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Lecture 11

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  • 1. Developmental and Cognitive Disorders Chapter 13
  • 2. Perspectives on Developmental Disorders
    • Normal vs. Abnormal Development
      • Childhood is associated with significant developmental changes
      • Disruption of early skills will likely disrupt development of later skills
    • Developmental Disorders
      • Diagnosed first in infancy, childhood, or adolescence
      • Attention deficit hyperactivity disorder (ADHD)
      • Learning disorders
      • Autism
      • Mental retardation
  • 3. Attention Deficit Hyperactivity Disorder (ADHD): An Overview
    • Nature of ADHD
      • Central features – Inattention, overactivity, and impulsivity
      • Associated with behavioral, cognitive, social, and academic problems
    • DSM-IV and DSM-IV-TR Symptom Clusters
      • Cluster 1 – Symptoms of inattention
      • Cluster 2 – Symptoms of hyperactivity and impulsivity cluster
      • Either cluster 1 or 2 must be present for a diagnosis
  • 4. ADHD: Facts and Statistics
    • Prevalence
      • Occurs in 4%-12% of children who are 6 to 12 years of age
      • Symptoms are usually present around age 3 or 4
      • 68% of children with ADHD have problems as adults
    • Gender Differences
      • Boys outnumber girls 4 to 1
    • Cultural Factors
      • Probability of ADHD diagnosis is greatest in the United States
  • 5. ADHD: Biological Contributions
    • Genetic Contributions
      • ADHD runs in families
      • Familial ADHD may involve deficits on chromosome 20
    • Neurobiological Contributions: Brain Dysfunction and Damage
      • Inactivity of the frontal cortex and basal ganglia
      • Right hemisphere malfunction
      • Abnormal frontal lobe development and functioning
      • Yet to identify a precise neurobiological mechanism for ADHD
    • The Role of Toxins
      • Allergens and food additives do not appear to cause ADHD
      • Maternal smoking increases risk of having a child with ADHD
  • 6. ADHD: Psychosocial Contributions
    • Psychosocial Factors Can Influence the Disorder Itself
      • Constant negative feedback from teachers, parents, and peers
      • Peer rejection and resulting social isolation
      • Such factors foster low self-image
  • 7. Biological Treatment of ADHD
    • Goal of Biological Treatments
      • To reduce impulsivity/hyperactivity and to improve attention
    • Stimulant Medications
      • Reduce the core symptoms of ADHD in 70% of cases
      • Examples include Ritalin, Dexedrine
    • Effects of Medications
      • Improve compliance and decrease negative behaviors in many children
      • Beneficial effects are not lasting following drug discontinuation
      • Negative side effects include insomnia, drowsiness, and irritability
  • 8. Behavioral and Combined Treatment of ADHD
    • Behavioral Treatment
      • Involve reinforcement programs
      • Aim to increase appropriate behaviors and decrease inappropriate behaviors
      • May also involve parent training
    • Combined Bio-Psycho-Social Treatments
      • Are highly recommended
  • 9. Learning Disorders
    • Scope of Learning Disorders
      • Problems related to academic performance in reading, mathematics, and writing
      • Performance is substantially below what would be expected
    • DSM-IV and DSM-IV-TR Reading Disorder
      • Discrepancy between actual and expected reading achievement
      • Reading is at a level significantly below that of a typical person of the same age
      • Problem cannot be caused by sensory deficits (e.g., poor vision)
    • DSM-IV and DSM-IV-TR Mathematics Disorder
      • Achievement below expected performance in mathematics
    • DSM-IV and DSM-IV-TR Disorder of Written Expression
      • Achievement below expected performance in writing
  • 10. Learning Disorders: Some Facts and Statistics
    • Incidence and Prevalence of Learning Disorders
      • 1% to 3% incidence of learning disorders in the United States
      • Prevalence is highest in wealthier regions of the United States
      • Prevalence rate is 10% to 15% among school age children
      • Reading difficulties are the most common of the learning disorders
      • About 32% of students with learning disabilities drop out of school
