Disorders of Childhood and

UNIT 12 CHILDHOOD AND Adolescents-I

NEURODEVELOPMENTAL
DISORDERS-I

Structure
12.0 Introduction
12.1 Childhood Depression
12.1.1 Causal Factors and Treatment
12.2 Elimination Disorder
12.3 Oppositional Defiant Disorder and Conduct Disorder
12.3.1 Clinical Picture
12.3.2 Causal Factors
12.3.3 Treatment
12.4 Attention-Deficit/Hyperactivity Disorder
12.4.1 Clinical Picture
12.4.2 Causal Factors
12.4.3 Treatment
12.5 Summary
12.6 Keywords
12.7 Review Questions
12.8 References and Further Reading
12.9 References for Images
12.10 Web Resources
Learning Objectives
After reading this Unit, you will be able to:
Explain the nature of the diverse clinical conditions associated with
childhood;
Discuss the clinical presentation, causal factors, and treatment of clinical
depression;
Explain the nature of elimination disorders; and
Elucidate the clinical picture, causal factors, and treatment of Oppositional
Defiant Disorder and Conduct Disorder and Attention-Deficit/Hyperactivity
Disorder.

12.0 INTRODUCTION
Before the twentieth century, there was no special attention given to mental
disorders in children. Children were seen as ‘miniature adults’ and the problems
in children were seen as extensions of adult-oriented diagnoses. It was only with
the beginning of mental health movement that clinicians began to understand

*Dr. Itisha Nagar,Assistant Professor of Psychology, Kamala Nehru College, University of Delhi,
New Delhi. 317
Disorders of Childhood and that problems of childhood deserve special recognition. Today, even though much
Adolescence Trauma Related
and Neurocognitive Disorders
progress has been made in treatment for mental disturbances in children, in many
parts of the world especially in developing and underdeveloped countries, most
children with mental health problems fail to receive evidence based early
intervention. In India for instance, parents who received the diagnosis of autism
for their child in 1990s, found the scientific understanding of autism inadequate
and the intervention services unavailable even in urban areas of the country.
Developmental psychopathology is a field in psychology that is dedicated to
studying the origins and cause of significant disturbances in context of normal
growth processes. In particular, the fast-growing field aims to help clinicians
diagnose and treat developmental disorders. Developmental disorders refer to
those conditions that occur early in life and may affect one or more domains of a
child’s development (physical, cognitive, social-emotional, and moral).

Unit 12 and 13 will focus on those conditions and disorders that emerge in
clinically significant ways during the childhood and adolescence. Some of these
disorders like Autism Spectrum Disorders, Attention-deficit/Hyperactivity
Disorder, Intellectual Disability, Specific Learning disability are better understood
as conditions that continue till adulthood while others like childhood depression
and elimination disorders may begin in childhood and may or may not extend till
adulthood. The former is categorized under the broader heading of
neurodevelopmental disorders or a group of severely disabling conditions
considered to be a result of structural and/or functional differences in the brain
that are usually evident at birth or become apparent as the child begins to develop.
Finally, disorders like Oppositional Defiant Disorder and Conduct Disorder are
classified as Disruptive, Impulse-Control and Conduct Disorders in DSM-5 since
they share the core features of aggressive or anti-social behaviour.

To assess whether a child’s behaviour is ‘normal’ or not, the behaviour needs to

be compared to a sample of children of the same age group, educational level,
and socio-cultural background. For instance, temper tantrums are common in
two-year-old children but not for a 10-year-old child. Consequently, a child’s
behaviour is understood as typical or atypical to his/her peers. Clinicians must
understand that the repercussions of the label ‘abnormal’ for a child or adolescent
are immensely stigmatizing and significant in determining the future outcomes
for an individual.

Early systems of classification for mental disorders either did not include the
emotional and mental disorders of childhood and adolescence or if they were
included then the information was found to be inaccurate and inappropriate. For
instance, the classification system developed for adults was continued to be being
used for children. Additionally, many disorders like autism and learning
disabilities did not have an adult counterpart. Diagnostic and Statistical
Manual for Mental Disorders (DSM-5) has made efforts to provide a classification
system for childhood and adolescence disorders that is consistent with latest
findings in the field and clinical practice. Let us now see the clinical features of
childhood depression, elimination disorder, oppositional defiant disorder/conduct
disorder and attention deficit/hyperactivity disorder. There causal factors and
treatment will also be discussed.

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 Disorders of Childhood and
12.1 CHILDHOOD DEPRESSION Adolescents-I

The perception of childhood period as a carefree and happy phase of life, makes
it difficult for a layperson to believe that children can experience clinical
depression. Many clinicians before 1970s shared this belief, that children are
incapable of exhibiting and experiencing depression. It is now widely accepted
that depressive features displayed by children is often consistent with the criteria
of Major Depressive Disorder and Persistent Depressive Disorder (dysthymia).
Children with depression exhibit symptoms like withdrawal from family and
friends, avoidance of eye contact, physical complaints, poor appetite and/or
aggressive behaviour. In some cases, the children may even attempt self-harm or
suicide. Depression in children is different from depression in adults in showing
more guilt but lower rates of early-morning depression and weight loss.

As is the case in adult depression, girls have higher prevalence rate of childhood
depression than boys. Majority of children with depression also have a comorbid
disorder most common being anxiety, conduct disorder, and ADHD. Although
most children with depression recover to a significant degree, research suggests
a high probability of experience of a subsequent depressive episode.

