Mental Illness - Childhood disorders

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The classification of abnormal behavior in childhood depends greatly on development in terms of what is and is not considered normal behavior for a child at a certain age. This often makes it difficult to diagnose certain disorders of childhood as children develop at different rates and only a qualified therapist can make the distinction between what is appropriate and inappropriate behavior. Also, childhood disorders can be a sensitive subject,

particularly learning disorders, as parents and children are afraid of the social stigma (shame) that often comes with a diagnosis. Children and adolescents strive for acceptance, and any indication of being different or being separated into "special" classes can have devastating effects on a child's self-esteem and the reaction of his or her peers to the situation.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) and other sources categorize the following conditions as "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" or simply "Childhood Disorders"; technically, there isn't any difference between these disorders and other mental disorders except for the higher incidence of diagnosis in childhood rather than adulthood.

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a disorder that involves difficulty in concentrating and overall inattentiveness. ADHD affects people of all ages but is usually diagnosed in childhood. This condition has received a great deal of attention in the media in the last ten to fifteen years, because there has been a marked increase in the number of diagnoses of this disorder by mental health practitioners in recent years. No longer seen just as a problem centering around hyperactivity, or excessive activity, the focus of ADHD is also on a child's difficulty in concentrating on tasks at hand. While most children have notoriously short spans of attention, children battling ADHD have increased difficulty controlling their level of activity and attention particularly in situations that call for maintaining a certain degree of composure, such as in the classroom or in public places like restaurants.

ADHD makes it difficult for sufferers to sit still or even to stop talking. When they are called upon to be quiet and remain seated, they might squirm, fidget, tap their hands, swing their feet and legs, and make noise. The diagnosis is often difficult to make, as most children can be full of energy, particularly during times of play. However, children suffering from ADHD are disorganized, bossy and ill-mannered more often than the average child. Because of the increased prevalence of this diagnosis in recent years, there has

been the suggestion that children who are appropriately energetic, hard to handle, or suffering from a conduct disorder (see below) are being given a diagnosis of ADHD unnecessarily. This assessment, however, is difficult to quantify or prove. Furthermore, the Council on Scientific Affairs of the American Medical Association has investigated the issue and determined that while there isn't a concern for general overdiagnosis, some students belonging to minority groups are being diagnosed at a disproportionate rate.

SYMPTOMS. According to the DSM, IV some of the symptoms of ADHD include lack of attention to details; difficulty paying attention in school or at play; not paying attention when being spoken to; not following through on instructions or failure to finish things; disorganization, forgetfulness, losing or misplacing important things; fidgeting excessively; difficulty in playing quietly; excessive talking, difficulty in awaiting turn, and a tendency to interrupt others. In order to be diagnosed with ADHD, more than one of these symptoms must be present, and those symptoms must be creating a specific problem for the sufferer (lack of friends, poor performance in school, etc.).

CAUSES. Although there is no known single cause for ADHD, there are theories as to why certain children develop ADHD while others do not. Some experts propose that ADHD is inherited, while others have blamed the development of the disorder on environmental toxins, such as food additives or nicotine while a child is growing in the mother's womb. Psychological causes may include demanding, authoritative parenting that creates stress and triggers the development of ADHD.

TREATMENTS. ADHD has been treated effectively with certain drugs, including Ritalin, a stimulant that helps improve concentration, behavior, and directed activities. However, Ritalin's effectiveness has not been proven for the long term and some researchers have suggested that Ritalin actually hampers a child's creativity. Operant conditioning (see Chapter 15: Mental Health Therapies) has also been successful in helping those with ADHD. This therapy, which centers on rewarding good behavior, supports the belief that ADHD means that a child has a lack of basic skills to help him or her be effective, rather than the belief that a child simply has too much energy.

Conduct Disorder

Although conduct disorders cover a wide array of "bad" behaviors, the underlying principle of the diagnosis is that an individual exhibits inappropriate behaviors that violate the basic rights of other people. These are behaviors that fall outside the scope of normal childhood pranks and mischief; rather, conduct disorder includes behavior that is often vicious, and sufferers typically display no remorse (regret or guilt for having done something wrong), something that links conduct disorder to antisocial personality disorder or psychopathy (see section on Personality Disorders below).

