Neurodevelopmental Disorders - Textbook

Neurodevelopmental Disorders CHAPTER OUTLINE...

Neurodevelopmental Disorders CHAPTER OUTLINE Overview of Neurodevelopmental Disorders What Is Normal? What Is Abnormal? Attention-Deficit/Hyperactivity Disorder Specific Learning Disorder Autism Spectrum Disorder Treatment of Autism Spectrum Disorder Intellectual Disability (Intellectual Development Disorder) Causes Prevention of Neurodevelopmental Disorders ©iStockPhoto.com/MBI_Images 8 14 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  [ student learning outcomes* ] Use scientific reasoning to interpret behavior: Identify basic biological, psychological, and social components of behavioral explanations (e.g., inferences, observations, operational definitions and interpretations) (APA SLO 1.1a) (see textbook pages 517–518, 526–528, 533–536) Engage in innovative and integrative thinking and Describe problems operationally to study them problem solving: empirically. (APA SLO 1.3a) (see textbook pages 511–517, 520–522, 524–526, 530–533) Describe applications that employ discipline-based Correctly identify antecedents and consequences of problem solving: behavior and mental processes (APA SLO 5.3c) Describe examples of relevant and practical applications of psychological principles to everyday life (APA SLO 5.3a) (see textbook pages 518–519, 528–530, 536–537) * Portions of this chapter cover learning outcomes suggested by the American Psychological Association (2012) in its guidelines for the undergraduate psychology major. Chapter coverage of these outcomes is identified above by APA Goal and APA Suggested Learning Outcome (SLO). Overview of Neurodevelopmental Disorders The family’s pediatrician assured them that Timmy was Almost all disorders described in this book are developmental disor- just developing at a different rate and would grow out of ders in the sense that they change over time. Most disorders originate it. When, at age 3, Timmy’s behavior persisted, his parents in childhood, although the full presentation of the problem may not consulted a second pediatrician. Neurological examina- manifest itself until much later. Disorders that show themselves early tions revealed nothing unusual but suggested, on the basis in life often persist as the person grows older, so the term childhood of Timmy’s delay in learning such basic skills as talking and disorder may be misleading. Because the developmental disorders in feeding himself, that he had severe intellectual disability. this group are all presumed to be neurologically based, DSM-5 catego- Timmy’s mother did not accept this diagnosis, and over the rizes them as neurodevelopmental disorders (American Psychiatric next few years she consulted numerous other professionals Association, 2013). In this chapter, we cover those disorders that are and received numerous diagnoses (including childhood revealed in a clinically significant way during a child’s developing schizophrenia, childhood psychosis, and developmental delay). years and are of concern to families and educators. Remember, how- By age 7, Timmy still didn’t speak or play with other children, ever, that these difficulties often persist through adulthood and are and he was developing aggressive and self-injurious behaviors. typically lifelong problems, not problems unique to children. His parents brought him to a clinic for children with severe Again, a number of difficulties and, indeed, distinct disorders disabilities. Here, Timmy was diagnosed as having autism. begin in childhood. In certain disorders, some children are fine The clinic specialists recommended a comprehensive edu- except for difficulties with talking. Others have problems relating cational program of intensive behavioral intervention to help Timmy with language and socialization and to counter his increasing tendency to engage in tantrums. The work continued TIMMY The Boy Who Looked daily for approximately 10 years, both at the clinic and at home. Right Through You During this time, Timmy learned to say only three words: “soda,” “cookie,” and “Mama.” Socially, he appeared to like other T immy, a beautiful blond baby, was born with the umbili- cal cord wrapped around his neck, so he had been without oxygen for an unknown period. Nonetheless, he appeared to be people (especially adults), but his interest seemed to center on their ability to get him something he wanted, such as a favor- ite food or drink. If his surroundings were changed in even a a healthy little boy. His mother later related that he was a good minor way, Timmy became disruptive and violent to the point baby who rarely cried, although she was concerned he didn’t of hurting himself; to minimize his self-injurious behavior, the like to be picked up and cuddled. His family became worried family took care to ensure that his surroundings stayed the about his development when he was 2 years old and didn’t same as much as possible. No real progress was made toward talk (his older sister had at that age). They also noticed that he eliminating his violent behavior, however, and as he grew big- didn’t play with other children; he spent most of his time alone, ger and stronger, he became increasingly difficult to work with; spinning plates on the floor, waving his hands in front of his he hurt his mother physically on several occasions. With great face, and lining up blocks in a certain order. reluctance, she institutionalized Timmy when he was 17. O v e rv i ew of Ne u rodev elop men ta l D i s order s 511 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. to their peers. Still other children have a combination of condi- (such as you saw with Timmy) and expect a negative prognosis, with tions that significantly hinder their development, as illustrated by the problems predetermined and permanent. Remember, however, the case of Timmy. that biological and psychosocial influences continuously interact As clinicians have grown to appreciate the far-reaching effects with each other. Therefore, even for disorders such as attention- of childhood problems and the importance of early intervention deficit/hyperactivity disorder and autism spectrum disorder that in treating most disorders, they have become more interested in have clear biological bases, the presentation of the disorder is differ- understanding the diversity of severe problems experienced in ent for each individual. Changes at the biological or the psychoso- early life. Timmy