CU-MA-PSY-SEM-I-Developmental Disorders Child Psychopathology- Second Draft-converted

MASTER OF ARTS PSYCHOLOGY SEMESTER-I DEVELOPMENTAL DISORDERS: CHILD PSYCHOPATHOLOGY 21MAP605

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CHANDIGARH UNIVERSITY Institute of Distance and Online Learning Course Development Committee Prof. (Dr.) R.S.Bawa Pro Chancellor, Chandigarh University, Gharuan, Punjab Advisors Prof. (Dr.) Bharat Bhushan, Director – IGNOU Prof. (Dr.) Majulika Srivastava, Director – CIQA, IGNOU Programme Coordinators & Editing Team Master of Business Administration (MBA) Bachelor of Business Administration (BBA) Coordinator – Dr. Rupali Arora Coordinator – Dr. Simran Jewandah Master of Computer Applications (MCA) Bachelor of Computer Applications (BCA) Coordinator – Dr. Raju Kumar Coordinator – Dr. Manisha Malhotra Master of Commerce (M.Com.) Bachelor of Commerce (B.Com.) Coordinator – Dr. Aman Jindal Coordinator – Dr. Minakshi Garg Master of Arts (Psychology) Bachelor of Science (Travel &Tourism Management) Coordinator – Dr. Samerjeet Kaur Coordinator – Dr. Shikha Sharma Master of Arts (English) Bachelor of Arts (General) Coordinator – Dr. Ashita Chadha Coordinator – Ms. Neeraj Gohlan Academic and Administrative Management Prof. (Dr.) R. M. Bhagat Prof. (Dr.) S.S. Sehgal Executive Director – Sciences Registrar Prof. (Dr.) Manaswini Acharya Prof. (Dr.) Gurpreet Singh Executive Director – Liberal Arts Director – IDOL © No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise without the prior written permission of the authors and the publisher. SLM SPECIALLY PREPARED FOR CU IDOL STUDENTS Printed and Published by: TeamLease Edtech Limited www.teamleaseedtech.com CONTACT NO:- 01133002345 For: CHANDIGARH UNIVERSITY 3 Institute of Distance and Online Learning CU IDOL SELF LEARNING MATERIAL (SLM)

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CONTENT Unit – 1 Nature Of Child Psychopathology...............................................................................6 Unit – 2 Historical Perspective ................................................................................................17 Unit – 3causes Of Child Psychopathology ..............................................................................27 Unit –4 Developmental Disorders: Mr - Part I ........................................................................37 Unit –5 Developmental Disorders: Mr -Part Ii ........................................................................56 Unit –6 Attention Deficit Hyper Activity Disorders- Part I ....................................................84 Unit –7 Attention Deficit Hyper Activity Disorders- Part Ii .................................................102 Unit –8 Case Studies..............................................................................................................124 Unit –9 Disorders: Oppositional Defiant Disorder – Part I ...................................................136 Unit –10 Disorders: Oppositional Defiant Disorder – Partii .................................................154 Unit –11 Disorders: Oppositional Defiant – Assessment, Prognosis & Treatment...............170 Unit –12 Conduct Disorder....................................................................................................194 Unit –13 Conduct Disorder – Assessment, Prognosis & Treatment......................................212 Unit –14 Case Studies............................................................................................................227 5 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT – 1 NATURE OF CHILD PSYCHOPATHOLOGY Structure 1.0 LearningObjectives 1.1 Introduction 1.2 Normal Development in Children 1.3 What is Child Psychopathology? 1.4 Significance of Child Psychopathology 1.5 Scope of Child Psychology 1.6 Identifying Psychopathology in Children 1.7 Summary 1.8 Keywords 1.9 Learning Activity 1.10 Unit End Questions 1.11 References 1.0 LEARNINGOBJECTIVES After studying this unit, you will be able to: • Explain the concept of child psychopathology • Describe the scope of child psychopathology • Elaborate on the role of child psychologists 1.1 INTRODUCTION Ben is an 8-year-old boy who lives in suburban Chicago, IL. He makes good grades and is one of the brightest kids in his class. However, he is constantly moving, gets distracted, talks 6 CU IDOL SELF LEARNING MATERIAL (SLM)

out of turn and to his peers during quiet time, and makes many careless mistakes on his tests. He often gets in trouble at school for his disruptive behavior. At home, his parents get frustrated because they have to repeat directions and remind him to complete chores frequently. Ben also loves baseball, but he keeps getting distracted while on the field and missing important opportunities during the game – his peers are getting frustrated with him. His parents can tell that Ben wants to make good behavioral choices, but for some reason, before even thinking, he ends up making a poor choice. Out of concern, his parents took Ben to see a child psychologist. Ben’s story, though hypothetical, is true of children. Although many young children may have excessive energy and struggle at times to stay on task, Ben’s difficulties seem to exceed that of his peers. His behavioral problems are causing impairment for him in multiple domains of life such as home, work, school, and social circles. Not all the children grow up in the same way. Some children go through abnormalities in development or behaviour. These abnormalities range from mild to severe degrees. In this paper, we will look into the field of child psychopathology, some of the common mental health disorder among children, their diagnostic criteria, symptoms, causes and treatment. 1.2 NORMAL DEVELOPMENT IN CHILDREN Families are unique social systems in so far as membership is based on combinations of biological, legal, affectional, geographic and historical ties. In contrast to other social systems,entry into family systems is through birth, adoption, fostering or marriage and members canleave only by death. Physical Development At birth infants candistinguish good and bad smells and sweet, sour and salt flavours. Even before birth, babies can respond to tactile stimulation and recognise their mother’s voice. The skill of localising a sound is also present at birth. In the first weeks of life infants can only focus on objects about a foot away and show a particular interest in dark-light contrasts. By three months they have relatively well-developed peripheral vision and depth perception and a major interest in faces. Visual acuity is usually fully developed by 12 months. Sensory stimulation is important for the development of the nervous system and inadequate stimulation may prevent normal neurological and sensory development. For example, children born with a strabismus (squint) which goes uncorrected may fail to develop binocular vision. 7 CU IDOL SELF LEARNING MATERIAL (SLM)

Different parts of the body develop at different rates following a cephalocaudal progression. The head and brain develop early but the limbs develop later. From birth until the onset of adolescence, the rate of growth slows. With adolescence a growth spurt occurs which concludes at the end of adolescence. Until adolescence the rates of growth for boys and girls are comparable. With the onset of adolescence, girls enter the growth spurt between one and two years earlier than boys. Height, muscle mass and shoulder width are the main areas of development during the adolescent growth spurt for boys. Girls add more overall fat and hip width than boys. In adolescence youngsters develop primary sexual characteristics (menstruation in women and the capacity to ejaculate in men) and secondary sexual characteristics (auxiliary hair, breasts and voice changes). The average age for the emergence of primary sexual characteristics for girls and boys is 12 and 14 years respectively. Cognitive Development A distinction between language development and the development of intelligence has traditionally been made by researchers in the field of cognitive development. This distinction will be used in summarising findings of relevance to the practice of clinical psychology below. Most of the research on intelligence which is relevant to the practice of clinical psychology has been conducted within three traditions (Neisser et al., 1996): • the psychometric intelligence-testing movement • the Piagetian cognitive development tradition • the information-processing approach. Emotional Development The range of emotions that a child can display increases over the first few years of life (Malatesta, 1985). At birth infants can express interest, as indicated by sustained attention, and disgust, in response to foul tastes and odours. Smiling, reflecting a sense of pleasure, in response to the human voice appears at 4 weeks. Sadness and anger in response to removing a teething toy are first evident at 4 months. Facial expressions reflecting fear following separation become apparent at 9 months. Anger, fear and sadness are three emotions of particular interest to clinical psychologists. Anger is the principal emotion associated with conduct disorder. Emotional disorders are usually characterised by fear and sadness. The peak prevalence for fears of threatening objects or animals in children is about 3 years (Marks, 1987). While children of all ages can experience sadness, the prevalence of extreme sadness accompanied by depressive cognition 8 CU IDOL SELF LEARNING MATERIAL (SLM)

and somatic features rises sharply in adolescence (Cohen et al., 1993). Anxiety and depression will be discussed in Chapters 12 and 16 respectively. Moral Development Research based on both Piaget’s and Kohlberg’s stage theories of moral development confirm that the basis on which children make moral judgements changes as they become older and more cognitively mature (Kagan and Lamb, 1987). Up until the age of 5 or 6 (during the preoperational period) children evaluate the wrongness of an action in terms of the amount of damage it caused. Children at this age believe that apparently immoral acts may be carried out justifiably if there is no chance of detection and punishment. When children progress to the concrete operational period at about 7 years they judge the wrongness of an action on the basis of both the amount of damage caused by the act and the actor’s intentions. The morality of an act is judged against the degree to which the actor conformed to rules of good conduct. However, rules are seen as rigid and absolute rather than an arbitrary, negotiated social contract. At about the age of 10, as children move into the period of formal operations, it is the actor’s motives that are the primary criterion used to evaluate the wrongness of a particular action. Rules are seen as a basis for judging the morality of an act and these rules are seen as useful social conventions. Development Of Identity Harter (1983) tackles the complex problem of personal identity by conceptualizing the functions of self-knowledge, self-evaluation and self-regulation as the three primary components of the self-system. Self-knowledge refers to all that the child knows about herself but particularly to autobiographical memory, which was referred to when we discussed information-processing models of intelligence. Self-knowledge also includes insights about how the child functions in her social world. Self-evaluation refers to the way in which the child judges herself against others and against herself at other developmental stages. Self- regulation refers to the capacity to persist in independent, focused, goal-directed behaviour despite distractions posed by competing internal impulses or external stimuli. 1.3 WHAT IS CHILD PSYCHOPATHOLOGY? Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and 9 CU IDOL SELF LEARNING MATERIAL (SLM)

autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. How do we currently define psychopathology? In short, this discipline can be understood as an in-depth study of problems related to mental health. Just like pathology is the study of the nature of disease (including causes, development, and outcomes), psychopathology is the study of the same Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. Child psychopathology refers to the scientific study of mental disorders in children and adolescents. Oppositional defiant disorder, attention-deficit hyperactivity disorder, and autism spectrum disorder are examples of psychopathology that are typically first diagnosed during childhood. This study of mental illness can include a long list of elements: symptoms, behaviours, causes (genetics, biology, social, psychological), course, development, categorization, treatments, strategies, and more. In this way, psychopathology is all about exploring problems related to mental health: how to understand them, how to classify them, and how to fix them. Because of this, the topic of psychopathology extends from research to treatment and covers every step in between. The better we can understand why a mental disorder develops, the easier it will be to find effective treatments. 1.4 SIGNIFICANCE OF CHILD PSYCHOPATHOLOGY There has been and continues to be a great deal of misinformation and folklore concerning disorders of childhood (Mash & Barkley, 2003). Many of these unsubstantiated theories have existed in both the popular and scientific literature, one example is the misconception that over-stimulation in the classroom causes insanity. Many of the constructs used to describe the characteristics and conditions of psychopathology in children have been globally and/or poorly defined (Mash & Barkley, 2003). The growing attention to children’s mental health problems and competencies arises from a number of sources. First, many young people experience significant mental health problems that interfere with normal development and functioning. In fact, as many as 1 in 5 children in the United States experiences some type of difficulty and 1 in 10 have a diagnosable disorder that causes some level of impairment (Mash & Barkley, 2003). Second, a significant 10 CU IDOL SELF LEARNING MATERIAL (SLM)

proportion of children do not grow out of their childhood difficulties, although the ways in which these difficulties are expressed change in both form and severity over time. Third, recent social changes and conditions may place children at increasing risk for the development of disorders and also for the development of more severe problems at younger ages. Fourth, for a majority of children who experience mental health problems, these problems go unidentified. Only about 20% receive help, a statistic that has not changed for some time (Mash & Barkley, 2003). Fifth, a majority of children with mental health problems who go unidentified and unassisted often end up in the criminal justice or mental health system as young adults. They are at greater risk of dropping out of school and of not being fully functional members of society. Finally, a significant number of children in North America are being subjected to maltreatment and chronic maltreatment during childhood that is associated with psychopathology in children and later in adults. It has been estimated that each year as many as 2,000 infants and young children die from abuse or neglect at the hands of their parents or caregivers (Mash & Barkley, 2003). 1.5 SCOPE OF CHILD PSYCHOPATHOLOGY: Just as the scope of psychopathology is broad ranging from research to treatment, so too is the list of types of professionals who tend to be involved in the field. At the research level, you will find research psychologists, psychiatrists, neuroscientists, and others trying to make sense of the different manifestations of mental disorders seen in clinical practice. At the clinical level, you will find many types of professionals attempting to apply the diagnostic systems that are in place to provide effective treatments to individuals living with psychopathology. These can include the following and more: • Clinical psychologists • Counsellors • Criminologists • Marriage and family therapists • Nurse practitioners • Psychiatric nurses • Psychiatrists • Social workers • Sociologists 11 CU IDOL SELF LEARNING MATERIAL (SLM)

1.6 IDENTIFYING PSYCHOPATHOLOGY IN CHILDREN How do psychologists and psychiatrists decide what extends beyond normal behavior to enter the territory of \"psychopathology?\" Psychiatric disorders can be conceptualized as referring to problems in four areas: deviance, distress, dysfunction, and danger. For example, if you were experiencing symptoms of depression and went to see a psychiatrist, you would be assessed according to a list of symptoms (most likely those in the DSM-5): Deviance: This term refers to thoughts, emotions, or behaviours that deviate from what is common or at odds with what is deemed acceptable in the society. In the case of depression, you might report thoughts of guilt or worthlessness that are not common among other people. Distress: This symptom refers to negative feelings either felt within a person or that result in discomfort in others around that person. In the case of depression, you might report extreme feelings of distress over sadness or guilt. Dysfunction: With this symptom, professionals are looking for the inability to achieve daily functions like going to work. In the case of depression, you might report that you can't get out of bed in the morning or that daily tasks take you much longer than they should. Danger: This term refers to behaviour that might put you or someone else at some type of detrimental risk. In the case of depression, this could include reporting that you are having thoughts of suicide or harming yourself. In this way, you can see that the distinction between normal versus psychopathological behavior comes down to how issues are affecting you or the people around you. Often it is not until things come to a crisis point that a diagnosis is made when someone comes in contact with a medical or mental health professional. 1.7 SUMMARY • Although it is sometimes assumed that childhood and adolescence are times of carefree bliss, as many as 20% of children and adolescents have one or more diagnosable mental disorders. • Most of these disorders may be viewed as exaggerations or distortions of normal behaviours and emotions. 12 CU IDOL SELF LEARNING MATERIAL (SLM)

• Like adults, children and adolescents vary in temperament. Some are shy and reticent; others are socially exuberant. Some are methodical and cautious, and others are impulsive and careless. • Whether a child is behaving like a typicalchild or has a disorder is determined by the presence of impairment and the degree of distress related to the symptoms. For example, a 12-yr-old girl may be frightened by the prospect of delivering a class report in front of her class. • This fear would be viewed as social phobia only if her fears were severe enough to cause significant impairments and distress. • Mental health problems in children are relatively common. This is defined as a disturbance in the areas of relationship, feelings, behaviour or development. • These disturbances must be of sufficient severity as to require professional intervention. • Many developmental, emotional and behavioural problems are short-lived. For instance, fears in small children, temper tantrums in toddlers and periods of defiance in adolescence are common; they may cause worry for a period without ever needing any professional intervention. • Childhood disorders are often organised in two broad categories, called externalising and internalising disorders. • Externalising disorders are characterised by behaviours, such as aggressiveness, noncompliance, over activity, and impulsiveness, and include the DSM IVTR categories of ADHD, conduct disorder (CD), and oppositional defiant disorder (ODD). • Internalising disorders are characterised by more inward-focused experiences and behaviours such as depression, social withdrawal, and anxiety, and include childhood anxiety and mood disorders. 1.8 KEYWORDS • Abnormal behavior - Maladaptive behavior detrimental to an individual or a group. • Adolescent medicine - a subspecialty of pediatric medicine with a focus on providing holistic healthcare to adolescent patients and treating medical problems that are common during adolescence. • Child and adolescent psychiatrists - licensed physicians (M.D. or D.O.) who specialize in the evaluation, diagnosis, and treatment of mental disorders in children and adolescents. Their medical and psychiatric training with children and adolescents prepares them to treat children and adolescents either individually, as part of and involving the family unit, and/or in a group setting. Child and adolescent psychiatrists can prescribe medications, if needed. 13 CU IDOL SELF LEARNING MATERIAL (SLM)

• Child psychologist - licensed mental health professional (Ph.D. or Psy.D.) who specializes in the evaluation, diagnosis, and treatment of mental disorders. Training prepares clinical psychologists to treat children either individually, as part of and involving the family unit, and/or in a group setting. Psychologists also conduct cognitive, academic, and personality testing. 1.9 LEARNING ACTIVITY 1. How can parents keep track of development milestones of their children? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. Discuss the importance of emotional development among children? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 1.10UNIT END QUESTIONS A. Descriptive Questions 14 Short Questions 1. What is Psychopathology? 2. What is normal developemnt? 3. Who is a child psychologist? 4. What is child pschopathology? 5. Name 2 Childhood psychiatric conditions Long Questions 1. How to we identify Psychopathology. 2. What are causes of psychopathology? 3. Explain different types of psychopathology? 4. What is significance of child psychopathology? 5. What is scope of child psychopathology? B. Multiple Choice Questions 1. The term “psychopathology” was first introduced by a. Carl Jung CU IDOL SELF LEARNING MATERIAL (SLM)

b. Sigmund Freud c. Karl Jasper d. Wilhelm Wundt 2. This term refers to thoughts, emotions or behavior that deviate from what is common or odds with what is deemed acceptable in the society. a. Distress b. Dysfunction c. Danger d. Deviance 3. Cause of psychopathology when you’re body’s defence take effect and create a stress response, which make you feel a variety of physical symptoms, behave differently and experience more intense emotion. a. Substance of alcohol abuse b. Traumatic or stressful experiences c. Feelings of isolation d. None of these 4. _______________ techniques have been improving and becoming more accessible. Such techniques are valuable tools for unravelling the neurobiological underpinnings of psychiatric disorders. a. Neuroimaging b. Magnetic Resonance Imaging (MRI) c. Variable foraging demand d. Experimental-induced perception 5. A rare disorder that is present at birth (congenital). It is characterized by a partial or complete absence (agenesis) of an area of the brain that connects the two cerebral hemispheres. a. Trauma b. Dissociative symptoms c. Agenesis of corpus callosum d. Epileptic seizure Answers 1-(c), 2-(d), 3-(b), 4-(a), 5-(c) 15 CU IDOL SELF LEARNING MATERIAL (SLM)