Box 12.1: Case Study: Childhood Depression

Ayush, l0-years-old, lives with his parents and grandmother. His parents
have been facing some financial troubles since the last 3 years and have
been extremely stressed. Ayush’s counselor calls his parents for a meeting
to discuss his behaviour after he was found crying in school bathroom. The
counselor informs the parents that his teacher reports that he is in danger of
failing the class, that he becomes preoccupied, often staring out the window,
and seldom finishes his work. Ayush told the school counselor that all the
other children in his class are much smarter than he is and that is why they
tease him calling him ‘stupid’. Ayush used to enjoy playing in the school
playground, but since the last three months he has stopped attending sports
classes also in school. Ayush’s parents inform the school counselor that when
he gets home each afternoon, he watches television and refuses to eat in
spite of his grandmother cajoling him to. Since the parents do not come
home until late at night they speak to him over the phone in the evenings to
make sure he’s all right. Ayush’s birthday is coming up, and his parents were
trying hard to plan a birthday party to “cheer him up” but Ayush replied to
his parents, “what’s the use of a birthday party, nobody is going to come,
nothing good will happen anyway?” and started crying.

12.1.1 Causal Factors and Treatment

Biological factors are implicated in childhood depression; research has found
that there is a strong association between parental depression and children’s
behavioural and mood problems. Suicide attempt rate is also found to be high in
cases of children of parents suffering from depression than for children of control
parents. Pre-natal exposure to alcohol in cases where mothers were abusing
alcohol during pregnancy has also be found to be related to rates of early childhood
depression. Additionally, an experience of trauma in childhood can also predispose
a child to develop depression. Trauma and experience of negative affect makes
children vulnerable to depression and suicidal ideation under stress. For instance, 319
Disorders of Childhood and children with divorced parents have higher likelihood of depressed moods.
Adolescence Trauma Related
and Neurocognitive Disorders
Researchers are examining the effect of mother-child interaction in transmission
of depressed affect. Depression in mothers makes them less responsive to the
needs of the child than their non-depressed counterparts. Depression in fathers
have also been related to depression in children. Overall, research has focussed
on how genetic factors may interact with stressors in family environment to result
in childhood depression. Interpersonal factors, especially the poor peer
relationships may contribute to the negative affect experienced by a child with
depression. A child with depression is likely to be ignored by her/his peers in
school and playground which may in turn aggravate the negative self-image of
the child. Further, consistent with Beck’s cognitive theory, cognitive distortions
and negative attributional style are associated with depression in children.

Predominant approach for treatment of depression in children has been the

combined use of medication and psychotherapy. Anti-depressants used with adults
have proven to have moderate effect on children with depression. Parents and
professionals have raised safety concerns regarding the use of medicines with
children especially since they are associated with undesirable side-effects like
nausea, headaches, nervousness, insomnia and seizures. Psychological therapy
with children aims to provide a supportive emotional environment for the children
to enable adaptive emotional expressions. This is especially effective for older
children and adolescents who benefit from discussing their feelings openly. Play
therapy in which the child can express his/her feelings and concerns through the
medium of play is popular for use with younger children. Finally, treatment is
incomplete without psychoeducation, supportive management, family and school
involvement.

Check Your Progress 1

1) What are neurodevelopmental disorders?
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2) Mention some of the symptoms of depression in children.
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12.2 ELIMINATION DISORDER

Elimination disorder concerns with defecating and urinating difficulties in
children. In this condition, children eliminate bodily substances at inappropriate
times and places. While most young children may have some occasional
“accidents” of defecation and urination, in children diagnosed with elimination
disorders this behaviour occurs regularly for a period of three months. There are
two types of elimination disorders, enuresis and encopresis.
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Occasional enuresis (bedwetting) is not considered to be a problem before the Disorders of Childhood and
Adolescents-I
age of 5 years. However, in some children there is habitual involuntary discharge
of urine, usually at night after 5 years of age. Bedwetting beyond this age may be
caused by organic causes such as disturbed cerebral control of bladder or because
of side effects of certain medications. According to DSM-5, children who
experience bed wetting beyond 5 years of age which is not organically caused
are classified with the problem of functional enuresis. Children who were never
learned bladder control are classified under primary enuresis whereas those
who have been toilet trained for at least one year but have regressed and start bed
wetting are classified with secondary enuresis. A common problem amongst
school going children, and the prevalence rate varies among different populations.
DSM IV studies suggest the rate to be 12-25 percent amongst four-year-olds, 8-
10 percent amongst eight-year-olds, and 2-3 percent amongst 12-year-old (APA,
2002). Prevalence in India is 7.6-16.3 percent for 6-7 years old children (De
sousa A, Kapoor, Jagtap & Sen, 2007)

Studies have found that age, parental history of enuresis, and siblings’ history of
enuresis were significant predictive factors for enuresis. Psychological and
emotional causal factors include faulty learning processes resultinig in failure to
acquire inhibition of reflexive bladder emptying. Emotional problems,
dysfunctional family interactions, anxiety and hostility between family members
and stressful events contribute to bedwetting. For instance, it’s common to find
that a child may regress to bed-wetting when the parents have another child who
becomes the centre of attention.

Medical treatment of enuresis involves prescription of an anti-depressant drug,

imipramine. The exact mechanism of its working is unclear, but it is suggested
that the drug lessens deepest stage of sleep to light sleep, enabling the child to
recognize the need to pass urine more effectively. Doctors claim that medications
by themselves do not cure enuresis, relapse is often common when the medicine
is discontinued. Therefore, conditioning procedures are often used and have been
found to be extremely effective. In a classic study by Mowrer and Mowrer
(1938), a child sleeps on a pad that is wired to a battery-operated bell. The bell is
set off when it comes in contact of the urine. Through classical conditioning, the
child comes to associate bladder tension with awakening.

Majority of parents do not experience distress over enuresis in their children

since they feel the child will ‘outgrow’ the habit. Therefore, parents may not go
for treatment in many cases of functional enuresis. Even though, incidence of
enuresis decreases with age, medical experts believe that functional enuresis
should be treated in childhood, as there is no way to predict which who will
remain enuretic till adulthood.

Encopresis refers to inability to learn toileting for bowel movements beyond the
age of 4 years. DSM-5 reports encopresis to be less common than enuresis, the
incidence rate for encopresis is about 1 percent of 5-year olds. About one-third
of children encopresis were also enuretic. Sex difference has also been reported
in studies, in some studies encopresis was about six times more common in boys
than girls.

