Children's Mental Health Test #1

What is abnormal?

• Not just a-typical but harmful that affects their everyday life

• Developmentally inappropriate

• Not meeting milestones

• Qualitatively different/ -Unresponsive

Behavioural indicators of disorder

Delays in development

Regression

High or low frequency of behaviour

Intensity of behaviour

Numerous problem behaviours

Qualitatively different from "normal"

Inappropriate to situation

Changes in behaviour

Over time

How common are mental health problems in children

Youth - 10% serious

10% mild

Ted Talk - gender is not a straight line

Sex = Private parts

Gender identity = what you identify as (male, female, etc.)

Gender expression = How you present yourself (dressing masculine, feminine,

Gender is a spectrum

Ted talk- Racism

Racist comments gave her anxiety to be in that class, hence effecting her mental health, pathological hypertension, depression, and thoughts of suicide from the chronic anxiety of being in that class

Benefits of forgiveness:

- Feeling free

- No more shame

- Mediates relationship with part of brain and your depressive + anxiety levels.

Impact of developmental level

• Some evidence that disorders have a particular age of onset

• The onset can be insidious

• At certain ages, you can be diagnosed with different disorders

Impact of gender

• Brain injuries higher in boys

• Symptoms show differently

Working with youth and their families

• Work often interdisciplinary

• Work involves parents

• Therapeutic alliance very important

• Must protect child's rights

• 
  

What is comorbidity

Multiple diagnoses that go hand in hand

3 Types of reactions to a perceived threat

1. Behavioural

2. Cognitive

3. Physical

Normal Fears

• Girls exhibit more fears than boys

• Fears decline with age

• Worry is more prominent with age

• Fears coincide with age

DSM-5 states that anxiety disorders are

very common

Trauma is

An event outside everyday experience that would be distressing to almost anyone.

we now understand that exposure to traumatic events may lead to significant distress and psychological impairment

PTSD and Acute stress disorder

• To have the diagnosis a young person must have experienced exposure to a traumatic event,

• It can be direct experience, witnessing a traumatic event, learning about a traumatic event, or learning that a traumatic event has happened to someone close to them.

• Repeated or extreme exposure to aversive information about a traumatic event not TV) may also be considered exposure*

4 Different clusters of PTSD symptoms

1. Re-experiencing

2. Avoidance

3. Negative alterations in cognition or mood

4. Arousal and reactivity

Re-experiencing:

• Disturbing memories

• Dreams

• Physical reaction

Dissociation:

• Alternatives in self-awareness

• Flashbacks

• 
  

Avoidance:

• Avoiding thoughts and feelings about the experience

Negative alterations in cognition and mood:

• Forgetting parts of the experience

• Exaggerated negative beliefs

Arousal or reactivity:

• Irritable

• Angry outbursts

• Reckless behaviour

• Startle responses

• Sleep problems

Acute stress disorder:

• Similar to PTSD but lasts for at least 3 days, but less than 4 weeks

• PTSD lasts at least 1 month

Younger children with PTSD

• In younger children the diagnosis does not require as many symptoms as older children

Reactive Attachment Disorder

• Defined by the absence of adequate caregiver during childhood

• Inhibited towards adults or disinhibited towards adults

Epidemiology:

The study of the distribution, patterns, and determinants of health and disease in populations, with the goal of using this knowledge to prevent and control illnesses

Epidemiology of PTSD

• Studies suggest that one quarter to two thirds of children will have some sort of traumatic experience

• One third of will develop PTSD

2 categories of ptsd

1. Non-abusive-flood: Natural disaster, accident, medical trauma, etc. likely to show a "flood" of symptoms right away.

2. Chronic/ abusive-sexual abuse (may learn to accommodate so less symptoms): (CPTSD) have learned to adapt, minimize or accommodate the abuse in order to survive. may appear only calm, detached, or functional.