was diagnosed with “autism” (now referred to cial level may reduce the impact of the disorder. as autism spectrum disorder) in the early 1970s. More than four One note of caution is appropriate here. There is real concern decades later, we know more—although still not enough—about in the profession, especially among developmental psychologists, how to help children who have autism spectrum disorder. Who that some workers in the field may view aspects of normal develop- can say what the prognosis for Timmy might be today, especially if ment as symptoms of abnormality. For example, echolalia, which he were diagnosed and treated at age 2 instead of at age 7? involves repeating the speech of others, was once thought to be a sign of autism spectrum disorder. When we study the develop- What Is Normal? What Is Abnormal? ment of speech in children without disorders, however, we find that repeating what someone else says is an intermediate step in Before we discuss specific disorders, we need to address the broad language development. In children with autism spectrum disorder, topic of development in relation to disorders usually first diagnosed therefore, echolalia is just a sign of relatively delayed language skills in infancy, childhood, or adolescence. What can we learn from and not a symptom of their disorder (Tager-Flusberg et al., 2009). children like Timmy, and what effect do the early disruptions in their Knowledge of development is important for understanding the skills have on their later lives? Does it matter when in the develop- nature of psychological disorders. mental period certain problems arise? Are disruptions in develop- With that caveat in mind, we now examine several disorders ment permanent, thus making any hope for treatment doubtful? usually diagnosed first in infancy, childhood, or adolescence, Recall that in Chapter 2 we described developmental psycho- including attention-deficit/hyperactivity disorder, which involves pathology as the study of how disorders arise and how they change characteristics of inattention or hyperactivity and impulsivity, and with time (Scott, 2012). Childhood is considered particularly specific learning disorder, which is characterized by one or more important, because the brain changes significantly for several years difficulties in areas such as reading and writing. We then focus on after birth; this is also when critical developments occur in social, autism spectrum disorder, a more severe disability, in which the emotional, cognitive, and other important competency areas. child shows significant impairment in social communication and These changes mostly follow a pattern: The child develops one skill has restricted patterns of behavior, interest, and activities. Finally, before acquiring the next. Although this pattern of change is only we examine intellectual disability, which involves considerable one aspect of development, it is an important concept at this point deficits in cognitive abilities. Communication and motor disabili- because it implies that any disruption in the development of early ties, which are also considered neurodevelopmental disorders, skills will, by the very nature of this sequential process, disrupt the are described in Table 14.1. development of later skills. For example, some researchers believe that people with autism spectrum disorder suffer from a disruption in early social development, which prevents them from developing Attention-Deficit/Hyperactivity Disorder important social relationships, even with their parents (Durand, Do you know people who flit from activity to activity, who start 2014). From a developmental perspective, the absence of early many tasks but seldom finish one, who have trouble concentrat- and meaningful social relationships has serious consequences. ing, and who don’t seem to pay attention when others speak? Children whose motivation to interact with others is disrupted may These people may have attention-deficit/hyperactivity disorder have a more difficult time learning to communicate; that is, they (ADHD), one of the most common reasons children are referred may not want to learn to speak if other people are not important to for mental health services in the United States (Taylor, 2012). them. Researchers don’t know whether a disruption in communi- The primary characteristics of such people include a pattern of cation skills is a direct outcome of the disorder or a by-product of disrupted early social development. Understanding this type of developmental relationship is important for several reasons. Knowing what processes are dis- DANNY The Boy Who Couldn’t rupted will help us understand the disorder better and may lead to Sit Still more appropriate intervention strategies. It may be important to D identify children with attention-deficit/hyperactivity disorder, for anny, a handsome 9-year-old boy, was referred to us example, because their problems with impulsivity may interfere because of his difficulties at school and at home. Danny with their ability to create and maintain friendships, an important had a great deal of energy and loved playing most sports, developmental consideration. Similarly, identifying a disorder such especially baseball. Academically, his work was adequate, as autism spectrum disorder at an early age is important for these although his teacher reported that his performance was children so that their social deficits can be addressed before they diminishing and she believed he would do better if he paid affect other skill domains, such as social communication. Too often, more attention in class. Danny rarely spent more than a few people see early and pervasive disruptions in developmental skills 512 C ha p ter 14 Neurodevelop men tal D is orde rs Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  It could be a result of inattention and impulsivity, and in some minutes on a task without some interruption: He would children this can be made worse by factors such as concur- get up out of his seat, rifle through his desk, or constantly rent learning disabilities. Genetic research on both ADHD and ask questions. His peers were frustrated with him because learning disabilities suggests that they may share a common bio- he was equally impulsive during their interactions: He logical cause (DuPaul, Gormley, & Laracy, 2013). Children with never finished a game, and in sports he tried to play all ADHD are likely to be unpopular and rejected by their