4.2.1 Paranoid Type In DSM-IV, paranoid-type schizophrenia is marked by hallucinations or delusions in the presence of a clear sensorium and unchanged cognition. Disorganized speech, disorganized behavior and flat or inappropriate affect are not present to any significant degree. The delusions are usually those of a persecutory or grandiose nature. The hallucinations most often revolve around a particular theme or a group of related themes. Because of these delusions, persons with schizophrenia may attempt to keep the interviewer at bay. This makes them appear to be hostile or angry during an interview. This sub-category of schizophrenia has a later age of onset and a better prognosis than the other subtypes. 4.2.2 Disorganized Type Disorganized schizophrenia was historically referred to as hebephrenic schizophrenia. Disorganized schizophrenia or hebephrenic schizophrenia presents itself with the followingpredominant symptoms including disorganized speech and/or disorganized behavior. They may also present with symptoms like flat or inappropriate (incongruent) affect. In case if there are delusions or hallucinations arepresent, they also tend to be of disorganized nature and are not rarely related to a single theme. Moreover, these patients could not be classified as having catatonic schizophrenia. Patients with this sub-category of schizophrenia in general have more severe deficits on neuropsychological tests. According to DSM-IV, these patients tend to have an earlier age at onset, an unremitting course, and a poor prognosis. 4.2.3 Catatonic Type Patients with catatonic type of schizophrenia havedistinct features that distinguish them from other subtypes of schizophrenia. During the acute phase of this disorder, patients usually demonstrate typical negativism or mutism along withsignificant psychomotor retardation or even severe psychomotor agitation, echolalia or repeating of sounds or words or phrases in a nonsensical manner, echopraxia or mimicking the behaviors of others, or bizarreness of voluntary movements and mannerisms. Some patients demonstrate a waxy flexibility, which is seen when a limb is repositioned on examination and remains in that position as if the patient were made of wax. Patients with catatonic stupor must be protected against bodily harm resulting from the profound psychomotor retardation. They may remain in the same position for weeks at a time. Because of extreme mutism or agitation, patients may not be able to report any difficulties. Some patients may experience extreme psychomotor agitation, with grimacing and bizarre postures. These patients may require careful monitoring to safeguard them from injury or deterioration in nutritional status or fluid balance. 51 CU IDOL SELF LEARNING MATERIAL (SLM)
4.2.4 Undifferentiated Type There is no specific symptom that distinguishes undifferentiated schizophrenia from other sub-categories. Therefore, it is the subtype that meets the criterion ‘A’ for schizophrenia but does not fit into the profile for either paranoid, disorganized, or catatonic schizophrenia. 4.2.5 Residual Type The diagnosis of residual schizophrenia, according to DSM-IV,is appropriately used when there is a past history of an acute episodeof schizophrenia but at the time of presentation the patientdoes not manifest any of the associated psychotic or positivesymptoms. However, there have beensignificant evidence of schizophreniathat manifested themselves in either negative symptoms or low-grade symptomsof criterion A. These may include odd behavior, some abnormalitiesof thought processes, or delusions or hallucinationsthat exist in a minimal form. This type of schizophrenia has anunpredictable, variable course. 4.3 INCIDENCE OF CHILDHOOD ONSET SCHIZOPHRENIA The incidence of any disease or disorder is defined as the number of new cases in a given population, usually per 1000 persons, during a specific period of time which is 1 year by convention. In an illness with an insidious onset, such as schizophrenia, accurate incidence rates can be difficult to determine. The incidence varies depending on the methods and the diagnostic criteria used. For example, the US–UK study is often cited as an example of epidemiological variation based on different diagnostic criteria (Kramer, 1969). This study, conducted in the 1960s, found a lower incidence of schizophrenia in the UK than in the USA. 4.4 PREVALENCE OF CHILDHOOD ONSET SCHIZOPHRENIA Roughly one in a thousand 12–17-year-olds have experienced a psychotic disorder. Approximately half of these psychotic disorders are schizophrenia, while most of the rest are linked to depression, mania or drugs. Although schizophrenia can occur in children as young as 7, onset is very uncommon before puberty and becomes increasingly common as adolescence progresses, peaking in early adult life. Though males are generally more vulnerable to early-onset schizophrenia, the sex ratio is reversed in the 11–14 age band, perhaps because girls are much more likely than boys to be post pubertal at this age. 4.5 ASSESSMENT OF CHILDHOOD ONSET SCHIZOPHRENIA Making an accurate diagnosis of schizophrenia requires highlevels of clinical acumen, extensive knowledge of schizophreniaand sophisticated application of the principles of differential diagnosis.It is unfortunately common for patients with psychoticdisorders to be misdiagnosed and consequently treated inappropriately.The importance of accurate diagnosis is underlined byan emerging database indicating that early detection and promptpharmacological intervention may improve the long-term prognosisof the illness. 52 CU IDOL SELF LEARNING MATERIAL (SLM)
Mental Status Examination There is no specific laboratory test, neuroimaging study, or clinicalpresentation of a patient that yields a definitive diagnosis of schizophrenia.Schizophrenia can present with a wide variety of symptoms,and a longitudinal history of symptoms and comorbid clinicalvariables such as medical illness and a history of substance abuseare necessary before a diagnosis can be considered. The MentalStatus Examination, much like the physical examination, is an additionalclinical tool that aids the psychiatrist in generating a differentialdiagnosis and appropriate treatment recommendations. Appearance Although a disheveled look is not pathognomonic for schizophrenia,patients with this disorder often present, especially acutely,with a disordered appearance. The description of a patient’s appearanceis an objective verbal sketch, much like the descriptionof a heart murmur that can uniquely identify a particular patient. A person with schizophrenia often has difficulty attendingto activities of daily living, either because of negative symptoms(apathy, social withdrawal, or motor retardation) or because ofthe presence of positive symptoms, such as psychosis, disorganization,or catatonia, that interfere with the ability to maintainpersonal hygiene. Also, schizophrenia patients often presentwith odd or inappropriate attire, such as a coat and hat worn duringthe summer or dark sunglasses worn during an interview. It is generally thought that the inappropriate dress is a manifestationof symptoms such as disorganization or paranoid ideation. Itshould be noted that some patients present quite neatly groomed.Thus appearance is noted but is not diagnostic. Attitude Individuals with schizophrenia may be friendly and cooperative,or they may be hostile, annoyed and defensive during aninterview. The latter may be secondary to paranoid symptoms,which can make patients quite cautious and guarded in their responsesto questions. Behavior Schizophrenic patients can have bizarre mannerisms or stereotypedmovements that can make them look unusual. Patientswith catatonia can stay in one position for weeks, even to thepoint of causing serious physical damage to their body; for example,a patient who stands in one place for days may developstress fractures, peripheral edema and even pulmonary emboli.Patients with catatonia may have waxy flexibility, maintaininga position after someone else has moved them into it. Patientswith catatonic excitement exhibit odd posturing or purposeless,repetitive, and often strange movements. Behaviors seen in schizophrenia patients include choreoathetoidmovements, which may be related to neuroleptic exposurebut have been reported in patients even before neuroleptic use.Other behaviors or movement disorders may be seen as parkinsonianfeatures, such as a shuffling gait or a pill-rolling tremor.Psychomotor retardation may be present and may be amanifestation of catatonia or negative symptoms. On close observation,it is usually 53 CU IDOL SELF LEARNING MATERIAL (SLM)
characterized, in this group of patients, asa lack of motor movements rather than slowed movements. Patients may present with agitation, ranging from minimalto extreme. This agitation is often seen in the acute state and mayrequire immediate pharmacotherapy. However, agitation may besecondary to neuroleptic medications, as in akathisia, which isfelt as an internal restlessness making it difficult for the personto sit still. Akathisia can manifest itself in limb shaking, pacing,or frequent shifting of position. Severely agitated patients maybe unresponsive to verbal limits and may require measures toensure their safety and the safety of others around them. Eye Contact Paranoid patients may look hyper vigilant, scanning a room orglancing suspiciously at an interviewer. Psychotic patients maymake poor eye contact, looking away, or appear to stare vacuouslyat the interviewer, making a conversational connectionseem distant. Characteristic responding to internal stimuli isseen when a patient appears to look toward a voice or an auditoryhallucination, which the patient may hear. A nystagmus may alsobe observed. This clinical finding has a large differential diagnosis,including Wernicke-Korsakoff syndrome; alcohol, barbiturate,or phenytoin intoxication; viral labyrinthitis; or brain stemsyndromes including infarctions or multiple sclerosis. Speech In a Mental Status Examination, one usually comments on therate, tone and volume of a patient’s speech, as well as any distinctdysarthria’s that may be present. Pressured speech is usually thoughtof in conjunction with mania; however, it can be seen in schizophreniapatients, particularly on acute presentation. This is oftendifficult to assess, as it may be a normal variant or a cultural phenomenon,because some languages are spoken faster than others.Tone refers to prosody, or the natural singsong quality ofspeech. Negative symptoms may include a lack of prosody, resultingin monotonous speech. Furthermore, odd tones may beconsistent with neurological disorders or bizarre behavior. Speech volume is important for a number of reasons. Loudspeech can be a measure of agitation; it can occur in conjunctionwith psychosis, or it could even be an indication of hearingloss. Speech that is soft may be an indication of guardedness oranxiety. Dysarthria’s are notable because they can be idiopathicand longstanding, or they can be an indication of neurologicaldisturbance. In patients who have been exposed to neuroleptics,or buccal tardive dyskinesia should be considered when there isevidence of slurred speech. Mood and Affect Affect, which is the observer’s objective view of the patient’semotional state, is often constricted or flat in patients with schizophrenia.In fact, this is one of the hallmark negative symptoms.Flattened affect may also be a manifestation of pseudo parkinsonism,an extrapyramidal side effect of typical neuroleptics. Inappropriate affect is commonly seen in patients with morepredominant positive symptoms. A smile or a laugh while relatinga sad tale is an example. Patients with catatonic excitement 54 CU IDOL SELF LEARNING MATERIAL (SLM)
orhebephrenia may have bizarre presentations or affective lability,laughing and crying out of context with the situation. Emotionalreactivity must alert the clinician to the possibility of neurologicalimpairment as well, as in the case of pseudobulbar palsy. Mood is based on a patient’s subjective report of how he orshe feels, emotionally, at the time of the interview. It is not uncommonfor patients with schizophrenia to be depressed (especiallypatients with history of higher premorbid functioning who mayhave some insight into the losses they are facing) or to be indifferent,with seemingly no emotional awareness of their situation. Thought Process Because actual thoughts cannot be measured, thought processesare assessed by extrapolation from the organization of speech.Thought disorders can be more or less obvious, and a trained listeneris one who appreciates the normal logical pattern of flow ofwords and ideas in speech and can thus sense abnormalities. There are many different versions of thought disorders:lack of logical connections of ideas (looseness of associations);shift of the original theme because of weak connections of ideas(tangentiality); overinclusiveness to the point of loss of the theme(circumstantiality); use of words and phrases with no relation togrammatical rules (word salad); repetition of words spoken byothers (echolalia); use of sounds of other words, such as “yellowbellow, who is this fellow?” (Clang associations); use of made-upwords (neologisms); and repetition of a particular word or phrase,such as “this and that, this and that” (perseveration). Other thought disorders are part of a constellation ofnegative symptoms. Examples would be thoughts that appearto stop abruptly, either because of interruption by an auditoryhallucination or because the thought is lost (thought blocking); absence of thoughts (paucity of thought content); and a delayedresponse to questions (increased latency of response). Thought Content Although not necessarily present in every patient, characteristicsymptoms of schizophrenia include the belief that outside forcescontrol a person’s thought or actions. A patient might report thatothers can insert thoughts into her or his head (thought insertion),broadcast them to others (thought broadcasting), or takethoughts away (thought withdrawal). Other delusions, or fixedfalse beliefs, may also be prominent. Patients may describe ideasof reference, which is the phenomenon of feeling that some externalevent or report relates to oneself specifically; for example, apatient may infer special meaning from an image seen on televisionor a broadcast heard on the radio. Paranoid ideation may be manifested as general suspiciousnessor frank, well-systematized delusions. The themes may beconsidered bizarre, such as feeling convinced that aliens are sendingsignals through wires in the patient’s ear, or non-bizarre, suchas being watched by the Central Intelligence Agency or believingthat one’s spouse is having an affair. These symptoms can be quitedebilitating and lead to a great deal of personal loss, which patientsmay not understand because the ideas are so real to them. 55 CU IDOL SELF LEARNING MATERIAL (SLM)