1.11REFERENCES • Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd. • American PsychiatricAssociation (2000).Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC:American Psychiatric Publishing, Inc.. • Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon. • Emery, R.E., & Oltmanns, T.F. (1998).Abnormal Psychology (2nd ed.). Upper Sadle River, NJ: Prentice-Hall, Inc. Carter, E. and McGoldrick, M. (1989). The Changing Family Lifecycle: A Framework for Family Therapy (second edition). Boston: Allyn and Bacon. • Papalia, D. and Wendkos-Olds, S. (1995). Human Development (sixth edition). New York: McGraw-Hill. • Rutter, M. and Rutter, M. (1993). Developing Minds: Challenge and Continuity Across the Lifespan. London: Penguin. • Vasta, R., Haith, M. and Miller, S. (1995). Child Psychology: The Modern Science (second edition). New York: Wiley. 16 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT – 2 HISTORICAL PERSPECTIVE Structure 2.0 LearningObjectives 2.1 Introduction 2.2 Nature of Child Psychopathology 2.3 Epidemiological Considerations 2.4 Key Concepts in Child Psychopathology 2.5 Historical Perspective of Child Psychopathology 2.6 Summary 2.7 Keywords 2.8 Learning Activity 2.9 Unit End Questions 2.10 References 2.0 LEARNINGOBJECTIVES After studying this unt, you will be able to: • Describe the historical development of child psychopathology • Elaborate the timeline through which child psychopathology • Describe the key development in field of child psychology 2.1 INTRODUCTION Since modern views of mental illness began to emerge in the late 18th and early 19th centuries, the study of psychopathology in children has lagged behind that of adults. The Field of psychopathology is of relatively recent origin. Prior to the 20th century, 17 CU IDOL SELF LEARNING MATERIAL (SLM)

psychopathology was concerned almost exclusively with adult behavioural disorders. Child behaviour disorders, though occasionally acknowledged, received little concerted attention. In all likelihood, this state of affairs resulted from then the prevailing viewpoint of children being simply little adults or homunculi (“little men”). Children were not thought to possess “personalities” of their own; rather they were viewed as miniature adults, evincing problems similar to adults, and benefitting from reasoned advice much like their adult counterparts (Aries, 1962). A “child psychopathology,” let alone a “child psychopathology,” was non- existent. 2.2 NATURE OF CHILD PSYCHOPATHOLOGY Child psychopathology is the manifestation of psychological disorders in childhood and adolescence; examples include Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Pervasive Developmental Disorders (Mash & Barkley, 2003). Factors Complicating the Study of Child Psychopathology Since modern views of mental illness began to emerge in the late 18th and early 19th centuries, there has been far less attention given to the study of child psychopathology than psychopathology in adults. An example of this is in 1812, when Benjamin Rush, the first American psychiatrist, suggested that children were less likely to suffer from mental illness because the immaturity of their developing brains would prevent them from retaining the mental events that caused insanity (Mash & Barkley, 2003). Fortunately, psychiatrists do not think this way. Recently interest in child psychopathology has increased. This is due to the growing realization that many childhood problems have lifelong consequences and costs both for children and for society, that most adult disorders are rooted in early childhood conditions and/or experiences, and that a better understanding of childhood disorders offers promise for developing effective intervention and prevention programs (Mash & Barkley, 2003). Another factor is that there are issues present concerning the conceptualization and definition of psychopathology in children continue to be debated. Also, there is the fact that in studies conducted with children, much of the knowledge gained is based on findings obtained at a single point in a child’s development and in a single context. A further complication is that childhood problems “do not come in neat packages” and that most forms of psychopathology in children are known to overlap and/or coexist with other disorders (Mash & Barkley, 2003, p. 4). 18 CU IDOL SELF LEARNING MATERIAL (SLM)

As you come to learn about child psychopathology, you will see how much overlap really does occur and why this is such a complication. There is also a problem that distinct boundaries between many commonly occurring childhood difficulties and those problems that become labelled as disorders are not easily drawn. There is also a growing recognition that all current diagnostic categories of child psychopathology are heterogeneous with respect to etiology and outcome, and will need to be broken down into subtypes, as you will see with the disorders mentioned on this page. It has also become increasingly evident that most forms of child psychopathology cannot be attributed to a single unitary cause. Some disorders cannot be linked to a single gene or a single event in life. There is also the complication that numerous determinants of child psychopathology have been identified, including genetic influences, hypo- or hyper-reactive early infant dispositions, insecure child-parent attachments, difficult child behaviour, social- cognitive deficits, deficits in social learning, emotion regulation, and/or impulse control and response inhibition (Mash & Barkley, 2003). The many causes and outcomes of child psychopathology operate in dynamic and interactive ways over time which makes it hard to disentangle them. To designate a specific favour as a cause or an outcome of child psychopathology usually reflects the point in an ongoing developmental process at which the child is observed and the perspective of the observer (Mash & Barkley, 2003). 2.3 EPIDEMIOLOGICAL CONSIDERATIONS Prevalence The overall lifetime prevalence rates for childhood problems are estimated to be high and on the order of 14-22% of all children (Mash & Barkley, 2003). Rutter, Tizard, and Whitmore (1970) found in the classic Isle of Wight Study that the overall rate of child psychiatric disorders to be 6-8% in 9 to 11-year-old children (as cited in Mash & Barkley, 2003). Richman, Stevenson, and Graham (1975) found in the London Epidemiological Study that moderate to severe behaviour problems for 7% of the population with an additional 15% of children having mild problems (as cited in Mash & Barkley, 2003). Boyle et al. (1987) and Offord et al. (1987) reported in the Ontario Child Health Study that 19% of boys and 17% of girls had one or more disorders (as cited in Mash & Barkley, 2003). Many other epidemiological studies have reported similar rates of prevalence. Age Differences 19 CU IDOL SELF LEARNING MATERIAL (SLM)

Some studies of nonclinical samples of children have found a general decline in overall problems with age, whereas similar studies of clinical samples have found an opposite trend. These and many other findings raise numerous questions concerning age differences in children’s problem behaviours. Answers to even a seemingly simple question such as “Do problem behaviours decrease (or increase) with age?” are complicated by a lack of uniform measures of behaviour that can be used across a wide range of ages, qualitative changes in the expression of behaviour with development, the interactions between age and sex of the child, the use of different informants, the specific problem behaviours of interest, the clinical status of the children being assessed, and the use of different diagnostic criteria for children of different ages (Mash & Barkley, 2003). Socioeconomic Status Although most children with mental health problems are from the middle class, mental health problems are overrepresented among the very poor. It is estimated that 20% or more of children in North America are poor, and that as many as 20% of children growing up in inner-city poverty are impaired to some degree in their social, behavioural, and academic functioning (Mash & Barkley, 2003). Sex Differences Findings relating to sex differences and child psychopathology are complex, inconsistent, and frequently difficult to interpret, the cumulative findings from research strongly indicate that the effects of gender are critical to understanding the expression and course of most forms of childhood disorder (Mash & Barkley, 2003). 2.4 KEY CONCEPTS IN CHILD PSYCHOPATHOLOGY Several recurrent and overlapping issues have characterized the study of psychopathology in children (Cicchetti & Toth, 2009; Rutter & Sroufe, 2000). A number of these are highlighted in this section, including (1) difficulties in conceptualizing psychopathology and normality (2) the need to consider healthy functioning and adjustment (3) questions concerning developmental continuities and discontinuities (4) the concept of developmental pathways (5) the notions of risk and resilience 20 CU IDOL SELF LEARNING MATERIAL (SLM)

(6) the identification of protective and vulnerability factors and (7) the role of contextual influences. Psychopathology Versus Normality The attempt to establish boundaries between what constitutes abnormal and normal functioning is an arbitrary process at best (see Achenbach, 1997), although this does not necessarily imply that such boundaries are meaningless if they are informative with respect to impairment and other clinically significant factors. Traditional approaches to mental disorders in children have emphasized concepts such as symptoms, diagnosis, illness, and treatment; by doing so, they have strongly influenced the way we think about child psychopathology and related questions (Richters & Cicchetti, 1993). Childhood disorders have most commonly been conceptualized in terms of deviancies involving breakdowns in adaptive functioning, statistical deviation, unexpected distress, or disability, and/or biological impairment. Wakefield has proposed an overarching concept of mental disorder as “harmful dysfunction.” This concept encompasses a child’s physical and mental functioning, and includes both value- and science-based criteria. In the context of child psychopathology, a child’s condition is viewed as a disorder only if (1) it causes harm or deprivation of benefit to the child, as judged by social norms and (2) it results from the failure of some internal mechanism to perform its natural function (e.g., “an effect that is part of the evolutionary explanation of the existence and structure of the mechanism). This view of mental disorder focuses attention on evolved adaptations or internal functional mechanisms—for example, executive functions in the context of self- regulation. Nevertheless, as Richters and Cicchetti (1993) have pointed out, this view only identifies the decisions that need to be made in defining mental disorders; it does not specify how such decisions are to be made. As is the case for most definitions of mental disorder that have been proposed, questions related to defining the boundaries between normal and abnormal, understanding the differences between normal variability and dysfunction, defining what constitute “harmful conditions,” linking dysfunctions causally with these conditions, and circumscribing the domain of “natural” or of other proposed mechanisms are matters of considerable controversy. Categories of mental disorder stem from human-made linguistic distinctions and abstractions, and boundaries between what constitutes normal and abnormal conditions, or between different abnormal conditions, are not easily drawn. Although it may sometimes appear that 21 CU IDOL SELF LEARNING MATERIAL (SLM)

