Other Childhood Disorders

1. Introduction to the communication disorders


  • The communication disorders are a group of difficulties that impact a child's ability to use language in some fashion such as the ability to use or understand a system of symbols for interpersonal communication. A person with a language disorder might have difficulty with language form (grammatical structures), content (vocabulary, basic concepts), organization (sequence of language, memory, problem solving), and use (social communication). A child with this disorder presents difficulty in expressive language, receptive language, or both.
  • Language and communication is crucial for anybody living in today's world. For those who have deficits or problems in communication their functioning can be severely impacted.




2. Expressive language disorder (315.31)


  • Definition.
    • ELD occurs when a person has problems expressing him or herself using spoken language. A child with an expressive language disorder is not able to communicate thoughts, needs, or wants at the same level or with the same complexity as his or her peers. The child often has a smaller vocabulary than his or her peers.
  • DSM-IV-TR diagnostic criteria.
    • A. The scores obtained from standardized individually administered measures of expressive language development are substantially below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language development. The disturbance may be manifest clinically by symptoms that include having a markedly limited vocabulary, making errors in tense, or having difficulty recalling words or producing sentences with developmentally appropriate length or complexity.
    • B. The difficulties with expressive language interfere with academic or occupational achievement or with social communication.
    • C. Criteria are not met for Mixed Receptive-Expressive Language Disorder or a Pervasive Developmental Disorders.
    • D. If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.
    • Coding note: If a speech-motor, sensory deficit, or neurological condition is present the condition should be coded on Axis II.
  • Associated features
    • Children with expressive language disorder have great difficulty in the use of expressive language - the ability to express his or herself verbally. Proper pronunciation of words, however, is not a difficulty. Instead, the child with ELD may instead show difficulty in constructing sentences, using correct grammar, or word finding which prevents him or her from communicating their needs and wants in an age-appropriate fashion. There may be disturbances in fluency and formulation with an abnormally rapid rate and erratic rhythm in speaking. There may also be disturbances in structure ("cluttering"). When it is acquired, there may be difficulties in motor articulation, speed, syllabic repetition, monotony, and proper syllabic stress.
    • While children with ELD have the same level of language, comprehension ability, and intelligence they generally show a smaller vocabulary than their peers. For example; many different ways in which expressive language disorder can manifest it. Some children do not properly use pronouns, or leave out functional words like "is" or "the." Other children cannot recall words that they want to use in the sentence and substitute general words like "thing" or "stuff." Some children cannot organize their sentences; these children would comprehend the material they are trying to express but they just cannot create the appropriate sentences to express their thoughts. Generally, ELD is dissevered into two types; the developmental and acquired type. The developmental type most commonly shows no specific cause and is generally apparent when the child first begins the learning process; whereas the acquired type is most commonly caused by damage to the brain (stroke, concussion).
  • Child vs. adult presentation
    • Children most often present with developmental ELD (see "Etiology"), whereas ELD in adults it is usually only seen after direct damage has been inflicted to the brain. Note, however, that acquired ELD can happen at any age.
  • Gender and cultural differences in presentation
    • Boys are more commonly diagnosed with developmental ELD than girls, with studies finding anywhere from a 2:1 to 5:1 ratio. In almost every culture you will find people that struggle with their own language and how to correctly express oneself. Therefore, it is hard to distinguish any difference in presentation among cultures.
    • Assessment should take into account individuals' cultural and language context, particularly individuals growing up in a bilingual environment. Standardized measures for language development and nonverbal intellectual capacity must be relevant for cultural and linguistic groups.
  • Epidemiology
    • A commonly seen disorder of which estimates of the number of of school age children qualifying for a ELD diagnosis range from 3-7%
    • Language delays occur in 10-15% of children under the age of three.
  • Etiology
    • There are two types of ELD; in the acquired type, one experiences some type of direct trauma to the brain, such as a stroke or traumatic brain injury, which results in difficulties in the use of expressive language. The developmental type of ELD is seen in children, has no known cause, and usually appears during early development when a child is learning to speak.
  • Empirically supported treatments
    • Expressive language disorder is normally treated in two ways. The first option for treatment is a child with this disorder to work one-on-one with a speech therapist, where the child practices communication and speech skills. Another type of treatment involves the parents and teachers of the child to work as a team to incorporate the needed language skills in the child's everyday activities. These treatments are often used together for a more effective treatment.

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3. Mixed Receptive-Expressive Language Disorder (315.32)

    • DSM-IV-TR criteria
      • A. The scores are obtained from a battery of standardized, individually administered measures of both receptive and expressive language development which are substantially below those obtained from standardized measures of nonverbal intellectual capacity. Symptoms include those for Expressive Language Disorder as well as difficulty understanding words, sentences, or specific types of words, such as spatial terms.
      • B. The difficulties with receptive and expressive language significantly interfere with academic or occupational achievement, or with social communication.
      • C. Criteria are not met for a Pervasive Developmental Disorder.
      • D. If Mental Retardation then a speech-motor, sensory deficit, or environmental deprivation is present; the language difficulties are in excess of those usually associated with these problems.
      • Coding note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.
    • Associated features
      • The essential diagnostic feature of Mixed Receptive-Expressive Language Disorder is a disability found in the development of both the receptive and expressive language as demonstrated by standardized testing that is individually administered and measures both receptive and expressive language development. The scores are significantly below the standardized measures of the nonverbal intellectual capacity as in Criterion A. When unable to or inappropriate to do standardize testing, the diagnosis can be based on a methodical practical assessment of the person’s language ability.
      • The language difficulties in communication may involve verbal and sign language. The difficulties with the communication hinder the academic or occupational achievement and social communication in accordance with Criterion B, and the symptoms do not meet the criteria for Pervasive Developmental Disorder as with Criterion C. Criterion D gives one more feature which is that if Mental Retardation, a speech-motor or sensory deficit, or environmental deficiency are present, the language difficulties are in excess. If a speech-motor or sensory deficit or a neurological condition is present, the disorder is coded on Axis III.
      • An individual diagnosed with Mixed Receptive-Expressive Language Disorder has the same difficulties as someone diagnosed with Expressive Language Disorder, but also has difficulties with understanding words, sentences, or specific types of words, which is receptive language development. There are milder cases where there are only difficulties with understanding particular types of words like spatial terms or with statements such as complex sentences. The more severe cases may have multiple disabilities.
      • These disabilities include an inability to understand basic vocabulary and/or simple sentences, along with a deficiency in the discrimination of sounds, association of sounds and symbols, recollection, storage, and sequencing. The development of expressive language in children depends on the acquisition of receptive language skills, therefore it is hardly ever seen that a child will be diagnosed with a pure receptive language disorder.
      • The linguistic features of Mixed Receptive-Expressive Language Disorder in the production impairment are quite similar to Expressive Language Disorder as previously stated. It is comprehension that distinguishes Mixed Receptive-Expressive Language Disorder from Expressive Language Disorder. The comprehensive distinguishing feature varies depending on the severity of the disorder and the age of the child. Difficulties with language comprehension are not as easily recognizable as language production difficulties. They may only appear under formal observation. The child will show poor or nonexistent conversational skills, may seem to follow directions incorrectly or not at all and give inappropriate answers to questions asked of them.
    • Child vs. adult presentation
      • Acquired Mixed Receptive-Expressive Language Disorder is seen at any age. Developmental Mixed Receptive-Expressive Language Disorder is seen in children with a normal onset at or around age 4. Severe forms of Mixed Receptive-Expressive Language Disorder can be detected by age 2. The milder forms may not be detected until the child reaches school where comprehension problems become more apparent.
    • Gender and cultural differences in presentation
      • The developmental type is more prevalent in males than in females. Prevalence estimates vary with age. When doing the assessment of the disorder, the cultural and language context must be taken into account. This is especially important in bilingual environments. The standardized measurements of the language development and nonverbal intellectual capacity have to be relevant for cultural and linguistic groups.
    • Epidemiology
      • Other disorders that are associated with Mixed Receptive-Expressive Language Disorder include Phonological Disorder, Learning Disorders, and deficits in the perception of speech and impairment of memory. In addition, Attention-Deficit/Hyperactivity Disorder, Developmental Coordination Disorder, and Enuresis are sometimes present in the developmental type. Mixed Receptive-Expressive Language Disorder is occasionally accompanied by EEG abnormalities, and other neurological signs.
      • Acquired Mixed Receptive-Expressive Language Disorder can happen at any age. A form of acquired Mixed Receptive-Expressive Language Disorder has an onset of 3-9 years of age. It is accompanied by seizures and referred to as Landau-Kleffner syndrome.
        The prognosis of acquired Mixed Receptive-Expressive Language Disorder depends on the severity of the brain damage and the location of the damage. It also depends on the extent of the language development when the disorder is acquired.
      • The developmental Mixed Receptive-Expressive Language Disorder has its onset as previously stated beginning at or around the age of four. There is an estimate of the developmental type of Mixed Receptive-Expressive Language Disorder that occurs in up to 5% of preschool children and 3% of school-age children. It is essentially less common than Expressive Language Disorder, Landau-Kleffner syndrome and the other forms of acquired Mixed Receptive-Expressive Language Disorder.
      • Severe forms of the developmental Mixed Receptive-Expressive Language Disorder have their onset by 2 years of age. The milder forms may not be detected until the child reaches elementary school. A child who has Mixed Receptive-Expressive Language Disorder will eventually acquire normal language skills, but the prognosis for those with Expressive Language Disorder is worse.
      • Developmental Mixed Receptive-Expressive Language Disorder is more common with first-degree biological relatives with the disorder than the general population. The acquired Mixed Receptive-Expressive Language Disorder has no evidence of familial ties.
    • Etiology
      • Mixed Receptive-Expressive Language Disorder can either be acquired or developed. Developmental Mixed Receptive-Expressive Language Disorder does not have a known cause. Research is being conducted to
        determine if the cause is biological, environmental, or both. Malnutrition during pregnancy probably plays a major role in developmental Mixed Receptive-Expressive Language Disorder.
      • Acquired Mixed Receptive-Expressive Language Disorder is generally caused by an injury to the brain. The injury to the brain can be either direct trauma such as head injuries or indirect trauma such as strokes, or seizures. Acquired Mixed Receptive-Expressive Language Disorder is commonly misdiagnosed as a Developmental Disorder. Developmental Mixed Receptive-Expressive Language Disorder and other receptive language disorders start showing symptoms beginning around the age of four.
      • The specific symptoms of acquired Mixed Receptive-Expressive Language Disorder depend on which area of the brain received damage, and also on how severe the damage is.
      • The symptoms for developmental Mixed Receptive-Expressive Language Disorder are extremely similar to the symptoms of Expressive Language Disorder. The symptoms vary considerably from child to child. Generally speaking, Mixed Receptive-Expressive Language Disorder is characterized by a difficulty with spoken communication. The child can pronounce the words, unlike Phonological Disorders, but has problems with coherent syntax, the usage of proper grammar, and word recollection.
      • A child who is diagnosed with Mixed Receptive-Expressive Language Disorder has trouble communicating his or her thoughts, needs, and what he or she wants at the same level or same complexity as other children the child's age. The child generally has a smaller vocabulary as well.
    • Empirically supported treatments
      • There can be complete or nearly complete clinical improvement in language abilities. There are some instances that may have incomplete recovery or progressive insufficiency. Mixed Receptive-Expressive Language should be treated as soon as you reach a diagnosis. Clinical improvement is more likely with early intervention.
      • Treatment involves anyone who interacts regularly with the child diagnosed with the disorder. One-on-one treatment regularly scheduled, that focuses on specific language abilities can be effective. Pair the one-on-one treatment with a more general approach with family and caregivers is more effective.
      • Teaching the child specific communication skills for interaction with his/her peers is extremely important. This could avoid problems later in life like social isolation, depression, and/or behavioral problems. Teaching the child reading skills will benefit the child to avoid serious long-term academic problems.