      • School experience for such persons tends to be quite negative
  • 11. Biological and Psychosocial Causes of Learning Disorders
    • Genetic and Neurobiological Contributions
      • Reading disorder runs in families, with 100% concordance rate for identical twins
      • Evidence for subtle forms of brain damage is inconclusive
      • Overall, genetic and neurobiological contributions are unclear
    • Psychological and motivational factors seem to affect eventual outcome
  • 12. Treatment of Learning Disorders
    • Requires Intense Educational Interventions
      • Remediation of basic processing problems (e.g., teaching visual skills)
      • Efforts to improve of cognitive skills (e.g., instruction in listening)
      • Targeting behavioral skills to compensate for problem areas
    • Data Support Behavioral Educational Interventions for Learning Disorders
  • 13. Pervasive Developmental Disorders: An Overview
    • Nature of Pervasive Developmental Disorders
      • Problems occur in language, socialization, and cognition
      • Pervasive – Means the problems span the person’s entire life
    • Examples of Pervasive Developmental Disorders
      • Autistic disorder
      • Asperger’s syndrome
  • 14. Autistic Disorder
    • Autism
      • Significant impairment in social interactions and communication
      • Restricted patterns of behavior, interest, and activities
    • Three Central DSM-IV and DSM-IV-TR Features of Autism
      • Problems in socialization and social function
      • Problems in communication – 50% never acquire useful speech
      • Restricted patterns of behavior, interests, and activities
  • 15. Autistic Disorder: Facts and Statistics
    • Prevalence and Features of Autism
      • Affects 2 to 20 persons for every 10,000 people
      • More prevalent in females with IQs below 35, and in males with higher IQs
      • Autism occurs worldwide
      • Symptoms usually develop before 36 months of age
    • Autism and Intellectual Functioning
      • 50% have IQs in the severe-to-profound range of mental retardation
      • 25% test in the mild-to-moderate IQ range (i.e., IQ of 50 to 70)
      • Remaining people display abilities in the borderline-to-average IQ range
      • Better language skills and IQ test performance predicts better lifetime prognosis
  • 16. Causes of Autism: Early and More Recent Contributions
    • Historical Views
      • Bad parenting
      • Unusual speech patterns
      • Lack of self-awareness
      • Echolalia
    • Current Understanding of Autism
      • Medical conditions – Not always associated with autism
      • Autism has a genetic component that is largely unclear
      • Neurobiological evidence for brain damage – Link with mental retardation
      • Cerebellum size – Substantially reduced in persons with autism
  • 17. Treatment of Pervasive Developmental Disorders
    • Psychosocial “Behavioral” Treatments
      • Skill building and treatment of problem behaviors
      • Communication and language problems
      • Address socialization deficits
      • Early intervention is critical
    • Biological and Medical Treatments Are Unavailable
    • Integrated Treatments: The Preferred Model
      • Focus on children, their families, parents, schools, and the home
      • Build in appropriate community and social support
  • 18. Mental Retardation (MR)
    • Nature of Mental Retardation
      • Disorder of childhood
      • Below-average intellectual and adaptive functioning
      • Range of impairment varies greatly across persons
    • Mental Retardation and the DSM-IV and DSM-IV-TR
      • Significantly subaverage intellectual functioning ( IQ below 70 )
      • Concurrent deficits or impairments two or more areas of adaptive functioning
      • MR must be evident before the person is 18 years of age
  • 19. DSM-IV and DSM-IV-TR Levels of Mental Retardation (MR)
    • Mild MR
      • Includes persons with an IQ score between 50 or 55 and 70
    • Moderate MR
      • Includes persons in the IQ range of 35-40 to 50-55
    • Severe MR
      • Includes people with IQs ranging from 20-25 up to 35-40
    • Profound MR
      • Includes people with IQ scores below 20-25
  • 20. Other Classification Systems for Mental Retardation (MR)
    • American Association of Mental Retardation (AAMR)
      • Defines MR based on levels of assistance required