Patients with schizophrenia commonly express an abundanceof vague somatic concerns, and a particular patient mightdevelop a delusion around a real physiological abnormality.Therefore, somatic symptoms should be evaluated appropriatelyin their clinical context without automatically dismissing themas psychotic. Preoccupations and obsessions are also seen commonlyin this population, and certain patients have comorbid obsessive– compulsive disorder. The mortality rate for suicide in schizophrenia is approximately10%. It is therefore imperative to evaluate a patient for bothsuicidal and homicidal ideation. Patients of all diagnoses, and particularlyschizophrenia, may not spontaneously articulate suicidalor homicidal ideation and must therefore be asked directly aboutsuch feelings. Moreover, psychotic patients may feel compelled byan auditory hallucination telling them to hurt themselves. Perceptions Perceptual disturbances involve illusions and hallucinations. Hallucinationsmay be olfactory, tactile, gustatory, visual, or auditory,although hallucinations of the auditory type are more typicalof schizophrenia. Hallucinations in the other sensory modalitiesare more commonly seen in other medical or substance-inducedconditions. Auditory hallucinations can resemble sounds, backgroundnoise, or human voices. Auditory hallucinations that consistof a running dialogue between two or more voices or a commentaryon the patient’s behavior are typical of schizophrenia. These hallucinations are distinct from verbalized thoughts thatmost humans experience. They are often described as originatingfrom outside the patient’s head, as if they were emanating fromthe walls or the radiators in the room. Less commonly, a patientwith schizophrenia describes illusions or misperceptions of a realstimulus, such as seeing demons in a shadow. Consciousness and Orientation Patients with schizophrenia most likely have a clear sensoriumunless there is some comorbid medical illness or substancerelatedphenomenon. A schizophrenia patient may be disoriented,but this could be a result of inattentiveness to details ordistraction secondary to psychotic preoccupation. Attention and Concentration Studies utilizing continuous performance task paradigms havedemonstrated repeatedly that schizophrenia patients havepervasive deficits in attention in both acute and residual phases.On a Mental Status Examination, these deficits may presentthemselves as the inability to perform mental exercises, such asspelling the word “earth” backward or serial subtractions. Memory Careful assessment of memory in patients with schizophreniamay yield some deficits. Acquisition of new information, immediaterecall, and recent and remote memory may be impaired insome individuals. Furthermore, answers to questions regardingmemory may lead to idiosyncratic responses related to delusions,thought disorder, or other overriding symptoms 56 CU IDOL SELF LEARNING MATERIAL (SLM)
of the illness.In general, schizophrenia patients do not show gross deficits ofmemory such as may be seen in patients with dementia or headtrauma. Fund of Knowledge Schizophrenia is not the equivalent of mental retardation, althoughthese syndromes can coexist in some patients. Patientswith schizophrenia generally experience a slight shift in intellectualfunctioning after the onset of their illness, yet they typicallydemonstrate a fund of knowledge consistent with their premorbidlevel. Schizophrenia patients manifest a characteristic discrepancyon standardized tests of intelligence, with the nonverbalscores being lower than the verbal scores. Abstraction A classical aberration of mental function in a patient with schizophreniainvolves the inability to utilize abstract reasoning, whichis similar to metaphorical thinking, or the ability to conceptualizeideas beyond their literal meaning. For example, when thepatient is asked what brought him or her to the hospital, a typicalanswer might be “an ambulance”. On a Mental Status Examination,this concrete thinking is best elicited by asking a patient tointerpret a proverb or state the similarities between two objects. For example, “a rolling stone gathers no moss” may mean, to thepatient with schizophrenia, that “if a stone just stays in one place,the moss won’t be able to collect”. More profound difficulties inabstraction and executive function, often seen in schizophrenia,such as inability to shift cognitive focus or set, may be assessedby neuropsychological tests. Judgment and Insight Individuals suffering from schizophrenia often display a lack ofinsight regarding their illness. Whether it is a reflection of a negativesymptom, such as apathy, or a constricted display of emotion,patients often appear to be emotionally disconnected from theirillness and may even deny that anything is wrong. Poor judgment,which is also characteristic and may be related to lack ofinsight, may lead to potentially dangerous behavior. For example, her or his shoes could be traced by surveillance cameras wouldbe displaying both poor judgment and poor insight. On a formalMental Status Examination, judgment is commonly assessed byasking patients what they would do if they saw a fire in a movietheater or if they saw a stamped, addressed envelope on the street.Insight can be ascertained by asking patients about their understandingof why they are being evaluated by a psychiatrist or whythey are receiving a certain medication. Physical Examination Although there are no pathognomonic physical signs of schizophrenia,some patients have neurological “soft” signs on physicalexamination. The neurological deficits include nonspecific abnormalitiesin reflexes, coordination (as seen in gait and fingertonose tests), graphesthesia (recognition of patterns marked outon the palm) and stereognosis (recognition of three-dimensionalpictures). Other neurological findings include odd or awkwardmovements (possibly correlated with thought disorder), alterationsin muscle tone, an 57 CU IDOL SELF LEARNING MATERIAL (SLM)
increased blink rate, a slower habituationof the blink response to repetitive glabellar tap and an abnormalpupillary response. The exact etiology of these abnormalities is unknown, butthey have historically been associated with minimal brain dysfunctionand may be more likely in patients with poor premorbidfunctioning. These neurological abnormalities have been seen inneuroleptic-naive patients as well as those with exposure to traditionalantipsychotic medication. Overall, the literature suggeststhat these findings may be associated with the disease itself. Neuroophthalmological investigations have shown thatpatients with schizophrenia have abnormalities in voluntary saccadiceye movements (rapid eye movement toward a stationaryobject) as well as in smooth pursuit eye movements. The influenceof attention and distraction, neuroleptic exposure and thespecificity of smooth pursuit eye movements for schizophreniahave raised criticisms of this area of study, and further investigationis necessary to determine its potential as a putative geneticmarker for schizophrenia. 4.6 PROGNOSIS OF CHILDHOOD ONSET SCHIZOPHRENIA Early onset generally carries a worse prognosis than adult onset. The best predictors of poor long-term outcome are premorbid social and cognitive impairments, a prolonged first psychotic episode, negative symptoms at onset, and a prolonged period without treatment. Is prognosis improved by detecting and treating first episodes of psychosis more rapidly? Unfortunately, there is little evidence that early intervention teams do lead to a long-term improvement in outcome. Perhaps delayed treatment is not damaging in itself – simply a marker for the insidious onset and negative symptoms that confer a worse prognosis even with rapid treatment. 4.7 TREATMENT FOR CHILDHOOD ONSET SCHIZOPHRENIA It could be argued that the successful Treatment for schizophreniarequires a greater level of clinical knowledge and sophisticationthan the Treatment for most other psychiatric and medical illnesses.It begins with the formation of a therapeutic psychiatrist–patientrelationship and must combine the latest developments in pharmacologicaland psychosocial therapeutics and interventions. The qualities of the relationship should include consistency,acceptance, appropriate levels of warmth that respect the patient’sneeds for titrating emotional intensity, no intrusiveness and, mostimportant, caring. “Old-fashioned” family doctors who knowtheir patients well, are easily approachable, have a matter-of-factstyle, attend to a broad range of needs, and are available and willingto reach out during crises provide a useful model for the psychiatrist– patient relationship in the Treatment for schizophrenia. 58 CU IDOL SELF LEARNING MATERIAL (SLM)
4.7.1 Psychiatrist–Patient Relationship The psychiatrist–patient relationship is the foundation for treatingpatients with schizophrenia. Because of the clinical manifestationsof the illness, the formation of this relationship is oftendifficult. Paranoid delusions may lead to mistrust of the psychiatrist. Conceptual disorganization and cognitive impairment makeit difficult for patients to attend to what the psychiatrist is sayingand to follow even the simplest directions. Negative symptomsresult in lack of emotional expression and social withdrawal,which can be demoralizing for the psychiatrist who is attemptingto “connect” with the patient. It is important for the psychiatrist to understand the waysin which the psychopathology of the illness affects the therapeuticrelationship. The psychiatrist should provide constancy to thepatient, which helps “anchor” patients in their turbulent world. 4.7.2 Antipsychotic medications Antipsychotic medications help patients with the psychotic symptoms of schizophrenia. Some people have side effects when they start taking medications, but most side effects go away after a few days. People respond to antipsychotic medications differently, so it is important to report any of these side effects to a doctor. Sometimes a person needs to try several medications before finding the right one. A patient should not stop taking a medication without first talking to a doctor. Suddenly stopping medication can be dangerous, and it can make schizophrenia symptoms worse. Choosing the right medication, medication dose, and treatment plan should be done under an expert’s care and based on an individual’s needs and medical situation. Only an expert clinician can help a patient decide whether the medication’s ability to help is worth the risk of a side effect. 4.7.3 Psychosocial treatments Psychosocial treatments help patients deal with everyday challenges of schizophrenia. These treatments are often most helpful after patients find a medication that works. Examples of treatment include: Family education: Teaches the whole family how to cope with the illness and help their loved one. Illness management skills: Helps the patient learn about schizophrenia and manage it from day to day. Cognitive behavioral therapy (CBT): Helps the patient identify current problems and how to solve them. A CBT therapist focuses on changing unhelpful patterns of thinking and behavior. Rehabilitation: Helps with getting and keeping a job or going to school and everyday living skills. Peer counseling: Encourages individuals to receive help from other people who are further along in their recovery from schizophrenia. 59 CU IDOL SELF LEARNING MATERIAL (SLM)
Self-help groups: Provides support from other people with the illness and their families. Treatment for drug and alcohol misuse: Is often combined with other treatments for schizophrenia. Psychosocial Rehabilitation Bachrach has defined psychosocial rehabilitation as “a therapeuticapproach which encourages a person with mental illness to develop hisor her capacities to their full extent through learning and environmental supports”(Bachrach, 2000). According to Bachrach, the rehabilitationprocess should appreciate the unique life circumstances ofeach person and respond to the individual’s special needs whilepromoting both the Treatment for the illness and the reduction ofits attendant disabilities. The treatment should be provided inthe context of the individual’s unique environment taking intoaccount social support network, access to transportation, housing,work opportunities and so on. Rehabilitation should exploitthe patient’s strengths and improve his/her competencies. Ultimately, rehabilitation should focus on the positive conceptof restoring hope to those who have suffered major setbacks infunctional capacity and their self-esteem due to major mental illness.To have this hope grounded in reality, it requires promotingacceptance of one’s illness and the limitations that come withit. While work offers the ultimate in sense of achievement andmastery, it must be defined more broadly for the mentally ill andshould include prevocational and nonvocational activities alongwith independent employment. It is extremely important thatwork is individualized to the talents, skills, and abilities of theindividual concerned. However, psychosocial rehabilitation hasto transcend work to encompass medical, social and recreationalthemes. Psychosocial treatment’s basic principle is to providecomprehensive care through active involvement of the patientin his or her own treatment. Thus, it is important that a holdingenvironment be created where patients can safely express theirwishes, aspirations, frustrations and reservations such that theyultimately mold the rehabilitation plan. Clearly, to achieve thesegoals, the intervention has to be ongoing. Given the chronicity of the illness, the process of rehabilitationmust be enduring to encounter future stresses and challenges.These goals cannot be achieved without a stable relationshipbetween the patient and rehabilitation counselor, which iscentral to an effective treatment and positive outcome. Thus, psychosocialrehabilitation is intimately connected to the biologicalintervention and forms a core component of the biopsychosocialapproach to the Treatment for schizophrenia. In the real world,programs often deviate from the aforementioned principles andend up putting excessive and unrealistic expectations on patients,thus achieving exactly the opposite of the intended values of theprogram (see Bachrach, 2000 for more details). Individual Psychotherapy Individual therapy in a nontraditional sense can begin on meeting apatient. Even the briefest of normalizing contacts with an agitated,acutely psychotic patient can have therapeutic value. 60 CU IDOL SELF LEARNING MATERIAL (SLM)
