[Abnormal Psychology]

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[Disorders Diagnosed in Infancy, Childhood and Adolescence]

Disorders Diagnosed in Infancy, Childhood, and

Adolescence

“Every adult, whether he is a follower or a leader, a member of a mass or of an elite, was once a child. He was
once small. A sense of smallness forms a substratum in his mind, ineradicably. His triumphs will be measured
against this smallness; his defeats will substantiate it." – Erik Erikson.

Classification of Childhood Disorders

General Categories of Childhood disorders

Childhood disorders are generally categorized based on behaviors associated with the disease.
The two broad categories are externalizing and internalizing disorders.

EXTERNALIZING DISORDERS
• These illnesses predominantly manifest with outward-directed behaviors, such as
overactivity, impulsiveness, and aggressiveness.
• In these behaviors, children are usually unable to control their behavior according to
socially acceptable standards.
• Some examples of disorders under this category are attention-deficit/hyperactivity disorder,
conduct disorder, and oppositional defiant disorder.
The following are symptoms of externalizing disorders:
1. Rule violation
2. Aggressive behavior
3. Negativity
4. Being angry all the time
5. Impulsivity
6. Hyperactivity
7. Distractibility

INTERNALIZING DISORDERS
• These illnesses predominantly manifest with inward-focused behaviors such as social
withdrawal, depression, and anxiety.
• Some examples of disorders under this category are mood disorders and anxiety
disorders.
Symptoms of internalizing disorders
1. Depressive symptoms
2. Anxiety
3. Refusal to go to school
4. Impaired social relationships
Some patients will exhibit clinical features of both disorders. Disease categories were revised in the latest
edition of the DSM (See Fig.1)

DSM-IV-TR DSM-V

Mental retardation Intellectual development disorder

Learning disorders Learning disorders

Pervasive developmental disorders Autism spectrum disorder

Motor skills disorders Motor disorders

Communication disorders Communication disorders

Feeding disorders of infancy or early childhood Feeding and eating disorders

Conduct disorder Disruptive, impulse control, and

conduct disorders
Oppositional defiant disorder

Other disorders of infancy, childhood, or adolescence Anxiety disorders (includes adult and
childhood disorders)
Separation anxiety disorder

Selective mutism Included in communication disorders

Comparison of DSM-IV-TRFig. 1
Comparison of DSM-IV-TR and DSM-V Classifications of childhood disorders

A. Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-Deficit/Hyperactivity Disorder (AD/HD) is one of the most common mental disorders
among children. In the United States, it is the most frequently diagnosed mental health illness among
children. It is frequently diagnosed among preadolescent boys before 8 years of age (See Fig. 1)

Fig. 1 Marty, a 9-year-old child diagnosed with attention-deficit/hyperactivity disorder

(ADHD), dancing around his room (Liss, S./Getty Images, 1998)

Clinical manifestations
o ADHD is seen in children who manifest difficulties in carrying out task-oriented behaviors.
o They clinically manifest with impulsivity, excessive motor activity, fidgeting, and difficulty
focusing on a single task.
o In school, teachers commonly observe that children with ADHD are easily distracted. Also,
they often find it difficult to follow instructions.
o They can be found aimlessly running or fidgeting. Because of these behavioral problems,
children with ADHD have academic difficulties, and some may even have learning disabilities.
o According to studies, they usually have a lower intelligence quotient (IQ) than the average
and poor overall academic functioning.
o Aside from academic problems, children with ADHD also suffer from poor quality of social
interactions.
o They tend to talk incessantly, which other people might find socially intrusive or immature.
Because of their impulsivity and overactivity, children have impaired relationships with their
parents and peers.
o Sometimes, their actions are interpreted as a result of anxiety, but studies show that children
with ADHD are not anxious.
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[Disorders Diagnosed in Infancy, Childhood and Adolescence]

Diagnosis
• Based on the DSM-V criteria, children should have a persistent inattention and/or
hyperactivity pattern that interferes with functioning and development for at least 6 months.
At least 6 symptoms of inattention or hyperactivity are required to be diagnosed with this
disorder.

• These symptoms should also be present prior to 12 years of age.