      • Examples of levels include intermittent, limited, extensive, or pervasive assistance
    • Classification of MR in Educational Systems
      • Educable mental retardation (i.e., IQ of 50 to approximately 70-75)
      • Trainable mental retardation (i.e., IQ of 30 to 50)
      • Severe mental retardation (i.e., IQ below 30)
  • 21. Mental Retardation (MR): Some Facts and Statistics
    • Prevalence
      • About 1% to 3% of the general population
      • 90% of MR persons are labeled with mild mental retardation
    • Gender Differences
      • MR occurs more often in males, male-to-female ratio of about 1.6:1
    • Course of MR
      • Tends to be chronic, but prognosis varies greatly from person to person
  • 22. Mental Retardation (MR): Biological Contributions
    • Genetic Research
      • MR involves multiple genes, and at times single genes
    • Chromosomal Abnormalities and Other Forms of MR
      • Down syndrome – Trisomy 21
      • Fragile X syndrome – Abnormality on X chromosome
    • Maternal Age and Risk of Having a Down’s Baby
    • Nearly 75% of cases cannot be attributed to any known biological cause
  • 23. Mental Retardation (MR): Psychosocial Contributions
    • Cultural-Familial Retardation
      • Believed to cause about 75% of MR cases and is the least understood
      • Associated with mild levels of retardation on IQ tests and good adaptive skills
    • Cultural-Familial Retardation: Difference vs. Developmental Views
      • Difference view – Mild MR is a matter of degree and kind
      • Developmental view – Mild MR reflects a slowing or delay of normal development
  • 24. Treatment of Mental Retardation (MR)
    • Parallels Treatment of Pervasive Developmental Disorders
      • Teach needed skills to foster productivity and independence
      • Educational and behavioral management
      • Living and self-care skills via task analysis
      • Communication training – Often most challenging treatment target!
      • Community and supportive interventions
    • Persons with MR Can Benefit from Such Interventions
  • 25. Summary of Developmental Disorders
    • Developmental Psychopathology and Normal and Abnormal Development
    • Attention Deficit Hyperactivity Disorder
      • Deficits in inattention, hyperactivity, or impulsivity
      • Disrupt academic and social functioning
    • Learning Disorders
      • All share deficits in performance below expectations for IQ and school preparation
    • Pervasive Developmental Disorder
      • All share deficits in language, socialization, and cognition
    • Mental Retardation
      • Subaverage IQ, deficits in adaptive functioning, onset before age 18
      • Prevention and Early Intervention Are Critical for Developmental Disorders
  • 26. Cognitive Disorders: An Overview
    • Perspectives on Cognitive Disorders
      • Affect cognitive processes such as learning, memory, and consciousness
      • Most develop later in life
    • Three Classes of Cognitive Disorders
      • Delirium – Often temporary confusion and disorientation
      • Dementia – Degenerative condition marked by broad cognitive deterioration
      • Amnestic disorders – Memory dysfunctions caused by disease, drugs, or toxins
    • Shifting DSM Perspectives
      • From “organic” mental disorders to “cognitive” disorders
      • Broad impairments in memory, attention, perception, and thinking
      • Profound changes in behavior and personality
  • 27. Delirium
    • Nature of Delirium
      • Central features – Impaired consciousness and cognition
      • Impairments develop rapidly over several hours or days
      • Examples include confusion, disorientation, attention, memory, and language deficits
    • Facts and Statistics
      • Affects 10% to 30% of persons in acute care facilities
      • Most prevalent in older adults, AIDS patients, and medical patients
      • Full recovery often occurs within several weeks
  • 28. 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
    • DSM-IV and DSM-IV Subtypes of Delirium
      • Delirium due to a general medical condition
      • Substance-induced delirium
      • Delirium due to multiple etiologies
      • Delirium not otherwise specified
  • 29. Treatment and Prevention of Delirium
    • Treatment
      • Attention to precipitating medical problems
      • Psychosocial interventions include reassurance, coping strategies
