Child psychopathology

Assist. Prof. Dr. Ezgi ULU

Section I: Neurodevelopmental Disorders: An

Introduction

 Intellectual Disability (Intellectual Developmental Disorder;

IDD)

 Autism Spectrum Disorder (ASD)

 Specific Learning Disabilities (SLD)

 Attention Deficit Hyperactivity Disorder (ADHD)

Intellectual Disability (Intellectual
Developmental Disorder; IDD)
Intellectual Disability (Intellectual
Developmental Disorder, IDD)

The DSM-5 has suggested two possibilities for

replacing the term “mental retardation,” which are
intellectual disability or intellectual developmental
disorder (IDD). Because the term IDD is consistent
with that used by the ICD system (International
Classification of Diseases) and AAIDD, it will be the
term that is used. Mental functioning is measured by
an individual intelligence test, while adaptive skills
are often evaluated through the use of structured
interviews that assess capacity in such areas as self-
Limitations in these global areas often result in problems in learning (both the quality and
quantity of information learned) and a slower pace of development compared to children who
do not have these limitations. Children with IDD may be delayed in the acquisition of
developmental milestones (talking, walking, self-help skills). There is a wide range of
functioning in these children and while some are only moderately delayed, others have severe
adaptive and learning problems.
DSM-5 (APA, 2013)
Clinical Classification and Diagnostic Criteria

IDD is the first disorder to appear under the major category of Neurodevelopmental
Disorders. This category is new to the DSM and is shared by seven disorders that have
childhood onset, and involve cognitive impairments (specific or general/global) that
significantly impact functioning in a major area, such as school or employment, and is
persistent across the life span. The other disorders in this category include: communication
disorders (language disorder, speech sound disorder, childhood-onset fluency
disorder/stuttering, social/pragmatic communication disorder); autism spectrum disorder
(ASD); attention-deficit/hyperactivity disorder; specific learning disorder; motor disorders
(developmental coordination disorder, stereotypic movement disorder, tic disorders) and other
neurodevelopmental disorders (other specified, or unspecified neurodevelopmental disorder).
The DSM-5 (APA, 2013) presents three main criteria for a diagnosis of IDD, as
follows:

1. Deficits in intellectual functioning (reasoning, problem solving, learning, etc.) that have
been verified by clinical observations and individual assessments;
2. Deficits in adaptive functioning resulting in an inability to meet developmental expectations
Significantly Subnormal Intellectual Functioning

According to the DSM, subnormal intellectual functioning is an IQ of approximately 70 or less

obtained on a standard and well-recognized instrument that has been developed specifically to

assess intelligence (e.g., Wechsler Intelligence Scale for Children: WISC-V; Stanford–Binet 5 th

Edition).
Severity Conceptual Domain Social Domain Practical Domain

Mild In very young children differences There may be delays in Individuals may be able
may not be easily recognized, but social engagement and to manage self-care,
may begin to be noticeable by school communication and some recreational outlets,
age, especially delays in acquiring children may miss subtle and jobs that are highly
core academic skills. Adults may social cues, or not structured.
experience problems with recognize risky situations. Management of
organization, money management There may be problems financial affairs, or
and other activities relying on with emotion and behavior making
functional academics. regulation. important decisions
(e.g.,
health care) likely will
require support.
Moderat Increased supports may be Making and keeping friends Training and practice
e needed to enhance academic skills, may be problematic due can
especially in areas requiring to language delays and be successful in
reasoning involving money or time. immature social skills. acquiring
Adult skill levels are likely to plateau Caregivers will be needed skills in self-care,
academically at an elementary to provide ongoing although
school level and assistance will be support for decision monitoring may be
required to manage day-to-day making in day to day needed. Ongoing
Severity Conceptual Domain Social Domain Practical Domain

Severe Ongoing support will be Individuals may be able All activities of self-
needed, due to limitations in to communicate using care and
understanding time, money, or simple speech and daily living will require
numbers. gestures; however, speech support and
is often limited. Speech supervision.
augmentation may be Some may exhibit
required. maladaptive and self
injurious behaviors.
Profound Extensive support is required due to Social engagement is Extensive support is
comorbid motor and sensory challenging due to required due to the
impairments, and limited ability to comorbid motor and complex nature of
comprehend written or spoken sensory impairments accompanying
language. and very limited ability comorbid
to understand speech or impairments.
gestures. Extensive
support
needed.
Assessment of Intellectual and Adaptive Functioning
The instruments have been developed to provide normative information
concerning the individual’s intellectual level (IQ) relative to similar-aged peers,
and of adaptive functioning in the areas mentioned relative to developmental
expectations.

