corpus callosum are affected, all of which are involved in coordination and smooth motor movement. The frontal lobes are also affected, specifically the portions involved in planning, carrying out tasks, and controlling impulsive behavior. All of these activities are difficult for many children with fetal alcohol syndrome. Psychological Factors: Problem Behaviors Individuals with mental retardation often show two types of problematic behaviors that are not specifically mentioned in the DSM-IV-TR criteria: (1) stereotyped behaviors (also referred to as stereotypies), which are repetitive behaviors that don’t serve a function, such as hand flapping, slight but fast finger and hand motions, and body rocking and (2) self- injurious behaviors, such as hitting the head against something and hitting or biting oneself. People with mental retardation who exhibit both stereotypic behaviors and self-injurious behaviors have greater deficits in nonverbal social skills than those with only one type of problematic behavior. Other problematic behaviors that often go along with mental retardation include consistently choosing to interact with objects rather than people, inappropriately touching others, and resisting physical contact or affection. How or why all these behaviors arise is not yet known. Social Factors: Under-Stimulation Another way in which mental retardation can arise is when an infant’s environment is severely under-stimulating or the infant is undernourished. However, in 30–40% of cases, there is no clear cause for the mental retardation; when there are clear etiological factors, the diagnosis is generally in the severe or profound range. In sum, most cases of mental retardation arise primarily from neurological factors—genes or teratogens, which in turn lead to abnormal brain structure and function, leading to cognitive deficits. Moreover, children with mental retardation may exhibit stereotyped or self-injurious behaviors. 4.8 SUMMARY • Mental retardation (MR) is one of the more common developmental disabilities. • It can be idiopathic and challenging to recognize in normal-appearing children who have developmental delays. • Conversely, MR can be easily recognized when the child presents with dysmorphic features associated with a known genetic MR disorder. 51 CU IDOL SELF LEARNING MATERIAL (SLM)
• Mental retardation (MR) is defined as a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior, as expressed in conceptual, social and practical adaptive skills. • Mental retardation currently is defined by the American Association on Mental Retardation (AAMR) as “significantly sub-average general intellectual functioning accompanied by significant limitations in adaptive functioning in a least two of the following skills areas: communication, self-care, social skills, self-direction, academic skills, work, leisure, health and/or safety. These limitations manifest themselves before 18 years of age.” • Mental retardation is cognitive limitation as characterized by scores greater than 2 standard deviations below the mean on a valid intelligence quotient (IQ) measure, with limitation of adaptive function in communication, self‐care, daily living skills at home or in the community, or social skills. 4.9 KEYWORDS • Down's Syndrome (Trisomy 21): A chromosomal abnormality which manifests itself in a set of common physical and mental characteristics, including: extra fold over the eyes, floppy muscles, loose joints, mental retardation, hearing loss, and visual problems. This abnormality is due to the presence of an extra chromosome and has an increased incident related to maternal age. • Dyslexia - a processing disorder characterized by difficulty in reading, writing, spelling, and sometime articulating words. • 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. • Learning disorder - learning disorders are characterized by difficulties in an academic area (either reading, mathematics, or written expression) such that the child's ability to achieve in the specific academic area is below what is expected for the child's age, schooling, and level of intelligence. • Intelligence quotient (IQ) is a total score derived from a set of standardized tests or subtests designed to assess human intelligence • Adaptive behavior refers to the age-appropriate behaviours that people with and without learning disabilities need to live independently and to function well in daily life • Mental retardation (MR) refers to substantial limitations in present functioning. It starts before age 18 and is characterized by significantly subaverage intellectual 52 CU IDOL SELF LEARNING MATERIAL (SLM)
functioning, existing concurrently with related limitations in two or more of the following applicable adaptive skill areas: communication • Fetal alcohol syndrome is a condition in a child that results from alcohol exposure during the mother's pregnancy. • Abstract thinking is the ability to understand concepts that are real, such as freedom or vulnerability, but which are not directly tied to concrete physical objects and experiences. 4.10 LEARNING ACTIVITY 1. How has our understanding of mental retardation changed over a period of time? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. parents of children with mental retardation face social isolation. Please elaborate. ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 4.11 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. what is “Intelligence” 2. Explain “Adaptive behaviour” 3. How do cognitive and intellectual disabilities such as mental retardation affect individuals? 4. What is the definition of developmental disabilities (DD)? 5. How does the DD definition compare with the AAMR definition of mental retardation? Long Questions 1. How many people are affected by mental retardation? 53 2. Explain if it necessary to continue to use the term “mental retardation?” 3. What is Intellectual Functioning (Mental Abilities) 4. Discuss behavioural and psychological features of Intellectual Disabilities 5. What are ICD-10 Codes for Mental & Behavioural Health CU IDOL SELF LEARNING MATERIAL (SLM)
B. Multiple Choice Questions 1. __________ refers to general mental capability. It involves the ability to reason, plan, solve problems, think abstractly, comprehend complex ideas, learn quickly and learn from experience. a. Adaptive Behavior b. Intelligence c. Behavior d. Reasoning 2. In what year WHO entered into a long-term collaborative project with the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) in USA aiming to facilitate further improvement in the classification and diagnosis of mental disorders. a. 1998 b. 1948 c. 1978 d. 1968 3. What is this product of collaborative work between numerous individuals and agencies from different countries who are concern with caring for mentally ill and their families worldwide? a. WHO b. DSM 5 c. BC 45 d. ICD 10 4. This is known to slow down some regions of the brain, like the prefrontal and temporal cortex, negatively affecting rationality and memory. a. Social abuse b. Depression c. Alcohol d. Lie events 5. A psychology theory that says certain personality traits may be a risk factor for developing psychotic disorder, such as schizophrenia. a. Cognitive Theory b. Schizotypy c. Humanistic d. Structuralism 54 CU IDOL SELF LEARNING MATERIAL (SLM)
Answers 1-(b), 2-(c), 3-(d), 4-(c), 5-(b) 4.12 REFERENCES Textbooks: • 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. • Krishnakumar, A., & Buehler, C. (2000). Interparental conflict and parenting behaviors: A meta‐analytic review. Family Relations. • Lamb, M. E. (Ed.). (2010). The role of the father in child development (5th ed). Hoboken, N.J.: Wiley. • Lovejoy, M. C., Weis, R., O'Hare, E., & Rubin, E. C. (1999). Development and initial validation of the Parent Behavior Inventory. Psychological Assessment. • Lundahl, B. W., Tollefson, D., Risser, H., & Lovejoy, M. C. (2007). A meta-analysis of father involvement in parent training. Research on Social Work Practice References: • Feinberg, M. E., Brown, L. D., & Kan, M. L. (2012). A multi-domain self-report measure of coparenting. Parenting. • Flouri, E. (2010). Fathers’ behaviors and children’s psychopathology. Clinical Psychology Review. • Frick, P. J. (1991). The Alabama parenting questionnaire. Unpublished rating scale, University of Alabama. • Horton, J. J., & Chilton, L. B. (2010, June). The labor economics of paid crowdsourcing. In Proceedings of the 11th ACM conference on Electronic commerce ACM. 55 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT –5 DEVELOPMENTAL DISORDERS: MR -PART II Structure 5.0 LearningObjectives 5.1 Introduction 5.2 Assessment with Cognitive Tests 5.3 Psychological Tests 5.4 Specific Syndrome Tests 5.5 Prognosis and Treatment for Mental Retardation 5.6 Summary 5.7 Keywords 5.8 Learning Activity 5.9 Unit End Questions 5.10 References 5.0 LEARNINGOBJECTIVES After studying this unit, you will be able to: • Describe the process of assessment for mental retardation. • Explain the psychological tests used by child psychologists • Describe the test used for specific disorders of learning • Explain the concept of prognosis with respect to mental retardation • Explain the treatments available for mental retardation 56 CU IDOL SELF LEARNING MATERIAL (SLM)
5.1 INTRODUCTION The term “intellectual disability” is gradually replacing the term “mental retardation” nationwide. Advocates for individuals with intellectual disability have rightfully asserted that the term “mental retardation” has negative connotations, has become offensive to many people, and often results in misunderstandings about the nature of the disorder and those who have it. Mental retardation or intellectual disability comprises five general categories: borderline, mild, moderate, severe, and profound. Categories are based on scores obtained through use of age-standardized tests of cognitive ability. If your child has an intellectual disability (ID), their brain hasn’t developed properly or has been injured in some way. Their brain may also not function within the normal range of both intellectual and adaptive functioning. In the past, medical professionals called this condition “mental retardation.” There are four levels of ID: • mild • moderate • severe • profound Sometimes, ID may be classified as: “other” “unspecified” ID involves both a low IQ and problems adjusting to everyday life. There may also be learning, speech, social, and physical disabilities. Severe cases of ID may be diagnosed soon after birth. However, you might not realize your child has a milder form of ID until they fail to meet common developmental goals. In almost all the cases, ID is diagnosed before the child reaches the age of 18. Levels Of Intellectual Disability ID is divided into four levels, based on your child’s IQ and degree of social adjustment. Mild intellectual disability 57 CU IDOL SELF LEARNING MATERIAL (SLM)
• Some of the symptoms of mild intellectual disability include: 58 • taking longer to learn to talk, but communicating well once they know how • being fully independent in self-care when they get older • having problems with reading and writing • social immaturity • increased difficulty with the responsibilities of marriage or parenting • benefiting from specialized education plans • having an IQ range of 50 to 69 Moderate intellectual disability If your child has moderate ID, they may exhibit some of the following symptoms: • are slow in understanding and using language • may have some difficulties with communication • can learn basic reading, writing, and counting skills • are generally unable to live alone • can often get around on their own to familiar places • can take part in various types of social activities • generally having an IQ range of 35 to 49 Severe intellectual disability Symptoms of severe ID include: • noticeable motor impairment • severe damage to, or abnormal development of, their central nervous system • generally having an IQ range of 20 to 34 Profound intellectual disability Symptoms of profound ID include: • inability to understand or comply with requests or instructions • possible immobility • incontinence • very basic nonverbal communication • inability to care for their own needs independently • the need of constant help and supervision • having an IQ of less than 20 Other intellectual disability CU IDOL SELF LEARNING MATERIAL (SLM)
