Childhood Psychopathology Exam 3 (sofia)

oppositional defiant disorder (ODD), conduct disorder (CD)

What are the two main types of conduct problems?

-angry/irritable mood
-argumentative/defiant behavior
-vindictiveness

What are the three categories of symptoms for ODD?

DSM-5 criteria for ODD

-symptoms must last at least 6 months and be present with someone OTHER THAN A SIBLING
-developmentally inappropriate for age

4 symptoms in 3 categories
*angry/irritable mood
-loses temper
-touchy/easily annoyed
-angry/resentful

*argumentative/defiant behavior
-argues with adults
-actively defies/refuses to comply
-deliberately annoys
-blames others

*vindictiveness
-spiteful/vindictive (plotting to get someone back)

opposition

active RESISTANCE to limitations/restrictions/directions

defiance

deliberate CONTRADICTING/provoking others

this is problematic regardless of age

4-5

Around what age is ODD typically diagnosed?

opposition, defiance

What are the two main features of ODD?

-aggression to people/animals (physical)
-destruction of property (i.e. fire setting)
-deceitfulness/theft (lying is typically to con someone; theft can be within the home)
-serious violations of rules (truancy/staying out late BEFORE AGE 13)

What are the four categories of symptoms for CD?

DSM-5 criteria for CD

-repetitive/persistent pattern of behavior that violates basic rights of others/societal norms
-only need 3 due to extreme nature of symptoms
-symptoms must last 12 months instead of the typical 6
-four symptom categories
*aggression to people/animals
*destruction of property
*deceitfulness/threat
*serious violations of rules

childhood-onset type, adolescent-onset type

What are the two different specifiers for CD?

childhood-onset type (CD specifier)

-starts around age 4-8
-at least one symptom present BEFORE AGE 10
-more severe, less frequent
-low remission (behaviors escalate over time)
-high innovation (symptoms vary; present in many settings)
*prognosis is very poor*

adolescent-onset type (CD specifier)

-late childhood/early adolescence
-NO SYMPTOMS BEFORE AGE 10
-less severe, more frequent
-high remission (behaviors can stop for a period of time)
-low innovation (typically focuses on only a small number of behaviors; only one or a couple settings)
-likely happens due to NEGATIVE PEER INFLUENCES

delinquency

LEGAL term for CRIMINAL behaviors
-someone is officially delinquent when they are ARRESTED/CONVICTED

(we see this in CD symptoms such as fire setting/truancy)

conduct disorder

CLINICAL term for a pattern of DISRUPTIVE/ANTISOCIAL behaviors, regardless of legality

this is more serious bc it happens repeatedly

most children with CD will also be considered delinquent, but there are many delinquents who don't have CD

How is delinquency associated with CD?

overt destructive (aggression/assault/cruelty)

In the four quadrants we discussed in class (covert/overt and destructive/nondestructive), the kids in which quadrant tend to have the worst prognosis and the highest risk for continued mental health issues into adulthood?

-instrumental aggression
-hostile aggression
-direct aggression
-indirect aggression

What are the four types of aggression we discussed?

instrumental aggression

aggression intended to ACHIEVE A GOAL; more common when kids are little, don't have language/social skills, but decreases over time

example: a two-year-old biting someone else to get the toy they want

hostile aggression

aggression intended to INFLICT HARM; this INCREASES over time in kids with CD

example: biting someone bc you want to hurt them

direct aggression

confronting/attacking victims directly; more common in boys

indirect aggression

SNEAKY harmful behaviors; more common in girls

example: spreading false rumors

*remember that the DSM-5 doesn't really capture this

many kids are diagnosed with ODD, but only a subset will go on to develop intermediate levels of CD, and even fewer will go on to develop advanced levels of CD

How are ODD and CD related? (look at the pyramid model on D2L)

adolescent-limited path, life-course persistent path

What are the two paths for CD? (discussed in class, diagram is on D2L)

adolescent-limited path (CD path)

-less likely to drop out of school
-stronger family ties
-LESS EXTREME behaviors
-behavior is restricted to TEMPORARY/SITUATIONAL influences, such as a bad peer group

life-course persistent path (CD path)

