CAP midterm

Multifinality vs Equifinality

Multifinality: the possibility of multiple end results from similar source exposure

Equifinality: the possibility of the same result from different source exposures

Etiology, nosology, epidemiology

Etiology - cause

nosology - classification system

epidemiology - how a disease presents in a population

• ex. prevalence based on gender, age, SES

National comorbidity study

50% of adults with mental illness presented by 14 and 75% by 24

ACEs

Adverse childhood experiences

• divorce

• neglect

• abuse

• domestic violence

• trauma

• mentally ill parent

having multiple ACEs increases likelihood of…

• bullying

• developing unhealthy habits

• SUDS

• early death and diseases

• smoking

• mental illness

• obesity

• STI’s

why do we care about ACE’s?

Becomes a public health / social issue with high job turnover, criminality

john locke

first to say we should raise children with care

tabula rasa - blank slate

phillipe pinel

French father of psychiatry

moved away from idea that psychopathy is caused by demonic possession

moral treatment

Jean-marc itard

tried to humanize victor the wild boy of ayveron who was found in the woods and unable to speak

failed, a sign of critical periods

Benjamin rush

father of american psychiatry

APA

first textbook on psychology

reformer

dorothea dix

reformed mental hospitals, founded humane ones

freud

psychosexual stages - sexual maturity is end of development

• oral

• anal

• phallic

• latent

• maturity

id, ego, superego

oedipus complex

penis envy

mahler

separation-individuation

• normal autism

• symbiosis

• differentiation

• practicing subphase

• rapproachment

• object constancy

object relations

end goal is object constancy

Piaget

cognitive development

• sensorimotor

• preoperational

• concrete operational

• formal operations

end goal is abstract thought and reasoning

pavlov, skinner, watson, bowlby

pavlov - classical conditioning

skinner - operant

watson - social learning

bowlby - attachment

risk factors

a variable preceding and increasing the likelihood of a negative outcome

• poverty, trauma, homelessness, mental illness of a parent

resilience factors

variables that increase ones ability to cope

• emotional regulation

• self-efficacy

sex differences between boys and girls

Girls:

• interested in faces

• mature about 20% faster until around puberty

  • toilet train faster

• use more words than boys

• more internalizing disorders, especially later in life

Boys:

• more interested in objects

• mature slower

• use less words

• more externalizing disorders, especially early in life

• more testosterone production and larger amygdala even in utero, preceding aggression

Health paradox of adolescence

adolescence is physically the healthiest time in life but you are 300% more likely to die because of sensation seeking, risk taking behaviors, and strong emotions

most common causes of death in adolescence?

accidents (particularly with firearms, or cars)

homicide

suicide

why does the adolescent paradox happen?

• increase in time alone, intimate relationships, responsibilities, etc.

• brain maturation is incomplete - ventral stratum (emotional brain) matures faster than the prefrontal cortex (inhibitions, planning)

• reward-driven

• evolutionary advantage to risk taking

• hormones like testosterone increase competition and oxytocin increase social bonding

• peer effects, emotional rejection is painful and teens would do just about anything to avoid it

pruning

during adolescence your brain gets rid of unused connections in a process called pruning, making your brain faster at the more specialized things you tend to do, but also making it harder to learn new things like langauges

gray matter vs white matter

more gray matter as a child, unrefined and may end up being used for anything

more white matter as an adult, more specialized, faster and specialized

DSM evolution

DSM-1 was mostly just descriptive with no real diagnostic criteria, disorders called “reactions”

DSM-2 largely similar

DSM-3 where things took a turn, included diagnostic criteria which greatly improved inter-rater reliability, disorders of childhood, and moved away from psychoanalytic tradition in favor of atheoretical approach

• criticized for moving away from psychoanalysis and for lack of evidence for including disorders of childhood

• Robert Spitzer

DSM-3R removed homosexuality

DSM-4 was multi-axial, added aspergers, and changed ADD to ADHD

DSM-5 has a more dimensional approach that recognized similarities between disorders, and is organized developmentally and clusters externalizing and internalizing disorders

• criticized for including “fad” disorders and painting everyday characteristics as abnormal

What are the sections of a child psych evaluation?

• Chief complaint

• history of present illness

• medical history

• psychiatric history

• family history

• psychosexual history

• developmental history

• educational history

• social history

• mental status exam

• biopsychosocial

• physical or neurological exams

What is included under history of present illness?

Patients describe illness

Parents describe illness

When did it start?

How intense?

How often?

Have they remained stable?

Are there any triggers / stressors?

Have you tried anything to help it?

How do symptoms affect function?

How is sleep history, energy levels, attention, appetite?

Major diagnostic categories to consider?

