Normal Childhood Development Normal Childhood Development and Symptoms of Bigger Issuesand Symptoms of Bigger Issues

Pupus with the PrincipalPupus with the PrincipalFacilitated ByFacilitated By

Victor L. Ruterbusch, MDVictor L. Ruterbusch, MDLCDR/MC/USNLCDR/MC/USN

La Jardin Academy, Lower School La Jardin Academy, Lower School 03NOV201003NOV2010

DISCLAIMERDISCLAIMER

The views expressed by this presenter are The views expressed by this presenter are not necessarily those of the military or of not necessarily those of the military or of Tripler Army Medical Center.Tripler Army Medical Center.

Dr. Ruterbusch is a Child and Adolescent Dr. Ruterbusch is a Child and Adolescent Psychiatry Fellow, not yet board eligible.Psychiatry Fellow, not yet board eligible.

I have no financial interests to disclose.I have no financial interests to disclose.

My daughter attends 2My daughter attends 2ndnd grade at LJA. grade at LJA.

OverviewOverview

Children are all different…Children are all different…Good parenting is about being creative, Good parenting is about being creative, yet consistent and providing the “best fit”.yet consistent and providing the “best fit”.Children are NOT a diagnosis, but rather a Children are NOT a diagnosis, but rather a “moving target” that you need to really “moving target” that you need to really focus on…focus on…Spring MetaphorSpring MetaphorYour hard work at this stage will make Your hard work at this stage will make your whole life better….your whole life better….

Stage TheoryStage Theory for Normal Developmentfor Normal Development

Put forth by Piaget, Kohlberg, Erikson, Freud Put forth by Piaget, Kohlberg, Erikson, Freud and othersand others

Based upon assumption that development Based upon assumption that development takes place in stages that follow the same basic takes place in stages that follow the same basic criteria:criteria:

– Describe Describe QualitativelyQualitatively different behaviors different behaviors– Refer to general issuesRefer to general issues– Unfold in an Unfold in an invariant sequence invariant sequence – Are Are culturally universalculturally universal

Cognitive Development (80%)Cognitive Development (80%)PiagetPiaget

Sensorimotor: (0-2)Sensorimotor: (0-2) Intentional behavior, “trial Intentional behavior, “trial and error”, beginning of mental picturesand error”, beginning of mental pictures

Pre-Operational: (2-6)Pre-Operational: (2-6) imaginative play, imaginative play, categorize, weights and numberscategorize, weights and numbers

Concrete Operations: (6-11)Concrete Operations: (6-11) “black and white” “black and white” conservation of mass, beginning of logic.conservation of mass, beginning of logic.

Formal Operations (11-20)Formal Operations (11-20) capable of capable of Abstract Abstract ThoughtThought “If /then propositions” comparisons and “If /then propositions” comparisons and deductions made from information NOT deductions made from information NOT concretely presented, “scientific thought”.concretely presented, “scientific thought”.

PiagetPiagetConcrete Operations: (6-11)Concrete Operations: (6-11)

SeriationSeriation—the ability to sort objects according to size, —the ability to sort objects according to size, shape, or any other characteristic. shape, or any other characteristic. TransitivityTransitivity- If A is taller than B, and B is taller than C, then - If A is taller than B, and B is taller than C, then A must be taller than C).A must be taller than C).ClassificationClassification—ability to name and identify sets of objects —ability to name and identify sets of objects according to appearance, size or other characteristicaccording to appearance, size or other characteristicDecenteringDecentering—the child takes into account multiple aspects —the child takes into account multiple aspects of a problem to solve it. of a problem to solve it. ReversibilityReversibility—the child understands that numbers or —the child understands that numbers or objects can be changed, then returned to their original state. objects can be changed, then returned to their original state. ConservationConservation—understanding that quantity, length or —understanding that quantity, length or number of items is unrelated to the arrangement or number of items is unrelated to the arrangement or appearance of the object or items.appearance of the object or items.Elimination of EgocentrismElimination of Egocentrism——the ability to view things the ability to view things from another's perspective (the “mountain experiment”)from another's perspective (the “mountain experiment”)

Eriksonian TasksEriksonian Tasks

Erikson viewed the whole life span as a series of Erikson viewed the whole life span as a series of “tasks”“tasks” that have to be successfully that have to be successfully “mastered”.“mastered”.

Their success is measured as a ratio.Their success is measured as a ratio.