In addition to the dysfunctional behaviors they exhibit, people with conduct disorders do not possess a great deal of empathy (understanding of other people's feelings) for others. Sufferers may also mistakenly think others are behaving aggressively toward them when they are not. Although an individual might seem to have a tough exterior, that person may in fact have low self-esteem, another feature common to those with conduct disorder. Recklessness, angry outbursts, and the tendency to get easily frustrated are also common traits of this problem.

SYMPTOMS. The DSM, IV splits conduct disorder into four categories: aggression toward people and animals (bullying, fighting, use of weapons, physical cruelty to both, stealing, and forced sexual contact); destruction of property (setting fires and destroying property deliberately through another method); deceitfulness or theft (breaking and entering, lying, covert stealing[e.g., forging a check]); and serious violations of rules (staying out past curfew at a young age, running away from home, and cutting school).

CAUSES. Just as with ADHD, there is no known single cause for conduct disorders, but there are theories as to why certain children develop conduct disorders while others do not. One theory is that conduct disorder may be an inherited ailment. Another possibility is that there is a lack of moral awareness in the family of origin of a person suffering from conduct disorder. In general, children learn what is right and wrong and refrain from breaking the boundaries of decency because they have been taught that it is wrong to hurt others. If, for whatever reason, these lessons are not learned in the home, a conduct disorder, and even more ominous psychological problems could develop. Furthermore, a child may witness disordered conduct from his or her parents and learn aggressive, improper behavior. Other researchers have postulated that children prone to developing conduct disorder could have flawed thinking processes. That is, very aggressive children may perceive an otherwise harmless event (for instance, being last in a line) as a slight, place unusual importance on the event, and hold a grudge because of the occurrence.

TREATMENTS. The most successful treatments of conduct disorders involve treating not just the child (or adult) but rather those around him or her as well (family and, in some cases, friends). Cognitive therapy, a form of therapy in which a therapist helps a patient become aware of maladaptive thinking and flawed belief systems and helps change beliefs that can interfere with healthy living (see Chapter 15: Mental Health Therapies), may also improve behavior as can teaching children moral reasoning skills.

Oppositional Defiant Disorder

Children often disobey their parents or teachers, particularly when they are extremely young, as a way of asserting their independence. However, when a child consistently is disobedient, disrespectful, hostile, and defiant toward parents, teachers, and other figures of authority for a period of six months, the child might be diagnosed with oppositional defiant disorder (ODD), a disorder that is not uncommon. Stubbornness and an unwillingness to deal rationally with others when there is disagreement are also signs of ODD.

Because defiant behavior is common in the development in both very young children and teenagers, it is cautioned that mental health practitioners make this diagnosis very carefully. Interestingly, more boys tend to suffer from ODD than girls do in the years before puberty; however, when adolescence arrives, both girls and boys are diagnosed at about the same rate.

The presence of this disorder is marked by a frequent loss of temper, arguing with adults, behaving annoyingly on purpose, blaming others for errors, anger, resentment, and spitefulness or vindictiveness. To be properly diagnosed with ODD, several of these characteristics must be noted for an extended period of time and these behaviors must prevent the child from performing properly at school or relating to family and friends.

While ODD may share similarities with both ADHD and conduct disorder, there are differences. Conduct disorder usually manifests itself in physical violence while ODD usually does not. ODD differs from ADHD in that the bratty behavior seen in ODD seems to be conscious and planned while ADHD suffers seem unable to control their actions. Treatment for ODD often involves cognitive therapy and operant conditioning therapy featuring a system of rewards.

Learning Disorders

Learning disorders refer to developmental problems relating to speech, motor, and academic or language skills that are not linked to a physical disorder or mental retardation (see section below). The presence of a learning disability is not a reflection of how intelligent an individual is. In fact, people with learning disabilities are often of average or above-average intelligence, but there is a problem in development or processing that prevents that person from performing at proper levels. Most often, parents and teachers become aware of learning disorders through a child's results on standardized academic tests administered by the school. It is believed that learning disorders may be inherited, particularly dyslexia (see Reading Disorder below).

The treatment of learning disorders focuses on instruction in the area in which there are problems. The most effective programs are those that give children a chance to make small steps toward progress that can help restore self-esteem and confidence.

Learning disorders are broken down into three separate diagnoses: reading disorder, mathematics disorder, and disorder of written expression; there is also a generalized diagnosis (Learning disorder not otherwise specified) to address problems in all three areas or a combination of two areas.