People in this category are often physically impaired, have hearing loss, are nonverbal, or have a physical disability. These factors may prevent your child’s doctor from conducting screening tests. Unspecified intellectual disability If your child has an unspecified ID, they will show symptoms of ID, but their doctor doesn’t have enough information to determine their level of disability. 5.2 ASSESSMENT WITH COGNITIVE TEST Cognitive testing, also called neurocognitive testing or psychometric testing, assesses your ability to think clearly and to determine if any mental conditions exist. If so, this testing allows one to determine if said condition is getting better or worse. Assessments of this kind can be used in mental health facilities or for employment screenings. Early versions of cognitive tests were established around 100 years ago and developed through the ages. “Pencil and pen” tests were widely used up until the advent of computerized testing in the 1970s and 1980s. These new tests offered more accurate data reporting and a better assessment on response time. Cognition tests are not necessarily considered intelligence tests, or IQ tests. As reported by Cog State, an Australian cognitive science and technology company, these assessments measure three common areas of cognition: memory, executive function, and attention. Of course, these areas have more specific facets. The questions asked during a cognitive test aim to explore basic function and these areas. Some cognitive regions that may be tested are: • Physical appearance including age, weight, height, and other vitals. This can help differentiate mental and physical conditions. This can be useful in the case of substance abuse or alcohol dependency. • Orientation of basic information such as your name, the date, the season, where you live, and names of family members. As confusion can be associated with some mental illnesses, this can help make a better and more accurate diagnosis. • Attention span, according to MedlinePlus, can be a determinant in the rest of the cognitive assessment. This tests your ability to complete a thought and think rationally. This portion of an assessment also looks at how easily you are distracted. • Recent past and memory can include questions on childhood memories, family members, your current job or living situation, or current events. As memory can be impacted with certain mental illnesses or substance addictions, it’s important to understand if and how severely memory has been impaired. 59 CU IDOL SELF LEARNING MATERIAL (SLM)
• Language testing involves your ability to read, write, and speak clearly. Testing may involve you writing or reading sentences or saying words out loud. • Judgment can be largely subjective but the questions generally asked during this stage of testing help a physician to understand any impairments to reasoning and problem-solving abilities. Questions might include moral decisions like what you might do if you found someone’s wallet or if you got pulled over by the police while driving. Cognitive Testing is Important Cognitive testing is crucial in assessing and diagnosing any mental health conditions you may have. Without a proper evaluation, very little can be done to solve the problem on a long-term basis. In order to appropriately treat someone for a mental health condition, its impact on the individual has to be known. When you enter treatment at a Foundations Recovery Network facility, our treatment professionals can evaluate your mental state and offer an informed course of action for treatment. Call us anytime to discuss options that are right for you with one of our treatment coordinators. Cognitive Assessment Cognitive assessment (or intelligence testing) is used to determine an individual’s general thinking and reasoning abilities, also known as intellectual functioning or IQ. Intelligence testing can assess various domains of your child’s cognitive capacity. An assessment and therapy clinic may test for the following: 1. Verbal comprehension: understanding verbal information, thinking in words, and expressing thoughts in words 2. Perceptual reasoning: ability to organize and reason with visual information, and to solve visual problems 3. Working memory: ability to retain and manipulate verbal information 4. Processing speed: ability to scan, process and identify information accurately. Usually, the average score for IQ and various domains is between 90 and 109. Higher scores represent higher cognitive functioning and lower scores represent poorer cognitive functioning. However, when the scores between domains varies greatly, individual domain scores may provide a more accurate reflection of an individual’s cognitive ability than the overall IQ score. There are many reasons why your child’s psychologist may suggest a cognitive assessment. For instance: 1. To obtain an accurate profile of an individual’s overall intellectual functioning or IQ level 2. To identify an individual’s cognitive strengths and weaknesses 60 CU IDOL SELF LEARNING MATERIAL (SLM)
3. To assist in exploring an individual’s learning difficulties 4. To assist in developing learning strategies and recommendations 5. To assist in the examination of: • Intellectual giftedness • Specific learning disabilities • Intellectual disability • Autism Spectrum Disorder • Attention Deficit Hyperactivity Disorder A cognitive assessment for children usually includes: 1. Gathering comprehensive background information through interviews with the child, parents, and school teachers 2. The administration of standardized tests by trained psychologists 3. A feedback session (& provision of a report) to explain findings, provide recommendations and opportunities to clarify information. Cognitive tests usually consist of verbal, numerical, abstract, and logical tests. Their complexity and difficulty level can vary significantly between the different tests in this category. 1) Cubiks Logiks 2) MMAT - McQuaig Mental Agility Test 3) GIA - Thomas International General Intelligence Assessment 4) HBRI - Hogan Business Reasoning Inventory 5) PLI - Predictive Index Learning Indicator 6) RCAT - Revelian Cognitive Ability Tests - Mainly used in Australia 7) WPT - Wonderlic Personnel Test - Mainly used in the US 8) CCAT - Criteria Cognitive Aptitude Test - Mainly used in the US Common Characteristics for Most Cognitive Ability Tests: 1. They cover more than one subject. Questions from a variety of subjects will be shuffled together during the course of the test. 2. Even single questions may not be dedicated to a single subject. 61 CU IDOL SELF LEARNING MATERIAL (SLM)
3. There are often a lot of questions to answer in a short time frame 4. Candidates are not expected to complete these tests in their entirety. 5. The subject matter is usually not difficult, however, with the addition of time constraints and the shift between subjects can make the tests challenging. Cognitive Ability Vs Cognitive Skills Tests Cognitive Ability Tests: The purpose of cognitive tests is to determine your ability to learn and apply new skills, your ability to adapt to change, your problem-solving skills and your ability to follow instructions. Essentially, these tests measure your general intelligence which is why they are commonly referred to as ‘intelligence’ tests. They do not measure your numerical or verbal skills outright. A higher score on this sort of exam demonstrates to upper management that you have had formal educational training, while a lower score indicates that you may require more detailed instruction and supervision for learning new skills. Cognitive Skills Tests: The cognitive skills test gauges if verbal and math career training programmes are needed for the entry-level job. Furthermore, this exam will tell your future employer where best to place you within the company. Unlike the cognitive ability test, the skills test will also measure your existing skills. The results will detect the specific skill sets the interviewer is looking for. Psychometrics and Testing Norms For Cognitive Test Once a test has been administered, assuming it has been done so according to standardized protocol, the test-taker's performance can be scored. In most instances, an individual's raw score, that is the number of items on which he or she responded correctly, is translated into a standard score based on the normative data for the specific measure. In this manner, an individual's performance can be characterized by its position on the distribution curve of normal performances. The majority of cognitive tests have normative data from groups of people who mirror the broad demographic characteristics of the population of the United States based on census 62 CU IDOL SELF LEARNING MATERIAL (SLM)
data. As a result, the normative data for most measures reflect the racial, ethnic, socioeconomic, and educational attainment of the population majorities. Unfortunately, that means that there are some individuals for whom these normative data are not clearly and specifically applicable. This does not mean that testing should not be done with these individuals, but rather that careful consideration of normative limitations should be made in interpretation of results. Selection of appropriate measures and assessment of applicability of normative data vary depending on the purpose of the evaluation. Cognitive tests can be used to identify acquired or developmental cognitive impairment, to determine the level of functioning of an individual relative to typically functioning same-aged peers, or to assess an individual's functional capacity for everyday tasks. Clearly, each of these purposes could be relevant for SSA disability determinations. However, each of these instances requires different interpretation and application of normative data. When attempting to identify a change in functioning secondary to neurological injury or illness, it is most appropriate to compare an individual's post injury performance to his or her premorbid level of functioning. Unfortunately, it is rare that an individual has a formal assessment of his or her premorbid cognitive functioning. Thus, comparison of the post injury performance to demographically matched normative data provides the best comparison to assess a change in functioning. For example, assessment of a change in language functioning in a Spanish-speaking individual from Mexico who has sustained a stroke will be more accurate if the individual's performance is compared to norms collected from other Spanish- speaking individuals from Mexico rather than English speakers from the United States or even Spanish-speaking individuals from Puerto Rico. In many instances, this type of data is provided in alternative normative data sets rather than the published population-based norms provided by the test publisher. In contrast, the population-based norms are more appropriate when the purpose of the evaluation is to describe an individual's level of functioning relative to same-aged peers. A typical example of this would be in instances when the purpose of the evaluation is to determine an individual's overall level of intellectual (i.e., IQ) or even academic functioning. In this situation, it is more relevant to compare that individual's performance to that of the broader population in which he or she is expected to function in order to quantify his or her functional capabilities. Thus, for determination of functional disability, demographically or ethnically corrected normative data are inappropriate and may actually underestimate an individual's degree of disability. In this situation, use of otherwise appropriate standardized and psychometrically sound performance-based or cognitive tests is appropriate. 63 CU IDOL SELF LEARNING MATERIAL (SLM)
Determination of an individual's everyday functioning or vocational capacity is perhaps the evaluation goal most relevant to the SSA disability determination process. To make this determination, the most appropriate comparison group for any individual would be other individuals who are currently completing the expected vocational tasks without limitations or disability. Unfortunately, there are few standardized measures of skills necessary to complete specific vocational tasks and, therefore, also no vocational-specific normative data at this time. This type of functional capacity is best measured by evaluation techniques that recreate specific vocational settings and monitor an individual's completion of related tasks. Until such specific vocational functioning measures exist and are readily available for use in disability determinations, objective assessment of cognitive skills that are presumed to underlie specific functions will be necessary to quantify an individual's functional limitations. Despite limitations in normative data as outlined, formal psychometric assessment can be completed with individuals of various ethnic, racial, gender, educational, and functional backgrounds. However, the authors note that “limited research suggests that demographic adjustments reduce the power of cognitive test scores to predict every-day abilities”. In fact, they go on to state “the normative standard for daily functioning should not include adjustments for age, education, sex, ethnicity, or other demographic variables”. Use of appropriate standardized measures by appropriately qualified evaluators as outlined in the following sections further mitigates the impact of normative limitations. Interpretation and Reporting Of Test Results Interpretation of results is more than simply reporting the raw scores an individual achieves. Interpretation requires assigning some meaning to the standardized score within the individual context of the specific test-taker. There are several methods or levels of interpretation that can be used, and a combination of all is necessary to fully consider and understand the results of any evaluation. This section is meant to provide a brief overview; although a full discussion of all approaches and nuances of interpretation is beyond the scope of this report, interested readers are referred to various textbooks. Interindividual Differences The most basic level of interpretation is simply to compare an individual's testing results with the normative data collected in the development of the measures administered. This level of interpretation allows the examiner to determine how typical or atypical an individual's performance is in comparison to same-aged individuals within the general population. Normative data may or may not be further specialized on the basis of race/ ethnicity, gender, and educational status. There is some degree of variability in how an individual's score may be interpreted based on its deviation from the normative mean due to various schools of 64 CU IDOL SELF LEARNING MATERIAL (SLM)