Individuals who master a task gain a “virtue”Individuals who master a task gain a “virtue”

Individuals who fail to master these tasks along Individuals who fail to master these tasks along the same time course as their peers suffer the the same time course as their peers suffer the “opposite” consequence, or maladaption.“opposite” consequence, or maladaption.

Eriksonian TasksEriksonian Tasks““Basic Trust vs. Mistrust”Basic Trust vs. Mistrust” birth to 1 year: If child’s birth to 1 year: If child’s primary caregiver consistently meets the child’s primary caregiver consistently meets the child’s needs, the child needs, the child mastersmasters basic trust with virtue of basic trust with virtue of Hope and DriveHope and Drive, or , or suffers the consequencesuffers the consequence of of proceeding through life “mistrusting” people. proceeding through life “mistrusting” people.

““Autonomy vs. Shame and Doubt”Autonomy vs. Shame and Doubt” (18 mo. to 3) (18 mo. to 3) Child learns to walk and talk, “I am what I will” Child learns to walk and talk, “I am what I will” ((Self Control vs. ImpulsivitySelf Control vs. Impulsivity))

““Initiative vs. Guilt”Initiative vs. Guilt” (3 to 6) Child builds (3 to 6) Child builds sentences, parental ideals, toileting, and a sentences, parental ideals, toileting, and a superego, (superego, (Purpose and direction vs. InhibitionPurpose and direction vs. Inhibition))

Eriksonian Tasks (continued)Eriksonian Tasks (continued)““Industry vs. Inferiority”Industry vs. Inferiority” (6 to 11) Child searches (6 to 11) Child searches for achievement in academics, sports, clubs, for achievement in academics, sports, clubs, especially in comparison with their peers. especially in comparison with their peers. ((Competence and Method vs. InertiaCompetence and Method vs. Inertia))

““Ego Identity vs. Role Confusion”Ego Identity vs. Role Confusion” (11 to 20) , (11 to 20) , peers become more important than parents, “I peers become more important than parents, “I know WHO I am”. (know WHO I am”. (Fidelity vs. FanaticismFidelity vs. Fanaticism))

““Intimacy vs. Isolation”Intimacy vs. Isolation” (20 to 40) (20 to 40)

““Generativity vs. Self-absorption” AdulthoodGenerativity vs. Self-absorption” Adulthood

““Integrity vs. Disgust and Despair” Old age. Integrity vs. Disgust and Despair” Old age.

Kohlberg’s MoralityKohlberg’s MoralityPosed as a series of “dilemmas”. Posed as a series of “dilemmas”. Answering yes or no to the dilemma did Answering yes or no to the dilemma did not matter. The moral development is not matter. The moral development is revealed in the revealed in the reasoningreasoning behind the behind the answer. Hans und das medicine...answer. Hans und das medicine...Kohlberg stages 1 and 2 (pre-conventional, Kohlberg stages 1 and 2 (pre-conventional, might is right)might is right)Kohlberg stages 3 and 4 (conventional, Kohlberg stages 3 and 4 (conventional, moral relativism)moral relativism)Kohlberg stages 5 and 6 (universal Kohlberg stages 5 and 6 (universal principles)principles)

Bigger IssuesBigger IssuesClinical/Differential Diagnosis/ComorbidityClinical/Differential Diagnosis/Comorbidity

ADHDADHDOppositional Defiant DisorderOppositional Defiant DisorderConduct DisorderConduct DisorderAnxiety DisorderAnxiety DisorderDepressive DisorderDepressive DisorderBipolar DisorderBipolar DisorderLearning DisabilityLearning DisabilityMedical Problem (hyperthyroid, lead poisoning, Medical Problem (hyperthyroid, lead poisoning, hearing or vision problem)hearing or vision problem)

General Population:General Population:- 3-12% in 6-12yo school age children- 3-12% in 6-12yo school age children- 2-4% in adults- 2-4% in adults- Inattentive > Hyperactive > Combined- Inattentive > Hyperactive > Combined

Clinically referred population:Clinically referred population:-2-10% in pediatric primary care-2-10% in pediatric primary care--40-60% in Child/Adolescent Psychiatry40-60% in Child/Adolescent Psychiatry-Combined > Inattentive > Hyperactive-Combined > Inattentive > Hyperactive

Epidemiology of ADHDEpidemiology of ADHD

Disorder of catecholamine Disorder of catecholamine UNDERACTIVITYUNDERACTIVITY ( (epinephrine, norepinephrine, dopamineepinephrine, norepinephrine, dopamine))

Behavioral Behavioral disinhibition + impaired executive function disinhibition + impaired executive function (FRONTAL LOBES)(FRONTAL LOBES)