-neurological influences PRESENT AT BIRTH
-SEVERE early trauma
-conduct problems continue throughout the lifespan

psychopathy

a pattern of callous, manipulative, deceitful, and remorseless behavior

-lack empathy
-impulsive
-engage in aggressive behavior

antisocial personality disorder

pervasive pattern of disregard for/violation of the rights of others

symptoms are similar to CD, but CD is for KIDS, whereas this is for ADULTS

*THIS CAN'T BE DIAGNOSED BEFORE AGE 18*

no; CD supersedes ODD

Can you have both ODD and CD simultaneously?

epidemiology of ODD

-2-10% prevalence
-develops earlier and is twice more common in BOYS

epidemiology of CD

-2-6% prevalence
-more common in BOYS (but this is likely bc the DSM-5 doesn't capture indirect aggression)

-ADHD
-drug/alcohol abuse (legal and illegal)
-mood/anxiety disorders

What are the most common comorbidities for ODD and CD?

one setting

Prognosis is better for conduct problems if the behavior only happens in __________________.

-biological factors
-social-cognitive factors
-family factors
-contextual factors

What are the four main categories for the etiology of ODD and CD?

-genetic influences (50% due to heredity)
-difficult child temperament (restless, impulsive, risk taking, emotionally labile)
-overactive behavioral activation system (higher sensitivity to rewards)
-underactive behavioral inhibition system (fail to respond to normal punishments)
-neuropsychological deficits (lower verbal IQ, executive function problems, impulsivity)

What are some BIOLOGICAL factors that can lead to higher risk of conduct problems?

difficult temperament (restless, impulsive, risk-taking, emotionally labile); around age 3

What is the earliest sign of antisocial behavior tendency and when do we begin to see it?

-social information processing deficit (HOSTILE ATTRIBUTION BIAS)
-poor social skills

What are some SOCIAL-COGNITIVE factors that can lead to higher risk of conduct problems?

hostile attribution bias

automatic negative/hostile thoughts about seemingly neutral stimuli

-parental psychopathology/criminality
-parenting (neglectful, authoritarian, inconsistent)
-family stress/instability (typically financial, but can also be unstable family structure such as divorces)
--regular unemployment
--low SES
--multiple family transitions
-marital conflict/family violence

What are some FAMILY factors that can lead to higher risk of conduct problems?

*remember that family stress/instability is specifically for the CHILDHOOD-ONSET type*

-poverty
--high risk neighborhoods (especially those with criminal subculture)
--poor school environment
-television/Internet violence

What are some contextual factors that can lead to higher risk of conduct problems?

poverty

What is one of the strongest predictors of CD/crime?

-parent management training
-cognitive problem-solving skills training
-multisystemic therapy

What are the three treatment methods we discussed for ODD and CD?

parent management training

goal is to teach EFFECTIVE PARENTING SKILLS, change coercive interactions

cognitive problem-solving skills training

-teach appropriate APPRAISALS/ATTRIBUTIONS
-emotional insight/management
-problem-solve in social situations

multisystemic therapy

-family system approach
-targets DYSFUNCTIONAL FAMILY RELATIONSHIPS
-may include other social influences (i.e. school)
-may include components of PMT/PSST

*this is typically used for TEENS

-intervene early
-apply parent/child/family therapy components to universal or at risk populations (parenting groups, FAST track, multisystemic family prevention)

What are some potential ways we can prevent the development of conduct problems?

-major depressive disorder
-persistent depressive disorder (dysthymia)
-disruptive mood dysregulation disorder

What are the three types of depressive disorders we discussed?

major depressive disorder

5+ symptoms present during the same TWO-WEEK period (although average episode lasts 8 months)
-depressed mood (or IRRITABLE)
-loss of interest/pleasure
-significant changes in appetite/weight (or FAILURE TO GAIN EXPECTED WEIGHT)
-insomnia/hypersomnia
-psychomotor agitation/retardation
-fatigue
-worthlessness/guilt
-difficulty concentrating/indecisiveness
-suicidal ideation

*what is highlighted is specific to KIDS

irritability, physical complaints

When it comes to the developmental trajectory of major depressive disorder, what do we more commonly see in YOUNG children?

sadness, hopelessness, anhedonia, vegetative symptoms, suicidal ideation

When it comes to the developmental trajectory of major depressive disorder, what do we more commonly see in OLDER children?

anhedonia

inability to experience pleasure; loss of interest in activities they used to enjoy

vegetative symptoms

sleep disturbances, changes in appetite/weight, fatigue

thought- can exist without a plan (example: "maybe things would be better if I wasn't here")
attempt- actually trying to carry out the plan

(thoughts are more common in the general population, attempts are not)

What is the difference between a suicidal thought and a suicidal attempt?

mood disorders

Those who have ________________ are at a higher risk for suicidal attempts.