Soiling of clothes is common under situations of duress. Common time is usually

afternoon after school, but incidents can also occur even during school time.
Most children may not know that they need to use the bathroom or may be too
321
Disorders of Childhood and shy to ask the teacher permission to go to the toilet. Conditioning procedures
Adolescence Trauma Related
and Neurocognitive Disorders
have also been used for treatment of encopresis.

Box 12.2: DSM-5 Criteria for Elimination Disorders

(APA, 2013)
Enuresis
A. Repeated voiding of urine into bed or clothing, which can be intentional
or involuntary.
B. The behaviour is clinically significant as manifested by either frequency
of at least twice a week for at least three consecutive months or the
presence of clinically significant distress or impairment in social,
academic (occupational), other other important areas of functioning.
C. The individual is chronologically or developmentally older than 5 years.
D. The behaviour is not attributable to biological effects of a substance
(e.g. diuretic or antipsychotic medicine) or another medical condition
(e.g. diabetes, spina bifida, a seizure disorder.)
Encopresis
A. Repeated passage of faeces into inappropriate places (e.g. clothing, floor)
whether involuntary or intentional.
B. At least one such event occurs each month for at least 3 months.
C. Chronological age is at least 4 years (or equivalent developmental level).
D. The behaviour is not attributable to the physiological effects of a
substance (e.g. laxatives) or another medical condition except through
a mechanism involving constipation.

Check Your Progress 2

1) What are the two different type of elimination disorders?
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2) How has classical conditioning been used to treat bedwetting?
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12.3 OPPOSITIONAL DEFIANT DISORDER AND

CONDUCT DISORDER
Oppositional Defiant Disorder (ODD) and Conduct Disorder are categorized
under Disruptive, Impulse-Control and Conduct Disorders in DSM-5 since they
share the core features of aggressive or anti-social behaviour. ODD and conduct
322
disorders may also involve behaviour that may be considered against the law Disorders of Childhood and
Adolescents-I
(juvenile delinquency). There is a debate regarding if ODD and conduct disorder
are distinct disorders or if ODD is a precursor or milder form of conduct disorder.
Some professionals find it important to distinguish between the two because of
the nature of seriousness of violations in case of conduct disorders. Violations in
case of ODD are relatively less serious. Also, while ODD is usually recognized
by the age of 8 years, full-blown conduct disorder usually develops by middle
childhood through adolescence.

12.3.1 Clinical Picture

Essential feature of ODD is presence of persistent negativistic, defiant,
disobedient, and hostile behaviour towards authority figures. There have been
some changes made in the category of ODD from DSM IV to DSM-5. Some of
the symptoms include: frequent temper tantrums, arguing with adults, refusing
instructions by adults, always questioning rules and non-compliance with rules
set, doing things to annoy or upset others, being easily annoyed, speaking unkindly
or angrily, and seeking revenge. The ODD disorder is now grouped into three
subtypes: angry/irritable mood, argumentative/defiant behavior and
vindictiveness. As is the case with other disorders in DSM-5, a severity rating
has also been included. Relative to other childhood disorders, the prevalence of
ODD is high. According to Nock et al., (2007) study (as cited in Butcher, Hooley,
& Mineka, 2020) lifetime prevalence of ODD is about 11 percent for boys and 9
percent for girls. Not all cases of ODD go on to develop conduct disorder, however
almost all cases of conduct disorder are preceded by ODD. ADHD is a common
co-morbid condition with ODD. Even though unruly behaviour is also present in
ADHD, but in case of ODD the unruly behaviour is judged to be more deliberate
whereas in case of ADHD it is usually attributed to poor attention or impulsivity.
In conduct disorder, a child has a repetitive and persistent pattern of behaving in
a way that violates other people’s rights or societal norms that are age appropriate.
DSM-5 describes the symptoms of conduct disorder are aggression to people
and animals, destruction of property, deceitfulness or theft, and serious violation
of norms. Children with conduct disorder shows covert or over aggression towards
others in the form of bullying, initiation of physical fights, and use of weapons
that can cause harm. Some show cruelty towards people and animals. There is
deliberate destruction of property through fire setting and/or other means. Lying,
stealing, vandalism, and breaking into someone’s house/car may also be common.
Children with conduct disorder are likely to be sexually uninhibited and may
inflict sexual aggression on others such as forcing someone especially children
younger than them into sexual activity. Such children may repeatedly run away
from their home or stay out at night in spite of parental restrictions often beginning
young (before 13 years of age). Two different courses of conduct disorders are
identified, life-course persistent pattern that starts early and continues into
adulthood and adolescence-limited course where anti-social behaviour begins in
adolescence for someone with a typical childhood and who would later go on to
live typical non-problematic adulthood.
Research has found that early-onset of conduct disorder is highly associated
with later development of conduct disorder. It also has a strong association with
development of substance use, abuse, and dependency later in life. According to
Mohan and Ray (2020), conduct disorder is also fairly common with life time
prevalence rate of in general population could range anything between 2 to 10
percent. Conduct disorder is three to four times more common in boys than girls. 323
Disorders of Childhood and
Adolescence Trauma Related Box 12.3: Case Study: Oppositional Defiant Disorder
and Neurocognitive Disorders
Usman is a 7-year-old male student studying in Class 1 who lives with his
parents and younger sister. Usman is an intelligent and caring young boy
who has been performing well academically. While Usman interacts well
with his peers, his parents noted that he can be easily influenced by them.
They also report that Usman gets upset when he does not receive recognition
or feels that he has been ignored. His teacher has observed that Usman can
sometimes act ‘socially immature’, and that he often demonstrates attention-
seeking behaviour. His mother reports difficulties at home with following
routines and remembering instructions. His parents describe emotional
reactivity as well as confrontational behaviours at home. He would often
get very angry and would hit his sister. Teacher also commented that he is
easily frustrated and emotionally impulsive. Over the past one year, Usman
has had several incidents of hitting, argumentative, lying, and disruptive
behaviour. Similar behavioural concerns of less severity had been observed
by teachers in pre-school, but were ignored by parents at the time.