  • -- Christian age four diagnosed with Mixed receptive-Expressive language disorder. See video

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4. Stuttering (315.31)

  • DSM-IV-TR criteria
    • A. Disturbance in the normal fluency and time patterning of speech (inappropriate for the individual's age), characterized by frequent occurrences of one or more of the following:
      • 1. Sound and syllable repetitions
      • 2. Sound prolongations
      • 3. Interjections
      • 4. Broken words (e.g., pauses within a word)
      • 5. Audible or silent blocking (filled or unfilled pauses in speech)
      • 6. Circumlocutions (word substitutions to avoid problematic words)
      • 7. Words produced with an excess of physical tension
      • 8. Monosyllabic whole word repetitions (e.g., "I-I-I-I see him")
    • B. The disturbance in fluency interferes with academic or occupational achievement and with social communication.
    • C. If a speech-motor or sensory deficit is present, the speech difficulties are in excess of those usually associated with these problems.
  • Associated features
    • When stuttering first comes about, the affected individual may not realize there is a problem. After time goes on, most people with stuttering issues will realize there is a problem; some may begin to fear that they will stutter in front of others. To avoid embarrassment, a person with a stuttering problem may try to create ways to avoid stuttering. They might avoid speaking in front of a crowd where they know they would become more anxious and more likely to stutter. They could also change the way they speak. Slowing down the rate of speech would make pauses less noticeable and drawing out certain words wouldn’t be as obvious either if all words were spoken at a slower pace.
    • In extreme cases, a person may choose to avoid social contact entirely in order to prevent occurrences where they now some form of stuttering will occur regardless of what precautions they may take.
    • Stress makes stuttering more likely to occur. The anxiety about stuttering can lead to several other issues with social functioning. Self-esteem in individuals with a stuttering problem is typically lower than the “normal” population who have less issues with social communication. Nervous twitches may arise in those who stutter such as eye blinks, tics, tremors, and other “twitches” non of which are uncommon.
- Other people may try to hide their unorthodox speech from others by rearranging the words in their sentence
(circumlocution), pretending to forget what they wanted to say, or declining to speak.
    • Child vs. adult presentation
      • The presentation of stuttering in children and adults is very similar; however, the manner in which it affects their lives can be quite different. In children and adults, stuttering can create a major impairment of social functioning.
      • In adults, this impairment may also carry over into the work place. Stuttering can limit career options for adults, considering occupations dealing with frequent speaking in front of groups could cause considerable distress or anxiety to an individual who stutters. Stuttering could also limit opportunity for job advancement.
      • In children, stuttering causes more of an issue in peer communication.
    • Gender and cultural differences in presentation
      • Stuttering is much more frequently diagnosed in males than in females. According to the DSM, for every female diagnosed with stuttering, there are approximately 3 males diagnosed. Other sources indicate that this ratio may actually be 4:1 (Stuttering).
      • While there are no known cultural differences in presentation, it may be possible to avoid being diagnosed with stuttering throughout different cultures due to different languages that may disguise the symptoms of stuttering,
    • Epidemiology
      • The prevalence of stuttering in children is approximately 1%. This falls to 0.8% in adolescence. 98% of cases of stuttering occur before age 10. The onset of stuttering typically occurs during the period of greatest language development in which individuals move from simple words and phrases to more complex ones. Later acquisition of the condition may be caused by brain lesions via strokes or other injuries in the speech-governing areas of the brain.
    • Etiology
      • Research has shown many individuals have a predisposition to stuttering. Research with twins have demonstrated that if one twin suffers from stuttering, the other is more likely to suffer from it.
      • The exact cause of stuttering is not known, because there are many brain mechanisms that may be involved in the process. Congenital brain damage has been implicated as well. There are also external causes that can contribute to the onset of stuttering.
      • Children who have negative experiences with stuttering may develop further problems with speech and communication. If stuttering doesn’t create any social discomfort for the child, they may correct the behavior themselves. Different people have different degrees of stuttering that cause different problems in social situations.
      • Some recent studies have shown that genetics play a role in stuttering. Some people inherit traits that put them at a higher risk level for developing a stutter.
    • Empirically supported treatments
      • Medicinal treatments for stuttering are not the usual route, since the exact cause of stuttering remains unknown. Instead, behavioral treatments are utilized to try and correct the patient’s stuttering. In these treatments, patients are taught how to control the way, speed, and overall manner in which they communicate (Stuttering). Treatments in speech are limited but can be done if the patient is committed and willing to work with their impairment. A person may also be taught how to control or monitor their breathing as a way of helping as well.

