Abnormal Child Psych Exam 3

Chapter 8: Mood Disorders

Historical perspective:

• Psychoanalytic view

• Masked depression

• Transient developmental phenomena common during development

Depression:

• Complex interplay of influences, complex clinical presentation

• Designation of different groups as “depressed” depends on how depression is defined and assessed

• Not possible at this point to say there is a “correct” definition

Depressive disorders:

• Major Depressive Disorder (MDD)

  • Depressed or irritable mood (which can be defined in children)

  • Loss of interest or pleasure

  • weight/appetite changes

  • Sleep problems

  • Motor agitation

  • Fatigue, loss of energy

  • Feelings of worthlessness or guilt

  • Difficulty thinking, concentrating, and making decisions

  • Thoughts of death, suicidal behavior/thoughts

• For diagnoses–one of the 1st two symptoms and 5 symptoms for two weeks, must cause significant stress or impairment

Persistent Depressive Disorder:

• Shares symptoms of depression – but less severe (less symptoms), more chronic (persists for a longer time)

• For diagnoses, depressed mood–at least one year, plus at least 2 of the following:

  • Depressed or irritable mood

  • Poor appetite or overeating

  • Sleep disturbance

  • Low energy of fatigue

  • Loss of esteem

  • Concentration or decision-making problems

  • Feelings of hopelessness

• Double depression

  • Instances when both dysthymia and major depressive episodes are present

Disruptive Mood Regulation Disorder (DMDD):

• Symptoms that have persistent irritability and frequent outbursts

• Added to deal with the problem of overdiagnosis of bipolar disorder

  • Purely a childhood disorder

  • Only 6-18-year-olds can be diagnosed

  • Children are more likely to develop co-occurring anxiety 

Depression: Empirical Approaches

• Defining depression in children a focus of research

  • Experience of depression may differ at various points in youth development

  • Depression in young people may be best understood as dimensional, not categorical

    • Those who do not meet the criteria for depression  may still:

      • Experience impairment

Epidemiology:

• MDD is most common

  • Among children with unipolar

    • 80% experience MDD

    • 10% dysthmia (no MDD)

    • 10% ”double depression”

  • Depression is less prevalent in children than in adolescence

  • After age 12, girls report depression more often

  • Co-occurence: anxiety, disruptive behavior disorder, eating disorders, substance use, and ADHD

• Lower SES is associated with higher rates

Depression & development:

• Difficult to assess infants & toddlers due to lack of expression:

  • Less active

  • fedding/sleeping problems

  • Irritability

  • Less positive affect

  • Sad facial expression

  • Excessive crying

  • Decreased responsiveness

  • Lethargy

  • Mood changes

• Middle childhood: (6-12 years)

  • Around 9-12,  may verbalize feelings of hopelessness, low self-esteem

• Adolescents: 

  • Depression in early adolescence may look similar to that in childhood

  • Later, starts to resemble adult depression

  • Median age–15.5 years

    • Differences may exist between prepubertal (less likely to persist into adulthood) and postpubertal onset depression

• Community sample:

  • Median duration–8 weeks

  • 26 % of adolescents had a recurrent episode

  • Earlier onset associated with longer episodes

• Clinical samples:

  • 70% had recurrent episodes

  • Median duration – 7 to 9 months

Etiology of Depression:

• Biological influences

  • Genetic influences: a genetic component is there, but the environment can be associated with the presentation of depression

  • Dysregulation of the stress hormone–cortisol

• Temperament:

  • Considered to have a genetic/biological basis, environmental influences also may affect its development

  • Negative affectivity (NA)--includes a tendency to experience negative emotions, to be sensitive to negative stimuli, and to be wary, vigilant

  • Positive affectivity (PA)--includes approach, 

• Social-psychosocial influences

  • Separation and loss

    • The loss of a parent isn't directly linked to depression, yet the lack of parental warmth/support is linked to depression

  • Interpersonal skills

  • Learned helplessness

    • Lack of care

    • SES 

    • Attributional/explanatory style

      • Hopelessness theory

    • Cognitive distortions –Beck’s theory

• Risk of depression when parents are depressed themselves

  • Familial stability can influence the impact of parental depression

• Peer rejection can lead to higher presentation of depression in children

  • Children  may exhibit perceived distortions in processing social information and interactions

Assessment of depression:

• Combined treatments are best

  • Confront maladaptive cognitions, attributions

  • Increase pleasurable experiences

  • Enhance social skills

  • Improve communication and conflict resolution

• ACTION Treatment Program

  • Focuses on problem-solving and how to cope

  • Recent (2010) school-based CBT program

  • Behavioral activation

  • Parent training

• IPT-A

  • Based on the premise that depression is associated with interpersonal relationships

  • Helping different social areas that a child has

    • Found to be effective 

Prevention of Depression

• Universal programs not successful

• Programs need to be longer and more extensive

Bipolar Disorder

• Manic episode–mania plus 3 of the following:

  • Elevated mood

    • Inflated self-esteem

    • Irritability

    • Distractability

    • More talkative than usual

    • Excessive levels of goofiness

    • Racing thoughts

    • Decreased need for sleep

  • Mania must last a week or more–must be a severe presentation

• Bipolar I – person has periods of mania and possible depression

• Bipolar II – person has periods of hypomania and depression

• Hypomania – milder form of mania

  • 4 consecutive days

• Cyclothymia – chronic but mild fluctuations in mood that do not meet the criteria for mania or depression

  • Children experience more rapid cycling, mixed episodes

  • Severe and more frequent mood dysregulation

  • Children are likely to have co-occurring disorders like ADHD

Epidemiology of bipolar disorder:

• Males and females are equally represented

• Co-occurs with ADHD, conduct disorder, oppositional defiant disorder, substance abuse/dependence

Course & prognosis

• Median duration of manic episode – 10.8 months

• Youths who have earlier onset,  like age 12, may be at a higher risk of developing bipolar disorder

• Children with earlier onset of MDD may be more likely to have bipolar disorder

Risk factors & etiology:

• Heritability – 60-90% 

• Gene-environment interaction

Assessment of bipolar disorders:

• Structured diagnostic interviews

Treatment

• Multimodal

Suicide:

• Completed suicides

  • 3rd leading cause of death among youth

  • Increase in suicides among younger children

  • Rate highest for males

• Suicidal ideation

  • High prevalence among adolescents

  • Females have higher rates of ideation and attempts

  • Rate of reattempt is higher than the general population.

  • Issues with problem-solving

• Prevention

Normal fears

• Parents may underestimate fears, especially in adolescents

• Girls exhibit more fears & more intensity than boys

• Fears commonly decline with age

  • Gender differences explain the expression of fears

• Worry becomes more complex and varied with age

• Certain fears coincide with different stages of development 

  • Cultural differences should be considered in diagnoses

DSM describes a number of anxiety disorders:

• Separation anxiety disorder

• Specific phobia

• Social anxiety disorders

Empirical approach

• Achenbach’s anxious/depressed syndrome 

Specific Phobias:

• Persistent fear in response to an object or situation 

• Diagnosis requires certain conditions:

  • An immediate anxiety response occurs almost every time

  • Person realizes that fear is unreasonable/excessive

  • Person must either avoid the anxiety situations or endure any exposure with anxiety or distress

  • Fears interfere significantly with child's routine, academic functioning, or social relationships

  • Duration–at least 6 months

• prelevance – 3 to 4%

  • Higher in girls than boys

Social Anxiety Disorder (social phobia):

• Marked, persistent fear of acting in an embarrassing or  humiliating way in social or performance situations

  • Must be fear of evaluation with peers & adults/teachers

    • Speaking, reading, writing, public performances

    • Initiating or maintaining conversations

    • Speaking to authority figures

    • Interacting in informal social situations

  • Focus on perceived negative attributes

  • May develop somatic symptoms

  • Miss school and other activities

  • Report lesser self-worth, sadness, loneliness

• How is it causing impairment or being excessive?

Selective Mutism (SM)

• Children with SM do not talk in specific situations (usually when peers do talk)

• Usual onset – 2.5 to 4 years of age

• A large percentage of SM children (perhaps 90-100%) also meet the criteria for social phobia (social anxiety disorder)

Separation Anxiety Disorder

• Excessive distress from separation from any major attachment figure

  • Must last at least 4 weeks in children/adolescents and typically 6 months or more in adults

  • Most common anxiety disorder among children younger than 12

    • May follow a stress or trauma 

    • Usually decreases with age

    • Comorbid with other diagnoses

School Refusal 

• Often associated with separation anxiety, but other causes are possible

• More likely to occur during major transitions

• If the child is over 10, treatment will be more difficult 

Generalized Anxiety Disorder (GAD):