READING DISORDER. A reading disorder is commonly known as dyslexia (pronounced dis-LEX-ee-a). Dyslexia comes from the Greek words "dys" (meaning poor or inadequate) and "lexis" (which refers to words or language). Dyslexia is a disorder that centers on difficulties with word recognition. Sufferers most often add, omit, or transpose (change the sequence of) letters in a word (for example, mistaking "sing" for "sign" or "left" for "felt"). All of these symptoms manifest themselves in problems with reading aloud, comprehending what is read, and spelling words correctly. Dyslexia can also affect mathematical skills, causing the person to add, omit, or transpose numbers.

MATHEMATICS DISORDER. While math can be difficult for many people, some children have difficulties that go beyond the normal scope. The problem can be as serious as someone being unable to recognize mathematical symbols and numbers to having difficulty following the proper steps in solving a mathematical equation. The degree of the difficulty is the key to making a diagnosis of mathematics disorder.

DISORDER OF WRITTEN EXPRESSION. This disorder centers on problems with writing skills. This, obviously, can affect many areas of academics, as can a reading disorder. Poor handwriting as well as difficulty with

punctuation, grammar, and spelling are common. While many young people may have difficulties with some or all of these things, what makes a diagnosis necessary is the degree to which the problem interferes with academic achievement.

Mental Retardation

Mental retardation is a condition of below-normal mental ability or intelligence due to disease, injury, or genetic defect. The average person has an intelligence quotient (IQ) between 70 and 130, with the majority of the population having IQs between 85 and 115. (IQ is the measure of one's intelligence as based on intelligence tests and the intelligence of the general population; see Chapter 11: Mental Health for more information on IQ.) Those suffering from some degree of mental retardation have IQs below 70 and as low as 20. Accompanying a low level of intelligence is trouble with adaptive behavior or functioning (skills such as dressing oneself, being socially responsive, understanding certain abstract concepts like time and money, etc.). These conditions are usually discovered prior to the age of eighteen.

CAUSES. Often, there is no identifiable biological cause for mental retardation, especially in the cases of mildly or moderately mentally retarded individuals.

However, in the cases of more severe mental retardation, genetic, or birth, defects—such as Down syndrome—can be the cause. Down syndrome usually causes people to have moderate to severe retardation. Furthermore, Down syndrome sufferers share certain physical characteristics that have become hallmarks of the disorder including oval, upward-slanting eyes; fine straight hair; and a stocky build and short stature. Other complications, including infectious diseases—such as encephalitis (swelling of the brain) and meningococcal meningitis (swelling of the lining around the brain or spinal cord)—can sometimes also cause mental retardation.

TREATMENTS. Treatment of mental retardation varies to the degree of retardation. Residential treatment, that is treatment in live-in residences, is very popular. Sometimes a patient will develop enough skills to move into a group home, which features a homey setting, living with patients at similar levels of functioning. Operant conditioning is often employed as well as certain cognitive therapies (see Chapter 15: Mental Health Therapies). Whatever the case, working with individuals to bring them to the highest level of functioning possible will benefit them; of course, compassion and protection are the key to helping these individuals lead comfortable, happy lives.

There are four major diagnoses relating directly to mental retardation:

MILD MENTAL RETARDATION. The IQ range for this diagnosis is between 50 and 55 to 70. Oftentimes, these individuals are not diagnosed as mentally retarded until later in their development because they are usually able to learn at a sixth-grade level. People who are mildly mentally retarded can usually hold jobs and often marry and successfully raise children. Approximately 85 percent of mentally retarded people have been diagnosed in this category.

MODERATE MENTAL RETARDATION. Ten percent of the mentally retarded are diagnosed with an IQ range of 35-40 to 50-55. Physical problems, including brain damage, are often present and tasks such as running or grasping things can be extremely difficult. Many people in this category live with their families or in supervised group homes with a great deal of success.

SEVERE MENTAL RETARDATION. Approximately three to four percent of individuals with mental retardation are at this level, with an IQ range of 20-25 to 35-40. Birth defects are often present and communication skills are limited. Although they may be able to do certain tasks under supervision, often they are unable to function independently in any capacity.