Although information is obtained through a structured interview format, results

provide standard scores that can be used to directly compare standard scores
for adaptive levels with standard scores for intellectual functioning. The
instruments also provide age equivalent scores to assist in determining current
developmental level. When obtaining information regarding a child’s
performance through interviews or rating scales, it is always advisable to
obtain information from different informants who can provide different
perspectives on behavior demonstrated in different environments.
Table 6.2
Global developmental delay:
New to the DSM-5 is the diagnosis of global developmental delay that aligns more
closely with the educational classification system’s (IDEA, 2004), emphasis on early
identification of developmental delays in children.

The DSM-5 has developed this special category for individuals under the age of 5
years who may be suspected of having IDD but cannot be assessed due to
circumstances (e.g., the child is too young). In this special case, the diagnosis of
global developmental delay will be given if the child does not achieve age-appropriate
developmental milestones in several areas of intellectual functioning. However, this is
only meant as a temporary diagnosis and is only valid for a period of time until
arrangements can be made for a full clinical assessment to be conducted.
The American Association on Intellectual and Developmental
Disabilities (AAIDD)

Definition and Criteria

In 1992, the American Association on Mental Retardation (AAMR) made a landmark decision to
shift emphasis from the DSM focus on severity of disorder (mild, moderate, severe and
profound) to a focus on intensity of intervention required (intermittent, limited, extensive or
pervasive). Doing away with levels of dysfunction also placed greater emphasis on the
intensity of intervention required in order to assist individuals to have greater functioning
ability. The levels of intensity of intervention were listed as:
• Intermittent
• Limited
• Extensive
• Pervasive.
At this time, the upper level for onset was also increased from 16 to 18 years of age. In 2007,
the American Association on Mental Retardation (AAMR) changed its name to the American
Association on Intellectual and Developmental Disabilities (AAIDD) to recognize how the
disorder was conceptualized internationally as intellectual disability or intellectual
developmental disorder (as it is recognized in the International Code of Diseases, ICD-10).
AAIDD continued to recognize the same three diagnostic criteria as the DSM-5, involving: IQ
cutoff for intellectual disability (70, plus or minus 5); adaptive deficits; and onset in the
When a diagnosis of IDD is made, AAIDD (2010) clearly focuses on the need to plan a
support system in order to reduce the gap between an individual’s capabilities and their
skills with the goal of promoting the most successful lifestyle possible. The AAIDD
continues to evolve how it defines an intellectual disability and the latest definition can be
found in the 11th Edition of the AAIDD Definition Manual (2010).

Although AIDD has supported an IQ range for IDD similar to that proposed by the DSM-5,
they have also more recently advocated for an IQ level that could potentially raise the
cutoff to 76.
Assessment of Intensity of Supports

When the definition of IDD was infused with the concept of intensity of
supports, it was soon recognized that the best way to determine the level
and nature of supports required was to develop a scale to measure
supports. Thompson and colleagues (2004) than developed Supports
Intensity Scale (SIS).

The SIS consists of six subscales that measure the nature and intensity of
supports needed in 49 different areas. The six subscales represent
domains of adaptive functioning and include:
1. Home living
2. Community living
3. Lifelong learning
4. Employment
5. Health and safety
IDEA (2004)

Educational Definition and Eligibility Criteria

There has been considerable change in the way that disabilities have been defined over the
years, and the education system is no exception in this regard. Historically, IDEA has modified
its definition of IDD and the recommended levels of IQ functioning to align with definitions and
IQ levels suggested by AAIDD. Initially, criteria for IDD within the educational system involved
an IQ range of 55 to 80 for classification as either educable mentally retarded (EMR) or
educable mentally handicapped (EMH). Students with IQs in the 25 to 55 range traditionally
have been most commonly classified by the educational system as trainable mentally
retarded (TMR) or trainable mentally handicapped (TMH).