• Excessive anxiety and worry about multiple, general life circumstances (not confined to a specific stress or situation)

  • Worry must occur–Nervous habits, sleep disturbances, restlessness, on edge, easily fatigued, difficulty concentrating, irritability, muscle tension

• Prevalence – 2 to 14% (all ages)

• Must be present most days, very frequently

• Must cause significant impairment

  • Median age of onset – 10

  • More commonly reported in girls

  • Commonly comorbid with depression, separation anxiety, and phobias

  • May be overdiagnosed

  • Symptoms tend to persist over the years

Panic Attacks & Panic Disorder

• An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and, during which time four (or more) of the following symptoms occur:

• Note: the abrupt surge can occur from a calm or anxious state

  • Palpitations

  • Sweating

  • Trembling or shaking

  • Sensations of shortness of breath 

  • Feelings of choking, chest pain or discomfort, nausea or abdominal distress

  • Panic attacks can co-occur with agoraphobia 

Panic Disorder

• Recurrent, unexpected attacks, must be unqued attacks

• For diagnosis, an attack must be followed by a month or more of the following:

  • Persistent concern about having other attacks

  • Worry about the implications of the attack (“going crazy”, having a heart attack)

  • Significant change in behavior related to attacks

    • The cognitive symptoms may not be as observable in children

  • Panic attacks are more common than panic disorder

  • Panic disorder is rare in childhood

  • More common in females

  • Few seek treatment

  • Appears to run in families

  • Commonly comorbid with other diagnoses

Agoraphobia

• A marked fear or anxiety about 2 or more things across situations:

  • Ex: using transportation–cars, buses, trains, ships, planes

  • Open spaces–parking lots, marketplaces, bridges

  • Enclosed spaces–shops, theaters, cinemas

  • Standing in line or being in a crowd

  • Being outside of the home alone

• The individual has fear about certain situations because of the thought of having panic-like symptoms

• Lasting an extended period of time, for 6 months or more

Etiology of Anxiety:

• Biological influences

  • Parents who have anxiety disorders are said to have children who may be at risk

  • Risk for anxiety disorder likely inherited 

    • Or tendency is inherited rather than specific disorder

  • Serotonin, GABA, CRH

  • Limbic system, particularly the amygdala

• Temperament

  • Behavioral inhibition

  • Negative affectivity

  • Effortful control: the ability to employ self-regulation processes

    • Both high negative affectivity and low effortful control can contribute to the development of anxiety disorders

• Psychosocial influences

  • 3 Pathway theory (Rachman):

    • Fear begins with exposure to trauma or threat 

    • Fear is modeled by parents, who also reinforce it

    • Fear acquired through transmission of verbal information

  • Parenting styles & practices

    • Avoidant solutions

    • Overprotective, intrusive

    • Insecure attachments

      • Many environmental factors & social/parental relations have an impact

Assessment:

• Interviews & self-report instruments

  • State trait inventory for children

  • Revised children's manifest anxiety scale

• Direct observations

• Physiological recordings

Interventions:

• Psychological treatment–exposure to anxiety-provoking situations central to treatment

• Relaxation (muscle melting)

• Desensitization/systematic desensitization 

  • Relaxation training paired with exposure

• Modeling

  • Participation modeling

• Contingency management

  • Stop reinforcing for avoidance

  • Reinforcement improvement

• Cognitive behavioral treatments (CBTs): 

  • Recognize signs of anxious arousal

  • Identify cognitive processes associated with anxious arousal

  • Employ strategies and skills for managing anxiety

    • FEAR acronym 

Prevention:

• Content for prevention programs highly similar to CBTs

• Programs targeting at-risk children

Obsessive-Compulsive Disorder

• Now is its own category in the DSM-5, Obsessive compulsive and related disorders

  • Obsessions – unwanted, repetitive, intrusive thoughts 

  • Compulsions – repetitive, stereotyped behaviors, meant to reduce anxiety or prevent something bad from happening

    • Disorder (OCD) may involve either or both:

  • Highly time-consuming, interferes with normal routines, academic functioning, social relationships

  • In children, compulsions are reported more often, children may not be able to identify/articulate these behaviors or reasons

  • Symptoms change in presentation overtime; OCD never goes away one just gets help to manage symptoms

    • Broad themes–preoccupation with cleanliness/averting danger and pervasive doubt (must be a particular way/feel right)

    • Parents may not be aware or may not see a problem with their child—parents may reinforce anxiety-induced behaviors