Box 12.4: DSM-5 Criteria for Oppositional Defiant Disorder (APA,

2013)
A. A pattern of angry/irritable mood, argumentative/defiant behavior, or
vindictiveness lasting at least 6 months as evidenced by at least four
symptoms of the following categories, and exhibited during interaction
with at least one individual who is not a sibling:
Angry/Irritable Mood
1) Often loses temper
2) Is often touchy or easily annoyed
3) Is often angry and resentful
Argumentative/Defiant Behavior
4) Often argues with authority figures or, for children and adolescents,
with adults
5) Often actively defies or refuses to comply with requests from
authority figures or with rules
6) Often deliberately annoys others
7) Often blames others for his or her mistakes or misbehavior.
Vindictiveness
8) Has been spiteful or vindictive at least twice within the past 6
months.
B. The disturbance in behavior is associated with distress in the individual
or others in his or her immediate social context (e.g., family, peer group,
work colleagues), or it impacts negatively on social, educational,
occupational, or other important areas of functioning.
C. The behaviors do not occur exclusively during the course of a psychotic,
substance use, depressive, or bipolar disorder. Also, the criteria are not
met for disruptive mood dysregulation disorder.

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 Disorders of Childhood and
Box 12.5: Case Study: Conduct Disorder Adolescents-I

Akash is a 15-year-old male who was brought to the psychiatrist by his

parents. He is the eldest child of his parents and has two younger siblings
including one brother and one sister, Akash recently dropped out of school
and refusing to go back to school claiming the “teachers don’t teach well.”
His parents reported that Akash had been eating gutka and paan regularly
since last one year. He started stealing from his neighbour’s house to buy
gutkha when he stopped receiving any pocket money from parents. Akash
had been stealing since the last three months but when cornered he would
always lie his way out claiming that the neighbours didnot like him and
were lying to get him into trouble. Recently he was caught red handed which
is the reason why his parents decided to take him to their family doctor who
suggested he should be taken to a psychiatrist. His parents report that while
Akash had always had temper tantrums, lately he had become very aggressive.
Akash would often fight with his parents and had become abusive towards
them. He would often beat up his younger siblings at the smallest of things.
His teachers at school were always unhappy with him since they found it
extremely difficult to discipline him. He would perform poorly in studies
and would never focus on the lessons, instead he would be found disturbing
other students in class. He had also started ‘bunking’ classes with other
students. The school had started getting complaints from the parents of other
students, especially female students who complained that Akash would
misbehave with them. He even sent objectionable pictures to his female
classmate who got very upset and informed her parents about it. He stopped
going to school after the school suspended him for a week for starting a
fight with junior students who complained that Akash would bully them and
force them into paying him their pocket money.

Box 12.6: DSM-5 Criteria for Conduct Disorder (APA, 2013)

A. A repetitive and persistent pattern of behavior in which the basic rights
of others or major age-appropriate societal norms or rules are violated,
as manifested by the presence of at least three of the following 15 criteria
in the past 12 months from any of the categories below, with at least one
criterion present in the past 6 months:
Aggression to People and Animals
1) Often bullies, threatens, or intimidates others.
2) Often initiates physical fights.
3) Has used a weapon that can cause serious physical harm to others (e.g.,
a bat, brick, broken bottle, knife, gun).
4) Has been physically cruel to people.
5) Has been physically cruel to animals.
6) Has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery).
7) Has forced someone into sexual activity.
Destruction of Property
8) Has deliberately engaged in fire setting with the intention of causing
serious damage.
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Disorders of Childhood and
Adolescence Trauma Related 9) Has deliberately destroyed others’ property (other than by fire setting).
and Neurocognitive Disorders
Deceitfulness or Theft
10) Has broken into someone else’s house, building, or car.
11) Often lies to obtain goods or favors or to avoid obligations (i.e., “cons”
others).
12) Has stolen items of nontrivial value without confronting a victim (e.g.,
shoplifting, but without breaking and entering; forgery).
Serious Violations of rules
13) Often stays out at night despite parental prohibitions,beginning before
age 13 years.
14) 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.
15) Is often truant from school, beginning before age 13 years.
B. The disturbance in behavior causes clinically significant impairment in
social, academic, or occupational functioning.
C) If the individual is age 18 years or older, criteria are not met for antisocial
personality disorder.

12.3.2 Causal Factors

Evidence from genetic studies is mixed, although heritability is likely to play a
role in conduct disorder. Researchers have found that criminal and anti-social
behaviour can be accounted for by both genetic and environmental factors.
Aggressive behaviour has been found to be heritable where other delinquent
behaviours like truancy, lying, and stealing may not be attributed to genetic factors.
Also, life-course persistent pattern of conduct disorder is likely to be heritable as
opposed to the adolescence-limited course pattern.

Neuropsychological studies have found childhood profiles of deficit in children

with conduct disorders. These deficits include poor verbal skills, difficulty with
higher order cognitive functioning (like the ability to anticipate, plan, self-
monitoring, and problem solving), and problems with memory. In addition,
children who develop conduct disorder at an earlier age are intellectually lower
than typical age-matched control group. Similar to individuals with anti-social
personality disorder, children with conduct disorder show low physiological
arousal and low heart rate suggesting that they are less likely to fear punishment
compared to typical peers. Whereas in case of typical adolescent the fear of
getting caught and punishment keeps them from behaving in anti-social manner,
a teen with conduct disorder goes on to behave in unchecked and unregulated
manner without the fear of any repercussions.

