DSM Disorders in Children

ADHD + Behavioural Disorders

Classical ConditioningPavlov

Dog is presented with meat powder to make it salivate

Meat powder = Unconditioned Stimulus (UCS) Salivation = Unconditioned Response (UCR)

A bell is rung before UCS is presented Bell = Neutral Stimulus (NS)

Repetition leads to salivation on hearing the bell before any meat powder is presented

Bell = Conditioned Stimulus (CS) Salivation = Conditioned Response (CR)

Classical ConditioningLittle Albert

Rat is presented to 11 month old boy who plays with it happily

Rat = Neutral Stimulus (NS)Loud steel bar is struck behind Albert’s head

after presenting with rat Loud noise = Unconditioned Stimulus (UCS) Fear = Unconditioned Response (UCR)

After 5 times, Albert shows extreme fear on presentation of the rat

Rat = Conditioned Stimulus (CS)

BehaviourismBehaviourism is the study of learning

i.e. Observable behaviour

Law of Effect:Behaviour that is followed by consequences

satisfying to the organism will be repeated, and behaviour that is followed by unpleasant consequences will be discouraged

Operant ConditioningBehaviour operates on the environment. All behaviour, internal or external, can be

explained by the environmental consequences it produces

“Stimulus-Response” becomes “Response-Consequence”

Freedom of choice is a myth and all behaviour is determined by the reinforcers provided by the environment

BehaviourismReinforcement

Positive Reinforcement Strengthening a tendency to respond in anticipation of

a pleasant event (reinforcer)Negative Reinforcement

Strengthens a response by removing an aversive eventModeling – e.g. sharing, aggression, fear.

PunishmentCan lead to anxious responses, or be taken as a

reinforcer if followed by a reinforcer E.g. Child may seek punishment or abuse because the

guilty parent may follow it with love

Behavioural TherapyExtinction: Fading out of conditioned

response through appropriate reinforcement

Counterconditioning: Eliciting a new response to a stimulus, using positive reinforcersSystematic Desensitization:

1. Deep muscle relaxation Gradual exposure

Aversive conditioning: Pairing an attractive stimulus with an unpleasant event

Skinner (1948) The Superstitious PigeonEight pigeons received reward every 15 seconds

One bird conditioned to turn counter-clockwise One repeatedly thrust its head into the upper

corner of the cage Pendulum motion “dance” Incomplete pecking movements

Reinforcement interval increased to one minute

Movements became more energeticExtinction

Took up to 10,000 responses before extinction occurred in one case

Skinner (1948)Non-contingent reinforcement

Behaviour is accidentally reinforced leading to a belief in a causal relationship between behaviour and reward

A relationship does still exist between the reward and the subject

Can produce a feeling of strength and control, reduce anxiety, improve performance

Locus of ControlAs a child develops, behaviours are

learned which are followed by some form of reinforcement

Reinforcement increases child’s expectancy that behaviour will produce desired reinforcement

External locus of controlInterpreting consequence as controlled by

luck, fate or powerful othersInternal locus of control

Interpreting ones own behaviour and personality as responsible for consequences

Applied Behaviour AnalysisImproves level of functioning in Mental

Retardation, learning Disabilities and AutismTarget behaviour is reinforced in small levels

(e.g. Eating – picking up spoon, scooping food, moving spoon to mouth, remove with lips etc)

Inappropriate and self-injurious behaviour is reduced (e.g. rocking, swaying, aggression)

Can bring children with severe cases of Autism to basic levels of social functioning by age 7.

http://www.youtube.com/watch?v=I_ctJqjlrHA

http://www.youtube.com/watch?v=gbH_jpYlYew

http://www.youtube.com/watch?v=hulVH9jpR8k

http://www.youtube.com/watch?v=PPWL5yimhyg

Stage 3: 18 months – 4 yearsSecurity in seperateness allows

the child to experiment with their own volition

Conscious self begins to emerge development of the ego

Beginning of control of impulses delayed gratification

Development of language

Stage 3: Language

Sub-units of behaviour (stimulus-response/response-consequence) are organised into patterns/sets Cause & Effect according with

environmentExploration of environment begins

formation of cognitive mapOperant units store in cognitive

mapsAssociated with neural learning

networks (enhanced with stimulation)