PROFOUND MENTAL RETARDATION. One to two percent of the mentally retarded have IQs falling below 20-25. These individuals require supervision for their entire lives. Because of physical deformities and other problems, people in this range often have a short life span.

Autism

Autism is a developmental disorder marked by the inability to relate socially to others and by severe withdrawal from reality. Language limitations and the extreme desire for things to remain constant are common traits of autism. Autistic children and adults seem to "look through" people and very often avoid eye contact. More often than not, they are unresponsive to touch and are unable to accept and display affection. An interest in ritual and repetitive body movements, such as rocking back and forth, and of repeating certain words or phrases, are also usually present. In many cases, speech is absent and, when it is present, autistic individuals are often unable to hold a conversation with others. In some cases, those with autism may form strong attachments to inanimate (nonliving) objects, such as keys or even a refrigerator.

Another aspect of autism is that while many suffering from the disorder are mentally retarded to some degree (approximately 80 percent), they also may display almost incredible skill in other areas, such as mathematics. This facet of autism has prompted the use of the term idiot savant. A savant is one with detailed knowledge in a specialized field, such as math or science. Some people suffering from autism may also have exceptional memories or have a profound physical grace. Others with autism may, however, exhibit awkward physical affectations and posture and may not possess any outstanding, savant-like abilities.

CAUSES. Autism was originally thought to be the result of emotionally distant parenting but this has not been proven. However, a specific biological cause also has not been found. Still, it is believed that autism has its origins in biology, and studies of twins have indicated that autism may be genetic. It is difficult to confirm this, however, because of the rarity of autism (two to five births in 10,000) and the fact that persons with autism rarely have children. Most of the symptoms of autism are usually present and a diagnosis made by the time a child reaches toddler age.

TREATMENT. Treatment for autism is not always effective. However, operant conditioning and modeling (see Chapter 15: Mental Health Therapies) have proven to be successful in enabling parents to, at the very least, bring their child into social situations without the child acting out. Some therapists have had success in using intense behavioral therapy as well.

Tourette's Disorder

Usually diagnosed before a person reaches the age of eighteen, the main feature of Tourette's disorder is the presence of multiple motor tics and at least one vocal tic (a tic is a quirk of behavior or speech that happens frequently). Examples of such tics include frequent eye blinking, throat clearing, sniffing, repeating words or sounds over and over, or coprolalia (repeatedly saying obscenities). Such symptoms must be exhibited for more than a year, without a lapse in symptoms exceeding three months in a row, and the condition must have a negative effect on one area of functioning (social, educational, professional, etc.). More common in males than females, the average onset age of Tourette's is seven.

SYMPTOMS. Symptoms accompanying Tourette's range from obsessions and compulsions (see section on Anxiety Disorders below), to hyperactivity, social discomfort, and depression. Social problems and depression may stem from embarrassment over a sufferer's inability to control his or her actions. Exaggerated behaviors not uncommon to Tourette's, such as head banging, knee bending, head jerking, and picking the skin, can cause injury and/or illness.

CAUSES. Tourette's disorder is genetic in origin. While not all individuals who inherit the predisposition toward Tourette's will develop the disorder, 70 percent of females and 99 percent of men carrying the genes will develop it.

TREATMENTS. Tourette's is often treated with prescription drugs, which can help to lessen the presence of tics and other symptoms.

Stuttering

Many people have heard another person stutter; what might strike many people is the number of individuals who have outgrown or overcome stuttering. Stuttering is a disturbance in verbal fluency of speech; for example, a stutterer might repeat whole words several times before being able to move on to the next word in the sentence ("I want to go-go-go-go to the movies."). Another sign may be a person's consistent difficulty in pronouncing certain consonants, or having long pauses between words in a sentence.

Stuttering is frustrating because, like Tourette's, it separates people from others by hampering easy communication. It can also affect learning, as a child may be embarrassed to ask or answer questions in class because of fear of classmates' teasing. Furthermore, stuttering can become worse when one is nervous, which can prevent a stutterer from answering difficult questions or doing any type of public speaking.

Stuttering affects more males than females and usually is present at or around the age of five. It has been estimated in the DSM, IV that eighty percent of stutterers recover, with sixty percent overcoming their stutter through no apparent reason. Speech-language pathologists (see Chapter 7: Health Care Careers) perform therapy with stutterers to help them overcome the disorder.