Symptoms of inattention
1. Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other
activities.
2. Often has difficulty sustaining attention in tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or workplace
duties.
5. Often has difficulty organizing tasks and activities.
6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort.
7. Often loses things necessary for tasks or activities.
8. Is often easily distracted by extraneous stimuli
9. Is often forgetful in daily activities

Symptoms of hyperactivity and impulsivity:

1. Often fidgets with or taps hands or feet or squirms in seat.
2. Often leaves seat in situations when remaining seated is expected.
3. Often runs about or climbs in situations where it is inappropriate.
4. Often unable to play or engage in leisure activities quietly.
5. Is often "on the go," acting as if "driven by a motor."
6. Often blurts out an answer before a question has been completed.
7. Often has difficulty waiting for his or her turn.
8. Often interrupts or intrudes on others.

Etiological considerations
• The precise causative factor that leads to ADHD remains unknown.
• However, several factors are associated with its development.
Genetic factors
• Studies were carried out among twins and adopted children. These studies suggest that there
is a genetic component to the development of this disorder.
• Heritability estimates were as high as 70-80% in some studies. Genes associated with the
neurotransmitter dopamine were also found to be associated with the development of this
disorder
Neurobiological factors
• Studies suggest that children with ADHD have a different brain structure from children who
behave normally. Parts of the brain that produce dopamine were found to be smaller in children
with ADHD.
• Dopamine is an important neurotransmitter for movement and intellectual function.
Perinatal and Prenatal factors
• Children who were born from mothers who abused alcohol and tobacco were found to be
more likely to develop symptoms of ADHD.
• Several studies also suggest that low birth weight is a predictor of the development of
ADHD.
 Environmental toxins
• Some researchers believe that exposure to environmental toxins plays a role in the development of
ADHD.
• Substances that were investigated include food additives (food coloring), lead exposure, and nicotine
exposure via maternal smoking.
• Despite these researchers, no conclusive evidence exists to establish direct causation of exposure to these
substances to the development of ADHD.

Psychological factors
• Children with this disorder often have strained social relationships, especially with their parents.
Because of the nature of their disease, children with ADHD find it difficult to obey their parents.
• As a result, this has a negative consequence on parenting style and behavior. In addition, parents who
also have ADHD may show characteristics that may worsen the behavior of children afflicted with
ADHD.
• Studies show that familial characteristics contribute to the exacerbation and maintenance of this
disease.

TREATMENT

I. Stimulant medication
• Medications are used to improve the symptoms of patients with ADHD.
• Stimulant medications were shown to improve attention, alertness and decrease hyperactivity
among children with ADHD.
• As a result, children have improved academic performance and social behavior.
• One of the most commonly used stimulant drugs to treat ADHD is Methylphenidate (Ritalin).

II. Psychological treatment

• Psychological treatment for patients with ADHD involves training both the parents and teachers to
monitor the children’s behavior and apply operant conditioning to reinforce good behavior. For
example, children are given stickers or stars whenever they behave appropriately.
• Also, daily report cards may be utilized to track the progress or decline in children’s behavior.
• The goal of psychological treatment is to improve the child’s functional outcome in terms of academic
performance, social behavior, completing household tasks, and to control symptoms of hyperactivity
and impulsivity.
• The combination of medication treatment with behavioral conditioning improves the success rate
of treatment for patients with this disorder.
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[Disorders Diagnosed in Infancy, Childhood and Adolescence]

B. Disruptive, Impulse-Control, and Conduct Disorder

As the name implies, children who suffer from these disorders do not regard social standards and societal
norms. As a result, they violate the basic rights of other people resulting in legal consequences. A disorder
that is representative of this category is conduct disorder, which is fairly common in the United States,
with an estimated prevalence of 9%.
Fig 2. Child exhibiting features of conduct disorder (ADHD & Depression Clinic,n.d.)

CLINICAL MANIFESTATION
• Children with conduct disorder manifest with unusual hostility towards others, verbal
aggressiveness, and destructiveness.
• These children engage in habitual bullying, stealing, and lying. They are also capable of legal
violations such as arson, theft, trespassing, and homicide.
• Children with conduct disorder may also have other problems, such as depression, anxiety, or
substance abuse disorder.
• This disorder is also associated with antisocial personality disorder development, which we will
discuss separately in a different module.

