ABNORMAL PSY-

CHOLOGY II
(PSY 402)
NEURODEVELOPMENTAL DISORDERS
 OUTLINE
• Neurodevelopmental disorders defined.

• Neurodevelopmental Disorders:
▫ ADHD
▫ Specific Learning Disorder
▫ Autism Spectrum Disorders
▫ Intellectual Disability
 NATURE OF DEVELOPMENTAL PSY-
CHOPATHOLOGY: AN OVERVIEW

• Normal vs. abnormal development

▫ Consider age and environment of child

• Developmental psychopathology
▫ Study of how disorders arise and change with time
▫ Disruption of early skills can affect later develop-
ment
NEURODEVELOPMENTAL DISORDERS
• They are neurologically based
• and usually diagnosed first in infancy, childhood, or
adolescence
• hence they are referred to as neurodevelopmental disor-
ders.

• Neurodevelopmental disorders are defined as a

group of conditions manifested early in devel-
opment that are characterized by deficits that
produce impairments of personal, social, aca-
demic or occupational functioning.
COMMUNICATION AND MOTOR DISORDERS
• Childhood Onset Fluency Disorder
▫ Speech difficulty that may include repeated syllabus
(stuttering), prolonging certain sounds, pauses or sub-
stituting words that are easier to pronounce.

• Language Disorder
▫ Limited speech in all situations; understanding of
speech is normal and problem may self-correct
COMMUNICATION AND MOTOR DISORDERS, CON-
TINUED
• Social (Pragmatic) Communication Disorder
▫ Difficulty with social aspects of communication (e.g. domi-
nating conversations, switching topics excessively), but
lacks other features of autism spectrum disorder (e.g., re-
strictive behaviors and interests)

• Tourette’s Disorder
▫ Involuntary motor movements and/or vocalizations (tics),
which may include obscenities. The tics often occur in rapid
succession, come on suddenly and happen in stereotyped
ways.
 ATTENTION DEFICIT HYPERACTIVITY
DISORDER (ADHD)
• Nature of ADHD
▫ Central features – inattention, over-activity, and
impulsivity

▫ Associated with numerous impairments

 Behavioral - injuries
 Cognitive - inattention
 Social (socially aloof) and academic problems (fail-
ing)
 ATTENTION DEFICIT HYPERACTIVITY
DISORDER (ADHD)
• DSM-5 symptom types

▫ Predominantly inattentive presentation

▫ Predominantly hyperactive/impulsive presenta-

tion

▫ Combined presentation
 DSM-5 CRITERIA: AD/HD
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with func-
tioning or development, as characterized by (1) and/or (2):
1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a
degree that is inconsistent with developmental level and that negatively impacts directly on social
and academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or
failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at
least five symptoms are required.
(a) Often fails to give close attention to details or makes careless mistakes in schoolwork, at work,
or during other activities; (b) often has difficulty sustaining attention in tasks or play activities; (c)
often does not seem to listen when spoken to directly; (d) often does not follow through on in-
structions and fails to finish schoolwork, chores, or duties in the workplace; (e) often has difficulty
organizing tasks and activities; (f) often avoids, dislikes, or is reluctant to engage in tasks that re-
quire sustained mental effort; (g) often loses things necessary for tasks or activities; (h) is often
easily distracted by extraneous stimuli (for older adolescents and adults, may include
unrelated thoughts); (i) is often forgetful in daily activities.
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at
least 6 months to a degree that is inconsistent with developmental level and that negatively im-
pacts directly on social and academic/occupational activities:
 DSM-5 CRITERIA: AD/HD, CONTINUED
Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or
failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at
least five symptoms are required.
(a) Often fidgets with or taps hands or feet or squirms in seat; (b) often leaves seat in situations
when remaining seated is expected;
(c) often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or
adults, may be limited to feeling restless.)
(d) Often unable to play or engage in leisure activities quietly. (e) Is often “on the go,” acting as if
“driven by a motor.” (f) Often talks excessively. (g) Often blurts out an answer before a question
has been completed. (h) Often has difficulty waiting his or her turn. (i) Often interrupts or in-
trudes on others.
B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings.
D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, aca-
demic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic
disorder and are not better explained by another mental disorder, substance intoxication, or
withdrawal.

From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
 DIFFERENTIAL DIAGNOSIS
Task: Identify characteristics that AD/HD shares
with the following disorders and those that are
unique to AD/HD.

