CU-MA-PSY-SEM-IV-Child Psychopathology-II

MASTER OF ARTS IN PSYCHOLOGY SEMESTER IV CHILD PSYCHOPATHOLOGY-II

CHANDIGARH UNIVERSITY Institute of Distance and Online Learning SLM Development Committee Prof. (Dr.) H.B. Raghvendra Vice- Chancellor, Chandigarh University, Gharuan, Punjab:Chairperson Prof. (Dr.) S.S. Sehgal Registrar Prof. (Dr.) B. Priestly Shan Dean of Academic Affairs Dr. Nitya Prakash Director – IDOL Dr. Gurpreet Singh Associate Director –IDOL Advisors& Members of CIQA –IDOL Prof. (Dr.) Bharat Bhushan, Director – IGNOU Prof. (Dr.) Majulika Srivastava, Director – CIQA, IGNOU Editorial Committee Prof. (Dr) Nilesh Arora Dr. Ashita Chadha University School of Business University Institute of Liberal Arts Dr. Inderpreet Kaur Prof. Manish University Institute of Teacher Training & University Institute of Tourism & Hotel Management Research Dr. Manisha Malhotra Dr. Nitin Pathak University Institute of Computing University School of Business © No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any formor by any means, electronic, mechanical, photocopying, recording and/or otherwise without the prior written permission of the authors and the publisher. SLM SPECIALLY PREPARED FOR CU IDOL STUDENTS 2 CU IDOL SELF LEARNING MATERIAL (SLM)

First Published in 2021 All rights reserved. No Part of this book may be reproduced or transmitted, in any form or by any means, without permission in writing from Chandigarh University. Any person who does any unauthorized act in relation to this book may be liable to criminal prosecution and civil claims for damages. This book is meant for educational and learning purpose. The authors of the book has/have taken all reasonable care to ensure that the contents of the book do not violate any existing copyright or other intellectual property rights of any person in any manner whatsoever. In the event, Authors has/ have been unable to track any source and if any copyright has been inadvertently infringed, please notify the publisher in writing for Corrective action. 3 CU IDOL SELF LEARNING MATERIAL (SLM)

CONTENT Unit 1 – Autism Part I ........................................................................................................... 5 Unit 2 – Autism Part II........................................................................................................ 20 Unit 3 – SCHIZOPHRENIA PART I .................................................................................. 33 Unit 4 – Schizophrenia Part II ............................................................................................. 49 Unit 5 – Communication Disorder Part I ............................................................................. 70 Unit 6 – Communication Disorder Part II ............................................................................ 81 Unit 7 – Learning Disorder Part I ........................................................................................ 98 Unit 8 – Learning Disorder Part II ..................................................................................... 110 Unit 9 – Feeding Disorder Part I........................................................................................ 127 Unit 10 – Feeding Disorder Part II .................................................................................... 140 Unit 11 – Eating Disorder Part I ........................................................................................ 155 Unit 12 – Eating Disorder Part II....................................................................................... 177 Unit 13 – Elimination Disorder Part I ................................................................................ 194 Unit 14 – Elimination Disorder Part II............................................................................... 207 4 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 1 – AUTISM PART I STRUCTURE 1.0 Learning Objectives 1.1 Introduction 1.2 Developmental Disorders 1.3 Autism 1.4 DSM Criteria 1.5 ICD 10 1.6 Causes of Autism 1.7 Summary 1.8 Key Words 1.9 Learning Activity 1.10 Unit End Questions 1.11 References 1.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Describe developmental disorders  Explain the nature and symptoms of Autism  Explain the DSM criteria of Autism  Explain the ICD 10 criteria of Autism  Describe the causes of Autism 1.1 INTRODUCTION Abhi is eight year old child. Taking him to school and making him stay in the school is a big task for his parents. His father has to carry a pack of glucose biscuits with him when taking Abhi to school. He keeps feeding Abhi those biscuits to coax him to enter the school. The problems don’t end there. Once he is in school, he is not able to sit patiently. For a whole hour after his father has left, he cries in a high pitch voice and screams continuously. He does not response to his teachers or any other school staff. He stays by himself most of the time. He does not interact or mingle with his classmates. The teachers have not seen him interacting with anyone in the school. He likes to be by himself. He does not participate in any of the activities of the school or group activities. Taru is also eight years old just like Abhi. However when compared to Abhi who does not communicate with words and cries or screams most of the times, Taru behaves in a bit different manner. She likes to study about different human races. Her favourite activity is to talk about the different human races that she must have read. She talks in detail about them 5 CU IDOL SELF LEARNING MATERIAL (SLM)

and is even aware of technical terms like Mongoloid, Negroid, Caucasian and so on. She has specific interests and is deeply engaged in her favourite activity. Her favourite singer is Mukesh and she talks about her them with people around her all the times. All the conversations revolve around them and even if the discussion starts with an unrelated topic, it somehow diverts to the areas that she likes to talk about. When it comes to other activities, she does not show any genuine interest in them. She is not able to converse about day to day topics like what she did on school or what was the last meal she had. She is good in her studies but does not gel well in social situations. Hence; she ends up getting bullied by her classmates. She is also teased by them sometimes. Since she is not able to handle the stress of interacting with everyone in school, her parents are even considering to get her drop out of the school. Chandru is different from Abhi or Taru. He is a young adult working in a nationalized bank. He has completed his post-graduation and has good work experience after working in different organizations in different parts of the country. He looks quite handsome and is well dressed. He is able to carry out his responsibilities at his workplace. He is married and has two children. They are also studying in prestigious public schools. However, his colleagues have noticed that his dressing sense is kind of old fashioned. They also describe him as acting weird sometimes. They feel that he is very rigid and does not bend or compromise. His wife says that he is a good husband and a responsible father but sometimes eccentric. Abhi, Taru and Chandru were all diagnosed with autism spectrum disorder at some point in their lives. However, when we look into their cases, we understand that there are stark differences in how their symptoms manifest into their behaviours. All three of them have very different forms of autism. This means that, autism affects people in strikingly different ways despite the similarities in the core impairments. However, in each individual who has autism, the symptoms of autism vary, in severity and expression. In this unit, we are going to look into the developmental disorders or pervasive developmental disorders as we all mention them. This and the next unit are dedicated to Autism spectrum disorder. In the first unit we will be introduced to the broad spectrum of autism. We will look in to the diagnostic criteria provided by Diagnostic and Statistical Manual (V) and International Classification of Disorders (ICD) that help the clinicians to diagnose a person with autism. Following which we will look into the causes of autism, which can be divided into genetic and neurological influences. In the next unit, we will look into the types of Autism Spectrum Disorders. We will also look into the incidence and prevalence of Autism Spectrum Disorders. And then we will look into the process of assessment used to diagnose a child with Autism Spectrum Disorders. Finally we will try and understand the prognosis or the natural course of Autism Spectrum Disorders and the pharmacological and non-pharmacological treatment available for the same. 6 CU IDOL SELF LEARNING MATERIAL (SLM)

1.2 DEVELOPMENTAL DISORDERS Developmental disabilities include limitations in function resulting fromdisorders of the developing nervous system. The limitations present themselves either during theinfancy or in childhood. This is the time when we see maximum development in the child be it physical, cognitive or academic. Sometimes the child is able to cope up or catch up to others as the time progresses. However, there may be instances, when the child experiences developmental delay in attaining significant milestones related to developmental tasks. There may be case wherein, there may be a lack offunction in one or multiple areas. These primarily include cognition or cognitive processes, motor performance,sense of vision, auditory senses and speech and language, and behavior. The delays in milestones or limitations may be seen in varying degrees. Moreover, the causative factors behindmost of the neurological and psychiatricdisorders which are not typically described as developmental disabilities can also be tracedto early neurological development. For many of the disorders discussed in subsequentchapters—namely epilepsy, depression, and schizophrenia—evidence suggestssuch a cause-and-effect relationship. As clinicians it is seen that the symptoms of developmental disorders and the way they present in the behaviours and abilities if children often vary in their severity. We have already seen in the previous section of the unit, that three people can have the same diagnosis; but the problems faced by them and the complaints of their family members or colleagues can be different for each of them. In the same manner we must note that some symptoms may be specific to a particular area of development or a specific area of function and the developmental limitations may be restricted to that aspect only. However, it is quite interesting to note that children with developmental disabilities may also be affected in multiple areas of functioning. Since the nature of brain in such that the extent ofbrain impairment or increased susceptibility to other causes of disability (e.g.,malnutrition, trauma, infection) among children with a single disability. Cognitive disabilities in children can be seen in the form of mental retardation or specificlearning disabilities. When children have subnormal levels of intelligence in the form of intelligence quotient or IQ, we say that they have mental retardation. On the other hand, when we see that a child has normal levels of intelligence but have problems in special academic areas, we can conclude that they have specific learning disabilities. Grades of mental retardation are typically defined in terms of IQ. The levels of functioning and adaptation depend on the level of intelligence quotient. When the IQ of a child is between 50 and 70, we say that the child has mild mental retardation. Children with mild mental retardation are the most common. The manifestation is seen in the form of limitations inacademic performance. This means that they have somewhat limited vocationalopportunities. Adults with mild mental retardation are able to lead typical independent lives. 7 CU IDOL SELF LEARNING MATERIAL (SLM)

When the IQ of a child is between 35 and 50, we say that the child has moderate mental retardation. Furthermore, when the IQ of a child is between 20 and 35, we say that the child has severe mental retardation. Moreover, when the IQ of a child is less than 20, we say that the child has profound mental retardation. Children with moderate mental retardation, severe mental retardation or profound mental retardation are more likely to have multiple disabilities. These disabilities can be seen in the form of impairment in vision, hearing impairment, motor disabilities,and/or seizure in addition to cognitive disability. They and to be dependent on others forbasic needs throughout their lives.In contrast, specific learning disabilities result not from global intellectualdeficit, but from impairments in one or more of the specific “processes of speech,language, reading, spelling, writing or arithmetic resulting from possible cerebraldysfunction.” Children with specific learning disabilities are usually identifiedas such only after entering school, where a significant discrepancy is noted betweentheir achievements in specific domains and their overall abilities. With specialeducational accommodations, these children may learn to overcome their limitationsand demonstrate normal or even superior levels of achievement.Developmental disabilities impose enormous personal, social, and economiccosts because of their early onset and the lifetime of dependence that often ensues. Children with intellectual or learning disabilities more so often have limited educational opportunities. Hence, when theygrow older, the employment options available to them are also limited, thus affecting their productivity, and quality of life. Furthermore, thecosts of developmental disabilities are difficult to quantify in settings where relevantdata and services are lacking. As a result, in low-income countries today, wheremore than 80 percent of the world's children are born, the magnitude of the impactsof developmental disabilities on individuals, families, societies, and economicdevelopment remains largely unrecognized and has yet to be addressed from apolicy perspective. People with pervasive developmental disorders all experience problems with language, socialization, and cognition. The word pervasive means that these problems are not relatively minor but significantly affect individuals throughout their lives. Included under the heading of pervasive developmental disorders are autistic disorder (or autism), Asperger’s disorder, Rett’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. 1.3 AUTISM Autistic disorder (autism) is a childhood disorder characterized by significant impairment in social interactions and communication and by restricted patterns of behavior, interest, and activities (Durand, in press-a). Individuals with this disorder have a puzzling array of symptoms. Case of Amy 8 CU IDOL SELF LEARNING MATERIAL (SLM)

