Week 7: childhood and adolescent disorders

externalising vs internalising

externalising disorders:

• create problems for external world

• breaking age-appropriate social rules/disobeying parents and teachers

• anger and depression

• impulsive

internalising disorders

• create problems for internal world

• anxiety

• sadness

ADHD external

A: Persistent pattern of inattention and or hyperactivity-impulsivity

• A1: inattention: 6 or < for at least 6 months

• A2: hyperactivity and impulsivity: 6 or more symptoms for at least 6 months (for >17 5+ for 6 months

B: serveral symptoms present BEFORE 12 years old

C: symptoms present in 2 or more settings

D: interfere with functioning

E: no other better explanation

Inattention A1 symptoms

a) often fails to give close attention to details

b) often has difficulty sustaining attention

c) often not seem to listen when spoken directly to

d) often does not follow through on instructions and fails to finish

e) Often difficulty organising

f) Often avoids, dislikes or reluctant to sustain mental effort

g) Often loses things

h) often easily distracted

i) often forgetful

hyperactivity/impulsivity symptoms

a) often fidgets

b) often leaves seat when being seated is expected

c) often runs about or climbs excessively

d) often difficulty playing quietly

e) Often “on the go”

f) Often talks excessively

g) Often blurts out

h) Often difficulty waiting

i) often interrupts or intrudes

Type of ADHD

• combined presentation ADHD-C: A1 and A2

• predominantly inattentive presentation ADHD-PI: A1 but no A2 for past 6 months

• predominately hyperactive-impulsive presentation (ADHD-HI): A2 but no A1 for past 6 months

Conduct disorder (CD)

A. a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following 15 criteria in the past 12 months for any category

• aggression to ppl and animals

• destruction of property

• deceitfulness or theft

• serious violation of rules

B. causes clinically significant impairment in social/academic/occupation

C. if 18 or <, and not met for antisocial personality disorder

aggression to ppl or animals

1. often bullies, threaten or intimidate others

2. often intiate physical fights

3. has used a weapon that can cause serious harm to others

4. has been physically cruel to ppl

5. has been physically cruel to animals

6. has stolen while confronting victim

7. has forced someone into sexual acitvity

Destruction of property

8. has enageged in fire-setting to cause serious damage

9. has destroyed others property on purpose

Deceitfulness or theft

10. has broken into someone’s house, cat or building

11. often lies to obtain goods

12. has stolen items of non-trivial value without confronting victim

serious violations of rules

13. often stays out at night even if not allowed (before 13 yrs old)

14. has run away from home overnight at least twice

15. is often truant from school before age 13

Specify if: conduct disorder

• with limited prosocial emotions

• lack of remorse

• callous - lack of empathy

• unconcerned about performance

• shallow or deficient affect

Prevalence and course

• ADHD most common in children and adolescents

  • 7.4% of all children in AUS have ADHD

  • most common in boys 12.9% of boys, 5.6% of girls

• average 4:1 in children and adolescents. 6:1 adults

• maybe because ADHD is different presenting in girls than boys

• 5.1% diagnosied with ODD*; 2.1% with CD**

• higher in males than females

Course:

• ADHD hyperactivity declines in adolescence

• ADHD persists to adulthood 50-60%

• ODD onset usually 2-3 years, CD late childhood or early adolescence

• half of children with ODD or CD continue in adulthood

Aetiology of externalising disorders

1. genetic risk

2. temperamental risk

3. neurobiological risk

4. parenting factors

5. psychological factors

6. peers, neighbourhoods and media

Treatment of ADHD

preschool: 4-5 years

• First-line treatment = behavioural interventions

• One prescribes stimulants if no significant improvements and moderate to severe impairment (short-acting)

Primary school 6-11 years

• First-line treatment = approved medication and or behavioural interventions - preferably both, stimulant tried first

adolescence 12-18 years

• first-line treatment= approved medication

• may include behavioural interventions

stimulants and non stimulants ADHD

psychostimulant e.g., ritalin:

• increase norepinephrine and dopamine

• side effects: decrease appetite, increased heart rate, sleep, motor tics

non-stimulants:

• SSRI - selective serotonin reuptake (antidepressant)