peers positions simultaneously. (Nijmeijer et al., 2008). This too may be the result of genetic fac- At home, Danny was considered a handful. His room was tors as well as environmental influences such as a hostile home in a constant mess because he became engaged in a game or environment and gene-environment interactions. For example, activity only to drop it and initiate something else. Danny’s some research shows that having a specific genetic mutation parents reported that they often scolded him for not carrying (i.e., a COMT gene polymorphism) and a low birth weight pre- out some task, although the reason seemed to be that he for- dicts later behavior problems in children with ADHD (Thapar, got what he was doing rather than that he deliberately tried Cooper, Jefferies, & Stergiakouli, 2012; Thapar et al., 2005). to defy them. They also said that, out of their own frustration, they sometimes grabbed him by the shoulders and yelled, Statistics “Slow down!” because his hyperactivity drove them crazy. An important analysis of prevalence of ADHD suggests that the disorder is found in about 5.2% of the child populations across all regions of the world (Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). This finding of comparable rates of ADHD inattention, such as being disorganized or forgetful about school worldwide is important because debates continue to rage about or work-related tasks, or of hyperactivity and impulsivity. These the validity of ADHD as a real disorder. Some people believe that deficits can significantly disrupt academic efforts, as well as social children who are just normally “active” are being misdiagnosed relationships. Consider the case of Danny. with ADHD. Previously, geographic differences were noted in the number of people diagnosed with this disorder. Children Clinical Description were more likely to receive the label of ADHD in the United Danny has many characteristics of ADHD. Like Danny, people States than anywhere else. For example, an analysis of data from with this disorder have a great deal of difficulty sustaining their surveying parents over the phone suggest that 11% of children attention on a task or activity (Taylor, 2012). As a result, their tasks in the U.S. aged 4 to 17 were labeled with ADHD between 2011 are often unfinished and they often seem not to be listening when and 2012 (Centers for Disease Control and Prevention, 2013). someone else is speaking. In addition to this serious disruption This higher number may suggest that it is being over-diagnosed in attention, some people with ADHD display motor hyperactiv- in the United States. ity. Children with this disorder are often described as fidgety in Based on these different rates of diagnosis, some have argued school, unable to sit still for more than a few minutes. Danny’s that ADHD in children is simply a cultural construct—meaning restlessness in his classroom was a considerable source of concern that the behavior of these children is typical from a develop- for his teacher and peers, who were frustrated by his impatience mental perspective and it is Western society’s intolerance (due and excessive activity. In addition to hyperactivity and prob- to the loss of extended family support, pressure to succeed lems sustaining attention, impulsivity—acting apparently with- academically, and busy family life) that causes labeling ADHD out thinking—is a common complaint made about people with as a disorder (Timimi & Taylor, 2004). The best data suggest, ADHD. For instance, during meetings at baseball practice, Danny however, that from 3% to 9% of the worldwide population cur- often shouted responses to the coach’s questions even before the rently meet the criteria for ADHD that significantly interferes coach had a chance to finish his sentence. with their quality of life (Taylor, 2012). For ADHD, DSM-5 differentiates two categories of symptoms. Boys are 3 times more likely to be diagnosed with ADHD than The first includes problems of inattention. People may appear not girls, and this discrepancy increases for children being seen in to listen to others; they may lose necessary school assignments, clinics (Spencer, Biederman, & Mick, 2007). The reason for this books, or tools; and they may not pay enough attention to details, gender difference is largely unknown. It may be that adults are making careless mistakes. The second category of symptoms more tolerant of hyperactivity among girls, who tend to be less includes hyperactivity and impulsivity. Hyperactivity includes fidg- active than boys with ADHD. Boys tend to be more aggressive, eting, having trouble sitting for any length of time, always being which will more likely result in attention by mental health profes- on the go. Impulsivity includes blurting out answers before ques- sionals (Rucklidge, 2010). Girls with ADHD, on the other hand, tions have been completed and having trouble waiting turns. Either tend to display more behaviors referred to as “internalizing”— the first (inattention) or the second and third (hyperactivity and specifically, anxiety and depression (Rucklidge, 2010). impulsivity) set of symptoms must be present for someone to be The higher prevalence of boys identified as having ADHD has diagnosed with ADHD (American Psychiatric Association, 2013). led some to question whether the DSM-5 diagnostic criteria for this Inattention, hyperactivity, and impulsivity often cause disorder are applicable to girls. Here is the quandary: Most research other problems that appear secondary to ADHD. Academic over the last several decades has used young boys as participants. performance often suffers, especially as the child progresses This focus on boys may have been the result of their active and in school. The cause of this poor performance is not known. disruptive behaviors, which caused concern among families and At t e nt ion-D e fici t /Hyperac t i v i t y D i s order 513 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Table 14.1 Common Communication and Motor Disorders Childhood-Onset Fluency Disorder Clinical Description Statistics Etiology Treatment A disturbance in speech Occurs twice as often among Rather than anxiety Parents are counseled about how to talk fluency that includes a boys as among girls. Begins causing childhood- to their children. Regulated-breathing number of problems with most often in children by the onset fluency disorder, method is a promising behavioral treat- speech, such