Diagnosis
Based on the DSM-V criteria, children with conduct disorder should have a persistent pattern of behavior
that violates conventional social rules and other people's basic rights. Children must have at least 3 of
the following symptoms for the past year or at least 1 symptom for the past 6 months to be diagnosed
with conduct disorder.

Aggression to People and Animals

1. Often bullies threaten or intimidate others.
2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical harm to others
4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim
7. Has forced someone into sexual activity

Destruction of Property
1. Has deliberately engaged in fire setting intending to cause serious damage.
2. Has deliberately destroyed others’ property (other than fire setting).

Deceitfulness or Theft
1. Has broken into someone else’s house, building, or car.
2. Often lies to obtain goods or favors or to avoid obligations.
3. Has stolen items of nontrivial value without confronting a victim

Serious Violation of Rules

1. Often stays out at night despite parental prohibitions, beginning before age 13 years.
2. Has run away from home overnight at least twice while living in the parental or parental surrogate home,
or once without returning for a lengthy period.
3. Is often truant from school, beginning before age 13 years.
ETIOLOGIC CONSIDERATIONS
The following factors are associated with the development of conduct disorder:

A. Genetic Factors
There are pieces of evidence that support the genetic component of the development of conduct
disorders. A large-scale twin study in Australia supports genetic influence on the development of
symptoms of conduct disorder among children rather than environmental influence. On the other hand,
adoption studies in Sweden, Denmark, and the United States show that genetic and environmental
factors influence criminal and antisocial behavior.

B. Neuropsychological factors
Children with conduct disorder were found to have neuropsychological deficits, such as poor verbal
skills, memory deficits, and difficulty planning and solving problems. Also, objective tests show that
children with conduct disorder have lower IQ scores than average children.

C. Psychological factors
Children with conduct disorder have a deficiency in moral awareness, which is the capacity to
distinguish what is right from wrong. Normally, people abide by conventional social rules and avoid
harming others because it will make them feel guilty. However, since children with conduct disorders
lack moral awareness, they usually show no remorse when harming others.

Behavioral theories can also explain the development and maintenance of conduct disorders. Modeling
and operant conditioning play a role in developing this disorder. Children who grew up in harsh
environments or those who were physically abused are likely to develop an aggressive attitude, as seen
in conduct disorders. Parenting style is also important for a child's development. Children who were
born from parents who do not teach the negative repercussions of poor behavior are more likely to feel
less guilty for their wrongdoings.

D. Peer influence
Studies link peer rejection to the development of aggressive behavior.
Children who are associated with socially deviant peers are also likely to imitate the same behavior.

E. Sociocultural factors
Higher levels of juvenile delinquency were found among children who grew up in impoverished
environments. Some of the contributory factors that were linked to aggressive behavior are
unemployment, poor educational facilities, poor family life, lack of parental supervision, and
normative cultural delinquency. Studies show that the combination of early aggressive behavior
in a child with poor socioeconomic background predicts early criminal behavior.

TREATMENT

Family Interventions
• The involvement of the child’s parents and family is important in controlling the symptoms
of conduct disorder. An example of a program that involves the family in the treatment of patients
with conduct disorder is parent management training (PMT).
• In this treatment, parents are oriented on how to modify their responses to their children so that
social behavior is enhanced.
• Principles of operant conditioning are being taught, wherein parents gain knowledge on
positive reinforcement when the child exhibits good behavior. This program is further enhanced
with cooperation from both parents and teachers in monitoring children's behavior with conduct
disorder.
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[Disorders Diagnosed in Infancy, Childhood and Adolescence]

Multi-systemic treatment (MST)

• In this form of treatment, the entire community, family, and school are involved in the therapy.
It is based on the principle that conduct disorders are affected by multiple factors, including social
relationships within the community.
• Some activities that are being carried out during treatment include identifying the social factors
that aggravate or maintain the child's symptoms, and the child's family members address these
factors regularly.
• This may require daily or weekly efforts from the child's family members.

C. Anxiety Disorders of Childhood and Adolescence

• During a child's normal development, he may experience fears and worries. For example, a
child may have a fear of dark places or certain animals.
• However, as a child grows up, most of these fears are outgrown.
• If not, children learn to adapt to what they are scared of. On the other hand, children with
anxiety disorders have maladaptive responses to normal stimuli.
• This causes impairments in a child's overall functioning and development.
• A disorder that is representative of this category is a separation anxiety disorder.