Psychodynamicinterpretations are not helpful during the acute stages of theillness and may actually agitate the patient further. The psychiatristusing individual psychotherapy should focus on forming andmaintaining a therapeutic alliance (which is also a necessary partof psychopharmacological treatment) and providing a safe environmentin which the patient is able to discuss symptoms openly. Asound psychotherapist provides clear structure about the therapeuticrelationship and helps the patient to focus on personal goals. Often, a patient is not aware of or does not have insightinto the fact that some beliefs are part of a specific symptom. Apsychotherapist helps a patient to check whether his or her realitycoincides with that of the therapist. The therapeutic interventionthen becomes a frank discussion of what schizophrenia is and howsymptoms may feel to the patient. This objectifying of psychoticor negative symptoms can prove of enormous value in allowingthe patient to feel more in control of the illness. A good analogyis to diabetic patients, who know they have a medical illness andare educated about the symptoms associated with exacerbation. Just as these patients can check blood glucose levels, schizophreniapatients can discuss with a therapist their sleep patterns, theirinterpersonal relationships and their internal thoughts, whichmay lead to earlier detection of relapses.Schizophrenia often strikes just as a person is leaving adolescenceand entering young adulthood. The higher the premorbidlevel of social adjustment and functioning, the more devastatingand confusing the onset of symptoms becomes. Young malepatients with a high level of premorbid function are at increasedrisk of suicide, presumably in part because of the tremendousloss they face. These feelings can continue for years, with schizophreniapatients feeling isolated and robbed of a normal life.Therefore, a component of individual work (which can also beachieved to some degree in a group setting) with these patients isa focus on the impact schizophrenia has had on their lives. Helpingpatients to grieve for these losses is an important process thatmay ultimately help them achieve a better quality of life. Group Psychotherapy Acutely psychotic patients do not benefit from group interaction.As their condition improves, inpatient group therapy prepares patientsfor interpersonal interactions in a controlled setting. Afterdischarge, patients may benefit from day treatment programs andoutpatient groups, which provide ongoing care for patients livingin the community. Because one of the most difficult challenges of schizophreniais the inherent deficits in relatedness, group therapy is an importantmeans of gathering patients together and providing themwith a forum for mutual support. Insight-oriented groups may bedisorganizing for patients with schizophrenia, but task-oriented,supportive groups provide structure and a decreased sense ofisolation for this population of patients. Keeping group focus onstructured topics, such as daily needs or getting the most out ofcommunity services, is useful for these patients. In the era of communitytreatment and brief 61 CU IDOL SELF LEARNING MATERIAL (SLM)
hospitalizations, many patients arebeing seen in medication groups, which they attend regularly todiscuss any side effects or problems and to obtain prescriptions. Psych educational Treatment One of the inherent deficits from which schizophrenia patientssuffer is an inability to engage appropriately in social or occupationalactivities. This debilitating effect is often a lasting feature ofthe illness, despite adequate psychopharmacological intervention.This disability often isolates patients and makes it difficult forthem to advocate appropriate social support or community services. Furthermore, studies have found that there is a correlationbetween poor social functioning and incidence of relapse One ofthe challenges of this area of study is the great deal of variabilityin individual patients. However, standardized measures have beendeveloped to ascertain objective ratings of social deficits. Theseassessments have become important tools in the determination ofeffective no pharmacological treatment strategies. The literature suggests that schizophrenia patients canbenefit from social skills training. This model is based on theidea that the course of schizophrenia is, in part, a product of theenvironment, which is inherently stressful because of the socialdeficits from which these patients suffer. The hypothesis is that if patients are able to monitor and reduce their stress, they couldpotentially decrease their risk of relapse. For this intervention tobe successful, patients must be aware of and set their own goals. Goals such as medication management, activities of daily livingand dealing with a roommate are achievable examples. Socialskills and deficits can be assessed by patients’ self-report, observationof behavioral patterns by trained professionals, or a measurementof physiological responses to specific situations (e.g., increasedpulse when asking someone to dinner). Patients can thenbegin behavioral training in which appropriate social responsesare shaped with the help of instructors. One example of such a program, discussed by Libermanand colleagues (1985), is a highly structured curriculum that includesa training manual, audiovisual aids and role-playing exercises.Behaviors are broken down into small bits, such as learninghow to maintain eye contact, monitor vocal volume, or amelioratebody language. The modules are learned one at a time, withrole-playing, homework and feedback provided to the participants. In several studies, Liberman and coworkers (1986) haveshown that patients who were treated with social skills trainingand medication spent less time hospitalized, with fewer relapsesthan those treated with holistic health measures (e.g., yoga, stressmanagement) on 2-year follow- up. Research such as this in thefield of social skills training is growing as the inherent deficitsin information processing, executive function and interpersonalskills are further elucidated. Social Skills Training In large number of patients, deficits in social competence persistdespite antipsychotic treatment. These deficits can lead tosocial distress whereas social competence can alleviate 62 CU IDOL SELF LEARNING MATERIAL (SLM)
distressrelated to social discomfort. Paradigms using instruction, modeling,role-playing and positive reinforcement are helpful. Controlledstudies suggest that schizophrenia patients are able toacquire lasting social skills after attending such programs andapply these skills to everyday life. Besides reducing anxiety, socialskills training also improve level of social activity and fosternew social contacts. This in turn improves the quality of life andsignificantly shortens duration of inpatient care. However, theirimpact on symptom resolution and relapse rates is unclear. Cognitive Remediation Patients with schizophrenia generally demonstrate poor performancein various aspects of information processing. Cognitivedysfunction can be a rate-limiting factor in learning and socialfunctioning. Additionally, impaired information processing canlead to increased susceptibility to stress and thus to an increaserisk of relapse. Practice appears to improve some of the cognitivedysfunction. Remediation of cognitive dysfunctions with socialskills training has been reported to have positive impact. Varioustypes of cognitive behavioral therapies were particularly effective. Social skills training program, cognitive training programto improve neurocognitive functioning and cognitive behavioraltherapy approaches are oriented towards coping with symptoms,the disorder and everyday problems. Cognitive Adaptation Training Cognitive adaptation training (CAT) is a novel approach to improveadaptive functioning and compensate for the cognitive impairmentsassociated with schizophrenia. A thorough functionalneeds assessment is done to measure current adaptive functioning. Besides measuring adaptive functioning and quantifyingapathy and disinhibition, a neurocognitive assessment using teststo measure executive function, attention, verbal and visual memory,and visual organization is also completed. Treatment plansare adapted to the patient’s level of functioning, which includespatient’s level of apathy. Interventions include removal of distractingstimuli, use of reminders such as checklists, signs and labels. Family Therapy A large body of literature explores the role of familial interactionsand the clinical course of schizophrenia. Many of these studieshave examined the outcome of schizophrenia in relation to thedegree of expressed emotion (EE) in family members. EE is generallydefined as excessive criticism and over involvement of relatives. Schizophrenia patients have been found to have a higherrisk of relapse if their relatives have high EE levels. Clearly, apatient’s disturbing symptoms at the time of relapse may affectthe level of criticism and over involvement of family members,but evidence suggests that preexisting increased EE levels inrelatives predict increased risk of schizophrenic relapse and thatinterventions that decrease EE levels can decrease relapse rates. Hogarty and colleagues (1986) examined the effectivenessof neuroleptics alone, neuroleptics plus psychoeducational familytreatment (based on addressing EE levels), social skills trainingfor neuroleptic-treated patients with schizophrenia, and thecombination of all three. 63 CU IDOL SELF LEARNING MATERIAL (SLM)
Perhaps not surprisingly, they found adecreased relapse rate in the patients treated with medication andfamily therapy as well as in the group treated with neurolepticand social skills training. The combination of the treatments hadan additive effect and was far superior to medication treatmentalone. Though family intervention studies suffer from methodologicallimitations, the efficacy of family intervention on relapserate is fairly well supported. This efficacy was particularly evidentwhen contrasted with low quality or uncontrolled individual treatments. The addition of family intervention to standard Treatment for schizophrenia has a positive impact on outcome to a moderateextent. Family intervention effectively reduces the short- term riskof clinical relapse after remission from an acute episode. There isevidence of effect on patient’s mental state and social functioning,or on any family-related variables. The elements common to mosteffective interventions are inclusion of the patient in at least somephases of the treatment, long duration, and information and educationabout the illness provided within a supportive framework. There is sufficient data only for male chronic patients living with high EE parents. Evidence is limited for recent onset patients, women, and people in different family arrangements and families with low EE. Research in family intervention is still a growing field. Thus, at present it is unclear if the effect seen with family therapy is due to family treatment or more intensive care. Leff (2000) concluded from his review that family interventions reduced relapse rates by one -half over the first year of combined treatment with medications and family therapy. Medications and family therapy augment each other. Psychoeducation by itself is not enough. It also seems that multiple family groups are more efficacious then single family sessions. Attempts are being made to generalize training of mental health workers in effectively implementing these strategies. Based on these findings, it is clear that there is a significant interaction between the level of emotional involvement and criticism of relatives of probands with schizophrenia and the outcomeof their illness. Identifying the causative factors in familialstressors and educating involved family members about schizophrenia lead to long-term benefits for patients. Future work in this field must examine these interactions with an understanding of modern sociological and biological advances in genetics, looking at trait carriers, social skills assessments, positive and negative symptoms, and medication management with the novel antipsychotic agents. Stigma Though tremendous progress has occurred in understanding and Treatment for schizophrenia, stigmatizing attitudes still prevail (Crisp et al., 2000); in a survey, schizophrenia elicited the most negative opinions and over 70% of those questioned thought that schizophrenia patients were dangerous and unpredictable. Thus, stigma surrounding schizophrenia can cause people suffering from the illness to develop low self-esteem, disrupt personal relationships and decrease employment opportunities. The World Psychiatric Association (WPA) has initiated 64 CU IDOL SELF LEARNING MATERIAL (SLM)