thought, all of which cannot be described in this text. One example of an interpretative approach would be that a performance within one standard deviation of the mean would be considered broadly average. Performances one to two standard deviations below the mean are considered mildly impaired, and those two or more standard deviations below the mean typically are interpreted as being at least moderately impaired. Intraindividual Differences In addition to comparing an individual's performances to that of the normative group, it also is important to compare an individual's pattern of performances across measures. This type of comparison allows for identification of a pattern of strengths and weaknesses. For example, an individual's level of intellectual functioning can be considered a benchmark to which functioning within some other domains can be compared. If all performances fall within the mildly to moderately impaired range, an interpretation of some degree of intellectual disability may be appropriate, depending on an individual's level of adaptive functioning. It is important to note that any interpretation of an individual's performance on a battery of tests must take into account that variability in performance across tasks is a normal occurrence especially as the number of tests administered increases. However, if there is significant variability in performances across domains, then a specific pattern of impairment may be indicated. Profile Analysis When significant variability in performances across functional domains is assessed, it is necessary to consider whether or not the pattern of functioning is consistent with a known cognitive profile. That is, does the individual demonstrate a pattern of impairment that makes sense or can be reliably explained by a known neurobehavioral syndrome or neurological disorder. For example, an adult who has sustained isolated injury to the temporal lobe of the left hemisphere would be expected to demonstrate some degree of impairment on some measures of language and verbal memory, but to demonstrate relatively intact performances on measures of visual-spatial skills. This pattern of performance reflects a cognitive profile consistent with a known neurological injury. Conversely, a claimant who demonstrates impairment on all measures after sustaining a brief concussion would be demonstrating a profile of impairment that is inconsistent with research data indicating full cognitive recovery within days in most individuals who have sustained a concussion. Interpreting Poor Cognitive Test Performance Regardless of the level of interpretation, it is important for any evaluator to keep in mind that poor performance on a set of cognitive or neuropsychological measures does not always 65 CU IDOL SELF LEARNING MATERIAL (SLM)
mean that an individual is truly impaired in that area of functioning. Additionally, poor performance on a set of cognitive or neuropsychological measures does not directly equate to functional disability. In instances of inconsistent or unexpected profiles of performance, a thorough interpretation of the psychometric data requires use of additional information. The evaluator must consider the validity and reliability of the data acquired, such as whether or not there were errors in administration that rendered the data invalid, emotional or psychiatric factors that affected the individual's performance, or sufficient effort put forth by the individual on all measures. To answer the latter question, administration of performance validity tests (PVTs) as part of the cognitive or neuropsychological evaluation battery can be helpful. Interpretation of PVT data must be undertaken carefully. Any PVT result can only be interpreted in an individual's personal context, including psychological/emotional history, level of intellectual functioning, and other factors that may affect performance. Particular attention must be paid to the limitations of the normative data available for each PVT to date. As such, a simple interindividual interpretation of PVT testing results is not acceptable or valid. Rather, consideration of intraindividual patterns of performance on various cognitive measures is an essential component of PVT interpretation. PVTs will be discussed in greater detail later in this chapter. Assessing Validity of Cognitive Test Performance Neuropsychological tests assessing cognitive, motor, sensory, or behavioural abilities require actual performance of tasks, and they provide quantitative assessments of an individual's functioning within and across cognitive domains. The standardization of neuropsychological tests allows for comparability across test administrations. However, interpretation of an individual's performance presumes that the individual has put forth full and sustained effort while completing the tests; that is, accurate interpretation of neuropsychological performance can only proceed when the test-taker puts forth his or her best effort on the testing. If a test- taker is not able to give his or her best effort, for whatever reason, the test results cannot be interpreted as accurately reflecting the test-taker's ability level. As discussed in detail in Chapter 2, a number of studies have examined potential for malingering when there is a financial incentive for appearing impaired, suggesting anywhere from 19 to 68 percent of SSA disability applicants may be performing below their capability on cognitive tests or inaccurately reporting their symptoms. However, an individual may put forth less than optimal effort due to a variety of factors other than malingering, such as pain, fatigue, medication use, and psychiatric symptomatology. 66 CU IDOL SELF LEARNING MATERIAL (SLM)
For these reasons, analysis of the entire cognitive profile for consistency is generally recommended. Specific patterns that increase confidence in the validity of a test battery and overall assessment include • Consistency between test behaviour or self-reported symptoms and incidental behaviour. • Consistency between test behaviour or self-reported symptoms and what is known about brain functioning and the type and severity of injury/illness claimed. • Consistency between test behaviour or self-reported symptoms and known patterns of performance (e.g., passing easy items and failing more difficult items; better performance on cued recall and recognition tests than free recall tests; intact memory requires intact attention). • Consistency between test behaviour or self-reported symptoms and reliable collateral reports or other background information, such as medical documentation. • Consistency between self-reported history and reliable collateral history or medical documentation; and • Consistency across tests measuring the same cognitive domain or across tests administered at different times. Specific tests have also been designed specially to aid in the examination of performance validity. The development of and research on these PVTs has increased rapidly during the past two decades. There have been attempts to formally quantify performance validity during testing since the mid-1900s, with much of the initial focus on examining the consistency of an individual's responses across a battery of testing, with the suggestion that inconsistency may indicate variable effort. However, a significant push for specific formal measures came in response to the increased use of neuropsychological and cognitive testing in forensic contexts, including personal injury litigation, workers compensation, and criminal proceedings in the 1980s and 1990s. Given the nature of these evaluations, there was often a clear incentive for an individual to exaggerate his or her impairment or to put forth less than optimal effort during testing, and neuropsychologists were being called upon to provide statements related to the validity of test results. Several studies documented that use of clinical judgment and interpretation of performance inconsistencies alone was an inadequate methodology for detection of poor effort or intentionally poor performance. As such, the need for formal standardized measures of effort and means for interpretation of these measures emerged. 67 CU IDOL SELF LEARNING MATERIAL (SLM)
PVTs are measures that assess the extent to which an individual is providing valid responses during cognitive or neuropsychological testing. PVTs are typically simple tasks that are easier than they appear to be and on which an almost perfect performance is expected based on the fact that even individuals with severe brain injury have been found capable of good performance. On the basis of that expectation, each measure has a performance cut-off defined by an acceptable number of errors designed to keep the false-positive rate low. Performances below these cut-off points are interpreted as demonstrating invalid test performance. 5.3 PSYCHOLOGICAL TEST Understanding psychological testing and assessment Psychological testing may sound intimidating, but it's designed to help you. Psychologists use tests and other assessment tools to measure and observe a client’s behaviour to arrive at a diagnosis and guide treatment. If you or a family member has been referred for psychological testing, you probably have some questions about what to expect. Or you may have heard about psychological testing and wonder if you or a family member should be tested. Psychological testing may sound intimidating, but it's designed to help you. In many ways, psychological testing and assessment are similar to medical tests. If a patient has physical symptoms, a primary care provider may order X-rays or blood tests to understand what's causing those symptoms. The results of the tests will help inform develop a treatment plan. Psychological evaluations serve the same purpose. Psychologists use tests and other assessment tools to measure and observe a client's behaviour to arrive at a diagnosis and guide treatment. Psychologists administer tests and assessments for a wide variety of reasons. Children who are experiencing difficulty in school, for example, may undergo aptitude testing or tests for learning disabilities. Tests for skills such as dexterity, reaction time and memory can help a neuropsychologist diagnose conditions such as brain injuries or dementia. If a person is having problems at work or school, or in personal relationships, tests can help a psychologist understand whether he or she might have issues with anger management or interpersonal skills, or certain personality traits that contribute to the problem. Other tests evaluate whether clients are experiencing emotional disorders such as anxiety or depression. 68 CU IDOL SELF LEARNING MATERIAL (SLM)
The underlying cause of a person's problems isn't always clear. For example, if a child is having trouble in school, does he or she have a reading problem such as dyslexia? An attention problem such as attention-deficit hyperactivity disorder (ADHD)? Difficulty with impulse control? Psychological tests and assessments allow a psychologist to understand the nature of the problem, and to figure out the best way to go about addressing it. Tests and assessments Tests and assessments are two separate but related components of a psychological evaluation. Psychologists use both types of tools to help them arrive at a diagnosis and a treatment plan. Testing involves the use of formal tests such as questionnaires or checklists. These are often described as “norm-referenced” tests. That simply means the tests have been standardized so that test-takers are evaluated in a similar way, no matter where they live or who administers the test. A norm-referenced test of a child's reading abilities, for example, may rank that child's ability compared to other children of similar age or grade level. Norm-referenced tests have been developed and evaluated by researchers and proven to be effective for measuring a particular trait or disorder. A psychological assessment can include numerous components such as norm-referenced psychological tests, informal tests and surveys, interview information, school or medical records, medical evaluation, and observational data. A psychologist determines what information to use based on the specific questions being asked. For example, assessments can be used to determine if a person has a learning disorder, is competent to stand trial or has a traumatic brain injury. They can also be used to determine if a person would be a good manager or how well they may work with a team. One common assessment technique, for instance, is a clinical interview. When a psychologist speaks to a client about his or her concerns and history, they're able to observe how the client thinks, reasons, and interacts with others. Assessments may also include interviewing other people who are close to the client, such as teachers, co-workers, or family members. (Such interviews, however, would only be performed with written consent from the client.) Together, testing and assessment allows a psychologist to see the full picture of a person's strengths and limitations. Seeing a psychologist Psychological tests are not one-size-fits-all. Psychologists pick and choose a specific set of assessments and tests for each individual client. And not just anyone can perform a 69 CU IDOL SELF LEARNING MATERIAL (SLM)