as repeat- age of 6, and 98% of cases this problem makes ment in which the person is instructed ing syllables or words, occur before the age of 10 people socially anxious to stop speaking when a stuttering prolonging certain sounds, (Maguire, Yeh, & Ito, 2012). (Ezrati-Vinacour & episode occurs and then to take a deep making obvious pauses, Approximately 80% of chil- Levin, 2004). Multiple breath (exhale, then inhale) before or substituting words to dren who stutter before they brain pathways appear proceeding (Onslow, Jones, O’Brian, replace ones that are enter school will no longer to be involved, and Packman, & Menzies, 2012). Altered difficult to articulate. stutter after they have been genetic influences may auditory feedback (electronically chang- in school a year or so (Kroll be a factor (Maguire ing speech feedback to people who & Beitchman, 2005). et al., 2012). stutter) can improve speech, as can using forms of self-monitoring, in which people modify their own speech for the words they stutter (Onslow et al., 2012). language Disorder Clinical Description Statistics Etiology Treatment Limited speech in all Occurs in 10% to 15% of An unfounded psy- May be self-correcting and may situations. Expressive children younger than chological explanation not require special intervention language (what is said) is 3 years of age (C. J. Johnson is that the children’s (Whitehurst et al., 1988). significantly below recep- & Beitchman, 2005) and is parents may not speak tive language (what is almost five times as likely to them enough. A understood); the latter is to affect boys as girls biological theory is that usually average. (Whitehurst et al., 1988). middle ear infection is a contributory cause. Social (Pragmatic) Communication Disorder Clinical Description Statistics Etiology Treatment Difficulties with the social Exact estimates not yet avail- Limited information. Individualized social skills training aspects of verbal and able, but the number of cases (e.g., modeling, role playing) with an nonverbal communica- identified appears to be rising emphasis on teaching important rules tion, including verbos- with increasing awareness necessary for carrying on conversa- ity, prosody, excessive (Baird et al., 2006; D. V. M. tions with others (e.g., what is too switching of topics, and Bishop, 2000). much and too little information) dominating conversations (Adams et al., 2012). (Adams et al., 2012). Does not have the restricted and repetitive behaviors found in ASD. Tourette’s Disorder Clinical Description Statistics Etiology Treatment Involuntary motor move- Of all children, up to 20% There are likely Psychological: Self-monitoring, relax- ments (tics), such as head show some tics during their multiple vulnerability ation training, and habit reversal. twitching, or vocalizations, growing years, and 1 to genes that influence such as grunts, that often 10 children out of every the form and severity occur in rapid succession, 1,000 have Tourette’s disorder of tics (Jummani & come on suddenly, and (Jummani & Coffey, 2009). Coffey, 2009). happen in idiosyncratic Usually develops before the or stereotyped ways. age of 14. High comorbidity Vocal tics often include between tics and ADHD, as the involuntary repetition well as obsessive-compul- of obscenities. sive disorder (Jummani & Coffey, 2009). Adapted from (Durand, 2011). 514 C ha p ter 14 Neurodevelop men tal D is orde rs Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. school personnel and therefore prompt- across age and gender bodes well for a © Cengage Learning® ed research into the nature, causes, and fuller understanding of the disorder. treatment of these problems. More boys Children with ADHD are first identi- displayed these behaviors, which made fied as different from their peers around it easier to find participants to study. But age 3 or 4; their parents describe them did this almost singular focus on boys as active, mischievous, slow to toilet result in ignoring how young girls expe- Edward: ADHD in a Gifted train, and oppositional (Taylor, 2012). rience this disorder? The symptoms of inattention, impulsiv- This concern is being raised by some Student ity, and hyperactivity become increas- psychologists, including Kathleen Nadeau “He’s very, very intelligent; his grades don’t ingly obvious during the school years. (a clinical psychologist who specializes reflect that because he will just neglect to do Despite the perception that children in girls with ADHD), who argues that a 240-point assignment if somebody doesn’t grow out of ADHD, their problems usu- more research is needed on ADHD in stay behind it.... What I try to do with him ally continue: it is estimated that about girls: “Girls experience significant strug- is come in and cut it down to ‘this is what I half of the children with ADHD have gles that are often overlooked because want by tomorrow, this is what I want day ongoing difficulties through adulthood their ADHD symptoms bear little resem- after tomorrow.’” (McGough, 2005). Over time, children blance to those of boys” (Crawford, 2003, with ADHD seem to be less impulsive, p. 28). She says that girls with ADHD Go to MindTap at although inattention persists. During were neglected because their symptoms www.cengagebrain.com adolescence, the impulsivity manifests differ so dramatically from boys’ symp- to watch this video. itself in different areas; for example, toms, although to date there is little firm teens with ADHD are at greater risk evidence for these differences (Rucklidge, for pregnancy and contracting sexually 2010). Just as researchers are now exploring ADHD among adults, transmitted infections. They are also more likely to have driving in addition to children, more research is now addressing the rela- difficulties, such as crashes; to be cited for speeding; and to have tive lack of research on girls and women. This expansion of research their licenses suspended (Barkley, 2006a). DSM 5 TABLE 14.1 Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as charac- terized by (1) and/or (2): 1. 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. a. 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). b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading). c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction). d. 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). e. 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). f. 