Amy, 3 years old, spends much of her day picking up pieces of lint. She drops the lint in the air and then watches intently as it falls to the floor. She also licks the back of her hands and stares at the saliva. She hasn’t spoken yet and can’t feed or dress herself. Several times a day she screams so loudly that the neighbors at first thought she was being abused. She doesn’t seem to be interested in her mother’s love and affection but will take her mother’s hand to lead her to the refrigerator. Amy likes to eat butter—whole pats of it, several at a time. Her mother uses the pats of butter that you get at some restaurants to help Amy learn and to keep her well-behaved. If Amy helps with dressing herself, or if she sits quietly for several minutes, her mother gives her some butter. Amy’s mother knows that the butter isn’t good for her, but it is the only thing that seems to get through to the child. The family’s pediatrician has been concerned about Amy’s developmental delays for some time and has recently suggested that she be evaluated by specialists. The pediatrician thinks Amy may have autism and the child and her family will probably need extensive support. 1.3.1 Clinical Description of Autism Autistic disorder (autism) is a childhood disorder characterized by significant impairment in social interactions and communication and by restricted patterns of behavior, interest, and activities (Durand, in press-a). Individuals with this disorder have a puzzlingarray of symptoms. Impairment in Social Interactions One of the defining characteristics of people with autistic disorder is that they do not develop the types of social relationships expected for their age. Amy never made friends among her peers and often limited her contact with adults to using them as tools—for example, taking the adult’s hand to reach for something she wanted. For young children, the signs of social problems usually include a failure to engage in skills such as joint attention. When sitting with a parent in front of a favorite toy, young children will typically look back and forth between the parent and the toy, smiling, in an attempt to engage the parent with the toy. However, this skill in joint attention is noticeably absent in children with autism. Research using sophisticated eye-tracking technology shows how this social awareness problem evolves as the children grow older. In one study, scientists showed an adult man with autism scenes from some movies and compared how he looked at social scenes with how a man without autism did so. This research suggests that people with autism—for reasons not yet fully understood—may not be interested in social situations and therefore may not enjoy meaningful relationships with others or have the ability to develop them. Impairment in Communication 9 CU IDOL SELF LEARNING MATERIAL (SLM)

People with autism nearly always have severe problems with communicating. About one- third never acquire speech. In those with some speech, much of their communication is unusual. Some repeat the speech of others, a pattern called echolalia we referred to earlier as a sign of delayed speech development. If you say, “My name is Eileen, what’s yours?” they will repeat all or part of what you said: “Eileen, what’s yours?” And often, not only are your words repeated, but so is your intonation. Some people with autism who can speak are unable or unwilling to carry on conversations with others. Restricted Behavior, Interests, and Activities The more striking characteristics of autism include restricted patterns of behavior, interests, and activities. Amy appeared to like things to stay the same: She became extremely upset if even a small change was introduced (such as moving her toys in her room). This intense preference for the status quo has been called maintenance of sameness. Often, people with autism spend countless hours in stereotyped and ritualistic behaviors, making such stereotyped movements as spinning around in circles, waving their hands in front of their eyes with their heads cocked to one side, or biting their hands (Durand, in press-a). Asperger’s Disorder Asperger’s disorder involves a significant impairment in the ability to engage in meaningful social interaction, along with restricted and repetitive stereotyped behaviors but without the severe delays in language or other cognitive skills characteristic of people with autism.First described by Hans Asperger in 1944, it was Lorna Wing inthe early 1980s who recommended that Asperger’s disorder bereconsidered as a separate disorder from autism, with an emphasison the unusual and limited interests (such as train schedules)displayed by these individuals. Clinical Description People with this disorder display impaired social relationshipsand restricted or unusual behaviors or activities (such as followingairline schedules or memorizing ZIP codes), but unlike individualswith autism, they can often be quite verbal. This tendencyto be much more interested in esoteric facts than in people, alongwith their often formal and academic style of speech, has ledsome to refer to the disorder as the “little professor syndrome.” Individuals with Asperger’s disorder show few severe cognitiveimpairments and usually have IQ scores within the average range. They often exhibit clumsiness and poorcoordination. Some researchers think Asperger’s disorder may bea milder form of autism rather than a separate disorder. What must it be like to have this disorder? Is it an exquisite solitude,divorced from the stressors of modern life? Or is it an oppressivestate of anxiety, filled with the need to try constantly to maintainsameness in a chaotic world? Such fundamental questions haveled 10 CU IDOL SELF LEARNING MATERIAL (SLM)

some researchers to interview these individuals, hoping to gaina better understanding of the disorder so as to aid those who haveit. 1.4 DSM CRITERIA 1.4.1 Diagnostic Criteria for Autistic Disorder Given below is the diagnostic criterion for Autistic Disorder A. A total of 6 (or more) items from 1, 2, and 3, with at least two from 1 and one each from 2 and 3: 1. Qualitative impairment in social interaction, as manifested by at least two of the following: a. Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction b. Failure to develop peer relationships appropriate to developmental level c. Lacking spontaneity in seekingpleasurable moments and also to share enjoyable events. No inclination to share one’s interests, or achievements with people around them. This is demonstrated by a lack of displaying objects of interest, bringing them to others or even pointing out objects of interest d. Lack of social or emotional reciprocity 2. Qualitative impairments are seen in the area of communication which is manifested by at least one of the following: a. Delay in spoken language or total lack of spoken language. This lack of development of spoken language is not compensatedby means of alternative modes of communication like gestures or mime. b. In children and adolescents with adequate speech development one can seesignificant impairment in the ability to initiate conversation or sustain a conversation with other people. c. Stereotyped and repetitive use of language or idiosyncratic language d. Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level 3. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: a. Includes preoccupation with one or more than onerestricted and stereotyped patterns of interest. This can be abnormal in terms of its intensity or focus b. Adherence to specific but nonfunctional routines or rituals c. Stereotyped and repetitive motor movements and mannerisms. This includes hand or finger flapping, twisting of hands or fingers or complex movements involving whole-body d. Persistent preoccupation with parts of objects B. Delays in attaining development milestones or abnormal functioning in at least one of the following areas. The onset of which is prior to age 3 years: 1. social interaction, 2. language as used in social communication 11 CU IDOL SELF LEARNING MATERIAL (SLM)

3. symbolic or imaginative play C. The disturbances in behaviour and social interaction and delays in attaining developmental delays are not accounted for by either Rett’s disorder or childhood disintegrative disorder. 1.4.2 Diagnostic Criteria for Asperger’s Disorder Given below are the diagnostic criteria for Asperger’s Disorder A. Significant and qualifiable impairment is seen in areas of social interaction. This is manifested by at least two of the following: 1. Noticeable impairment in the use of multiple nonverbal behaviors including eye-to-eye gaze or maintaining eye contact, use of facial expression to communicate emotions, body postures and gestures to accompany verbal communication and regulate social interaction 2. Failure to develop peer relationships appropriate to developmental level 3. A lack of spontaneity in seeking to shared enjoyment, lack of interest in shared activities and lack of interestsregarding achievements with other people.This is demonstrated by a lack of displaying toys or objects of interest, bringing out toys and pointing out objects of interest to other people 4. Lack of social or emotional reciprocity B. Restricted repetitive and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following: 1. Encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus 2. Apparently inflexible adherence to specific, nonfunctional routines or rituals 3. Stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements) 4. Persistent preoccupation with parts of objects C. The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning. D. There is no clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than in social interaction), and curiosity about the environment in childhood. E. Criteria are not met for another specific pervasive developmentaldisorder or schizophrenia. 1.5 ICD 10 CRITERIA 1.5.1 ICD 10 Criteria for Autism Usually there is no prior period of unequivocally normal development but, if there is, abnormalities become apparent before the age of 3 years. There are observable and quantifiable impairments in interpersonal and social interaction. These are manifested in the form of an insufficient appreciation of social and emotional cues. Some of which include a lack of responsiveness to other’s emotions and/or a lack of behaviour manipulation based onsocial context; poor use of social signals and a weak integration of social, emotional, and communicative behaviour as well as a lack of socio-emotional reciprocity. 12 CU IDOL SELF LEARNING MATERIAL (SLM)

Similarly, qualitative impairments in communications are universal. These are seen in the form of a lack of use social linguistic skills; impairments in makebelieve play and social imitative play; poor synchronization and lack of reciprocity in interpersonal conversationsand exchange; poor flexibility in expressive language and a relative lack of creativity and fantasy in thought processes; lack of emotional response to other people's verbal and nonverbal overtures; impaired use of variations in cadence or emphasis to reflect communicative modulation; and a similar lack of accompanying gesture to provide emphasis or aid meaning in spoken communication. The condition is also characterized by restricted, repetitive, and stereotyped patterns of behaviour, interests, and activities. These take the form of a tendency to impose rigidity and routine on a wide range of aspects of day-to day functioning; this usually applies to novel activities as well as to familiar habits and play patterns. In early childhood particularly, there may be specific attachment to unusual, typically non-soft objects. The children may insist on the performance of particular routines in rituals of a nonfunctional character; there may be stereotyped preoccupations with interests such as dates, routes or timetables; often there are motor stereotypies; a specific interest in nonfunctional elements of objects (such as their smell or feel) is common; and there may be a resistance to changes in routine or in details of the personal environment (such as the movement of ornaments or furniture in the family home). In addition to these specific diagnostic features, it is frequent for children with autism to show a range of other nonspecific problems such as fear/phobias, sleeping and eating disturbances, temper tantrums, and aggression. Self-injury by biting one’s own or others wrist is quite common, especially when the child also has severe intellectual impairments associated with autism spectrum disorder. Most children and adolescents with autism also show lack of spontaneity, taking initiative as well as demonstrating creativity when it comes to organizing their leisure time. They and have difficulty applying abstract concepts in practical decision-making in school and work situations when they grow up.Hence, even when the tasks are well within their capacity of the individual, they are still not able to accomplish them. The manifestation of deficiency in characteristic related to autism change as the children grow older, however these deficits continue to show themselves into adolescenceas well as through adult life. The broad pattern of problems as well as the areas of deficits remains similar. Deficits are commonly seen in the areas of socialization, communication, and patterns of interest. Developmental abnormalities must manifest themselves in the first three years in order to make a definitive diagnosis of Autism spectrum disorderhowever these syndromes can be diagnosed in all age groups. All levels of IQ can occur in association with autism, but there is significant mental retardation in some three-quarters of cases. Includes:  autistic disorder  infantile autism 13 CU IDOL SELF LEARNING MATERIAL (SLM)