Psychosis

ADHD

Mood disorders

Anxiety

Tics

Externalizing disorders

Autism

Eating disorders

Self-injurious behaviors

Trauma

Differential diagnoses vs comorbidity

Differential diagnosis: The process of considering and distinguishing between multiple possible disorders that could explain a patient's symptoms

Comorbidity: having more than one disorder to account for symptoms

What is in a mental status examination?

CURRENT, nothing “reported” and therefore doesn’t necessarily need to match a diagnosis

• behavior

• appearance

• mood

• affect

• speech

• thought processes

• thought content

• cognition

• judgement

• attention and memory

What is in a biopsychosocial exam and why are they done?

Providing evidence for a chosen diagnosis by examining the interaction of biological, psychological, and social factors

Aims to understand where the symptoms are coming from, how they are maintained, and how they can best be treated

Biological: Genetics, brain development, medical conditions, sleep, medications

Psychological: Thoughts, emotions, coping skills, temperament, learned behaviors

Social: Family, peers, school, culture, socioeconomic stressors

rule out vs ruled out

A “rule out” is a suspected disorder that has not yet been confirmed or excluded

something that is “ruled out” has been evaluated for and excluded

What is the most common intelligence scale?

Wechsler Intelligence scales

• processing speed

• working memory

• perceptual reasoning

• verbal comprehension

IQ vs achievement tests

IQ tests are a good predictor of academic achievement, and not much else

• Cannot predict creativity or social ability

• descriptive not explanatory

Achievement tests are a test of what you actually know

What does the IQ distribution bell curve look like?

100 is the average

standard deviation is 15

below 70 is one part of qualifying for intellectual disability

above 130 is gifted

What is the purpose of a neuropsychological assessment and why might you do one?

Looks at domains like:

• attention

• executive functioning

• language ability

• visual-spatial ability

• processing speed

• motor coordination

• social cognition

You might do one if there is a perceived gap between intelligence and varied performance across domains, and a learning disability is suspected

The goal is to be able to provide specific remediations or accommodations to improve functioning

What is projective testing used for?

A personality test based on ambiguous stimuli like a TAT, sentence completion, or rorschach test

The subject leads the description of these things and it allegedly provides a look into their unconscious

What is theory of mind?

Having theory of mind means knowing that others have different thoughts, feelings, and perspectives than your own

slow to develop in those with autism

measured with things like the sally anne test

cognition definition

ability to think and problem solve

What does IDEA stand for and provide for?

Individuals with disabilities education act

Guarantees a free, appropriate, public education for all (from birth)

• Ex. services that may go along with an IEP

• LRE

What are the DSM diagnostic categories for a learning disorder?

SLD - specific learning disorder with subtypes based on specific impairments

• SLD with impairment in reading: most common type, characterized by difficulty with decoding and understanding written words

• SLD with impairment in math

• SLD with impairment of a written expression: may understand written words but struggles to reproduce themselves

What does the term dyslexia refer to?

All reading issues as an umbrella term, language based learning disorder

What factors influence reading development?

phonemic awareness

decoding

acquisition of vocab

application of reading comprehension strategies

automaticity with words

working memory

NOT creativity or handwriting

Accommodation versus modification versus remediation

Accommodation still expects and teaches the same things but allows an adjusted environment or format to get there, such as extended time or preferential seating

Remediation aims to fix the root problem of a learning gap to bring someone up to standards and meet original expectations, but would be extra or targeted instruction rather than just a difference in receiving the same instruction

Modification changes the actual standards or expectations

Intellectual disability versus learning disability

A learning disability is characterized by a gap between intelligence, functional adaption, and actual performance on achievement tests

Someone with an intellectual disability would perform poorly on all three, whereas someone with a learning disability would be performing below their perceived potential on an achievement test based on their IQ

What are the categories for intellectual disability?

Mild - most common, IQ between 50-55 and 70, doesn’t look very different from developmentally normal functioning until a later age and often can still hold a job, go to school, acquire communication etc.

Moderate - IQ between 35-40 and 50-55, most acquire communication skills but are identified as markedly different around preschool, generally can perform skilled or unskilled work for a living but struggle with social conventions of adolescence

Severe - IQ between 20-25 and 35-40, acquire little to no communication or speech and instead really can only aim to master “survival vocab”, able to perform simple tasks while supervised and may adapt well to life in the community or with families

• very vulnerable population, 50% are physically abused

Profound - IQ below 20-25, most have an identifiable neurological condition that accounts for their ID, considerable impairment in sensorimotor function

As characterized by a low IQ / cognitive capacity and a low level of adaptive functioning

Most common causes of ID?

Down syndrome - extra 21st chromosome

Fragile X syndrome - less severe in women with two X’s as compared to men

Fetal Alcohol syndrome

What are the diagnostic categories associated with autism?

