CAMS - Final Exam

Oppositional Defiant Disorder (ODD) [DSM]

A) Pattern of angry/irritable mood, argumentative/defiant behaviour for ≥ 6mo. ≥4 sx from any category: (angry/irritable mood; argumentative/defiant behaviour; vindictiveness) + present during interaction w/ someone other than sibling

B) Causes distress in self/others or causes functional impairment in social'/educational/occupational area(s)

C) Not due to substance use or other psychotic disorders

ODD Specifiers (DSM)

• Mild: sx only present in one setting

• Moderate: sx present in ≥ 2 settings

• Severe: sx present in ≥ 3 settings

Course of ODD

• Typically begins during preschool yrs, sx evident by 8

• Behaviours first observed at home

• Defiant behaviours then extend to school and other settings

• In adolescence: remission or persistence

• Most children enter remission, but:

  • 30-40% develop conduct disorder in adolescence

  • 30-40% of adolescents w/ conduct disorder develop antisocial personality disorder in adulthood

ODD Myths

Myths:

• Naughty child

• Disobedient

• Behavioural Problem

Reality:

→ Emotional dysregulation

Maintenance of OCD - Escalation Cycle

• The coercive cycle → the trap both sides build

• A negative feedback loop where adult demands and child escalation feed into each other, reinforcing defiant reactions

Breaking Cycle in ODD

• Behaviour modification - reinforce adaptive behaviour and decrease defiant behaviour

• Treatments:

  • Parent training and family-focused interventions

  • Psychotherapy

Parent Management Training (ODD)

• Highly effective

• Caregivers learn skills to reward positive behaviour and set calm, consistent consequences instead of harsh punishments

• Increase wanted behaviour:

  • Attention top ups (special time, positive attention, attending skills)

  • Descriptive praise (“I love how you are playing quietly”)

  • Rewards (for wanted behaviour; bigger reward for continued behaviour)

• Decreasing unwanted behaviour:

  • Planned ignoring (for annoying/interrupting)

  • Redirect (give small instruction then praise)

• 2-step Process

  • 1) Get down to eye level, say name, give instruction in neutral voice

  • 2) If complies → praise/reward. If doesn’t → repeat instruction. If still doesn’t comply, give logical consequence or time out

Psychotherapy (ODD)

• Emotion regulation strats, problem solving, coping skills

• Address negative thought patterns contributing to defiance

• Address co-occurring mental health struggles

• Ask:

  • How does it feel when you fight w/ parent/teacher? Do you like this feeling? What can we do next time you feel you’re about to yell?

• Regulation activities (traffic light → stop, take 3 breaths, choose what to do next; wall push; box breathing)

• Co-regulation activities (breathe/sit quietly together; play together; squish sandwich)

Major Depressive Disorder (MDD) [DSM]

A) ≥ 5 sx in same 2-week period and represent change from previous functioning. at least one sx (1) or (2)

• (1) depressed mood nearly every (*in youth, can be irritable mood)

• (2) diminished interest in activities

• (3) significant weight loss

• (4) insomnia/hypersomnia

• (5) pyschomotor agitation/retardation

• (6) feelings of worthlessness/guilt

• (7) diminished ability to concentrate

• (8) recurrent thoughts of death

D) Major depressive disorder not due to schizophrenia spectrum and other psychotic disorders

E) No history of manic/hypomanic ep

Clinical Presentation of MDD

• DSM criteria don’t differ for youth

• Often irritability instead of sadness

• Somatic complaints

• Often academic decline

• Failure to reach expected weight instead of weight loss, or increased/decreased appetite

Prevalence of MDD

• Preschool children: ~1%

• Early childhood: ~2%

• Adolescents: 4-8%

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• Equal gender prevalence in childhood, female predominance emerging after puberty (~2:1)

• Rising rates of depression since COVID-19

Clinical Course of MDD

• 90% of children and adolescents w/ MDD go into remission 1-2 yrs after onset but…

  • ~50% relapse within 2 mos of partial remission

  • Recurrence common

    • Within 2 yrs: 20-60% have sx again

    • After 5 yrs: 70% have sx again

Clinical Course of MDD [Cont.]