Neuroimaging shows involvement in frontal cortex, Neuroimaging shows involvement in frontal cortex, striatum, and cerebellumstriatum, and cerebellum (usually smaller volumes, (usually smaller volumes, decreased blood flow PET decreased blood flow PET scanscan))

May be predisposed if there are early neuro-May be predisposed if there are early neuro-developmental problems (esp. developmental problems (esp. 22ndnd trimester trimester))

Etiology of ADHDEtiology of ADHD

ADHD - InattentiveADHD - InattentiveSixSix or more or more of the following symptoms have been present for of the following symptoms have been present for at at least least 6 months6 months to a point that is to a point that is disruptive and inappropriatedisruptive and inappropriate for for developmental level: developmental level:

OFTEN…OFTEN…

1) Has poor attention to details or makes 1) Has poor attention to details or makes careless mistakescareless mistakes in in schoolwork, work, or other activities. schoolwork, work, or other activities.

2) Has 2) Has trouble keeping attentiontrouble keeping attention on tasks or play activities. on tasks or play activities. 3) 3) Does not seem to listenDoes not seem to listen when spoken to directly. when spoken to directly. 4) 4) Does not follow instructionsDoes not follow instructions, fails to finish schoolwork, chores, etc , fails to finish schoolwork, chores, etc

(not oppositional behavior or failure to understand)(not oppositional behavior or failure to understand) 5) Has 5) Has trouble organizingtrouble organizing activities. activities. 6) Avoids, 6) Avoids, dislikesdislikes or doesn't want to do or doesn't want to do things that take a lot of mental things that take a lot of mental

efforteffort7) 7) Loses thingsLoses things needed for tasks and activities (e.g. pencils, books, tools) needed for tasks and activities (e.g. pencils, books, tools)

8) 8) Easily distractedEasily distracted. . 9) 9) ForgetfulForgetful in daily activities. in daily activities.

ADHD - Hyperactive & ImpulsiveADHD - Hyperactive & Impulsive

SixSix or more or more of the following symptoms have been present for of the following symptoms have been present for at at least least 6 months6 months to a point that is to a point that is disruptive and inappropriatedisruptive and inappropriate for developmental level: for developmental level:

OFTEN…OFTEN… 1) 1) FidgetsFidgets with hands or feet or with hands or feet or squirmssquirms in seat. in seat.

2) 2) Gets up from seatGets up from seat when remaining in seat is expected. when remaining in seat is expected. 3) Runs about or climbs when and where it is not3) Runs about or climbs when and where it is not

appropriate (adolescents or adults may feel very restless). appropriate (adolescents or adults may feel very restless). 4) Has 4) Has troubletrouble playing or playing or enjoying leisure activities quietlyenjoying leisure activities quietly. . 5) “On the go" or often acts as if "5) “On the go" or often acts as if "driven by a motordriven by a motor". ". 6) 6) Talks excessivelyTalks excessively. .

7) 7) Blurts outBlurts out answers before questions have been finished. answers before questions have been finished. 8) Has 8) Has trouble waiting one's turntrouble waiting one's turn. . 9) 9) Interrupts or intrudesInterrupts or intrudes on others (e.g., butts into on others (e.g., butts into

conversations or games). conversations or games).

AssessmentAssessment

COLLATERAL INFORMATION!!!COLLATERAL INFORMATION!!! (need symptoms (need symptoms in 2 settingsin 2 settings))

ADHD is a ADHD is a CLINICAL DIAGNOSISCLINICAL DIAGNOSIS

Other assessment tools include Other assessment tools include Connors scales, Connors scales, Continuous Performance Test, Vanderbilt scalesContinuous Performance Test, Vanderbilt scales….….

……ButBut should should not be used solely for diagnostic purposesnot be used solely for diagnostic purposes (most helpful with charting progress over time) (most helpful with charting progress over time)

Any Any Questions?Questions?

ReferencesReferences

1.1. Theories of DevelopmentTheories of Development, William Crain., William Crain.

2.2. Childhood and Society, Childhood and Society, Erik H. Erikson.Erik H. Erikson.

3.3. Textbook of Child and Adolescent Textbook of Child and Adolescent Psychiatry, Psychiatry, Dulcan and Wiener.Dulcan and Wiener.

Recommended ReadingRecommended Reading

1.1. Theories of DevelopmentTheories of Development, William Crain., William Crain.

2.2. Between Parent and Child, Between Parent and Child, Ginott.Ginott.