 infantile psychosis  Kanner's syndrome Differential diagnosis. Apart from the other varieties of pervasive developmental disorder it is important to consider: specific developmental disorder of receptive language (F80.2) with secondary socio-emotional problems; reactive attachment disorder (F94.1) or disinhibited attachment disorder (F94.2); mental retardation (F70-F79) with some associated emotional/behavioral disorder; schizophrenia (F20.-) of unusually early onset; and Rett's syndrome (F84.2). Excludes:  autistic psychopathy (F84.5) Diagnosis of autism spectrum disordercan be made based on the combination of clinically significantgeneral delay in the areas of language and cognitive development,the presence of qualitative deficiencies in reciprocal social interaction as well asrestricted, repetitive, stereotyped patterns of behaviour, interests, andactivities. There may or may not be difficulties in interpersonal communication which are similar tothose associated with autism, but significant deficiency in the area of language development wouldrule out the diagnosis. Includes:  autistic psychopathy  schizoid disorder of childhood Excludes:  anankastic personality disorder (F60.5)  attachment disorders of childhood (F94.1, F94.2)  obsessive-compulsive disorder (F42.-)  schizotypal disorder (F21)  simple schizophrenia (F20.6) 1.6 CAUSES OF AUTISM At present, few workers in the field of autism believe that psychologicalor social influences play a major role in the developmentof this disorder. To the relief of many families, it is now clear that poor parenting is not responsible for autism. Deficits in suchskills as socialization and communication appear to be biologicalin origin. Biological theories about the origins of autism, examinednext, have received much empirical support. Genetic Influences It is now clear that autism has a geneticcomponent. Families that haveone child with autism have a 5% to 10% risk of having anotherchild with the disorder. This rate is 50 to 200 times the risk in thegeneral population, providing strong evidence of a genetic componentin the disorder. The exact genes involved in the developmentof autism remain elusive. There is 14 CU IDOL SELF LEARNING MATERIAL (SLM)

evidence for some involvementwith numerous chromosomes, and work is ongoing inthis complex field. One area that is receiving attention involves the genes responsiblefor the brain chemical oxytocin. Because oxytocin is shown tohave a role in how we bond with others and in our social memory,researchers are looking for whether genes responsible for thisneurochemical are involved with the disorder. Preliminary workidentifies an association between autism and an oxytocin receptorgene, and researchers expect more connectionswill be identified in the coming years. Neurobiological Influences As in the area of genetics,many neurobiological influencesare being studied to helpexplain the social and communicationproblems observed inautism. One intriguing theory involvesresearch on the amygdala—thearea of the brain that, as yousaw is involvedin emotions such as anxietyand fear. Researchers studyingthe brains of people with autismafter they died note thatadults with and without thedisorder have amygdalae ofabout the same size but thatthose with autism have fewerneurons in this structure. Earlier research showed that young children with autism actuallyhave a larger amygdala. The theory being proposed is that theamygdala in children with autism is enlarged early in life— causingexcessive anxiety and fear (perhaps contributing to their socialwithdrawal). With continued stress, the release of the stress hormonecortisol damages the amygdala, causing the relative absenceof these neurons in adulthood. The damaged amygdala may accountfor the different way people with autism respond to socialsituations. An additional neurobiological influence we mentioned in thesection on genetics involves the neuropeptide oxytocin. Rememberthat this is an important social neurochemical that influences bondingand is found to increase trust and reduce fear. Some research onchildren with autism found lower levels of oxytocin in their blood, and givingpeople with autism oxytocinimproved their ability toremember and process informationwith emotion content(such as remembering happyfaces), a problem that is symptomaticof autism. This is one of anumber of theories being exploredas possible contributorsto this puzzling disorder. One highly controversialtheory is that mercury—specifically, the mercury previouslyused as a preservativein childhood vaccines (thimerosal)—is responsible for theincreases seen in autism overthe last decade. Large epidemiologicalstudies conductedin Denmark show that there isno increased risk of autism inchildren who are vaccinated. Despite this and other convincingevidence, the correlation between when a child is vaccinatedfor measles, mumps, and rubella (12–15 months) and whenthe symptoms of autism first become evident (before 3 years),continues to fuel the belief by many families that there must besome connection. The study of autism is a relatively young field and still awaitsan integrative theory of how biological, psychological, and socialfactors work together to put an individual at risk for developingautism. It is likely, however, that further research will identify thebiological mechanisms that may explain the social aversion experiencedby many people with the 15 CU IDOL SELF LEARNING MATERIAL (SLM)

disorder. Also to be outlined arethe psychological and social factors that interact early with thebiological influences, producing deficits in socialization and communication,as well as the characteristic unusual behaviors. 1.7 SUMMARY  People with pervasive developmental disorders all experience trouble progressing in language, socialization, and cognition.  The use of the word pervasive means these are not relatively minor problems (like learning disabilities) but are conditions that significantly affect how individuals live. Included in this group are autistic disorder, Rett’s disorder, Asperger’s disorder, and childhood disintegrative disorder.  Autistic disorder, or autism, is a childhood disorder characterized by significant impairment in social interactions, gross and significant impairment in communication, and restricted patterns of behavior, interest, and activities.  It probably does not have a single cause; instead, a number of biological conditions may contribute, and these, in combination with psychosocial influences, result in the unusual behaviors displayed by people with autism.  Asperger’s disorder is characterized by impairments in social relationships and restricted or unusual behaviors or activities, but people with Asperger’s disorder do not have the language  delays observed in people with autism.  Rett’s disorder, almost exclusively observed in females, is a progressive neurological disorder characterized by constant hand-wringing, intellectual disability, and impaired motor skills.  Childhood disintegrative disorder involves severe regression in language, adaptive behavior, and motor skills after a period of normal development for 2 to 4 years.  Pervasive developmental disorder not otherwise specified is a childhood disorder characterized by significant impairment in social interactions, gross and significant impairment in communication, and restricted patterns of behavior, interest, and activities.  Children who have this disorder are similar to those with autism but may not meet the age criterion for autism or may not meet the criteria for some symptoms of autism. 1.8 KEY WORDS  Aetiology: The study of the origins of disease: physical, mental or emotional.  Apraxia of speech: Also known as verbal apraxia or dyspraxia, this is a speech disorder in which a person has trouble saying what he or she wants to say correctly and consistently. 16 CU IDOL SELF LEARNING MATERIAL (SLM)

 Asperger’s disorder/syndrome: A form of autism spectrum disorder, characterized by normal IQ but impairments in social interaction and communication.  Autism Spectrum Disorder (ASD): A neurological disorder characterized by social/ communication deficits, fixated interests and repetitive behaviours.  Developmental disorder: A disorder that interrupts normal development in childhood. A developmental disorder may affect a single area of development (specific developmental disorder) or several (pervasive developmental disorder).  Echolalia: Repeating words or phrases, often over and over, without necessarily understanding their meaning.  Aetiology: The study of the origins of disease: physical, mental or emotional. 1.9 LEARNING ACTIVITY 1. Explain with the help of the case study given in the unit, the DSM criteria for autism? ___________________________________________________________________________ ___________________________________________________________________________ 2. Explain with the help of the case study given in the unit, the ICD 10 criteria for autism? ___________________________________________________________________________ ___________________________________________________________________________ 1.10 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. Define developmental disorders 2. What is Autism? 3. Define Pervasive Developmental Disorder 4. Define Rett’s Syndrome. 5. Define Asperger’s Syndrome. 6. What is the age of onset of Autism? Long Questions 1. What are the key characteristics of Autism? 2. Write in detail the core symptoms of Autism? 3. Write in short about the different syndromes in Autism Spectrum Disorder. 4. Write in detail the DSM criteria for Autism. 5. Write in detail the ICD 10 criteria for Autism. 6. Explain the causes of Autism in detail. 17 CU IDOL SELF LEARNING MATERIAL (SLM)

B. Multiple Choice Questions 1. Autism spectrum disorder (ASD) is a ___________ disability a. developmental b. mood c. psychotic d. learning 2. Autism spectrum disorder (ASD) affects ______________ a. All of these b. behaviour c. speech d. cognition 3. Children with autism show ___________ a. anxiety b. fear c. repeated behaviour d. compulsions 4.Autsim cannot be ___________ a. cured b. managed c. diagnosed d. all of these 5. Interventions help to manage ______________ a. none of these b. symptoms c. grade d. hand writing Answers 1-a, 2-a, 3-c, 4-c, 5-b 1.11 REFERENCES Textbooks  Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (PVT) Ltd. 18 CU IDOL SELF LEARNING MATERIAL (SLM)

 American PsychiatricAssociation (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc.  Clifford Morgan, Richard King, John Weisz, John Schopler (2004) Introduction to Psychology, McGraw-Hill, New Delhi  Damjan Michael (2010). The Principles of Learning and Behavior (6th Edition) Wadsworth, Cengage Learning.  Hergenhahn B R (2008). An introduction to the history of psychology, Wadsworth, Cengage Learning.  Robert S. Feldman (2011) Understanding Psychology, McGraw-Hil, New Delhi.  Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books  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., &Oltmans, T.F. (1998). Abnormal Psychology (2nd ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.  Kay J, Tasman A. (2006) Essentials of Psychiatry, Chichester, John R. Wiley and Sons. Sadock, Benjamin, J., & Virginia A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams &Wilkins.  Sarason I., G & Sarason B. R. (2005). Abnormal psychology: The problem of maladaptive behavior. (11th edn). PHI Learning Private limited.  World Health Organization (1993). The ICD-10 Classification of Mental and Behavioral Disorders Websites  www.simplypsychology.com  http://www.human-memory.net  www.simplypsychology.org  https://psychcentral.com  https://courses.lumenlearning.com  https://www.sparknotes.com 19 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 2 – AUTISM PART II STRUCTURE 2.0 Learning Objectives 2.1 Introduction 2.2 Types of Autism 2.3 Incidence of Autism 2.4 Prevalence of Autism 2.5 Assessment of Autism 2.6 Prognosis of Autism 2.7 Treatment for Autism 2.8 Summary 2.9 Keywords 2.10 Learning Activity 2.11 Unit End Questions 2.12 References 2.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Explain the incidence of Autism  Explain the prevalence of Autism  Describe the process of assessment of Autism  Describe the prognosis of Autism  Explain the Treatment for Autism 2.1 INTRODUCTION People with pervasive developmental disorders all experience problems with language, socialization, and cognition (Durand, in press-a). The word pervasive means that these problems are not relatively minor but significantly affect individuals throughout their lives. Included under the heading of pervasive developmental disorders are autistic disorder (or autism), Asperger’s disorder, Rett’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. These disorders under the title “autism spectrum disorders” in DSM-5; this spectrum of disorders would include autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. 20 CU IDOL SELF LEARNING MATERIAL (SLM)