    • Prevention
      • Address proper medical care for illnesses
      • Address proper use and adherence to therapeutic drugs
  • 30. Dementia
    • Nature of Dementia
      • Gradual deterioration of brain functioning
      • Affects judgment, memory, language, and advanced cognitive processes
      • Dementia has many causes and may be reversible or irreversible
    • Progression of Dementia: Initial Stages
      • Memory impairment, visuospatial skills deficits
      • Agnosia – Inability to recognize and name objects (most common symptom)
      • Facial agnosia – Inability to recognize familiar faces
      • Other symptoms – Delusions, depression, agitation, aggression, and apathy
    • Progression of Dementia: Later Stages
      • Cognitive functioning continues to deteriorate
      • Person requires almost total support to carry out day-to-day activities
      • Death results from inactivity combined with onset of other illnesses
  • 31. Dementia: Facts and Statistics
    • Onset and Prevalence
      • Can occur at any age, but most common in the elderly
      • Affects 1% of those between 65-74 years of age
      • Affects over 10% of persons 85 years and older
      • 47% of adults over the age of 85 have dementia of the Alzheimer’s type
    • Incidence of Dementia
      • Affects 2.3% of those 75-79 years of age and 8.5% of persons 85 and older
      • Rates of new cases appear to double with every 5 years of age
    • Gender and Sociocultural Factors
      • Dementia occurs equally in men and women
      • Dementia occurs equally across educational level and social class
  • 32. DSM-IV and 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
  • 33. Dementia of the Alzheimer’s Type
    • DSM-IV-TR Criteria and Clinical Features
      • Multiple cognitive deficits that develop gradually and steadily
      • Predominant impairment in memory, orientation, judgment, and reasoning
      • Can include agitation, confusion, depression, anxiety, or combativeness
      • Symptoms are usually more pronounced at the end of the day
    • Range of Cognitive Deficits
      • Aphasia – Difficulty with language
      • Apraxia – Impaired motor functioning
      • Agnosia – Failure to recognize objects
      • Difficulties with planning, organizing, sequencing, or abstracting information
      • Impairments have a marked negative impact on social and occupational functioning
    • An Autopsy Is Required for a Definitive Diagnosis
  • 34. Alzheimer’s Disease: Some Facts and Statistics
    • Nature and Progression of the Disease
      • Deterioration is slow during the early and later stages, but rapid during middle stages
      • Average survival time is about 8 years
      • Onset usually occurs in the 60s or 70s, but may occur earlier
    • Prevalence of Alzheimer’s Disease
      • Affects about 4 million Americans and many more worldwide
      • Prevalence is greater in poorly educated persons and women
      • Prevalence rates are low in some ethnic groups (e.g., Japanese, Nigerian, Amish)
  • 35. Vascular Dementia
    • Nature of Vascular Dementia
      • Progressive brain disorder 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, and most require formal care in later stages
    • DSM-IV and DSM-IV Criteria and Incidence
      • Cognitive disturbances are identical to dementia
      • Unlike Alzheimer’s, obvious neurological signs of brain tissue damage occur
      • Incidence is believed to be about 4.7% or men and 3.8% of women
  • 36. Dementia Due to HIV Disease
    • Overview and Clinical Features
      • HIV causes neurological impairments and dementia
      • Cognitive slowness, impaired attention, forgetfulness, and clumsiness
      • Repetitive movements (e.g., tremors/leg weakness), apathy, and social withdrawal
    • Progression of HIV-Related Cognitive Impairments
      • Tend to occur during the later stages of HIV infection
      • Impairments are observed in 29% to 87% of people with AIDS
      • Subcortical dementia – Refers to deficits that affect inner brain regions
      • Aphasia is uncommon in subcortical dementia, but anxiety and depression occur
  • 37. Other Causes of Dementia: Head Trauma and Parkinson’s Disease
    • Head Trauma
      • Accidents are leading causes of such cognitive impairments
      • Memory loss is the most common symptom