efforts to categorize mental disorders are “carving nature at its joints,” whether or not such “joints” actually exist is open to debate. However, clear distinctions do not necessarily need to exist for categorical distinctions to have utility. For instance, there is no joint at which one can carve day from night, although distinguishing the two has proven incredibly useful to humans in going about their social discourse and engagements. Likewise, although the threshold for determining disorder from high levels of symptoms may be fuzzy, it could be stipulated as being at that point along a dimension where impairment in a major, culturally universal life activity befalls the majority of people at or exceeding that point. Thus, despite the lack of clear boundaries between what is normal and abnormal, categorical distinctions are still useful as long as they adequately predict which children will be most likely to benefit from access to special education, treatment, or disability status. Children’s Mental Health Being mentally healthy during childhood means reaching developmental and emotional milestones and learning healthy social skills and how to cope when there are problems. Mentally healthy children have a positive quality of life and can function well at home, in school, and in their communities. Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, which cause distress and problems getting through the day. Many children occasionally experience fears and worries or display disruptive behaviours. If symptoms are serious and persistent and interfere with school, home, or play activities, the child may be diagnosed with a mental disorder. Mental health is not simply the absence of a mental disorder. Children who don’t have a mental disorder might differ in how well they are doing, and children who have the same diagnosed mental disorder might differ in their strengths and weaknesses in how they are developing and coping, and in their quality of life. Mental health as a continuum and the identification of specific mental disorders are both ways to understand how well children are doing. 2.5 HISTORICAL PERSPECTIVE OF CHILD PSYCHOPATHOLOGY An early use of the term \"psychopathology\" dates back to 1913 when the book General Psychopathology was first introduced by Karl Jaspers,1 a German/Swiss philosopher and 22 CU IDOL SELF LEARNING MATERIAL (SLM)

psychiatrist. This new framework for understanding the mental experience of individuals followed a long history of varied attempts at making meaning out of \"abnormal experiences.\" The Field of psychopathology is of relatively recent origin. Prior to the 20th century, psychopathology was concerned almost exclusively with adult behavioural disorders. Child behaviour disorders, though occasionally acknowledged, received little concerted attention. In all likelihood, this state of affairs resulted from then the prevailing viewpoint of children being simply little adults or homunculi (“little men”). Children were not thought to possess “personalities” of their own; rather they were viewed as miniature adults, evincing problems similar to adults, and benefitting from reasoned advice much like their adult counterparts (Aries, 1962). A “child psychopathology,” let alone a “child psychopathology,” was non- existent. Although it is obvious to any student of child development that behaviour, whether “normal” or “abnormal,” must be examined within a developmental context, it is only recently that child psychiatry and clinical child psychology have paid more than lip service to this notion. Both theory and nomenclature were originally adapted from work with adults, and the important changes in behaviour and cognitive capacity that occur as a function of physical maturation and psychological development were largely overlooked. Instead, attempts were made to extend adult models downward, and theories of adult psychopathology were unsuccessfully adapted to childhood problems. 2.6 SUMMARY • The development of psychological problems in children and adolescents is influenced bymany factors. • A distinction may be made between risk factors which predispose children todeveloping psychological problems, precipitating factors which trigger the onset or markedexacerbation of psychological difficulties, maintaining factors which perpetuate psychologicalproblems once they have developed, and protective factors which prevent furtherdeterioration and have implications for prognosis and response to treatment. • Predisposing riskfactors, protective factors and maintaining factors may be subclassified as falling into thepersonal or contextual domains, with personal factors referring to biological andpsychological characteristics of the child, and contextual factors referring to features of thechild’s psychosocial environment including the family, the school, the peer group andinvolved treatment agencies. 23 CU IDOL SELF LEARNING MATERIAL (SLM)

2.7 KEYWORDS • Incidence: Ratio of the number of new cases of the disease occurring in a population during a specified time to the number of persons at risk for developing the disease during that period. • Prevalence: Ratio of the number of cases of a specific disease present in a population at a specific time to the number of persons in the population at the time specified. • Adolescence: transitional phase of growth and development between childhood and adulthood. • chronic illness is a long-term health condition that may not have a cure. Examples of chronic illnesses are: Alzheimer disease and dementia. Arthritis. Asthma • Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders • Neurochemical : It is alterations resulting due to endocrine changes or exposure to some drug often tilt the fine balance of nervous system functioning and have been observed even in mood changes, depression and neurological diseases of significance. • Autism: it is a developmental disorder characterized by difficulties with social interaction and communication, and by restricted and repetitive behavior. 2.8 LEARNING ACTIVITY 1. Discuss how child psychopathology is similar to or different from child psychopathology. ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. How can we find out the prevalence of any disorder? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2.9 UNIT END QUESTIONS A. Descriptive Questions 24 Short Questions 1. What are key concepts of Child Psychopathology 2. What is mental health? 3. What is child mental health? CU IDOL SELF LEARNING MATERIAL (SLM)

4. What is prevalence? 5. What is incidence? Long Questions 1. Explain the nature of child psychopathology. 2. What factors are complicating the study of child psychopathology? 3. Write about the history of child psychopathology? 4. Is there a need to study child psychopathology as a separate field? 5. What is difference between child psychopathology and adult psychopathology? B. Multiple Choice Questions 1. ________________ among children are described as serious changes in the way children typically learn, behave, or handle their emotions which cause distress and problems getting through the day. a. Stress b. Fears c. Disruptive behavior d. Mental disorder 2. Examples of behavior often seen in children with depression a. Not wanting to do or enjoy doing things. b. Having a hard time paying attention c. Showing changes in sleep patterns-eating a lot more or at less than usual d. All of these 3. Form of therapy that is used to change negative thoughts into more positive, effective ways of thinking, leading to more effective behavior. a. Behavior therapy b. Counselling therapy c. Cognitive therapy d. Talking therapy 4. When children act out persistently so that it causes serious problem at home, in school, or with peers, they may be diagnosed with ______________. a. Oppositional Defiant Disorder b. Attention-deficit/hyperactivity disorder c. Conduct disorder 25 CU IDOL SELF LEARNING MATERIAL (SLM)

5. This is the most common viral syndrome. Infection is confined to the meninges. This include fever, headache, neck stiffness, photophobia and vomiting. a. Acute flaccid paralysis b. Encephalitis c. Aseptic meningitis d. Encephalo-myelitis Answers 1-(d), 2-(d), 3-(c), 4-(a), 5-(c) 2.10 REFERENCES • Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd. • American PsychiatricAssociation (2000).Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC:American Psychiatric Publishing, Inc.. • Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon. • Emery, R.E., & Oltmanns, T.F. (1998).Abnormal Psychology (2nd ed.). Upper Sadle River, NJ: Prentice-Hall, Inc. • Carter, E. and McGoldrick, M. (1989). The Changing Family Lifecycle: A Framework for Family Therapy (second edition). Boston: Allyn and Bacon. • Papalia, D. and Wendkos-Olds, S. (1995). Human Development (sixth edition). New York: McGraw-Hill. • Rutter, M. and Rutter, M. (1993). Developing Minds: Challenge and Continuity Across the Lifespan. London: Penguin. • Vasta, R., Haith, M. and Miller, S. (1995). Child Psychology: The Modern Science (second edition). New York: Wiley. 26 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT – 3CAUSES OF CHILD PSYCHOPATHOLOGY Structure 3.0 LearningObjectives 3.1 Introduction 3.2 Signs of Child Psychopathology 3.3 Causes of Child Psychopathology 3.4 Summary 3.5 Keywords 3.6 Learning Activity 3.7 Unit End Questions 3.8 References 3.0 LEARNINGOBJECTIVES After studying this unt, you will be able to: • Elaborate on the causes of child psychopathology • Describe the biological causes of child psychopathology • Describe the psychological causes of child psychopathology • Describe the social causes of child psychopathology 3.1 INTRODUCTION Child development, with its physical, cognitive and social facets, occurs within the context of the family lifecycle. The family lifecycle may be conceptualised as a series of stages, each characterised by a set of tasks family members must complete to progress to the next stage. With respect to physical development, children progress through an ordered sequence of milestones. 27 CU IDOL SELF LEARNING MATERIAL (SLM)

Environmental factors such as socioeconomic status and nutrition, in addition to genetic factors, can alter the rate of progression through these milestones, and this may have consequences for social adjustment. For example, at adolescence early-maturing girls show adjustment problems whereas early-maturing boys do not. Three different approaches have been taken to the study of cognitive development. Piaget’s stage-based cognitive developmental theory shows how problem solving at different stages of development is based on different representational cognitive structures. The information-processing approach to cognition highlights the way different strategies are used to solve problems so that the output of a limited information-processing capacity is maximised. The psychometric approach to intelligence focuses on how abilities are organised and how individual differences in these abilities are distributed within populations. 3.2 SIGNS OF PSYCHOPATHOLOGY Signs of psychopathology vary depending on the nature of the condition. Some of the signs that a person might be experiencing some form of psychopathology include: • Changes in eating habits • Changes in mood • Excessive worry, anxiety, or fear • Feelings of distress • Inability to concentrate • Irritability or anger • Low energy or feelings of fatigue • Sleep disruptions • Thoughts of self-harm or suicide • Trouble coping with daily life • Withdrawal from activities and friends 28 CU IDOL SELF LEARNING MATERIAL (SLM)