an international program aimed at developing tools to fight stigma and discrimination (Sharma, 2001). 4.8 SUMMARY Childhood schizophrenia is an uncommon but severe mental disorder in which children and teenagers interpret reality abnormally. Schizophrenia involves a range of problems with thinking (cognitive), behavior or emotions. It may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs your child's ability to function. Childhood schizophrenia is essentially the same as schizophrenia in adults, but it starts early in life — generally in the teenage years — and has a profound impact on a child's behavior and development. With childhood schizophrenia, the early age of onset presents special challenges for diagnosis, treatment, education, and emotional and social development. Schizophrenia is a chronic condition that requires lifelong treatment. Identifying and starting treatment for childhood schizophrenia as early as possible may significantly improve your child's long-term outcome. Schizophrenia signs and symptoms in children and teenagers are similar to those in adults, but the condition may be more difficult to recognize in this age group. As children with schizophrenia age, more typical signs and symptoms of the disorder begin to appear. When childhood schizophrenia begins early in life, symptoms may build up gradually. Early signs and symptoms may be so vague that you can't recognize what's wrong. Some early signs can be mistaken for typical development during early teen years, or they could be symptoms of other mental or physical conditions. Relapse appears to be triggered by hostile and critical family environments characterized by high expressed emotion. Successful treatment for people with schizophrenia rarely includes complete recovery. However, the quality of life for these individuals can be meaningfully affected by combining antipsychotic medications with psychosocial approaches, employment support, and community-based and family interventions. Treatment typically involves antipsychotic drugs that are usually administered with a variety of psychosocial treatments, with the goal of reducing relapse and improving skills in deficits and compliance in taking the medications. The effectiveness of treatment is limited, because schizophrenia is typically a chronic disorder. 65 CU IDOL SELF LEARNING MATERIAL (SLM)
4.9 KEY WORDS Acting out: In psychoanalysis, a term for the behaviour of a patient who has to act on a powerful and deep-rooted impulse and is unable to reflect on it and talk about it instead. Anhedonia: Diminished ability to experience pleasure. Avolition: The inability or lack of desire to engage in goal-directed or motivated activities. Avolition is a common negative symptom in schizophrenia. Children's Apperception Test: A version of the thematic apperception test adapted for children. Psychoeducation: Learning about mental illness and ways to communicate, solve problems and cope. Psychosocial Interventions: Non-medication therapies for people with mental illness and their families. Therapies include psychotherapy, coping skills, training and supported employment and education services. Psychotherapy: Treatment for mental illness by talking about problems rather than by using medication. Psychological debriefing: A type of crisis intervention that requires individuals who have recently experienced a traumatic event to discuss or process their thoughts and feelings related to the traumatic event, typically within 72 hours of the event Psychological model:Psychological model includes learning, personality, stress, cognition, self-efficacy, and early life experiences and how they affect mental illness Psychological tests: Used to assess the client’s personality, social skills, cognitive abilities, emotions, behavioral responses, or interests and can be administered either individually or to groups in paper or oral fashion Psychopathology: The scientific study of psychological disorders Public stigma: When members of a society endorse negative stereotypes of people with a mental disorder and discriminate against them 4.10 LEARNING ACTIVITY 1. Explain the process of assessment undertaken in order to diagnose a child with childhood onset schizophrenia? ___________________________________________________________________________ ___________________________________________________________________________ 2. Explain the process of treatment provided to a child with childhood onset schizophrenia? ___________________________________________________________________________ ___________________________________________________________________________ 66 CU IDOL SELF LEARNING MATERIAL (SLM)
4.11 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What are some of the types of schizophrenia? 2. What is paranoid schizophrenia? 3. What is disorganized schizophrenia? 4. What is catatonic schizophrenia? 5. What is residual schizophrenia? 6. What are the some of the medications given to treat childhood schizophrenia? 7. What is meant by psychosocial rehabilitation? Long Questions 1. Explain the different types of schizophrenia in detail? 2. What is the prognosis of childhood onset schizophrenia? 3. Explain the incidence and prevalence of childhood onset of schizophrenia? 4. Explain the mental status examination as a part of assessment process? 5. What are the psychological treatments for childhood onset schizophrenia? 6. Explain the importance of the relation between psychiatrist and patient? B. Multiple Choice Questions 1. What is NOT a positive symptom of schizophrenia? a. Delusions b. Avolition c. Disorganized thinking and speech d. Hallucinations 2. CT scans of the brains of some young schizophrenics show __________ than normal. a. wider ventricles b. smaller fissures c. smaller ventricles d. fewer fissures 3. The dopamine-psychosis link is based on the observation that a. Low dopamine levels of activity in the brain seem to produce psychotic symptoms. b. There are high levels of dopamine activity in the brains of psychotic people. c. There are high levels of amphetamine in the brains of schizophrenics. d. Dopamine interacts with serotonin creating psychosis. 67 CU IDOL SELF LEARNING MATERIAL (SLM)
4. Sensory experiences that occur in the absence of a stimulus are called a. Illusions. b. Hallucinations. c. Delusions. d. Affect episodes. 5. In Schizophrenia psychotic symptoms such as hallucinations delusions, disorganized speech and grossly disorganized or catatonic behaviours are known as: a. Negative symptoms b. Positive symptoms c. Mediating symptoms d. Catastrophic symptoms Answer 1-b, 2-a, 3-b, 4-b, 5-b 4.12 REFERENCES Textbooks Ahuja N (2002). A short text book of Psychiatry. (5th edn). New Delhi: Jaypee Brothers Medical. Publishers (PVT) Ltd. American PsychiatricAssociation (2000). Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington, DC: American Psychiatric Publishing, Inc. 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. 68 CU IDOL SELF LEARNING MATERIAL (SLM)
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 69 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT 5 – COMMUNICATION DISORDER PART I STRUCTURE 5.0 Learning Objectives 5.1 Introduction 5.2 Communication Disorder 5.3 DSM Criteria 5.4 ICD 10 Criteria 5.5 Causes of Communication Disorder 5.6 Summary 5.7 Key Words 5.8 Learning Activity 5.9 Unit End Questions 5.10 References 5.0 LEARNING OBJECTIVES After studying this unit, you will be able to, Describe Communication Disorder Explain the nature and symptoms of Communication Disorder Explain the DSM criteria of Communication Disorder Explain the ICD 10 criteria of Communication Disorder Describe the causes of Communication Disorder 5.1 INTRODUCTION RD presented as a 5-year-old girl, the only child of professional parents who had attempted for many years prior to her birth to conceive a child. Her birth was received with joy and relief, and her parents admitted to having indulged her, even by their privileged standards. Her developmental history was unremarkable, except for some slight delay in toilet training compared with her agemates. She received appropriate well-child care, and had no major illnesses or injuries. Her adjustment to preschool was considered appropriate when she entered at age 3, and she got along well with the other children for 2 years. She enjoyed the preschool, where individuality was accepted and encouraged. Her parents sought psychiatric evaluation for her after she reported being fearful about returning to school. When her parents questioned her, she stated that new children had come to her school for kindergarten and they were teasing her. The teacher informed the parents that new students were in fact present, but that no teasing had been observed. Upon evaluation, a picture emerged of concerned parents who were sensitive to their child’s emotional state, and had sought to remedy their inexperience with 70 CU IDOL SELF LEARNING MATERIAL (SLM)
children through a great deal of study and inquiry. RD appeared initially as a somewhat anxious child, who separated from her mother with mild trepidation, but who soon relaxed with the psychiatrist. She was able to relate openly, gave no evidence of a majorthought or affective disorder, and seemed to be of averageintelligence. She exhibited a number of articulation errors,substituting /w/ for /l/ and /r/, and /the/ for /s/, and omittingor dropping a number of closing sounds. She stated thatshe was shocked at the comments of her new classmatesthat her speech was infantile. These children were as of yetunaccustomed to the uncritical atmosphere of the school. She had never thought that her speech was unusual, norhad her parents who believed it was normal for a child ofher age. The teacher explained that she had noticed someerrors in RD’s speech, but did not wish to offend her or herparents by pointing them out. The psychiatrist intervenedby helping the child to understand that some childrenadopted “grown-up” speech later than others, and that herprogress could be assisted by a helping adult. He referredthe family to a speech and language pathologist, whosesession the parents described to the child as a “conversationparty”. The psychiatrist worked with the parents in jointbrief focal psychotherapy, addressing issues related to theparents’ sense of failure because of their child’s problemand their delay in recognizing it. After 6 months, RD’sspeech had improved and was accepted as normal byher classmates. By age 9 her speech was regarded asentirely normal by her parents and teachers andshe wasfunctioning well in all spheres. However, she continued tohave subtle phonological findings as an adolescent. 5.2 COMMUNICATION DISORDER Psychiatric practice depends upon communication and language. Language and or learning disorders have been linked in the past, but in DSM-IV-TR (American Psychiatric Association, 2000) they are regarded as separate although often associated conditions. This section covers: Expressive Language Disorder, Mixed Receptive-Expressive Language Disorders, Phonological Disorder, Stuttering and Communication Disorder NOS. They are defined by criteria in DSM-IV-TR. In all cases a test score or assessment measure alone does not define these conditions. An individual must also experience social, academic or occupational difficulties directly related to the condition. DSM-IV-TR does not consider receptive language disorders in isolation. Receptive language disorders in children seldom, if ever, can occur without concurrent (and perhaps resultant) problems with expression. This is in direct contrast with such entities as Wernicke’s aphasia in adults, which affect reception alone. Outside of DSM-IV-TR, the term “phonologic disorder” may refer to a condition characterized by difficulty in generating sound combinations, as for example in the case of laryngeal dysfunction. 71 CU IDOL SELF LEARNING MATERIAL (SLM)
5.3 DSM CRITERIA A. The scores obtained from standardized individually administered measures ofexpressive language development are substantially below those obtained fromstandardized measures of both nonverbal intellectual capacity and receptivelanguage development. The disturbance may be manifest clinically by symptomsthat include having a markedly limited vocabulary, making errors in tense, orhaving difficulty recalling words or producing sentences with developmentallyappropriate length or complexity. B. The difficulties with expressive language interfere with academic or occupationalachievement or with social communication. C. Criteria are not met for Mixed Receptive-Expressive Language Disorder or aPervasive Developmental Disorders. D. If Mental Retardation, a speech-motor or sensory deficit, or environmentaldeprivation is present; the language difficulties are in excess of those usuallyassociated with these problems. Coding note: If a speech-motor or sensory deficit or a neurological condition ispresent, code the condition on Axis III. Diagnostic criteria for 315.39 Phonological Disorder A. Failure to use developmentally expected speech sounds that are appropriate forage and dialect (e.g., errors in sound production, use, representation, ororganization such as, but not limited to, substitutions of one sound for another [useof /t/ for target /k/ sound] or omissions of sounds such as final consonants). B. The difficulties in speech sound production interfere with academic oroccupational achievement or with social communication. C. If Mental Retardation, a speech-motor or sensory deficit, or environmentaldeprivation is present, the speech difficulties are in excess of those usuallyassociated with these problems. Coding note: If a speech-motor or sensory deficit or a neurological condition ispresent, code the condition on Axis III. Diagnostic criteria for 315.31 Mixed Receptive-Expressive Language Disorder A. The scores obtained from a battery of standardized individually administeredmeasures of both receptive and expressive language development are substantiallybelow those obtained from standardized measures of nonverbal intellectual capacity.Symptoms include those for Expressive Language Disorder as well as difficultyunderstanding words, sentences, or specific types of words, such as spatial terms. B. The difficulties with receptive and expressive language significantly interfere withacademic or occupational achievement or with social communication. C. Criteria are not met for a Pervasive Developmental Disorder. D. If Mental Retardation, a speech-motor or sensory deficit, or environmentaldeprivation is present, the language difficulties are in excess of those usually associatedwith these problems. 72 CU IDOL SELF LEARNING MATERIAL (SLM)
