of ADHD: Psychosocial Contributions • Psychosocial factors – Can influence the nature of ADHD – ADHD children are often viewed negatively by others – Constant negative feedback from peers and adults – Peer rejection and resulting social isolation – Such factors foster low self-esteem

Biological Treatment of ADHD • Goal of biological treatments – To reduce impulsivity and hyperactivity and to improve attention • Stimulant medications – Reduce core symptoms in 70% of cases – Examples include Ritalin, Dexedrine

Biological Treatment of ADHD • Other medications with more limited efficacy – Imipramine and clonidine (antihypertensive) – Designer drugs • Effects of medications – Improve compliance and decrease negative behaviors – Do not affect learning and academic performance – Benefits are not lasting following discontinuation

Behavioral and Combined Treatment of ADHD • Behavioral treatment – Reinforcement programs • To increase appropriate behaviors • Decrease inappropriate behaviors – May also involve parent training • Combined bio-psycho-social treatments – Are highly recommended – Superior to medication or behavioral treatments alone

Learning Disorders: An Overview • Scope of learning disorders – Academic problems in reading, mathematics, and writing – Performance substantially below expected levels

Learning Disorders: An Overview • DSM-IV-TR reading disorder – Discrepancy between actual and expected achievement – Performance significantly below age or grade level – Cannot be caused by sensory deficits • DSM-IV-TR mathematics disorder – Achievement below expected performance • DSM-IV-TR disorder of written expression – Achievement below expected performance in writing

Learning Disorders: Statistics • Prevalence of learning disorders – 5 -10% prevalence in the United States – Highest in wealthier regions of the United States – Six million children have been diagnosed – 4 -10% prevalence for reading difficulties – School experience tends to be generally negative

Biological and Psychosocial Causes of Learning Disorders • Genetic and neurobiological contributions – Reading disorder runs in families – Evidence for subtle forms of brain damage is mounting – Overall, contributions are unclear • Psychosocial contributions are largely unknown

Treatment of Learning Disorders • Requires intense educational interventions – Remediation of basic processing problems – Improvement of cognitive skills – Targeting skills to compensate for problem areas • Data support behavioral educational interventions

Pervasive Developmental Disorders: An Overview • Nature of pervasive developmental disorders – Problems occur in language, socialization, and cognition – Pervasive – problems span many life areas • Examples of pervasive developmental disorders – Autistic disorder – Asperger’s syndrome

The Nature of Autistic Disorder: An Overview • Autism – significant impairments – Social interactions and communication – Restricted patterns of behavior, interest, and activities

The Nature of Autistic Disorder: An Overview • Three central DSM-IV-TR features of autism – Qualitative impairment of social interaction – Problems in communication • 50% never acquire useful speech – Restricted patterns of behavior, interests, and activities

Autistic Disorder: Statistics • Prevalence and features of autism – One in every 500 births – More prevalent in females with IQs below 35 – More prevalent in males with higher IQs – Occurs worldwide – Symptoms usually develop before 36 months of age

Autistic Disorder: Statistics • Autism and intellectual functioning – 45%- 60% with autism have average or above average IQs • Reliable indicators of good prognosis – Language ability and IQ

Causes of Autism: Early and More Recent Contributions (continued) • Current understanding of autism – Medical conditions – not always related to autism – Genetic component is largely unclear – Neurobiological evidence of brain damage – Substantially reduced cerebellum size • Psychosocial contributions are unclear

Asperger’s Disorder: Part of the Autistic Spectrum • The nature of Asperger’s disorder – Show significant social impairments – Restricted and repetitive stereotyped behaviors – May be clumsy – Often quite verbal – No severe language and/or cognitive delays

Asperger’s Disorder: Part of the Autistic Spectrum • Prevalence of Asperger’s disorder – Often under diagnosed – Affects about one - two persons per 10, 000 people – More often in boys that girls • Causes of Asperger’s disorder are somewhat unclear

Treatment of Pervasive Developmental Disorders: Example of Autism • Psychosocial “behavioral” treatments – Skill building – Reduction of problem behaviors – Target communication and language problems – Address socialization deficits – Early intervention is critical