Risk factors for developing PTSD

• Prior level of anxiety

• Negative coping strategies

• Support system

• Parent functioning

• Coping strategy

• Parent reaction

Developmental Course and prognosis of PTSD

• In general symptoms of PTSD will decrease over time

• If the child uses negative coping skills the symptoms can persist longer

• Environments (violent) have an impact

• Long exposure to these environments show children can become desensitized

Treatment for PTSD

• CBT (especially if parents are involved & is trauma focused)

• Psychoeducation

• Parenting skills

• Relaxation skills

• Affective modulation

• Cognitive coping skills (thoughts/feelings/behaviours)

• Trauma narration book

• Enhancing safety

Mood Disorder History

• Thought depression in children was just part of their development

• Since depression in children can look different (acting out/anger) than it does in adults (sadness) historically it often went undiagnosed

Unipolar

• One mood is experienced (typically depression)

Bipolar

• Both moods are experienced (depression and mania)

"Depressed" depends on:

• How depression is defined and assessed

• It is possible that a child could be diagnosed using one method like The DSM-5 and not diagnosed if another method is being used.

Depressive Disorders: 3 types

• Major depressive disorder (MDD)

• Persistent depressive disorder (dysthymia)

• Disruptive mood dysregulation disorder (DMDD)

Major Depressive Disorder (MDD) symptoms

• Symptoms are the same for children, adolescents, and adults with one exception:

• In children and adolescents irritable mood can be substituted for depressed mood.

MDD diagnosis requires

• 5 or more symptoms: depressed mood, diminished interest of pleasure, weight loss/gain, insomnia, psychomotor agitation/slowed, fatigue, feeling of worthlessness, concentration problems, suicidal thoughts)

• Must include depressed (or irritable) mood or loss of pleasure

• Symptoms must be present for 2 weeks minimum

• Must cause clinically significant distress or impairment of life functioning

Persistent Depressive Disorder (Dysthymia)

• A more chronic form of depression

• Similar symptoms as MDD: Perhaps in less severe forms but can persist for longer periods of time

Diagnosis of Dysthymia requires:

• Depressed/ irritable mood in children and adolescents is present for a minimum of 1 year

• Along with 2 or more of the other symptoms

Disruptive Mood Dysregulation Disorder (DMDD)

• Diagnosis added in DSM-5 in an attempt to decrease confusion and over diagnosis of bipolar disorder in children

• Described as symptoms of persistent irritability and frequent outbursts

• Young persons angry/irritable mood is present even between temper outbursts and is present most of the day every day

• Age of onset for symptoms is before 10 years old

• Diagnosis not intended to be given before 6 years old or after the age of 18

Depression in children:

• May also have symptoms of anxiety

• May look different at one age than at another (at 12 it looks like anger and at 16 looks like sadness)

• Those who do not meet the criteria for a diagnosis of depression may still need help

• May be at risk for later difficulties

Epidemiology or prevalence of MDD in youth: Unipolar Disorders

• 80% experience MDD

• 10% Dysthymia (no MDD)

• 10% Double depression (MDD and dysthymia)

• At 11 years, boys have a higher rate but after 12 years its more common in girls

• Overall rates for MDD are 12%

• More common for lower socioeconomics

• 1-4 youth will experience depression at some time

Co-Occurring difficulties: Mood Disorders

• Increased potential that youth will be diagnosed with another disorder

• Common additional non-mood disorders are: Anxiety, disruptive behaviour disorders, eating disorders, substance abuse disorders, ADHD

Identification of Problems in youth

• Developmental norms

• Cultural norms

• Gender norms

• Situational norms

• Role of adults

• Changing views of abnormality

Anxiety

• A future-oriented emotion

• Characterized by perceptions of uncontrollability and unpredictability over potentially aversive events

• A rapid shift in attention to the focus of potentially dangerous events or one's own affective response to these events.

Phobias:

As contrasted with developmentally appropriate fears, are of concern because they are excessive, cannot be reasoned away, are beyond voluntary control, lead to avoidance, and interfere with functioning.