-any mental disorder
-alcohol use/abuse
-sudden stressful event
-history of a past attempt
-pressure from society

What are some risk factors for suicidal attempts?

history of a past attempt

What is the single best predictor of a suicide attempy?

hallucinations

About 30-50% of patients with MDD have psychotic symptoms such as _______________, which tend to decrease with age, and the presence of these symptoms often leads to a POOR PROGNOSIS.

13-15

What is the typical age of onset for MDD?

epidemiology of MDD

-1-3% in school-age children
-2-8% in adolescents
-typical age of onset: 13-15 years old
-prevalence INCREASES with age, especially in GIRLS
*in school age children, there is usually no gender difference*

persistent depressive disorder

depressed mood most of the day, more days than not for 1+ YEARS (IRRITABLE MOOD)

2+ of the following:
-poor appetite/overeating
-insomnia/hypersomnia
-fatigue
-low self-esteem
-difficulty concentrating/indecisiveness
-hopelessness

highlighted info is specific to kids

MDD- shorter, more intense; PDD- longer, less intense

When comparing MDD and PDD, MDD is ________________ but _____________, whereas PDD is _________________ but _______________.

epidemiology of PDD

-1% of children, 5% of adolescents
-age of onset: 11-12 years
-initial period usually lasts around 4 years
-tends to develop into other disorders

-anxiety (most common)
-major depressive disorder (may not appear until adulthood)
-conduct disorder (especially in males)

What are some of the other disorders that PDD can develop into?

disruptive mood dysregulation disorder

-SEVERE/RECURRENT/DEVELOPMENTALLY INAPPROPRIATE temper outbursts occurring 3+ times per week and in 2+ settings

-consistently irritable/angry mood between outbursts

-most commonly diagnosed in school-age boys

-problems in intellectual/academic functioning
-depressive ruminative style
-ineffective coping
-low self-esteem
-social withdrawal

What are some features of the general adaptation for MDD/PDD?

family history

What is the single best predictor of MDD?

etiology of MDD/PDD

-genetic factors
-neurotransmitters (not enough norepinephrine/serotonin)
-psychosocial factors (attachment theory, cognitive theory, behavioral theory)

cognitive theory

idea that depressive disorders are caused by "depressogenic cognitions" (negative cognitive schemas, also called depressive ruminative style)

cognitive triad

idea that people with depressive disorder experience negative thoughts about SELF, WORLD, FUTURE

depressive attributional style

negative outcomes: INTERNAL, STABLE, GLOBAL

positive outcomes: EXTERNAL, UNSTABLE, SPECIFIC

treatments for depressive disorders

-cognitive-behavioral therapy (address negative cognitions, increase pleasurable activities)
-interpersonal therapy (focus on DYSFUNCTIONAL RELATIONSHIPS, more common in teens)
-antidepressants (such as SSRIs)

manic episode

1+ WEEK period of ELEVATED/expansive/irritable mood and increased goal-directed activity/energy

3+ of the following:
-inflated self-esteem/grandiosity
-decreased need for sleep
-more talkative than usual
-racing thoughts/ideas (similar to loose associations)
-distractibility
-increase in goal-directed activity/agitation
-excessive risky activities (can manifest in different ways)

hypomanic episode

symptoms last for 4+ DAYS; LESS SEVERE than manic episodes

-symptoms are generally same but not as impairing
-no psychotic symptoms
-can make people very productive

-bipolar I
-bipolar II
-cyclothymic disorder

What are the three different types of bipolar disorders?

bipolar I disorder

1+ MANIC episodes and 1+ MAJOR DEPRESSIVE episodes

bipolar II disorder

1+ HYPOMANIC episodes and 1+ major depressive episodes

*NEVER a full manic episode*

cyclothymic disorder

2 years (1 year in youth) of hypomanic/depressive SYMPTOMS (show some symptoms but don't meet full criteria for bipolar I or II)

features of manic episodes in children

-irritability
-explosive temper tantrums (different from conduct disorder bc kids with bipolar actually feel GUILT)
-low frustration tolerance
-impulsivity
-difficulty sleeping
-difficulty concentrating on tasks
-moody/sad
-problems with academic performance
-nightmares
-frenzied activity (going from one thing to another very quickly)

-auditory hallucinations
-delusions of persecution
-passive feelings of mind control
-thought disorganization
-loose associations

What are some psychotic features associated with bipolar disorders in children?

developmental trajectory of bipolar disorders

AGE OF ONSET is an important factor
-usually within first 20 years
-adolescence = high vulnerability
*earlier onset = worse prognosis*

early onset bipolar disorder

has a CHRONIC/CONTINUOUS course (fewer/no periods of normal functioning)
-fewer episodes of remission
-severe symptoms
-mixed presentation of mania and depression

ADHD

Bipolar disorders share many features in common with which other disorder?