Treatment of Pervasive Developmental Disorders: Example of Autism • Biological and medical treatments are unavailable • Integrated treatments: The preferred model – Focus on children, their families, schools, and home – Build in appropriate community and social support

Intellectual disability (ID): An Overview • Nature of mental retardation – Disorder of childhood – Below-average intellectual and adaptive functioning – Range of impairment varies greatly across persons

Intellectual disability (ID): An Overview • DSM-IV-TR criteria – Significantly sub-average intellectual functioning – Deficits or impairments in present adaptive functioning – Must be evident before the person is 18 years of age

DSM-IV-TR Levels of Intellectual disability (ID) • Mild ID – IQ score between 50 or 55 and 70 • Moderate ID – IQ range of 35 -40 to 50 -55 • Severe ID – IQs ranging from 20 -25 up to 35 -40 • Profound ID – IQ scores below 20 -25

Other Classification Systems for Intellectual disability (ID) • American Association of Mental Retardation (AAID) – Defines ID based on levels of assistance required – Levels of assistance • Intermittent, limited, extensive, pervasive

Other Classification Systems for Intellectual disability (ID) • Classification of ID in educational systems – Educable (IQ of 50 to 70 -75) – Trainable (IQ of 30 to 50) – Severe (IQ below 30) • Implications of different ID classification systems

Intellectual disability (ID): Some Facts and Statistics • Prevalence – About 1 -3% of the general population – 90% are labeled with mild intellectual disability • Course of ID – Tends to be chronic – Prognosis varies greatly from person to person

Causes of Intellectual disability (ID): Biological Contributions • Hundreds of known causes – Environmental – deprivation, abuse – Prenatal – exposure to disease or a drug/toxin – Perinatal – difficulties during labor – Postnatal – head injury

Causes of Intellectual disability (ID): Biological Contributions • Genetic research – Multiple genes, and at times single genes • Chromosomal abnormalities – Down syndrome and fragile X syndrome – PKU – Lesch-Nyhan syndrome

Causes of Intellectual disability (ID): Biological Contributions • Down syndrome – Maternal age and risk of having a Down’s baby – Amniocentesis – Chorionic villus sampling (CVS)

• Cultural-familial intellectual disability – Believed to cause about 75% of ID cases – Is the least understood – Associated with • Mild levels of retardation on IQ tests • Good adaptive skills

Treatment of Intellectual disability (ID) • Parallels treatment of pervasive developmental disorders • Teach needed skills – To foster productivity – To foster independence – Educational and behavioral management – Living and self-care skills via task analysis – Communication training – often most challenging

Treatment of Intellectual disability (ID) • Community and supportive interventions – Persons with ID can benefit from such interventions

Summary of Developmental Disorders • Developmental psychopathology • Attention deficit hyperactivity disorder – Deficits in attention, hyperactivity, or impulsivity • Learning disorders – Deficits in performance below expectations

Summary of Developmental Disorders • Pervasive developmental disorder – All share deficits in language, socialization, and cognition • Intellectual disability – Sub-average IQ, deficits in adaptive functioning – Onset before age 18 • Prevention and early intervention are critical

Nature of Cognitive Disorders: An Overview • Perspectives on cognitive disorders – Affect learning, memory, and consciousness – Most develop later in life • Three classes of cognitive disorders – Delirium – temporary confusion and disorientation – Dementia – marked by broad cognitive deterioration – Amnestic disorders – memory dysfunctions

Nature of Cognitive Disorders: An Overview • Shifting DSM perspectives – From “organic” mental disorders to “cognitive” disorders – Broad impairments in cognitive functioning – Profound changes in behavior and personality

Delirium: An Overview • Nature of delirium – Central features – impaired consciousness and cognition – Develops rapidly over several hours or days – Appear confused, disoriented, and inattentive – Marked memory and language deficits

Delirium: An Overview (continued) • Facts and statistics – Affects up 30% of persons in acute care facilities – Most prevalent in older adults • Those undergoing medical procedures • AIDS patients and cancer patients – Full recovery often occurs within several weeks