• Partial remission: no significant sx of depression for up to 2 mos OR some sx but full criteria of MDE not met

• Full remission: no significant sx for > 2 mos

• Relapse: return of depressive sx in first 2 mos of partial remission

• Recurrence: Return of depressive sx after complete recovery

Maintenance of MDD

• Lethargy Cycle

  • Suicidal/harm thoughts lead to negative feelings (anxious, hopeless, anhedonia, worthlessness), which lead to harmful behaviours, repeat

Assessing MDD

• Common validated instruments for youth: Mood and Feelings Questionnaire (MFQ [ages 8-18]; Patient Health Questionnaire — Adolescent [ages 12-18]

• MFQ:

  • Child & parent self-report survey that assess core depressive sx over 2 week period

  • Items scored 0 (not true), 1 (sometimes), 2 (true)

  • Score range 0-26 (0-7 = minimal; 8-11 = elevated; 12+ = severe)

Bipolar Disorder - Manic Episode (DSM)

A) Period of abnormally elevated, expansive, or irritable mood and increased goal-directed activity/energy for at least 1 week (or any duration if hospitalised)

B) During period of mood disturbance and increased energy/activity, > 3 sx (> 4 sx if mood only irritable) present to a significant degree and represent noticeable change from usual behaviour

• Inflated self-esteem or grandiosity

• Decreased need for sleep

• More talkative

• Flight of ideas

• Distractibility

• Increase in goal-directed activity or psychomotor agitation

• Excessive involvement in activities w/ potential for painful consequences

Clinical Presentation of Manic Episode

• In extreme cases, mania can include delusions or hallucinations

• Impairment: causes significant disruption in social work or daily functioning

• Psychotic sx

Bipolar Disorder - Hypomanic Episode (DSM)

Similar criteria to manic episode except:

• Lasts 4 consecutive days (instead of 1 week)

• Ep not severe enough to cause marked impairment in social/occupational functioning, or does not require hospitalisation

• No psychotic features

• > 3 of manic sx (or > 4 if only irritable mood)

Bipolar I Disorder (DSM)

• At least one lifetime manic ep (not due to other psychotic disorder)

• Major depressive eps common but not required for dx

Bipolar II Disorder (DSM)

• At least one hypomanic ep and one major depressive ep

• No history of manic ep

• More time spent depressed than hypomanic

Bipolar I or Bipolar II Disorder

• Mania and some depressive sx → bipolar I disorder

• Hypomania and major depressive eps → bipolar II disorder

• Many children fall into a subthreshold or “bipolar spectrum” category, and later develop BPD I or II

• Disorder onset typically during late adolescence

Cyclothymic Disorder (DSM)

*Classified as a bipolar disorder in DSM

A) For ≥ 1 yr for children and adolescents (2 yrs for adults), numerous periods of hypomanic sx not meeting full criteria for hypomanic eps and numerous periods of depressive sx not meeting full criteria for MDE

B) During this time, sx present at least 50% of time, never w/o sx for more than 2 mos at a time

C) Criteria for MD, manic, hypomanic eps never met

Assessment of Bipolar Disorders (DSM)

Child Mania Rating Scale

• 21-item parent report tool → evaluates mania sx in children and adolescents (9-17 yrs)

• Items scored on 4-point Likert scale (never, sometimes, often, very often) to differentiate b/w bipolar disorders or ADHD

• Score ≥ 20 often = diagnosis

Treatment of Major Depressive Disorder and Bipolar Disorders

• Psychotherapy or combined psychotherapy + medication for more intense sx profiles

  • Psychotherapy (primarily CBT)

  • Medication

    • For MDD: SRRIs

    • For Bipolar Disorders: mood stabilisers or antipsychotics

CBT for MDD

• Challenges lethargy cycle (thoughts, feelings, behaviours) → how these interact to trap you in a negative cycle

  • Thoughts: cognitive restructuring/detective thinking

  • Feelings: emotion regulation strats, coping skills, psychoeducation around feelings and emotions (breating/relaxation techniques, weather report: heavy feelings = temporary weather patterns)

  • Behaviours: behavioural activation (schedule small daily enjoyable tasks), behavioural experimentation (test negative predictions)

Cognitive Challenging (Detective Thinking)

• Child-friendly way to teach cognitive restructuring—critically examining thoughts

• Shift thinking from “my first must be true” to “my thought is something i can test”

What is Anxiety?