2.2 TYPES OF AUTISM 2.2.1 Asperger’s Syndrome Although the term Asperger’s syndrome was quite common before 2013, the term is actually no longer used by medical professionals. It has since been reclassified as level 1 autism spectrum disorder by the DSM-5 diagnostic manual. Still, Asperger’s syndrome may be used informally — in fact, autism communities use it more often than level 1 spectrum disorder. A child with level 1 spectrum disorder will have above average intelligence and strong verbal skills but will experience challenges with social communication. In general, a child with level 1 autism spectrum disorder will display the following symptoms:  Inflexibility in thought and behavior  Challenges in switching between activities  Executive functioning problems  Flat monotone speech, the inability to express feelings in their speech, or change their pitch to fit their immediate environment  Difficulty interacting with peers at school or home 2.2.2 Rett Syndrome Rett syndrome is a rare neurodevelopmental disorder that is noticed in infancy. The disorder mostly affects girls, although it can still be diagnosed in boys. Rett syndrome presents challenges that affect almost every aspect of a child's life. The good thing is your child can still enjoy and live a fulfilling life with the proper care. You can have family time together and provide support to allow the child to do what they enjoy. Common symptoms of Rett syndrome include:  Loss of standard movement and coordination  Challenges with communication and speech  Breathing difficulties in some cases 2.2.3 Childhood Disintegrative Disorder (CDD) Childhood disintegrative disorder (CDD), also known as Heller's syndrome or disintegrative psychosis, is a neurodevelopmental disorder defined by delayed onset of developmental problems in language, motor skills, or social function. A child experiences normal development in these areas only to hit a snag after age three and up to age 10. The developmental loss can be very heartbreaking for parents who had no idea their child had autism challenges all along. The cause of CDD is unknown though researchers link it to the neurobiology of the brain. Childhood disintegrative disorder is more common in boys. Out of every 10 cases of the disorder, nine will be boys, and only one will be a girl. 21 CU IDOL SELF LEARNING MATERIAL (SLM)

In CDD, the child will have normal development up to the time when the disorder starts, and regressions suddenly start to occur in more than two developmental aspects of their life. The child may lose any of the following skills and abilities:  Toileting skills if they had already been established  Acquired language or vocabularies  Social skills and adaptive behaviors  Some motor skills 2.2.4 Kanner’s Syndrome Kanner’s syndrome was discovered by psychiatrist Leo Kanner of John Hopkins University in 1943 when he characterized it as infantile autism. Doctors also describe the condition as a classic autistic disorder. Children with Kanner's syndrome will appear attractive, alert, and intelligent with underlying characteristics of the disorder such as:  Lack of emotional attachment with others  Communication and interaction challenges  Uncontrolled speech  Obsession with handling objects  A high degree of rote memory and visuospatial skills with major difficulties learning in other areas 2.2.5 Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) is a mild type of autism that presents a range of symptoms. The most common symptoms are challenges in social and language development. Your child may experience delays in language development, walking, and other motor skills. You can identify this type of autism by observing the child and noting what area the child displays a deficit in, such as interacting with others. PDD-NOS is sometimes referred to as “sub threshold autism,” as it is a term used to describe an individual that has some but not all symptoms of autism. 2.3 INCIDENCE OF AUTISM Autism was once thought to be a rare disorder, although more recent estimates of its occurrence seem to show an increase in its prevalence. Previous estimates found a rate of 2 to 20 per 10,000 people, although it is now believed to be as high as 1 in every 500 births. This rise in the rates may be the result of increased awareness on the part of professionals who now distinguish the pervasive developmental disorders from intellectual disability. However, other environmental factors (such as exposure to toxic chemicals) cannot as yet be ruled out as contributing to this rise. As the recognition of autism spectrum disorder has improved, the reported prevalence has increased, with several recent good quality studies suggesting a rate of around 1%. ‘Classical’ 22 CU IDOL SELF LEARNING MATERIAL (SLM)

autism accounts for between 25% and 60% of all autism spectrum disorder. The male: female ratio is approximately 4:1. There is no clear relation to socio-economic status; the links with high socio-economic status reported by early studies were probably due to ascertainment bias. Whereas autism was formerly viewed as an extremely rare condition with a unique combination of the three characteristic features described below, it is increasingly being realized that each of these features is itself a spectrum, present to a greater or lesser extent. Some individuals have just one or two of these features to a marked degree. Studies are underway to determine whether autism reflects the co-occurrence of the three features by chance, or whether the combination is more common than would occur by coincidence. Autistic disorder appears to be a universal phenomenon, identified in every part of the world. 2.4 PREVALENCE OF AUTISM The prevalence of autism spectrum disorders (which include autistic disorder, pervasive developmental disorder not otherwise specified, and Asperger’s disorder) is estimated as high as 1 in every 110 births. Gender differences for autism vary depending on the IQ level of the person affected. For people with IQs under 35, autism is more prevalent among females; in the higher IQ range, it is more prevalent among males. The reason for these differences is not known. 2.5 ASSESSMENT OF AUTISM A thorough history and examination should be carried out looking for the core features and associated conditions as described above. There are standardized interviews such as the Autism Diagnostic Interview (ADI) that help clarify the diagnosis through algorithms that take into account severity on each of the three featured dimensions. However, a history is not enough and more subtle abnormalities of social interaction and communication may be helpfully assessed using standardized observational tests, such as the Autism Diagnostic Observation Schedule (ADOS). Because such assessments are time- consuming, it can help to use one of a number of screening questionnaires (for example, the Social Communication Questionnaire, SCQ) that have reasonable psychometric properties. Differential diagnosis A. Developmental or acquired language disorders Unlike individuals with autism, children and adolescents with ‘pure’ phonological-syntactic language disorders can communicate successfully by gesture and have a good capacity for social interaction. However, there are ‘overlap’ cases involving a severe phonological- syntactic language problems with a lesser degree of pragmatic language impairment, resulting in language difficulties that do affect social interaction, sometimes combined with other mild or patchy features of autism that are too mild to warrant the diagnosis of an ASD. 23 CU IDOL SELF LEARNING MATERIAL (SLM)

In future classifications, such children and adolescents may be classified as having a Social Communication Disorder. Acquired aphasia with epilepsy may also involve social withdrawal and behavioral disturbance, but is not usually hard to distinguish from an ASD. B. Intellectual disability without features of autism Language and pretend play will be absent if mental age is under 12months. Simple stereotypies are common. These children are sociallyresponsive in line with their mental age. C. Intellectual disability with some features of autism Many children with intellectual disability have a ‘triad’ of impairmentsaffecting (1) social interaction; (2) communication; and (3) play, as well asvarying degrees of repetitive and restricted behaviours. Only some of thesechildren meet the full diagnostic criteria for autism, but many more can bediagnosed as having atypical autism (though not all clinicians think this isa useful thing to do). D. Rett syndrome This syndrome is usually due to a mutation in the MECP2 gene on the Xchromosome, but occasionally results from a mutation in other genes. Themutation is typically new (that is, not present in either parent), but maybe inherited from a phenotypically normal mother who has a germlinemutation. Male fetuses with the mutation usually die before birth since,unlike females, they lack a second normal X chromosome. As a result,recognized cases of Rett syndrome occur almost exclusively in girls (affectingabout one in 10,000 live-born females). The features of the syndromemay be confused with autism. There is global developmental regressionwith loss of acquired abilities at about 12 months of age, accompaniedby: deceleration of head growth; characteristic ‘hand washing’ stereotypiesand restricted hand use; episodic over-breathing and unprovoked laughter;and progressively impaired mobility. Most children with Rett syndromeare appropriately socially responsive once allowance is made for their lowmental age and physical disabilities. The disease is progressive and affectedindividuals are usually in wheelchairs by their late teens and die before 30. E. Neurodegenerative disorders with progressive dementia These need to be considered when a period of normal (or nearly normal)development is followed by the loss of skills and the emergence of featuresof autism. With time, frank neurological impairments emerge and theaffected individual eventually dies. There are many such genetic disorders,all of which are fortunately rare. Examples include adrenoleukodystrophy,juvenile Huntington disease and Batten disease. HIV encephalopathy isprobably the commonest cause of childhood dementia worldwide. F. Disintegrative disorder Also known as disintegrative psychosis or Heller syndrome, this very rarecondition (with a prevalence of roughly 1 in 50,000) involves entirelynormal development for two to six years, followed first by a phase of regression (often accompanied by marked anxiety and loss of bladder and bowel control), leading to lifelong severe intellectual disability with pronounced features of autism. G. Intense early deprivation 24 CU IDOL SELF LEARNING MATERIAL (SLM)

Severe psychosocial deprivation is sometimes followed by persistent features of autism. This has been evident from studies of trans-nationally adopted children who have been deprived in their first year or two of life of adequate nutrition, physical care, cognitive and linguistic stimulation, and ordinary social interaction. Though most such children do remarkably well within a few years of being adopted, a small minority continue to have social and communicative impairments associated with intense circumscribed interests, and preoccupations with specific sensations. In early childhood, the distinction from autism can be difficult. As the children mature, the clinical picture evolves, with loss of autistic-like features in around a quarter, leaving social disinhibition and circumscribed intense interests as the predominant features. H. The fragile X syndrome This is commonly associated with behaviours that bear a superficial resemblance to autism. Social avoidance and poor eye contact are common, but they seem to result from social anxiety rather than social indifference. Setting aside these features that superficially resemble autism, it remains controversial whether the fragile X syndrome is any more likely than other intellectual disability syndromes to result in classical autism. I. Deafness This is often suspected when young children with autism pay no heed to people speaking to them. A careful history usually establishes that they have no difficulty hearing sounds that interest them, for example, the rustle of a crisp packet! Unlike children with autism, deaf children are typically sociable and keen to communicate, for example, by gesture. 2.6 PROGNOSIS OF AUTISM As described earlier, classical studies showed that roughly 70% of children with the full autistic syndrome acquired useful speech – which may be an underestimate nowadays since autism is more broadly defined and mild cases are more likely to be recognized. Children who have not acquired useful speech by the age of 5 years are unlikely to do so subsequently. Autistic aloofness improves in the majority of cases, being replaced by an ‘active but odd’ social interest. Adolescence is associated with several changes:  The peak age for onset of seizures is 11–14 years.  Earlier over-activity may be replaced by marked under-activity and inertia.  About 10% of individuals with autism go through a phase in adolescence when they lose language skills, sometimes with intellectual deterioration as well; this decline is not progressive, but the lost skills are not generally regained.  Agitation seems more common, sometimes leading to serious aggressive outbursts.  Inappropriate sexual behaviour can become troublesome. By adult life, roughly 10% of individuals who initially had the full autistic syndrome are working and able to look after themselves. Fewer have good friends, marry, or become parents. The best predictors of long-term social independence are IQ and whether speech was 25 CU IDOL SELF LEARNING MATERIAL (SLM)

present by 5 years of age. Individuals with a non-verbal IQ of under 60 are very likely to be severely socially impaired in adult life and unable to live independently. Individuals with higher IQs are more likely to become independent, particularly if they have acquired useful speech by the age of 5. Even with IQ and speech on their side, however, people with classical autism only have around a 50% chance of a good social outcome in adult life. The prognosis is generally better for those milder variants of autism that are now increasingly recognized. Though some individuals with ASDs subsequently develop psychotic symptoms, this is a distinctly unusual outcome. 2.7 TREATMENT FOR AUTISM Most treatment research has focused on children with autism, sowe primarily discuss treatment research for these individuals.However, because treatment for all of the pervasive developmentaldisorders relies on a similar approach, this research should berelevant across disorders. One generalization that can be madeabout autism, as well as the other pervasive developmental disorders,is that no completely effective treatment exists. Attempts made toalleviate the social problems experienced by persons suffering from autism spectrum disorderhave also not been successful to date. Rather, like the approach to individualswith intellectual disability, most efforts at treating peoplewith pervasive developmental disorders focus on enhancingtheir communication and daily living skills and on reducing problembehaviors, such as tantrums and self-injury (Durand, in presa).We describe some of these approaches next, including work onearly intervention for young children with autism. 2.7.1 Psychosocial Treatments Early psychodynamic treatments were based on the belief thatautism is the result of improper parenting, and they encouragedego development (the creation of a self-image). Given our current understanding about the nature of thedisorder, we should not be surprised to learn that treatments basedsolely on ego development have not had a positive impact on thelives of people with autism Greatersuccess has been achieved with behavioral approaches that focuson skill building and behavioral Treatment for problem behaviors.This approach is based on the early work of Charles Ferster andIvar Lovaas. Although the work of Ferster and Lovaas has beengreatly refined over the past 30 years, the basic premise—thatpeople with autism can learn and that they can be taught someskills they lack—remains central. There is a great deal of overlapbetween the Treatment for autism and the Treatment for intellectualdisability. With that in mind, we highlight several treatment areasthat are particularly important for people with autism, includingcommunication and socialization.Problems with communication and language are among the defining characteristics of this disorder. People with autism often donot acquire meaningful speech; they tend either to have limitedspeech or to use unusual speech, such as echolalia. 26 CU IDOL SELF LEARNING MATERIAL (SLM)