•Oppositional defiant disorder

•Bipolar mood disorder

•Conduct disorder
11
 ADHD: FACTS AND STATISTICS
• Prevalence
▫ Occurs in approximately 5% of school-aged children
▫ Symptoms are usually present around age three or four
▫ Children with ADHD have similar problems as adults e.g.
traffic offenses, STIs, drug use
• Gender differences:
• Boys outnumber girls 3:1
• Predominantly hyperactive/impulsive presentation – most
common among boys according to research

• Cultural factors
▫ ADHD most commonly diagnosed in the United States, al-
though prevalence appears fairly constant worldwide
THE CAUSES OF ADHD: BIOLOGICAL CONTRIBU-
TIONS
• Genetic contributions
▫ ADHD seems to run in families
▫ DAT1 – dopamine transporter gene has been im-
plicated
 Some ADHD drugs e.g. Ritalin work by inhibiting
the gene (DAT1) and increasing the amount of
dopamine available
THE CAUSES OF ADHD: BIOLOGICAL
CONTRIBUTIONS
• Neurobiological correlates of ADHD

▫ Smaller brain volume

▫ Inactivity of the frontal cortex and basal ganglia
▫ Abnormal frontal lobe development and function-
ing

Task: find out about the functions of the brain areas mentioned
above.
THE CAUSES OF ADHD: BIOLOGICAL
CONTRIBUTIONS (CONTINUED)

• The role of toxins

▫ Food additives (e.g. dyes, pesticides) may play

very small role in hyperactive/impulsive behavior
among children

▫ Maternal smoking increases risk

 THE CAUSES OF ADHD: PSYCHOSO-
CIAL CONTRIBUTIONS

• Psychosocial factors

▫ ADHD children are often viewed negatively by

others > Frequent negative feedback from peers
and adults
 Peer rejection and resulting social isolation
 Such factors foster low self-esteem
BIOLOGICAL TREATMENT OF ADHD
• Goal of biological treatments
▫ To reduce impulsivity and hyperactivity and to
improve attention

• Stimulant medications
▫ Low doses of stimulants improve focusing abilities
▫ Examples include Ritalin, Dexedrine, Adderall
▫ Problem: May increase risk for later substance
abuse
BIOLOGICAL TREATMENT OF ADHD
• Other medications with more limited efficacy
▫ Imipramine and clonidine (antihypertensive)

• Genes affect individuals’ response to meds

▫ Some trial and error is necessary (dose & type of
meds)

• Effects of medications
▫ Improve compliance, decrease negative behaviors
▫ Do not affect learning/academics directly
▫ Benefits are not lasting following discontinuation
BEHAVIORAL AND COMBINED TREAT-
MENT OF ADHD
• Behavioral treatment
▫ Reinforcement programs
 To increase appropriate behaviors
 Decrease inappropriate behaviors
▫ May also involve parent training
▫ Social skills training

• Combined bio-psycho-social treatments

▫ Often recommended
▫ May be superior to medication or behavioral treat-
ments alone, but more research is needed
 SPECIFIC LEARNING DISORDERS:
AN OVERVIEW
• Scope of learning disorders
– Academic problems in reading, mathematics,
and/or writing
– Performance substantially below expected
levels based on age, IQ score and educa-
tion.
– Problems persist for 6+ months despite targeted
intervention
Specific Learning Disorder: Types
• With impairment in reading, may include:
▫ Word reading accuracy
▫ Reading rate or fluency
▫ Reading comprehension

• With impairment in written expression, may in-

clude:
▫ Spelling accuracy
▫ Grammar punctuation and accuracy
▫ Clarity/organization of written expression
 SPECIFIC LEARNING DISORDER:
TYPES
• With impairment in mathematics, may include:
▫ Number sense
▫ Memorization of arithmetic facts
▫ Accurate or fluent calculation
▫ Accurate math reasoning
 DSM-5 CRITERIA: SPECIFIC LEARNING DIS-
ORDER
A. Difficulty learning and using academic skills, as indicated by the presence of at least
one of the following symptoms that have persisted for at least 6 months, despite the
provision of interventions that target those difficulties: (1) Inaccurate or slow and ef-
fortful word reading; (2) difficulty understanding the meaning of what is read; (3) diffi-
culties with spelling; (4) difficulties with written expression; (5) difficulties mastering
number sense, number facts, or calculation; (6) difficulties with mathematical reason-
ing (e.g., has severe difficulty applying mathematical concepts, facts, or procedures to
solve quantitative problems)

B. The affected academic skills are substantially and quantifiably below those expected
for the individual’s chronological age and cause significant interference with academic
or occupational performance, or with activities of daily living, as confirmed by individ-
ually administered standardized achievement measures and comprehensive clinical as-
sessment. For individuals age 17 years and older, a documented history of impairing
learning difficulties may be substituted for the standardized assessment.
 DSM-5 CRITERIA: SPECIFIC LEARNING DISORDER CONT’D

C. The learning difficulties begin during school-age years but may not become fully
manifest until the demands for those affected academic skills exceed the individual’s
limited capacities (e.g., as in timed tests, reading, or writing lengthy complex reports
for a tight deadline, excessively heavy academic loads).