Fig. 3. Child exhibiting separation anxiety disorder symptoms (Postmedia Network Inc, 2015)

Clinical Manifestation
• Children with separation anxiety disorder are constantly worried that they will be harmed
once they are left alone away from their parents.
• These children are often observed to trail behind one of his parents even when they are at
home.
• This disorder is usually diagnosed at the beginning of school because it is the first time that
children will be separated from their parents for a considerable amount of time.
• They usually exhibit overwhelming fear, self-conscious behavior, and oversensitivity. They also
tend to have nightmares and sleep disturbances.
• Because they are always preoccupied with their fears, children with anxiety disorders lack
confidence in communicating with others. They are shy, agitated, easily worried, and
discouraged.

Diagnosis
Children with separation anxiety disorder exhibit excessive fear or anxiety when being physically
separated from their parents or to whomever they are deeply attached. This causes significant
impairment in a child’s functional capacity. Three or more symptoms of anxiety should be persistent for
at least four weeks in children and adolescents to be diagnosed with a separation anxiety disorder.
Based on the DSM-V manual, the following are symptoms of anxiety:
1. Excessive distress when anticipating or experiencing separation from home or major attachment
figures.
2. Excessive worry about losing a major attachment figure or about possible harm to them, such as
illness, injury, disasters, or death
3. Excessive worry about experiencing an untoward event that causes separation from a major
attachment figure. Examples are being kidnapped or having an accident.
4. Refusal to go out, away from home, to school, or elsewhere because of fear of separation
5. Excessive fear of being alone
6. Refusal to sleep away from home or away from a major attachment figure
7. Repeated nightmares involving the theme of separation
8. Repeated complaints of physical symptoms when separation from a major attachment figure
occurs or is anticipated.

ETIOLOGICAL CONSIDERATIONS
Genetic and socio-cultural factors
Studies show that anxiety behaviors may be heritable in as much as 29-50% of cases. However, socio-
cultural also contribute to the development of anxiety disorders in children. For example, results from
one study showed that there is an increased risk of developing anxiety and depression among
immigrant Latino youth.

Psychological factors
Parenting practices may also play a role in the development of anxiety disorders.
Overprotectiveness and parental control are associated with childhood anxiety. Problems with emotion
regulation and insecure attachment during infancy are also theorized to be psychological factors
that may contribute to the development of anxiety disorders.

Treatment
Medications
Treatment with anti-anxiety medications relieves symptoms in patients with anxiety disorders.
However, patients should be carefully evaluated for the presence of other conditions that may be
aggravated with the use of anti-anxiety medications.

Psychological treatment
Behavioral therapy
This is commonly done in schools to help reduce symptoms of anxiety in children with anxiety
disorders. This involves training them to become more confident by mastering basic academic
skills. To reduce anxiety or fear towards an object, desensitization therapy may be used. In this form
of therapy, the child is exposed gradually to the stimulus that arouses feelings of fear. Exposure to
the same stimuli appears to reduce anxiety.

Cognitive-behavioral therapy
In this form of therapy, children are taught how to recognize their emotions, especially fear and
anxiety, through group sessions. Therapists teach children how to cope with their emotions more
effectively. Parents also participate in seminars or workshops wherein they are taught how to manage
children's anxious behavior. Studies show that cognitive-behavioral therapy reduces anxiety among
children.

D. Elimination Disorders, Sleepwalking, Tics

Elimination disorders
Two types of elimination disorders are:
Enuresis
• This disorder is commonly known as “bed-wetting”, wherein children inappropriately acquire
the habit of urinating at night while they are asleep.
• Enuresis may occur nightly or only in instances wherein the child is unusually tired or
stressed. This most commonly happens among 5 year-olds, with an estimated incidence of
5-10%.

Studies suggest that the following may be associated factors in the development of enuresis:
1. Improper learning of bladder control
2. Immaturity, which may be associated with maladaptive coping mechanisms
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[Disorders Diagnosed in Infancy, Childhood and Adolescence]

3. Strained relationship with the family

4. Stressful events

Treatment of this condition involves the use of an anti-depressant medication called imipramine. The
way this medication treats this condition remains unclear, but it may be related to lessening the deep
stages of sleep, which enables the child to recognize physiologic needs more efficiently. This condition
may also resolve spontaneously without any form of treatment.