Teaching peopleto speak in a useful way is difficult. Think about how we teachlanguages: It mostly involves imitation. Imagine how you wouldteach a young girl to say the word spaghetti. You could wait forseveral days until she said a word that sounded something likespaghetti (maybe confetti) and then reinforce her. You could thenspend several days or weeks trying to shape confetti into somethingcloser to spaghetti. Or you could just prompt, “Say ‘spaghetti.’”Fortunately, most children can imitate and learn to communicateefficiently. But a child who has autism can’t or won’t imitate. In the mid-1960s, the late Ivar Lovaas and his colleaguestook a monumental first step toward addressing the difficulty ofgetting children with autism to respond. They used the basic behavioralprocedures of shaping and discrimination training toteach these nonspeaking children to imitate others verbally. The first skill theresearchers taught the children was to imitate other people’s speech. They began by reinforcing a child with food and praisefor making any sound while watching the teacher. After the childmastered that step, they reinforced the child only if she made asound after the teacher made a request—such as the phrase, “Say‘ball’” (a procedure known as discrimination training). Once thechild reliably made some sound after the teacher’s request, theteacher used shaping to reinforce only approximations of the requestedsound, such as the sound of the letter “b.” Sometimes theteacher helped the child with physical prompting—in this case,by gently holding the lips together to help the child make thesound of “b.” Once the child responded successfully, a secondword was introduced—such as “mama”—and the procedure wasrepeated. This continued until the child could correctly respond tomultiple requests, demonstrating imitation by copying the wordsor phrases made by the teacher. Once the children could imitate,speech was easier, and progress was made in teaching some ofthem to use labels, plurals, sentences, and other more complexforms of language. Despite the success of somechildren in learning speech, other children do not respond to thistraining, and workers sometimes use alternatives to vocal speech,such as sign language and devices that have vocal output and canliterally “speak” for the child. One of the most striking features of people with autism is theirunusual reactions to other people. Although social deficits areamong the more obvious problems experienced by people withautism, they can also be the most difficult to teach. A number ofapproaches are now used to teach social skills (for example, howto carry on a conversation and ask questions of other people),including the use of peers who do not have autism as trainers, andthere is evidence that those with autism can improve their socializationskills. Lovaas and his colleagues at the University of California, LosAngeles, reported on their early intervention efforts with youngchildren. They used intensive behavioral treatmentfor communication and social skills problems for 40 hoursor more per week, which seemed to improve intellectual and educationalfunctioning. Follow-up suggests that these improvementsare long lasting. These studiescreated considerable interest, as well as controversy. 27 CU IDOL SELF LEARNING MATERIAL (SLM)

Somecritics question the research on practical, as well as experimental,grounds, claiming that one-on-one therapy for 40 hours per weekwas too expensive and time consuming; they also criticized thestudies for having no proper control group. Nevertheless, the findingsfrom this important work and a number of replicationsaround the world suggest that early intervention is promising forchildren with autism. 2.7.2 Biological Treatments No one medical treatment has been found to cure autism. In fact,medical intervention has had little success on the core symptomsof social and language difficulties. A variety of pharmacologicaltreatments are used to decrease agitation, and the major tranquilizersand serotonin-specific reuptake inhibitors seem helpful here.Because autism may result from a variety of deficits, it is unlikelythat one drug will work for everyone with this disorder.Much current work is focused on finding pharmacological treatmentsfor specific behaviors or symptoms. 2.7.3 Integrating Treatments The Treatment for choice for people with pervasive developmentaldisorder—including autism and Asperger’s disorder—combinesvarious approaches to the many facets of this disorder. For children,most therapy consists of school education with special psychologicalsupports for problems with communication and socialization.Behavioral approaches have been most clearly documented as benefiting children in this area. Pharmacological treatments can helpsome of them temporarily. Parents also need support because of thegreat demands and stressors involved in living with and caring forsuch children. As children with autism grow older, interventionfocuses on efforts to integrate them into the community, often withsupported living arrangements and work settings. Because therange of abilities of people with autism is so great, however, theseefforts differ dramatically. Some people are able to live in their ownapartments with only minimal support from family members. Others,with more severe forms of cognitive impairment, require moreextensive efforts to support them in their communities. 2.8 SUMMARY  The autism spectrum refers to the variety of potential differences, skills, and levels of ability that are present in autistic people.  Autism spectrum disorder is now the umbrella term for the group of complex neurodevelopmental disorders that make up autism. It is a condition that affects communication and behavior.  In the past, doctors diagnosed autism according to four different subtypes of the condition. Healthcare professionals classify autism spectrum disorder as one broad category. This category is further divided into three different levels which specify the degree of support required by a person with autism. 28 CU IDOL SELF LEARNING MATERIAL (SLM)

 Symptoms of autism spectrum disorder can be seen in a child within the first 24 months of life. It is also noted that autism spectrum disorder is three to four times more likely to be seen in boys than in girls.  Although there is some research which indicates this could be due to bias, sincethere could be girls suffering from autism which may go undiagnosed and hence not documented for.  While individuals with autism spectrum disorder may face many challenges in their life. We should know that they may have certain skills that many would consider as strengths or opportunities.  Doctors and clinicians diagnose autism spectrum disorder by assessing the differences in the child’s behaviour and mannerisms, interacting with the child or observing interactions between the child and parent or caregiver, and asking parents and caregivers questions.  Specific therapies and behavioral interventions can help improve the targeted behavioursof people with autism spectrum disorder.  Healthcare professionals often recommend that the treatment for autism spectrum disorder begin as soon as possible after a child receives their diagnosis. Early intervention can reduce their difficulties and also allow them to adapt and learn new skills.  Autism spectrum disorder is a spectrum disorder that doctors diagnose in levels, depending on how many of the differences are present in individuals.  While people on the severe end of the spectrum may require help and assistance to function and manage their lives, with the right treatment, many people with autism spectrum disorder can live productive, independent, and fulfilling lives. 2.9 KEY WORDS  Autistic: Description of a child, possibly suffering from a neurological disorder, who is characterized by being withdrawn and unable to form relationships with people, to respond to environmental stimuli, or to use language.  Autism Diagnostic Interview–Revised: A diagnostic interview for autism spectrum disorder. Autism Diagnostic Observation Schedule: A diagnostic tool for autism spectrum disorder.  Bayley Scales of Infant Development: A well-known American test for assessing the development of infants and young children.  Behaviour modification: The deliberate changing of a particular pattern of behaviour by behaviorist methods.  Cognitive Behaviour therapy: A type of psychotherapeutic treatment that helps patients understands the thoughts and feelings that influence Behaviours. CBT is commonly used to treat depression and anxiety. 29 CU IDOL SELF LEARNING MATERIAL (SLM)

 Developmental tasks: Skills and achievements that are considered necessary for children to attain at certain ages to ensure their psychological well-being, e.g. walking, talking, reading.  Discrete Trial Training: An ABA method which requires the therapists to break down skills into small tasks that are achievable and are taught in a very structured manner.  Down's Syndrome: A form of congenital mental retardation which is due to a genetic abnormality.  Early Intensive Behavioral Intervention: An individualized, intensive intervention program which involves the systematic use of ABA techniques.  Fine motor skills: Activities which require the co-ordination of smaller body muscles, for example, writing.  Psychotherapy: The use of psychological techniques to treat psychological disturbances. 2.10 LEARNING ACTIVITY 1. Explain the process of assessment undertaken in order to diagnose a child with autism? ___________________________________________________________________________ ___________________________________________________________________________ 2. Explain the process of treatment provided to a child with autism? ___________________________________________________________________________ ___________________________________________________________________________ 2.11 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What is the occurrence of Autism? 2. What do you mean by incidence rate? 3. What is the prevalence of Autism? 4. What are some of the treatments available for children with autism? 5. Which is the most commonly used tool used for assessment of autism? Long Questions 1. Explain the incidence and prevalence of Autism in detail. 2. Write a detail about the process of assessment for diagnosing Autism? 3. Write a note on scale for Autism. 4. What is the pharmacological treatment for children with Autism? 30 CU IDOL SELF LEARNING MATERIAL (SLM)

5. Write in detail about the non-pharmacological treatment given to children with Autism? 6. What is the course and prognosis of Autism? B. Multiple Choice Questions 1. Autism can be cured with: a. Behavioral therapy b. Medicine c. Brain surgery d. Exercise 2. Which of the following is NOT one of the disabilities classified as an autism spectrum disorder (ASD)? a. Childhood disintegrative disorder (CDD) b. Cerebral palsy c. Pervasive developmental disorder (PDD-NOS) d. Rett syndrome 3. How long after conception do our brains begin to develop and how long until their basic anatomical structure is complete? a. 3 weeks and 7 months b. 3 weeks and 8 months c. 3 weeks and 10 months d. 3 weeks and 2 months 4. What do we mean by labelling? a. identifying the genes an individual has and labelling them b. identifying the needs of a child and labelling them c. a way of trying to prevent repeated behaviours d. identifying a series of atypical behaviours and labelling them 5. The incidence of autism is approximately a. 1 out of every 87 births. b. 1 out of every 100 births. c. 1 out of every 250 births. d. 1 out of every 400 births. Answer 1-a, 2-b, 3-a, 4-d, 5- d 31 CU IDOL SELF LEARNING MATERIAL (SLM)