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). g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paper- work, eyeglasses, or mobile telephones). h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). i. Is often forgetful in daily activities (e.g., chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments). Continued At t e nt ion-D e fici t /Hyperac t i v i t y D i s order 515 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. DSM 5 TABLE 14.1 Diagnostic Criteria for Attention Deficit/Hyperactivity Disorder—cont’d 2. 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 failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. a. Often fidgets with or taps hands or feet or squirms in seat. b. 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). c. Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) d. Often unable to play or engage in leisure activities quietly. e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for an extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). f. Often talks excessively. g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation). h. Often has difficulty waiting his or her turn (e.g., while waiting in line). i. 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 or adults, may intrude into or take over what others are doing). B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. 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). D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. E. 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). Specify whether: Combined presentation: If both Criterion A1 (inattention) and Criterion A2 (hyperactivity-impulsivity) are met for the past 6 months. Predominantly inattentive presentation: If Criterion A1 (inattention) is met but Criterion A2 (hyperactivity-impulsivity) is not met for the past 6 months. Predominantly hyperactive/impulsive presentation: If Criterion A2 (hyperactivity-impulsivity) is met and Criterion A1 (inattention) is not met for the past 6 months. From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. What happens to children and adolescents with ADHD as manifestations of ADHD change as people grow older, many of they become adults? Rachel Klein and her colleagues followed their problems persist. up on more than 200 boys with this disorder and report on their Diagnosing children with ADHD is complicated. Several status 33 years later (Klein et al., 2012). When compared with other DSM-5 disorders, also found in children, appear to overlap a group without ADHD, the majority of these men (84%) were significantly with this disorder. Specifically, oppositional defiant employed but in jobs with significantly lower positions than disorder (ODD), conduct disorder, and bipolar disorder all have the comparison group. They also had 2.5 fewer years of edu- characteristics seen in children with ADHD. ODD is a DSM-5 cation and were much less likely to hold higher degrees. These disorder that includes behaviors such as “often loses temper,” men were also more likely to be divorced and to have substance “argues with adults,” “often deliberately annoys people,” “touchy use problems and antisocial personality disorder (Klein et al., and easily annoyed by others,” and “often spiteful and vindictive” 2012). In addition, the effects of their tendency to be impulsive (Pardini, Frick, & Moffitt, 2010). The impulsivity and hyperactiv- may account for their increased risk of displaying risky driv- ity observed in children with ADHD can manifest themselves in ing, having a sexually transmitted disease, increased chance of some of these symptoms. Similarly, conduct disorder—which, as having a head injury, and more emergency department admis- you saw in Chapter 12, can be a precursor to antisocial personality sions (Ramos Olazagasti et al., 2013). In short, although the disorder—is also observed in many children with ADHD (Nock, 516 C ha p ter 14 Neurodevelop men tal D is orde rs Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Kazdin, Hiripi, & Kessler, 2006). Bipolar specific areas of current interest for © Cengage Learning® disorder—which, you will recall from ADHD are the brain’s attention system, Chapter 7, is one of the mood disorders— working memory functions, inattentive- also overlaps significantly with ADHD. ness, and impulsivity. Researchers are This overlap can complicate diagnosis in now trying to tie specific genetic defects these children. to these cognitive processes to make the ADHD: Sean link between genes and behavior. Some Causes research indicates that poor “inhibitory “[He] would never think before he did stuff. Important information about the genet- And actually, the thing that really made me control” (the ability to stop responding ics of ADHD is beginning to be uncov- go, ‘Something is desperately wrong here’— to a task when signaled) may be com- ered (Taylor, 2012). Researchers have we had a little puppy. Real tiny little dog. mon among both children with ADHD known for some time that ADHD is more And Sean was upstairs playing with it. And and their unaffected family members common in families in which one person my daughter had gone upstairs, and went, (siblings and parents) and may be one has the disorder. For example, the rela- ‘Mom, something’s wrong with the dog’s genetic marker (an endophenotype) for tives of children with ADHD have been paw.’ And I looked and this poor little dog had this disorder (Goos, Crosbie, Payne, & found to be more likely to have ADHD a broken paw. Sean had dropped her. But— Schachar, 2009). themselves than would be expected didn’t say anything to anyone. Just left the The strong genetic influence in in the general population (Fliers et al., poor little dog sitting there. And I thought, ADHD does not rule out any role for 2009). It is important to note that these ‘Wow. This is just not normal.’” the environment (Ficks & Waldman, families display an increase in psycho- 2009). In one of a growing number of pathology in general, including conduct gene–environment interaction studies of Go to MindTap at disorder, mood disorders, anxiety dis- ADHD, for example, researchers found www.cengagebrain.com orders, and substance abuse (Faraone et that children with a specific mutation to watch this video. al., 2000). This research and the comor- involving the dopamine system (called bidity in the children themselves suggest the DAT1 genotype) were more likely to that some shared genetic deficits may contribute to the problems exhibit the symptoms of ADHD