Stage 3: Operant Units

A - B - Cwordpicture object

Association of arbitrary units

C - AObject word

Backward associationMost important evolutionary leap in

development of human language which is apparently unique to the human

Stage 3: LanguagePrimary language - images and emotionsCognitive language develops from

associations of arbitrary units, not only by direct teaching

Early associations will be more general, ◦ e.g. “Dog” may become the word for any

external object, or any black object◦ “Dada” may refer to all males

Psychological associations become more complex, arising in logical thought

Memory as we know it may correspond with the development of language, hence people “not remembering” their early years

Stage 3: WillAs identity separates into an

individual unit, the child develops the power to choose their own actions

Action-Consequence I am what I do

Good-bad associations with self (pleasure/ guilt) are controlled by the inner executive (central executive functions)

The right to act in awareness of punishment and obedience ◦E.g. the hot stove

Stage 3: TraumaImproperly restricting the child

may result in decreasing will, thus decreasing spontaneity and confidence

May cause stunting of inner authority – the right to be free

Stage 3: Comparative models

Erikson: Autonomy vs shame and guilt

Reich/Lowen: Masochist (Endurer) structure◦Psychopath challenger-defender

Stage 3: Comparative modelsPiaget: Preoperational

◦Increase in speed of movement and thought

◦Symbolic thought and language development

◦“Magic” thought◦Animism (living objects)◦Egocentric world-view

Stage 3: Comparative models

Freud: Anal stage◦ Toilet training: obsession with the erogenous

zone of the anus with retention or expulsion of feces

◦ Social pressures put on internal pleasure◦ Stubbornness or malicious excretion◦ Anal expulsive character: messy, disorganised,

careless and defiant◦ Anal retentive character: neat, precise, orderly,

careful, with-holding, passive-aggressive◦ Possession and attitudes towards authority

Freud

Freud did not reach his discoveries through a clearly defined scientific methodology

Careful observations of patients over decades of clinical analysis

Many Freudian theories cannot be tested scientifically

Many are proven to be unreliable

Freudian Personality Structure

Id Basic biological urges – hunger, thirst, sexual impulse

Pleasure principle Immediate gratification, regardless of reason, logic,

safety or morality Constantly seeks expression Operates at an unconscious level

Eros and Thanatos

Freudian Theory

Ego Limits and controls the impulses of the id

Reality Principle Alert to the real world (conscious) and the consequences

of behaviour Satisfies id’s urges using rational means which are

reasonably safe and socially acceptable

Freudian Theory

Superego Limits the ego to moral and ethical internalised rules

between good and bad. Instilled by your parents (locus of control) Conscience – controls with guilt Operates on both conscious and unconscious levels

Freudian Theory

The ego tries to balance the needs and urges of the id with the moral requirements of the superego

Psychopathology is an imbalance or malfunction, usually if the demands of the id are too strong to be controlled

Anxiety arises with fear – free-floating anxiety causing the onset of defense mechanisms

Defense Mechanisms

Psychological mechanisms to protect against anxiety

Self-deceiving and reality-distorting Repression Regression Projection Reaction Formation Sublimation

Defense Mechanisms

Repression Forcing disturbing thoughts out of consciousness Anxiety associated with “forbidden” thoughts is

avoided – usually sexual desires Hidden conflicts may be revealed through slips of the

tongue, dreams, psychoanalysis, free association or hypnosis

Psychological problems can arise in the form of neuroses

Defense Mechanisms

Regression Ego guards against anxiety by causing the person to

retreat to the behaviour of an earlier stage of development

Earlier speech patterns, childlike behaviour Mid-life crises Going home to mother when there is a marriage

problem

Defense Mechanisms

Projection Unconscious urges are noted in other people’s

behaviour Externalising anxiety-provoking feelings to reduce

anxiety E.g. Husband feeling impulses of being unfaithful may

project his desires onto his wife by becoming insanely jealous and angry

Projections are truly believed

Defense Mechanisms

Reaction Formation “The Lady doth protest too much, me thinks” Engages in behaviours that are the exact opposite of

the id’s real urges Exaggerated or obsessive Complete rejection blocks anxiety E.g. homophobia – gay bashing

Defense Mechanisms

Sublimation Finding socially acceptable ways of discharging

energy that is the result of unconscious forbidden desires

Necessary for a productive and healthy life Through evolution of civilisation, humans sublimate

their primitive biological impulses

Freudian Theory

Ramachandran (1995) examined a neuropsychological cause of repression in paralysed patients Patients who are paralysed on one half of their body

who show repression Always choose impossible two-handed tasks instead of

one-handed tasks Show no disappointment when they fail Vestibular irrigation brought back repressed feelings

in some patients

Freudian Theory

Homophobia Homophobics more aroused by homosexual stimulus

than non-homophobics Under-report their arousal

Anna Freud and others have written extensively on Freudian theory and focused it into scientifically testable areas