psychological evaluation. Licensed clinical psychologists are expertly trained to administer assessments and tests and interpret the results. In many cases, psychologists who administer tests will then treat patients with psychotherapy. Some psychologists focus only on evaluating patients, and then refer them to other specialists for treatment after they've made a diagnosis. In either case, the testing or assessment process will help ensure that the client receives treatment that's tailored to his or her individual needs. What to expect Psychological testing isn't like taking a multiple-choice exam that you either pass or fail. Rather, psychologists use information from the various tests and assessments to reach a specific diagnosis and develop a treatment plan. Some people are tempted to peek at the tests ahead of time. If they suspect they may have a particular problem, they may look online for a practice test of that problem. That's a bad idea, experts say. In fact, practicing ahead of time usually backfires — when you try to take the test in a certain way, the answers may be inconsistent and make you appear to have more problems than you actually do. Remember, psychological testing and assessment is nothing to fear. It's not something you need to study for. Rather, it's an opportunity for psychologists to determine the best way to help you. Psychological testing is the administration of psychological tests. Psychological tests are administered by trained evaluators. A person's responses are evaluated according to carefully prescribed guidelines. Scores are thought to reflect individual or group differences in the construct the test purports to measure. The science behind psychological testing is psychometrics. Proper psychological testing is conducted after vigorous research and development in contrast to quick web-based or magazine questionnaires that say \"Find out your Personality Colour,\" or \"What's your Inner Age?\" Proper psychological testing consists of the following: • Standardization - All procedures and steps must be conducted with consistency and under the same environment to achieve the same testing performance from those being tested. • Objectivity - Scoring such that subjective judgments and biases are minimized, with results for each test taker obtained in the same way. 70 CU IDOL SELF LEARNING MATERIAL (SLM)
• Test Norms - The average test score within a large group of people where the performance of one individual can be compared to the results of others by establishing a point of comparison or frame of reference. • Reliability - Obtaining the same result after multiple testing. • Validity - The type of test being administered must measure what it is intended to measure. Sample of behaviour The term sample of behaviour refers to an individual's performance on tasks that have usually been prescribed beforehand. The samples of behaviour that make up a paper-and-pencil test, the most common type of psychological test, are a series of test items. Performance on these items produce a test score. A score on a well-constructed test is believed to reflect a psychological construct such as achievement in a school subject like mathematics knowledge, cognitive ability, aptitude, emotional functioning, personality, etc. Differences in test scores are thought to reflect individual differences in the construct the test is purported to measure. TYPES There are several broad categories of psychological tests: Achievement tests Achievement tests are tests that assess an individual's knowledge in a subject domain. Academic achievement tests are designed to be administered by a trained evaluator to an individual or a group of people. During achievement tests, a series of test items is presented to the person being evaluated. A score on a test is believed to reflect achievement in a school subject. Many achievement tests are norm-referenced. The person's responses are scored according to standardized protocols and the results can be compared to the responses of a norming group after the test is completed. Some achievement tests are criterion referenced, the purpose of which is find out if the test- taker mastered a predetermined body of knowledge rather than to compare the test-taker to everyone else who is taking the test. The Kaufman Test of Educational Achievement is an example of an individually administered achievement test for students. 71 CU IDOL SELF LEARNING MATERIAL (SLM)
Aptitude tests Psychological tests have been designed to measure specific abilities, such as clerical, perceptual, numerical, or spatial aptitude. Sometimes these tests must be specially designed for a particular job, but there are also tests available that measure general clerical and mechanical aptitudes, or even general learning ability. An example of an occupational aptitude test is the Minnesota Clerical Test, which measures the perceptual speed and accuracy required to perform various clerical duties. A widely used aptitude test in business is the Wonderlic Test. There are aptitudes that are believed to be related to specific occupations and are used for career guidance as well as selection and recruitment. Evidence suggests that aptitude tests like IQ tests are sensitive to past learning and cannot avoid measuring past achievement, although they were once thought to measure untutored ability. The SAT, which used to be called the Scholastic Aptitude Test, had its named changed because performance on the test is sensitive to training. Attitude scales An attitude scale assesses an individual's disposition regarding an event (e.g., a Supreme Court decision), person (e.g., a governor), concept (e.g., wearing face masks during a pandemic), organization (e.g., the Boy Scouts), or object (e.g., nuclear weapons) on a unidimensional favorable-unfavorable attitude continuum. Attitude scales are used in marketing to determine individuals' preferences for brands. Historically social psychologists have developed attitude scales to assess individuals' attitudes toward the United Nations and race relations. Typically Likert scales are used in attitude research. Historically, the Thurstone scale was used prior to the development of the Likert scale. The Likert scale has largely supplanted the Thurstone scale. Biographical Information Blank The Biographical Information Blanks or BIB is a paper-and-pencil form that includes items that ask about detailed personal and work history. It is used to aid in the hiring of employees by matching the backgrounds of individuals to requirements of the job. Clinical tests The purpose of clinical tests is to assess the presence of symptoms of psychopathology .[18] Examples of clinical assessments include the Minnesota Multiphasic Personality Inventory, Millon Clinical Multiaxial Inventory-IV, Child Behaviour Checklist, Symptom Checklist 90, and the Beck Depression Inventory. 72 CU IDOL SELF LEARNING MATERIAL (SLM)
Clinical tests like the MMPI are also norm-referenced, with 50 the middlemost score on a symptom subscale such as the Depression scale and 60 a score that places the individual one standard deviation above the mean for the symptom scale. Criterion-referenced A criterion-referenced test is an achievement test in a specific knowledge domain.[1] An individual's performance on the test is compared to a criterion. Test-takers are not compared to each other. A passing score, i.e., the criterion performance, is established by the teacher or an educational institution. Criterion-referenced tests are part and parcel of mastery-based education. Direct observation Psychological assessment can involve the observation of people as they complete activities. This type of assessment is usually conducted with families in a laboratory or at home. Sometimes the observation can involve children in a classroom or the schoolyard. The purpose may be clinical, such as to establish a pre-intervention baseline of a child's hyperactive or aggressive classroom behaviours or to observe the nature of a parent-child interaction in order to understand a relational disorder. Time sampling methods are also part of direct observational research. The reliability of observers in direct observational research can be evaluated using Cohen's kappa. The Parent-Child Interaction Assessment-II (PCIA) is an example of a direct observation procedure that is used with school-age children and parents. The parents and children are video recorded playing at a make-believe zoo. The Parent-Child Early Relational Assessment is used to study parents and young children and involves a feeding and a puzzle task. The MacArthur Story Stem Battery (MSSB) is used to elicit narratives from children. The Dyadic Parent-Child Interaction Coding System-II tracks the extent to which children follow the commands of parents and vice versa and is well suited to the study of children with Oppositional Defiant Disorders and their parents. Interest inventories Psychological tests include interest inventories. These tests are used primarily for career counselling. Interest inventories include items that ask about the preferred activities and interests of people seeking career counselling. The rationale is that if the individuals of activities and interests is similar to the modal pattern for people who are successful in a given occupation, then the chances are high that the individual would find satisfaction in that occupation. A widely used interest test is the Strong Interest Inventory, which is used in career assessment, career counselling, and educational guidance. 73 CU IDOL SELF LEARNING MATERIAL (SLM)
Neuropsychological tests Main article: Neuropsychological test Neuropsychological tests are designed to be an objective and standardized measure of a sample of behaviour. Norm-referenced tests Items on norm-referenced tests have been tried out on a norming group and scores on the test can be classified as high, medium, or low and the gradations in between. These tests allow for the study of individual differences. Scores on norm-referenced achievement tests are associated with percentile ranks vis-á-vis other individuals who are the test-taker's age or grade. Personality tests Main article: Personality test Personality tests assess constructs that are thought to be the constituents of personality. Examples of personality constructs include traits in the Big Five, such as introversion- extroversion and conscientiousness. Personality constructs are thought to be dimensional. Personality measures are used in research and in the selection of employees. They include self-report and observer-report scales. Examples of norm-referenced personality tests include the NEO-PI, the 16PF, the OPQ, and the FFPI-C. The IPIP scales are assess the same personality traits that the NEO and the other scales assess but IPIP scales and items are available free of charge. Projective tests Projective testing originated in the first half of the 1900s. Examples of projective tests are storytelling, drawings, or sentence-completion tasks. Public safety employment tests Vocations within the public safety field (i.e., fire service, law enforcement, corrections, and emergency medical services) often require Industrial and Organizational Psychology tests for initial employment and advancement throughout the ranks. The National Firefighter Selection Inventory - NFSI, the National Criminal Justice Officer Selection Inventory - NCJOSI, and the Integrity Inventory are prominent examples of these tests. 74 CU IDOL SELF LEARNING MATERIAL (SLM)