Coding note: If a speech-motor or sensory deficit or a neurological condition is present,code the condition on Axis III. Diagnostic criteria for 307.0 Stuttering A. Disturbance in the normal fluency and time patterning of speech (inappropriatefor the individual's age), characterized by frequent occurrences of one or more ofthe following: (1) Sound and syllable repetitions (2) Sound prolongations (3) Interjections (4) Broken words like pauses within a word (5) Audible or silent blocking like filled or unfilled pauses in speech (6) Circumlocutionslike word substitutions to avoid problematic words (7) Wordsare produced with excess of physical tension (8) Monosyllabic whole-word repetitions (e.g., \"I-I-I-I see him\") B. The disturbance in fluency of speaking will interfere with academic activities, participationin classroom or occupationalachievement or with social communication. C. If a speech-motor or sensory deficit is present, the speech difficulties are inexcess of those usually associated with these problems. Coding note: If a speechmotor deficit or any sensory deficit or a neurological condition ispresent, code the condition on Axis III. 5.4 ICD 10 CRITERIA ICD 10 Criteria for Stuttering [stammering] Stuttering refers to speech that is characterized by frequent repetition or prolongation of sounds or syllables or words, or by frequent hesitations or pauses that disrupt the rhythmic flow of speech. Minor dysrhythmias of this type are quite common as a transient phase in early childhood or as a minor but persistent speech feature in later childhood and adult life. They should be classified as a disorder only if their severity is such as markedly to disturb the fluency of speech. There may be associated movements of the face and/or other parts of the body that coincide in time with the repetitions, prolongations, or pauses in speech flow. Stuttering should be differentiated from cluttering (see below) and from tics. In some cases there may be an associated developmental disorder of speech or language, in which case this should be separately coded under F80.-. Excludes: Cluttering (F98.6) Neurological disorder giving rise to speech dysrhythmias (Chapter VI of ICD-10) Obsessive-compulsive disorder (F42.-) tic disorders (F95.-) ICD 10 Criteria for Cluttering A rapid rate of speech with breakdown in fluency, but no repetitions or hesitations, of a severity to give rise to reduced speech intelligibility. Speech is erratic and dysrhythmic, with 73 CU IDOL SELF LEARNING MATERIAL (SLM)
rapid, jerky spurts that usually involve faulty phrasing patterns (e.g. alternating pauses and bursts of speech, producing groups of words unrelated to the grammatical structure of the sentence). Excludes: Neurological disorder giving rise to speech dysrhythmias (Chapter VI of ICD-10) Obsessive-compulsive disorder (F42.-) stuttering (F98.5) tic disorders (F95.-) 5.5 CAUSES OF COMMUNICATION DISORDER 5.5.1 Genetic Influences No clear mechanisms of genetic transmission have been elucidated, but a number of instances of family aggregation have been reported. At least one of these (Gopnik and Crago, 1991) suggested the presence of a single dominant autosomal gene. Tomblin (1989) reported increased concordance of language disorders among siblings. An increasing number of family studies now suggest that these disorders are familial, including the Twins Early Development Study (TEDS) in the United Kingdom (Plomin and Dale, 2000). These reports cannot absolutely prove any genetic hypothesis but are provocative and suggest a polygenetic basis. A genetic basis for stuttering has been proposed for many years. The Yale Family Study of Stuttering suggested that 15% of first degree relatives of probands are affected at some time in their lives (Kidd, 1983). 5.5.2 Neurophysiological Factors Communication disorders arise from at least three interrelatedsets of factors: neurophysiologic (including structural), cognitive-perceptual and environmental. However, the great majorityof children with communication disorders exhibit no specificCNS damage, and thus minimal or subclinical damage has beenpostulated. The relative frequency of “soft” neurologic signsand lateral dominance problems in this population provokes thisspeculation. However, no clear neurophysiologic mechanisms orpathology can be correlated with these disorders. Some interestingfindings are emerging, including suggested anatomical differencesin the left cerebral cortex in stuttering, prenatal alcoholexposure and the physical sequelae of abuse and neglect. 5.5.3 Cognitive and Perceptual Factors Perceptual hypotheses relate communication disorders to variousdeficits in the reception, acquisition, processing, storage, or recallof different elements of communication. Table below notes variousperceptual deficits that have been implicated, including auditory discrimination, attention, memory and visual association. More purely cognitive hypotheses have also been proposed, involving deficits in symbolization, categorizing, hierarchical 74 CU IDOL SELF LEARNING MATERIAL (SLM)
processing and related areas. Some authors (Friel-Patti, 1992; Helmuth, 2001) propose that there are certain language-specific cognitive deficits. The special phenomenology of stuttering suggests the possibility of dyssynchrony between phonation and articulation, as reported by Perkins (2001). 5.5.4 Environmental Factors This category refers both to the psychosocial environment of the child and to general medical factors such as perinatal complications or recurrent otitis media. The relationship of socioeconomic status to the occurrence of communication disorders is uncertain. Variables such as class, family size, income and birth order all clearly affect the amount of verbal interaction children receive and have been implicated. The association between the exacerbation of stuttering and stress is well known, although work in this area has frequently confounded predisposing, triggering and maintaining factors. Review of these influences reveals a considerable amount of overlap, and clinical observation seldom if ever suggests a unitary causality of Communication Disorders in real patients. Table: Hypotheses About Influencing Factors in Communication Disorders Types of Hypotheses Specific Hypotheses Neurological impairments Perceptual deficits Specific localizable brain damage Subclinical (minimal) brain damage Cognitive deficits Deficits in auditory discrimination Environmental factors Deficits in auditory attention Deficits in auditory figure-ground Deficits in auditory memory Deficits in auditory–visual association Deficits in the processing of specific linguistic units Deficits in symbolic or concept development Deficits in anticipatory imagery Deficits in sorting or categorizing Deficits in hierarchical processing Inadequate parent–child interaction Socioeconomic factors (large family size, lower social class, late birth order, environmental deprivation) 75 CU IDOL SELF LEARNING MATERIAL (SLM)
Multifactorial etiology Medical factors (e.g., prematurity, history of recurrent otitis media) Combinations of all of the above Adapted from Baker L (1990) Specific communication disorders, in Psychiatric Disorders in Children and Adolescents (eds Garfinkel BD, Carlson GA and Weller EB). Copyright 1990, with permission from Elsevier. 5.6 SUMMARY Language isthe rule-based use of speech sounds to communicate (Sternberg, 2000). Languagedisorders or language impairments involve the processing of linguisticinformation. Problems that may be experienced can involve grammar (syntaxand/or morphology), semantics (meaning), or other aspects of language. Disordered language may be due to a receptive problem, that is, a difficulty inunderstanding speech sounds (involving impaired language comprehension). The use of speech sounds in combinations and patterns that fail to follow thearbitrary rules of a particular language is a language disorder. For instance, thelack of communication etiquette is considered a language disorder. Talking outof turn, not talking when it is your turn, or not responding when you are expectedto could be disorders if frequently observed in one’s language behaviour. Language disorder is a disorder that is found in the development or use of theknowledge of language. It shows the breakdown in the development of languageabilities on the usual developmental schedule. The disorders that come underlanguage disorders are: Autism, Learning Disability, Specific LanguageImpairment, Developmental Phonological Disorders include Aphasia, Dyspraxia,etc. A child with a communication disorder has trouble communicating with others. He or she may not understand or make the sounds of speech. The child may also struggle with word choice, word order, or sentence structure. The beginning of these problems is used to be in the first stages of the development and they are not caused by either any auditory or sensory problems of any kind, motor disorders, or other intellectual problems (such as intellectual disability or global development delay). On the other hand, the phonological disorder is characterized by the fact that individuals have difficulties to distinguish and articulate the phonemes which make their speech unintelligible for others and, in consequence, their oral communication is severely affected. 76 CU IDOL SELF LEARNING MATERIAL (SLM)
In the case of childhood fluency disorders or cluttering, patients show alterations in the productions of fluently oral messages which appear as syllable, sounds or monosyllable repetitions, prolongations of some consonants or vowels, pauses in the middle of words, pauses in the speech. Cluttering causes anxiety in people suffering it and the same academic, labor and social problems than phonological and language disorders. 5.7 KEY WORDS Aetiology: The study of the origins of disease: physical, mental or emotional. Alternative and augmentative communication: Use of sign language, picture communication symbols or speech generating devices to replace or augment the speech of a person with autism. Aphasia: Total or partial loss of the ability to use or understand language; usually caused by stroke, brain disease, or injury. Aphonia: Complete loss of voice. Apraxia: Inability to execute a voluntary movement despite being able to demonstrate normal muscle function. Articulation disorder: Inability to correctly produce speech sounds (phonemes) because of imprecise placement, timing, pressure, speed, or flow of movement of the lips, tongue, or throat. Babble: Speech sounds made by infants from which recognizable language develops. Expressive communication: Sending information or messages to other people. This could involve use of speech or augmentative communication. Psychological debriefing: A type of crisis intervention that requires individuals who have recently experienced a traumatic event to discuss or process their thoughts and feelings related to the traumatic event, typically within 72 hours of the event Psychological model:Psychological model includes personality, learning, stress, self- efficacy, cognition and early life experiences and the way in which they affect mental illness Psychological tests: Psychological tests are used for assessment of different attributes personality, social skills, intelligence, cognitive abilities, emotional responses, behavioral responses and interests. They can be administered either individually or to groups using pen and paper or oral method. Psychopathology: The scientific study and research on psychological disorders Public stigma: When people in a society approve negative stereotypes towards a person with a mental disorder and discriminate against them. 77 CU IDOL SELF LEARNING MATERIAL (SLM)
5.8 LEARNING ACTIVITY 1. Explain with the help of the case study given in the unit, the DSM criteria for communication disorder? ___________________________________________________________________________ ___________________________________________________________________________ 2. Explain with the help of the case study given in the unit, the ICD 10 criteria for communication disorder? ___________________________________________________________________________ ___________________________________________________________________________ 5.9 UNIT END QUESTIONS A. Descriptive Questions Short Questions 1. What are communication disorders related to? 2. Name any three of the communication disorders? 3. What are the genetic causes of communication disorder? 4. What are the environmental causes of communication disorder? 5. What are the Cognitive and Perceptual Factors of communication disorder? Long Questions 1. Explain the DSM criteria for communication disorders? 2. Explain the ICD criteria for communication disorders? 3. Write in detail the causes of communication disorder. 4. Explain the hypothesis for communication disorder. B. Multiple Choice Questions 1. Which of the following is NOT a physical cause often associated with Phonological disorder? a. A hearing impairment b. Cleft palate c. Small frontal lobes d. Cerebral palsy 2. Which of the following is the percentage of pre-school children who are diagnosed with a phonological disorder of unknown origin? a. 4% b. 5% 78 CU IDOL SELF LEARNING MATERIAL (SLM)
c. 6% d. 3% 3. Stuttering is a disturbance in the normal fluency and time patterning of speech that is inappropriate for the individual's age. It involves which of the following? a. Frequent repetitions or prolongations of sounds b. Pauses within words c. Filled or unfilled pauses in speech d. All of the above 4. Which of the following may occur in Expressive Language Disorder? a. Limited amount of speech b. Difficulty learning new words c. Difficulty finding the right word d. All of the above 5. Which of the following procedures can be used to identify Down Syndrome prenatally? a. Amniocentesis b. Amnioprolaxis c. Amniophalaxi d. Amniocalesis Answer 1-c, 2-d, 3-c, 4-d, 5-a 5.10 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. 79 CU IDOL SELF LEARNING MATERIAL (SLM)
