Personality and Childhood Disorders

Learning outcomes

By the end of this section, you will be able to:

  • Describe the nature of personality disorders and how they differ from other disorders
  • List and distinguish between the three clusters of personality disorders
  • Identify the basic features of borderline personality disorder and antisocial personality disorder, and the factors that are important in the etiology of both
  • Describe the nature and symptoms of attention deficit/hyperactivity disorder and autism spectrum disorder
  • Discuss the prevalence and factors that contribute to the development of these disorders

Personality Disorders

The term personality refers loosely to one’s stable, consistent, and distinctive way of thinking about, feeling, acting, and relating to the world. People with personality disorders exhibit a personality style that differs markedly from the expectations of their culture, is pervasive and inflexible, begins in adolescence or early adulthood, and causes distress or impairment (APA, 2013). Generally, individuals with these disorders exhibit enduring personality styles that are extremely troubling and often create problems for them and those with whom they come into contact. Their maladaptive personality styles frequently bring them into conflict with others, disrupt their ability to develop and maintain social relationships, and prevent them from accomplishing realistic life goals.

The DSM-5 recognizes 10 personality disorders, organized into 3 different clusters. Cluster A disorders include paranoid personality disorderschizoid personality disorder, and schizotypal personality disorder. People with these disorders display a personality style that is odd or eccentric. Cluster B disorders include antisocial personality disorder, histrionic personality disordernarcissistic personality disorder, and borderline personality disorder. People with these disorders usually are impulsive, overly dramatic, highly emotional, and erratic. Cluster C disorders include avoidant personality disorderdependent personality disorder, and obsessive-compulsive personality disorder (which is not the same thing as obsessive-compulsive disorder). People with these disorders often appear to be nervous and fearful. Table provides a description of each of the DSM-5 personality disorders:

DSM-5 Personality Disorders
DSM-5 Personality Disorder Description Cluster
Paranoid harbors a pervasive and unjustifiable suspiciousness and mistrust of others; reluctant to confide in or become close to others; reads hidden demeaning or threatening meaning into benign remarks or events; takes offense easily and bears grudges; not due to schizophrenia or other psychotic disorders A
Schizoid lacks interest and desire to form relationships with others; aloof and shows emotional coldness and detachment; indifferent to approval or criticism of others; lacks close friends or confidants; not due to schizophrenia or other psychotic disorders, not an autism spectrum disorder A
Schizotypal exhibits eccentricities in thought, perception, emotion, speech, and behavior; shows suspiciousness or paranoia; has unusual perceptual experiences; speech is often idiosyncratic; displays inappropriate emotions; lacks friends or confidants; not due to schizophrenia or other psychotic disorder, or to autism spectrum disorder A
Antisocial continuously violates the rights of others; history of antisocial tendencies prior to age 15; often lies, fights, and has problems with the law; impulsive and fails to think ahead; can be deceitful and manipulative in order to gain profit or pleasure; irresponsible and often fails to hold down a job or pay financial debts; lacks feelings for others and remorse over misdeeds B
Histrionic excessively overdramatic, emotional, and theatrical; feels uncomfortable when not the center of others’ attention; behavior is often inappropriately seductive or provocative; speech is highly emotional but often vague and diffuse; emotions are shallow and often shift rapidly; may alienate friends with demands for constant attention B
Narcissistic overinflated and unjustified sense of self-importance and preoccupied with fantasies of success; believes he is entitled to special treatment from others; shows arrogant attitudes and behaviors; takes advantage of others; lacks empathy B
Borderline unstable in self-image, mood, and behavior; cannot tolerate being alone and experiences chronic feelings of emptiness; unstable and intense relationships with others; behavior is impulsive, unpredictable, and sometimes self-damaging; shows inappropriate and intense anger; makes suicidal gestures B
Avoidant socially inhibited and oversensitive to negative evaluation; avoids occupations that involve interpersonal contact because of fears of criticism or rejection; avoids relationships with others unless guaranteed to be accepted unconditionally; feels inadequate and views self as socially inept and unappealing; unwilling to take risks or engage in new activities if they may prove embarrassing C
Dependent allows others to take over and run her life; is submissive, clingy, and fears separation; cannot make decisions without advice and reassurance from others; lacks self-confidence; cannot do things on her own; feels uncomfortable or helpless when alone C
Obsessive-Compulsive pervasive need for perfectionism that interferes with the ability to complete tasks; preoccupied with details, rules, order, and schedules; excessively devoted to work at the expense of leisure and friendships; rigid, inflexible, and stubborn; insists things be done his way; miserly with money C

Slightly over 9% of the U.S. population suffers from a personality disorder, with avoidant and schizoid personality disorders the most frequent (Lezenweger, Lane, Loranger, & Kessler, 2007). Two of these personality disorders, borderline personality disorder and antisocial personality disorder, are regarded by many as especially problematic.