However, the suggested IQ level to serve as threshold for IDD has changed over the years and
has dropped from an initial consideration of 85 to its current cut-off score of an IQ of 70 (+5), in
most states. Although IDEA provides the general driving force for educational determination,
funds for special education programs are allocated by state codes that also set cutoff scores
that determine eligibility for programs. As a result, actual IQ ranges for IDD may vary from state
to state.
Studies that have looked at classification and placement procedures have found
considerably disparity in their results. For example, MacMillan and Forness (1998) suggest
that placement decisions may be made more on compliance issues (allotted placements per
category) than on predetermined criteria. In one sample in their California study, they found
that of 43 children, scoring below 75 on their IQ test, only 6 of the 43 were designated as
IDD. Fifty percent of children with IQ scores at this level were classified as Learning Disabled
(LD). When IDEA was reauthorized in 1990, the definition of IDD used by IDEA (1990) was in
agreement with definitions of IDD set by AAIDD at that time.
As a result, three key areas were deemed necessary for identification of having IDD:
1. Significant limitations in intellectual functioning;
2. Significant limitations in adaptive functioning;
3. Onset prior to 18 years of age.
Early Identification Procedures and Developmental Delay

Sections of IDEA (2004) that are concerned with early identification of children at the
beginning of the process (infants and toddlers) are covered under Part C). In Part C, Section
635, IDEA (2004) defines developmental delay as a delay of 35% or more in one of the
developmental areas or 25% or more delayed in two or more of the developmental areas.
There are five global areas of potential delay outlined in IDEA (2004, Sec. 632):
• Cognitive development
• Motor skills
• Communication skills
• Social or emotional development
• Adaptive functioning.
Included under adaptive functioning are those skills involved in daily living, such as self-help,
being able to dress or feed oneself and so forth. IDEA (2004) also mandates services for
infants and toddlers who have a diagnosed physical or mental condition that has a high
likelihood of resulting in a developmental delay.
IDD: Developmental and Associated Features

Today the majority of children and youth with IDD would fall within the
mild level of impairment. As such, these children will most likely reside
and attend schools in their local community, unless they are transported
to different schools for special programs that are not available in their
home schools. The features of IDD vary widely depending on the
severity, associated personality and behavioral characteristics and the
developmental level. While some children may experience
developmental delays and in a sense, catch up with increased maturity
and stimulation/enrichment, others with diagnosable IDD may vary only
within a limited range of development. As was noted earlier, some
individuals with IDD live a relatively normal life despite cognitive
limitations due to their adequate adaptive skills. Associated features
that may become more obvious over time are delays in achieving
milestones in areas that are key to developmental progress. Examples
include delays in the following global areas:
• Gross motor skills (sitting independently, crawling, walking);
• Fine motor skills (drawing, printing, coloring);
• Communication skills (late speech development, trouble talking);
• Cognitive skill development (problems understanding, problem
solving, remembering and transferring information from one situation to
another);
Comorbidity Individuals with IDD are three to four times more likely to have a
comorbid disorder, than individuals in the population at large. In
addition, comorbid disorders associated with IDD are often more
complex and more difficult to diagnose and treat, because disorder
features may be modified by the presence of IDD (APA, 2013).

According to the DSM-5 (APA, 2013) the most common comorbid

disorders associated with IDD include: ADHD, depressive and bipolar
disorders, anxiety disorders, autism spectrum disorders, stereotypic
movement disorder, impulse control disorders and major neurocognitive
disorder. Different disorders that fall under the umbrella of IDD (such as
Fragile X, Prader-Willi) have different features and etiology and different
types of comorbid associations. For example, while children with
Fragile X often have high rates of comorbid ADHD and social phobia,
Etiology and IDD Subtypes

The Biopsychosocial Model

There are many causes of IDD. The most common causes are
those that relate to the biomedical and genetic domain, and
include: genetic conditions, problems during pregnancy
(toxins), problems during delivery or health-related problems.
IDD Due to Genetic Conditions and Chromosome Abnormalities
Sometimes IDD is caused by genetic defects that can be
inherited from parents, or result from chromosomal
abnormalities when genes combine, or other genetic reasons.
Examples of genetic conditions are Down syndrome, Prader-
Willi syndrome, Angelman syndrome, Williams
syndrome,
Down Syndrome

Down syndrome (DS) is a chromosomal abnormality involving

chromosome 21 (incorrect number of chromosomes or damaged
chromosomes). There are variations within the disorder and not
all features are present in everyone with DS.

Some of the more classic features include: short stature, short

broad hands and feet, round face, almond-shaped eyes (oblique
eye fissures), flat facial features (protruding tongue), and low
muscle tone. Language and motor skills are the most impaired in
children with DS.