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 80 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT 6 – COMMUNICATION DISORDER PART II STRUCTURE 6.0 Learning Objectives 6.1 Introduction 6.2 Types of Communication Disorder 6.3 Incidence of Communication Disorder 6.4 Prevalence of Communication Disorder 6.5 Assessment of Communication Disorder 6.6 Prognosis of Communication Disorder 6.7 Treatment for Communication Disorder 6.8 Summary 6.9 Key Words 6.10 Learning Activity 6.11 Unit End Questions 6.12 References 6.0 LEARNING OBJECTIVES After studying this unit, you will be able to, Explain the incidence of Communication Disorder Explain the prevalence of Communication Disorder Describe the process of assessment of Communication Disorder Describe the prognosis of Communication Disorder Explain the Treatment for Communication Disorder 6.1 INTRODUCTION Communication is so pervasive in any community in its day-to-day activities that it is often taken for granted. Normal language develops over a period and it is sequential or ordered. A child acquires vocalization, speech sounds (vowels and consonants) and then prosodies. This acquisition is in recognizable stages that entail acquisition of form, content, and use. The form is the system of symbols that convey meaning and it is made up of the phonology, morphology, and syntax of a language. The content includes the individual words and combinations of words to produce meaning in the language. Content is made up of the semantics of a language. Use involves how we use words in contexts and is made up of the pragmatics of a language. 81 CU IDOL SELF LEARNING MATERIAL (SLM)
Many things could go wrong with the natural order of language acquisition and development. In every community, we encounter individuals with language and/ or a speech disorders. One in 10 people in the United States is affected by a communication disorder (speech, language, or hearing disorders). Unfortunately there is much ignorance as far as identifying these disorders is concerned. The ignorance more often than not leads to mishandling of the persons with language and speech disorders. Features Common to All Communication Disorders Inadequate development of some aspect of communication Absence (in developmental types) of any demonstrable causes of physical disorder, neurological disorder, global mental retardation, or severe environmental deprivation Onset in childhood Long duration Clinical features resembling the functional levels of younger normal children Impairments in adaptive functioning, especially in school Tendency to occur in families Predisposition toward boys Multiple presumed etiological factors Increased prevalence in younger age range Diagnosis requiring a range of standardized techniques Tendency toward certain specific associated problems, such as attention- deficit/hyperactivity disorder Wide range of subtypes and severity 6.2 TYPES OF COMMUNICATION DISORDER 6.2.1 General Communication Disorders Cantwell and Baker (1991) demonstrated that approximately half of the children with a speech or language disorder have some other definable Axis I clinical disorder. Similarly, among children with a psychiatric diagnosis first made, there is a remarkably increased likelihood of speech and language disorders, which often go undetected. Beitchman (1985) found more than four times the prevalence of psychiatric illness in kindergartners with communication disorders compared with non-disordered children. Cantwell and Baker also found that psychiatric illness in their population was associated with greater severity of communication problems. Conversely, the presence of communication disorders may be associated with increased severity of some psychiatric conditions, most notably the Disruptive Behavior Disorders. Physicians must recognize that these disorders do not occur in an isolated context. 82 CU IDOL SELF LEARNING MATERIAL (SLM)
6.2.2 Expressive Language Disorder and Mixed Receptive-expressive Language Disorder Phonological Disorder and Learning Disorders are common among children with this disorder. Other neurodevelopmental conditions are also seen, such as motor delays, coordination disorders and enuresis, although the rate of association is uncertain. These disorders and the stresses they create frequently lead to Adjustment Disorders and social withdrawal. Cantwell and Baker (1991) found that the most common psychiatric disorder among children with communication disorders overall was Attention Deficit Hyperactivity Disorder (ADHD), representing 19% of their sample of 600 children referred for a communication evaluation. Some authors have speculated that ADHD may be concordant with an entity known as Central Auditory Processing Disorder (CAPD), which refers to deficits in the processing of audible signals, and which can be subsumed under the DSM-IV language disorders. A total concordance is unlikely, but Riccio et al. (1994) suggest that 50% of children with CAPD also have ADHD. 6.2.3 Expressive Language Disorder This condition varies with age and severity. Vocabulary, wordfinding, sentence length, variety of expression and grammatical complexity may all be reduced. Most children with the developmental subtype of this disorder demonstrate delayed language development. Often auxiliary words or prepositions are omitted, resulting in telegraphic speech: “he was going to school” becomes “he going school”. Word order may be garbled: “Him like too me” for “I like him, too”. Words or phrases may be repeated to the degree that speech may be echolalic, perseverative, or both. Conversation may be tangential, with sudden inappropriate changes of topic, or conversely, perseveration. Pragmatic difficulties, such as in initiating or terminating conversations, are seen, as is avoidance of conversation. These children frequently are regarded as socially inappropriate or inept, and at times may be suspected of having a formal thought disorder or a Pervasive Developmental Disorder. They frequently have academic problems because of their difficulty in responding verbally to exercises. They may have motor coordination problems and various other neurodevelopmental abnormalities, documented upon neurological examination, EEG, or neuroimaging, although no consistent patterns are seen. 6.2.4 Mixed Receptive-expressive Language Disorder Children with this disorder may have all the problems of Expressive Language Disorder. In addition, they do not understand all that they hear. The deficits may be mild or severe, and at times deceptively subtle, since patients may conceal them or avoid interaction. All areas and levels of language comprehension may be disturbed. Thus the child may not understand 83 CU IDOL SELF LEARNING MATERIAL (SLM)
speech that is rapid, certain words or categories of words, such as abstract quantities, or types of statements, such as conditional clauses. These children may seem not to hear or attend, or to misbehave by not following commands correctly. At times, when conversation is redirected to them in a slower or more concise fashion, they may understand and respond belatedly, and thereby be accused of willful avoidance. More severely impaired children may not follow the rules of syntax or word order, and thus confuse subjects and objects or questions and declarations. Often in more severe cases, disabilities may be multiple and pervasive, affecting processing, recall and association. Such deficits have immense social consequences. 6.2.5 Phonologic Disorder Children with this problem may have clear causal factors, such as anatomic, neurological, or cognitive disorders, although most do not. They do have a higher prevalence of language disorders, with all their associated problems, than do normal controls. They appear more likely to have ADHD, though probably not as commonly as do children with language disorders. Children with Phonological Disorders, especially when associated with stuttering or hyperactivity, are prone to social discrimination and isolation, with subsequent consequences. This category is characterized by persistent errors in the production of speech. These include omission of sound, substitution or distortion of sounds. Omissions include single or multiple sounds: “I go o coo o the but” (I go to school on the bus); or “I re a boo” (I read a book). Substitutions include w/l, t/s, w/r, and d/g: “I taw a wittle wed wadio. It pwayed dood music”. Lisping, the frontal or lateral misarticulation of sibilants, is a common distortion. Defects in the order of sounds or insertions of extraneous sounds may also be heard: “catht” for “cats”. The occurrence of these errors is persistent but not constant. Usually only some sounds are affected. Some articulation errors are expected in early childhood, especially involving sounds that are usually mastered at a later age (in English, /l/, /r/, /s/, /z/, /th/, /ch/); these errors are not regarded as pathological unless they persist and result in adverse consequences to the individual. Ninety percent or more of children have mastered the more difficult sounds by age 6 to 8. 6.6.6 Stuttering Other communication disorders are more frequently reported in those with stuttering than in normal controls. Stuttering is frequently accompanied by many linguistic mechanisms and social maneuvers to avoid its manifestation, and is often exacerbated by anxiety or stress. Persons with stuttering face social discrimination. They have been mocked in drama and cinema (including cartoons) for centuries, and all too often are regarded as intellectually impaired. Stuttering is the most easily recognized communication disorder. It varies in severity among individuals. It may vary over time and circumstance. It is typically more severe when the affected child is stressed or anxious, and especially when communication is expected. 84 CU IDOL SELF LEARNING MATERIAL (SLM)
Because of its often gradual onset, children are at first frequently not aware of its presence. Over time children may become more anxious and they may withdraw themselves from conversation resulting from a degree of social discrimination they experience increases. Stuttering may sometimes be accompanied by various movements which may either seem to express or reduce anxiety of the person, such as blinking, grimacing, or hyperventilation. Children who stutter may sing or talk to themselves without difficulty. Sometimes children may attempt to stop stuttering by slowing down or pausing in their speech; but this is frequently unsuccessful and leads to an exacerbation. Thus a pattern of habitual fear and avoidance emerges. 6.6.7 Communication Disorder Not Otherwise Specified This category, used to include disorders that do not fit the criteriafor any of the other Communication Disorders, is generally usedonly to describe disorders of voice, including pitch, intonation,volume, or resonance. Hyponasality is characterized by the “adenoidal”speech simulated by speaking with the nose pinched. Hypernasality, secondary to velopharyngeal insufficiency, maybe associated with serious voice problems. Air escapes into thenasal cavity, resulting in nasal air emission, snorting or a nasalgrimace during speech. 6.3 INCIDENCE OF COMMUNICATION DISORDER It was found that hearing Impairment was the most prevalent among the children diagnosed as having communication disorders.It was found to be in both children (30.81%) and adults (32.1%). Furthermore, specific language impairment (8.04%), Delayed Speech and Language secondary to Cerebral palsy (7.21%) and delayed speech and language secondary to Intellectual Disability (6.15%) were also a few of the communication disorders seen. Among the risk factors causing communication disorders, consanguineous marriage (20.78%) was found to be the prominent causative factor followed by positive family history of speech and language disorder (7.12%), delayed birth cry (7.07%) and neonatal seizure (5.86%) etc. 6.4 PREVALENCE OF COMMUNICATION DISORDER Prevalence of communication disorders varying from 1 to 13% have been reported for language disorders, and numbers as high as 32% for speech disorders (Baker, 1990). In development of the DSM-IV-TR, researchers Found that: Acquired language disorders appear less common than the developmental types. 3–7% of all children were suspected of having a developmental Expressive Language Disorder. Mixed Expressive – Receptive Language Disorder appears in up to 3% of school-age children. 85 CU IDOL SELF LEARNING MATERIAL (SLM)
Phonological Disorder occurs in approximately 2% of six and seven-year old’s, falling to 0.5% by age 17. Stuttering occurs in approximately 1% of children 10 and younger, declining to 0.8% in later adolescence. All of these conditions have a male to female predominance; that of stuttering is as high as 3: 1. 6.5 ASSESSMENT OF COMMUNICATION DISORDER Interview and Observation The psychiatrist seeing children must be familiar with normal milestones of speech and language development and ask the parents or guardians about the child’s speech and language,both past and current. Much can be learned from even a fewquestions: Does the child seem to hear and understand whatis being said? Does the child require visual prompts? Does thechild in fact use spoken language to communicate? How longand complicated are his sentences? Does the child “make sense”to outsiders? Can she be clearly understood, even by strangers? Which sounds does the child fid difficult? Does the child useunusual volume, pitch, or nasality? Does he observe the rulesof conversation? Parent–child communication should also beobserved.For younger children, assessment may best be carried outin a play situation. Rutter (1987) recommends that the clinicianassess inner language, comprehension, production, phonationand pragmatics. Inner language means symbolization, whichmay be observed in the child’s representational use of play materials. Comprehension is assessed through conversation and theuse of developmentally appropriate questions and commands,especially with nonverbal augments or prompts. The clinicianshould note how well a child can follow and draw inferences froma conversation. Production refers to speech, its fluency and intelligibility. Pragmatics are those aspects of language that render ituseful for social communication beyond the most concrete level.Does the child appreciate the nuances of her partner’s conversation,as, for example, when they signal beginnings and endingsof conversations, topic changes, or the patient’s turn to talk?Pragmatic language involves nonverbal elements. Deficiencies inthis area impair abstraction and may render the individual almost“robot-like”. In all cases, observations should be made in as relaxed afashion as possible, avoiding interrogation or rote exercises. Ifa child fails to communicate a given item, necessary help, includingnonverbal prompts, should be offered, so that the childhas the experience of success. A sense of failure will stiflecommunication. 86 CU IDOL SELF LEARNING MATERIAL (SLM)