Social Anxiety Disorder:

• A marked of persistent fear of acting in an embarrassing or humiliating way in social or performance situations

Selective mutism (social anxiety):

• Does not talk in specific situations

Separation Anxiety:

• An anxiety regarding separation from a major attachment figure and / or home.

• This anxiety exceeds what might be expected given their developmental level.

Generalized Anxiety Disorder:

• This anxiety exceeds what might be expected given their developmental level.

Symptoms of Generalized Anxiety Disorder:

1. Restlessness, feeling keyed up or on edge

2. Being easily fatigued

2. Being easily fatigued

4. Irritability

5. Muscle tension

6. Disturbed sleep

Panic attacks

A discrete period of intense fear or terror that has sudden onset and reaches a peak quickly within a few minutes

Symptoms of a panic attack

(4 or more must be present during an episode)

1. Cardiac reactions (rapid heart rate)

2. Sweating

3. Shaking or trembling

4. Feeling short of breath or smothering

5. Feeling as if choking

6. Feeling chest discomfort or pain

7. Feelings of abdominal distress or nausea

8. Feeling faint or lightheaded

9. Feeling a chill or flushed

10. Feeling numbness or tingling

11. Feelings of unreality (derealization) or of being detached from oneself (depersonalization)

12. Fear of "going crazy" or losing control

13. Fear of dying

Panic Disorder:

• Involve recurrent unexpected panic attacks

• to be diagnosed with panic disorder a month or more of persistent concern about having other panic attacks or worry about the implications of the attack and a significant maladaptive change in behaviour related to the attacks must occur.

Interventions for Anxiety Disorders:

• Psychological treatments

• Relaxation and desensitization

• Modeling

• Contingency management

• Cognitive- Behavioural treatments

Obsessive- Compulsive Disorder (OCD)

• Obsessions are unwanted, repetitive, intrusive thoughts that are not simply excessive real-life concerns and that, in most individuals, cause considerable distress or anxiety

• Compulsions involve repetitive, stereotyped behaviours that the person feels compelled to perform and that are meant to reduce anxiety or to prevent a dreaded event

• OCD involves either obsessions or compulsions, or both.

Treating OCD

• CBT

• Exposure therapy

• Support and belief

Symptoms of a major depressive episode

1. depressed or irritable mood

2. loss of interest or pleasure

3. change in weight or appetite

Dysthymia symptoms

1. Depressed or irritable mood

2. Poor appetite or overeating

3. Sleep disturbance

4. Low energy or fatigue

5. Loss of self-esteem

6. Concentration or decision-making problems

7. Feelings of hopelessness

Treatment of depression

1. Selective serotonin reuptake inhibitors (SSRI's)

2. CBT

3. Combined treatments

4. Psychosocial treatments

Mania episode symptoms:

1. Inflated self-esteem

2. ecreased need for sleep

3. More talkative than usual

4. Racing thoughts

5. Distractibility

6. Increased goal-directed activity or motor agitation

7. Excessive activity that can lead to negative outcomes (e.g., excessive spending, sexual indiscretions)

Bipolar Disorder:

• Involves the presence of mania as well as depressive symptoms

Mania

• A period of abnormally, persistently elevated or irritable mood and increased energy or activity.

• Euphoria

Treatment for bipolar disorder

• Most common treatment is pharmacotherapy (mood stabilizers)

• Psychoeducation

• Dialectical behaviour therapy

Intermittent Explosive Disorder:

• Recurring and frequent behavioural outbursts (verbal and/or physical)

• Outbursts are impulsive or angry

• Outbursts are rapid and brief

Antisocial Personality Disorder (APD):

• Individuals who display a persistent pattern of aggressive and antisocial behaviour after the age of 18.