D. The learning difficulties are not better accounted for by intellectual disabilities, un-
corrected visual or auditory acuity, other mental or neurological disorders, psychoso-
cial adversity, lack of proficiency in the language of academic instruction, or inade-
quate educational instruction.

Note: The four diagnostic criteria are to be met based on clinical synthesis of the indi-
vidual’s history (developmental, medical, family, educational), school reports, and psy-
cho-educational assessment.

From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, DC.
SPECIFIC LEARNING DISORDER: STA-
TISTICS
• Prevalence of learning disorders
▫ Six million children have been diagnosed in the
United States
▫ Highest rate of diagnosis in wealthier regions, but
children with low SES more likely to have difficul-
ties
▫ Reading difficulties most common, affect 4-10% of
the general population
▫ School experience tends to be generally negative
BIOLOGICAL AND PSYCHOSOCIAL CAUSES OF SPECIFIC
LEARNING DISORDER
• Genetic and neurobiological contributions
▫ Learning disorders run in families, but specific difficulties are not
inherited
▫ Evidence for subtle neurological difficulties (brain impairment) is
mounting (e.g., decreased functioning of areas responsible for
word recognition)
▫ This includes both functional and structural impairment
▫ Overall, contributions are unclear

• Psychosocial contributions are likely important e.g. child manage-

ment practices, cultural expectations, socioeconomic status,
parental interactions and expectations.
 TREATMENT OF SPECIFIC LEARNING
DISORDER
• Requires intense educational interventions
▫ Remediation of basic processing problems
▫ Improvement of cognitive skills e.g. decision mak-
ing and problem solving
▫ Targeting skills to compensate for problem areas

• Data support behavioral educational interven-

tions
 AUTISM SPECTRUM DISORDER
• Problems occur in language, socialization, and cognition
• Pervasive – problems span many life areas

• Two main areas of impairment:

▫ Communication and social interaction
 25% don’t acquire effective speech
▫ Restricted, repetitive patterns of behavior, in-
terests, or activities
 Need to maintain “sameness” - high level of consis-
tency in activities or experience
 AUTISM SPECTRUM DISORDER
• Label is new to DSM-5

• Encompasses several disorders previously classi-

fied as “pervasive developmental disorders” (in
DSM-IV-TR) :
▫ Asperger’s disorder
▫ Autistic disorder
▫ Childhood disintegrative disorder
▫ Rett syndrome
 30

THREE LEVELS
• DSM V categorises ASD into three levels accord-
ing to the amount of support needed by the indi-
vidual:

• Level 1 – requiring support

• Lecel 2 – requiring substantial support
• Level 3 – requiring very substantial support
 DSM-5 CRITERIA: AUTISM SPECTRUM DISORDER
A. Persistent deficits in social communication and social interaction across multiple con-
texts, as manifested by the following, currently or by history:
1. Deficits in social–emotional reciprocity, ranging, for example, from abnormal social ap-
proach and failure of normal back-and-forth conversation, to reduced sharing of interests,
emotions, and 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 exam-
ple, from difficulties adjusting behavior to suit various social contexts, to difficulties in shar-
ing imaginative play and in making friends, to absence of interest in peers.
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at
least two of the following, currently or by history:
(1) stereotyped or repetitive motor movements, use of objects or, speech; (2) insistence on
sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal
behavior; (3) highly restricted, fixated interests that are abnormal in intensity or focus;
 DSM-5 CRITERIA: AUTISM SPECTRUM DIS-
ORDER
(4) hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the
environment
C. Symptoms must be present in the early developmental period, but they may not be-
come fully manifest until social demands exceed limited capacities, or they may be masked
by learned strategies in later life.
D. Symptoms cause clinically significant impairment in social, occupational, or other impor-
tant areas of current functioning.
E. The disturbances are not better explained by intellectual disability (intellectual devel-
opmental disorder) or global developmental delay. Intellectual disability and autism spec-
trum disorder frequently co-occur; to make comorbid diagnoses of autism spectrum
disorder and intellectual disability, social communication should be below that expected
for general developmental level.