All of the phenomena seen in a clinical interview may alsobe pursued in school settings, and teacher input is essential in theevaluation of these children.A number of instruments are available for the assessment ofcommunication. Some of these are listed in table below. Most arebeyond the training of physicians, whose most important contributionsare interview skills and medical assessment; but a familiaritywith them can help the physician develop a repertoireand knowledge of screening measures. Because of the complexcomorbidity of these disorders, they are often best assessed byan interdisciplinary team (McKirdy, 1985; Klykylo, 2005). Table: Language Tests Ages Functions Assessed Tests Language Tests Sequenced Inventory of 0y4m to 4y0m Sound discrimination, auditory memory, Communication Development receptive and expressive language (SICD) Test of Early Language Development Receptive and expressive language; oral 3y0m to 7y11m and (TELD) pointing responses Test of Language Development 4y0m to 9y0m Auditory discrimination and memory, (TOLD) receptive and expressive language; oral and pointing responses Test of Adolescent Language 11y0m to17y5m Receptive and expressive language; oral (TOAL) and written responses Clinical Evaluation of Language 5y0m to 17y0m Screening test for auditory memory, Function (CELF) receptive and expressive language; oral responses Fluharty Preschool Speech and 2y0m to 6y0m Screening test for articulation and Language Screening Test language disorder Tests of Specific Functions Peabody Picture Vocabulary Test 1y9m to18y0m Receptive auditory vocabulary; pointing (PPVT) to pictures Token Test 3y0m to 12y0m Receptive auditory syntax; following verbal instructions 87 CU IDOL SELF LEARNING MATERIAL (SLM)
Goldman-Fristoe-Woodcock 3y0m to12y0m Auditory memory; pointing to pictures Auditory Selective Attention Test Goldman-Fristoe-Woodcock Test of Auditory discrimination of words; 3y0m to adult pointing to pictures Auditory Discrimination Expressive One-Word Vocabulary 3y0m to 12y0m Expressive vocabulary; picture naming Test (EOWVT) Arizona Articulation Proficiency 3y0m to 11y0m Speech articulation; picture naming Scale Source: Feinstein C and Aldershof A (1991) Developmental disorders of learning and language, in Textbook of Child and Adolescent Psychiatry (Ed Wiener JM). American Psychiatric Press, Washington DC. Theteam’s activities are usually coordinated by a case manager, oftena pediatrician or a child and adolescent psychiatrist. Oftenthe team includes an audiologist, a psychologist, medical specialistsincluding pediatric neurologists and otorhinolaryngolists, aneducational specialist or liaison special educator, and a speechand language pathologist. The speech and language pathologist (SLP) has graduateprofessional degree and should be certified by The AmericanSpeech, Language and Hearing Association (ASHA). The SLP uses a combination of interview techniques, behavioral observations and standardized instruments to identify Communication Disorders, as well as patterns of communication that are not pathologic.The assessment of an SLP is usually the definitive measure of the presence or absence of a Communication Disorder. Families may consult an SLP directly or be referred by other clinicians. The responsibility of psychiatrists and other professionals in this process is simple and straightforward: any suspicion of any communication problem in any patient should prompt referral to a qualified SLP. Even when a disorder appears to be limited andbenign, communication evaluation by an SLP can disclose subtleimpairments that could have profound consequences. table below lists indication for referral. Table: Indications for Referral for Communication Evaluation Language • The child does not use any single words by 16–18 mo. • At 18 months, the child cannot follow simple instructions such as “Give me your shoe”, or cannot point to body parts or common objects following a verbal request. • The child does not combine words for short utterances by the age of 2. • The child does not communicate with complete sentences by the age of 3. • At 3, the child echoes parts of questions or commands rather than responding appropriately. For example, when asked “What’s your name?” The child responds, “Your name”. 88 CU IDOL SELF LEARNING MATERIAL (SLM)
• Sentence structures are still short and noticeably defective at the age of 4. • At 4, the child uses words incorrectly, or frequently substitutes an associative word for the intended word. For example, the child may say “cut” for “scissors” or “dog” for “cow”. Articulation • The child does not babble using consonant sounds (particularly b, m, d, and n) by 8 or 9 months of age. • The child uses mostly vowel sounds and gestures for communication after 18 mo. • The speech is usually unintelligible at the age of 3. • The child frequently omits consonants in words at the age of 3. • The speech is difficult to understand at the age of 4. • At the age of 6, the child is still unable to produce many sounds. • The child is omitting, substituting, or distorting any sounds after the age of 7. • The child is embarrassed or disturbed by his speech at any age. Voice • The voice is hoarse, harsh, breathy, or of poor quality. • The voice is always too loud or too soft. • The pitch is inappropriate for the child’s age or sex. • Pitch breaks occur frequently. • The voice is hypo nasal or hyper nasal. • There is nasal air emission, a nasal “rustle”, snorting, or a nasal grimace during speech. Stuttering • The parents have expressed a concern about stuttering. • The child has an abnormal number of repetitions, hesitations, prolongations, blocks, or disruptions in the natural flow of speech. • The child exhibits tension during speech. • The child avoids speaking situations due to a fear of stuttering. • The child considers himself to be a stutterer. Source: Feinstein C and Aldershof A (1991) Developmental disorders of learning and language, in Textbook of Child and Adolescent Psychiatry (ed Wiener JM). American Psychiatric Press, Washington DC. 89 CU IDOL SELF LEARNING MATERIAL (SLM)
6.6 PROGNOSIS OF COMMUNICATION DISORDER Expressive and Mixed Receptive-expressiveLanguage Disorders Contrary to some popular beliefs, language disorders do not usuallyspontaneously resolve. In general, the course of these disordersis lengthy, and the more severe disorders are usually themore persistent. Language disorders of the developmental typegenerally appear gradually early in life, while those secondaryto other medical illnesses tend to occur more precipitously and atany age. In the case of Expressive Language Disorder, DSM-IVTRreports that most children with this condition acquire more orless normal language abilities by late adolescence, but that subtledeficits may persist. In the case of Mixed Receptive-expressive Language Disorders only a minority of children are free of communicationproblems in adulthood. Even when their communicationskills seem grossly normal, subtle deficits may persist, andthey may experience educational difficulties. The prognosis forindividuals with acquired language disorders often depends uponthe severity of injury or illness, as well as their premorbid state. Phonation Disorder The course of Phonation Disorder is much more encouraging thanthose of other communication disorders. Milder cases may not bediscovered until the child starts school. These cases often recoverspontaneously, especially if the child does not encounter adversepsychosocial consequences because of his speech. Severe casesassociated with anatomic malformations may at times requiresurgical intervention. Between these two extremes are childrenwho gradually improve, often to the point of total remission, andwhose improvement may be accelerated by speech therapy. Stuttering Stuttering usually appears in early childhood, at as early as twoyears of age and frequently around five, with a typically gradualonset. A study by Yairi et al. (1993) suggested that often early-appearingstuttering takes on a moderate to severe form. Childrenare generally not aware of this condition in themselves until it ispointed out to them by others. The disorder can wax and waneduring childhood. By early adolescence, it abates spontaneouslyin some cases, and from 60 to 80% of individuals eventually recovertotally or to a major extent. DSM-IV-TR asserts that spontaneousrecovery typically occurs before the age of 16. Stutteringmay persist into adulthood, often leading to adverse social andoccupational consequences. 6.7 TREATMENT FOR COMMUNICATION DISORDER Speech and Language Therapy Speech and language therapy typically has three major goals: the development of communication skills with concurrent remediation of deficits; 90 CU IDOL SELF LEARNING MATERIAL (SLM)
the development of alternative or augmentative communication strategies, where required; and the social habilitation of the individual with regard to communication. The speech and language pathologist plays the most direct role in Treatment for these conditions. SLPs employ a wide range of techniques with children that require both science and art. Asin child psychotherapy, the participation of parents is necessary.Parent–infant work involves demonstration and modeling of language-stimulation techniques. Individual therapy can usually bebegun by three years of age, and early initiation of therapy isfrequently recommended. Individual sessions can include formalexercises along with seemingly less structured but nonethelesscarefully directed verbal and play interactions. Group therapycan also be used, especially in the development of language skillsapplied to a social context; but it should not be regarded as a lowbudgetsubstitute for individual treatment. Treatment requiresregular reassessment, ongoing support to parents and regular re-consultationwith other professionals. The need for clinicians to avoid regarding variations in accentand dialect as pathologic has been cited. Very little empiricalliterature on cultural variations in communication therapy is extant.McCrary (1992) and others have pointed out the need forcultural sensitivity in treatment, citing the efforts of ASHA inthis area.The Treatment for stuttering addresses both the mechanicsof speech and associated attitudinal and affective patterns. Guitar (1985) notes that therapists attempt to modify speechrhythm and speed, leading subjects to regularize rhythm and,as a temporary measure, prolong their speech. Treatment alsoaddresses respiration, airflow and “gentle” onset of phonation.Success rates for various treatments of up to 70% have been reported,though with varying follow-up periods and relapse rates.Some speech and language pathologists specialize in the Treatment for this disorder. The Role of the Psychiatrist Children with these disorders may present for Treatment for psychiatricdisorders based on or related to communication problems.Thus, the psychiatrist may in the first place be a casefinder or case manager, facilitating the evaluation and Treatment for these disorders by a multidisciplinary team. The psychiatriccomorbidity of these disorders will necessitate the psychiatrist’sinvolvement on many levels, both as a clinician primarily treatinga child, and as a therapist, counselor, and agent of advice andsupport for the entire family. Individual and family psychotherapy may be a useful augmentin reducing the stress these children encounter, even thoughpsychotherapy does not directly address language disorders. Thepsychotherapist must, in any event, be sensitive to the manner inwhich communication disorders can affect or interfere with thetherapeutic process. Nonverbal augments or prompts should besensitively provided children who need them. The role of psychotropic medication in the managementof these disorders is mainly limited to the Treatment for comorbidpsychiatric problems according to standard practices. From timeto time, some interest in the use of drugs specifically for theseconditions has arisen. The author 91 CU IDOL SELF LEARNING MATERIAL (SLM)
has received occasional reportsof Treatment for stuttering in the past with tricyclic antidepressantsand, more recently, selective serotonin re-uptake inhibitors. The rationale for these treatments appears to be a hypotheticalconnection between stuttering and similar compulsive behaviors.These accounts are provocative but do not suggest any real indicationfor these medications for stuttering alone. Outcome Outcome studies of communication therapy, especially for thelanguage disorders, have often been complicated by multipletheories of language development, diagnostic and methodologicvariations, lack of standardization of therapeutic techniques, andcomorbidity. Thus the literature in this area is relatively sparse andnot always conclusive. Nonresponse to initial treatment may becommon, requiring patience and persistence. It is important to notein assessing these issues that, even when communication therapydoes not lead to apparent improvements in language beyond developmentalimprovements, it may still facilitate the child’s use ofextant language for environmental and self-control. 6.8 SUMMARY Most young children with these disorders are able to speak by the time they enter school. But they still have problems with communicating. School-aged children often have problems understanding and making words. Teens may have more trouble understanding or expressing abstract ideas. Most children with these disorders are referred to a speech-language pathologist. This is a speech expert who treats children who are having problems communicating. Your child may also see a child psychiatrist. There are essentially three main goals for communication disorder treatments: to help children to develop and improve their communication abilities, to help children develop coping strategies and alternative communication options enabling them to compensate for times when their communications abilities are insufficient, and to help children get used to using and practicing their communication skills and coping strategies in real-world environments such as home, at school, and with friends. Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is. A speech-language pathologist will work with your child to improve his or her communication skills. Treatment is often a team effort. Parents, teachers, and mental health experts may also be involved. Experts don’t know at this time how to prevent these disorders in children. But finding them early and taking action right away can help with your child’s development and school issues. They can improve the child’s quality of life. 92 CU IDOL SELF LEARNING MATERIAL (SLM)