• A pattern of disregard for, and violation of, the rights of others

Oppositional Defiant Disorder Symptoms

1. Loses temper

2. Easily annoyed/touchy

3. Angry and resentful

4. Argues with adults/authority figures

5. Refuses to comply with or defies adult's requests or does not follow rules

6. Deliberately annoys others

7. Blames others for own mistakes or bad behavior

8. piteful or vindictive

Four or more symptoms needed for a diagnosis

Conduct Disorder (CD)

• Represents more seriously aggressive and antisocial behaviour

• Many of the behaviours would considerably impact individuals, families, and communities

The 4 Categories of Conduct Disorder

1. Aggression to people and animals

2. Destruction of property

3. Deceitfulness or theft

4. Serious violations of rules

Substance Use

• The use of alcohol and other drugs may be a part of a pattern of antisocial and rule-breaking behaviour.

• Multiple risk factors including individual differences, and family, peer, and larger community and societal influences likely contribute to the development of substance use.

• CD and ODD epidemiology

• Conduct problems are one of the most frequently occurring child and adolescent difficulties.

• CD and ODD are more commonly diagnosed in boys.

• An increasing prevalence of CD with age is often reported.

The pattern for ODD is less clear.

• Contextual factors such as poverty and the stress of high-crime neighbourhoods are thought to increase the risk of conduct problems.

Depression & Development: Infants

• Less active

• Withdrawn

• Sleep/eating problems

• Irritability

• Excessive crying

Depression & Development: Preschoolers

• Similar to infants but can also be stomachaches, toilet training problems, lack of interest in food, muted affect

Depression & Development: Middle childhood

• By 9 years old, children are able to verbalize feelings of hopelessness and low self-esteem

Depression & Development: Adolescents

• In older adolescents the symptoms closely resemble the symptoms of adult depression

Neuroendocrine Systems:

• Connection between the brain, hormones, and various organs

• Dysregulation of this system is considered a hallmark of depression

Negative Affectivity:

• The tendency to experience negative emotions

• To be wary

• To be sensitive to negative stimuli (high levels are associated with depression and anxiety)

Positive Affectivity:

• includes approach, energy, and sociability (low levels are associated with depression)

Etiology: Social-Psychological Influences

• Separation and loss

• Cognitive -Behavioural /Interpersonal Perspectives

• Interpersonal Skills

• Cognitive distortions, catastrophize, overgeneralize, and personalize

• Learned helplessness

• Attributional style-blame themselves when negative things happen.

• Feelings about what control they have and their ability to cope

Impact of parental depression

• There area variety of mechanisms where depressive mood state of parents can be associated with dysfunction in their children:

• Biological - genetics, heredity

Non-biological: Parent/child interaction, coaching and teaching practices, child's social environment

Etiology: Peer relationships

• Peer relation difficulties may both contribute to the development and be a consequence of depression.

• Depression has been found to be associated with several interpersonal characteristics important to peer relationships.

• Peer relationships are an integral part of typical adolescent development -difficulties in this has been associated with increased risk for depression.

Bipolar disorder types:

• Bi-Polar 1- mania plus history of major depression

• Bi-Polar 2 - history of major depression and hypomania (less severe than mania)

• Cyclothymic- chronic but mild fluctuations between periods of hypomanic and depressive symptoms

Bipolar in children:

• In children bipolar can look more chronic rather than distinct episodes with good periods in between(adults).

• Also, in children, with bipolar the mood shifts are often more frequent and swifter.

• Children often are moody, so when do distinguish what is normal behaviour from what are concerning moods

• The DSM-5 uses frequency , intensity , number, and duration to assess the difference.

• Bipolar in children is more likely to be associated with antisocial behaviour issues, school problems, and substance abuse.