Medical Conditions Related to Delirium • Medical conditions – Drug intoxication, poisons, withdrawal from drugs – Infections – Head injury and several forms of brain trauma – Sleep deprivation, immobility, and excessive stress

Medical Conditions Related to Delirium • DSM-IV-TR subtypes of delirium – Delirium due to a general medical condition – Substance-induced delirium – Delirium due to multiple etiologies – Delirium not otherwise specified

Treatment and Prevention of Delirium • Treatment – Attention to precipitating medical problems – Psychosocial interventions include reassurance • Focus on coping strategies • Inclusion of patients in treatment decisions • Prevention – Address proper medical care for illnesses – Address proper use and adherence to therapeutic drugs

Dementia: An Overview • Nature of dementia – Gradual deterioration of brain functioning – Deterioration in judgment and memory – Deterioration in language / advanced cognitive processes – Has many causes and may be irreversible

Dementia: Initial and Later Stages • Initial stages – Memory and visuospatial skills impairments – Agnosia – inability to recognize and name objects – Facial agnosia – inability to recognize familiar faces – Other symptoms • Delusions, apathy, depression, agitation, aggression

Dementia: Initial and Later Stages • Later stages – Cognitive functioning continues to deteriorate – Total support is needed to carry out day-to-day activities – Death due to inactivity and onset of other illnesses

DSM-IV-TR Classes of Dementia • Dementia of the Alzheimer’s type • Vascular dementia • Dementia due to other general medical conditions • Substance-induced persisting dementia • Dementia due to multiple etiologies • Dementia not otherwise specified

Dementia of the Alzheimer’s Type: An Overview • DSM-IV-TR criteria and clinical features – Multiple cognitive deficits – Develop gradually and steadily – Memory, orientation, judgment, and reasoning deficits – Additional symptoms may include • Agitation, confusion, or combativeness • Depression and/or anxiety – “Sundowner syndrome”

Dementia of the Alzheimer’s Type: Extent of Deficits • Range of cognitive deficits – Aphasia – difficulty with language – Apraxia – impaired motor functioning – Agnosia – failure to recognize objects – Difficulties with • • Planning Organizing Sequencing Abstracting information – Negative impact on social and occupational functioning

Dementia of the Alzheimer’s Type: Extent of Deficits • Until recently an autopsy is required for a definitive diagnosis

Alzheimer’s Disease: Some Facts and Statistics • Nature and progression of the disease – Deterioration is slow during the early and later stages – Deterioration is rapid during middle stages – Average survival time is about eight years – Onset usually occurs in the 60 s or 70 s

Alzheimer’s Disease: Some Facts and Statistics • Prevalence of Alzheimer’s disease – Prevalence greater in • Poorly educated persons – Prevalence rates are low in some ethnic groups

Vascular Dementia: An Overview • Nature of vascular dementia – Caused by blockage or damage to blood vessels – Second leading cause of dementia next to Alzheimer’s – Onset is often sudden (e. g. , stroke) – Patterns of impairment are variable – Most require formal care in later stages

Vascular Dementia: An Overview • DSM-IV-TR criteria and incidence – Cognitive disturbances – identical to dementia – Obvious neurological signs of brain tissue damage – Prevalence 1. 5% in people 70 and 15% for people over 80 – Risk slightly higher in men

Other Causes of Dementia: Head Trauma • Head trauma – accidents are leading cause – Memory loss is the most common symptom

Other Causes of Dementia: HIV-1 • HIV-1 – Causes neurological impairments and dementia – Cognitive slowness, impaired attention, and forgetfulness – Apathy and social withdrawal

Other Causes of Dementia: Parkinson’s Disease • Parkinson’s disease – degenerative brain disorder – Affects about one out of 1, 000 people worldwide – Motor problems – central feature of this disorder • Caused by damage to dopamine pathways – 75% survival rate for 10 years

Other Causes of Dementia: Huntington’s • Huntington’s disease – Genetic autosomal dominant disorder – Manifests initially as chorea, usually later in life – About 20 -80% display dementia – Dementia follows a subcortical pattern