From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
 AUTISM SPECTRUM DISORDER: PREVA-
LENCE

•1 in 50 school-aged children in then US meet cri-

teria
•More commonly diagnosed in males
•IQ interaction
– 38% show intellectual disabilities
•Occurs worldwide
PSYCHOLOGICAL AND SOCIAL DIMENSIONS
• Historical views
▫ Failed parenting
 Perfectionistic, cold, and aloof
 High socioeconomic status
 Higher IQs

▫ Lack of self-awareness (uses 2nd person to refer to self)

▫ Behavioral correlates
 Echolalia - repeating what someone else has said (immediate, de-
layed, mitigated)
 Self-injury – biting, bashing head against the wall
 BIOLOGICAL DIMENSIONS
• Significant genetic component
▫ Familial component: If have one child with autism, the
chance of having a second child with autism is 20%
(100x greater risk than general population)

• Numerous genes on several chromosomes involved

• Oxytocin receptor genes

▫ Bonding and social memory

• Older parents associated with increased risk

BIOLOGICAL DIMENSIONS
• Neurobiological influences

▫ Amygdala
 Larger size at birth = higher anxiety, fear
 Elevated cortisol (stress hormone)
 Neuronal damage in the amygdala results from high
stress, which may affect processing of social situa-
tions

▫ Oxytocin (social-neuro chemical)

 Lower levels
 CAUSES OF AUTISM SPECTRUM DIS-
ORDER : BIOLOGICAL
• Neurobiological influences
– Vaccinations do NOT increase the risk of autism
• Mercury in some vaccinations was rumored to in-
crease autism risk
• Large scale studies do NOT support this
• High rates of vaccinations do NOT increase risk for
autism in the community at large
• Health risk of not vaccinating is substantial
 TREATMENT OF AUTISM SPECTRUM DISORDER
• Psychosocial treatments
▫ Behavioral approaches
 Skill building
 Reduce problem behaviors e.g. tantrums and self in-
jury
 Communication and language training
 Increase socialization
 Naturalistic teaching strategies (teaching away from
the classroom)

▫ Early intervention is critical – may “normalize” the

functioning of the developing brain
TREATMENT OF AUTISM SPECTRUM DISOR-
DER
• Biological treatments
▫ Medical intervention has had little positive impact
on core dysfunction (social & language difficulties)
▫ Some drugs decrease agitation
 Tranquilizers
 Serotonin Specific Reuptake Inhibitors (SSRIs)

• Indicators of good prognosis

▫ High IQ, good language ability
TREATMENT OF AUTISM SPECTRUM DISOR-
DER
• Integrated treatments
▫ Preferred model: Multidimensional, comprehen-
sive focus
 Children offered special education at school focusing
on communication
 Judicious use of medication in some cases
 Families given support too

▫ When older, focus on integrating into the commu-

nity while maximizing independence
 INTELLECTUAL DISABILITY (ID)
• Overview
▫ Below-average intellectual and adaptive function-
ing
▫ First evident in childhood
▫ Range of impairment varies greatly
▫ Previously called mental retardation
 INTELLECTUAL DISABILITY
• IQ typically below 70-75
▫ Previously distinguished different levels of sever-
ity; IQ may be as low as under 20

• Previously diagnosed on DSM-IV Axis II

▫ Reserved for conditions that 1) are chronic and
pervasive and 2) are likely to influence the presen-
tation of other mental disorders
 INTELLECTUAL DISABILITY
• DSM-5 identifies difficulties in three domains:

▫ Conceptual (e.g., skill deficits in areas such as lan-

guage, reasoning, knowledge, and memory)

▫ Social (e.g., problems with social judgment and the

ability to make and retain friendships)

▫ Practical (e.g., difficulties managing personal care or

job responsibilities)

• Devalued by society
 DSM-5 CRITERIA: INTELLECTUAL DISABILITY
Intellectual disability (intellectual developmental disorder) is a disorder with onset dur-
ing the developmental period that includes both intellectual and adaptive functioning
deficits in conceptual, social, and practical domains. The following three criteria must
be met:
A. Deficits in intellectual functions, such as reasoning, problem solving, planning, ab-
stract thinking, judgment, academic learning, and learning from experience, confirmed
by both clinical assessment and individualized, standardized intelligence testing.

B. Deficits in adaptive functioning that result in failure to meet developmental and so-
ciocultural standards for personal independence and social responsibility. Without on-
going support, the adaptive deficits limit functioning in one or more activities of daily
life, such as communication, social participation, and independent living, across multi-
ple environments such as home, school, work, and community.