BORDERLINE PERSONALITY DISORDER

The “borderline” in borderline personality disorder was originally coined in the late 1930s in an effort to describe patients who appeared anxious, but were prone to brief psychotic experiences—that is, patients who were thought to be literally on the borderline between anxiety and psychosis (Freeman, Stone, Martin, & Reinecke, 2005). Today, borderline personality disorderhas a completely different meaning. Borderline personality disorder is characterized chiefly by instability in interpersonal relationships, self-image, and mood, as well as marked impulsivity (APA, 2013). People with borderline personality disorder cannot tolerate the thought of being alone and will make frantic efforts (including making suicidal gestures and engaging in self-mutilation) to avoid abandonment or separation (whether real or imagined). Their relationships are intense and unstable; for example, a lover may be idealized early in a relationship, but then later vilified at the slightest sign she appears to no longer show interest. These individuals have an unstable view of self and, thus, might suddenly display a shift in personal attitudes, interests, career plans, and choice of friends. For example, a law school student may, despite having invested tens of thousands of dollars toward earning a law degree and despite having performed well in the program, consider dropping out and pursuing a career in another field. People with borderline personality disorder may be highly impulsive and may engage in reckless and self-destructive behaviors such as excessive gambling, spending money irresponsibly, substance abuse, engaging in unsafe sex, and reckless driving. They sometimes show intense and inappropriate anger that they have difficulty controlling, and they can be moody, sarcastic, bitter, and verbally abusive.

The prevalence of borderline personality disorder in the U.S. population is estimated to be around 1.4% (Lezenweger et al., 2007), but the rates are higher among those who use mental health services; approximately 10% of mental health outpatients and 20% of psychiatric inpatients meet the criteria for diagnosis (APA, 2013). Additionally, borderline personality disorder is comorbid with anxiety, mood, and substance use disorders (Lezenweger et al., 2007).

Biological Basis for Borderline Personality Disorder

Genetic factors appear to be important in the development of borderline personality disorder. For example, core personality traits that characterize this disorder, such as impulsivity and emotional instability, show a high degree of heritability (Livesley, 2008). Also, the rates of borderline personality disorder among relatives of people with this disorder have been found to be as high as 24.9% (White, Gunderson, Zanarani, & Hudson, 2003). Individuals with borderline personality disorder report experiencing childhood physical, sexual, and/or emotional abuse at rates far greater than those observed in the general population (Afifi et al., 2010), indicating that environmental factors are also crucial. These findings would suggest that borderline personality disorder may be determined by an interaction between genetic factors and adverse environmental experiences. Consistent with this hypothesis, one study found that the highest rates of borderline personality disorder were among individuals with a borderline temperament (characterized by high novelty seeking and high harm-avoidance) and those who experienced childhood abuse and/or neglect (Joyce et al., 2003).

ANTISOCIAL PERSONALITY DISORDER

Most human beings live in accordance with a moral compass, a sense of right and wrong. Most individuals learn at a very young age that there are certain things that should not be done. We learn that we should not lie or cheat. We are taught that it is wrong to take things that do not belong to us, and that it is wrong to exploit others for personal gain. We also learn the importance of living up to our responsibilities, of doing what we say we will do. People with antisocial personality disorder, however, do not seem to have a moral compass. These individuals act as though they neither have a sense of nor care about right or wrong. Not surprisingly, these people represent a serious problem for others and for society in general.

According to the DSM-5, the individual with antisocial personality disorder (sometimes referred to as psychopathy) shows no regard at all for other people’s rights or feelings. This lack of regard is exhibited a number of ways and can include repeatedly performing illegal acts, lying to or conning others, impulsivity and recklessness, irritability and aggressiveness toward others, and failure to act in a responsible way (e.g., leaving debts unpaid) (APA, 2013). The worst part about antisocial personality disorder, however, is that people with this disorder have no remorse over one’s misdeeds; these people will hurt, manipulate, exploit, and abuse others and not feel any guilt. Signs of this disorder can emerge early in life; however, a person must be at least 18 years old to be diagnosed with antisocial personality disorder.

People with antisocial personality disorder seem to view the world as self-serving and unkind. They seem to think that they should use whatever means necessary to get by in life. They tend to view others not as living, thinking, feeling beings, but rather as pawns to be used or abused for a specific purpose. They often have an over-inflated sense of themselves and can appear extremely arrogant. They frequently display superficial charm; for example, without really meaning it they might say exactly what they think another person wants to hear. They lack empathy: they are incapable of understanding the emotional point-of-view of others. People with this disorder may become involved in illegal enterprises, show cruelty toward others, leave their jobs with no plans to obtain another job, have multiple sexual partners, repeatedly get into fights with others, and show reckless disregard for themselves and others (e.g., repeated arrests for driving while intoxicated) (APA, 2013).

A useful way to conceptualize antisocial personality disorder is boiling the diagnosis down to three major concepts: disinhibition, boldness, and meanness (Patrick, Fowles, & Krueger, 2009). Disinhibition is a propensity toward impulse control problems, lack of planning and forethought, insistence on immediate gratification, and inability to restrain behavior. Boldness describes a tendency to remain calm in threatening situations, high self-assurance, a sense of dominance, and a tendency toward thrill-seeking. Meanness is defined as “aggressive resource seeking without regard for others,” and is signaled by a lack of empathy, disdain for and lack of close relationships with others, and a tendency to accomplish goals through cruelty (Patrick et al., 2009, p. 913).