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5. Selective Mutism (313.23)

    • DSM-IV-TR criteria
      • A. Consistent failure to speak in specific social situations (in which there is an expectation for speaking, e.g. at school) despite speaking in other situations.
      • B. The disturbance interferes with educational or occupational achievement or with social communication.
      • C. The duration of the disturbance is at least one month (not limited to the first month of school).
      • D. The failure to speak is not due to a lack of knowledge of, or comfort with, the spoken language required in the social situation.
      • E. The disturbance is not better accounted for by a communication disorder (e.g. stuttering) and does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic disorders.
    • Associated features
      • In unfamiliar settings or situations a child with Selective Mutism is often described as “excessively shy”. This can be misleading due to the fact that shy children can withhold from conversations for hours or days, but will eventually begin speaking. Shy children can function in social settings.
      • Children with Selective Mutism suffer from fear of social embarrassment, social isolation and withdrawal, clinging, compulsive traits, negativism, temper tantrums, or controlling behavior, along with the excessive shyness that is seen in children that are shy.
      • When confronted with a conversation, a child with this disorder will attempt to avoid it, using stiff body language, avoiding eye contact, maintaining a blank facial expression.
      • These children are often very normal in the home and around the family members. They are also sometimes teased by their peers. There may also be an associated Communication Disorder or a general medical condition causing abnormalities of articulation.
      • Children suffering from this can be over dependent on their parents.
      • Mute children are not mute because they do not want to speak but because they are afraid to speak.
    • Child vs. adult presentation
      • Children are affected by Selective Mutism, which usually appears between the ages of 4-6. When children leave the home setting, usually for school or daycare, the symptoms begin to appear. Children do not outgrow this disorder, but it has usually been treated and overcome by adolescence.
    • Gender and cultural differences in presentation
      • Children of immigrants are often more uncomfortable or unfamiliar with the new country’s language and this lack of communication should not be confused with or misdiagnosed as Selective Mutism.
      • Females tend to present with Selective Mutism more frequently than males. According to the Developmental and Behavioral Pediatrics “A Handbook for Primary Care,” females with this disorder outnumber males 2:1.
    • Epidemiology
      • 90% of children with Selective Mutism also have a social phobia. In many cases Selective Mutism lasts for only a few months, however, the symptoms may last up to several years.
      • Selective Mutism is very rare, with rates of 0.1% to 0.7% in the general population and 1% in mental health institutes being reported. These extremely low rates are due, in part, to limited research.
    • Etiology
      • There is a genetic predisposition to Selective Mutism, with most cases having a first degree family history; 70% being a Social Phobia or 30% being Selective Mutism. Since this condition is so rare, the etiology is poorly understood. There are many theories on etiological factors for this disorder, but three main ones have emerged, due to consistency in cases.
      • The three main etiological factors for Selective Mutism are anxiety, developmental delays, and not being exposed to the local language. Many clinicians consider trauma as a factor for Selective Mutism,(before the age of 3) however, trauma tends to cause global mutism (refusal to speak to everyone) instead of a selective development.
      • In one study, Kristensen linked Selected Mutism with many nonlinguistic developmental problems. Some of these problems included motor delays, elimination disorders, and pre- and perinatal problems. Selective Mutism is also highly found among immigrant children, although sometimes it may be misdiagnosed due to unfamiliarity or uncomfortableness with the host country’s language. When these children cannot speak the language, it may affect their confidence.
      • Other children may also tease them about their inability to speak well, their accent, or minor grammatical errors. The child cannot participate in school due to the language barrier, which predisposes them to Selective Mutism, a disease only reinforced by the teasing.
      • One study by BarHaim also suggested that a deficit may exist in the child’s auditory efferent system. This deficit prevents the child from desensitizing their own vocalizations if the child is anxious they will cope with this deficit by developing Selective Mutism.
    • Empirically supported treatments
      • When treating Selective Mutism, the main goal is to treat the anxiety, not to force the child to speak. Treating Selective Mutism usually begins with therapy. Family members, teachers, and the therapist should work together to attempt to reduce the child’s anxiety, reduce the pressure they feel to speak, and increase their self esteem.
      • Therapy also attempts to create a desensitized atmosphere so that the child is able to practice speaking. Cognitive Behavioral Therapy is used to help the child to work toward specific goals. Therapy can be difficult because the child refuses to speak and feels uncomfortable.
      • In the most chronic cases, usually after all other options have been exhausted, medications have been used in combination with therapy. Selective serotonin reuptake inhibitors (SSRIs) have proven to be effective in some cases. SSRIs do not treat the Selective Mutism but the anxiety symptoms which is a main etiological factor. These medications are usually given for 9 to 12 months.

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6. Phonological Disorder (315.39)

    • DSM-IV-TR criteria
      • A. Failure to use developmentally expected speech sounds that are appropriate for age and dialect (e.g., errors in sound production, use, representation, or organization such as, but not limited to, substitutions of one sound for another [use of /t/ for target /k/ sound] or omissions of sounds such as final consonants).
      • B. The difficulties in speech sound production interfere with academic or occupational achievement or with social communication.
      • C. If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the speech difficulties are in excess of those usually associated with these problems.
      • Coding Note: If a speech-motor or sensory deficit or a neurological condition is present, code the condition on Axis III.
    • Associated features
      • Knowing and learning the various aspects of speech rather than being unable to physically pronounce words are the signs of a phonological disorder. For example, a child with a phonological disorder may not know a word whereas a child with an articulation disorder knows the word but is unable to get their articulators to shape the word so that they can say it.
      • According to the American Speech-Language-Hearing Association, signs of a phonological disorder “involve patterns of sound errors. For example, substituting all sounds made in the back of the mouth like "k" and "g" for those in the front of the mouth like "t" and "d" (e.g., saying "tup" for "cup" or "das" for "gas").” (http://www.asha.org)
      • Young children expectantly leave out sounds when they are learning to speak, especially when pronouncing words that begin with two consonants, such as the word spoon, but as the child gets older, these problems should dissipate. If they do not, the child could be showing signs of a phonological process disorder. Person’s with phonological disorders are presumed to experience difficulty acquiring the rules that underlie speech. (Bleile, 2003)
    • Child vs. adult presentation
      • Phonological disorder is most commonly a childhood disorder. If a child’s speech is not easily understood by non-family members by the age of 4, a phonological disorder may be present. Most will grow out of the disorder by third grade, but spontaneous recovery becomes less likely after the fourth grade (around age 8).
      • In severe cases, the disorder may be unremitting through adulthood. Children who misarticulate only a few phonemes are more prone to a spontaneous recovery. If articulation problems are still present after the age of 5, children are at higher risk for auditory problems.
    • Gender and cultural differences in presentation
      • Taking dialect features into consideration is important so that the patient is not misdiagnosed. Bilingual phonology is a field that there is not enough knowledge in.
      • Currently bilingual children are assessed using monolingual standards. According to the MIT encyclopedia of communication disorders,
      • Nearly two-thirds of Children under the age of 18 who are diagnosed with speech-language disorders are male. Communication disorders are twice as likely to be diagnosed in males age 45 and younger than in females. African Americans younger than 45 and of the same age are one-third as likely to be diagnosed as Caucasians. (Bleile, 2003)
    • Epidemiology
      • Phonological and Articulation disorders compose nearly 32% of the communication disorders. Six million children under the age of 18 are estimated to have a language disorder. According to Arsano, et al. (2008), approximately 20% of pre-school aged children and 6% of school aged children are affected by phonological disorder. The prevalence rates decrease as age increases.
    • Etiology
      • According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), “Phonological Disorder includes phonological production (i.e., articulation) errors that involve the failure to form speech sounds correctly and cognitively based forms of phonological problems that involve a deficit in linguistic categorization of speech sounds (e.g., a difficulty in sorting out which sounds in the language make a difference in meaning).” (American Psychiatric Association, 2000).
      • Some professionals prefer to distinguish between language knowledge (phonological) and speech-motor control (articulation). Phonological disorder can develop due an environment where the child is abused or neglected, placed in an environment with a bad teacher, or long term hospitalization. Direct physical damage to the brain or body can also be responsible for the development of the disorder.
      • A child who presents with another disorder, such as attention deficit disorder (ADD), can suffer indirect physical damage due to the fact that they may not be able to concentrate long enough to acquire complex communication skills. While phonological disorder is usually an isolated problem, occasionally it occurs simultaneously with another medical condition such as cognitive limitations, neurological conditions, hearing impairments, orofacial anomalies, structural deficits of the oral peripheral speech mechanism, psychosocial problems, or respiratory problems.
    • Empirically supported treatments
      • Children who present with moderate to severe disorders are usually recommended for treatment. The two most popular forms of treatment are the phonological approach and the traditional approach. According to Kaplan & Saddock, the phonological approach is for children with extensive patterns of multiple speech sound errors where treatment involves practice of specific sounds and is then extended into using the words in meaningful words and sentences.
      • The traditional approach involves speech therapy by a speech-language pathologist (SLP). The American Speech-Language-Hearing Association defines speech-language pathologists as professionals who identify, assess, and provide treatment for individuals with speech, language, and swallowing problems. (http://www.asha.org ) They are trained individuals who not only work with the individual experiencing phonological problems, but they also work with the family, teachers, and other professionals involved in the process of correction.
      • According to the US Department of Education Institute of Education Sciences, “phonological awareness training is a general practice aimed at enhancing young children's phonological awareness abilities. It can involve various training activities that focus on teaching children to identify, detect, delete, segment, or blend segments of spoken words (i.e., words, syllables, onsets and rimes, phonemes) or that focus on teaching children to detect, identify, or produce rhyme or alliteration.” (http://www.ed.gov)
  • -- Children with phonological disorder believe they are articulating the words they attempt to say although they are not. They often become frustrated when they are told they are not speaking correctly. See video below for example.