    • Parkinson’s Disease
      • Degenerative brain disorder
      • Affects about 1 out of 1,000 people worldwide
      • Motor problems are characteristic of this disorder
      • Damage to dopamine pathways is believed to cause motor problems
      • Pattern of impairments are similar to subcortical dementia
  • 38. Other Causes of Dementia: Huntington’s and Pick’s Disease
    • Huntington’s Disease
      • Genetic autosomal dominant disorder (i.e., chromosome 4)
      • Manifests initially as chorea, usually later in life (around 40s or 50s)
      • About 20% to 80% of persons go on to display dementia of the subcortical pattern
    • Pick’s Disease
      • Rare neurological condition that produces a cortical dementia like Alzheimer’s
      • Also occurs later in life (around 40s or 50s)
      • Little is known about what causes this disease
  • 39. Other Dementias: Creutzfeldt-Jakob Disease and Substance-Induced Dementia
    • Creutzfeldt-Jakob Disease
      • Affects 1 out of 1,000,000 persons
      • Linked to mad cow disease
    • Substance-Induced Persisting Dementia
      • Results from drug use in combination with poor diet
      • Examples include alcohol, inhalants, and sedative, hypnotic, and anxiolytic drugs
      • Resulting brain damage may be permanent
      • Dementia is similar to that of Alzheimer’s
      • Deficits may include aphasia, apraxia, agnosia, or disturbed executive functioning
  • 40. Causes of Dementia: The Example of Alzheimer’s Disease
    • Early and Largely Unsupported Views: The Example of Smoking
    • Current Neurobiological Findings
      • Neurofibrillary tangles – Occur in all brains of Alzheimer’s patients
      • Amyloid plaques – Accumulate excessively in brains of Alzheimer’s patients
      • Brains of Alzheimer’s patients tend to atrophy
    • Current Neurobiological Findings
      • Multiple genes are involved in Alzheimer’s disease (chromosomes 21, 19, 14, 12, 1)
      • Chromosome 14 – Associated with early onset Alzheimer’s
      • Chromosome 19 – Associated with a late onset Alzheimer’s
  • 41. The Contributions of Psychosocial Factors in Dementia
    • Do not cause dementia directly, but may influence onset and course
    • Lifestyle factors – Drug use, diet, exercise, stress
    • Cultural factors – Risk for certain diseases and accidents vary by ethnicity and class
    • Psychosocial factors – Educational attainment, coping skills, social support
  • 42. Medical and Psychosocial Treatment of Dementia
    • Medical Treatment: Best if Enacted Early
      • Few medical treatments exist for most types of dementia
      • Most medical treatments attempt to slow progression of deterioration
      • Examples include glial cell-derived neurotrophic factor, Cognex, vitamin E, aspirin
      • Medical treatments do not stop progression of dementia
    • Psychosocial Treatments
      • Focus on enhancing the lives of dementia patients and their families/caregivers
      • Teach adaptive skills
      • Use memory enhancement prosthetic devices (e.g., memory wallet)
      • Main emphasis of psychosocial interventions appears to be on the caregivers
  • 43. Prevention of Dementia
    • Reducing Risk of Dementia in Older Adults Via
      • Estrogen-replacement therapy – Reduces risk of Alzheimer’s dementia in women
      • Proper treatment of cardiovascular diseases
      • Use of anti-inflammatory medications
    • Other Targets of Prevention Efforts
      • Increasing safety behaviors to reduce head trauma
      • Reducing exposure to neurotoxins and use of drugs
  • 44. Amnestic Disorder
    • Nature of Amnestic Disorder
      • Inability to transfer information from short-term memory into long-term memory
      • Often results from medical conditions, head trauma, or long-term drug use
    • DSM-IV and DSM-IV-TR Criteria for Amnestic Disorder
      • Cover the inability to learn new information
      • Inability to recall previously learned information
      • Memory disturbance causes significant impairment in functioning
    • The Example of Wernicke-Korsakoff Syndrome
      • Caused by thalamic damage resulting from stroke or chronic heavy alcohol use
      • Attempt to restore thiamine deficiency in the case of chronic alcohol abuse
    • Research on Amnestic Disorders Is Scant

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