Risk Factors for Antisocial Personality Disorder

Antisocial personality disorder is observed in about 3.6% of the population; the disorder is much more common among males, with a 3 to 1 ratio of men to women, and it is more likely to occur in men who are younger, widowed, separated, divorced, of lower socioeconomic status, who live in urban areas, and who live in the western United States (Compton, Conway, Stinson, Colliver, & Grant, 2005). Compared to men with antisocial personality disorder, women with the disorder are more likely to have experienced emotional neglect and sexual abuse during childhood, and they are more likely to have had parents who abused substances and who engaged in antisocial behaviors themselves (Alegria et al., 2013).

Table shows some of the differences in the specific types of antisocial behaviors that men and women with antisocial personality disorder exhibit (Alegria et al., 2013).

Gender Differences in Antisocial Personality Disorder
Men with antisocial personality disorder are more likely than women with antisocial personality disorder to Women with antisocial personality disorder are more likely than men with antisocial personality to
  • do things that could easily hurt themselves or others
  • receive three or more traffic tickets for reckless driving
  • have their driver’s license suspended
  • destroy others’ property
  • start a fire on purpose
  • make money illegally
  • do anything that could lead to arrest
  • hit someone hard enough to injure them
  • hurt an animal on purpose
  • run away from home overnight
  • frequently miss school or work
  • lie frequently
  • forge someone’s signature
  • get into a fight that comes to blows with an intimate partner
  • live with others besides the family for at least one month
  • harass, threaten, or blackmail someone

Family, twin, and adoption studies suggest that both genetic and environmental factors influence the development of antisocial personality disorder, as well as general antisocial behavior (criminality, violence, aggressiveness) (Baker, Bezdjian, & Raine, 2006). Personality and temperament dimensions that are related to this disorder, including fearlessness, impulsive antisociality, and callousness, have a substantial genetic influence (Livesley & Jang, 2008). Adoption studies clearly demonstrate that the development of antisocial behavior is determined by the interaction of genetic factors and adverse environmental circumstances (Rhee & Waldman, 2002). For example, one investigation found that adoptees of biological parents with antisocial personality disorder were more likely to exhibit adolescent and adult antisocial behaviors if they were raised in adverse adoptive family environments (e.g., adoptive parents had marital problems, were divorced, used drugs, and had legal problems) than if they were raised in a more normal adoptive environment (Cadoret, Yates, Ed, Woodworth, & Stewart, 1995).

Researchers who are interested in the importance of environment in the development of antisocial personality disorder have directed their attention to such factors as the community, the structure and functioning of the family, and peer groups. Each of these factors influences the likelihood of antisocial behavior. One longitudinal investigation of more than 800 Seattle-area youth measured risk factors for violence at 10, 14, 16, and 18 years of age (Herrenkohl et al., 2000). The risk factors examined included those involving the family, peers, and community. A portion of the findings from this study are provided in Figure.

A table is titled “risk factors during adolescence that predict later violence.” Risk factors are matched to age groups of “age 10 predictor (elementary school),” “age 14 predictor (middle school),” and “age 16 predictor (high school).” In the “family” category, “parental violence” is marked for age 14, “parent criminality” for ages 14 and 16, “poor family management” for ages 14 and 16, “family conflict” for ages 14 and 16, “parental attitudes favorable to violence” for age 10, and “residential mobility” for age 16. In the “peer” category, “peer delinquency” is marked for ages 10, 14, and 16; “gang membership” is marked for ages 14 and 16. In the “community” category, “economic deprivation” is marked for ages 10 and 16, “community disorganization” is marked for ages 14 and 16, “availability of drugs” is marked for ages 10, 14, and 16, and “neighborhood adults involved in crime” is marked for ages 14 and 16.
Longitudinal studies have helped to identify risk factors for predicting violent behavior.

Those with antisocial tendencies do not seem to experience emotions the way most other people do. These individuals fail to show fear in response to environment cues that signal punishment, pain, or noxious stimulation. For instance, they show less skin conductance (sweatiness on hands) in anticipation of electric shock than do people without antisocial tendencies (Hare, 1965). Skin conductance is controlled by the sympathetic nervous system and is used to assess autonomic nervous system functioning. When the sympathetic nervous system is active, people become aroused and anxious, and sweat gland activity increases. Thus, increased sweat gland activity, as assessed through skin conductance, is taken as a sign of arousal or anxiety. For those with antisocial personality disorder, a lack of skin conductance may indicate the presence of characteristics such as emotional deficits and impulsivity that underlie the propensity for antisocial behavior and negative social relationships (Fung et al., 2005).