if their mothers smoked during experienced by individuals with these disorders (Brown, 2009). pregnancy (Kahn, Khoury, Nichols, & Lanphear, 2003). Prenatal ADHD is considered to be highly influenced by genetics. smoking seemed to interact with this genetic predisposition to Environmental influences play a relatively small role in the cause increase the risk for hyperactive and impulsive behavior. Other of the disorder when compared with many other disorders we dis- research is now pointing to additional environmental factors, such cuss in this book. As with other disorders, researchers are finding as maternal stress and alcohol use, and parental marital instability that multiple genes are responsible for ADHD (Nikolas & Burt, and discord, as involved in these gene–environment interactions 2010). In its simplest form we tend to think of genetic “prob- (Ficks & Waldman, 2009; Grizenko et al., 2012). lems” in terms of having genes turned off (not making proteins) The association between ADHD and maternal smoking is one when they should be turned on and vice versa. Research on of the more consistent findings in this area. In addition, a variety ADHD (and on other disorders) is finding that in many cases, of other pregnancy complications (for example, maternal alcohol however, mutations occur that either create extra copies of a gene consumption and low birth weight) may play a role in increasing the on one chromosome or result in the deletion of genes (called copy chance that a child with a genetic predisposition for ADHD will dis- number variants—CNVs) (Elia et al., 2009; Lesch et al., 2010). play the symptoms characteristic of this disorder (Barkley, 2006d). Because our DNA is structured to function with corresponding Unfortunately, many of the studies in this area confound socio- or matching pairs of genes on each chromosome, the additions or economic and genetic factors (for example, there is an increased deletions of one or more genes result in disrupted development. likelihood of smoking among women who also have low socioeco- Most attention to date focuses on genes associated with the neu- nomic status or are under other stressors), and there may not be a rochemical dopamine, although norepinephrine, serotonin, and direct link between maternal smoking and ADHD (Grizenko gamma-aminobutyric acid (GABA) are also implicated in the cause et al., 2012; Lindblad & Hjern, 2010). of ADHD. More specifically, there is strong evidence that ADHD For several decades, ADHD has been thought to involve brain is associated with the dopamine D4 receptor gene, the dopamine damage, and this notion is reflected in the previous use of labels transporter gene (DAT1), and the dopamine D5 receptor gene. such as “minimal brain damage” or “minimal brain dysfunction” DAT1 is of particular interest because methylphenidate (Ritalin)— (Ross & Pelham, 1981). The rapid advances in scanning technol- one of the most common medical treatments for ADHD—inhibits ogy now permit us to see just how the brain may be involved in this gene and increases the amount of dopamine available (Davis et this disorder. A great deal of research on the structure and the al., 2007). Such research helps us understand at a microlevel what function of the brain for children with this disorder has been might be going wrong and how to design new interventions. conducted over the past few years. In general, researchers now As with several other disorders we’ve discussed, researchers are know that the overall volume of the brain in those with this looking for endophenotypes, those basic deficits—such as specific disorder is slightly smaller (3% to 4%) than in children without attentional problems—characteristic of ADHD. The goal is to link this disorder (Taylor, 2012). A number of areas in the brains of these deficits to specific brain dysfunctions. Not surprisingly, those with ADHD appear affected, especially those involved in At t e nt ion-D e fici t /Hyperac t i v i t y D i s order 517 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  self-organizational abilities (Valera, Faraone, Murray, & Seidman, hyperactivity, and attention, combined with attempts to control 2007). These changes seem less pronounced in persons who these children, may lead to rejection and consequent poor self- received medication (Taylor, 2012). image. An integration of the biological and psychological influ- A variety of such toxins as allergens and food additives have been ences on ADHD suggests that both need to be addressed when considered as possible causes of ADHD over the years, although designing effective treatments (Taylor, 2012). little evidence supports the association. The theory that food addi- tives such as artificial colors, flavorings, and preservatives are Treatment of ADHD responsible for the symptoms of ADHD has been highly controver- Treatment for ADHD has proceeded on two fronts: psychosocial sial. Feingold (1975) presented this view, along with recommenda- and biological interventions (Subcommittee on Attention-Deficit/ tions for eliminating these substances as a treatment for ADHD. As Hyperactivity Disorder & Management, 2011). Psychosocial treat- a result, hundreds of thousands of families put their children on the ments generally focus on broader issues such as improving aca- Feingold diet, despite arguments by some that the diet has little or no demic performance, decreasing disruptive behavior, and improving effect on the symptoms of ADHD (Barkley, 1990; Kavale & Forness, social skills. Typically, the goal of biological treatments is to 1983). Some large-scale research now suggests that there may be a reduce the children’s impulsivity and hyperactivity and to improve small but measurable impact of artificial food colors and additives on their attention skills. Current thinking in this area points to using the behavior of young children. One study found that 3-year-old and parent and/or teacher delivered behavioral interventions for 8- to 9-year-old children who consumed typical amounts of preser- young children before attempting medication (Subcommittee on vatives (sodium benzoate) and food colorings had increased levels Attention-Deficit/Hyperactivity Disorder & Management, 2011). of hyperactive behaviors (inattention, impulsivity, and overactivity) (McCann et al., 2007). Other research now points to the possible role Psychosocial Interventions of the pesticides found in foods as contributing to an increased risk of