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7. Rumination Disorder (307.53)



    • DSM-IV-TR criteria
      • A. Repeated regurgitation and rechewing of food for a period of at least one month following a period of normal functioning.
      • B. The behavior is not due to an associated gastrointestinal or other medical condition (e.g.,esophageal reflux).
      • C. The behavior does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa. If the symptoms occur exclusively during the course of Mental Retardation or a Pervasive Developmental Disorder, they are sufficiently severe to warrant clinical attention.
    • Associated features
      • A child or infant with rumination disorder will often experience repeated regurgitation and/or re-chewing of food as well as weight loss, bad breath and tooth decay, repeated stomachaches and indigestion, and raw and chapped lips. Vomitus may be seen on the individual’s chin, neck, and clothing, but the regurgitation is often not visible to others. When associated weight loss and growth failure occurs, it can often seem unexplained.
      • In children and adults, regurgitation typically occurs within minutes of a meal and may last several hours. It generally occurs regularly after most meals. The individual with rumination disorder may appear to gain satisfaction from mouthing the regurgitated food rather than being disgusted by the vomitus, as well.
      • The adult also experiences tooth decay and erosion as well as aspiration, but generally does not experience weight loss as with children and infants. The aspiration associated with this disorder can cause recurrent bronchitis or pneumonia, bronchospasms, reflex laryngospasms, and asthma.
    • Child vs. adult presentation
      • Little is known about the prevalence of rumination disorder. We do know that rumination has been reported in not only infants and adults with mental retardation but also in infants, children, and adults of normal intelligence.
      • Lack of information on the prevalence of the disorder may be due to secrecy of those actually diagnosed.
    • Gender and cultural differences in presentation
      • Rumination occurs in both males and females, but seems to be more common among male infants. Rumination disorder has often been reported in other countries, but the frequency is unclear. Most of the studies conducted relating to the disorder have been shown to be unreliable.
    • Epidemiology
      • Although there are no recent systematic prevalence reports of rumination disorder, the cases that have been studied and reported suggest that rumination is a very rare disorder. The typical age of onset is between the age of 3 and 12 months.
      • In individuals with mental retardation, the onset of this disorder can occur at any age, but typically occurs around the age of 6.
    • Etiology
      • The exact cause of rumination is unclear. However, several theories, ranging from psychosocial to organic origins have been proposed. One of the most common psychosocial theories of the etiology of rumination disorder is the development due to an abnormal mother-infant/child relationship. In terms of this relationship, lack of stimulation, neglect, and stressful life situations are some of the factors associated with this disorder.
      • One of the most common learning based-theories proposes that the development of this disorder is for the purpose of self-stimulation. The self-stimulation tends to increase after the pleasurable sensations produced by the process of rumination or the increased attention from others after the ruminating. Negative Reinforcement relating to stress may play a part in the cause of rumination.
    • Empirically supported treatments
      • Treatment of this disorder often depends on the etiology and associated behavior. Treatment is usually a behavioral modification plan designed to promote normal eating behavior. In this type of treatment, efforts are typically directed toward the parent-child relationship and are often focused on improving the caregiver’s ability to recognize and respond to the child’s needs in the appropriate fashion. Parents may be taught parenting techniques that aim to increase attention, interaction, and stimulation.
      • Generally, rumination in infants of average intelligence stops on its own, but the disorder should still be treated because infants without treatment could experience malnutrition and dehydration, which could eventually lead to death.

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8. Tourette’s Disorder (307.23)

    • DSM-IV-TR criteria
      • A. Both multiple motor tics and one or more vocal tics must be present at the same time, although not necessarily concurrently (A tic is a sudden, rapid, recurrent, non-rhythmic, stereotyped motor movement or vocalization).
      • B. The tics must occur many times a day nearly every day(usually in bouts) nearly everyday or intermittently over more than one year, and during this period there must not have been a tic-free period of more than three consecutive months.
      • C. The onset is before age 18 years.
      • D. The disturbance must not be due to the direct physiological effects of a substance (e.g., stimulants) or general medical condition (e.g., Huntington's disease or positive encephalitis).

    • Associated features
      • According to the American Psychiatric Association (2000), “associated features of Tourette’s disorder commonly include obsessions and compulsions. These can include clicking of the tongue, squatting, sniffing, hopping, skipping, throat clearing, and stuttering. Other common associated features are hyperactivity, distractibility, and impulsivity.” Rejection by others due to the tics and other disruptions can impair both functioning and acceptance in social, school, and work settings.
      • Individuals with Tourette’s may also have an increased anxiety about having tics in social situations, causing them to stray away from going out or being accepted by others. “In severe cases of Tourette’s Disorder, the tics may directly interfere with daily activities, such as reading and writing” (American Psychiatric Association, 2000). Other disorders that are frequently associated with Tourette’s include Obsessive-Compulsive Disorder, Attention-Deficit/Hyperactivity Disorder, and Learning Disorders (American Psychiatric Association, 2000).
      • Epidemiology shows the high relevance of Tourette’s Disorder to Obsessive-Compulsive Disorder; around 30% of children diagnosed with OCD also have Tourette’s. On the reverse side, 60% of children with Tourette’s will also generally have some form of OCD (Wagner, 2006, p.65). Furthermore, there are also signs of self-injurous behaviors, sleep disturbances, aggression, anxiety, and depression.
    • Child vs. adult presentation
      • Tourette's Disorder appears to be more profound among boys than girls during early childhood, but to be more severe in women than men in adulthood.
      • In most cases the disorder peaks in severity at 10-12 years of age. In about 25% of patients the disorder does not improve until adolescence. In 10% of patients the disorder is severe and persists through adulthood.
    • Gender and cultural differences in presentation
      • Tourette's Syndrome occurs in people from all ethnic groups; males are affected about three to four times more often than females. Through different cultures, it appears that associated features vary.
      • In clinical settings the disorder is diagnosed approximately 3 to 5 times more often in males than in females, the gender ratio is perhaps low as 2:1 in community samples.
    • Epidemiology
      • Since TS develops in the adolescence years and must be present before age 18, children are more likely to develop TS than adults. In fact, TS is known, for most cases, to decrease in severity and frequency and can even disappear entirely by early adulthood. TS has been reported in a wide variety of both racial and ethnic groups. TS occurs more frequently in males than females with a ratio of 1.5:3 times more likely (APA, 2000).
      • A person with Tourette's has about a 50% chance of passing the genes to one of his or her children. Based on cases in North America and Europe, it tends to be most common is males. There is a male to female ratio of 3:1 or 4:1 and a mean onset age of about 7 years old. Vocal tics usually occur later than motor tics, around a mean of age 11.
    • Etiology
      • The etiology of TS is purely biological, but the disorder does have some psychological disorders associated with it. Some associated co-morbid disorders include obsessive compulsive disorder (OCD), anxiety disorders, learning disorders, and attention deficit/hyperactivity disorder (ADHD). TS is a neurological disorder that comes in two forms: genetic, or vulnerability, and non-genetic. The term “vulnerability”, means that the child has developed TS genetically. Individuals are at a greater risk for TS if they have a first degree relative who has the disorder. Not everyone who inherits the disorder with express the symptoms associated with the disorder, such as tics. There are a variety of ways that vulnerability can be expressed and include full-blown Tourette’s Disorder, Chronic Motor or Vocal Disorder, OCD, and some Attention/Hyperactivity Disorders (APA, 2000). When TS is said to be non-genetic, the individual usually will not have TS since it is a biological disorder associated with genes. The non-genetic individual could be experiencing tics from having another mental disorder, certain medications, or a general medical condition.
    • Empirically supported treatments
      • The primary supported therapy for TS is habit reversal training (HRT). In HRT, a person first learns to know when and where he/she is going to have a tic, followed by development of competing responses that prevent you from physically being able to perform the tic. These responses are held until the urge to tic dissipates. Over time, particularly with motor tics, the client learns that they do not need to tic to feel the release and relaxation. In many cases, TS can be effectively managed, and approprimately one third of child patients can outgrow TS by adulthood. If TS is severe enough, antipsychotic medications can be helpful. These include but are not limited to Chlorpromazine, Haloperidol, and Pimozide.
      • Alternative treatments for treating TS have proven to be helpful for patients. These complementative treatments are herbal medicines, nutritional, vitamin, and mineral supplements and behavioral therapies. It should be known that these treatments should be used as complementary and never as a substitute.
    • LINKS:
      • Author David Sedaris describes his childhood with Tourette's. This story begins at minute 30:40 and ends at 45:30.
      • The following video discusses Tourette's Syndrome. See Video: http://www.youtube.com/watch?v=hNSHLOI_-aU&feature=fvst. (uploaded by drmdk)
      • A real life story of a young man with TS who has encouraging results with surgery. See video http://www.youtube.com/watch?v=nDkrD1uCGsM. (uploaded by Westymedia)
      • The following link from NPR's Day to Day program follows writer Marcus McPeek Villatoro as he discusses his and his daughter's Tourette's Syndrome.