While emotional deficits may contribute to antisocial personality disorder, so too might an inability to relate to others’ pain. In a recent study, 80 prisoners were shown photos of people being intentionally hurt by others (e.g., someone crushing a person’s hand in an automobile door) while undergoing brain imaging (Decety, Skelly, & Kiehl, 2013). Prisoners who scored high on a test of antisocial tendencies showed significantly less activation in brain regions involved in the experience of empathy and feeling concerned for others than did prisoners with low scores on the antisocial test. Notably, the prisoners who scored high on the antisocial test showed greater activation in a brain area involved self-awareness, cognitive function, and interpersonal experience. The investigators suggested that the heightened activation in this region when watching social interactions involving one person harming another may reflect a propensity or desire for this kind of behavior.

Summary

Individuals with personality disorders exhibit a personality style that is inflexible, causes distress and impairment, and creates problems for themselves and others. The DSM-5 recognizes 10 personality disorders, organized into three clusters. The disorders in Cluster A include those characterized by a personality style that is odd and eccentric. Cluster B includes personality disorders characterized chiefly by a personality style that is impulsive, dramatic, highly emotional, and erratic, and those in Cluster C are characterized by a nervous and fearful personality style. Two Cluster B personality disorders, borderline personality disorder and antisocial personality disorder, are especially problematic. People with borderline personality disorder show marked instability in mood, behavior, and self-image, as well as impulsivity. They cannot stand to be alone, are unpredictable, have a history of stormy relationships, and frequently display intense and inappropriate anger. Genetic factors and adverse childhood experiences (e.g., sexual abuse) appear to be important in its development. People with antisocial personality display a lack of regard for the rights of others; they are impulsive, deceitful, irresponsible, and unburdened by any sense of guilt. Genetic factors and socialization both appear to be important in the origin of antisocial personality disorder. Research has also shown that those with this disorder do not experience emotions the way most other people do.

Review Questions

People with borderline personality disorder often ________.

  1. try to be the center of attention
  2. are shy and withdrawn
  3. are impulsive and unpredictable
  4. tend to accomplish goals through cruelty

Antisocial personality disorder is associated with ________.

  1. emotional deficits
  2. memory deficits
  3. parental overprotection
  4. increased empathy

Critical Thinking Question

Imagine that a child has a genetic vulnerability to antisocial personality disorder. How might this child’s environment shape the likelihood of developing this personality disorder?

Disorders in Childhood

Most of the disorders we have discussed so far are typically diagnosed in adulthood, although they can and sometimes do occur during childhood. However, there are a group of conditions that, when present, are diagnosed early in childhood, often before the time a child enters school. These conditions are listed in the DSM-5 as neurodevelopmental disorders, and they involve developmental problems in personal, social, academic, and intellectual functioning (APA, 2013). In this section, we will discuss two such disorders: attention deficit/ hyperactivity disorder and autism.

ATTENTION DEFICIT/HYPERACTIVITY DISORDER

Diego is always active, from the time he wakes up in the morning until the time he goes to bed at night. His mother reports that he came out the womb kicking and screaming, and he has not stopped moving since. He has a sweet disposition, but always seems to be in trouble with his teachers, parents, and after-school program counselors. He seems to accidently break things; he lost his jacket three times last winter, and he never seems to sit still. His teachers believe he is a smart child, but he never finishes anything he starts and is so impulsive that he does not seem to learn much in school.

Diego likely has attention deficit/hyperactivity disorder (ADHD). The symptoms of this disorder were first described by Hans Hoffman in the 1920s. While taking care of his son while his wife was in the hospital giving birth to a second child, Hoffman noticed that the boy had trouble concentrating on his homework, had a short attention span, and had to repeatedly go over easy homework to learn the material (Jellinek & Herzog, 1999). Later, it was discovered that many hyperactive children—those who are fidgety, restless, socially disruptive, and have trouble with impulse control—also display short attention spans, problems with concentration, and distractibility. By the 1970s, it had become clear that many children who display attention problems often also exhibit signs of hyperactivity. In recognition of such findings, the DSM-III (published in 1980) included a new disorder: attention deficit disorder with and without hyperactivity, now known as attention deficit/hyperactivity disorder (ADHD).

A child with ADHD shows a constant pattern of inattention and/or hyperactive and impulsive behavior that interferes with normal functioning (APA, 2013). Some of the signs of inattention include great difficulty with and avoidance of tasks that require sustained attention (such as conversations or reading), failure to follow instructions (often resulting in failure to complete school work and other duties), disorganization (difficulty keeping things in order, poor time management, sloppy and messy work), lack of attention to detail, becoming easily distracted, and forgetfulness. Hyperactivity is characterized by excessive movement, and includes fidgeting or squirming, leaving one’s seat in situations when remaining seated is expected, having trouble sitting still (e.g., in a restaurant), running about and climbing on things, blurting out responses before another person’s question or statement has been completed, difficulty waiting one’s turn for something, and interrupting and intruding on others. Frequently, the hyperactive child comes across as noisy and boisterous. The child’s behavior is hasty, impulsive, and seems to occur without much forethought; these characteristics may explain why adolescents and young adults diagnosed with ADHD receive more traffic tickets and have more automobile accidents than do others (Thompson, Molina, Pelham, & Gnagy, 2007).