2.12 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.  Clifford Morgan, Richard King, John Weisz, John Schopler (2004) Introduction to Psychology, McGraw-Hil, New Delhi  Domjan Michael (2010). The Principles of Learning and Behavior (6th Edt) Wadsworth, Cengage Learning.  Hergenhahn B R (2008). An introduction to the history of psychology, Wadsworth, Cengage Learning.  Robert S. Feldman (2011) Understanding Psychology, McGraw-Hil, New Delhi.  Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books  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., &Oltmans, T.F. (1998). Abnormal Psychology (2nd ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.  Kay J, Tasman A. (2006) Essentials of Psychiatry, Chichester, John R. Wiley and Sons. Sadock, Benjamin, J., & Virginia A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams &Wilkins.  Sarason I., G & Sarason B. R. (2005).Abnormal psychology: The problem of maladaptive behavior. (11th edn). PHI Learning Private limited.  World Health Organization (1993). The ICD-10 Classification of Mental and Behavioral Disorders Websites  www.simplypsychology.com  http://www.human-memory.net  www.simplypsychology.org  https://psychcentral.com  https://courses.lumenlearning.com  https://www.sparknotes.com 32 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 3 –SCHIZOPHRENIA PART I STRUCTURE 3.0 Learning Objectives 3.1 Introduction 3.2 Childhood Onset Schizophrenia 3.3 DSM Criteria 3.4 ICD 10 Criteria 3.5 Causes of Childhood Onset Schizophrenia 3.6 Summary 3.7 Key Words 3.8 Learning Activity 3.9 Unit End Questions 3.10 References 3.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Describe Childhood Onset Schizophrenia  Explain the nature and symptoms of Childhood Onset Schizophrenia  Explain the DSM criteria of Childhood Onset Schizophrenia  Explain the ICD 10 criteria of Childhood Onset Schizophrenia  Describe the causes of Childhood Onset Schizophrenia 3.1 INTRODUCTION Schizophrenia is a debilitating neuropsychiatric disorder characterized by disruptions in cognition, perception and social relatedness. The World Health Organization (2008) has ranked schizophrenia as one of the leading causes of disability worldwide. Schizophrenia rarely first presents in childhood, but it increases in prevalence through adolescence. “Early- onset schizophrenia” (EOS) is defined as schizophrenia with onset prior to age 18 years; “childhood-onset schizophrenia” (COS) refers to this disorder with onset prior to age 13 years. Although EOS is considered to be continuous with adult-onset schizophrenia, it presents with unique developmental and social challenges. The features of schizophrenia are often divided into positive and negative symptoms. This terminology is potentially confusing since it could imply that positive symptoms are good and negative symptoms are bad. In fact, ‘positive’ refer to the presence of symptoms that should not normally be there (for example, hallucinations, delusions, thought disorder, motor abnormalities), while ‘negative’ refers to a reduction in characteristics that should normally 33 CU IDOL SELF LEARNING MATERIAL (SLM)

be there (for example, less speech, sociability, emotional involvement or motivation to do things). Multivariate analyses suggest that the two-way distinction between positive and negative symptoms should perhaps be replaced by a three-way distinction between negative symptoms, reality distortion (hallucinations and delusions), and disorganization (thought disorder, bizarre behaviour, inappropriate affect). Schizophrenic symptoms are fairly similar at all ages, though passivity phenomena and poverty of thought are less prominent than in adult-onset schizophrenia. In line with developmental level, delusions in children are generally less complex than in adults, and less likely to have sexual or other adult themes. Schizophrenia characteristically involves a mixture of psychotic episodes (with prominent positive symptoms) and a progressive accumulation of negative symptoms. In the long term, it is generally the negative symptoms that are more disabling, and more upsetting to relatives. 3.2 CHILDHOOD ONSET SCHIZOPHRENIA Schizophrenia is a serious psychiatric condition and a chronic mental illness. Schizophrenia results in long term impairments in an individual’s thoughts, emotions and behavior. If left untreated there can be may limitations in the person’s lifestyle and it can deteriorate the quality of life and subjective wells-being of the person and his or her family.Schizophrenia, in simple words is a debilitating condition that effectson an average more than 1 percent of the world's population. Individuals affected with this disorder experience symptom of hallucinations, disorganized thinking, and hence they are prone to false and paranoid beliefs. Along with these and other symptoms make the person extremely fearful, withdrawn and also difficult to interact with. Schizophrenia is also a chronic condition and hence the impact of the symptoms last for a long time. The symptoms and their impact on an individual’s social life are so severe that it makes the return to social and work life difficult. The symptoms of this mental disorderaffects the way anindividual thinks, acts, expresses emotions, perceives reality, and relates to others. Schizophrenia is not as common as other major mental illnesses. However, we can easily say that it is the most chronic and disabling of them. People with schizophrenia as mentioned earlier have problems in performing well in society, at work, at school, as well asmaintaining interpersonal relationships. They might feel frightened because of their delusions and hence cannot trust people easily. This means that they remain withdrawn most of the time. For others it could appear that they have lost touch with reality. The most difficult part is that schizophrenia is lifelong disease. It cannot be cured but only can be controlled with proper treatment. Contrary to popular belief, schizophrenia different from dissociative disorders like split personality disorder or multiple personality disorder. Schizophrenia is a form of psychosis. Psychosis is a type of mental illness in which a person cannot differentiate from what he or she thinks or imagines from what exists in reality. During such times, people with psychotic 34 CU IDOL SELF LEARNING MATERIAL (SLM)

disorders like schizophreniaoften confuse their thoughts with reality. The world for them seems like a mess of confusing thoughts, images, and sounds. They respond to their imaginary fears and anxieties in a concrete manner. People around them find their behavior to be confusing, strange and even shocking. Schizophrenia is a chronic illness with long term impact. Sometimes when the person experiences full blown periods of symptoms. During those times, people around observe a sudden change in personality and behavior. This can also be referred to as a psychotic episode. The severity of schizophreniavaries from individual to individual. There are instances wherein some patients have only one psychotic episode in their lifetime.While other individuals have multiple episodes during their lifetime. Such people lead relatively normal lives in between their episodes. There may be individuals who have trouble in performing their day-to-day activities. With each passing episode, the time period between two episodes gets lesser and lesser. Also the improvement between full-blown psychotic episodes gets poorer. Schizophrenia symptoms seem to worsen and improve in cycles known as relapses and remissions. Schizophrenia and its symptoms take a massive toll on afflicted families. Many individuals with schizophrenia have difficulty maintaining a job or living independently. Although it is important to recognize the effectiveness of treatment.Specially at the onset of symptoms treatment allows individuals with a diagnosis of schizophrenia to lead meaningful, productive lives. Early Symptoms of Schizophrenia Schizophrenia can be seen equally in men and women. The rates of incidence and prevalence of schizophrenia are also equal among the two genders across the world in almost all the ethnic groups. The symptom presentation and age of onset do differ between the sexes, however. However, we can see subtle differences in the terms of age of onset and nature of symptoms when we compare the two genders. The age of onset for men is much lesser than women. The peak age for onset in men is between ages 21 and 25. Women are more likely to be diagnosed between ages 25 and 30, and again after age 45. In women with late onset, hormonal changes associated with perimenopause or menopause are thought to be a contributing factor but the mechanism is unclear and has been a source of debate within the field of psychiatry. Schizophrenia with onset in childhood is very rare. However, there has been documented evidence about cases of schizophreniaoccurring in children. Moreover, awareness related childhood-onset schizophrenia is increasing. It can be extremely difficult to diagnose schizophrenia in children and teenagers. The first signs of schizophrenia include social withdrawal or withdrawal from friends, a gradual decline in academic progress or dropping 35 CU IDOL SELF LEARNING MATERIAL (SLM)

ofgrades, sleep problems, and irritability. These can be seen in younger adults as normal developmental changes or common adolescent behaviors. The period just prior to acute onset is known as the prodromal period. In this phase, we see a person withdrawing from his or her usual social life, reducing interactions with people around them. Family members often see them as lot in their own world or lost in thoughts.They also experience an increase in unusual thoughts and suspicions. It is crucial to seek a professional opinion if the family or caregivers are suspecting a prodromal period. This is because early intervention can greatly minimize symptoms and alter the course of the disease, leading to much higher lifetime functioning. People with schizophrenia also display hostility or aggression. However, we should keep it ate the back of our mind that the vast majority of people with schizophrenia are not aggressive and pose much more danger to themselves than to others.Schizophrenia is typically a chronic condition and people with this diagnosis cope with symptoms throughout life. However, many people with schizophrenia lead rewarding and meaningful lives in their communities. From what we seen so far, an episode of schizophrenia is marked by distinct but gradual changes in behaviour which is referred to as prodromal stage. The common symptoms in prodromal stage can be listed as follows:  A change in grades  Social withdrawal  Trouble concentrating  Temper flares  Difficulty sleeping This is followed by a full-blown episode. During an episode an individual experiences both positive and negative symptoms. Let us now look into these symptoms in detail. Positive Symptoms The word positive indicates presence of something. In other words, positive symptoms of schizophrenia refer to excessive behaviours seen in a person. Positive symptoms can be seen in the form of changes in behaviour of the person such as aggression or restlessness and thoughts such as hallucinations or delusions. Hallucinations Hallucinations are related to perceptions. They can occur in any modality. Hallucinations occur where someone sees, hears, smells, tastes or feels things that do not exist outside their mind. In other words, when an individual perceives something without and actual concrete stimuli, we can say that he or she is hallucinating. The most common form of hallucination is auditory hallucination, wherein the person complaints of hearing voices. Hallucinations are very real to the person experiencing them.Even though people around them may not be able to hear the voices or experience the sensations. 36 CU IDOL SELF LEARNING MATERIAL (SLM)

Research isconducted in order to understand the nature of auditory hallucinations by utilizing brainscanning equipment. The results of these studies have foundsignificant changes in the speech area in the brains of people with schizophrenia when they experience auditory hallucinations or hear voices. These research studies also show that the experience of hearing voices is a real one for people experiencing them. It sounds as if the brain mistakes their owninternal thoughts for real voices.Some people describe the voices they hear in auditory hallucination as friendly and pleasant, but more than often they end up being rude, critical, abusive or annoying. The voices might describe activities taking place, discuss the hearer's thoughts and behaviour, give instructions, or talk directly to the person. Voices may come from different places or a single place, such as the television. Delusions Hallucinations are related to perception and delusions are related to thoughts. A delusion refers to a belief person holds on with complete conviction. This belief may be based on a mistake, strange or unrealistic view. Delusions greatlyinfluence the way the person behaves. Delusions can develop suddenly or may gradually develop over weeks or months. People experience different forms of delusions. They are developed to serve different purposes. Some people develop a delusional idea to explain a hallucination they're having. For example, if they have heard voices describing their actions, they may have a delusion that someone is monitoring their actions. An example of delusion could be delusion of grandiose, where a person may strongly believe that they are distinct or special when compared to others. They either possess incomparable strength or special skills or powers. Another example could be delusion of persecution, wherein they believe they're being harassed or persecuted. They may believe they're being chased, followed, watched, plotted against or poisoned, often by a family member or friend.Some people who experience delusions interpret everyday events or occurrences in different ways than what normal people would. They may believe people on TV or in newspaper articles are communicating messages to them alone, or that there are hidden messages in the colors of cars passing on the street. Confused thoughts (thought disorder) People experiencing psychosis often have trouble keeping track of their thoughts and conversations. Some people find it hard to concentrate and will drift from one idea to another. They may have trouble reading newspaper articles or watching a TV programme.People sometimes describe their thoughts as \"misty\" or \"hazy\" when this is happening to them. Thoughts and speech of people with schizophrenia become jumbled or confused. Their conversations do not have a definite flow and hence are difficult and hard for other people to understand. Thought disorder can be seen in the following forms: thought insertion, thought withdrawal and thought withdrawal. Thought insertion refers to the phenomenon when a person feel that 37 CU IDOL SELF LEARNING MATERIAL (SLM)