The majority of children with DS demonstrate significant

problems with language, including linguistic grammar, expressive
language, and articulation. Grammatically, most children with DS
are equivalent to a child of approximately 3 years of age in their
grammatical abilities and fall well below their overall mental age
levels in this area. Expressive language abilities have been
reported in as many as 83% to 100% of children with DS. Yet
despite deficits in grammar, expressive language, and
Prader-Willi Syndrome
Chromosome 15 is implicated in Prader-Willi
syndrome, and the disorder is inherited from
the father, unlike Angel man syndrome, also
involving chromosome 15, but which is
inherited from the mother. It was one of the
first examples of gene imprinting, where the
expression of genes is imprinted by the parent,
and in this case the male.The prevalence rate
for Prader-Willi syndrome ranges from 1 in
15,000 to 1 in 30,000 births.
Angelman Syndrome

Originally labeled as “Happy Puppet” syndrome, Angelman

syndrome also involves chromosome 15 but in this case
gene imprinting is inherited from the mother. It is
estimated that prevalence rates for Angelman syndrome
range between 1 in 10,000 to 1 in 40,000 births.

There are four characteristics that have been identified

consistently in individuals with Angel man syndrome:
developmental delay, speech impairment, movement
disorder and frequent and often inappropriate
laughing/smiling. Easily excitable and over aroused, they
have short attention span and hyperactivity. Other
characteristics often evident include: microcephaly,
Williams Syndrome

Williams syndrome (WS) was identified in 1961

by a New Zealand cardiologist, Dr. J.C.

Williams. The genetic neurodevelopmental

disorder is rare occurring in approximately 1 in

7,500 births.

The disorder develops as a result of a deletion

on chromosome 7 (part of the chromosome is

missing). Although the deletion occurs as a

random genetic mutation, individuals with WS

 As a result, individuals with WS often suffer from cardiovascular problems at an early age
and may have premature death (average life span of 50 years). Other features of WS
include: hypersensitivity to sound and a distinctive facial appearance with puffiness around
the eyes, a short nose with a broad tip, wide mouth, full cheeks and lips and small chin. As
infants, they are usually colicky and irritable and often experience feeding problems.
Chronic abdominal problems are characteristic of adolescence, while the majority develop
diabetes or prediabetes in their thirties.

Most individuals with WS have mild to moderate intellectual impairments and have
relatively well developed verbal skills (verbal IQ) compared with very poor performance
skills (performance IQ). Those with WS demonstrate strengths in language (concrete and
practical language rather than abstract) and significant weaknesses in areas of visual
cognition and visuospatial functioning, with the exception of facial recognition which
remains intact.
The personality of those with WS is remarkable in that they are highly gregarious and
driven to social engagement.

Bellugi and colleagues (2007) address the issue that despite being driven to engage
socially, children with WS often exhibit problems maintaining relationships with peers.
They speculate that the disconnect between social-perceptual abilities and social-
expressive behaviors may be found in the fact that although children with WS are
socially fearless, they are also endowed with nonsocial anxiety that may undermine
their ability to relate to others.
Fragile X

This is the most common inherited cause of IDD in the mild to moderate levels and occurs when
there is a change or mutation in a gene called the Fragile X Mental Retardation 1 (FMR1) gene
that is responsible for producing a protein necessary for normal brain development. If only mild
changes in the gene are present, there may be few symptoms; however, greater change in the
gene produces increased symptoms of fragile X syndrome.

The symptoms of fragile X, which can vary relative to the degree of change in the gene, include:
intellectual deficits, and possible physical characteristics (longer ears, faces and jaws). There
may also be challenging behaviors (fearfulness, anxiety), and males may tend to be inattentive
or aggressive, while females may appear withdrawn and shy. Language problems are also often
evident and children may exhibit heightened sensitivity to sound, touch and bright light (National
Institute of Child Health & Development: NICHD). A number of children with Fragile X will also
have comorbid autism.
Phenylketonuria (PKU)

A number of disabilities can be caused by recessive

genes. One of the most commonly occurring recessive
disorder that can cause serious intellectual disabilities
is phenylketonuria, or PKU. Infants born with two
recessive genes lack a necessary enzyme that is
responsible for converting one of the basic amino acids
that make up proteins into a product (phenylalanine)
that is essential to body functioning (tyrosine). If the
enzyme is not present, phenylalanine will continue to
build, reaching toxic levels that can damage the central
nervous system (CNS).
Problems During Pregnancy: Environmental Toxins

IDD can result when the fetus is exposed to environmental toxins

(called teratogens) that can cause damage to the unborn fetus
when they cross the placenta during pregnancy, when vital organs
and the nervous system are in the process of being developed. After
birth, exposure to toxins in the environment (e.g., high levels of
lead, mercury) can also alter the course of cognitive, physical and
emotional development.
Substance Use/Abuse

Babies born to mothers who use cocaine can suffer a wide range of side effects after birth,
including physical defects and brain dysfunction in hemorrhages and seizures.