ADHD occurs in about 5% of children (APA, 2013). On the average, boys are 3 times more likely to have ADHD than are girls; however, such findings might reflect the greater propensity of boys to engage in aggressive and antisocial behavior and thus incur a greater likelihood of being referred to psychological clinics (Barkley, 2006). Children with ADHD face severe academic and social challenges. Compared to their non-ADHD counterparts, children with ADHD have lower grades and standardized test scores and higher rates of expulsion, grade retention, and dropping out (Loe & Feldman, 2007). they also are less well-liked and more often rejected by their peers (Hoza et al., 2005).

Previously, ADHD was thought to fade away by adolescence. However, longitudinal studies have suggested that ADHD is a chronic problem, one that can persist into adolescence and adulthood (Barkley, Fischer, Smallish, & Fletcher, 2002). A recent study found that 29.3% of adults who had been diagnosed with ADHD decades earlier still showed symptoms (Barbaresi et al., 2013). Somewhat troubling, this study also reported that nearly 81% of those whose ADHD persisted into adulthood had experienced at least one other comorbid disorder, compared to 47% of those whose ADHD did not persist.

Life Problems from ADHD

Children diagnosed with ADHD face considerably worse long-term outcomes than do those children who do not receive such a diagnosis. In one investigation, 135 adults who had been identified as having ADHD symptoms in the 1970s were contacted decades later and interviewed (Klein et al., 2012). Compared to a control sample of 136 participants who had never been diagnosed with ADHD, those who were diagnosed as children:

  • had worse educational attainment (more likely to have dropped out of high school and less likely to have earned a bachelor’s degree);
  • had lower socioeconomic status;
  • held less prestigious occupational positions;
  • were more likely to be unemployed;
  • made considerably less in salary;
  • scored worse on a measure of occupational functioning (indicating, for example, lower job satisfaction, poorer work relationships, and more firings);
  • scored worse on a measure of social functioning (indicating, for example, fewer friendships and less involvement in social activities);
  • were more likely to be divorced; and
  • were more likely to have non-alcohol-related substance abuse problems. (Klein et al., 2012)

Longitudinal studies also show that children diagnosed with ADHD are at higher risk for substance abuse problems. One study reported that childhood ADHD predicted later drinking problems, daily smoking, and use of marijuana and other illicit drugs (Molina & Pelham, 2003). The risk of substance abuse problems appears to be even greater for those with ADHD who also exhibit antisocial tendencies (Marshal & Molina, 2006).

Causes of ADHD

Family and twin studies indicate that genetics play a significant role in the development of ADHD. Burt (2009), in a review of 26 studies, reported that the median rate of concordance for identical twins was .66 (one study reported a rate of .90), whereas the median concordance rate for fraternal twins was .20. This study also found that the median concordance rate for unrelated (adoptive) siblings was .09; although this number is small, it is greater than 0, thus suggesting that the environment may have at least some influence. Another review of studies concluded that the heritability of inattention and hyperactivity were 71% and 73%, respectively (Nikolas & Burt, 2010).

The specific genes involved in ADHD are thought to include at least two that are important in the regulation of the neurotransmitter dopamine (Gizer, Ficks, & Waldman, 2009), suggesting that dopamine may be important in ADHD. Indeed, medications used in the treatment of ADHD, such as methylphenidate (Ritalin) and amphetamine with dextroamphetamine (Adderall), have stimulant qualities and elevate dopamine activity. People with ADHD show less dopamine activity in key regions of the brain, especially those associated with motivation and reward (Volkow et al., 2009), which provides support to the theory that dopamine deficits may be a vital factor in the development this disorder (Swanson et al., 2007).

Brain imaging studies have shown that children with ADHD exhibit abnormalities in their frontal lobes, an area in which dopamine is in abundance. Compared to children without ADHD, those with ADHD appear to have smaller frontal lobe volume, and they show less frontal lobe activation when performing mental tasks. Recall that one of the functions of the frontal lobes is to inhibit our behavior. Thus, abnormalities in this region may go a long way toward explaining the hyperactive, uncontrolled behavior of ADHD.

By the 1970s, many had become aware of the connection between nutritional factors and childhood behavior. At the time, much of the public believed that hyperactivity was caused by sugar and food additives, such as artificial coloring and flavoring. Undoubtedly, part of the appeal of this hypothesis was that it provided a simple explanation of (and treatment for) behavioral problems in children. A statistical review of 16 studies, however, concluded that sugar consumption has no effect at all on the behavioral and cognitive performance of children (Wolraich, Wilson, & White, 1995). Additionally, although food additives have been shown to increase hyperactivity in non-ADHD children, the effect is rather small (McCann et al., 2007). Numerous studies, however, have shown a significant relationship between exposure to nicotine in cigarette smoke during the prenatal period and ADHD (Linnet et al., 2003). Maternal smoking during pregnancy is associated with the development of more severe symptoms of the disorder (Thakur et al., 2013).