Encopresis
This condition is less common than enuresis, with a prevalence rate of 1% among 5 year-olds.
Children with encopresis have poor toileting habits.
They frequently soil their clothing, especially when they are under stress.
This is usually diagnosed after the age of 4, wherein children are expected to have undergone toilet
training.
The etiology of this disorder is unknown.
Some children report that they are embarrassed to use bathrooms in school, while others do not know
when they need to defecate.
Children are usually treated with behavioral therapy using the principles of conditioning to learn
appropriate behavior. Some of these children are also found to have constipation, for which
medical treatment can be provided.

Sleep-walking disorder
In the DSM-V, the sleepwalking disorder is classified under the category of parasomnias.
In children, this disorder usually occurs between the ages of 6 to 12. Children affected with this
disorder are observed to walk unconsciously during sleeping hours.
According to studies, sleepwalking is fairly common, and an estimated 10-30% of children can
experience a single episode of sleep-walking.
While sleep-walking, children's eyes may be partially or fully open. They may also respond to
commands and avoid hazards while walking.
When they are awakened, they are usually surprised to find themselves walking, and they do not have a
recollection of the episode.
At present, there is no standard treatment for the sleepwalking disorder. However, behavioral
therapy has been described in one study.

Tic Disorders
A tic is a repetitive and persistent localized muscle twitch or spasm.
Children with tic disorders are usually observed to blink abnormally, twitch their mouths, or clear their
throats. This disorder commonly occurs between the ages of 2 and 14.
At times, children with tic disorders may perform certain actions repetitively without being fully aware
of them. An example of a severe form of a tic disorder is Tourette's disorder, wherein repetitive
movements involve multiple motor and vocal patterns. Children affected with this disorder suffer from
uncontrollable urges to do stereotypical movements such as moving their heads or a particular part of
their body. Children may also produce unusual sounds while doing uncontrollable movements. This
disease is produces impaired social skills and other behavioral problems.
 Some children benefit from medications that suppress tic movements. Some examples of medications
that are being used for tic are Clonazepam, clonidine, and tiapride. Behavioral therapy was also found
to be helpful in some studies.
An example of this treatment is habit reversal treatment (HRT), which involves awareness-training,
relaxation training, appropriate responses, and modification of the patient's overall action. However,
some children do not receive any treatment, allowing tics to persist throughout adulthood.

Autism
Autism spectrum disorder is one of the most disabling developmental disorders among children.
Children with autism show multiple behaviors that cause impairment in their social interaction with
other people.
This is one of the most common developmental disorders in childhood. In the United States, estimates
are as high as 1 in 50. This condition usually persists into adulthood (See Fig. 4).

Clinical manifestation
• Children with autism have social and emotional disturbances. They do not readily approach
other people and usually have poor eye contact. They usually do not initiate engaging with social
interactions with other children. They often refuse to play with others and would rather play by
themselves. Children have a deficiency in joint attention, which is the ability to pay attention to
others during social interaction.

• Children with autism have communication deficits. They have delayed language milestones
compared to other children. For example, at 2 years of age, children usually utter 2-word phrases
to express themselves. An example is "Me cookie," which means that they want a cookie. Usually,
children with autism are unable to do this. Autistic children usually exhibit pronoun reversal and
echolalia. In pronoun reversal, children refer to themselves as "he/she" instead of "I ."For example,
when being asked what he is doing, he will reply, "He is playing," rather than "I am playing
."Echolalia is when a child repeats what he hears from another person. For example, if a parent
asks, "What do you want to eat?" the autistic child may respond by saying, "What do you want to
eat?".

• Children with autism may display repetitive and ritualistic acts. For example, they usually have
a bedtime routine, and any slight change in that routine may make them feel very upset.
Sometimes, even a slight rearrangement of their toys throws them into tantrums. Children with
autism may also show stereotypical movements like body rocking, spinning objects, or flapping
of hands.

Fig. 4 Six-year-old Gwendoline, an autistic child, works with Professor Gilbert Lelord
while under his care at Bretonneau hospital in Tours, France. Bretonneau specializes in
psychiatric problems in children. (Bisson, B./Sygma via Getty Images, n.d.)