Children behave in socially appropriate behaviour not only because they fear
punishment, but also because they would experience guilt if they do not. Moral
development or the understanding of right and wrong seems to be deficit in
children with conduct disorder. Children with conduct disorder also seem to lack
moral awareness and remorse.
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Behavioural theories suggest that children with aggressive parents may model Disorders of Childhood and
Adolescents-I
their parent’s aggressive and hostile behaviour. Inconsistent and harsh parenting
with poor monitoring are consistently associated with development of conduct
disorder. Children with no previous history of delinquent behaviour may imitate
aggressive behaviour on TV or emulate aggressive peers who seem to be enjoying
high social status because of his/her aggressive demeanours. Social rejection of
aggressive children by peers puts them at highest risk for adolescent delinquency
and probably for adult antisocial personality. Parents, teachers, and peers may
react to aggressive children with anger and rejection. The combination of rejection
by parents, peers, and teachers may make these children to become isolated and
alienated. Not surprisingly, they often turn to deviant peer groups for
companionship, at which point a good deal of imitation of the antisocial behavior
of their deviant peer models may occur. In such circumstances children with
conduct disorder are likely to select more deviant peer (social selection view).
However, environmental influence of neighbourhood (poverty in neighbourhood)
and family (parental neglect) may also play a role in whether children associate
with deviant peers.

Finally, socio-cultural influences like poverty, urban living, unemployment and

low educational standards of parents, and dysfunctional family dynamics combine
with anti-social behaviour in children to predict early criminal arrests.

12.3.4 Treatment
By and large, the attitude of the society towards aggressive youth is punitive,
“teach the child a lesson”. This attitude seems to aggravate and intensify anti-
social and aggressive behaviour in children with conduct disorder. Mental health
professionals have found that the most effective treatment of conduct disorder
involves family intervention. Parents of children with conduct disorders are seen
to lacking parenting skills and behaving in inconsistent patterns. Children may
learn to escape harsh criticism and disciplining through anti-social behaviour
like lying and deceitfulness to which parents may respond with aggression. The
child observes this increased aggression and models this aggressive pattern. Parent
management programs teach parents to modify their responses when dealing
with their children so that they consistently reinforce prosocial behaviour rather
than antisocial behaviour. They are also taught to give clear instructions and lay
ground rules so as to provide consistent and expected consequences to undesirable
behaviour. Often parents may themselves be burdened because of interpersonal
relationships, unemployment, poverty and/or psychopathology and may find it
difficult to practice effective parenting skills. Mental health professionals have
exercised the importance of a warm and accepting environment for children with
conduct disorders.

Another promising program is the Multi Systemic Treatment (MST) that

recognizes that anti-social behaviour is influenced by multiple factors in family,
school and neighbourhood. The program attempts to deliver comprehensive
therapy services in the community targeting the adolescent, family, peers and
school. Program identifies individual and family strengths, social contexts that
contribute to aggressive and anti-social behaviour, and action-oriented and present
focussed approach. In comparison to adolescents who received traditional
psychotherapy, MST has been found to be more effective in treatment of conduct
disorders in adolescents.
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Disorders of Childhood and
Adolescence Trauma Related
and Neurocognitive Disorders

Fig. 12.1: Multisystemic Treatment (MST) includes consideration of multiple factors

when developing a child’s treatment, including family, school, community, and peers
Source: http://www.mstuk.org

Check Your Progress 3

1) How is conduct disorder different from oppositional defiant disorder?
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2) What are some socio-cultural factors influencing conduct disorder
and oppositional defiant disorders?
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3) What is multi-systemic treatment?
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12.4 ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER
Children with Attention-Deficit/Hyperactivity Disorder (ADHD) display
difficulties in maintaining sustained attention, excessive and exaggerated motor
activity, and impulsivity relative to their developmental level leading to social,
occupational/academic activities. The classification criteria for ADHD remains
largely unchanged in DSM-5. An exception being that ADHD is no longer
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considered as a Disruptive Behaviour Disorder and instead lists it as a Disorders of Childhood and
Adolescents-I
neurodevelopmental disorder. Other change specified in DSM-5 (DSM IV
specified presence of some of the symptoms before 7 years of age), is several
inattentive or hyperactive-impulsive symptoms to be present prior to 12 years of
age. Additionally, similar to other disorders in DSM-5, it has added specification
for current severity: mild, moderate and severe. Consistent with DSM IV criteria,
DSM-5 codes Attention Deficit/Hyperactivity Disorder under three sub-types:
combined presentation, predominately inattentive presentation (Attention Deficit
Disorder; ADD) and predominately Hyperactive/Impulsive presentation. ADHD
combined type is the most common presentation, whereas ADHD predominantly
inattentive type may be cases of pure ADD or may include children who display
attention difficulties along with sub-threshold hyperactivity.

Attention

Hyperactivity

Impulse-control

Fig. 12.2: Symptoms of ADHD

12.4.1 Clinical Picture

Attention deficit is a multi-dimensional construct that includes problems with
arousal, alertness, selective focus, sustained attention/vigilance, and distractibility.
These difficulties can manifest in many situations making it difficult to function
adequately in school, workplace or with friends and family. Issues with arousal
and alertness can lead to children failing to give attention to details, losing track
of time or things, making careless mistakes or day dreaming. A child with deficit
selective attention is likely to fail to understand instructions and follow through
instructions. She/he could appear to others as if she/he is”not listening” or that
their “mind is elsewhere”. Problems with sustained attention can most often be
seen in boring and repetitive activities but can also be apparent in free play. The
child has a tendency to “tune out” of these tasks, and would perceive tasks
requiring sustained attention (e.g. reading, mathematics, board games, etc.) are
seen as aversive and are generally avoided. Sustained attention deficits may lead
the child to shift from one task to another without completing any one of them.
Finally, distractibility is the ability to be easily attend to irrelevant stimuli in the
environment (e.g. noise, background conversations, object in a room, etc.).
Attentional difficulties affect daily lives of people with ADHD. Their work is
often messy, disorganized and appears to have been done without any considered
thought. School material like pen, tiffin boxes, books and notepads are often
scattered, lost or damaged. Attentional problems also make children and
adolescents forgetful, for instance they would forget to bring lunch, books,
homework etc. Socially, ADHD individuals find it difficult to keep track of
conversations. Such children often find it challenging to follow rules in games
or different activities.
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Disorders of Childhood and
Adolescence Trauma Related
and Neurocognitive Disorders
“Careless”