Test Security Many psychological and psychoeducational tests are not available to the public. Test publishers put restrictions on who has access to the test. Psychology licensing boards also restrict access to the tests used in licensing psychologists. Test publishers hold that both copyright and professional ethics require them to protect the tests. Publishers sell tests only to people who have proved their educational and professional qualifications. Purchasers are legally bound not to give test answers or the tests themselves to members of the public unless permitted by the publisher. The International Test Commission (ITC), an international association of national psychological societies and test publishers, publishes the International Guidelines for Test Use, which prescribes measures to take to \"protect the integrity\" of the tests by not publicly describing test techniques and by not \"coaching individuals\" so that they \"might unfairly influence their test performance.\" 5.4 SPECIFIC SYNDROME TESTS Under functioning of the thyroid gland has been associated with mental handicap for many years. The thyroid hormones are essential for protein synthesis and any condition which interferes with the production of these hormones may affect both the development and the function of the brain. The synthesis of thyroxine and triiodothyronine may be interfered with in many ways. Severe iodine deficiency during pregnancy may produce Endemic Cretinism which covers a wide range of severity and may result in spastic diplegia, deafness and motor disorders in addition to mental handicap. Hypothyroidism, which may also be cause by auto-immune mechanisms, goitrogenic agents, drugs, congenital partial absence of the thyroid gland and genetic disorders may cause mental handicap or mental slowing, often associated with mental disorders depending upon the age of onset. Hypothyroidism is particularly associated with Down's syndrome and since the symptoms of mental and physical slowing and increase in weight are often found in Down's syndrome without thyroid disorder and since the onset is usually insidious the diagnosis may be overlooked. It is therefore, necessary to test thyroid function periodically in order not to miss the diagnosis. The diagnosis of hyperthyroidism is relatively easy to make and the treatment which is pure replacement therapy by the administration of oral thyroxine, is both inexpensive and completely effective 75 CU IDOL SELF LEARNING MATERIAL (SLM)
5.5 PROGNOSIS AND TREATMENT FOR MENTAL RETARDATION Certain causes of intellectual disability are preventable. The most common of these is fetal alcohol syndrome. Pregnant women shouldn’t drink alcohol. Getting proper prenatal care, taking a prenatal vitamin, and getting vaccinated against certain infectious diseases can also lower the risk that your child will be born with intellectual disabilities. In families with a history of genetic disorders, genetic testing may be recommended before conception. Certain tests, such as ultrasound and amniocentesis, can also be performed during pregnancy to look for problems associated with intellectual disability. Although these tests may identify problems before birth, they cannot correct them. Certain causes of intellectual disability are preventable. The most common of these is fetal alcohol syndrome. Pregnant women shouldn’t drink alcohol. Getting proper prenatal care, taking a prenatal vitamin, and getting vaccinated against certain infectious diseases can also lower the risk that your child will be born with intellectual disabilities. In families with a history of genetic disorders, genetic testing may be recommended before conception. Certain tests, such as ultrasound and amniocentesis, can also be performed during pregnancy to look for problems associated with intellectual disability. Although these tests may identify problems before birth, they cannot correct them. Intellectual disability may be suspected for many different reasons. If a baby has physical abnormalities that suggest a genetic or metabolic disorder, a variety of tests may be done to confirm the diagnosis. These include blood tests, urine tests, imaging tests to look for structural problems in the brain, or electroencephalogram (EEG) to look for evidence of seizures. In children with developmental delays, the doctor will perform tests to rule out other problems, including hearing problems and certain neurological disorders. If no other cause can be found for the delays, the child will be referred for formal testing. For babies and toddlers, early intervention programs are available. A team of professionals works with parents to write an Individualized Family Service Plan, or IFSP. This document outlines the child’s specific needs and what services will help the child thrive. Early intervention may include speech therapy, occupational therapy, physical therapy, family counseling, training with special assistive devices, or nutrition services. 76 CU IDOL SELF LEARNING MATERIAL (SLM)
School-age children with intellectual disabilities (including preschoolers) are eligible for special education for free through the public school system. This is mandated by the Individuals With Disabilities Education Act (IDEA). Parents and educators work together to create an Individualized Education Program, or IEP, which outlines the child’s needs and the services the child will receive at school. The point of special education is to make adaptations, accommodations, and modifications that allow a child with an intellectual disability to succeed in the classroom. Mental retardation cannot be “cured,” but interventions can help people to function more independently in daily life. Such interventions are designed to improve the person’s ability to communicate and other skills. But more than that, clinicians try to prevent mental retardation from arising in the first place. Prevention efforts seek to avert or reduce the factors that cause mental retardation. Targeting Neurological Factors: Prevention Because the key causes of mental retardation are neurological, this type of factor is the target of prevention efforts. Two successful prevention efforts focus on phenylketonuria (PKU) and exposure to lead. Since the 1950s, virtually all newborns in the United States receive a test to detect whether they have PKU, which consists of a problem metabolizing the enzyme phenylalanine hydroxylase. For newborns testing positive, lifelong dietary modifications can prevent any brain damage, thus preventing mental retardation. Another successful prevention effort involves childhood exposure to lead, which can lead to brain abnormalities. Targeting Psychological and Social Factors: Communication Given the defi cits and heterogeneous symptoms that accompany mental retardation, no single symptom is the focus of all psychological and social treatments. Rather, psychological and social treatments depend on the individual’s specific constellation of symptoms of mental retardation and possible comorbid disorders. In some cases, treatment is designed to target significant communication deficits. Such treatment may teach non-vocal communication, for example, using a technique called the Picture Exchange Communication System (PECS). With this system, children learn to give a picture of the desired item to someone in exchange for that item. Important elements of the program include learning to recognize which picture corresponds to what is wanted (cognitive skill), going over to someone to give the picture (social skill), and responding appropriately to the question “What do you want?” (social and communication skills). Targeting Social Factors: Accommodation in the Classroom 77 CU IDOL SELF LEARNING MATERIAL (SLM)
It’s the Law With the passage of the Americans with Disabilities Act in 1990 and the subsequent Individuals with Disabilities Education Act (IDEA) in 1997, eligible children with disabilities between the ages of 3 and 21 are guaranteed special education and related services that are individually tailored to the child’s needs, at no cost to the parents. Each child with disabilities receives a comprehensive evaluation, and the child is placed in the least restrictive environment that responds to his or her needs. An individualized education program (IEP) specifies educational goals as well as supplementary services or products that should be used to help the student utilize the regular curriculum. For many children, one goal of the IEP is to facilitate inclusion—placing students with disabilities in a regular classroom, with guidelines for any accommodations that the regular classroom teacher or special education teacher should make. Note that mainstreaming is not the same as inclusion; mainstreaming simply refers to placing a child with disabilities into a regular classroom, with no curriculum adjustments to accommodate the disability. With inclusion, a child with mild mental retardation placed in a regular classroom may take much longer than his or her classmates to learn to read, and his or her reading fluency will not be as high as that of classmates. At school, such children may meet regularly with a speech and language therapist and a reading and math specialist during periods when the rest of the class is doing work that is beyond their ability. Legal mandates have also brought people with mental retardation (and other disabilities) out from the shadows of institutional living into society: Depending on the severity of their retardation, they live in communities, hold jobs, and have families. Steps to help your intellectually disabled child include: • Learn everything you can about intellectual disabilities. The more you know, the better advocate you can be for your child. • Encourage your child’s independence. Let your child try new things and encourage your child to do things by themselves. Provide guidance when it’s needed and give positive feedback when your child does something well or masters something new. • Get your child involved in group activities. Taking an art class or participating in Scouts will help your child build social skills. • Stay involved. By keeping in touch with your child’s teachers, you’ll be able to follow their progress and reinforce what your child is learning at school through practice at home. • Get to know other parents of intellectually disabled children. They can be a great source of advice and emotional support. 78 CU IDOL SELF LEARNING MATERIAL (SLM)
5.6 SUMMARY • The parents are supposed to take the right action to their children with mental disability this is because this person is important in life and can bring about changes in a community provided important services that are required are provided. • This will be important as the goals that are set should show the things that a parent for a child who is disabled is supposed to do. (David, 2001) • In so doing these people will lead to better lives. In general goal setting will be targeted at ensuring that they provide services and financial assistance so that these affected people who are mainly discriminated in their families and countries can get better lives through having access to schools and job market. • This will mean that this person will be able to get skills that are received by other who are in their better lives and they do this through ensuring that the right action is taken to cover the affected people. • The gateway art is important to disabled people because they are able to provide health care for them. This is in terms of ensuring that proper treatment is given for a person who is disabled in that they are given diagnosis and if a child is found with this problem then the right action is taken. This will imply that a child who is in a mental disability will not be left out but the care that is important to live right lives is provided. This is only possible through educating and counselling the parents so that they can know the importance of having their children been diagnosed at the right time. • It is able to offer treatment for these affected people so that they can encourage others to see the importance of getting to know the status of their children. This only through ensuring that they make further investments to get information technology projects so that they can promote more efficient purchase and delivery care health care. This will mean that with proper delivery health care then the cases of mental retardation that is caused by delivery problems is dealt with in the right manner. (Ben, 1994) • This gateway art ensures that they provide necessary public health safety where women are safe and children who get this problem during their early ages can be treated in the right time before the problem worsens. The organization also addresses the structural deficiencies which are adversely and have impact to the functioning of the critical capital asset this is important in that the organization will have the know- how of how much it is supposed to spend on health care so that problems of lack of finance are no longer in existence. 79 CU IDOL SELF LEARNING MATERIAL (SLM)