Diagnosis
According to DSM-V, patients with autism should have persistent deficits in social communication and
social interaction. They should also manifest with at least two symptoms of restricted, repetitive
patterns of behavior, interests, or activities. These symptoms should be present in early childhood,
causing significant impairment in daily living.

Symptoms of deficits in communication

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[Disorders Diagnosed in Infancy, Childhood and Adolescence]

1. Deficits in social-emotional reciprocity range from abnormal social approach and failure of normal
back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or
respond to social interactions.

2. Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from
poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language
or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal
communication.

3. Deficits in developing, maintaining, and understanding relationships, ranging, for example, from
difficulties adjusting behavior to suit various social contexts; to difficulties in sharing imaginative play or
in making friends; to the absence of interest in peers.

Symptoms of repetitive behavior

1. Stereotyped or repetitive motor movements, use of objects, or speech
2. The insistence on sameness, inflexible adherence to routines, or ritualized patterns of behavior
3. Highly restricted, fixated interests that are abnormal in intensity or focus.
4. Abnormally excessive or absent reaction to sensory stimuli (e.g., Adverse reaction to a certain scent or
sound).

Etiologic considerations
Genetic Factors
Multiple studies done on twins support the evidence that autism spectrum disorders may be genetically
inherited. The risk of acquiring this disorder is higher for children with siblings who have autism. Some
researchers link a specific genetic abnormality to the development of autism. However, this research needs
to be validated with further studies.

Neurobiological Factors
Several studies suggest that there is an inherent neurological abnormality in patients with an autism
spectrum disorder. One study investigated if there is a difference in the brain size of a child with autism
compared to one who does not have this condition. Results showed that children with autism have an
increase in the size of the brain by the time they reach 2 years old, compared to normal children. The
researchers attribute poor function to an increase in the growth of the brain. Interestingly, the increase in
brain size does not continue past 4 or 5 years old. Also, other areas of the brain are associated with the
development of autism. The amygdala is a part of the brain that is associated with emotional and social
behavior. Studies show that the amygdala of children with autism is larger than normal children. The
researchers suggest that this enlargement is secondary to poor function, which is analogous to previously
mentioned studies.

Treatment
 Medications
• In the past, some specialists prescribe anti-depressants, antipsychotic medications, and
stimulants. However, the evidence does not support their use unless there are no other ways to
control a child's behavior.
• At present, there are no approved medications for relieving the symptoms of autism.

Behavioral Treatment
• The most successful intervention to improve the symptoms of n autism is behavior therapy. The
pioneer in this form of treatment is Ivan Lovaas. His intervention involves one-on-one teaching
sessions with children.
• This is usually conducted in the children's homes instead of an institution. He used operant
conditioning principles by giving positive reinforcements when the child behaves well and
negative reinforcements in the form of punishment when the child behaves poorly.
• Parents are also involved, wherein they are taught how to engage their children in social
interactions. This form of treatment improved intellectual functioning in children with
autism. However, one of the disadvantages of this treatment is that it requires a therapist
to work with the child for at least 40 hours per week for two years.

Glossary

Externalizing disorders - illnesses predominantly manifest with outward-directed behaviors, such as

overactivity, impulsiveness, and aggressiveness.

Desensitization - a form of therapy wherein repeated exposure to stimuli will result in a reduced adverse
reaction to it.

Habit reversal treatment is a form of treatment for tic disorders that involves awareness-training,
relaxation training, developing appropriate responses, and modifying a patient's overall action.

Internalizing disorders - illnesses predominantly manifest with inward-focused behaviors such as

social withdrawal, depression, and anxiety.

Joint attention - the ability to pay attention when communicating with another person.

Multi-systemic treatment- a form of treatment for children with conduct disorders that involves
comprehensive therapy in the community setting, which gives focus on the child and his social
relationships with his family, peers, and school administrators.

Parent management training - a form of treatment for patients with conduct disorder wherein parents
are oriented on how to modify their responses to their children so that social behavior is enhanced.

Tic - a repetitive and persistent localized muscle twitch or spasm

References
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http://www.gettyimages.com/license/583261902
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[Photograph found in Postmedia Network Inc]. (2015). In Vancouver Sun.
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