-ADHD is chronic; bipolar is more episodic
-age of onset: ADHD symptoms must appear before age 10; bipolar not until around 12
-psychotic symptoms present in bipolar but not in ADHD
-ADHD does not have elevated mood/grandiosity

What are the main differences in the nature and course of bipolar disorders vs. ADHD?

*remember that children who have both bipolar disorder and ADHD should NOT receive a stimulant bc this could make their manic episodes worse*

vulnerability-stress model (biological/genetic and environmental factors must BOTH be present)

What is the etiology for bipolar disorders?

treatment for bipolar disorders

tends to be MULTIMODAL
-medication: mood stabilizers (i.e. lithium, depakote); these have severe side effects
-psychotherapy (needed for long term)

medication treats mania, psychotherapy treats depression

When it comes to treating bipolar disorder, _______________ is typically used to treat the ________________, whereas ________________ is used for the ________________.

-prevent relapse, control symptoms
-provide psychoeducation to parents/family
-plan for future
-help to comply with medications

What are the purposes of psychotherapy for bipolar disorder?

yes (lithium treats the manic episodes, SSRIs can treat the major depressive episodes)

Can a person be on lithium and SSRIs at the same time?

normal fears/worry

UNIVERSAL reactions to unsafe situations/threats
-can be adaptive
-follow standard developmental trajectory

anxiety

characterized by strong negative emotions/bodily symptoms of tension in which FUTURE danger/misfortune is anticipated

we need SOME anxiety to get things done, but too much can be impairing

sympathetic nervous system

The ___________________ is activated by feelings of anxiety.

physical, cognitive, behavioral

What are the three main categories of symptoms for anxiety disorders?

-separation anxiety disorder (SAD)
-social anxiety disorder (social phobia)
-generalized anxiety disorder (GAD)

What are the three main anxiety disorders we discussed?

separation anxiety disorder

developmentally inappropriate/excessive fear concerning separation from attachment figures

3+ of the following:
-recurrent/excessive distress when separated/anticipating separation
-persistent/excessive worry about losing attachment figures
-persistent/excessive worry about untoward events causing separation
-reluctance/refusal to go out BC OF FEAR
-fear/reluctance of being alone
-refusal to sleep alone
-persistent nightmares involving separation
-complaints of physical symptoms when separated

separation anxiety (SAD) in young children

-clingy at home, shadow parents, become upset if parent is out of sight (even if it's just for a brief period of time)
-unhappy/inconsolable until reunited with caregiver
-refuse to sleep alone

separation anxiety (SAD) in older children

-call home repeatedly
-visit during middle of day
-problems concentrating in school
-refuse extracurricular activities
-refuse to go to school
-seek parents' approval, lack independence
-refuse to sleep alone

social anxiety disorder (social phobia)

marked fear about 1+ social situations involving possible scrutiny

for kids this must occur in PEER SETTINGS

-fear of NEGATIVE EVALUATIONS
-social situations are avoided or endured with intense anxiety (crying, tantrums, freezing, clinging, shrinking, failure to speak)

*they WANT friends/relationships, but their anxiety stops them from seeking them out*

-tend to be lonely/sad/inhibited
-fear doing most things in front of others
-begin to avoid social activities/school (due to fear of BEING EVALUATED)

What is the general adaptation for kids with social anxiety disorder?

generalized anxiety disorder (GAD)

EXCESSIVE/UNCONTROLLABLE anxiety/worry more days than not for 6+ months

-worry about a number of different events/activities
-1+ associated features (for adults it's 3)
--restlessness
--fatigue
--irritability
--muscle tension
--trouble concentrating

-overestimate bad things, underestimate ability to cope
-low self-esteem
-perfectionistic
-excessive need for reassurance

What is the general adaptation for kids with generalized anxiety disorder?

obsessive-compulsive disorder (OCD)

characterized by the presence of obsessions/compulsions