Is ADHD caused by poor parenting? Not likely. Remember, the genetics studies discussed above suggested that the family environment does not seem to play much of a role in the development of this disorder; if it did, we would expect the concordance rates to be higher for fraternal twins and adoptive siblings than has been demonstrated. All things considered, the evidence seems to point to the conclusion that ADHD is triggered more by genetic and neurological factors and less by social or environmental ones.

AUTISM SPECTRUM DISORDER

A seminal paper published in 1943 by psychiatrist Leo Kanner described an unusual neurodevelopmental condition he observed in a group of children. He called this condition early infantile autism, and it was characterized mainly by an inability to form close emotional ties with others, speech and language abnormalities, repetitive behaviors, and an intolerance of minor changes in the environment and in normal routines (Bregman, 2005). What the DSM-5 refers to as autism spectrum disorder today, is a direct extension of Kanner’s work.

Autism spectrum disorder is probably the most misunderstood and puzzling of the neurodevelopmental disorders. Children with this disorder show signs of significant disturbances in three main areas: (a) deficits in social interaction, (b) deficits in communication, and (c) repetitive patterns of behavior or interests. These disturbances appear early in life and cause serious impairments in functioning (APA, 2013). The child with autism spectrum disorder might exhibit deficits in social interaction by not initiating conversations with other children or turning their head away when spoken to. These children do not make eye contact with others and seem to prefer playing alone rather than with others. In a certain sense, it is almost as though these individuals live in a personal and isolated social world others are simply not privy to or able to penetrate. Communication deficits can range from a complete lack of speech, to one word responses (e.g., saying “Yes” or “No” when replying to questions or statements that require additional elaboration), to echoed speech (e.g., parroting what another person says, either immediately or several hours or even days later), to difficulty maintaining a conversation because of an inability to reciprocate others’ comments. These deficits can also include problems in using and understanding nonverbal cues (e.g., facial expressions, gestures, and postures) that facilitate normal communication.

Repetitive patterns of behavior or interests can be exhibited a number of ways. The child might engage in stereotyped, repetitive movements (rocking, head-banging, or repeatedly dropping an object and then picking it up), or she might show great distress at small changes in routine or the environment. For example, the child might throw a temper tantrum if an object is not in its proper place or if a regularly-scheduled activity is rescheduled. In some cases, the person with autism spectrum disorder might show highly restricted and fixated interests that appear to be abnormal in their intensity. For instance, the person might learn and memorize every detail about something even though doing so serves no apparent purpose. Importantly, autism spectrum disorder is not the same thing as intellectual disability, although these two conditions are often comorbid. The DSM-5 specifies that the symptoms of autism spectrum disorder are not caused or explained by intellectual disability.

Life Problems From Autism Spectrum Disorder

Autism spectrum disorder is referred to in everyday language as autism; in fact, the disorder was termed “autistic disorder” in earlier editions of the DSM, and its diagnostic criteria were much narrower than those of autism spectrum disorder. The qualifier “spectrum” in autism spectrum disorder is used to indicate that individuals with the disorder can show a range, or spectrum, of symptoms that vary in their magnitude and severity: some severe, others less severe. The previous edition of the DSM included a diagnosis of Asperger’s disorder, generally recognized as a less severe form of autistic disorder; individuals diagnosed with Asperger’s disorder were described as having average or high intelligence and a strong vocabulary, but exhibiting impairments in social interaction and social communication, such as talking only about their special interests (Wing, Gould, & Gillberg, 2011). However, because research has failed to demonstrate that Asperger’s disorder differs qualitatively from autistic disorder, the DSM-5 does not include it, which is prompting concerns among some parents that their children may no longer be eligible for special services (“Asperger’s Syndrome Dropped,” 2012). Some individuals with autism spectrum disorder, particularly those with better language and intellectual skills, can live and work independently as adults. However, most do not because the symptoms remain sufficient to cause serious impairment in many realms of life (APA, 2013).

Currently, estimates indicate that nearly 1 in 88 children in the United States has autism spectrum disorder; the disorder is 5 times more common in boys (1 out of 54) than girls (1 out of 252) (CDC, 2012). Rates of autistic spectrum disorder have increased dramatically since the 1980s. For example, California saw an increase of 273% in reported cases from 1987 through 1998 (Byrd, 2002); between 2000 and 2008, the rate of autism diagnoses in the United States increased 78% (CDC, 2012). Although it is difficult to interpret this increase, it is possible that the rise in prevalence is the result of the broadening of the diagnosis, increased efforts to identify cases in the community, and greater awareness and acceptance of the diagnosis. In addition, mental health professionals are now more knowledgeable about autism spectrum disorder and are better equipped to make the diagnosis, even in subtle cases (Novella, 2008).

WHY IS THE PREVALENCE RATE OF ADHD INCREASING?