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9. Transient Tic Disorder (307.21)

    • DSM-IV-TR criteria
      • A. Single or multiple motor and/or vocal tics (i.e., sudden, rapid, recurrent, nonrhythmic, stereotyped motor movements or vocalizations).
      • B. The tics occur many times a day, nearly every day for at least 4 weeks, but for no longer than 12 consecutive months.
      • C. The onset is before age 18 years.
      • D. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington’s disease or postviral encephalitis).
      • E. Criteria have never been met for Tourette's Disorder or Chronic Motor or Vocal Tic Disorder.
      • Specify if: Single Episode or Recurrent.
    • Associated features
      • Transient Tic Disorder generally has the same characteristics as Tourette’s Disorder, except the symptoms are not as severe. Common associated features with this disorder are depression (loss of pleasure in everyday activities), too much sleep or not enough, guilt (inappropriate feelings of worthlessness that could even be delusional), trouble concentrating, or having obsessions. Brief and jerky movements and sounds tend to be associated with Transient Tic Disorder also.
    • Child vs. adult presentation
      • Transient Tic Disorder is presented in children, before age 18 and is usually seen by the pre-school to early school-age, but has been seen as early as 2 years.
    • Gender and cultural differences in presentation
      • Transient Tic Disorder, much like the other Tic Disorders, is more common in males than females. The disorder is seen across the map in all ethnic and cultural groups but appears to be more prevalent in Caucasians than African Americans.
    • Epidemiology
      • Transient Tic Disorder may not be reported in all cases because the symptoms are short-lived; however, it appears to occur in 4 to 24% of all school-aged children.
    • Etiology
      • Although there has been no finding of a “tic gene”, the disorder appears frequently within the same families. Genetic factors are definitely thought to be a cause, but environmental factors such as the stress level a child is exposed to as well as the parental method a child is under, could play a role in the cause too. Transient Tic Disorder may also be physical or mental.
    • Empirically supported treatments
      • Treatment for Transient Tic Disorder is much like the treatment for all of the Tic Disorders, but in this particular disorder, educating the family is one, if not the most, important thing to do. Physicians will tell the family to ignore the tics in the beginning because the unwanted notice of the tics could reinforce them, causing them to become more frequent. If the tics are bad enough that they are interfering with the child’s lifestyle and functioning, behavioral treatments and possibly even pharmacotherapy are suggested.

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10. Chronic Motor and Vocal Tic Disorder (307.22)


    • DSM-IV-TR criteria
      • A. Single or multiple motor or vocal tics (i.e., sudden, rapid, recurrent, non-rhythmic, stereotyped motor movements or vocalizations), but not both, have been present at some time during the illness.
      • B. The tics occur many times a day nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.
      • C. The onset is before age 18 years.
      • D. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington’s disease or postviral encephalitis).
      • E. Criteria have never been met for Tourette’s Disorder.
    • Associated features
      • Chronic Motor and Vocal Tic Disorder is more common than Tourette’s Disorder. Individuals with Chronic Motor and Vocal Tic Disorder have a very hard time suppressing the urges that a tic can bring. The tension, for most people, can be described as an occurrence that falls in between a voluntary motion and an involuntary motion; similar to the need to scratch an itch, it can be avoided but the tension isn’t relieved until a tic takes place. Some common complex motor tics include Copropraxia, (making obscene and inappropriate gestures) and Echopraxia, (mimicking another person’s movement). Some common complex vocal tics include Echolalia, (mocking a statement or phrase or noise that was heard most recently) and Coprolalia, (saying something that is vulgar or socially unacceptable).
    • Child vs. adult presentation
      • People most often present with Chronic Motor and Vocal Disorder before age 18 and it is rarely diagnosed after the age of 18. If the disorder develops between the ages of 6 and 8, the chances of the individual getting control of the tics and living a normal life are ideal; however, if it is diagnosed later on in life the individual will probably always have to deal with the disorder.
    • Gender and cultural differences in presentation
      • This disorder presents itself in all ethnic groups, but is three to four times more common in males than females, and is generally found in children rather than adults.
    • Epidemiology
      • Occurring more often than Tourette’s syndrome, chronic Motor and Vocal Disorder is prevalent in 1 to 2% of our population. It is less common than transient tic disorder.
    • Etiology
      • Heredity plays a large role in the development of Chronic Motor and Vocal Tic Disorder. Tourette’s Disorder may also be genetically shared with Chronic Motor and Vocal Tic Disorder because it is often seen in the same families.
    • Empirically supported treatments
      • Depending on how severe and how often the tics occur determines the treatment method used. Also, depending on how the tics affect the individual’s daily life, such as the distress it causes because of work or school, will depend on the treatment method as well. Behavioral therapy is one approach; this is where things like relaxing techniques and habit-reversal training are taught. Pharmacologic therapy is another approach; here drugs are used to reduce the individuals tics and urges but does not ever completely eliminate them. One last approach is Psychological therapy; counseling is provided to the individual and sometimes even the family, in order to help deal with the social and emotional issues that an individual develops because of this disorder.
  • Links

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11. Developmental Coordination Disorder (315.4)

    • DSM-IV-TR criteria
      • A. Performance in daily activities that requires motor coordination is substantially below that expected given that person’s chronological age and measured intelligence. This may manifested by marked delays in achieving motor milestones (e.g., walking, crawling, sitting), dropping things. “clumsiness,” poor performance in sports or poor handwriting.
      • B. The disturbance is Criterion A significantly interferes with academic achievements or activities of daily living.
      • C. The disturbance is not due to a general medical condition (e.g., cerebral palsy, hemiplegia, or muscular dystrophy) and does not meet criteria for a Pervasive Developmental Disorder.
      • D. If Mental Retardation is present, the motor difficulties are in excess of those usually associated with it.
    • Associated features
      • Associated features for Developmental Coordination Disorder include clumsiness, awkwardness, speech delay and/or poor coordination skills. Developmental Coordination Disorder all so includes impairments in the development of motor coordination such as playing ball, handwriting, walking, and running. Others have problems with muscle skills such as fastening buttons or tying shoes. Speech- language disorders may be closely linked to Developmental Coordination Disorder, but the reason is unclear right now
      • Children with developmental coordination disorder tend to suffer from depression, followed by poor self esteem, and are often disruptive in social and school situations. This is caused by the physical inability to socialize with peers (playing games or sports) and the frequent inability of writing letters, coloring, making sculptures, etc. The child may become so frustrated with the situation that they stop trying and just disrupt the class. Individualized therapy specializing in arts/crafts, writing, and playground skills can alleviate these problems.
    • Child vs. adult presentation
      • Children that exhibit Developmental Coordination Disorder has trouble with motor skills development that affects the whole child because some of the associated conditions may include sensory integration disorder, specific language impairment, and also mixed expressive-receptive language disorder. Developmental Coordination Disorder in adults is the same as with children where they have difficulty in motor skills such as hand-eye coordination.
    • Gender and cultural differences in presentation
      • There are no known cultural differences for patience that a diagnosis with Developmental Coordination Disorder. However, it is thought that males and females are equally likely to have this disorder, but might be diagnosed more often in males.
    • Epidemiology
      • It has been reported that 5-9% of children in the normal population is diagnosis with Developmental Coordination Disorder. Also about 6% between age 5 and 11 have have DCD.
    • Etiology
      • The etiology is unclear but it is believed that it is caused by neuronal damage at the cellular level in the receptor system and/or neurotransmitter.
    • Empirically supported treatments
      • There is no known treatment for Developmental Coordination Disorder at this point. Experts would recommend the patient to continue working on there motor skills and motor control with peers, perhaps by going to an occupational therapist. Special education and physical education seem to be beneficial also.
    • There are different names used for Developmental Coordination Disorder. One of the most common names in the UK is Dyspraxia. This link will take you to a video of a very well-known researcher of this condition and give more information about it. http://www.youtube.com/watch?v=s832Yv-Dbwc
    • See Video to observe a child with Developmental Coordination Disorder

