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• Children can be diagnosed as ADHD combined type, predominantly inattentive, or predominantly impulsive-hyperactive
• Research by Virginia Douglas at McGill demonstrated that inability to sustain attention and control impulses, not higher activity levels, were key features of this disorder
DISORDERS OF CHILDHOOD
ADHD and other disorders
• high rates of comorbidity with oppositional defiant disorder (80%), conduct disorder (40%), and antisocial personality disorder (25%) in adolescence
• also, high rates of comorbidity with learning disabilities
• assessed primarily with rating scales (e.g., Connors)
DISORDERS OF CHILDHOOD
ADHD – Long-term prognosis
• Follow-up studies of children with ADHD show elevated rates of school problems, conduct disorders or antisocial personality, substance abuse, criminal behaviour
• But this long-term trend is observed mostly with aggression associated with ADHD
DISORDERS OF CHILDHOOD
ADHD – Long-term prognosis
• Moreover, some children seem to outgrow ADHD (see figure 5.1 in text)
• at age 10, 250 cases per 1000 for ADHD in boys; drops to < 50 cases per 1000 by age 20
• girls remain at low rates (75 cases per 1000) from ages 10 to 20
DISORDERS OF CHILDHOOD
ADHD - Etiology
• likely some biological predisposition
• 30-50% heritability component
• food additives and sugar – no evidence that these are causal factors
• PET and MRI research suggests some brain abnormalities, such as reduced glucose metabolism
• reduced impulsiveness and hyperactivity and improved attention, but little evidence of improvement in academic achievement
DISORDERS OF CHILDHOOD
ADHD - Treatment
• proliferation of medications for treatment of ADHD
• rates of use quadrupled in Canada from 1990 to 1995, then increased by 85% per year from 1996-98 (McCubbin & Cohen, 1999)
• concerns about side effects about use of stimulant medication
DISORDERS OF CHILDHOOD
ADHD - Treatment
• behavioural management at home and school
• these strategies can also help, but appear less powerful and are more demanding of adults than medications
• combination of medication and behavioural treatment may be most beneficial
DISORDERS OF CHILDHOOD
OPPOSITIONAL DEFIANT DISORDER (ODD)
• diagnosed when children behave in a negative, hostile, or defiant manner; related to problems in relationships and at school
• symptoms emerge before age 8
• 1 in 4 boys will go on to develop CD
DISORDERS OF CHILDHOOD
CONDUCT DISORDER (CD)
• “repetitive and persistent pattern of conduct in which the basic rights of others and major age-appropriate societal norms or rules are violated”
• aggression is a major concern; also property destruction, lying, theft, rule violation
• poor interpersonal skills and peer rejection
DISORDERS OF CHILDHOOD
Diagnostic issues in ODD & CD
• more common in boys (2:1)
• many boys with ODD do not develop CD
• minority of those with CD don’t develop antisocial personality disorder
• CD linked with ADHD and substance abuse
DISORDERS OF CHILDHOOD
Etiology of ODD & CD
• subclinical neurological signs
• temperament
• inter-generational patterns
• marital conflict, divorce, abuse
• attachment problems
• parenting
DISORDERS OF CHILDHOOD
Long-term development of ODD & CD
• form of behaviour changes over time – from overt to covert
• severity and frequency of problems best predictors of who will continue to have problems in the future
• many children do improve over time
DISORDERS OF CHILDHOOD
Treatment of ODD & CD
Coercive process – Gerry Patterson
• parents behaviour impacts on child; child’s behaviour impacts on adult
• in families of children with ODD or CD, parents lack child management skills and often end up in coercive interactions that sprial out of control and are self-perpetuating
DISORDERS OF CHILDHOOD Treatment of ODD & CDParents’ impact on child
Brother Brother and and sister at sister at playplay
Children play Children play cooperativelycooperatively
Parent Parent ignores ignores childrenchildren
Extinction of Extinction of cooperative cooperative playplay
Brother Brother and and sister at sister at playplay
Children fightChildren fight Parent Parent criticizes criticizes or scolds or scolds childrenchildren
Positive Positive reinforcement reinforcement for fightingfor fighting
DISORDERS OF CHILDHOOD Treatment of ODD & CDChilds’ impact on parent
Children Children fightfight
Parent Parent criticizes criticizes or scoldsor scolds
Children stop Children stop fighting fighting (temporarily)(temporarily)
Negative Negative reinforcement reinforcement for criticism or for criticism or scoldingscolding
DISORDERS OF CHILDHOOD
Patterson’s parent training for ODD & CD
Defining and pinpointing behaviour
• “I want Johnny to be a good student”
• “I want Johnny to stop being aggressive”
• “I want Johnny to stop hitting his peers”
DISORDERS OF CHILDHOOD
Patterson’s parent training for ODD & CD
Focusing on the positive – alternative, incompatible behaviours
• yelling
• whining
• interrupting
• non-compliance
DISORDERS OF CHILDHOOD
Patterson’s parent training – key focus is on obtaining compliance from child
• commands vs. requests
• positive reinforcement (praise)
• extinction (ignoring)
• punishment (timeout)
DISORDERS OF CHILDHOOD
Community Parent Education Program (COPE) for ODD & CD – Cunningham et al.
(1993)
• parent training in schools and community centres
• school-based intervention
DISORDERS OF CHILDHOOD
Other treatments for ODD & CD
• Problem-solving skills training
• Family therapy – multisystemic therapy
• the earlier the treatment, the better long-term prognosis
DISORDERS OF CHILDHOOD
Separation Anxiety Disorder
• only SAD remains in DSM-IV as an anxiety disorder unique to childhood
• distress upon being separated from a parent or fears that parent will be harmed
• average age of onset is 9
• typically occurs after a major stressor
DISORDERS OF CHILDHOOD
SAD – Diagnosis and assessment
• severe and excessive anxiety when faced with separation from a parent
• also related to mood problems, school refusal, somatic complaints
• need for multi-dimensional assessment
DISORDERS OF CHILDHOOD
SAD – Long-term development
• social withdrawal, poor school performance
• not much known about long-term course if left untreated, possibly related to adult anxiety disorders such as agoraphobia and panic disorder
DISORDERS OF CHILDHOOD
SAD – Etiology
• strong heritability component, concordance for anxiety disorders is 3 times higher in MZ than DZ twins