Many people believe that the rates of ADHD have increased in recent years, and there is evidence to support this contention. In a recent study, investigators found that the parent-reported prevalence of ADHD among children (4–17 years old) in the United States increased by 22% during a 4-year period, from 7.8% in 2003 to 9.5% in 2007 (CDC, 2010). Over time this increase in parent-reported ADHD was observed in all sociodemographic groups and was reflected by substantial increases in 12 states (Indiana, North Carolina, and Colorado were the top three). The increases were greatest for older teens (ages 15–17), multiracial and Hispanic children, and children with a primary language other than English. Another investigation found that from 1998–2000 through 2007–2009 the parent-reported prevalence of ADHD increased among U.S. children between the ages of 5–17 years old, from 6.9% to 9.0% (Akinbami, Liu, Pastor, & Reuben, 2011).

A major weakness of both studies was that children were not actually given a formal diagnosis. Instead, parents were simply asked whether or not a doctor or other health-care provider had ever told them their child had ADHD; the reported prevalence rates thus may have been affected by the accuracy of parental memory. Nevertheless, the findings from these studies raise important questions concerning what appears to be a demonstrable rise in the prevalence of ADHD. Although the reasons underlying this apparent increase in the rates of ADHD over time are poorly understood and, at best, speculative, several explanations are viable:

  • ADHD may be over-diagnosed by doctors who are too quick to medicate children as a behavior treatment.
  • There is greater awareness of ADHD now than in the past. Nearly everyone has heard of ADHD, and most parents and teachers are aware of its key symptoms. Thus, parents may be quick to take their children to a doctor if they believe their child possesses these symptoms, or teachers may be more likely now than in the past to notice the symptoms and refer the child for evaluation.
  • The use of computers, video games, iPhones, and other electronic devices has become pervasive among children in the early 21st century, and these devices could potentially shorten children’s attentions spans. Thus, what might seem like inattention to some parents and teachers could simply reflect exposure to too much technology.
  • ADHD diagnostic criteria have changed over time.

Causes of Autism Spectrum Disorder

Early theories of autism placed the blame squarely on the shoulders of the child’s parents, particularly the mother. Bruno Bettelheim (an Austrian-born American child psychologist who was heavily influenced by Sigmund Freud’s ideas) suggested that a mother’s ambivalent attitudes and her frozen and rigid emotions toward her child were the main causal factors in childhood autism. In what must certainly stand as one of the more controversial assertions in psychology over the last 50 years, he wrote, “I state my belief that the precipitating factor in infantile autism is the parent’s wish that his child should not exist” (Bettelheim, 1967, p. 125). As you might imagine, Bettelheim did not endear himself to a lot of people with this position; incidentally, no scientific evidence exists supporting his claims.

The exact causes of autism spectrum disorder remain unknown despite massive research efforts over the last two decades (Meek, Lemery-Chalfant, Jahromi, & Valiente, 2013). Autism appears to be strongly influenced by genetics, as identical twins show concordance rates of 60%–90%, whereas concordance rates for fraternal twins and siblings are 5%–10% (Autism Genome Project Consortium, 2007). Many different genes and gene mutations have been implicated in autism (Meek et al., 2013). Among the genes involved are those important in the formation of synaptic circuits that facilitate communication between different areas of the brain (Gauthier et al., 2011). A number of environmental factors are also thought to be associated with increased risk for autism spectrum disorder, at least in part, because they contribute to new mutations. These factors include exposure to pollutants, such as plant emissions and mercury, urban versus rural residence, and vitamin D deficiency (Kinney, Barch, Chayka, Napoleon, & Munir, 2009).

Child Vaccinations and Autism Spectrum Disorder

In the late 1990s, a prestigious medical journal published an article purportedly showing that autism is triggered by the MMR (measles, mumps, and rubella) vaccine. These findings were very controversial and drew a great deal of attention, sparking an international forum on whether children should be vaccinated. In a shocking turn of events, some years later the article was retracted by the journal that had published it after accusations of fraud on the part of the lead researcher. Despite the retraction, the reporting in popular media led to concerns about a possible link between vaccines and autism persisting. A recent survey of parents, for example, found that roughly a third of respondents expressed such a concern (Kennedy, LaVail, Nowak, Basket, & Landry, 2011); and perhaps fearing that their children would develop autism, more than 10% of parents of young children refuse or delay vaccinations (Dempsey et al., 2011). Some parents of children with autism mounted a campaign against scientists who refuted the vaccine-autism link. Even politicians and several well-known celebrities weighed in; for example, actress Jenny McCarthy (who believed that a vaccination caused her son’s autism) co-authored a book on the matter. However, there is no scientific evidence that a link exists between autism and vaccinations (Hughes, 2007). Indeed, a recent study compared the vaccination histories of 256 children with autism spectrum disorder with that of 752 control children across three time periods during their first two years of life (birth to 3 months, birth to 7 months, and birth to 2 years) (DeStefano, Price, & Weintraub, 2013). At the time of the study, the children were between 6 and 13 years old, and their prior vaccination records were obtained. Because vaccines contain immunogens (substances that fight infections), the investigators examined medical records to see how many immunogens children received to determine if those children who received more immunogens were at greater risk for developing autism spectrum disorder. The results of this study, a portion of which are shown in Figure, clearly demonstrate that the quantity of immunogens from vaccines received during the first two years of life were not at all related to the development of autism spectrum disorder. There is not a relationship between vaccinations and autism spectrum disorders.