Social-emotional difficulty

• abnormal social approach, failure of normal back and forth

  conversation, reduced sharing of interests/emotions/affect,

  failure to initiate or respond to social interaction

Communication difficulties

• poorly integrated verbal/non-verbal communication,

  abnormalities in eye contact/body language, deficits in

  understanding gestures, lack of facial expression

Restricted interested, stereotyped behaviors and movements

• Insistence on sameness, inflexible adherence to

  routines or ritualized patterns or verbal non-verbal

  behavior, hypersensitivity to sensory input, repetitive motor movements or speech

Etiological theories of autism

mirror neurons - light up in our brain when watching others perform tasks and in turn when we perform tasks, thought to be less active in those with autism

amygdala - threat detection and emotional processing, under-active and often smaller in those with autism, thought to be larger at birth and potentially has a toxic reaction and shrinks

fusiform gyrus - responsible for recognizing faces, autistic people don’t often look at peoples eyes, more likely to look at mouths, activates when we see faces or things we like but for autistic people only familiar faces like caregivers

• facial inversion effect: lacking in those with autism, they are equally bad or good at recognizing faces at either orientation

basal ganglia - responsible for repetitive movements

Giving autistic people synthetic oxytocin (responsible for social bonding) intra-nasally did increase eye contact but unsure if it’s actually a useful treatment or not

Copy number variants - large deletions or duplications of DNA segments, can alter gene dosage and disrupt normal brain development

disproven etiologies of autism?

diet - only evidence is open label studies

vaccines - actually reduce chances of autism

refrigerator mothers

Common comorbidities with autism?

Intellectual disabilities - in math in particular

NVLD - motor difficulties and difficulty with tactile perception and nonverbal social cues but fine verbal skills

ADHD

insomnia

OCD

epilepsy

anxiety

depression

Why has the epidemiology changed so much?

currently somewhere around 1 in 35-45 have autism

the range of what counts of autism has expanded greatly

removed the restriction that ADHD and autism couldn’t be comorbid

How do we clinically evaluate autism?

ADOS (autism diagnostic observational schedule) done directly with child and ADI-R (autism diagnostic interview revised) done with a parent

• interviewer watches how child acts in certain scenarios such as to evaluate for theory of mind

CHAT and mCHAT (checklist for autism in toddlers) screens for symptoms

Developmental history

• either may have had differences from birth like lack of eye contact, disinterest in physical contact

• Or may have APPEARED to develop normally before beginning to show signs of autism

Aspergers today

NVLD

HFA - level 1

Used to think individuals with aspergers didn't experience any communicative difficulty, but really they do communicate differently

• inappropriate grammar, prosody, repetition of phrases, monotonous

Social pragmatic communication disorder - issues only with the practical use of language

What are the levels of autism

level 1 - least support required

level 2

level 3

what are predictors of a good outcome for autism

high IQ

early intervention

ability to speak - relatively high functioning

strong support systems

NOT things like parenting or family history

Role of neuropsychological testing for children with ASD?

may assess for:

• intellectual functioning

• executive functioning

• attention and working memory

• language and social cognition

• visual-spatial processing

testing aims to identify services that may help child with ASD like for a mathematical disorder, ADHD, NVLD, etc.

Many symptoms of autism are developmentally…

normal

What are the diagnostic and functional criteria for ADHD?

6/9 symptoms in the following subtypes

• hyperactive-impulsive: fidgets, leaves seat, runs or climbs

• inattentive: easily distracted, often forgetful, disorganized

• combined

present before age 12

present in multiple contexts

persisting for 6 months at least

What were the main findings of the MTA study?

Stimulant meds are the most effective treatment for ADHDs core symptoms

Behavioral therapy in combination with meds is also effective across a wider context

Factors important to a convincing ADHD diagnosis?

Consistency across settings and in group settings in particular

Differential diagnosis

Multiple informants (clinical interview and collateral interviews)

Characteristic patterns of behavior

treatment trials although these are not diagnostic on their own

Continuous performance tasks

• may press button more often than they should in an act of commission

CANNOT diagnose from brain imaging alone

Prevalence of ADHD?

3-7% of people however it is overdiagnosed and overtreated

• possibly because of people who are med seeking, or the fact that ADHD annoys adults

• CDC reported closer to 11% because of the way they conducted the study

Age, gender, and race related differences

Girls typically show more inattentive symptoms than boys and ADHD is generally more common in boys than girls, but when girls do show hyperactive impulsivity its often perceived as more severe than when boys do

In preschool the hyperactive impulsive subtype is most common

in grade school the combined subtype is most common

in adolescence the inattentive subtype with some restlessness is common

in adulthood the inattentive subtype with periods of impulsivity is common

white children are most likely to get diagnosed and receive stimulant meds

What are some examples of impairment in executive function

• Working memory - forgetting multi-step instructions, myopia of time

• Planning and organizing

• cognitive flexibility between tasks

• sustained attention

• emotional regulation

• inhibitory control - blurting out answers in class

What brain areas are inhibited in ADHD

prefrontal cortex

striatum

parietal cortex

low dopamine