• SNRI - selective norepinephrine reuptake inhibitor

• alpha-agonists

• increase serotonin levels in brain

Behavioural interventions ADHD

• parent education and support - most successful

  • triple P - positive parenting program

  • strategies to strengthen relationship, communication etc

• classroom accommodations

• organisational supports

Personal coping skills ADHD

learn to compensate for executive function deficits

• make mental info physical to compensate for lack of working memory (cues, to do lists)

• make time physical eg clock

• break up lengthy tasks

• make motivation external - immediate reinforcement/consequence

• make problem solving manual eg math tasks

• refill self-regulation (i can do this, relax, meditate)

Treatment of ODD/CD

• evidence-based parenting support e.g., triple P, PCIT, incredible years

• individual skills development

• multisystemic therapy

• residential programs

the triple P program

Pilot RCT

• decrease in child behaviour concerns

• improved parenting and adjustment (depression and stress)

• good consumer satisfaction

• reduction in barriers to mainstream services-

→ local health workers needed support

National think tank

• tailored training to increase confidence e.g., more time, less texts

• pre-accreditation workshops

• dealing with logistical barriers

• workplace support e.g., manager briefings

• peer networking

• clinical and cultural supervision

Practitioner support evaluation

• peer networking and coaching

• positive family outcomes

• supportive coaching led to program sustainment 3 years later

→ first nations implementation consultants

→ first indigenous trainer

Remote community trial

• 38 local workers trained

• positive training outcomes (knowledge, confidence)

• positive family outcomes (child adjustment, parenting, self-efficacy, parental adjustment

• worker and parent empowerment

community partnership: cherbourg positive parenting collaborative

tailoring:

• community survey re parenting concerns and service needs

• project scope developed

• localised adaptations

results:

• child adjustment - significant decrease in disruptive behaviours

• parenting - significant decrease in inconsistent parenting and coercive parenting

• parental adjustment - significant increase in parent self-efficacy

Internalising disorders

• defines depressive and anxiety disorders same for children as adults

• depressive symptoms

  • depression in children/adolescents often comorbid with both externalising problems and anxiety

  • depressed mood → may show as irritability

• children’s fears and anxiety

  • often identity their anxiety but they are more aware of their fears

  • consider age-appropriate fears (distress, duration and interference)

DSM-5-TR Internalising disorder

depressive symptoms: 5 or < during the same 2 week period

• depressed mood (irritability)

• diminished interest or pleasure - in typically satisfying activities

• significant weight loss or gain

• insomnia or hypersomnia

• psychomotor agitation or retardation

• fatigue

• feelings of worthlessness or excessive/inappropriate guilt

• diminished ability to concentrate/indecisiveness

• recurrent thoughts of death

separation anxiety disorder and selective mutism

• developmentally inappropriate and excessive fear or anxiety concerning separation from home for 4+ weeks

• distress when anticipating or experiencing separations

• worry about losing an attachment figure

• worry about experienced untoward events (getting lost, being kidnapped)

• refusal to go out or sleep away from home without attachment figure

• fear or reluctance about being alone

• nightmares with separation themes

selective mutism

• consistent failure to speak in certain social situations (when expected to)

• speak to small number of people

prevalence and course

among AUS 1-17 years old:

• 3.2% diagnosed with MDD (higher for 12-17 years old 5%)

• 6.9% diagnosed with anxiety disorders (separation anxiety most common 4.3% selective mutism rate ,1%)

• similar rates for male and female until age 12

• higher in female 12-17

course:

• some internalising problems persist into adulthood

• linked to relationship difficulties, other anxiety disorders and mental health problems

• functional impairment in social and personal life

• childhood depression predicts 6-fold increase suicide in young adults

aetiology of internalising disorders

biological factors:

• few behavioural genetic studies have been conducted

• some indication to heritability

social factors

• experience of life stress, loss or trauma

• attachment issues

• parental overprotectiveness

• maltreatment

psychological factors

• emotion regulation

• rumination predicts future depression

• caretaking children of depressed parents

  • unable to make depressed parents happy

  • feel guilty and responsible

  • programs may be able to prevent this

treatment of internalising disorders

depression:

• individual psychotherapy

• CBT

• Family therapy

• antidepressant medication not as effective as with adults

anxiety

• child focussed CBT = gold standard

• family therapy / child + parent interventions e.g., fear-less triple P

• medication: selective serotonin reuptake inhibitors SSRIs most common

• CBT components: psychoeducation, emotion regulation etc