• Normal emotion characterised by feeling tense, having worried thoughts, and physical changes

• Physical sx: tense muscles, breathing faster, trembling, nausea, racing heart

• Mental sx: constant worry, fear of catastrophe, unease

• A little anxiety necessary/helpful

  • adaptive response to threat → trigger fight-or-flight response

  • motivates performance, learning, and safety behaviours

Anxiety Disorders in Children

• Children may not recognise fears as unreasonable

• In younger children, more physical sx described

• In adolescents, more verbal worry

• Behaviours that might indicate anxiety: physical aches and pains, difficulty falling asleep, avoidance of leaving house or doing activities, need for reassurance

Prevalence of Anxiety Disorders

• Most common psychiatric condition in adolescents

• Girls more likely than boys to report anxiety disorders (~2:1)

• Untreated anxiety increases risk of: other anxiety disorders, depression, education underperformance, and substance use

Clinical Course of Anxiety Disorders

• Anxiety disorders among earliest onset psychiatric disorders

• Sx may wax and wane

• One anxiety disorder may evolve into another

• Many children improve w/ treatment, but w/o intervention, anxiety often persists

Panic Attacks

• Sudden, intense eps of fear/discomfort, often peaking within mins, that trigger physical sx

• Common

• Lasts 5-30 mins, triggered by stress, trauma, or occur unexpectedly

• Panic attacks alone aren’t disorder — panic disorder = recurrence of unexpected panic attacks

Some Anxiety Disorder in DSM

• Separation Anxiety Disorder

• Specific Phobia

• Social Anxiety Disorder (Social Phobia)

• Generalised Anxiety Disorder (GAD)

Separation Anxiety Disorder (DSM)

A) Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom individual in attached. > 3 sx

• recurrent distress when anticipating or experiencing separation

• worry about losing attachment figures

• worry about events leading to separation

• reluctance/refusal to go to school or elsewhere

• fear of being alone or w/o attachment figures

• refusal to sleep away from home/ w/o caregiver nearby

• nightmares abt separation

• physical sx during separation

B) Fear, anxiety, or avoidance persistent, lasting ≥ 4 weeks in children and adolescents and ≥ 6 mos in adults

C) Disturbance causes clinically significant distress or impairment in social/academic/occupational areas

D) Disturbance not to another mental disorder

Separation Anxiety Disorder - More Info

• Affected children tend to come from closely knit fams

• Prevalence estimates ~ 4% in children and adolescents

• Excessive worry abt own or parent’s safety and health when separated

• Sx include difficulty sleeping alone, nightmares w/ themes of separation, somatic complaints, school refusal, concerns abt death/dying

• Commonly earliest age of onset among anxiety disorders

Specific Phobia Disorder (DSM)

A) Marked fear or anxiety about a specific object or situation

B) Almost always provokes immediate fear/anxiety

C) Actively avoided or endured w/ intense fear/anxiety

D) Out of proportion to the actual danger posed and the sociocultural context

E) Persistent, typically lasting for 6 mos of more

F) Clinically significant distress or impairment in social/occupational/other areas

G) Not due to another mental disorder

Specific Phobia Specifiers (DSM)

• Animal (e.g., spiders, dogs)

• Natural Env. (e.g., heights, storms, water)

• Blood-injection-injury (e.g., needles, invasive medical procedures)

• Situational (e.g., airplanes, elevators)

• Other (e.g., situations that may lead to choking or vomiting)

Avoidance Cycle

• Maintains phobias

• Anxiety → Avoidance → Short-term relief from anxiety → Long-term anxiety growth →

Social Anxiety Disorder (SAD) [DSM]

• Marked fear/anxiety about social situations in which individual exposed to possible scrutiny by others

  • social interactions (having a convo)

  • being observed (eating)

  • performing in front of others (giving a speech)

*In children, anxiety must not occur exclusively in interactions w/ adults

• Individual fears that they will act in a way or show anxiety sx that will be negatively evaluated