Mothers who are addicted to crack often give birth to infants who suffer from low birth
weight and damage to the central nervous system.
Fetal Alcohol Syndrome (FAS)

Approximately 33% of all babies born to mothers who are heavy consumers of alcohol
will be born with fetal alcohol syndrome (FAS). Clinical features of FAS include:
central nervous system dysfunction (intellectual disabilities, hyperactivity, irritability);
impaired motor coordination; and over activity.

Physically, these children often evidence slow growth and unusual facial features,
including underdeveloped upper lip, flattened nose, or short and upturned, widely
spaced eyes, and small head. Although facial features become less pronounced with
age, cognitive deficits remain.
Risks and Protective Factors

Knowing the possible causes of IDD is one of the most valuable

protective factors, because many of the causes are risks that are
preventable. Ensuring that you are inoculated against contracting
rubella prior to contemplating pregnancy is an important step in
protecting the unborn child.

Eating properly, and ensuring that housing is free of lead-based

paint, will also reduce the risk of mental impairments. Refraining
from substances during pregnancy that are known contributors to
mental impairments is another protective factor.
Assessment

There are several steps in the assessment of possible IDD:

1. A full developmental and medical history is essential in order to
determine the potential etiology, onset (prior to 18), and to rule out
other competing diagnoses. As the severity of IDD increases, clinicians
will also need to be on the lookout for existing medical complications.
Developmental milestones provide valuable information concerning
which aspects of development might be most affected (for example,
delays in sitting or walking may indicate motor problems; while delays
in language acquisition might signal language problems). The degree
of delay can also be helpful in determining extent of problem (e.g., 1
month’s delay compared to 2 years’ delay). Information about a child’s
strengths can also be very helpful for future intervention. Some
children with IDD have excellent ability to imitate others and in this
case, modeling can be an effective intervention strategy.
2. An individual intellectual assessment is also crucial to determine
whether the IQ score falls within the ranges associated with IDD.
Although an IQ score of 70 is normally associated as the upper limit of
the IDD range, in recognition of measurement error in any test
administration (e.g., performance many fluctuate due to fatigue,
illness, etc.), an additional 5 points (reflecting 5% variance) can be
added to raise the score to 75. A list of the most common assessment
instruments for measuring intelligence is available (in Table 6.2). The
AAIDD has emphasized that it is crucial that intelligence be evaluated
using the most up-to-date norms, possible, to control for the Flynn
effect (observed rise in IQ scores over time, resulting in norms obsolescence).

3. In addition to a low IQ (approximately two standard deviations

below the mean), a diagnosis of IDD also requires identification of
significant deficits in adaptive behaviors (found in Table 6.2 below
Intervention and Prevention
Intervention Programs:
Interventions for children with IDD vary widely depending on the
specific area targeted for improvement. The majority of interventions
focus on the reduction of behavioral/emotional issues, or increasing
social, educational or adaptive functioning.

Behavioral Interventions:
Behavioral programs have been very successful in targeting and
altering problematic social, emotional and behavioral concerns. The
reason for the success of the behavioral programs can be linked to the
programs’ focus on breaking down problem behaviors into component
parts (simplicity) and to systematically shaping behaviors into more
socially adaptive behaviors through contingency management.
Parent Training Programs:

Including parents in the intervention process (whether academic,

behavioral or social) is extremely important. Research has demonstrated
that parents can be effective monitors of their child’s progress and
improve overall success by helping children to transferring skills from one
situation to the next. There are many ways that parents can increase their
child’s success, such as helping in transferring skills learned at school to
the home environment or skills learned in leisure activities to social
activities (generalizability). Remember that transferring information
across situations is one of the more difficult tasks for children with IDD.

Educational Programs:

There is continual and at times heated debate over whether children with
IDD are better served within special education programs or the regular
class (a practice referred to as mainstreaming or inclusion). It is possible
to find support for either side of the debate in research studies. Hocutt
(1996) reviewed over 100 studies from the past 25 years comparing
special education to regular class placement for children with mild IDD
and found that there was considerable variability in results.
Prevention and Early Intervention

The importance of prevention and early intervention cannot be

overemphasized. Prevention programs have been launched at all
levels of intervention from prenatal awareness campaigns (effects
of drug abuse, and alcohol; genetic counseling) to early
intervention programs targeting parenting skills and early
stimulation programs (the High/Scope Perry Preschool Project).

Impact of early intervention programs within the first 5 years of life

has been clearly documented in the prevention of increasing
cognitive declines.