Other Causes of Dementia: Pick’s Disease • Pick’s disease – Rare neurological condition – Produces a cortical dementia like Alzheimer’s – Also occurs later in life (around 40 s or 50 s) – Little is known about what causes this disease

Other Dementias: Creutzfeldt-Jakob Disease • Creutzfeldt-Jakob disease – Affects one out of 1, 000 persons – Linked to mad cow disease

Other Dementias: Substance-Induced Dementia • Substance-induced persisting dementia – Results from drug use in combination with poor diet – Several drugs can lead to symptoms of dementia – Resulting brain damage may be permanent – Dementia is similar to that of Alzheimer’s – Deficits may include • Aphasia, apraxia, agnosia • Disturbed executive functioning

Causes of Dementia: The Example of Alzheimer’s Disease • Early and largely unsupported views – Implicated smoking, negative correlation

Causes of Dementia: The Example of Alzheimer’s Disease • Current neurobiological findings – Neurofibrillary tangles – Amyloid plaques – The role of deterministic genes • Beta-amyloid precursor gene • Presenilin-1 and Presenilin-2 genes – The role of susceptibility genes - Apo. E 4 gene – Brains of Alzheimer’s patients tend to atrophy

Causes of Dementia: The Example of Alzheimer’s Disease • Current neurobiological findings – Multiple genes are involved in Alzheimer’s disease – Chromosomes 21, 19, 14, 12, – Chromosome 14 • Associated with early onset Alzheimer’s – Chromosome 19 • Associated with late onset Alzheimer’s

The Contributions of Psychosocial Factors in Dementia • Psychosocial factors – Do not cause dementia directly – May influence onset and course – Lifestyle factors – drug use, diet, exercise, stress – Cultural factors • Risk for certain conditions vary by ethnicity and class – Psychosocial factors • Educational attainment, coping skills, social support

Medical and Psychosocial Treatment of Dementia • Medical treatment: Best if enacted early – Few exist for most types of dementias – Most attempt to slow progression of deterioration – Do not stop progression of dementia – Caregiver can be negatively impacted

Medical and Psychosocial Treatment of Dementia • Psychosocial treatments – aims – To enhance lives of patients and their families – To teach compensatory skills – To use memory enhancement devices, if needed – Psychosocial interventions appear to focus on caregivers

Prevention of Dementia • Reducing risk of dementia in older adults – Estrogen-replacement therapy – Proper treatment of cardiovascular diseases – Use of anti-inflammatory medications – Control blood pressure and lead an active social life • Other targets of prevention efforts – Increasing safety behaviors to reduce head trauma – Reducing exposure to neurotoxins and use of drugs

Amnestic Disorder: An Overview • Nature of amnestic disorder – Circumscribed loss of memory – Inability to transfer information into long-term memory – No loss of other high-level cognitive functions

Amnestic Disorder: An Overview • Causes may include – Medical conditions, head trauma, or long-term drug use • DSM-IV-TR criteria – Inability to • Learn new information or recall learned information – Significant impairment in functioning

Amnestic Disorder: An Overview • The example of Wernicke-Korsakoff syndrome – Damage to the thalamus – Thiamine (vitamin B-1) deficiency – Resulting from stroke or chronic heavy alcohol use • Prevention – Use of thiamine supplements with heavy drinkers • Research on amnestic disorders is scant

Summary of Cognitive Disorders • Cognitive disorders span a range of deficits – Affect attention, memory, language, and motor behavior – Causes include • Medical conditions • Drug use • Environmental factors

Summary of Cognitive Disorders • Most result in progressive deterioration of functioning • Few treatments exist to reverse damage and deficits

Dementia: Statistics • Onset and prevalence – Can occur at any age, but most common in the elderly – Affects over 10% of persons 85 years and older • Incidence of dementia – Affects 8. 5% of those 85 and older – Rates seem to double with every five years of age

Dementia: Facts and Statistics • Gender and sociocultural factors – Occurs equally in men and women – Occurs equally across educational level and social class