3.3 CAUSES OF CHILD PSYCHOPATHOLOGY This lifecycle model draws attention to the ways in which the family meets the developing child’s needs and also the way in which the family places demands upon children and other members at different stages of the lifecycle. For example, the parents of a teenager may meet her needs for increasing autonomy by allowing greater freedom and unsupervised travel, and she may meet her grandparents’ needs for continued connectedness by visiting regularly. Family lifecycle models also focus attention on the transitions that the child and other family members must make as one stage is left behind and another stage is entered. For example, the transition from being a family with young children to being a family with teenage children requires a renegotiation of family rules and roles. The hierarchical relationship between the parents and children must be renegotiated, and in some families, concurrently women may decrease their focus on home making while increasing their focus on their career. This may coincide with men taking a more active role within the household. Families require some degree of flexibility to adapt the way relationships are organised as each of these transitions is negotiated. They also require the capacity to maintain stable roles and routines during each of the stages. A third important requirement is the capacity to permit children movement from dependency towards autonomy as development progresses. This is as true for the transition into adolescence as it is for the launching stage where children are leaving home. There is not a single cause for psychopathology. There a number of factors that can increase the risk of mental illness, including: Personal Predisposing Factors Genetic vulnerabilities, the consequences of prenatal and perinatal complications, and the sequelae of early insults, injuries and illnesses may predispose youngsters to developing problems in later life (Rutter and Casaer, 1991). In addition to these biological predisposing factors, a number of psychological characteristics, traits and relatively enduring belief systems may also predispose youngsters to developing psychological difficulties. Low intelligence, difficult temperament, low self-esteem and an external locus of control are some of the more important variables in this category (Rolf et al., 1990). Biological Factors Consist of anything physical that can cause adverse effects on a person's mental health. This includes genetics, prenatal damage, infections, exposure to toxins, brain defects or injuries, and substance abuse. 29 CU IDOL SELF LEARNING MATERIAL (SLM)

Genetic Factors Twin and adoption studies show that the development of many psychological characteristics such as temperament and intelligence is in part influenced by genetic factors. The size of this influence is of the order of 30–60 per cent of overall variation within a population for most such characteristics (Rutter, 1991). The mechanism of influence is usually polygenetic. With the possible exceptions of conditions such as autism, Down’s syndrome and bipolar affective disorder, genetic factors determine the development of specific psychological problems through their influence on broader psychological characteristics such as temperament (Plomin, 1986). Physical Injuries and Diseases Head injuries later in childhood are associated with the development of cognitive impairment, disinhibition and behavioural problems, although the nature and extent of these sequelae depend upon both the severity and location of the injury and the social context within which the injury and recovery occur (Goodman, 1994a; Snow and Hooper, 1994). For example, the overall psychological consequences for a child who sustains a head injury as a result of abuse which leads to a rnultiplacement experience will be quite different from that of a child who sustains a similar injury through a road traffic accident and who recovers within a stable family context. Chronic Medical Conditions Living with a chronic illness can be debilitating; both physically and mentally. The toll it can take on your body is bound to affect your ability to cope with psychological and emotional stress. Not only can a chronic illness make it impossible to do the things you enjoy, it can also rob you of a sense of hope for the future. Temperament In their 25-year longitudinal study of 133 children, Chess and Thomas (1995) classifiedinfants into three subgroups. Easy-temperament children constituted 40 per cent of thesample. They established regular patterns for feeding, toileting and sleeping. They approachednew situations and adapted easily to such environmental changes while showing positivemood responses of mild or moderate intensity. Easy-temperament children had a goodprognosis. They attracted adults and peers to form a supportive network around them. Easytemperament is therefore a protective factor. 30 CU IDOL SELF LEARNING MATERIAL (SLM)

Difficult-temperament children constituted 10 per cent of the group studied. They haddifficulty establishing regular routines for eating, toileting and sleeping. They tended to avoidnew situations and responded to change with intense negative emotions. Family Members With Mental Illness Parental adjustment problems such as depression, alcohol abuse or criminality may render children vulnerable to psychological difficulties for two main reasons. First, such problems may compromise parents’ capacity to offer their children a secure attachment relationship, adequate intellectual stimulation and an authoritative parenting environment. For example, depressed mothers find it difficult to interpret their infant’s distress signals and to respond appropriately and quickly so as to foster secure attachment. Fathers with alcohol problems often play a very peripheral role in family life, making little input to the child’s parenting environment. Looking after a family member with a mental illness can be an extremely stressful time and coping with the stress may rouse various reactions such as somatic problems (migraines, loss of appetite, fatigue, insomnia), cognitive and emotional problems (anxiety, depression, guilt, fear, anger, confusion) and behavioural. Parent-Child Factors In Early Life The quality of parent-child attachment, the degree to which parents offer their children ageappropriate intellectual stimulation, and the way in which control and warmth are combined to form a parenting style have been shown to have highly significant effects on children’s later psychological adjustment (Bretherton and Waters, 1985; Bradley et al., 1989; Darling and Steinberg, 1993). However, it is important to preface a summary of key findings on these three areas with a brief discussion of bonding, since this concept has given rise to many misconceptions within the field. Intelligence, Self-Esteem And Locus Of Control A number of personal psychological characteristics, which have been discussed in Chapter 1, have been found to predispose children to developing psychological difficulties (Rolf et al., 1990). Low intelligence as measured by IQ tests is a risk factor for conduct disorders in particular. Low self-esteem places children at risk for both conduct and emotional disorders. Entrenched beliefs about having little control over important sources of reinforcement and significant aspects of one’s situation are also associated with conduct and emotional problems. Such beliefs are reflected in an external locus of control (Rotter, 1966). Coping Strategies 31 CU IDOL SELF LEARNING MATERIAL (SLM)

The construct of defence mechanisms evolved within the psychodynamic tradition and it is assumed that these methods for regulating negative emotions usually operate unconsciously. Coping strategies, on the other hand, are assumed to be consciously and deliberately used. The construct of coping strategies has developed within the stress and coping literature of the cognitive-behavioural tradition (Zeidner and Endler, 1996). Coping strategies are used to manage situations in which there is a perceived discrepancy between stressful demands and available resources. A distinction is made between problem- and emotion-focused coping strategies, with the latter being appropriate for uncontrollable stresses such as bereavement and the former being appropriate for controllable stresses such as school examinations. In either instance, a distinction may be made between functional and dysfunctional strategies. Stresses In Early Life In the absence of adequate supports, major threats to the child’s needs for safety, care, control or intellectual stimulation may predispose the child to developing psychological problems in later life (Goodyer, 1990). Chief among these early life stresses are bereavements, parent- child separations, child abuse, social disadvantage and institutional upbringing. When you experience a traumatic event, your body’s defences take effect and create a stress response, which may make you feel a variety of physical symptoms, behave differently and experience more intense emotions. It is also important to realize that mental health can change over time. The Centres for Disease Control and Prevention (CDC) suggests that 50% of all people will be diagnosed with a mental illness at some point in their life. 3.4 SUMMARY • The development of psychological problems in children and adolescents is influenced by many factors. • A distinction may be made between risk factors which predispose children to developing psychological problems, precipitating factors which trigger the onset or marked exacerbation of psychological difficulties, maintaining factors which perpetuate psychological problems once they have developed, and protective factors which prevent further deterioration and have implications for prognosis and response to treatment. • Predisposing risk factors, protective factors and maintaining factors may be subclassified as falling into the personal or contextual domains, with personal factors 32 CU IDOL SELF LEARNING MATERIAL (SLM)

referring to biological and psychological characteristics of the child, and contextual factors referring to features of the child’s psychosocial environment including the family, the school, the peer group and involved treatment agencies. • The development of psychological problems may be conceptualised as arising from risk factors which predispose children to developing psychological problems, precipitating factors which trigger the onset or marked exacerbation of psychological difficulties, maintaining factors which perpetuate psychological problems once they have developed, and protective factors which prevent further deterioration and have implications for prognosis and response to treatment. • Most of these factors may be subclassified as falling into the personal or contextual domains, with personal factors referring to biological and psychological characteristics of the child, and contextual factors referring to features of the child’s psychosocial environment 3.5 KEYWORDS • The risk factor model : The risk factor model is a paradigm that facilitates the understanding of developmental deviations. • Behaviour genetics : Behaviour genetics is the study of individual differences in behaviour that are attributable in part to differences in genetic makeup. • Authoritative parenting : The authoritative parenting style is one in which the parents are both very warm and careful to set clear limits and restrictions regarding certain kinds of behaviour, but also allow considerable freedom within certain limits. • Authoritarian parenting : Authoritarian parenting refers to a style in which Parents are high on control but low on warmth toward the child. • Permissive-indulgent parenting : The permissive-indulgent parenting style is one in which parents are high on warmth but low on discipline and control. 3.6 LEARNING ACTIVITY 1. Do you think that the socio economic and cultural background can make a child prone to mental illness? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. How does a pregnant lady’s health influence an unborn child? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 33 CU IDOL SELF LEARNING MATERIAL (SLM)

3.7 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What factors are complicating the study of child psychopathology 2. What is significance of child psychopathology 3. What are key concepts of Child Psychopathology 4. Explain common childhood mental disorders 5. What is anxiety and depression Long Questions 1. What are the signs of child psychopathology? 2. What are the biological and genetic causes of child psychopathology? 3. What is the relation between medical illness and injuries to child psychopathology? 4. Does family situation and parenting styles impact child psychopathology? 5. What is relation between temperament and childhood disorders? B. Multiple Choice Questions 1. ________________ among children are described as serious changes in the way children typically learn, behave, or handle their emotions which cause distress and problems getting through the day. a. Stress b. Fears c. Disruptive behavior d. Mental disorder 2. Examples of behavior often seen in children with depression a. Not wanting to do or enjoy doing things. b. Having a hard time paying attention c. Showing changes in sleep patterns-eating a lot more or at less than usual d. All of these 3. Form of therapy that is used to change negative thoughts into more positive, effective ways of thinking, leading to more effective behavior. a. Behavior therapy b. Counselling therapy c. Cognitive therapy 34 CU IDOL SELF LEARNING MATERIAL (SLM)

d. Talking therapy 4. When children act out persistently so that it causes serious problem at home, in school, or with peers, they may be diagnosed with ______________. a. Oppositional Defiant Disorder b. Attention-deficit/hyperactivity disorder c. Conduct disorder 5. This is the most common viral syndrome. Infection is confined to the meninges. This include fever, headache, neck stiffness, photophobia and vomiting. a. Acute flaccid paralysis b. Encephalitis c. Aseptic meningitis d. Encephalo-myelitis Answers 1-(d), 2-(d), 3-(c), 4-(a), 5-(c) 3.8 REFERENCES • Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (pvt) Ltd. • American PsychiatricAssociation (2000).Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC:American Psychiatric Publishing, Inc.. • Carson, R. C., Butcher, J. N., & Mineka, S. (2002).Abnormal psychology over time. In Fundamentals of abnormal psychology and modern life. New York: Allyn & Bacon. • Emery, R.E., & Oltmanns, T.F. (1998).Abnormal Psychology (2nd ed.). Upper Sadle River, NJ: Prentice-Hall, Inc. • Goodyer, I. (1990). Life Experiences, Development, and Childhood Psychopathology. Chichester: Wiley. • Reder, P. and Lucey, C. (1995). Assessment of Parenting: Psychiatric and Psychological Contributions. London: Routledge. • Rolf, J., Masten, A., Cicchetti, D. et al. (1990). Risk and Protective Factors in the Development of Psychopathology. New York: Cambridge University Press. • Rutter, M. and Casaer, P. (1991). Biological Risk Factors for Psychosocial Disorders. Cambridge: Cambridge University Press. 35 CU IDOL SELF LEARNING MATERIAL (SLM)