6.9 KEY WORDS Broca ' s Area: Named after Paul Broca, a nineteenth-century French surgeon, it is an area of the brain closely involved with producing speech and formerly referred to as the speech centre. 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. Down's Syndrome: A form of congenital mental retardation which is due to a genetic abnormality. Psychotherapy: The use of psychological techniques to treat psychological disturbances. Psychological model:Psychological model includes personality, learning, stress, self- efficacy, cognition and early life experiences and the way in which they affect mental illness Psychological tests: Psychological tests are used for assessment of different attributes personality, social skills, intelligence, cognitive abilities, emotional responses, behavioral responses and interests. They can be administered either individually or to groups using pen and paper or oral method. Psychopathology: The scientific study and research on psychological disorders Public stigma: When people in a society approve negative stereotypes towards a person with a mental disorder and discriminate against them. 6.10 LEARNING ACTIVITY 1. Explain the process of assessment undertaken in order to diagnose a child with communication disorder? ________________________________________________________________________ ________________________________________________________________________ 2. Explain the process of treatment provided to a child with communication disorder? ________________________________________________________________________ ________________________________________________________________________ 6.11 UNIT END QUESTIONS 93 A. Descriptive Questions Short Questions 1. Write a note on General Communication Disorders. CU IDOL SELF LEARNING MATERIAL (SLM)
2. Write a note on Expressive Language Disorder and Mixed Receptive-expressive Language Disorder. 3. Write a note on Expressive Language Disorder. 4. Write a note on Mixed Receptive-expressive Language Disorder. 5. Write a note on Phonological Disorder. 6. Write a note on Stuttering. Long Questions 1. Explain the incidence and prevalence of communication disorders. 2. What is process used for assessing communication disorder? 3. Write in detail about different language tests? 4. Explain the prognosis of communication disorders. 5. Explain the treatment for communication disorders. B. Multiple Choice Questions 1. which of the following is a technique used to address stuttering? a. Purposeful speech b. Practical speech c. Delayed speech d. Prolonged speech 2. Speech and language disorders are prevalent among children with disabilities. The most common speech disorders are ____________ disorders. a. dysfluency. b. Articulatory and phonological c. a voice disorder. d. language impairments 3. Students with speech impairments are generally served in a. Special education classes. b. special schools c. Clinics. d. General education classes. 4. Two categories of articulation and phonological disorders are functional and _____________. a. Speech b. Organic c. Cognitive d. Phonological 94 CU IDOL SELF LEARNING MATERIAL (SLM)
5. Teachers who suspect a child of having a speech disorder must determine if the disorder is interfering with overall __________. a. Cognitive development b. Speech development c. Language development d. Academic performance Answer 1-a, 2-b, 3-d, 4-b, 5-d 6.12 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 Baker L (1990) Specific communication disorders, in Psychiatric Disorders in Children and Adolescents (eds Garfinkel BD, Carlson GA, and Weller EB). WB Saunders, Philadelphia, pp. 257–270. Bashir AS and Scavuzzo A (1992) Children with language disorders: Natural history and academic success. J Learn Disabil 25(1), 53–65. Beitchman JH (1985) Speech and language impairment and psychiatric risk: Toward a model of neurodevelopmental immaturity. Psychiatry Clin N Am 8, 721–735. Cantwell DP and Baker L (1991) Psychiatric and Developmental Disorders in Children with Communication Disorder. American Psychiatric Press, Washington DC. 95 CU IDOL SELF LEARNING MATERIAL (SLM)
Feinstein C and Aldershof A (1991) Developmental disorders of learning and language, in Textbook of Child and Adolescent Psychiatry (ed Wiener JM). American Psychiatric Press, Washington DC. Friel-Patti S (1992) Research in language disorders: What do we know and where are we going? Folia Phoniatr 44, 126–142. Gopnik M and Crago MB (1991) Familial aggregation of a developmental language disorder. Cognition 39, 1–50. Guitar B (1985) Stammering and stuttering, in The Clinical Guide to Child Psychiatry (eds Shaffer D, Ehrhardt AA and Greenhill L). Free Press, New York, pp. 97–109. Helmuth L (2001) From the mouths (and hands) of babes. Science 293, 1758–1759. Kidd K (1983) Genetic aspects of speech and language disorders, in Genetic Aspects of Speech and Language Disorders (eds Ludlow C and Cooper J). Academic Press, New York, pp. 197–213. Klykylo W (2003) Childhood disorders: communication disorders, in Psychiatry, 2nd edn (eds Tasman A, Kay J and Lieberman J). Wiley and Sons, London, pp. 743–756. Lewis BA and Fairbairn L (1992) Residual effects of preschool phonology disorders in grade school, adolescence, and adulthood. J Speech Hear Res 35, 819–831. McCrary MB (1992) Urban multicultural trauma patients. ASLHA 34(4), 37–40, 42. McKirdy LS (1985) Childhood language disorders, in The Clinical Guide to Child Psychiatry (eds Shaffer D, Ehrhardt AA and Greenhill L). Free Press, New York, pp. 79–96. Perkins WH (2001) Stuttering: A matter of bad timing. Science 294, 786. Plomin R and Dale PS (2000) Speech and language impairments in children: Causes, characteristics, intervention, and outcome, in Speech and Language Impairments in Children (eds Bishop DVM and Leonard BE). Psychology Press, Hove, East Coast Sussex, pp. 35–51. Riccio CA, Hynd GW, Morris MJ et al. (1994) Comorbidity of central auditory processing disorder and attention-deficit hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 33(6), 849–857. Rutter M (1987) Assessment objectives and principles, in Language Development and Disorders (eds Yule W and Rutter M). JB Lippincott, Philadelphia. Tomblin JB (1989) Familial concentration of developmental language impairment. J Speech Hear Disord 54, 287–295. Yairi E, Ambrose NG and Niermann R (1993) The early months of stuttering: A developmental study. J Speech Hear Res 36, 521–528. 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. 96 CU IDOL SELF LEARNING MATERIAL (SLM)
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 97 CU IDOL SELF LEARNING MATERIAL (SLM)
UNIT 7 – LEARNING DISORDER PART I STRUCTURE 7.0 Learning Objectives 7.1 Introduction 7.2 Learning Disorder 7.3 DSM Criteria 7.4 ICD 10 Criteria 7.5 Causes of Learning Disorder 7.6 Types of Learning Disorders 7.7 Summary 7.8 Key Words 7.9 Learning Activity 7.10 Unit End Questions 7.11 References 7.0 LEARNING OBJECTIVES After studying this unit, you will be able to, Describe Learning Disorder Explain the nature and symptoms of Learning Disorder Explain the DSM criteria of Learning Disorder Explain the ICD 10 criteria of Learning Disorder Describe the causes of Learning Disorder 7.1 INTRODUCTION Billy started first grade and did not do well. He did not master the early skills of reading and writing. The school decision was to have him repeat first grade. He did not make much more progress during his second year in first grade. Because of his age, he was promoted to second grade. He struggled through this year but fell further and further behind. When he entered third grade, he was overwhelmed. He knew that he was a year older than the other students. He was unable to do the work in class or at home and felt frustrated and stupid. Soon, he began to clown around inclass and to get into fights with the other students. Two other things happened during this third-grade year. 98 CU IDOL SELF LEARNING MATERIAL (SLM)
First, his teacher became frustrated. She was trying to help him learn and he was not making progress. He was disrupting the class and preventing her from teaching the other children. The teacher handled her frustration by blaming it on the parents. She began to call them. “Billy is not completing his schoolwork.” “His homework is incorrect.” “He is teasing and fighting with the other children.” She seemed to be saying to the parents, “Do something. Fix your kid.” She did not realize that the parents were just as confused and frustrated as the teacher. Secondly, the parents began to disagree on parenting decisions. One felt that the best way to help Billy was to be firm and strict, and the other felt that the best way was to be understanding and permissive. They began to argue with each other and became less available to support each other. Finally, the principal asked the parents to come to school. They were informed that Billy was not making academic progress. They were also told that the reason for his failure was that he was emotionally disturbed because of the marital conflicts. The parents were encouraged to see a mental health professional. This psychiatrist noted that Billy had difficulty with reading, reading comprehension, handwriting and written language. He found Billy to be frustrated with a poor self-image and low self-esteem. The parents seemed to be competent people who were also frustrated with Billy’s difficulties. A full psychoeducational testing was requested. The results showed Billy to be of above-average ability but with significant learning disabilities. The psychiatrist concluded that the primary diagnosis was the learning disability. The emotional, behavioral, social and family problems were secondary to the frustrations and failures experienced by Billy, his parents and his teacher. By working with the family, he helped to get Billy identified as having a disability and to obtain the necessary services to help him. His behavior problems diminished and then ceased. 7.2 LEARNING DISORDER In spite of average or above average intelligence and adequate schooling some children lag behind in their academic skill acquisition. These children are generally considered as learning disabled. Learning disabilities are diagnosed particularly when children start going to schools and are engaged in academic activities with other children in the school. Academic skill acquisition involves one or more of the basic psychological processes, such as attention, perception, memory, logical thinking and so on. When there is some deficit in these basic processes required in understanding or using language, spoken or written; it may be manifested in the imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations. In spite of their average or above average intelligence, they have difficulty in learning scholastic skills. The disorder is called ‘specific learning disability’. The disability is ‘specific’ in the sense that this can be differentiated from other general forms of deficits that affect acquisition of other skills in general, such as mental retardation. 99 CU IDOL SELF LEARNING MATERIAL (SLM)
Although even a person with mental retardation can have learning disability if there is a major discrepancy between intelligence and the index skill, generally mental retardation is excluded from this category. Hence, ‘specific learning disability’ includes those skill deficits which are confined to scholastic performance in subjects like reading, writing and arithmetic. Even having average or above average intelligence, these children perform poorly in these academic tasks. Learning disability is believed to be present if there is ‘substantial’ difference between expected and actual performance based on intelligence, ruling out other contributing factors such as poor learning-teaching environment, second language etc. For diagnosis of specific learning disability the person should not only have at least average intelligence, but should have adequate opportunity for learning. The child should be free from sensory impairment if any, that could affect learning. These are the necessary conditions for the identification of children with learning disability. Here, ‘substantial’ difference means the difference between level of intelligence and academic performance is technically more than two standard deviations on a standardized test of academic achievement, measuring these academic skills 7.3 DSM CRITERIA A. The specific ability, as measured by individually administered standardized tests, is substantially below that expected given the person’s chronological age, measured intelligence, and age-appropriate education. B. The disturbance in Criterion A significantly interferes with academic achievement or activities of daily living that require reading skills. C. If a sensory deficit is present, the learning difficulties are in excess of those usually associated with the sensory deficit. DSM-IV-TR lists specific deficits for each type of learning disorder (American Psychiatric Association, 2000): Reading disorder is characterized by difficulty with reading accuracy, speed, or comprehension, to the point that the difficulty interferes with academic achievement or activities of daily functioning that involve reading. Mathematics disorder is characterized by difficulty with recognizing numbers or symbols, paying attention to and remembering all the different steps in a math problem, particular arithmetic skills such as multiplication, or translating written problems into arithmetic symbols. Disorder of written expression is diagnosed when poor spelling or handwriting occurs along with significant grammatical or punctuation mistakes or problems in paragraph organization. (This is the least studied of the learning disorders.) 100 CU IDOL SELF LEARNING MATERIAL (SLM)
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