“Often loses
“Daydreams”
things”

“Does not
“Easily
seem to Inattention
distracted”
listen”

Fig. 12.3: Descriptions used by Parents and teachers for children with significant
attentional difficulties

Hyperactivity refers to excessive activity manifested in two forms: motor

hyperactivity (restlessness, squirminess, and unnecessary body movements) and
vocal hyperactivity (excessive talking). Manifestation of hyperactivity may vary
with developmental level. In pre-school children hyperactivity can be seen in
children to engage in excessive jumping and climbing on furniture, running around
the house, and in difficulty in engaging the children in sedentary activity like
listening to story. In school aged children similar behavior may be seen in
hyperactive children although the behavior maybe lesser in intensity and
frequency. Hyperactivity in children can be seen in the child’s difficulty to remain
seated, they get up frequently, squirm, and hang onto the edge of their seat. Not
only do they fidget during academic activities, they also find it challenging to sit
through meals, TV, or play that requires them to sit in one place. One is likely to
find them fidgeting with objects, pen, or shaking legs.

Girls with ADHD are more likely to display hyperactivity through excessive
talking and interruptions when others are talking. It is a common misbelief that
adolescents/adults “out grow” their hyperactivity. However, in older children

“Keeps running “Difficulty

and climbing at playing or engag-
home and ing quietly in
school” leisure activities”

“Often on the
“Cannot sit go as if driven
still” by a motor”
Parent’s
description of
Hyperactivity

Fig. 12.4: Descriptions used by parents and teachers for children with hyperactivity
330
hyperactivity manifests more as restlessness, excessive speech, difficulty in Disorders of Childhood and
Adolescents-I
engaging in solitary activities and increased aggression and conflicts.
Professionals stress on pervasiveness of hyperactivity, ADHD children display
hyperactivity throughout the day and even during night. ADHD children find it
difficult to fall asleep and may wake up early. Hyperactivity is pervasive and
displayed in all domains including home, school, and playground. Impulsivity
refers to the tendency to act on urges, apparently without thinking. Impulsivity
is one of the most common complaints parents and teacher’s make about people
with ADHD.

Most common complaint made about children with ADHD by parents and teachers
is about this symptom. Impulsivity can be seen in impatience, difficulty in waiting
for their turn, inability to blurt out answers, interrupting and intruding others to
the point of causing difficulties in school, social or occupational setting.
Impulsivity is often responsible for the many accidents that hyperactive children
get into. More often than not children with ADHD may knock over objects, bang
into people, grab to hold a hot pan, or even engage in potentially harmful activity
like repeatedly climbing trees and riding bicycle in traffic.

Children with ADHD also display some secondary problems. ADHD is related
to cognitive and academic difficulties as children with ADHD are found to have
delay in intelligence of about 7-10 IQ points, may be at high risk for learning
disability, and have lower academic intelligence than their peers. Many children
with ADHD suffer from socio-emotional difficulties also. There is high rate of
rejection by peers amongst ADHD children, which is not because they are
unfriendly but because ADHD may make them inattentive to social cues and
peers may get tired of their hyperactivity and excessive talking. Unpopularity
amongst peers may also be a result of aggression and depression. Peer rejection
and negative criticism from parents and teachers negatively effects the self-esteem
of these children.

The prevalence rate of ADHD has been increasing over the years. The average
prevalence of ADHD worldwide is found to be 5.9 - 7.1 percent and 2.6 - 4.5
percent (Willicut 2012, Polanczyk et al. 2015). Some researchers believe that
the increase in the number of children diagnosed with ADHD may be a result of
an increase in awareness about ADHD or society’s intolerance to childhood
activities because of urban life pressures and loss of support, or extended family.
Also, boys are three times more likely to be diagnosed with ADHD. This may be
because adults may be more tolerant of hyperactivity in girls who engage in less
direct aggressive. Secondly, research on ADHD has focussed on boys, thereby
ignoring the experience and manifestation of ADHD symptoms in girls. There is
high co-morbidity of aggression and depression in ADHD.

Box 12.7: Case Study: Attention Deficit Hyperactivity Disorder

Rubin is a 9-year-boy who has been referred to a child psychologist at the
request of his school counsellor. The counsellor had been receiving multiple
complaints about Rubin from his class teacher. The teacher complained that
Rubin is extremely restless, he is hardly ever on his seat and roams around
in the class in spite of the many instructions given against getting up in
class. He finds it difficult to pay attention to lessons in class and his work is
messy and incomplete. His restlessness disturbs other children. Sometimes,
he talks to other students making it difficult for them to concentrate on their
331
Disorders of Childhood and
Adolescence Trauma Related individual classwork. The teacher reports that Rubin does not seem to have
and Neurocognitive Disorders any control over his unpredictable behaviour and is quite polite and good
natured. Clinical interview with parents revealed that Rubin has had
behavioural difficulties ever since he was a toddler. Even when he was three
years old, he was and extremely restless who required little sleep and woke
before anyone else. When he was four, he had managed to unlock the door
of the house and wandered off by himself on a busy road. He was brought
back by a neighbour who found him wondering on the streets. Teachers in
play school complained that Rubin would find it difficult to follow any
instructions given to him and his restlessness made it difficult for the teacher
to look after his well-being.