A graph has an x-axis labeled “total cumulative immunogens” and a y-axis with percentage numbers. For children aged 0–3 months, the data is approximately as follows: 0–25 immunogens are about 48% for ASD cases and 41% for controls, 26–50 immunogens are 5% for ASD cases and 6% for controls, and for 3000–3258 immunogens45% for ASD cases and 50% for controls. For children aged 0–7months, the data is approximately as follows: 26–50 immunogens are about 20% for ASD cases and 18% for controls, 51–75 immunogens are 25% for ASD cases and 22% for controls, 3000–3258 immunogens are 45% for ASD cases and 52% for controls, 6000–6258 immunogens are 10% for ASD cases and 8% for controls, and for 9000–9258 immunogens 33% for ASD cases and 40% for controls. For children aged 0–24 months, the data is approximately as follows: 151–175 immunogens are about 25% for ASD cases and 25% for controls, 176–200 immunogens are 18% for ASD cases and 13% for controls, 9000–9528 immunogens are 17% for ASD cases and 20% for controls, and for 12000–12258 immunogens 25% for ASD cases and25% for controls.
In terms of their exposure to immunogens in vaccines, overall, there is not a significant difference between children with autism spectrum disorder and their age-matched controls without the disorder (DeStefano et al., 2013).

Why does concern over vaccines and autism spectrum disorder persist? Since the proliferation of the Internet in the 1990s, parents have been constantly bombarded with online information that can become magnified and take on a life of its own. The enormous volume of electronic information pertaining to autism spectrum disorder, combined with how difficult it can be to grasp complex scientific concepts, can make separating good research from bad challenging (Downs, 2008). Notably, the study that fueled the controversy reported that 8 out of 12 children—according to their parents—developed symptoms consistent with autism spectrum disorder shortly after receiving a vaccination. To conclude that vaccines cause autism spectrum disorder on this basis, as many did, is clearly incorrect for a number of reasons, not the least of which is because correlation does not imply causation, as you’ve learned.

Additionally, as was the case with diet and ADHD in the 1970s, the notion that autism spectrum disorder is caused by vaccinations is appealing to some because it provides a simple explanation for this condition. Like all disorders, however, there are no simple explanations for autism spectrum disorder. Although the research discussed above has shed some light on its causes, science is still a long way from complete understanding of the disorder.

Summary

Neurodevelopmental disorders are a group of disorders that are typically diagnosed during childhood and are characterized by developmental deficits in personal, social, academic, and intellectual realms; these disorders include attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder. ADHD is characterized by a pervasive pattern of inattention and/or hyperactive and impulsive behavior that interferes with normal functioning. Genetic and neurobiological factors contribute to the development of ADHD, which can persist well into adulthood and is often associated with poor long-term outcomes. The major features of autism spectrum disorder include deficits in social interaction and communication and repetitive movements or interests. As with ADHD, genetic factors appear to play a prominent role in the development of autism spectrum disorder; exposure to environmental pollutants such as mercury have also been linked to the development of this disorder. Although it is believed by some that autism is triggered by the MMR vaccination, evidence does not support this claim.

Review Questions

Which of the following is not a primary characteristic of ADHD?

  1. short attention span
  2. difficulty concentrating and distractibility
  3. restricted and fixated interest
  4. excessive fidgeting and squirming

One of the primary characteristics of autism spectrum disorder is ________.

  1. bed-wetting
  2. difficulty relating to others
  3. short attention span
  4. intense and inappropriate interest in others

Critical Thinking Questions

Compare the factors that are important in the development of ADHD with those that are important in the development of autism spectrum disorder.

Personal Application Question

Discuss the characteristics of autism spectrum disorder with a few of your friends or members of your family (choose friends or family members who know little about the disorder) and ask them if they think the cause is due to bad parenting or vaccinations. If they indicate that they believe either to be true, why do you think this might be the case? What would be your response?

glossary

antisocial personality disorder:
characterized by a lack of regard for others’ rights, impulsivity, deceitfulness, irresponsibility, and lack of remorse over misdeeds
attention deficit/hyperactivity disorder:
childhood disorder characterized by inattentiveness and/or hyperactive, impulsive behavior
autism spectrum disorder:
childhood disorder characterized by deficits in social interaction and communication, and repetitive patterns of behavior or interests
borderline personality disorder:
instability in interpersonal relationships, self-image, and mood, as well as impulsivity; key features include intolerance of being alone and fear of abandonment, unstable relationships, unpredictable behavior and moods, and intense and inappropriate anger
neurodevelopmental disorder:
one of the disorders that are first diagnosed in childhood and involve developmental problems in academic, intellectual, social functioning
personality disorder:
group of DSM-5 disorders characterized by an inflexible and pervasive personality style that differs markedly from the expectations of one’s culture and causes distress and impairment; people with these disorders have a personality style that frequently brings them into conflict with others and disrupts their ability to develop and maintain social relationships