5.7 KEYWORDS • Expressive language disorder - a communication disorder identified by developmental delays and difficulties in the ability to produce speech. • Verbal comprehension: understanding verbal information, thinking in words, and expressing thoughts in words • Intellectual disability (ID): Intellectual disability (ID), once called mental retardation, is characterized by below-average intelligence or mental ability and a lack of skills necessary for day-to-day living. • Cognitive testing: Cognitive testing, also called neurocognitive testing or psychometric testing, assesses your ability to think clearly and to determine if any mental conditions exist. • Psychological assessment: Psychological assessment is a series of tests conducted by a psychologist, to gather information about how people think, feel, behave and react. • Cognitive test: Cognitive test measures a person’s cognitive abilities— problem solving, reasoning, vocabulary, comprehension, and memory. • Educational testing: Educational testing is conducted to test how much an individual has progressed in learning a specific subject—like mathematics, reading comprehension—to identify any difficulties they may have had in it. • Neuropsychological tests: Neuropsychological tests analyse how an individual’s brain works, in order to identify any problems in its functioning. 5.8 LEARNING ACTIVITY 1. how does a psychologists confirm if the child is having mental retardation or specific learning disorder? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. Describe the ways in which the society can be made inclusive for children with mental retardation? ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 5.9 UNIT END QUESTIONS A. Descriptive Questions 80 CU IDOL SELF LEARNING MATERIAL (SLM)
Short Questions 1. What are four levels of intellectual disability 2. What are symptoms of intellectual disability 3. Explain importance of Cognitive Testing 4. Why might a cognitive assessment help child? 5. How is a cognitive assessment usually run? Long Questions 1. What Are Cognitive Ability Tests? 2. What are characteristics of Cognitive Ability Tests 3. Explain Interindividual Differences and Intraindividual Differences 4. Discuss Interpreting Poor Cognitive Test Performance 5. Explain broad categories of psychological tests: B. Multiple Choice Questions 1. _____________ also called neurocognitive testing or psychometric testing, assesses your ability to think clearly and to determine if any mental condition exist. a. Cognitive Testing b. Psychological Testing c. Behavioral Testing d. Specific-syndrome Testing 2. Children who are experiencing difficulty in school, for example, may undergo _______ or test for learning disabilities. a. Psychological assessment b. Entrance exam c. Aptitude Testing d. Behavioral Testing 3. All procedures and steps must be conducted with consistency and under the same environment to achieve the same testing performance from those being tested. a. Objectivity b. B. Test Norms c. Reliability d. Standardization 81 CU IDOL SELF LEARNING MATERIAL (SLM)
4. The term _____________ refers to an individual’s performance on tasks that have usually been prescribed beforehand. a. Sample of Behavior b. Seeing a psychologist c. Results of test d. Evaluation 5. Obtaining the same result after multiple testing. a. Consistency b. Reliability c. Validity d. Objectivity Answers 1-(a), 2-(c), 3-(d), 4-(a), 5-(b) 5.10 REFERENCES Textbook • 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. • Casler, K., Bickel, L., & Hackett, E. (2013). Separate but equal? A comparison of participants and data gathered via Amazon’s MTurk, social media, and face-to-face behavioral testing. Computers in Human Behavior. • Catalyst (2015). Quick take: Working parents. New York: Catalyst. • Chandler, J., & Shapiro, D. (2016). Conducting clinical research using crowdsourced convenience samples. Annual Review of Clinical Psychology. • Chorpita, B. F., Reise, S., Weisz, J. R., Grubbs, K., Becker, K. D., & Krull, J. L. (2010). Evaluation of the brief problem checklist: Child and caregiver interviews to measure clinical progress. Journal of Consulting and Clinical Psychology. 82 CU IDOL SELF LEARNING MATERIAL (SLM)
References: • Arnold, D. S., O'Leary, S. G., Wolff, L. S., & Acker, M. M. (1993). The Parenting Scale: A measure of dysfunctional parenting in discipline situations. Psychological Assessment. • Benson, M. J., Buehler, C., & Gerard, J. M. (2008). Interparental hostility and early adolescent problem behavior: Spillover via maternal acceptance, harshness, inconsistency, and intrusiveness. The Journal of Early Adolescence. • Bögels, S., & Phares, V. (2008). Fathers’ role in the etiology, prevention and treatment of child anxiety: A review and new model. Clinical Psychology Review. • Bureau of Labor Statistics (2015). Employment characteristics of families. The Economics Daily. U.S. Department of Labor. 83 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT –6 ATTENTION DEFICIT HYPER ACTIVITY DISORDERS- PART I Structure 6.0 LearningObjectives 6.1Introduction 6.2 Attention Disorder 6.3 DSM Criteria 6.4 ICD Criteria 6.5 Incidence 6.6 Prevalence 6.7 Summary 6.8 Keywords 6.9 Learning Activity 6.10 Unit End Questions 6.11 References 6.0 LEARNINGOBJECTIVES After learning this unit, you will be able to: • Explain the concept of attention deficit and hyperactivity disorder • Describe the criteria used for diagnosing attention deficit and hyperactivity disorder under DSM and ICD – 10 • Explain the incidence of attention deficit and hyperactivity disorder • Explain the prevalence of attention deficit and hyperactivity disorder 84 CU IDOL SELF LEARNING MATERIAL (SLM)
6.1 INTRODUCTION Behavioural disorders involve a pattern of disruptive behaviours in children that last for at least 6 months and cause problems in school, at home and in social situations. Behavioural disorders involve a pattern of disruptive behaviours in children that last for at least 6 months and cause problems in school, at home and in social situations. Nearly everyone shows some of these behaviours at times, but behaviour disorders are more serious. Behavioural disorders may involve: • Inattention • Hyperactivity • Impulsivity • Defiant behaviour • drug use • criminal activity Behavioural disorders include: • Attention Deficit Hyperactivity Disorder (ADHD) • Oppositional Defiant Disorder (ODD) • Conduct Disorder Danny, a handsome 9-year-old boy, was referred to us because of his diffi culties at school and at home. Danny had a great deal of energy and loved playing most sports, especially baseball. Academically, his work was adequate, although his teacher reported that his performance was diminishing and she believed he would do better if he paid more attention in class. Danny rarely spent more than a few minutes on a task without some interruption: He would get up out of his seat, rifle through his desk, or constantly ask questions. His peers were frustrated with him because he was equally impulsive during their interactions: He never finished a game, and in sports he tried to play all positions simultaneously. At home, Danny was considered a handful. His room was in a constant mess because he became engaged in a game or activity only to drop it and initiate something else. Danny’s parents reported that they often scolded him for not carrying out some task, although the reason seemed to be that he forgot what he was doing rather than that he deliberately tried to defy them. They also said that, out of their own frustration, they sometimes grabbed him by the shoulders and yelled, “Slow down!” because his hyperactivity drove them crazy. 85 CU IDOL SELF LEARNING MATERIAL (SLM)
6.2 ATTENTION DISORDER Attention-deficit/hyperactivity disorder (ADHD), often referred to as hyperactivity, is characterized by difficulties that interfere with effective task-oriented behavior in children - particularly impulsivity, excessive or exaggerated motor activity, such as aimless or haphazard running or fidgeting, and difficulties in sustaining attention. Children with ADHD are highly distractible and often fail to follow instructions or respond to demands placed on them. Perhaps as a result of their behavioral problems, children with ADHD are often lower in intelligence, usually about 7 to 15 IQ points below average. Children with ADHD also tend to talk incessantly and to be socially intrusive and immature. Recent research has shown that many children with ADHD show deficits on neuropsychological testing that are related to poor academic functioning. Children with ADHD generally have many social problems because of their impulsivity and overactivity. Hyperactive children usually have great difficulty in getting along with their parents because they do not obey rules. Their behavior problems also result in their being viewed negatively by their peers. In general, however, hyperactive children are not anxious, even though their overactivity, restlessness, and distractibility are frequently interpreted as indications of anxiety. They usually do poorly in school and often show specific learning disabilities such as difficulties in reading or in learning other basic school subjects. Hyperactive children also pose behavior problems in the elementary grades. The cause or causes of ADHD in children have been much debated. It still remains unclear to what extent the disorder results from environmental or biological factors. Recent research points to both genetic and social environmental precursors. Many researchers believe that biological factors such as genetic inheritance will turn out to be important precursors to the development of ADHD. 6.3 DSM CRITERIA DSM-5 Child Mental Disorder Classification The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) includes changes to some key disorders of childhood. Two new childhood mental disorders were added in the DSM-5: social communication disorder (or SCD) and disruptive mood dysregulation disorder (or DMDD). There were age-related diagnostic criteria changes for two other mental disorder categories particularly relevant to the definition of serious 86 CU IDOL SELF LEARNING MATERIAL (SLM)
emotional disturbance (SED): attention-deficit/hyperactivity disorder (ADHD) and post- traumatic stress disorder (PTSD). An ADHD diagnosis now requires symptoms to be present prior to the age of 12 (rather than 7, the age of onset from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM-IV]). PTSD includes a new subtype specifically for children younger than 6 years of age. New Childhood Mental Disorders Added to the DSM-5 Social (Pragmatic) Communication Disorder (SCD, under Neurodevelopmental Disorders) The DSM-5 communication disorders include a new condition for persistent difficulties in the social uses of verbal and nonverbal communication: social (pragmatic) communication disorder or SCD. SCD is characterized by a primary difficulty with pragmatics—the social use of language or communication—resulting in functional limitations in effective communication, social participation, development of social relationships, and academic achievement. Symptoms of SCD include difficulties in the acquisition and use of spoken language and inappropriate responses in conversation. Although diagnosis is rare for children younger than 4 years old, symptoms must be present in early childhood even if not recognized until later. Individuals with SCD have never had effective social communication. This new disorder cannot be diagnosed if social communication deficits are part of the two main characteristics of the new autism spectrum disorder (ASD). ASD is characterized by (1) deficits in social communication and social interaction and (2) restricted repetitive behaviours, interests, and activities (RRBs). Because both components are required for an ASD diagnosis, SCD is diagnosed if no RRBs are present or there is no past history of RRBs. As described by the American Psychiatric Association (APA), the symptoms of some patients diagnosed with DSM-IV pervasive developmental disorder not otherwise specified (PDD- NOS) may meet the DSM-5 criteria for SCD (American Psychiatric Association, 2013c) Disruptive Mood Dysregulation Disorder (or DMDD) (under Depressive Disorders) DMDD is a new addition to DSM-5 that aims to combine bipolar disorder that first appears in childhood with oppositional behaviours (Axelson, 2013). DMDD is characterized by severe and recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation. These occur, on average, three or more times each week for 1 year or more (see Table 6 for a description of DSM-5 DMDD diagnostic criteria). The key feature of DMDD is chronic irritability that is present in between episodes of anger or temper tantrums. A diagnosis requires symptoms to be present in at least two settings (at home, at school, or with peers) for 12 or more months, and symptoms must be severe in at least one of these settings. Onset of DMDD must occur before age 10, and a child must be at least 6 years old to receive a diagnosis of DMDD. The main driver behind the conceptualization of DMDD was concern 87 CU IDOL SELF LEARNING MATERIAL (SLM)