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12. Encopresis (307.7)


    • DSM-IV-TR criteria
      • A. Repeated passage of feces into inappropriate places, whether involuntary or intentional.
      • B. At least one such event a month for at least 3 months
      • C. Chronological age is at least 4 years (or equal developmental level)
      • D. The behavior is not due exclusively to the direct physiological effects of a substance (e.g. laxatives) or a general medical condition except through a mechanism involving constipation.
      • Code as follows:
        • 787.6 - With Constipation and Overflow Incontinence
        • 307.7 - Without Constipation and Overflow Incontinence
    • Associated features
      • A child with Encopresis may be embarrassed or ashamed because of the soiling of clothing. They may often avoid social situations (e.g. summer camp or school). A sudden change in routine can also cause an increase in the risk. The soiling can often affect self-esteem in an individual with Encopresis. Smearing of the feces can often be caused by a child’s attempt to clean up the feces. When the incontinence is deliberate it may have an association to Oppositional Defiant Disorder or Conduct Disorder. Many children with Encopresis and chronic constipation are enuretic and may be associated with vesico-ureteric reflux and chronic Urinary tract infections.
    • Child vs. adult presentation
      • Primarily a childhood disorder.
      • The disorder usually doesn't present itself until around the age of 4.
    • Gender and cultural differences in presentation
      • The disorder is thought to be more common in males than females, by a ratio of 6 to 1
    • Epidemiology
      • The prevalence of this disorder is approximately 1% of 5 year olds. Males are more likely than females to present with this disorder. May effect 1-2% of children under the age of 10. About 90% of cases are due to functional constipation.
    • Etiology
      • There are two types of Encopresis, with constipation and overflow incontinence (787.6) and without constipation and overflow Incontinence (307.7).
      • Encopresis without constipation and overflow incontinence: There is no evidence of constipation on physical examination or by history. Feces are likely to be of normal form and consistency, and soiling is intermittent. Feces may be deposited in a prominent location. This is usually associated with the presence of Oppositional Defiant Disorder or Conduct Disorder or may be the consequence of anal masturbation. Soiling without constipation appears to be less common than soiling with constipation.
      • Encopresis with constipation and overflow incontinence: There is evidence of constipation on physical examination or a history of a stool frequency of less than three per week. Feces in overflow incontinence are characteristically (but not invariably) poorly formed, and leakage can be infrequent and continuous, occurring mostly during the day and rarely during sleep. Only part of the feces is passed during toileting, and the incontinence resolves after treatment of the constipation.
    • Empirically supported treatments
      • There is typically three phase associated with the treatment process. The three phases of treatment are “cleaning out”, stool softening agents, and scheduled sitting times on the commode. The first phase “cleaning out” consists of an enema or suppository to help promote the removal of fecal matter from the colon. Phase two is often called the top down approach. The use of stool softening agents to help prevent constipation and thus reducing the probability of constipation. Phase three is a non medicated approach. This approach attempts to control excreting fecal matter by assigning specific times to use the restroom, decreasing the risk of constipation.
      • Dietary changes are important
      • Reduction in the intake of constipating foods such as dairy, peanuts, cooked carrots, and bananas.
      • Increase in high-fiber foods such as bran, whole wheat products, and fruits and vegetables.
      • Higher intake of liquids, such as juices, although an increased risk of diabetes and/or tooth decay has been attributed to excess intake of sweetened juices.
      • *Note*- It is important not to punish or humiliate the child because this does not improve the situation.
    • Additional information can be found at the Mayo Clinic website on this disorder.

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13. Reactive Attachment Disorder of Infancy or Early Childhood (313.89)


    • DSM-IV-TR criteria
      • A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2):
        • (1) Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness).
        • (2) Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures).
      • B. The disturbance in Criterion A is not accounted for solely by developmental delay (as in mental retardation) and does not meet criteria for a Pervasive Developmental Disorder.
      • C. Pathogenic care as evidenced by at least one of the following:
        • (1) Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection.
        • (2) Persistent disregard of the child’s basic physical needs.
        • (3) Repeated changes or primary caregivers that prevent formation of stable attachments (e.g., frequent changes in foster care).
      • D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
      • Specific types: Inhibited Type: if Criterion A1 predominates in the clinical presentation. Disinhibited Type: if Criterion A2 predominates in the clinical presentation.
    • Associated features
      • Certain situations may cause parents to develop a way of caring, known as pathological caring. These situations may include things such as long hospitalization of the child, extreme poverty, and the inexperience of the parents or caretaker (DSM-IV-TR, 2000). Pathological care is defined as a parental caring type in which they ignore the child’s basic needs; these needs may be emotional and/or physical needs. Grossly pathological care does not always cause the development of Reactive Attachment Disorder (DSM-IV-TR, 2000). Some children cared for in this manner are still able to form “normal” social attachments. Extreme neglect does however increase the risk for development of Reactive Attachment Disorder. This disorder may also be associated with developmental delays, Feeding Disorder of Infancy or Early Childhood, Pica, or Rumination Disorder (DSM-IV-TR, 2000).
    • Child vs. adult presentation
      • Reactive Attachment Disorder typically begins before the child is 5 years of age. Remission of this disorder can occur by receiving proper care and a supportive environment. If such things are not provided, the disorder will follow a continuous course, causing the individual’s inability to form “normal” social attachments. Therefore Reactive Attachment Disorder can present in both children and adults, but will ultimately be diagnosed in children before age 5 years.
    • Gender and cultural differences in presentation
      • There is no research indicating that there are gender differences in Reactive Attachment Disorder. Reactive Attachment Disorder is more commonly diagnosed in the UK . Also, this disorder may be more commonly diagnosed in children who live in inner city neighborhoods and rural areas. This is due to the fact that children may be subjected to severe isolation especially for those that are part of a minority group who are not properly cared for by their parents or guardians.
    • Epidemiology
      • There is not much information or research found on Reactive Attachment Disorder. It is believed to be a fairly uncommon disorder.
      • The prevalence of reactive attachment disorder has been estimated at 1% of all children under the age of five. Children orphaned at a young age have a much higher likelihood of this problem.
    • Etiology
      • All children are affected differently by pathogenic caring, some go on to develop attachments despite of the pathogenic caring, others do not.
      • Reactive Attachment Disorder is mainly caused by abuse or neglect of an infant's needs (for example: food, physical safety, and touching).
    • Empirically supported treatments
      • Little research has been done for the treatment of Reactive Attachment Disorder. Teaching the caretaker proper nurturing skills may improve Reactive Attachment Disorder in some children if the caretaker implements the newly learned skills into the child’s life. Holding therapy is a possible treatment for Reactive Attachment Disorder, although there has been little research confirming its effectiveness. This procedure consists of the mother or the caretaker holding the child while incorporating eye contact, touch, smiling, and talking. The anticipated end result is recreating the bond between caretaker and child that was not present when the child was an infant.
      • Behavioral Management Training has been seen as a fairly effective treatment for Reactive Attachment Disorder. Children undergoing Behavioral Management Training show decreased problematic behaviors as well as increased compliance with caregiver and teacher commands. These children also show increased play with age-appropriated peers.
    • LINKS:
      • A story about a couple who adopted a son from a Romanian orphanage when he was seven years old. During the time he was in the orphanage, he lived in a crib with another child and never developed relationships with his caregivers. About six months after he was adopted, he began acting out and was later diagnosed with Attachment Disorder. Story begins at minute 9:30 and ends at minute 36.
        • Attachment Disorder
        • "Unconditional Love." This American Life. Chicago Public Radio. Aug. 31, 2007
        • Example of Reactive Attachment Disorder in Early Childhood in video below.