Box 12.8: DSM-5 Criteria for ADHD (APA, 2013)

A. A persistent pattern of inattention and/or hyperactivity- impulsivity that
interferes with functioning 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 (for children up to age 16) 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 school work, at work, or during other activities (e.g., overlooks or
misses details, work is inaccurate).
b) Often has difficulty sustaining attention in tasks or play activities (e.g.,
has difficulty remaining focused during lectures, conversations, or
lengthy reading).
c) Often does not seem to listen when spoken to directly (e.g., mind seems
elsewhere, even in the absence of any obvious distraction).
d) Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (e.g., starts tasks but
quickly loses focus and is easily side-tracked).
e) Often has difficulty organizing tasks and activities (e.g., difficulty
managing sequential tasks; difficulty keeping materials and belongings
in order; messy, disorganized work; has poor time management; fails
to meet deadlines).
f) Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (e.g., schoolwork or homework; for older
adolescents and adults, preparing reports, completing forms, reviewing
lengthy papers).
g) Often loses things necessary for tasks or activities (e.g., school materials,
pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile
telephones).
332
 Disorders of Childhood and
h) Is often easily distracted by extraneous stimuli (for older adolescents Adolescents-I
and adults, may include unrelated thoughts).
i) Is often forgetful in daily activities (e.g., doing chores, running errands;
for older adolescents and adults, returning calls, paying bills, keeping
appointments).
2) Hyperactivity and impulsivity: Six (or more) of the following
symptoms have persisted for at least 6 months (children up to the age
of 16 years) to a degree that is inconsistent with developmental level
that negativ impacts directly on social and academic/occupational
activities:
Note: The symptoms are not solely a manifestation of oppositional
behavior, defiance, hostility, or a 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 feetor squirms in seat.
b) Often leaves seat in situations when remaining seated is expected (e.g.,
leaves his or her place in the classroom, in the office or other workplace,
or in other situations that require remaining in place).
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 amotor”(e.g., is unable to be
or uncomfortable being still for extended time, as in restaurants,
meetings; may be experienced by others as being restless or difficult to
keep up with).
f) Often talks excessively.
g) Often blurts out an answer before a question has been completed (e.g.,
completes people’s sentences; cannot wait for turn in conversation).
h) Often has difficulty waiting his or her turn (e.g., while waiting in line).
i) Often interrupts or intrudes on others (e.g., butts into conversations,
games, or activities; may start using other people’s things without asking
or receiving permission; for adolescents and adults, may intrude into or
take over what others are doing).
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 (e.g., at home, school, or work; with friends or
relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce the
quality of, social, academic, 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 (e.g., mood disorder, anxiety disorder,
dissociative disorder, personality disorder, substance intoxication or
withdrawal). 333
Disorders of Childhood and
Adolescence Trauma Related
12.4.2 Causal Factors
and Neurocognitive Disorders
Researchers understand that the causes of attention deficit hyperactivity disorder
are not social in origins. Genetic factor's plays a role in ADHD as twin and
family studies report high degree of heritability of ADHD. Adoption researches
have also reported higher rates of hyperactivity in biological parents of hyperactive
children than adoptive parents of such children. Molecular genetic studies have
found that multiple genes contribute to the risk for ADHD. In particular, DAT-1
or dopamine transporter gene has been implicated. Neuropsychological studies
have found structural and functional difference in brains of people with ADHD
and typical control. In particular, difference have been seen in frontal lobe, basal
ganglia, and cerebellum. Executive functions (high order cognitive processes),
such as working memory, attention, and inhibition of responses has been found
to be poorer for ADHD individuals relative to typical control. ADHD is related
to dysfunction in two neurotransmitters, dopamine and nor-epinephrine. Scientists
have found that inattention and distractibility appear to be related to low levels
of norepinephrine whereas impulsivity and hyperactivity problems appear to be
related to low levels of dopamine in the brain. Thus, because child feels lack of
stimulation in the brain, hyperactivity is a way to compensate for that. That is
why, stimulants are prescribed as medicines for children with ADHD. Pregnancy
and birth factors like mother’s age at delivery (younger), mother’s educational
level (lower), time between labour (longer), and premature delivery related to
higher probability of the child developing ADHD. Prenatal exposure to
environmental toxins like lead, alcohol and tobacco have been implicated. Certain
medicines, such as medicines for seizures are likely to result in problems with in
attention and hyperactivity. Some researchers also report that the behavior of
some ADHD children is worsened after eating foods with artificial colors, certain
preservatives, and/or allergens.

While social factors like parenting style, schooling, and peer relations may
moderate the types and degrees of impairment but they do not cause ADHD.
Overall critical, harsh and negative behaviour of parents of hyperactive children
is related to difficult, disruptive and non-compliant behaviour of ADHD children.
Early TV viewing has also been found to shorten attention span of children.
Aggressive and hyperactive portrayal of characters in TV shows has also been
found to exaggerate difficult behavior.

12.4.3 Treatment
Some of the treatment options for ADHD are indicated below:
Prescription of medicine, like, Ritalin (methylphenidate), an amphetamine in
some children with attention deficit hyperactivity disorder is a common treatment
for ADHD. Ritalin is a stimulant and has a quietening effect on a child with
ADHD, opposite of what is expected for a typical adult for whom stimulant
leads to increased arousal and experience of excess energy. Ritalin has been
found to help children reduce restlessness and aggression, helping them focus
on studies and moderate difficult behaviours in classroom and home. Some
significant side effects are also related to the use of Ritalin in children including
decreased blood flow to the brain, which can result in impaired thinking ability
and memory loss; disruption of growth hormone, leading to suppression of growth
in the body and brain of the child; insomnia; psychotic symptoms; and others.
Medicines like Ritalin do not cure ADHD, but they do result in moderation of
334
behavioural symptoms. Disorders of Childhood and
Adolescents-I
Psychological interventions along with medications are important in providing
holistic treatment. Behavioural strategies include selective reinforcements in
classroom and structuring of material in a way that enhances the experiences of
success. For instance, a girl with ADHD should be praised for increasing the
amount of time she sits in classroom even if she sits for 15 minutes in a half an
hour class, if she was unable to previously sit for anything more than say five
minutes. Family therapy helps in making parents and sibling understand
behavioural strategies to maximize productive behavior and extinction of
aggressive and destructive behavior.