C. Onset of intellectual and adaptive deficits during the developmental period.

From American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
Washington, DC.
OTHER CLASSIFICATION SYSTEMS FOR IN-
TELLECTUAL DISABILITY

• American Association of Intellectual and Devel-

opmental Disabilities (AAIDD)
▫ Based on assistance required
 Intermittent
 Limited
 Extensive
 Pervasive

▫ Keeps the emphasis on what assistance is needed

 INTELLECTUAL DISABILITY: STATISTICS
• Prevalence = 2% of general population
▫ 9 in 10 people with ID have mild impairment (IQ
50-70)
• Chronic course
• Highly variable individual prognosis
▫ Independence is possible for many individuals
with mild impairment when provided with appro-
priate resources (e.g. skills training)
 CAUSES OF INTELLECTUAL DISABILITY
• Hundreds of known causes
▫ Environmental (e.g. abuse, deprivation, neglect)
▫ Prenatal – exposure to disease or drugs while still
in the womb
▫ Perinatal (e.g. problems with labor or delivery)
▫ Postnatal – e.g. infections and head injury
CAUSES OF INTELLECTUAL DISABILITY -
PRENATAL

• Examples
▫ Fetal alcohol syndrome
▫ Exposure to other illness in the womb
▫ Lack of oxygen (anoxia) during birth
▫ Malnutrition
▫ Head injuries
▫ Childhood abuse
 CAUSES OF INTELLECTUAL DISABILITY
• Genetic influences
▫ Chromosomal disorders (e.g. Down Syndrome)
▫ Multiple genetic mutations
▫ Single genes can be responsible
 Dominant genes less often responsible for ID (be-
cause people with ID are less likely to have children)
 Recessive genes more often responsible
• Most cases of ID have no identified etiology
 CAUSES OF INTELLECTUAL DISABILITY
• Genetic influences
– De novo disorders (genetic mutation occurring in
the sperm or egg after fertilization)
– Lesch-Nyham syndrome
• Intellectual disability, symptoms of cerebral palsy,
self-injurious behavior
• Recessive allele on the X chromosome > only affects
males (females have an additional X chromosome to
balance)
 CAUSES OF INTELLECTUAL DISABILITY
• Phenylketonuria (PKU)
▫ Cannot break down phenylalanine, which is found
in some foods
▫ Results in ID when the individual eats phenylala-
nine
▫ Now, test at birth can detect PKU > diets without
phenylalanine actually prevent development of in-
tellectual disability and other problems
 CAUSES OF INTELLECTUAL DISABILITY
• Chromosomal influences
▫ Down syndrome
 Most common chromosomal cause of intellectual disability
 Extra 21st chromosome (Trisomy 21)
 Distinctive physical symptoms
 Higher risk with advanced maternal age

 Detectable with some prenatal tests

 Amniocentesis
 Chorionic villus sampling (CVS)
 Mother’s blood tests
 Tests do not indicate severity of impairment
 1 in 4 mothers elects to terminate the pregnancy
 53

FETAL ALCOHOL SYNDROME DOWN SYNDROME

CAUSES OF INTELLECTUAL DISABILITY
• Fragile X syndrome
▫ Symptoms
 Learning disabilities
 Hyperactivity
 Short attention spans
 Gaze avoidance
 Perseverative speech

▫ Gender differences
 Primarily affects males
 Women with Fragile X have mild symptoms
CAUSES OF INTELLECTUAL DISABILITY

• Cultural-familial intellectual disability: Refers to

intellectual disability influenced by social envi-
ronmental factors, such as:
▫ Abuse
▫ Neglect
▫ Social deprivation

• These factors likely interact with existing biolog-

ical factors
TREATMENT OF INTELLECTUAL DISABILITY
▫ Severe ID: Treatment similar to that for autism spectrum disor-
der

▫ Mild ID: Treatment similar to that for learning disorders

▫ Goals are similar across severity; level of assistance differs

▫ Behavioral interventions teach:

 Basic skills (e.g., dressing, hygiene)
 Social skills
 Practical skills (e.g., paying bills)
TREATMENT OF INTELLECTUAL DISABILITY
• Common goals

▫ Participate in community life

▫ Benefit from education
▫ hold a job or other productive pursuits (e.g., vol-
unteering)
▫ Build meaningful relationships
PREVENTION OF NEURODEVELOPMENTAL
DISORDERS
• Efforts are still in early stages

• Early interventions for at-risk children

▫ Head Start Program: Educational, medical (e.g.
nutritional) and social support

• Future directions: Genetic screening

▫ Detection and correction
▫ Prenatal gene therapy
 SUMMARY OF NEURODEVELOPMENTAL DISOR-
DERS
• This category encompasses a wide range of dis-
orders with varying severity
• May be caused by genetic or environmental fac-
tors or have indeterminate cause
• Treatment focuses on mitigating functional im-
pairment