ATTENTION DEFICIT/HYPERACTIVITY DISORDER

Attention Deficit: difficulty sitting still (e.g. class/meals)

Hyperactivity: unable to stop moving or talking

Description:

- Disorganised, erratic, tactless, obstinate and bossy- Difficulty getting along with peers and establishing friendships- (in part due to: ) aggressiveness, annoying and intrusive behaviours- different social goals (e.g. sensation seeking over team-work)- Miss social cues (may recognise social cues in cognitive exercises but not in actuality)

3 – 7% of school-age children worldwide

ATTENTION DEFICIT/HYPERACTIVITY DISORDER

15 – 30% of children with ADHD have a learning disability in math, reading or spelling

Often put in special education because of difficulty with classroom environment

Overlap of 30-90% between ADHD and Conduct Disorder

ADHD is associated with earlier age of onset of Conduct Disorder symptoms

ATTENTION DEFICIT/HYPERACTIVITY DISORDER

30% of ADHD diagnoses comorbid with internalizing disorders (e.g. Depression and anxiety)

65-80% of children with ADHD still meet criteria for the disorder in adolescence.

Up to 50% of children meet the criteria in adulthood (Rates vary depending on method of assessment)

DIAGNOSIS OF ADHD

1. Predominately Inattentive type2. Predominately Hyperactive-Impulsive

type3. Combined type

ETIOLOGY OF ADHD Genetics:

Heritability estimates as high as 70-80% 50% of children from ADHD parents are likely to have it Genetic evidence associated with Dopamine

neurotransmitter

Neurobiology:

Frontal Lobe Dysfunction:

- Lobes are under-responsive, under-sized.- Cerebral blood flow is reduced Tobacco/Nicotine:

- Environmental toxins, food additives, Lead poisoning- Low birth weight and maternal coldness

ETIOLOGY OF ADHD

Psychology: Parent-Child relationships:

- Commanding, negative parents AND less compliant, negative kids- Child behaviour has a negative effect on parents’ behaviour

TREATMENT OF ADHD

Stimulant Medications:- Methylphenidate (MPH)

e.g. Ritalin, Adderall- Reduce disruptive behaviour- Improve concentration and goal-directed activity in 75% of cases- 80% of 11 million prescriptions between 1996-2000 were for children diagnosed with ADHD (problems with diagnosis?)- Side-effects: loss of appetite, sadness, headaches, stomach aches

TREATMENT OF ADHD

Psychological Treatment- Behavioural conditioning (point systems, reward charts, etc)

Combinations most effective cross-culturally

CONDUCT DISORDER(INCLUDING OPPOSITIONAL DEFIANT DISORDER)

Description: - Aggression and cruelty toward people or animals, damaging property, lying and stealing- Callousness, viciousness, lack of remorse Adult antisocial personality disorder

4-16% of boys, 1.2-9% of girlsBehaviour peaks at 17 and reduces in young

adulthood

CONDUCT DISORDER

Life-course Persistent form: shows problems from age 3 into adulthood

Adolescent limited

15-45% comorbidity with Anxiety and Depression

Most likely to occur with parent of low verbal intelligence or antisocial personality disorder

ETIOLOGY OF CONDUCT DISORDER

Genetic: Vague and mixed

MAOA gene – Monoamine Oximade enzyme metabolizes neurotransmitters.

Children who have low MAOA activity AND are maltreated are more likely to develop conduct disorder

ETIOLOGY OF CONDUCT DISORDER

Neurobiological Poor verbal skills Executive functioning (self-control,

planning) Memory problems

ETIOLOGY OF CONDUCT DISORDER

Psychological “Moral Awareness”

Guilt, altruism Physical abuse Reinforcers

Agression reinforced by achieving a goal Interpretation of ambiguous acts as aggressive Peer groups

Harsh and inconsistent parental discipline Sociocultural factors – educational facilities, family

life, neighbourhoods etc

TREATMENT OF CONDUCT DISORDER Parental Management Training (PMT) Multisystemic Treatment

Family, school, community and peers Cognitive therapy

Anger management, etc.