• Rutter, M., Taylor, E. and Hersov, L. (1994). Child and Adolescent Psychiatry: Modern Approaches (third edition). Oxford: Blackwell. 36 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT –4 DEVELOPMENTAL DISORDERS: MR - 37 PART I Structure 4.0 LearningObjectives 4.1 Introduction 4.2 Mental Retardation 4.3 DSM Criteria 4.4 ICD Criteria 4.5 Incidence of Mental Retardation 4.6 Prevalence of Mental Retardation 4.7 Causes of Mental Retardation 4.8 Summary 4.9 Keywords 4.10 Learning Activity 4.11 Unit End Questions 4.12 References 4.0 LEARNINGOBJECTIVES After studying this unit, you will be able to: • Explain the concept of Mental Retardation as developmental disorder • Elaborate on the criteria for mental retardation under DSM and ICD – 10 • Explain the incidence of mental retardation • Explain the causes of mental retardation CU IDOL SELF LEARNING MATERIAL (SLM)

• Explain the biological causes of mental retardation • Explain the psychological causes of mental retardation 4.1 INTRODUCTION The definition used most often in the United States is from the American Association on Mental Retardation (AAMR). According to AAMR, mental retardation is a disability that occurs before age 18. It is characterized by significant limitations in intellectual functioning and adaptive behaviour as expressed in conceptual, social, and practical adaptive skills. It is diagnosed through the use of standardized tests of intelligence and adaptive behaviour. AAMR points out that both functioning and adaptive behaviour are affected positively by individualized supports (AAMR, 2002). What assumptions are essential to applying this definition? Limitations in present functioning must be considered within the context of community environments typical of the individual’s age, peers, and culture. Valid assessment considers cultural and linguistic diversity as well as difference in communication, sensory, motor, and behavioural factors. Within an individual, limitations often coexist with strengths. An important purpose of describing limitations is to develop a profile of needed supports. With appropriate personalized supports over a sustained period, the life functioning of the person with mental retardation generally will improve (AAMR, 2002). Intelligence Intelligence refers to a general mental capability. It involves the ability to reason, plan, solve problems, think abstractly, comprehend complex ideas, learn quickly, and learn from experience. Intelligence is represented by Intelligent Quotient (IQ) scores obtained from standardized tests given by trained professionals. Mental retardation is generally thought to be present if an individual has an IQ test score of approximately 70 or below (AAMR, 2002). Adaptive behaviour Adaptive behaviour is the collection of conceptual, social, and practical skills that have been learned by people in order to function in their everyday lives. Significant limitations in adaptive behaviour impact a person’s daily life and affect the ability to respond to a particular 38 CU IDOL SELF LEARNING MATERIAL (SLM)

situation or to the environment. Limitations like the following can be determined by using standardized tests: Conceptual skills: receptive and expressive language, reading and writing, money concepts, and self-direction. Social skills: interpersonal, responsibility, self-esteem, is not gullible or naïve, follows rules, obeys laws, and avoids victimization. Practical skills: personal activities of daily living such as eating, dressing, mobility, and toileting; instrumental activities of daily living such as preparing meals taking medication, using the telephone, managing money, using transportation, and doing housekeeping activities; occupational skills; maintaining a safe environment. A significant deficit in one area impacts individual functioning enough to constitute a general deficit in adaptive behaviour (AAMR, 2002). The effects of these disabilities vary considerably among people who have them, just as the range of abilities varies considerably among all people. Children may take longer to learn to speak, walk and take care of their personal needs, such as dressing or eating. People may take longer learning in school. As adults, many people will be able to lead independent lives in the community without paid supports. A small percentage will have serious, lifelong limitations in functioning. However, with early intervention, an appropriate education and supports as an adult, all can lead satisfying lives in the community. In American society, being labelled with “mental retardation” can be stigmatizing. People sometimes feel excluded or belittled. Supports include the resources and individual strategies necessary to promote the development, education, interests, and well-being of a person. Supports enhance individual functioning. Supports can come from family, friends, and community or from a service system. Job coaching is an example of a support provided by a service system. Supports can also be provided by a parent, sibling, friend, teacher, or any other person, such as a co-worker who provides a little extra support to someone on the job. Supports can be provided in many settings, and a “setting” or location by itself is not a support. 4.2 MENTAL RETARDATION Mental retardation refers to intelligence that is significantly below normal - an IQ approximately equal to or less than 70 (where the mean IQ is set at 100)—and that impairs daily functioning. The deficits in intellectual ability and daily functioning must have begun before 18 years of age, and thus cannot be the result of brain trauma in adulthood. The IQ cutoff of 70 or less is two standard deviations or more below average ability. Mental retardation, along with personality disorders, is an Axis II diagnosis because the authors of DSM-IV wanted to ensure that symptoms of Axis I disorders do not overshadow the possibility that a given individual has comorbid mental retardation. The term intellectual disability is sometimes used as a synonym for mental retardation. 39 CU IDOL SELF LEARNING MATERIAL (SLM)

DSM-IV-TR specifi es the following four levels of mental retardation, which are set by ranges of IQ scores (Criterion A). In general, the lower the IQ score, the more impaired the individual is likely to be. However, an individual’s IQ scores can vary by about 5 points because of testing error, so the ranges generally allow a 5-point leeway for assigning the level of retardation and level of adaptive functioning: • Mild mental retardation The IQ score can range from 50–55 to 70; 85% of people with mental retardation fall into this group. People in this mild range may be able to function relatively independently with training but usually need additional help and support during stressful periods. • Moderate mental retardation. The IQ score can range from 35–40 to 50–55; 10% of people with mental retardation fall into this group. Although they are not able to function independently, with training and supervision, people in this group may be able to perform unskilled work and take basic care of themselves. • Severe mental retardation. The IQ score can range from 20–25 to 35–40; approximately 3–4% of people with mental retardation fall into this group. Adults in this group are likely to live with their family or in a supervised setting and are able to perform simple tasks only with close supervision. They may be able to learn to read a few basic words and do simple counting. During childhood, they may begin speaking later than other children. • Profound mental retardation. The IQ score falls below 20 or 25; 1–2% of those with mental retardation fall into this group. People in this group need constant supervision or help to perform simple tasks; they are likely to have signifi cant neurological problems. 4.3 DSM CRITERIA DSM-5 defines intellectual disabilities as neurodevelopmental disorders that begin in childhood and are characterized by intellectual difficulties as well as difficulties in conceptual, social, and practical areas of living. The American Psychiatric Association's (APA) diagnostic criteria for intellectual disability (ID, formerly mental retardation) are found in the Diagnostic and Statistical Manual of 40 CU IDOL SELF LEARNING MATERIAL (SLM)

Mental Disorders (DSM-5, APA 2013). A summary of the diagnostic criteria in DSM-5 are as follows: 1. Deficits in intellectual functioning This includes various mental abilities: • Reasoning. • Problem solving. • Planning. • Abstract thinking. • Judgment. • Academic learning (ability to learn in school via traditional teaching methods). • Experiential learning (the ability to learn through experience, trial and error, and observation). These mental abilities are measured by IQ tests. A score of approximately two standard deviations below average represents a significant cognitive deficit. These scores would occur about 2.5% of the population. Or stated differently, 97.5% of people of the same age and culture would score higher. The tests used to measure IQ must be standardized and culturally appropriate. This is typically an IQ score of 70 or below. Intellectual Functioning (Mental Abilities) An intellectual disability (ID, formerly mental retardation) is a specific type of disability. This disability is caused by significant limitations in intellectual functioning (mental abilities). These limitations make it difficult to acquire important life skills. This is called adaptive functioning. Intellectual functioning is determined by many factors. However, a primary source of this capacity is mental ability or \"intelligence.\" Intelligence refers to the ability to reason, plan, think, and communicate. These abilities allow us to solve problems, to learn, and to use good judgment. One measure of intelligence is called the intelligence quotient, or IQ. There are standard tests that measure IQ. When someone's IQ score is below 70, it's likely they will have some problems. Because of how these tests are designed, 97.5% of the population would score above 70. These tests are discussed here. Although ID affects learning abilities, it is not the same as another type of disability called learning disability. Learning disabilities are limited to a specific type of learning. This type is called academic learning. These are the sorts of things taught in schools. Therefore, learning disabilities affect reading, writing, and math. In contrast, intellectual disabilities 41 CU IDOL SELF LEARNING MATERIAL (SLM)