people around then are inserting ideas or thoughts into their mind through a physical means like radio waves. Thought withdrawal is when they feel that the thoughts are removed from their mind without their consent. Thought broadcasting refers to when a person feels that the thoughts are transmitted to all the people around through a device like microwave oven, etc. Changes in behaviour and thoughts When a person experiences hallucinations and delusions, a person is in great mental distress. Their thoughts and emotions get translated into their behaviour. Their behaviour may become more disorganized and unpredictable. Some people describe that their thoughts are being controlled by someone else. Others feel that the thoughts they have are not their own. In other words their thoughts someone else has been planting these thoughts in their mind.Another expression would be thattheir thoughts are disappearingand they feel that someone is removing them from their mind. Some people feel someone else hastaken over their body that person is controlling or directing their movements and actions. Negative Symptoms Along with positive symptoms, a person also experiences negative symptoms. As the name suggests, negative refers to absence of something. The negative symptoms unlike positive symptoms of schizophreniacan appear or manifest themselvesmany years prior to a person experiencing their first acute schizophrenic episode. The initial stage during which a personexperiences predominantly negative symptoms is often known as the prodromal stage of schizophrenia. Symptoms experienced during the prodromal period appear gradually and get worse slowly over time. Negative symptoms include the person becoming more socially withdrawn. They do not care about their appearance and do not take care of personal hygiene. It can however become difficult to differentiate whether the symptoms are part of the development of schizophrenia or caused by something else. Negative symptoms experienced by people living with schizophrenia include:  Anhedonia – losing interest and motivation in life and pleasurable activities, including relationships and sex  Cognitive problems – lackof concentration, not wanting to leave the house, and changes in sleeping patterns  Apathy – being less likely to initiate conversations and feeling uncomfortable with people, or feeling there's nothing to say The negative symptoms of schizophrenia can often lead to relationship problems with friends and family as they can sometimes be mistaken for deliberate laziness or rudeness. 3.3 DSM CRITERIA DSM criteria for diagnosing a person with schizophrenia can be seen below. 38 CU IDOL SELF LEARNING MATERIAL (SLM)

A. Characteristic symptoms: 2 (or more) of thesymptoms given below are seen where each of them are present for a substantialamount of timeduring a one month period (or even less if it is treated successfully): 1. delusions 2. hallucinations 3. disorganized speech involving frequent derailment of speech orincoherence of speech 4. grossly disorganized in the form of catatonia or catatonic behavior 5. negative symptoms like flattening of affective, alogiaor avolition Note: A. Delusions or Hallucinations: Only first criterion is present.In such cases, any of the symptoms are required if delusionsare bizarre or auditory hallucinations is present consisting of a voice making up acontinuous commenting on the individual’s behavior or thoughts,or two or more voices are heard conversing with each other. B. Social/occupational dysfunction: Since the onset of the disorder one or moremajor areas of functioning such as work, interpersonalrelations, or self-care are markedly below the levelachieved prior to the onset. In case where the onset of schizophrenia is inchildhood or adolescence we see failure to achieve expected levelof interpersonal, academic, or occupational achievement). This disturbance is seen for a significant portion of the time. C. Duration: Continuous signs of the disturbance are seenat least for 6 months. This 6-month period must includeat least 1 month of symptoms like delusions or hallucinations that meet criterion A. This phase is referred to as activephaseand the symptoms are referred to as active phase symptoms.This period includes periods of prodromal symptoms orresidual symptoms. We can see the signs of significant disturbancesand presence of negative symptoms or two or more symptomslisted in criterion A present in a diminished form likeodd beliefs as well as unusual perceptual experiences. D. Exclusion of schizoaffective and mood disorder:We should rule out schizoaffective disorder and mood disorder withpsychotic features because either 1. No major depressive, manic, or mixed episodes is present or haveconcurrently occurred with the active-phase symptoms;or 2. Even if mood episodes have occurred concurrently during activephasesymptoms, their total duration has been briefrelative to the duration of the active and residual periods. E. Exclusion of substance/general medical condition: Thesymptomsarenot a result of physiological effectsof a substanceincluding psychoactive drug of abuse, a medication or ageneral medical condition. F. Relationship with a pervasive developmental disorder: Ifthere is a history of autistic disorder or another pervasivedevelopmental disorder, the additional diagnosis ofschizophrenia is made only if prominent delusions orhallucinations are also present for at least a month (or lessif successfully treated). DSM Criteria for Paranoid Type 39 CU IDOL SELF LEARNING MATERIAL (SLM)

The patient is diagnosed with paranoid schizophrenia when the criteria given below aremet: A. The patient is preoccupied with one or more delusions or has frequentauditory hallucinations. B. The symptoms like disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect are not prominent. DSM Criteria for Catatonic Type The patient is diagnosed with catatonic schizophrenia when the criteria given below are met: 1. motoric immobility as evidenced by catalepsy (includingwaxy flexibility) or stupor 2. excessive motor activity which is apparent without any purposeand is not influenced by any external stimuli 3. extreme negativism is seen as apparent andwithout any purpose or resistanceto all instructions or maintenance of a rigid postureagainst attempts to be moved or mutism 4. Peculiarities of voluntary movement as evidenced byposturing (voluntary assumption of inappropriate orbizarre postures), stereotyped movements, prominentmannerisms, or prominent grimacing. DSM Criteria for Disorganized Type The patient is diagnosed with disorganized schizophrenia when the criteria given below are met: A. All of the following are prominent: 1. disorganized speech 2. disorganized behavior 3. flat or inappropriate affect B. The criteria are not met for catatonic type. DSM Criteria for Undifferentiated Type The patient is diagnosed with catatonic undifferentiated when the symptoms that meetcriterion A are present, but the criteria are not met for theparanoid, disorganized, or catatonic type. DSM Criteria for Residual Type The patient is diagnosed with residual schizophrenia when the criteria given below are met: A. Absence of positive symptoms like delusions, hallucinations,disorganized speech, and grossly disorganized orcatatonic behavior. B. There is continuing evidence of the disturbance,as indicated by the presence of negative symptomsor two or more symptoms listed in criterion A forschizophrenia, present in an attenuated form (e.g., oddbeliefs, unusual perceptual experiences). 40 CU IDOL SELF LEARNING MATERIAL (SLM)

3.4 ICD 10 CRITERIA The normal requirement for a diagnosis of schizophrenia is that a minimum of one very clear symptom (and usually two or more if less clear-cut) belonging to any one of the groups listed as (a) to (d) above, or symptoms from at least two of the groups referred to as (e) to (h), should have been clearly present for most of the time during a period of 1 month or more. Conditions meeting such symptomatic requirements but of duration less than 1 month (whether treated or not) should be diagnosed in the first instance as acute schizophrenia-like psychotic disorder (F23.2) and reclassified as schizophrenia if the symptoms persist for longer periods. Symptom (i) in the above list applies only to the diagnosis of Simple Schizophrenia (F20.6), and a duration of at least one year is required. Although no strictly pathognomonic symptoms can be identified, for practical purposes it is useful to divide the above symptoms into groups that have special importance for thediagnosis and often occur together, such as: 1. thought echo, thought insertion or thought withdrawal, and thought broadcasting; 2. delusions of control, delusions of influence, or delusions of passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception; 3. hallucinatory voices giving a running commentary on the patient's behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body; 4. persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (e.g. being able to control the weather, or being in communication with aliens from another world); 5. persistent hallucinations in any modality, when accompanied either by fleeting or half- formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end; 6. breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms; 7. catatonic behaviour, such as excitement, posturing, or waxy flexibility, negativism, mutism, and stupor; 8. \"negative\" symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clears that these are not due to depression or to neuroleptic medication; 9. a significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal. 41 CU IDOL SELF LEARNING MATERIAL (SLM)

3.5 CAUSES OF CHILDHOOD ONSET SCHIZOPHRENIA The exact causes of schizophrenia are unknown. Research suggests a combination of physical, genetic, psychological and environmental factors can make a person more likely to develop the condition. Some people may be prone to schizophrenia, and a stressful or emotional life event might trigger a psychotic episode. However, it's not known why some people develop symptoms while others do not. Many factors may cause schizophrenia, including genetics, environment and disruptions in brain structures, brain function, and brain chemistry. Genetics Schizophrenia tends to run in families, but no single gene is thought to be responsible. It's more likely that different combinations of genes make people more vulnerable to the condition. However, having these genes does not necessarily mean you'll develop schizophrenia. Evidence that the disorder is partly inherited comes from studies of twins. Identical twins share the same genes. In identical twins, if a twin develops schizophrenia, the other twin has a 1 in 2 chance of developing it, too. This is true even if they're raised separately. In non-identical twins, who have different genetic make-ups, when a twin develops schizophrenia, the other only has a 1 in 8 chance of developing the condition. While this is higher than in the general population, where the chance is about 1 in 100, it suggests genes are not the only factor influencing the development of schizophrenia. Brain development Studies of people with schizophrenia have shown there are subtle differences in the structure of their brains. These changes are not seen in everyone with schizophrenia and can occur in people who do not have a mental illness. But they suggest schizophrenia may partly be a disorder of the brain. Neurotransmitters Neurotransmitters are chemicals that carry messages between brain cells. There's a connection between neurotransmitters and schizophrenia because drugs that alter the levels of neurotransmitters in the brain are known to relieve some of the symptoms of schizophrenia. Research suggests schizophrenia may be caused by a change in the level of 2 neurotransmitters: dopamine and serotonin. Some studies indicate an imbalance between the 2 may be the basis of the problem. Others have found a change in the body's sensitivity to the neurotransmitters is part of the cause of schizophrenia. Pregnancy and birth complications 42 CU IDOL SELF LEARNING MATERIAL (SLM)