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14. Pica (307.52)

    • DSM-IV-TR criteria
      • A. Persistent eating of nonnutritive substances for a period of at least one month.
      • B. The eating of nonnutritive substances is inappropriate to the developmental level.
      • C. The eating behavior is not part of a culturally sanctioned practice.
      • D. If the eating behavior occurs exclusively during the course of another mental disorder (e.g., Mental Retardation, Pervasive Developmental Disorder, Schizophrenia), it is sufficiently severe to warrant independent clinical attention.
    • Associated features
      • Pica is commonly Associated with Pervasive Developmental Disorders as well as Mental Retardation. Mineral and vitamin deficiencies have been reported in some cases though no specific biological abnormalities have been found. In some cases it is only after general medical complications that Pica comes into attention. Poverty, lack of parental supervision, developmental delay, and neglect can increase the risk for the condition. Pica is considered to be a serious eating disorder that could result in health problems such as lead poisoning, bowel problems, dental injury, and parasitic infections. In order for the action of ingesting these abnormal non-nutritive substances to be considered pica, the actions have to occur for more than one month at a cognitive level that recognizes the abnormality.
    • Child vs. adult presentation
      • Pica is more of a young child disorder and can occasionally be seen in pregnant females. This disorder is more commonly observed in children than adults. Pica in children occurs about the same in boys as in girls between the ages of 2 and 3. It can be found in ages younger, but eating items such as dirt, clay, paper, soap, mucus, cigarette butts, etc. are considered normal at a younger age. Pica is observed more in adults with mental retardation around the ages of 10-20 years. More common forms of Pica involve the ingestion of ice.
    • Gender and cultural differences in presentations
      • Although no specific data exist regarding racial predilection, the practice is reported to be more common among certain cultural and geographic populations. For example, geophagia (eating of soil) is accepted culturally among some families of African lineage and is reported to be problematic in 70% of the provinces in Turkey. People who live in the tropics, tribe-oriented societies, and in poverty are the places that geophagia is the most common form of pica. Pica is a widespread practice around different many places such as: western Kenya, southern Africa, India, Australia, Canada, Israel, Iran, Uganda, Wales, Turkey, and Jamaica. For instance, in Uganda, they purchase soil only for the purpose of ingestion. In the Unites States Pica is less common than international places; it is a disorder that is often unrecognized and not reported.
    • Epidemiology
      • It is estimated that Pica is seen in about 4-26% of institutionalized populations. The prevalence of Pica also increases with mental retardation, with it being high as15% for adults with severe mental retardation.
    • Etiology
      • The cause or etiology of Pica has been attributed to various cases, including nutritional, mental retardation or brain damage, cultural and economic, and emotional deprivation. Although specific causes of Pica are unknown, there are some certain conditions and situations that an increase a person’s risk for Pica: nutritional deficiencies, dieting, cultural factors, parental neglect, lack of supervision, food deprivation, developmental problems, mental health problems (OCD and Schizophrenia), and pregnancy increase that risk. http://www.pregnancy-info.net/pica.html
    • Empirically supported treatments
      • Sources such as the Handbook for Clinical Child Psychology support general behavioral strategies as being the most effective treatment for Pica. This involves specific training for the child on edible versus non-edible foods and positive reinforcement. The primary prevention of Pica is the efforts to remove or alter factors involved in its etiology. It must be directed toward improving the mental health of children in infancy and early childhood.”
      • The treatment of Pica can be very difficult to treat. Parents are told to encourage children to eat a healthy and balanced diet. Anything that is dangerous and can be ingested should be removed from your home, so they will be not be tempted to ingest those substances. Any nutritional deficiencies should be identified to help with the treatment. “Parents should consider consulting with a behaviorally-trained mental health clinician, as a comprehensive behavioral plan based squarely on principles of learning theory may be necessary to manage and ultimately eliminate Pica.”
      • “Pica will unconsciously reappear in young children and pregnant women, but may never go away if it is left untreated.” Also, the doctor can educate the child on acceptable and unacceptable "food". Child-safety locks and high shelving are also good options to get the items out of the child's reach.
    • Additional Information can be found at the KidsHealth website.
    • The video below is a sattirical view of Pica. It is not an acutaul portrayal of Pica


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15. Feeding Disorder of Infancy or Early Childhood (307.59)


    • DSM-IV-TR criteria
      • A. Feeding disturbance as manifested by persistent failure to eat adequately with significant failure to gain weight or significant loss of weight over at least one month.
      • B. The disturbance is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux).
      • C. The disturbance is not better accounted for by another mental disorder (e.g., Rumination Disorder) or by lack of available food.
      • D. The onset is before the age of 6.
    • Associated features
      • Infants with feeding disorders can be more irritable and difficult to console when feeding then others of their age. They appear withdrawn and apathetic and may also show developmental delays. Sometimes parent-child interaction problems may add to or exacerbate the infant's feeding problems. Inadequate caloric intake can make associated features worse and further impact to feeding difficulties. Factors that may be associated with Feeding Disorder of Infancy or Early Childhood include temperamental characteristics or intrauterine growth retardation. Preexisting developmental impairments that make the child less responsive could also be factors. Some other associated factors include parental psychopathology and child abuse or neglect.
    • Child vs. adult presentation
      • Due to the nature of the disorder, adults cannot present with feeding disorders. This disorder is primarily focused on the presentation in children from infants to early childhood.
      • A later onset, during toddler years, is associated with developmental delay and malnutrition. Growth retardation may be observed.
    • Gender and cultural presentation
      • Feeding Disorder of Infancy or Early Childhood seems to be equally common in both males and females.
    • Epidemiology
      • Of all pediatric hospital admissions, 1%-5% are for failure to thrive, and up to one-half of these may reflect feeding disturbances without any apparent predisposing general medical condition. Data from community samples suggest a point prevalence of around 3% for failure to thrive.
    • Etiology
      • Feeding problems often occur in infant and children who are tube fed for extended periods of time due to some other illness or disability. In premature infants, the underdeveloped sphincter muscle, between the stomach and esophagus, can cause the infant to spit up frequently during feedings. Because this is uncomfortable for the child, he or she may not want to eat.
      • Disorders of the digestive system can also cause feeding problems, and include abnormalities of the throat and esophagus that cause pain during swallowing, inhaling food into the lungs, constipation, and celiac disease, a hereditary disorder in which a cereal protein called gluten, which is found in wheat, causes an allergic reaction that results in poor absorption of fats from the diet.
      • Other digestive-type disorders that can cause feeding problems include necrotizing entercolitis, a condition seen mainly in premature newborns where the inner surface of the intestine becomes injured and inflamed; Hirschprung disease, in which a section of the large intestine is abnormally developed; short bowel syndrome; pyloric stenosis, caused by a narrowing or blockage at the stomach outlet; and gastroesophageal reflux (GER), which occurs when the acid contents of the stomach flow back, or reflux, into the esophagus.
      • Feeding disorders can be caused by food allergies, by difficulty with the movement of the mouth or tongue (oromotor), or may be a cry for attention by a neglected child or a child with a behavioral disorder. Some other factors include poverty, dysfunctional caregiver child-caregiver interactions, and parental misinformation.
    • Empirically supported treatments
      • Depending on the severity of the condition of the infant the amount of calories and intake of fluids should be increased. You should also correct any vitamin or mineral deficiencies that the child may have. It is also very important to identify any physical problem that may be causing the disorder.
      • To be able to effectively accomplish these goals, a brief hospital stay may be necessary. Isolating the child in the constant care of the hospital for a short time will make sure all the proper procedures are taken. Also, gastroenterologists, behavioral psychologists, and occupational and/or speech therapists.

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16. Enuresis (307.6)



The term enuresis comes from the Greek word meaning "I make water" and refers to the involuntary voiding of urine, after an age at which toilet training is expected to have been completed.