ADHD (Bouchard, Bellinger, Wright, & Weisskopf, 2010). Researchers recommend various behavioral interventions to Psychological and social dimensions of ADHD may further help these children at home and in school (Fabiano et al., 2009; influence the disorder itself—especially how the child fares over Ollendick & Shirk, 2010). In general, the programs set such goals time. Negative responses by parents, teachers, and peers to the as increasing the amount of time the child remains seated, the affected child’s impulsivity and hyperactivity may contribute to number of math papers completed, or appropriate play with peers. feelings of low self-esteem, especially in children who are also Reinforcement programs reward the child for improvements and, depressed (Anastopoulos, Sommer, & Schatz, 2009). Years of at times, punish misbehavior with loss of rewards. Other parent constant reminders by teachers and parents to behave, sit quietly, education programs teach families how to respond constructively and pay attention may create a negative self-image in these chil- to their child’s behaviors and how to structure the child’s day to dren, which, in turn, can negatively affect their ability to make help prevent difficulties (Fabiano et al., 2009). Social skills training friends. Thus, the possible biological influences on impulsivity, for these children, which includes teaching them how to interact appropriately with their peers, also seems to be an important treat- ment component (de Boo & Prins, 2007). For adults with ADHD, cognitive-behavioral intervention to reduce distractibility and improve organizational skills appears quite helpful. Most clini- cians typically recommend a combination of approaches designed to individualize treatments for those with ADHD, targeting both short-term management issues (decreasing hyperactivity and impulsivity) and long-term concerns (preventing and reversing academic decline and improving social skills). Biological Interventions The first types of medication used for children with ADHD were stimulants. Since the use of stimulant medication for children with ADHD was first described (Bradley, 1937), hundreds of stud- ies have documented the effectiveness of this kind of medication in reducing the core symptoms (hyperactivity, impulsiveness) of the disorder. It is estimated that more than 4 million children in the United States are being treated with medication for symptoms David Young-Wolff/PhotoEdit of ADHD (Centers for Disease Control and Prevention, 2013). Drugs such as methylphenidate (Ritalin, Adderall) and several nonstimulant medications such as atomoxetine (Strattera), guan- facine (Tenex), and clonidine have proved helpful in reducing the core symptoms of hyperactivity and impulsivity and in improv- A child with ADHD is likely to behave inappropriately regardless of ing concentration on tasks (Subcommittee on Attention-Deficit/ the setting. Hyperactivity Disorder & Management, 2011). 518 C ha p ter 14 Neurodevelop men tal D is orde rs Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Originally, it seemed paradoxical or contrary to expect that or may not lead to having ADHD or another disorder). Will the children would calm down after taking a stimulant. However, desire to better target drug treatments outweigh these types of on the same low doses, children and adults with and without ethical and privacy concerns? Most new technical advances, like ADHD react in the same way. It appears that stimulant medica- those promised with psychopharmacogenetics, also uncover new tions reinforce the brain’s ability to focus attention during prob- problems, and it is essential that ethical issues be part of the dis- lem-solving tasks (Connor, 2006). Although the use of stimulant cussion as researchers move forward in this area. medications remains controversial, especially for children, most Some portion of children with ADHD do not respond to clinicians recommend them temporarily, in combination with medications, and most children who do respond show improve- psychosocial interventions, to help improve children’s social and ment in ability to focus their attention but do not show gains academic skills. in the important areas of academics and social skills (Smith, The concerns over the use of stimulant medications now include Barkley, & Shapiro, 2006). In addition, the medications often their potential for abuse. In Chapter 11, we discussed that drugs result in unpleasant side effects, such as insomnia, drowsiness, such as Ritalin and Adderall are sometimes abused for their ability or irritability (Kollins, 2008). to create elation and reduce fatigue (Varga, 2012). And, the wide- spread misperception that use of these prescription medications is harmless is also of great concern (Desantis & Hane, 2010). This Combined Approach to Treatment is particularly worrisome for children with ADHD because they To determine whether or not a combined approach to treatment are at increased risk for later substance abuse (Wagner & Pliszka, is the most effective, a large-scale study initiated by the National 2009). As mentioned previously, other nonstimulant drugs such as Institute of Mental Health was conducted by six teams of research- atomoxetine (Strattera) also appear effective for some children with ers (Jensen et al., 2001). Labeled the Multimodal Treatment of ADHD. This drug is a selective norepinephrine-reuptake inhibi- Attention-Deficit/Hyperactivity Disorder (MTA) study, this tor and therefore does not produce the same “highs” when used in 14-month study included 579 children who were randomly larger doses. Research suggests that other drugs, such as some anti- assigned to one of four groups. One group of the children received depressants (imipramine) and a drug used for treating high blood routine care without medication or specific behavioral interven- pressure (clonidine) may have similar effects as atomoxetine on tions (community care). The three treatment groups consisted people with ADHD. Not all children with ADHD have depression of medication management (usually methylphenidate), intensive or high blood pressure (although depression can be a problem in behavioral treatment, and a combination of the two treatments. some of these children), but these drugs work on the same neu- Initial reports from the study suggested that the combination of rotransmitter systems (norepinephrine and dopamine) involved in behavioral treatments and medication, and