Research studies with patients with schizophrenia have shown people who develop schizophrenia are more likely to have experienced complications before and during their birth, such as:  a low birthweight  premature labour  a lack of oxygen (asphyxia) during birth It may be that these things have a subtle effect on brain development. Triggers Triggers are things that can cause schizophrenia to develop in people who are at risk. These include stress and drug abuse. Stress The main psychological triggers of schizophrenia are stressful life events, such as:  bereavement  losing your job or home  divorce  the end of a relationship  physical, sexual or emotional abuse These kinds of experiences, although stressful, do not cause schizophrenia. However, they can trigger its development in someone already vulnerable to it. Drug abuse Drugs do not directly cause schizophrenia, but studies have shown drug misuse increases the risk of developing schizophrenia or a similar illness. Certain psychoactive drugs like cannabis, cocaine, LSD or amphetamines are likely to trigger symptoms of schizophrenia in people who are susceptible. Using amphetamines or cocaine may also lead to psychosis. They can cause a relapse in people recovering from an earlier episode. Research also has shown that teenagers and young adults who use cannabis regularly are more likely to develop schizophrenia in later adulthood. 3.6 SUMMARY  Schizophrenia is characterized by a broad spectrum of cognitive and emotional dysfunctions that include delusions and hallucinations, disorganized speech and behavior, and inappropriate emotions.  The symptoms of schizophrenia can be divided into positive, negative, and disorganized. Positive symptoms are active manifestations of abnormal behavior, or an excess or distortion of normal behavior, and include delusions and hallucinations. 43 CU IDOL SELF LEARNING MATERIAL (SLM)

 Negative symptoms involve deficits in normal behavior on such dimensions as affect, speech, and motivation. Disorganized or behavioral symptoms of schizophrenia include rambling of speech, erratic behaviors and mannerisms and inappropriate affect.  DSM-IV-TR classifies schizophrenia into five subtypes.  People with the paranoid type of schizophrenia have prominent positive symptoms like delusions or hallucinations where as their cognitive skills as well as affect remain relatively intact.  People with the disorganized type of schizophrenia tend to show marked disruption in their speech and behavior; they also show flat or inappropriate affect.  People with the catatonic type of schizophrenia have unusual motor responses, such as remaining in fixed positions (waxy flexibility), excessive activity, and being oppositional by remaining rigid. In addition, they display odd mannerisms with their bodies and faces, including grimacing.  People who do not fit neatly into these subtypes are classified as having an undifferentiated type of schizophrenia. Some people who have had at least one episode of schizophrenia but who no longer have major symptoms are diagnosed as having the residual type of schizophrenia.  Several other disorders are characterized by psychotic behaviors, such as hallucinations and delusions; these include schizophreniform disorder (which includes people who experience the symptoms of schizophrenia for less than 6 months); schizoaffective disorder (which includes people who have symptoms of schizophrenia and who exhibit the characteristics of mood disorders, such as depression and bipolar affective disorder); delusional disorder (which includes people with a persistent belief that is contrary to reality, in the absence of the other characteristics of schizophrenia); brief psychotic disorder (which includes people with one or more positive symptoms, such as delusions, hallucinations, or disorganized speech or behavior over the course of less than a month); and shared psychotic disorder (which includes individuals who develop delusions simply as a result of a close relationship with a delusional individual).  A number of causative factors have been implicated for schizophrenia, including genetic influences, neurotransmitter imbalances, structural damage to the brain caused by a prenatal viral infection or birth injury, and psychological stressors. 3.7 KEYWORDS  Aetiology: The study of the origins of disease: physical, mental or emotional.  Childhood-onset schizophrenia: Childhood-onset schizophrenia is a severe form of psychotic disorder that occurs at age 12 years or younger. 44 CU IDOL SELF LEARNING MATERIAL (SLM)

 Catatonic: Descriptive of psychotic state generally considered to be a form of schizophrenia. Characterized by violent changes in behaviour from mainly rigid, frozen states (including catalepsy) to occasional extremes of excitement and activity.  Delusions: Beliefs that have no basis in reality.  Hallucinations: Hearing, seeing, touching, smelling or tasting things that are not real.  Negative Symptoms: Examples of negative symptoms that “take away” from life include social withdrawal, lost interest in life, low energy, emotional flatness, reduced ability to concentrate and remember.  Positive Symptoms: Psychotic symptoms are often classified as positive or negative. Examples of positive symptoms that “add to” a person’s experiences include delusions (believing something to be true when it is not) and hallucinations (seeing, hearing, feeling, smelling or tasting something that is not real).  Schizophrenia: A severe mental disorder that appears in late adolescence or early adulthood. People with schizophrenia may have hallucinations, delusions, loss of personality, confusion, agitation, social withdrawal, psychosis and/or extremely odd behavior. 3.8 LEARNING ACTIVITY 1. Explain with the help of the case study given in the unit, the DSM criteria for childhood onset schizophrenia? ___________________________________________________________________________ ___________________________________________________________________________ 2. Explain with the help of the case study given in the unit, the ICD 10 criteria for childhood onset schizophrenia? ___________________________________________________________________________ ___________________________________________________________________________ 3.9 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What is childhood onset schizophrenia? 2. What are the positive symptoms of schizophrenia? 3. What are the negative symptoms of schizophrenia? 4. Name any two sub types of schizophrenia? 5. What is the general prevalence of children with schizophrenia? Long Questions 45 CU IDOL SELF LEARNING MATERIAL (SLM)

1. What are hallucinations? Explain the different types of hallucinations in detail. 2. What are delusions? Explain the different types of delusions in detail. 3. Explain in detail the causes of schizophrenia. 4. What is the DSM criterion for Schizophrenia? 5. What is the ICD 10 criterion for Schizophrenia? B. Multiple Choice Questions 1. Childhood schizophrenia is essentially the _________ as schizophrenia in adults a. same b. unique c. common d. different 2. The onset of Childhood schizophrenia is in ______________ a. teenage b. infancy c. toddlerhood d. before 5 years 3. Schizophrenia is _______________ health condition a. physical b. emotional c. mental d. social 4. Schizophrenia usually appears in ______________________ a. Late adolescence b. Early Childhood c. Old age d. Middle age 5. The phenomenon in Schizophrenia, known as 'downward drift' means which of the following? a. Falling to the bottom of the social ladder b. Become homeless c. Inability to hold down a job d. All of these 46 CU IDOL SELF LEARNING MATERIAL (SLM)

Answer 1-a, 2-a, 3-c, 4-a, 5-d 3.10 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.  Clifford Morgan, Richard King, John Weisz, John Schopler (2004) Introduction to Psychology, McGraw-Hil, New Delhi  Domjan Michael (2010). The Principles of Learning and Behavior (6th Edt) Wadsworth, Cengage Learning.  Hergenhahn B R (2008). An introduction to the history of psychology, Wadsworth, Cengage Learning.  Robert S. Feldman (2011) Understanding Psychology, McGraw-Hil, New Delhi.  Robert. A. Baron, Psychology, (2008) Prentice Hall India. Reference books  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., &Oltmans, T.F. (1998). Abnormal Psychology (2nd ed.). Upper Saddle River, NJ: Prentice-Hall, Inc.  Kay J, Tasman A. (2006) Essentials of Psychiatry, Chichester, John R. Wiley and Sons. Sadock, Benjamin, J., & Virginia A. (2002). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (9th ed.). Lippincott Williams &Wilkins.  Sarason I., G & Sarason B. R. (2005).Abnormal psychology: The problem of maladaptive behavior. (11th edn). PHI Learning Private limited.  World Health Organization (1993). The ICD-10 Classification of Mental and Behavioral Disorders Websites  www.simplypsychology.com  http://www.human-memory.net  www.simplypsychology.org  https://psychcentral.com  https://courses.lumenlearning.com 47 CU IDOL SELF LEARNING MATERIAL (SLM)

 https://www.sparknotes.com 48 CU IDOL SELF LEARNING MATERIAL (SLM)

UNIT 4 – SCHIZOPHRENIA PART II STRUCTURE 4.0 Learning Objectives 4.1 Introduction 4.2 Types of Childhood Onset Schizophrenia 4.3 Incidence of Childhood Onset Schizophrenia 4.4 Prevalence of Childhood Onset Schizophrenia 4.5 Assessment of Childhood Onset Schizophrenia 4.6 Prognosis of Childhood Onset Schizophrenia 4.7 Treatment for Childhood Onset Schizophrenia 4.8 Summary 4.9 Key Words 4.10 Learning Activity 4.11 Unit End Questions 4.12 References 4.0 LEARNING OBJECTIVES After studying this unit, you will be able to,  Explain the incidence of Childhood Onset Schizophrenia  Explain the prevalence of Childhood Onset Schizophrenia  Describe the process of assessment of Childhood Onset Schizophrenia  Describe the prognosis of Childhood Onset Schizophrenia  Explain the Treatment forChildhood Onset Schizophrenia 4.1 INTRODUCTION People with schizophrenia may have trouble organizing their thoughts or making logical connections. These people may feel like their thoughts are jumping from one thought to another unrelated thought. Sometimes they experiencea phenomenon of \"thought withdrawal,\" which refers to a feeling that a person’s thoughts are removed from their head, or phenomenon of \"thought blocking,\" when a person's flow of thought gets interrupted suddenly. The disease has a major impact in many ways. People may talk and not make sense, or they make up words. People with schizophrenia may either be agitated or aggressive or they may show no expression. They also have trouble maintaining personal cleanliness as well as maintaining their surrounding and keeping their homes clean. Some repeat behaviors, such as pacing. Despite myths, the risk of violence against others is small. 49 CU IDOL SELF LEARNING MATERIAL (SLM)

The personal, social and economic costs of brain disorders have been underestimated for decades because of the lack of valid and acceptable information. Schizophrenia is consistently demonstrated to have a major negative impact on quality of life, linked with disempowerment and social exclusion. People with schizophrenia often have trouble finding or keeping a job. This is partly because the disease affects thinking, concentration, and communication. But it also stems from the fact that symptoms start in young adulthood, when many people are starting their careers. Vocational and occupational rehabilitation can help people with schizophrenia in developing practical skills applicable in work place settings.Relationships can be rocky for people with schizophrenia. Their unusual thoughts and behaviors may keep friends, co-workers, and family members away. Treatment can help. One form of therapy focuses on forming and nurturing relationships. People suffering from schizophrenia are much more likely to abuse alcohol or illicit drugs than other people. Some substances they use include marijuana and cocaine. This substance can make their symptoms worse. Drug abuse also interferes with treatments for schizophrenia. Living with a close relative who suffering from a mental illness may result inlong term and debilitating negative impacts on that person and family. This may include developing symptoms of schizophrenia or the illness itself. Familial care for a person with mental illness has its advantages, yet it has multiple social and psychological challenges. Coping strategies and skills are crucial for the well-being of the caregiver as well as the patient. Addressing these psychosocial challenges may require a collaborative approach between the health care providers and government so that the needs of the family caregivers and those of the patients can be addressed accordingly. It can be hard to convince someone with schizophrenia to get help. Treatment Forten begins when a psychotic episode results in a hospital stay. Once the person is stabilized, family members can do these things to help prevent a relapse:  Encourage the person to stay on medication  Go with them to their follow-up appointments  Be supportive and respectful 4.2 TYPES OF CHILDHOOD ONSET SCHIZOPHRENIA In DSM-IV, schizophrenia has been categorized into various clinical subtypes. These subtypes are based on field trials of the reliability of symptom clusters. The subtypes are divided by the most prominent symptoms, although it is acknowledged that the specific subtype may exist simultaneously with or change over the course of the illness. DSM-IV also initiates an optional dimensional descriptor, which allows the condition to be characterized by the presence or absence of a psychotic, disorganized, or negative symptom dimension over the entire course of the illness. 50 CU IDOL SELF LEARNING MATERIAL (SLM)