School based intervention programs aim to teach teachers to deal with

hyperactivity and inattention difficulties in classroom.

Check Your Progress 4

1) Classify the sub-types of ADHD.
.............................................................................................................
.............................................................................................................
.............................................................................................................
2) What is the role of social factors in etiology of ADHD?
.............................................................................................................
.............................................................................................................
.............................................................................................................
3) Define impulsivity.
.............................................................................................................
.............................................................................................................
.............................................................................................................

12.5 SUMMARY
Now that we have come to the end of this unit, let us list all the major points that
we have already learnt.
Developmental psychopathology is a field in psychology that is dedicated
to studying the origins and cause of significant disturbances in context of
normal growth processes.
Children with depression exhibit symptoms like withdrawal from family
and friends, avoidance of eye contact, physical complaints, poor appetite
and/or aggressive behaviour. In some cases, the children may even attempt
self-harm or suicide. Depression in children is different from depression in
adults in showing more guilt but lower rates of early morning depression
and weight loss. Genetic factors interact with stressors in family environment
to result in childhood depression.

335
Disorders of Childhood and Elimination disorder concerns with defecating and urinating difficulties in
Adolescence Trauma Related
and Neurocognitive Disorders
children. In this condition children eliminate bodily substances at
inappropriate times and places.
Oppositional Defiant Disorder and Conduct Disorder are categorized under
Disruptive, Impulse-Control and Conduct Disorders in DSM-5 since they
share the core feature of aggressive or anti-social behaviour.
Multisystemic Treatment (MST) includes consideration of multiple factors
when developing a child’s treatment, including family, school, community,
and peers.
Children with Attention-Deficit/Hyperactivity Disorder display difficulties
in maintaining sustained attention, excessive and exaggerated motor activity,
and impulsivity relative to their developmental level leading to social,
occupational/academic activities.

12.6 KEYWORDS
Neurodevelopmental Disorders: A group of severely disabling conditions
considered to be a result of structural and/or functional differences in the brain
that are usually evident at birth or become apparent as the child begins to develop.
Childhood Depression: Children with depression exhibit symptoms like
withdrawal from family and friends, avoidance of eye contact, physical
complaints, poor appetite and/or aggressive behaviour. In some cases, the children
may even attempt self-harm or suicide.
Enuresis: Bedwetting or habitual involuntary discharge of urine after the age of
5 years which is not organically caused.
Encopresis: Inability to learn toileting for bowel movements beyond the age of
4 years.
Oppositional Defiant Disorder: Characterised by presence of persistent
negativistic, defiant, disobedient, and hostile behaviour towards authority figures.
Conduct Disorder: A disorder in which a child has a repetitive and persistent
pattern of behaving in a way that violates other people’s rights or societal norms
that are age appropriate.
Multisystemic Treatment (MST): It includes consideration of multiple factors
when developing a child’s treatment, including family, school, community, and
peers.
Attention-Deficit/Hyperactivity Disorder: Includes difficulties in maintaining
sustained attention, excessive and exaggerated motor activity, and impulsivity
relative to their developmental level leading to social, occupational/academic
activities.

12.7 REVIEW QUESTIONS

1) Which of the following is NOT an example of a neurodevelopmental
disorder?
a) ADHD

336 b) Childhood Depression

 c) ASD Disorders of Childhood and
Adolescents-I
d) SLD
2) Developmental disorders refer to those conditions that occur ________in
life.
a) Early, b) Late, c) After retirement
3) Children with ____ seem to have particular difficulty controlling their activity
in situations that call for sitting still, such as in the classroom or at mealtimes.
4) Hyperactivity refers to excessive activity manifested in two forms: ________
hyperactivity and ____________ hyperactivity.
5) There are two types of elimination disorders, ________ and _____________.
6) Discuss the causes of Oppositional Defiant Disorder and Conduct Disorder.
7) Describe the clinical picture of Attention Deficit/Hyperactivity Disorder.
8) Explain the causal factors and treatment of childhood depression.
9) Discuss the diagnostic criteria of elimination disorders.

12.8 REFERENCES AND FURTHER READING

Barlow, D.H. & Durand, M.V. (2015). Abnormal Psychology (7th Edition). New
Delhi: Cengage Learning India Edition.
Mineka, S., Hooley, J.M., & Butcher, J.N., (2017). Abnormal Psychology (16th
Edition). New York: Pearson Publications.
Kring, A. M., Davison, G. C., & Neale, J. M. (2014). Abnormal Psychology (13th
Edition). New York: John Wiley & Sons.

12.9 REFERENCES FOR IMAGES

Multisystemic Treatment (MST) of Conduct Disorder. Retrieved 7th
September 2019, from http://www.mstuk.org/about/about-2.
Foetal Alcohol Syndrome. Retrieved 10th September 2019, from https://
healthand.com/in/topic/general-report/fetal-alcohol-syndrome
Non-Verbal Communication. Retrieved 14th September 2019, from https://
g l o b a l c o m m u n i c a t i o n c o r p o r a t i o n . w e e b l y. c o m / n o n - v e r b a l -
communications.html
Reciprocal relationship between socialization and communication
impairments in autism. Retrieved 14 th September 2019, https://
www.autismempowerment.org/2014/03/22/communication-autism-
personal-reflections/

12.10 WEB RESOURCES

ADHD brain.
https://www.webmd.com/add-adhd/adult-adhd-17/video-adult-adhd-brain
Micheal Phelp’s Story of ADHD. https://www.understood.org/en/learning-
attention-issues/personal-stories/famous-people/celebrity-spotlight-how-
michael-phelps-adhd-helped-him-make-olympic-history

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Disorders of Childhood and Answers to Fill in the Blannks (1-5)
Adolescence Trauma Related
and Neurocognitive Disorders (1) Childhood Depression, (2) Early, (3) Attention Deficit/Hyperactivity disorder,
(4) motor and vocal (5) enuresis and encopresis.

338