affect three different types of learning. These are academic learning, experiential learning, and social learning. Children with learning disabilities have trouble with one type: academic learning. Children with intellectual disabilities have trouble with all three: First, intellectual disabilities affect experiential learning. This type of learning occurs through cause and effect. For example, suppose a child touches a hot stove. This experience causes the child to learn to avoid touching a stove. A child with an ID does not learn from this painful experience. She does not understand the stove (the cause) caused the painful burn (the effect). Second, intellectual disabilities affect social learning. This learning occurs by observing other people in social situations. We learn social customs and rules by watching others. For instance, we might notice it is customary to greet people by shaking hands or offering a hug. Social learning enables us to learn social skills. These skills are needed to get along well with other people. Moreover, social skills are critical to life success. Third, intellectual disabilities affect academic learning. We learn useful skills and knowledge via formal education. These skills are reading, writing, and math. Thus, learning disabilities differ from ID because learning disabilities are limited to academic skills. In contrast, IDs include many types of learning problems. These learning difficulties make it hard to develop many practical life skills. In addition to learning problems, limited intellectual functioning affects social and emotional functioning. Many persons with ID function on an emotional and social level far below what is average for their age. Some people consider this emotional immaturity an endearing quality. The child-like innocence, trust, wonder, and sincerity can be quite charming. However, these very same qualities make people vulnerable to victimization and cruelty. Behavioural And Psychological Features Of Intellectual Disabilities Intellectual disabilities (ID, formerly mental retardation) have multiple causes. For example, there are many genetic causes. Brain injuries can cause an intellectual disability. Some types of medical conditions can also affect the brain's development. These causes are discussed in another section. These different causes mean each person's disability is unique. There is no single set of shared traits or features. For example, there are no personality traits common to people with ID. However, certain specific syndromes that cause ID have personality characteristics associated with that particular syndrome. For example, children with Williams's syndrome tend to be outgoing. However, by definition, all people with ID have limited intellectual functioning. These limitations often create some commonly observed difficulties. 42 CU IDOL SELF LEARNING MATERIAL (SLM)

One such problem is impulse control. You may recall that people with ID have trouble connecting cause and effect. This in turn causes problems with impulse control. For instance, suppose a child sees yummy, hot cookies coming out of the oven. The child wants to grab one immediately. If not controlled, this impulse will cause a nasty burn. Experience is usually a great teacher. So, most children only make this impulsive mistake once or twice. They form a connection between the hot cookie (cause) and the burn (effect). They learn to control the impulse to grab a cookie right out of the oven. However, this is not so easily learned by people with ID. This poor impulse control leads to many unpleasant consequences. A related problem is poor frustration tolerance. When an impulse is inhibited, it requires the ability to tolerate a bit of frustration. This ability is called frustration tolerance. Frustration tolerance is an important developmental skill. It allows people to comfortably endure the small frustrations of everyday life. This in turn serves to limit the unpleasant consequences associated with impulsive behaviour. Returning to the previous example, it is frustrating to inhibit the impulse to grab a cookie. However, it avoids the consequence of a nasty burn. Frustration tolerance also enables people to build confidence. When we attempt to solve problems, our initial efforts may fail. This can be very frustrating. Without frustration tolerance, people give up. As a result, they do not put forth any effort. Clearly, if we make no effort to solve problems, we cannot develop the skills we need to solve them! Poor frustration tolerance is not the only problem. This is coupled with many more opportunities to become frustrated. Return to the prior example of a child's impulse to grab a hot cookie. If a caregiver attempted to stop the child from grabbing the cookie, it frustrates the child. She would not readily understand her caregiver's benevolent motivation. It bears mentioning that not all people with ID become easily frustrated. This example simply illustrates that the opportunities for frustration are significantly increased. The increased opportunities for frustration highlight the importance of frustration tolerance. People respond to frustration in different ways. Some people respond in an impulsive, stubborn, and aggressive manner. Others respond with passivity, withdrawal, and compliance. Poor frustration tolerance may cause aggression toward caregivers. It may also lead to self-injurious behaviour. These behaviours are observed in some people with ID. Another common difficulty is low self-esteem. Self-esteem naturally develops as children learn to solve problems. The ability to solve problems builds self-confidence. However, limited intellectual functioning makes it difficult to solve problems. Skilful problem solving requires sustained attention and persistence in the face of difficulty. These abilities are limited in persons with limited intellectual functioning. Thus, a low self-esteem may develop. Psychiatric disorders related to low self-esteem, such as depression, may accompany 43 CU IDOL SELF LEARNING MATERIAL (SLM)

intellectual disabilities. However, many people with ID are quite happy and content. They don't exhibit problematic behaviour. Genetic Causes Of Intellectual Disabilities: Down Syndrome Many intellectual disabilities (ID, formerly mental retardation) are caused by genetic abnormalities. The two most common genetic causes of intellectual disabilities are Down syndrome and Fragile X syndrome. 4.4 ICD 10 CRITERIA In 1978, WHO entered into a long-term collaborative project with the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) in the USA, aiming to facilitate further improvements in the classification and diagnosis of mental disorders, and alcohol- and drug- related problems (3). A series of workshops brought together scientists from a number of different psychiatric traditions and cultures, reviewed knowledge in specified areas, and developed recommendations for future research. A major international conference on classification and diagnosis was held in Copenhagen, Denmark, in 1982 to review the recommendations that emerged from these workshops and to outline a research agenda and guidelines for future work. Several major research efforts were undertaken to implement the recommendations of the Copenhagen conference. One of them, involving centres in 17 countries, had as its aim the development of the Composite International Diagnostic Interview, an instrument suitable for conducting epidemiological studies of mental disorders in general population groups in different countries (5). Another major project focused on developing an assessment instrument suitable for use by clinicians (Schedules for Clinical Assessment in Neuropsychiatry). Still another study was initiated to develop an instrument for the assessment of personality disorders in different countries (the International Personality Disorder Examination). In addition, several lexicons have been, or are being, prepared to provide clear definitions of terms. A mutually beneficial relationship evolved between these projects and the work on definitions of mental and behavioural disorders in the Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD-10) (9). Converting diagnostic criteria into diagnostic algorithms incorporated in the assessment instruments was useful in uncovering inconsistencies, ambiguities and overlap and allowing their removal. The work on refining the ICD-10 also helped to shape the assessment instruments. The final result was a clear set of criteria for ICD-10 and assessment instruments which can produce data necessary for the classification of disorders according to the criteria. 44 CU IDOL SELF LEARNING MATERIAL (SLM)

The Copenhagen conference also recommended that the viewpoints of the different psychiatric traditions be presented in publications describing the origins of the classification in the ICD-10. This resulted in several major publications, including a volume that contains a series of presentations highlighting the origins of classification in contemporary psychiatry (10). The Clinical descriptions and diagnostic guidelines was the first of a series of publications developed from Chapter V (F) of ICD-10 (11). This publication was the culmination of the efforts of numerous people who have contributed to it over many years. The work has gone through several major drafts, each prepared after extensive consultation with panels of experts, national and international psychiatric societies, and individual consultants. The draft in use in 1987 was the basis of field trials conducted in some 40 countries, which constituted the largest ever research effort of its type designed to improve psychiatric diagnosis. The results of the trials were used in finalizing the clinical guidelines. The text presented here has also been extensively tested (14), involving researchers and clinicians in 32 countries. A list of these is given at the end of the book together with a list of people who helped in drafting texts or commented on them. Further texts will follow: they include a version for use by general health care workers, a multiaxial presentation of the classification, a series of 'fascicles' dealing in more detail with special problems (e.g. a fascicle on the assessment and classification of mental retardation) and \"crosswalks\" - allowing cross-reference between corresponding terms in ICD-10, ICD-9 and ICD-8. Use of this publication is described in the Notes for Users. The Appendix provides suggestions for diagnostic criteria which could be useful in research on several conditions which do not appear as such in the ICD-10 (except as index terms) and crosswalks allowing the translation of ICD-10 into ICD-9 and ICD-8 terms. The Acknowledgements section is of particular significance since it bears witness to the vast number of individual experts and institutions, all over the world, who actively participated in the production of the classification and the various texts that accompany it. All the major traditions and schools of psychiatry are represented, which gives this work its uniquely international character. The classification and the guidelines were produced and tested in many languages; the arduous process of ensuring equivalence of translations has resulted in improvements in the clarity, simplicity, and logical structure of the texts in English and in other languages. The ICD-10 proposals are thus a product of collaboration, in the true sense of the word, between very many individuals and agencies in numerous countries. They were produced in the hope that they will serve as a strong support to the work of the many who are concerned with caring for the mentally ill and their families, worldwide. 45 CU IDOL SELF LEARNING MATERIAL (SLM)

No classification is ever perfect: further improvements and simplifications should become possible with increases in our knowledge and as experience with the classification accumulates. The task of collecting and digesting comments and results of tests of the classification will remain largely on the shoulders of the centres that collaborated with WHO in the development of the classification. Their addresses are listed below because it is hoped that they will continue to be involved in the improvement of the WHO classifications and associated materials in the future and to assist the Organization in this work as generously as they have so far. Numerous publications have arisen from Field Trial Centres describing results of their studies in connection with ICD-10. A full list of these publications and reprints of the articles can be obtained from WHO, Division of Mental Health, Geneva. A classification is a way of seeing the world at a point in time. There is no doubt that scientific progress and experience with the use of these guidelines will require their revision and updating. I hope that such revisions will be the product of the same cordial and productive worldwide scientific collaboration as that which has produced the current text. Common Icd-10 Codes For Mental & Behavioural Health Mental, Behavioural and Neurodevelopmental disorders (F01-F99) Type 2 Excludessymptoms, signs and abnormal clinical laboratory findings, not elsewhere classified (R00-R99) Includesdisorders of psychological development This block comprises a range of mental disorders grouped together on the basis of their having in common a demonstrable etiology in cerebral disease, brain injury, or other insult leading to cerebral dysfunction. The dysfunction may be primary, as in diseases, injuries, and insults that affect the brain directly and selectively; or secondary, as in systemic diseases and disorders that attack the brain only as one of the multiple organs or systems of the body that are involved. 4.5 INCIDENCE OF MENTAL RETARDATION The World Health Organization describes mental health as a state of wellbeing in which every person realizes its own potential and can face the normal stress of life, work productively and is capable of contributing to his/her community. Health is both physical and mental wellbeing rather than mere absence of a disease (1). 46 CU IDOL SELF LEARNING MATERIAL (SLM)