that diagnosis of bipolar disorder was being applied inconsistently across clinicians because of the disagreement about how to classify irritability in the DSM-IV. In addition, chronic childhood irritability has not been shown to predict later onset of bipolar disorder, suggesting that irritability may be best contained within a separate mood dysregulation category (Leigh, Smith, Milavic, & Stringaris, 2012). Age-Related Diagnostic Criteria Changes to Mental Disorders in the DSM-5 Attention-Deficit/Hyperactivity Disorder (ADHD, under Neurodevelopmental Disorders) Description. ADHD is a chronic neurodevelopmental disorder according to DSM-5 that is characterized by a persistent and pervasive pattern of inattention and/or hyperactivity- impulsivity that interferes with functioning or development. ADHD was placed in the neurodevelopmental disorders chapter to reflect brain developmental correlates with ADHD and the DSM-5 decision to eliminate the DSM-IV chapter that includes all diagnoses usually first made in infancy, childhood, or adolescence. The diagnostic criteria for ADHD in DSM-5 are similar to those in DSM-IV. The same 18 symptoms noted in the DSM-IV are used, and continue to be divided into two symptom domains (inattention and hyperactivity/impulsivity), of which at least six symptoms in one domain are required for diagnosis. The majority of ADHD criteria changes were geared toward improving detection of ADHD among adults. However, one change may have relevance to the estimation of SED: the onset criterion has been changed from “symptoms that caused impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12.” Post-traumatic Stress Disorder (PTSD, under Trauma- and Stressor-Related Disorders) DSM-5 criteria for PTSD differ significantly from those in DSM-IV for children and adolescents. The arousal cluster will now include irritability or angry outbursts and reckless behaviours. PTSD in the DSM-5 is more developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Separate criteria have been added for children aged 6 years or younger. These criteria have been designed to be more developmentally appropriate for young children by including caregiver-child–related losses as a main source of trauma and focus on behaviourally expressed PTSD symptoms. According to the DSM-5, PTSD can develop at any age after 1 year of age. Clinical re-experiencing can vary according to developmental stage, with young children having frightening dreams not specific to the trauma. Young children are more likely 88 CU IDOL SELF LEARNING MATERIAL (SLM)
to express symptoms through play, and they may lack fearful reactions at the time of exposure or during re-experiencing phenomena. It is also noted that parents may report a wide range of emotional or behavioural changes, including a focus on imagined interventions in their play. The preschool subtype excludes symptoms such as negative self-beliefs and blame, which are dependent on the ability to verbalize cognitive constructs and complex emotional states. The developmental preschool PTSD subtype lowers the Cluster C threshold from three to one symptom. The new criteria were based on Schering and colleagues’ proposed alternative algorithm, which was derived from studies performed in young children using modified DSM-IV PTSD criteria (Scheeringa, Zeanah, & Cohen, 2011). These studies showed that children’s loss of a parent/caregiver through death, abandonment, foster care placement, and other main caregiver-related events can be experienced as traumatic events. Given young children’s need for a parent/child relationship to feel safe, caregiver loss may be perceived as a serious threat to a child’s own safety and psychological/physical survival, which is part of the criteria defining a traumatic event. The relevance of caregiver loss as a source of trauma also applies among older children, since the loss of parents/caregivers is more associated with trauma than high-magnitude events, like a motor vehicle crash. One report of children in foster care found that the most common trauma identified by children aged 6 to 12 to their therapists was “placement in foster care” (Scheeringa et al., 2011). Table 8 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for PTSD. Changes to Other Mental Disorders with Minor to No Implication for SED Prevalence Estimates Several minor changes have been made to other mental disorders sometimes assessed in psychiatric epidemiological studies of children and adolescents. These changes are summarized below, but are largely expected to have little to no impact on SED estimates either because of minimal DSM-5 changes or their very low base rate in children and adolescents. Major Depressive Episode/Disorder (under Depressive Disorders) A major depressive episode (MDE) is characterized by the combination of depressed mood or loss of interest or pleasure lasting for most of the day, nearly every day for 2 weeks or more (American Psychiatric Association, 2013b). The primary symptom (depressed mood or loss of interest/pleasure) must be accompanied by four or more additional symptoms and must cause clinically significant distress or impairment. The primary difference between MDE and 89 CU IDOL SELF LEARNING MATERIAL (SLM)
MDD is that MDD includes all of the criteria for MDE as well as MDE exclusionary criteria for mania and hypomania. Changes in the MDE/MDD criteria from DSM-IV to DSM-5 have been minimal. There have been some changes in the way that “mixed states” are described for diagnostic coding (mixed states now fall under the specifier “with mixed features”). In addition, the examples provided to describe a depressed mood have been expanded in DSM-5 from “e.g., feels sad or empty” (American Psychiatric Association, 1994, p. 327) to “e.g., feels sad, empty, and hopeless” (American Psychiatric Association, 2013b, p. 160). This change in wording has not received much attention (Uher, Payne, Pavlova, & Perlis, 2013). However, the wording change has the possibility of increasing the prevalence of MDE/MDD if survey respondents and clinicians were not already equating feeling hopeless with feeling sad, empty, or depressed. The more substantive change is that the formal bereavement exclusion for MDE/MDD in DSM-IV has been removed from DSM-5. The bereavement exclusion criterion has been a longstanding feature of MDE/MDD, designed to allow clinicians to distinguish between normal grieving and a mental illness (Fox & Jones, 2013). It has been replaced with text noting that MDE/MDD should not be confused with normal and appropriate grief but that the presence of bereavement is not prohibitive of an MDE/MDD diagnosis. All MDE/MDD changes are expected to have minimal impact on the estimation of SED in children and adolescents. 6.4 ICD 10 CRITERIA The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria F10-F19 Mental and behavioural disorders due to psychoactive substance use F10. - Mental and behavioural disorders due to use of alcohol F11. - Mental and behavioural disorders due to use of opioids F12. - Mental and behavioural disorders due to use of cannabinoids F13. - Mental and behavioural disorders due to use of sedatives and hypnotics F14. - Mental and behavioural disorders due to use of cocaine F15. - Mental and behavioural disorders due to use of other stimulants, including caffeine F16. - Mental and behavioural disorders due to use of hallucinogens 90 CU IDOL SELF LEARNING MATERIAL (SLM)
F17. - Mental and behavioural disorders due to use of tobacco F18. - Mental and behavioural disorders due to use of volatile solvents F19. - Mental and behavioural disorders due to multiple drug use and use of other psychoactive substances F1x.0 Intoxication 6.5 INCIDENCE Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, causing distress and problems getting through the day.1 Among the more common mental disorders that can be diagnosed in childhood are attention-deficit/hyperactivity disorder (ADHD), anxiety, and behaviour disorders. There are different ways to estimate which children have difficulties with mental health. CDC uses surveys, like the National Survey of Children’s Health, to understand which children have diagnosed mental disorders and whether they received treatment. In this type of survey, parents report on the diagnoses their child has received from a healthcare provider. Learn more facts about children’s mental disorders below. Facts about mental disorders in U.S. children • ADHD, behaviour problems, anxiety, and depression are the most commonly diagnosed mental disorders in children • 9.4% of children aged 2-17 years (approximately 6.1 million) have received an ADHD diagnosis. • 7.4% of children aged 3-17 years (approximately 4.5 million) have a diagnosed behaviour problem. • 7.1% of children aged 3-17 years (approximately 4.4 million) have diagnosed anxiety. • 3.2% of children aged 3-17 years (approximately 1.9 million) have diagnosed depression. • Some of these conditions commonly occur together. For example: • Having another disorder is most common in children with depression: about 3 in 4 children aged 3-17 years with depression also have anxiety (73.8%) and almost 1 in 2 have behaviour problems (47.2%). • For children aged 3-17 years with anxiety, more than 1 in 3 also have behaviour problems (37.9%) and about 1 in 3 also have depression (32.3%). 91 CU IDOL SELF LEARNING MATERIAL (SLM)
• For children aged 3-17 years with behaviour problems, more than 1 in 3 also have anxiety (36.6%) and about 1 in 5 also have depression (20.3%). • Depression and anxiety have increased over time • “Ever having been diagnosed with either anxiety or depression” among children aged 6–17 years increased from 5.4% in 2003 to 8% in 2007 and to 8.4% in 2011–2012. • “Ever having been diagnosed with anxiety” increased from 5.5% in 2007 to 6.4% in 2011–2012. • “Ever having been diagnosed with depression” did not change between 2007 (4.7%) and 2011-2012 (4.9%). • Treatment rates vary among different mental disorders • Nearly 8 in 10 children (78.1%) aged 3-17 years with depression received treatment. • 6 in 10 children (59.3%) aged 3-17 years with anxiety received treatment. • More than 5 in 10 children (53.5%) aged 3-17 years with behaviour disorders received treatment. • Mental, behavioural, and developmental disorders begin in early childhood • 1 in 6 U.S. children aged 2–8 years (17.4%) had a diagnosed mental, behavioural, or developmental disorder. • Rates of mental disorders change with age • Diagnoses of depression and anxiety are more common with increased age. • Behaviour problems are more common among children aged 6–11 years than children younger or older. 92 CU IDOL SELF LEARNING MATERIAL (SLM)
Figure 6.1 Depression, Anxiety , Behaviour Disorders by Age • Many family, community, and healthcare factors are related to children’s mental health • Among children aged 2-8 years, boys were more likely than girls to have a mental, behavioural, or developmental disorder. • Among children living below 100% of the federal poverty level, more than 1 in 5 (22%) had a mental, behavioural, or developmental disorder. • Age and poverty level affected the likelihood of children receiving treatment for anxiety, depression, or behaviour problems. Note: The rates reported on this page are estimates based on parent report, using nationally representative surveys. This method has several limitations. It is not known to what extent children receive these diagnoses accurately. Estimates based on parent-reported diagnoses may match those based on medical records, but children may also have mental disorders that have not been diagnosed. 93 CU IDOL SELF LEARNING MATERIAL (SLM)
6.6 PREVALENCE The term “serious emotional disturbance” refers to a diagnosed mental health problem that substantially disrupts a child's ability to function socially, academically, and emotionally. It is not a formal DSM-IV diagnosis, but rather an administrative term used by state and federal agencies to identify a population of children who have significant emotional and behavioural problems and who have a high need for services. The official definition of children who have serious emotional disturbance adopted by the Substance Abuse and Mental Health Services Administration (SAMHSA) refers to “persons from birth up to age 18 who currently or at any time during the past year had a diagnosable mental, behavioural, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the DSM-III-R, and that resulted in functional impairment which substantially interferes with or limits the child's role or functioning in family, school, or community activities (SAMHSA, 1993, this definition is also used with newer diagnostic systems such as DSM-IV). The term does not signify any particular diagnosis per se; rather, it is a legal term that triggers a host of mandated services to meet the needs of these children.”12 The epidemiology of mental disorders varies according to which definition of “caseness” is used. For this article, “case” is an epidemiological term for someone who meets the criteria for a disease or disorder, or who is at-risk. Efforts are underway in the epidemiology of mental disorders to establish an agreed-upon minimum level of functional limitation required to establish a “case.” It is sometimes difficult to determine when a set of symptoms proceeds to the level of a mental disorder. In many instances, symptoms are not of sufficient severity or duration in certain domains to meet criteria for a disorder and that may differ from culture to culture. The underutilization of supports and services by families of children with emotional/behavioural disturbances also contributes to underestimated prevalence. Families may underutilize supports and services because they are unsure if their child's behaviour is sufficiently different from other children to require help. They may realize the child's behaviour needs professional attention, but may avoid treatment because it is painful or frightening, or they may regard it as a personal failure. They may fear their child will be inappropriately labelled, or they may be experiencing anger about the blame that continues to be placed on families with emotionally disturbed children. The perceived stigma of mental health care can also interfere with help-seeking. All of these reasons contribute to low numbers being reported to the city, state, and/or federal government. The underreporting problem is exacerbated in studies of children, where we struggle with the issues associated with combining data from multiple informants, some of whom (the parents) may wish to avoid blame (real or perceived) for the problems of their children. Health care 94 CU IDOL SELF LEARNING MATERIAL (SLM)