How parents describe mania:

• Having irritating silliness

• Unrealistic optimism

• Irritable moods

• Outbursts

• Mood Swings

• Oppositional behaviours

• Being rude

• Having mood swings in a day

• Grandiose

• Disorganized

Conditions commonly co-occurring in youth diagnosed with Bipolar Disorder are:

• ADHD

• Conduct disorder

• Oppositional defiant disorder

• Substance use or dependence

Assessment of Bipolar disorder:

• Interviews

• Scales (-5 is very bad, +5 is very good)

Bipolar treatment

• Multimodal

• May need hospitalization if suicide is a concern

• Pharmacotherapy

• Mood -stabilizing drugs

• Atypical anti-psychotics

• Combination of both

• SSRI'S with caution

• Psychoeducation

• CBT ( Cognitive Behavioural Therapy)

• DBT ( Dialectic Behaviour Therapy)

Intermediate Explosive Disorder:

• Recurring/frequent outbursts that can be verbal and physical

• Not premeditated or committed as to achieve a tangible objective

• Grossly out of proportion

• Not under 6 years old

DSM approach: Category of disruptive, impulse-control, and conduct disorders

• Early Childhood: Oppositional Defiant Disorder (related disorder): The problem behaviors are noncompliance and being oppositional with temper tantrums

• Middle Childhood: Oppositional Defiant Disorder (related disorder): Behaviours are overt/covert antisocial behaviour and relational aggression

• Adolescence: Conduct Disorder ( related disorder): Behaviours are delinquency , substance abuse, high risk behaviour and sexual behaviour

Antisocial Personality Disorder Symptoms

• Aggressive

• Antisocial

• Disregard for Others

• After the age of 18 years

• Often involved in illegal behaviours

• Pattern must be present before the age of 15 years with evidence that the individual did or could have met the criteria for Conduct Disorder

Three clusters of oppositional defiant disorder in early childhood

1. angry/irritable mood

2. argumentative/defiant

3. vindictive

Oppositional Defiant Disorder (ODD): Early Childhood

• displayed in one setting considered mild, two settings moderate and three severe

• must be careful not to over diagnose . All kids act up.

• must have a behavioural and emotional component ( if both it is concerning for future).

4 categories of conduct disorder in middle childhood:

1. aggression to people and animals

2. destruction to property

3. deceitfulness or theft

4. serious violation of rules

Conduct Disorder: Middle Childhood

• More seriously aggressive and antisocial behaviours

• Violates the rights of others and societal norms for their age

• 3 or more behaviours for at least 12 months ( one in last 6 months)

• Meaningful impairment

Gender differences for conduct problems

• Physical aggression (associated more often with boys)

• Relational aggression( more associated with girls).

• Both forms need to be assessed or 80% of girls might not be assessed as aggressive

Fire Setting:

• Fire Setting: as attention seeking -a cry for help

• Fire Setting: may be part of a larger picture of more general psychopathology

Youth Violence: 2 concerns

1. Youth as perpetrators

2. Youth as victims are at increased risk for later problems

Youth responsible for 15% of arrests in US in 2010

10% -murder

15% -rape

25%- robbery

• Bullying- often ignored/ for victim having a friend helps- being a bully 60% ofbullies in grade 6 had a conviction by 24

Epidemiology of Conduct Disorders

Rates :

• ODD - 1% to 15%

• CD - 2% to 10%

• Conduct Disorder is diagnosed 3:1 or 4: 1 more in boys than girls

Co-occurence with Conduct Disorders:

• Co-occurence is frequent (96% of boys age 7-12 diagnosed with CD also met criteria for ODD)

• Not all those with ODD meet criteria for CD

• Average onset for ODD is 6 years old and CD is 9 years old

• Co-occurence between CD and ADHD

• Depression and anxiety disorders also co-occur (33 %) with conduct disorder

Developmental Course of conduct problems

• Childhood onset (most concerning): Some refer to this as life-course- persistent antisocial behaviour. Important to remember that many children will not persist on this pathway.

• Adolescent onset (more common among females): less aggressive and less likely to progress beyond adolescence.

Is Bipolar diagnosed in children?

Disruptive Mood Dysregulation Disorder: Was introduced as a depressive disorder because of concerns regarding the over diagnosis of bipolar disorder in children