• Social situations almost always provoke fear/anxiety. They are avoided or endured w/ intense fear/anxiety. Fear/anxiety out of proportion

Maintenance of SAD

• Development of negative cognitive biases (mind reading, catastrophising)

• Attention bias to threat

• Safety behaviours: rehearse speech, avoid participation, avoid eye contact

• These maintain disorder

Generalised Anxiety Disorder (GAD) [DSM]

• Excessive anxiety and worry occurring most days for ≥ 6 mos about a number of events/activities

• Individual finds it difficult to control the worry

• The anxiety and worry associated w/ following sx (> 1 for children; > 3 for adults)

  • restlessness

  • being easily fatigued

  • difficulty concentrating

  • irritability

  • muscle tension

  • sleep disturbance

Maintenance of GAD

• Worry as cognitive avoidance

• Intolerance of uncertainty

• Overestimation of threat

• Underestimation of coping ability

Assessment of Anxiety Disorder

• Consider physical, behavioural, cognitive sx

• Common validated instruments:

  • Screen for Child Anxiety Related Emotional Disorders (SCARED)

  • Spence Children’s Anxiety Scale (SCAS)

Treatment for Anxiety Disorders

• Typically involves psychotherapy or combined psychotherapy + medication for more severe cases

  • Psychotherapy:

    • CBT - cognitive restructuring

    • Mindfulness - breathing exercises

    • Exposure therapy

  • Medication

    • SSRIs

    • For moderate-severe

CBT Model for Anxiety Disorders

• Challenge harmful thoughts, feelings, behaviours using top down and bottom up therapy strats

1) Thoughts: cognitive restructuring/detective thinking

2) Feelings: mindfulness activities

3) Behaviours: exposure therapy strats

Exposure and Response Prevention (ERP)

• Specialised form of exposure therapy used to treat anxiety disorders by gradually exposing individuals to fearful stimulo

• Goal: learn that anxiety decreases on its own and that feared outcomes unlikely to happen

• Build a fear ladder by ranking exposure activities from least scary to most scary

• Gradual exposure to fear-eliciting stimuli + abstinence from escape/avoidance behaviours

Top Down Therapeutic Strategies

Use thinking and logic to influence emotions and feelings (e.g., detective thinking)

Bottom Up Therapeutic Strategies

Use the body and nervous system to help regulate the mind (e.g., breathing exercises)

Obsessions vs. Compulsions

• Obsessions: recurrent and persistent thoughts, urges, or images that are intrusive and unwanted

  • Obsessions are NOT infatuation, fantasies, over-thinking, upsetting memories, worrying, intrusive thoughts

• Compulsions: repetitive behaviours or mental acts that an individual feels compelled to engage in

  • Compulsions are NOT tidiness, habits, impulses, addictions, or superstitious behaviours

Obsessive-Compulsive Disorder (OCD) [DSM]

A) Presence of obsessions, compulsions, or both

B) Obsessions/compulsions are time-consuming or cause clinically significant distress or functional impairment

C) Obsessive-compulsive sx not due to substance use or another medical condition

D) Disturbance not due to another mental disorder

Obsessions

• In DSM, defined by (1) and (2)

1) Recurrent and persistent thoughts, urges, or images that are experienced as intrusive or unwanted and that cause marked anxiety/distress

2) Individual attempts to ignore or suppress such thoughts, urges, or images, or neutralise them with another thought/action

• Common obsessions: contamination (germs), aggression (fear of hurting others), sexual content (having perverse sexual thoughts), superstitions (step on crack, break mom’s back), scrupulosity (“religious OCD”)

Compulsions

• In DSM, defined by (1) and (2)

1) Repetitive behaviours (e.g., hand washing, ordering) or mental acts (e.g., praying, counting) that person feels driven to perform

2) Behaviours or mental acts aimed at preventing/reducing anxiety/distress or preventing some dreaded event; but these behaviours/mental acts excessive or unrelated to the event

• Common compulsions: contamination (ritualistic handwashing), aggression (no actual intent. compulsions may be rituals to neutralise thoughts), sexual content (no actual intent, compulsions rituals to neutralise thoughts), superstitions (counting, tapping), scrupulosity (excessive praying)