medication alone, ADHD (Subcommittee on Attention-Deficit/Hyperactivity Disor- were superior to behavioral treatment alone and community der & Management, 2011). All these drugs seem to improve com- intervention for ADHD symptoms. For problems that went pliance and decrease negative behaviors in many children, and their beyond the specific symptoms of ADHD, such as social skills, effects do not usually last when the drugs are discontinued. academics, parent–child relations, oppositional behavior, and Psychopharmacogenetics is the study of how your genetic anxiety or depression, results suggested slight advantages of makeup influences your response to certain drugs. The hope for combination over single treatments (medication management, this field is that medications can be matched or even “designed” behavioral treatment) and community care. for individuals to better complement their specific needs Some controversy surrounds the interpretation of these (Weinshilboum, 2003). For example, one study looked at the findings—specifically, whether or not the combination of use of methylphenidate (Ritalin) for children and adolescents behavioral and medical treatments is superior to medication with ADHD (Polanczyk, Zeni, et al., 2007). For those who had alone (Biederman, Spencer, Wilens, & Greene, 2001; Pelham, a specific gene defect—the adrenergic alpha-2A receptor gene 1999). One of the concerns surrounding the study was that (ADRA2A)—methylphenidate had a strong positive effect, espe- although medication continued to be dispensed, the behavioral cially on their problems with inattention. This was not the case for treatment was faded over time, which may account for the those with ADHD who did not have the ADRA2A gene defect. observed differences. Currently, the use of drug treatments tends to be by trial and error: Practically, if there is no difference between these two treat- A medication is attempted at a particular dose; if it is not effective, ments, most parents and therapists would opt for simply pro- the dose is changed. If that does not work, a different medication is viding medication for these children because of its ease of use tried. This new study holds the promise of potentially eliminating and less time commitment (Subcommittee on Attention-Deficit/ this guesswork by tailoring the treatment to the individual. Hyperactivity Disorder & Management, 2011). Behavioral inter- This exciting new approach to medical treatment for mental ventions have the added benefit, however, of improving aspects illness brings with it some weighty concerns. Central to these con- of the child and family that are not directly affected by medi- cerns are issues of privacy and confidentiality. Genetic screening cation. Reinterpretations of the data from this large-scale study to identify defects is likely to identify any number of potential continue, and more research likely will be needed to clarify genetic problems in each of us. How will schools, employment the combined and separate effects of these two approaches to sites, and insurance companies view this information if they have treatment (Ollendick & Shirk, 2010). Despite these advances, access? The concern is that people will be discriminated against however, children with ADHD continue to pose a considerable based on this information (for example, having the genes that may challenge to their families and to the educational system. At t e nt ion-D e fici t /Hyperac t i v i t y D i s order 519 Copyright 201 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it. Specific Learning Disorder Clinical Description According to DSM-5 criteria, Alice would be diagnosed as having Academic achievement is highly valued in our society. We often a specific learning disorder (in her case especially in the area of compare the performance of our schoolchildren with that of chil- reading), which is defined as a significant discrepancy between a dren in other cultures to estimate whether we are succeeding or person’s academic achievement and what would be expected for failing as a world leader and economic force. On a personal level, someone of the same age—referred to by some as “unexpected because parents often invest a great deal of time, resources, and underachievement” (Fletcher, Lyon, Fuchs, & Barnes, 2006; emotional energy to ensure their children’s academic success, it Scanlon, 2013). More specifically, the criteria require that the per- can be extremely upsetting when a child with no obvious intel- son perform academically at a level significantly below that of a lectual deficits does not achieve as expected. In this section, we typical person of the same age, cognitive ability (as measured on describe specific learning disorder—which is characterized by an IQ test), and educational background. In addition, a diagnosis performance that is substantially below what would be expected of specific learning disorder requires that the person’s disability given the person’s age, intelligence quotient (IQ) score, and educa- not be caused by a sensory difficulty, such as trouble with sight or tion. We also look briefly at disorders that involve how we com- hearing, and should not be the result of poor or absent instruc- municate. Consider the case of Alice. tion. DSM-IV-TR listed specific disorders in reading, mathemat- ics, and written expression as separate disorders, but because of the significant overlap in these disabilities they are now combined ALICE Taking a Learning to assist clinicians in taking a broader view of the individual’s Disorder to College learning styles (Scanlon, 2013). Clinicians can use the specifiers for disorders of reading, written expression, or mathematics to high- A lice, a 20-year-old college student, sought help because light specific problems for remediation. As with other disorders, of her difficulty in several of her classes. She reported clinicians rate the disorder on levels of severity. that she had enjoyed school and had been a good student Historically, a specific learning disorder would be defined until about the sixth grade, when her grades suffered signifi- as a discrepancy of more than 2 standard deviations between cantly. Her teacher informed her parents that she wasn’t achievement and IQ. There was considerable controversy, how- working up to her potential and she needed to be better ever, over using the discrepancy between IQ and achievement motivated. Alice had always worked hard in school b