professionals are hesitant to assign diagnosis that may be stigmatizing.12 The underreporting of childhood emotional disturbances in rural areas and from the private sector (private schools and private physicians) has also been well documented. Another factor in the underestimation of emotional/behavioural disorders in young children is the lack of diagnosis due to lack of medical care, resulting from the lack of follow-up with a treatment plan for the family, and barriers such as medical care availability, poverty that affects transportation, or variations in types of medical care available. Parents/guardians are also often told their children will “grow out of it.” This presents problems because when they do not pursue treatment, the problem is not reported. The field of infant mental health is relatively new and there are few people trained in relationship-based mental health promotion, prevention, and intervention practices. There are even fewer trained to understand how culture can be used as a resource in working with families. Furthermore, there is very little public understanding of the critical importance of early parent/child relationships and how they influence child development. Another challenge is the lack of standard measures of “need for treatment” (symptoms that require intervention), particularly those that are culturally appropriate. Such measures are at the heart of a public health approach to mental health. Other studies report paediatricians receive relatively little training in child psychopathology and child development, leaving them ill-prepared and uncomfortable when addressing mental health problems. A recent study indicates that a substantial number of psychosocial problems raised during paediatric appointments are not addressed.16 In high-volume practices, this problem may be exacerbated by the relatively little time devoted to individual patients. It would be impossible for some paediatricians to complete an adequate mental health screening during a routine visit, as it would probably take 45–60 minutes to gather information about social/emotional development and other relevant issues. Another factor that affects prevalence to some unknown degree is the underestimation of children counted by the U.S. Census. After each recent Census, the Census Bureau has undertaken a thorough assessment to determine the quality of the data collected (including post-enumeration surveys and demographic analysis). Surprisingly, the assessments have shown that children are missed more often than any other group. The Census Bureau estimates that more than 2 million children were missed in the 1990 Census, accounting for more than half the total net undercounted population.17 The estimated undercount rate for children below age 10 doubled, increasing from 2.0% in 1980 to 4.1% in 1990. (The 2000 undercount figures have not been published.) 95 CU IDOL SELF LEARNING MATERIAL (SLM)
It is noteworthy that the undercount rates for children are often high in the states where the child poverty rate is high, underscoring the link between living in poverty and being missed in the Census. For example, large cities have high poverty rates and high undercount rates among children.17 Most experts believe that this reflects the high undercount rate for people living in the moderately distressed inner-city neighbourhoods. Undercount rates are even higher for minority children in many big cities. Many impoverished rural areas also experience high undercount rates. The high undercount rate for children means significant numbers of kids most in need of assistance are not even included in the data used to distribute public funds for supports and services. Estimates of the number of children suffering from serious emotional/behavioural problems vary significantly depending on the study cited. A literature review revealed estimates ranging from 5% to 26%: • 7% (15% mild) by Richman et al. (1975)18 • 11% by Earls (1980)19 • 11.8% by Gould et al. (1980)20 • 5% by Vikan (1985)21 (he considered socio-demographic variables an explanation for the low prevalence) • 26% by Verhulst et al. (1985)22 • 14.1% by Cornely and Bromet (1986)23 • 16.5% by Offord et al. (1987)24 • 9% to 13% by Friedman et al. (1996 and 1998)25,26 • 16% to 20% by Anderson et al. (1987),27 Costello et al. (1988a),28 Bird et al. (1989),29 Costello (1989),30 Velez et al.(1989),31 Brandenburg et al. (1990),13 Esser et al. (1990),32 McGee et al. (1990),33 and • 3% to 21.4% by Lavigne et al. (1996)34 The variations in estimated prevalence might be explained in part by the varying reasons the studies were conducted—for example, developmental perspectives, patterns of symptoms, and studies of prevalence—and for what purposes their estimates would be used. The methodology for selecting the study populations also varied among the studies. The studies applied numerous diagnoses of disorder obtained from many types of reports and measures. 96 CU IDOL SELF LEARNING MATERIAL (SLM)
They incorporated variations of reports based on structured interviews from different informants and data combining two or more sources. And their uses of “functional impairment” also varied. Studies reflecting higher prevalence rates represent a more inclusive cut-off point, while the lower prevalence rates tended to result from more conservative, less inclusive cut-off points. While it is impossible to compare scores of variant measures from different instruments used, it seems reasonable to conclude that a score of one (1) internal impairment may not be a good approximation of the Centre for Mental Health Services/Office of Mental Health concept of “substantial” impairment. Such an inclusive cut- off may inflate estimates. Report prevalence in ranges Prevalence should be expressed in ranges, allowing treatment for children before they are “labelled” as emotionally disturbed. This would also allow for ranges of minimum functional limitation, rather than just one cut-off point. Expressing prevalence in ranges associated with minimum functional limitations would also address the need for variations for different age groups, racial and ethnic groups, genders, and socioeconomic groups. Based on our analysis of the findings from the studies reviewed, the sampling, measurement, overall methodological considerations, and levels of minimum functional impairment, we estimate the prevalence of emotional/behavioural disturbance in children 0–5 years of age is in the range of 9.5% to 14.2%. 6.7 SUMMARY • Attention deficit hyperactivity disorder (ADHD) is a common neurobehavioral disorder, with about 11 percent of children ages 4 through 17 having been diagnosed. • In the United States, there are significant geographical variations in the rate of diagnosis and treatment, and the prevalence has increased over time. • The most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5)has revised the diagnostic criteria for ADHD. To be diagnosed with ADHD, a child or younger adolescent needs to meet six out of nine possible inattentive symptoms (such as failing to give close attention to details or being easily distracted) and/or six out of nine possible hyperactivity/impulsivity symptoms (such as being “on the go” or difficulty waiting their turn). • Also, symptoms need to be present for at least 6 months, occur in at least two different settings, be present before 12 years of age, and not be better explained by another disorder. • For older adolescents and adults, the number of required symptoms per category is reduced to five out of nine. 97 CU IDOL SELF LEARNING MATERIAL (SLM)
• ADHD has three presentations: (1) predominantly inattentive, (2) predominantly hyperactive/impulsive, and (3) combined, based on how many symptoms in each diagnostic category an individual meets. • ADHD that does not clearly fall into these categories can be referred to as ADHD-Not Otherwise Specified. Psychostimulants can be effective in reducing distractibility, improving sustained attention, reducing impulsive behaviors, and improving activity level. • Nonpharmacologic therapies (e.g., behavioral therapy, psychotherapy, psychosocial interventions, and complementary and alternative medicine interventions), either alone or in combination with medication management, could potentially address core symptoms of ADHD or the long-term impairments that are associated with the disorder. • Understanding the role of nonpharmacologic therapies can be challenging because they encompass a broad range of approaches to care, ranging from highly structured behavioral interventions to complementary medicines. • Despite growing research on treatment for ADHD and awareness of the condition’s course of illness, important questions remain about ADHD diagnosis and management. Ensuring appropriate diagnosis and avoidance of misdiagnosis is a key concern for clinical practice. • For treatment, Key Questions include how to best tailor therapy to individuals based on their characteristics (e.g., age, sex, ADHD symptoms, comorbid conditions, prior and current therapy) and how to efficiently and effectively monitor individuals with ADHD over time 6.8 KEYWORDS • Attention-deficit/hyperactivity disorder (ADHD) - a behavior disorder, usually first diagnosed in childhood, that is characterized by inattention, impulsivity, and, in some cases, hyperactivity. • Anxiety. A general feeling of apprehension about possible danger. • Anxiety disorder. An unrealistic, irrational fear or anxiety of disabling intensity. DSM-IV-TR recognizes seven types of anxiety disorders: phobic disorders (specific or social), panic disorder (with or without agoraphobia), generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. • 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. 98 CU IDOL SELF LEARNING MATERIAL (SLM)
6.9 LEARNING ACTIVITY 1. Some children are active. But not all off them have ADHD. Elaborate. ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 2. With awareness, the cases of children with ADHD are increasing. According to you is this a positive or a negative sign? Explain your reasons. ---------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------- 6.10 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What are causes of ADHD (Attention Deficit Hyperactivity Disorder)? 2. What are the symptoms of ADHD? 3. What is the difference between ADD (Attention Deficit Disorder) vs. ADHD? 4. Diagnosing ADHD 5. What are ADHD treatment options? Long Questions 1. How is behaviour therapy done in schools? 2. How does behaviour therapy for ADHD work for adults? 3. What Is CBT (Cognitive Behavioural Therapy)? 4. How Does CBT Help People with ADHD? 5. What is Disruptive Mood Dysregulation Disorder B. Multiple Choice Questions 1. Behavioral disorders may involve: a. Inattention b. Hyperactivity c. Criminal Activity d. All of these 99 CU IDOL SELF LEARNING MATERIAL (SLM)
2. Children with this form of ADHD are not overly active. a. Combined Inattentive b. Hyperactivity c. Inattentive d. Impulsivity 3. Also known as behavior modification. Involves reinforcing desired behaviors through rewards and praise and decreasing problem behavior by setting limits and consequences. a. Behavioral therapy b. Cognitive Behavioral therapy c. Cognitive Therapy d. Medication Therapy 4. Is a new DSM-5 addition that is characterized by severe and recurrent temper outburst that are grossly out of proportion in intensity or duration to the situation. a. Disruptive Disorder b. Disruptive Mood Dysregulation Disorder c. Social Communication Disorder d. Child Mental Disorder 5. This refers to a diagnosed mental health person that substantially disrupts a child’s ability to function socially, academically, and emotionally. a. Caseness b. Diagnostic system c. Serious emotional disturbance d. Mental Disorder Answers 1-(d), 2-(c), 3-(a), 4-(b), 5-(c) 6.11 REFERENCES Textbook • 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.. 100 CU IDOL SELF LEARNING MATERIAL (SLM)
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