Mental retardation includes below-average intellectual functioning with significant limitation of adaptive functioning, which occurs before the age of 18 (2). According to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-X) (3), mental retardation is defined as a condition of delayed or incomplete development of the mind characterized by impairment of skills contributing to overall development of intelligence, i.e. reasoning, speech, motor control and social contacts demonstrated during the development. Mental retardation is divided to four sub-categories (3): mild mental retardation (IQ 50 - 70), moderate mental retardation (IQ 35 - 49), severe mental retardation (IQ 20 – 34), and profound mental retardation (IQ is below 20 (3). In the next revision, ICD-11, it is expected that the term mental retardation will be replaced either by the term intellectual disability or intellectual developmental disorder, which are already used by the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.)(DSM-5) (2,4). Intellectual disability affects around 1-3% of the general population (5,6). Global developmental delay (GDD) occurs in psychomotor development of 3% of children under the age of 5 and is defined as developmental disorder with a delay in two or more developmental areas: gross or fine motor skills, speech, cognition (cognitive processes), social functioning and everyday activities (7). Around 75-90% of persons with intellectual difficulties have mild intellectual disability. Approximately one quarter of cases is caused by a genetic disorder (8). Due to high incidence of physical and mental comorbidity with intellectual disability, such persons require more attention than mere health care services and have a higher need for resources in health care than persons from the general population (9). Persons with intellectual disability need equal access to health care without any discrimination based on their disability. Without adequate health care, medical problems of persons with intellectual disability often remain unrecognized (10). Even when they are identified, such problems are often insufficiently or inadequately addressed (11,12). Such differences among persons with intellectual disability in general population significantly increase the risk for treatment of the disease and may lead to early death (13). Stigma may be a key factor for failure to ask for assistance and has a negative impact on seeking assistance. Facing and prevention of stigma and discrimination should be integral parts of a support process to all persons with mental disorders, particularly children and young people (14). Persons with intellectual disability often have poor access to medical services and their treatment involves very high costs for the health care system and the entire society (15-17). Despite those facts persons with intellectual disability are mostly neglected in the field of mental health, where specialized services are limited. Such specialized services can be provided mainly in countries with high income, primarily western countries. The war in Bosnia and Herzegovina caused serious suffering of the population and led to devastation of psychosocial institutions, therefore, a small number of psychosocial 47 CU IDOL SELF LEARNING MATERIAL (SLM)

institutions has remained operational, the Public Institute for Placement of Persons with Mental Disability “Drin” Fojnica being among them. It also accommodates patients with psychiatric disorders and provides them with psychological, social, and medical support in addition to persons with mental retardation, who were its original beneficiaries. The aim of this retrospective study was to investigate frequency of mental retardation in comparison with other psychiatric disorders at the Public Institute for Placement of Persons with Mental Disabilities „Drin“ Fojnica, Bosnia and Herzegovina (B&H), in the period 2013-2014 to asses psychosocial condition and necessary support for persons diagnosed with mental retardation depending on a degree of mental retardation. The research will provide guidelines for the protection and promotion of mental health of persons placed in psychosocial institutions. 4.6 PREVALENCE OF MENTAL RETARDATION The Prevalence of Mental Retardation Research on prevalence clearly illustrates many of the problems concerning our current conception of mental retardation. The difficulties in identifying mentally retarded persons make it nearly impossible to arrive at totally accurate figures. Moreover, professionals in the field don't always agree on the definition of retardation — a factor that makes it difficult to arrive at universally acceptable figures on prevalence. There is little disagreement on the criteria for defining moderate, severe, and profound mental retardation. However, authorities are not always in agreement on how to define the largest proportion of the mentally retarded population — those generally termed as mildly retarded. Society itself seems to have difficulty with this distinction. For example: Some children have enough problems with school subjects to be labelled as mentally retarded by the school system itself. However, when these children go home at the end of the day — or leave school permanently — they function relatively well in society. Thus, while school personnel and classroom peers may consider such children as mentally retarded, family, friends and neighbours outside the school setting may consider them merely \"slow.\" Surveys of organizations, agencies and clinics identify only those persons who have come into contact with those organizations. Varying testing methods utilized by different schools and agencies tend to cloud the issue of what is mental retardation. Current cut-off points for mental retardation range from IQ 70 to IQ 80. A low IQ, of course, is not the only criterion for mental retardation. A mentally retarded person must also exhibit impaired adaptive behaviour. Only those studies which measure both intelligence and adaptive behaviour meet the demands of the current definition of mental retardation. 48 CU IDOL SELF LEARNING MATERIAL (SLM)

Current prevalence figures range from 2.36 percent to 3.52 percent. One summary of the best prevalence studies available indicates that 2.5 to 3 percent of the general population is mentally retarded — based on the 1980 census, this totals from 5.5 to 6.7 million people. According to one report, the vast majority of the retarded population, an estimated 87 percent, is mildly retarded. Roughly 10 percent is moderately retarded, and only 3 percent is severely or profoundly retarded. While mental retardation strikes all segments of society, it is far more likely to occur in some groups than in others. Prevalence studies indicate that there are more mentally retarded males than females — perhaps a 60-40 ratio. Male susceptibility to traumatic experiences such as premature birth, brain damage, and various dangers after birth, account for some differences in the ratio of mental retardation. However, there is some evidence that parental and teacher attitudes toward male \"behavioural problems\" have a definite bearing on prevalence figures. Both parents and teachers prefer quiet children to disruptive children. Thus, the boy who expresses his anger or aggression is more likely to be sent to the school psychologist or the principal. Apparently, there is a difference between the prevalence of mental retardation in males and females — but the difference may not be as marked as some authorities have reported. Is mental retardation more prevalent in one age group than in another? While some studies indicate a preponderance of retardation in some age groupings, other researchers feel that differences in prevalence at different ages are the result of inaccurate reporting procedures. As mentioned, individuals who appear mentally retarded in some settings do not appear retarded in others. One study showed that individuals labelled as mentally retarded in school went on to lead independent, productive lives in the community. There is an obvious relationship between poverty and mental retardation. Malnutrition, lead poisoning and a lack of proper medical care are only a few of the factors that may contribute to the disproportionate incidence of mental retardation among the disadvantaged members of our society. Lead poisoning is almost exclusively associated with conditions of poverty. Inadequate medical care contributes to a higher rate of infant mortality, and a higher rate of birth defects. There is a marked difference between current prevalence studies and studies completed during the early 1900s. At least two factors account for these differences: improved methods of research and changing definitions of mental retardation. Many mildly retarded individuals who would have blended into society some years ago are now being counted before they take their places in the community. 49 CU IDOL SELF LEARNING MATERIAL (SLM)

In the future, it may be that the term \"mentally retarded\" will be reserved only for the most severely disabled individuals. An ongoing characteristic of mental retardation is the fact that, in one respect, the more we learn about this disability, the harder it is to define. An ever- increasing number of mildly retarded persons are taking their places in society. Probably the majority of the people in this country who have been labelled as mentally retarded fall into that grey area of \"relative retardation.\" Except for the most extreme cases, mentally retarded persons refuse to fit neatly into one category or another. Methods of testing intelligence frequently fail to show how a particular individual has adjusted to his environment and made a place for himself. The presence of this large, Gray area of mental retardation makes it next to impossible to accurately determine the number of mentally retarded individuals living in society. Still, the fact that there is a problem in determining the prevalence of mental retardation is a healthy sign for those concerned with the welfare of mentally retarded citizens: We are becoming less aware of the differences in people, and more aware of the similarities. 4.7 CAUSES OF MENTAL RETARDATION There are many neurological paths to mental retardation, some of which arise because the fetus is exposed to certain types of substances (such as drugs or a virus) or to other stimuli (such as radiation); such harmful substances and stimuli are referred to as teratogens. Mental retardation may also arise from particular complications during labor (such as occurs when a newborn receives insufficient oxygen during birth) or from exposure to high levels of lead prenatally or during childhood. Neurological Factors: Teratogens And Genes One type of teratogen is environmental toxins, to which a fetus typically is exposed through the placenta after the toxin has entered the mother’s bloodstream. Examples of environmental toxins include synthetic chemicals such as methyl mercury, polychlorinated biphenyls (PCBs), and mixtures of chemicals such as those found in pesticides. Exposure to these toxins in the fi rst trimester of pregnancy can affect important early developmental processes of the central nervous system. In contrast, with other forms of mental retardation, people have smaller than normal heads. For example, this occurs in people who suffer from fetal alcohol syndrome. This syndrome is a set of birth defects caused by the mother’s alcohol use during pregnancy (alcohol is a teratogen). Moreover, smaller head size may arise because the sizes of some specific brain areas are reduced. In fetal alcohol syndrome, the cerebellum, the basal ganglia, and the 50 CU IDOL SELF LEARNING MATERIAL (SLM)