    • DSM-IV-TR criteria
      • A. Repeated voiding of urine into bed or clothes (whether involuntary or intentional).
      • B. The behavior is clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
      • C. Chronological age is at least 5 years (or equivalent developmental level).
      • D. The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition (e.g., diabetics, spina bifida, a seizure disorder).
      • Specify type:
        • Nocturnal (Nighttime urination) Only
        • Diurnal (Daytime urination) Only
        • Nocturnal and Diurnal (a mixture of both)
    • Associated features
      • An associated feature of Enuresis is a function of the limitation on the child's social activities, it has effects on the child's self-esteem, the degree of social ostracism by peers, and the anger, punishment, and rejection on the part of caregivers. Motor skills delays, language, speech delays, and learning delays are present in children with Enuresis. Along with having Enuresis, some children/adults may exhibit Sleepwalking Disorder and/or Sleep Terror Disorder. Urinary tract infections are more common in children with Enuresis, most common in the one's with Diurnal Type than those who are continent.
    • Child vs. adult presentation
      • There are not many differences in the presentation among children and adults. Usually, adults that have this condition also had it when they were children and it carried on throughout their lives. Adults will usually have wetting during the day, as well as the night.
    • Gender and cultural differences in presentation
      • Studies have shown that enuresis tends to appear significantly greater in males than females. Enuresis can be found more among African American population than any other ethnicities studied. Reports show that boys aged 7 to 10 years old have about an 8% prevalence, while the average for girls is about 4.5%.
    • Epidemiology
      • The prevalence of Enuresis is around 5-10% among 5 years old, 3-5% among 10 years old, and around 1% among individuals of the age of 15 and older.
    • Etiology
      • There can be an organic cause of Enuresis, however it is highly unlikely. Some examples of organic causes are a urinary tract infection, constipation, and food allergies. Most agree that there are a number of factors that contribute to Enuresis. One is genetic factors. If a parent had this, then it is very likely that their child will develop this as well. If both parents had Enuresis, there is about a 75% chance that their child will have it too. The rate significantly goes down if neither parents had it. Another factor is sleep patterns. There are differences between children with Enuresis and without in their sleeping patterns.
      • One common belief is that Enuresis is caused by psychological factors. However, many studies show that children with this disorder behave in the same way as children without this disorder. For the most part, it has been found that because of the Enuresis, secondary psycho-social problems develop in children. Some researchers have found that low bladder capacity is related to nocturnal Enuresis. However, some question this because they feel that the child would have symptoms throughout the day if they had a low bladder capacity.
      • Another common factor that many researchers have found is delayed development of the central nervous system. This causes the child not to realize that they need to empty their bladder during the night.
    • Empirically supported treatments
      • There are a number of behavioral treatments that can be used to help children with Enuresis. A few examples are a pad or a buzzer/alarm. Medication is also an option. One option is a nasal spray that is anti-diuretic. Also, an anti-depressant called imipramine is useful in treatment. If these do not work, the condition could be more serious and may result in the child and family needing to see a psychiatrist.

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17. Separation Anxiety Disorder (309.21)


    • DSM-IV-TR criteria
      • A. Developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the individual is attached, as evidenced by three (or more) of the following:
        • recurrent excessive distress when separation from home or major attachment figures occurs or is anticipated
        • persistent and excessive worry about losing, or about possible harm befalling, major attachment figures
        • persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)
        • persistent reluctance or refusal to go to school or elsewhere because of fear of separation
        • persistent and excessively fearful or reluctant to be alone or without major attachment figures at home or without significant adults in other settings
        • persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home
        • repeated nightmares involving the theme of separation
        • repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, and vomiting) when separation from major attachment figures occurs or is anticipated
      • B. The duration or the disturbance is at least 4 weeks.
      • C. The onset is before age 18 years.
      • D. The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
      • E. The disturbance does not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and, in adolescents and adults, is not better accounted for by Panic Disorder With Agoraphobia.
      • Specify if:
        • Early Onset: if onset occurs before age 6 years
    • Associated features
      • When separated from the home of family, people with Separation Anxiety Disorder may exhibit sadness, apathy, social withdrawal, difficulty concentrating on play and/or work. Also, depending on one's age, they may be scared of animals, monsters, darkness, plane travel, burglars, kidnappers and other situations that might be dangers to their family or themselves. Because the child might be scared of leaving their family, they may refuse to attend school which my cause school and academic difficulties and social avoidance. When left alone, young children may report seeing people strangers entering their room, seeing monsters and other creatures, and also seeing eyes following them around.
      • Studies show that children suffering from separation anxiety disorder are much more likely to have ADHD, bipolar disorder, panic disorders, and other disorders later in life.
    • Child vs. adult presentation
      • Separation Anxiety Disorder is seen in all age groups, but adult separation anxiety disorder is seen in about 7% of adults. Childhood separation anxiety disorder is seen in about 4% of children.
      • The manifestations of the disorder may vary with age. Younger children may not express specific fears of definite threats to parents, home, or themselves. As children get older, worries or fears are often of specific dangers. Anxiety and anticipation of separation become manifest in mid-childhood.
      • Adults with this disorder are typically overly concerned about their offspring and spouses and experience marked discomfort when separated from them.
    • * The prevalence of separation anxiety disorder is slightly more frequent in females than males; the prevalence of school refusal is approximately equal between males and females.
    • Epidemiology
      • The prevalence of this disorder is estimated to have an average of about 4% in children and young adolescents. For children age 7-11, it is seen in about 4.1%. Children between the ages 12-14 show a prevalence of about 3.9%, and teens from 14-16 have about 1.3% that suffer from separation anxiety disorder.
      • In clinical samples, the disorder is apparently equally common in males and females.
      • In epidemiological samples, the disorder is more frequent in females.
    • Etiology
      • Studies have shown that children who are raised by a parent having anxiety disorders are more likely to develop anxiety disorders themselves. Experts have postulated that early and traumatic separation from the attachment figure may increase the likelihood of the child and, later on, the adolescent or adult developing separation anxiety disorder. Also traumatic experiences, a serious separation, stress in the family, a significant change, and an illness are all possible cause that might trigger Separation Anxiety Disorder.
    • Empirically supported treatments
      • One of the treatments used for this disorder is social skills training. This treatments deals with things like skill awareness, situational awareness, practice and role play. Another form of treatment is cognitive behavioral therapy, where the therapist teaches the child to challenge negative thoughts, develop new, positive thoughts, and practice alternative behaviors. Furthermore, reassurances of love, safety, and preparation for the child for upcoming separations will benefit the child in the long run.

A brief explanation of Separation Anxiety Disorder
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18. Stereotypic Movement Disorder (307.3)

    • DSM-IV-TR criteria
      • A. Repetitive, seemingly driven, and nonfunctional motor behavior (e.g., hand shaking or waving, body rocking, head banging, mouthing of objects, self-biting, hitting own body).
      • B. The behavior markedly interferes with normal activities or results in self-inflicted bodily injury that requires medical treatment (or would result in an injury if preventive measures were not used).
      • C. If Mental Retardation is present, the stereotypical or self-injurious behavior is often of sufficient severity to become a focus of treatment.
      • D. The behavior is not better accounted for by a compulsion (as in Obsessive-Compulsive Disorder), a tic (as in Tic Disorder), a stereotype that is part of a Pervasive Developmental Disorder, or hair pulling (as in Trichotillomania).
      • E. The behavior is not due to the direct physiological effects of a substance or a general medical condition.
      • F. The behavior persists for 4 weeks or longer.
      • Specify if:
        • With Self-Injurious Behavior
    • Epidemiology
      • Approximately 2-3% of children with some form of mental retardation suffer from Stereotopic Movment Disorder in the community.
      • 25% of all people institutionalized with mental retardation have Sterotypic Movement Disorder.
      • Among those with severe or profound retardation, the rate is about 60%, with 15% showing behavior that causes self-injury (Steroetypic Movement Disorder).
    • Comorbidity
      • Stereotypic Movement Disorder is extremely common in children who are considered severely retarded.
      • Occurs most often in children with autism, childhood degenerative disorder, Asperger's disorder, and most other pervasive developmental disorders (Stereotypic Movement Disorder).
    • Etiology
      • May be caused by major disorders such as Autism and/or mental retardation.
      • Children with Anxiety disorders may be more likely to suffer from Stereotypic Movement Disorder.
    • Treatment
      • Few treatments used specifically for this disorder are successful.
      • Drugs that have been used with some success to treat stereotypic movement disorder include clomipramine (Anafranil), desipramine (Norpramin), haloperidol (Haldol) and chlorpromazine (Thorazine)(Stereotypic Movement Disorder).

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders(4th ed., text revision). Washington, DC: Author.


Stereotypic movement disorder . (2010). Encyclopedia of Mental Disorders. Retrieved from
http://www.minddisorders.com/Py-Z/Stereotypic-movement-disorder.html

Stuttering. (n.d.). Retrieved from American-Speech-Language-Hearing Association website:
http://www.asha.org/public/speech/disorders/stuttering.htm#four



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