    • Mean age of onset 10 years of age

    • Commonly comobid with at least one other disorder

  • Prevalence – about 1%

  • Boys more common that girls in childhood, evens out by teens

• Etiology:

  • Strong biological basis

    • Higher heritability in children of adults with OCD

    • Studies linked OCD to problems in the basal ganglia, frontal lobes

    • PANDAS

• Assesment: 

  • Children's yale-brown obsessive compulsive scale (CY-BOCS)

• Treatment:

  • CBT is the first treatments of choice

    • ERP: Exposure with response to prevention

      • Child is gradually exposed to the anxiety-induced situation

  • Medications are also an option, but CBT is still preferred

Schizophrenia:

• COS: child onset schizophrenia

• Positive symptoms:

  • Delusions (false beliefs), hallucinations (erroneous perceptions), disorganized speech (quality), disorganized behavior, catatonic behavior (motor behaviors)

  • 2 must be present, but 1 of the 1st three must be present

• Negative symptoms:

  • A reduction or lack of normal behaviors

    • Flat affect, poverty of speech (alogia), lack of goal-directed behaviors (avolition)

  • Not all criteria needed

  • Diagnosis prior to age 13 is rare

  • Adolescent onset may be more acute, severe

• Hallucinations and delusions are common in children with schizophrenia

• Delusions are different than hallucinations

  • Auditory most common hallucination

  • Delusions occur in majority of children with schizophrenia

  • Become more elaborate with age

• Thought disorder evidenced by disorganized speech

  • Illogical, incoherent, vague, repetitive, abstract speech

• Secondary features:

  • Motor problems and poor coordination

  • Impaired communication

  • Borderline intelligence

  • Shyness withdrawal

  • Depression, anxiety

• Epidemiology:

  • Very rare in children – about 1% of population

  • May be more common in males (children) around the age of 16

  • Childhood onset forms are typically insidious (gradual) with nonpsychotic symptoms appearing first

  • Full recovery is very uncommon (about 20% have good outcome)

• Neurobiological abnormalities

  • Reduced brain volume

• Etiology

  • Genetics

  • Prenatal and pregnancy complications

  • Psychosocial 

    • Family influenced

    • Neurodevelopmental model: Complex picture of risk in that brain abnormalities may additionally be associated with environmental/gene interaction

      • Premorbid (cognitive) difficulties

• Assessment

• Prevention

  • Decrease prenatal/birth complications

  • Early identification and treatment

  • Targeted intervention intervention for at-risk groups 

  • Treatment

    • Antipsychotics–can alleviate hallucinations, no guarantee itll work

      • Typical

      • Atypical–fewer side affects

    • Psychosocial

      • Skills training

      • CBT

      • Family therapy

Chapter 7: Trauma and Stressor-Related Disorders

What is Trauma?:

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

• Exposure to trauma can result in risk for disorders or none

Defining PTSD:

• Diagnosis requires:

  • Exposure to a traumatic event (directy or witnessed)

  • And symptoms from 4 clusters:

    • Reexperiencing: 

      • disturbing memories, recurrent traumatic dreams, prolonged psychological stres, dissociative reactions, derealization (living in a dream), flashback

        • Childrens expression of these symptoms are different than adults

        • Preschool (under the age of 6) criteria is different

    • Avoidance:

      • Persistent efforts to avoid, avoidance of external stimuli like people, places, things

    • Negative altercations in cognitions and mood:

      • Distorted thoughts, exaggerated expectations, persistent negative states

    • Arousal and reactivity:

      • Marked alteration in the persons reactivity that begins or worsens; irritable behviors, exaggerated startled responses, sleep difficulties

• Reactive attachment disorder (RAD)

• Disinhibited social engagement disorder (DSED)

  • Both have estalished experiences of social neglect:

    • A persistent lack of having caregivers provide for basic needs such as affection, comfort, and stimulation

    • Repeated changes of primary caregivers–thus limiting opportunities to form stable attachments

    • and/or rearing in unusual situations (instituions with poor child–staff ratios) that severely limit opportunities to form attachments

Post Traumatic Stress Symptoms:

• PTSS is distress and interference with functioning that doesn’t meet PTSD criteria

• Most youth who experience PTSS recover

• 20-30% experience persistent symptoms and are diagnosed with PTSD

Developmental course:

• PTSS symptoms usually declines over time

• High family support can mediate the development of PTSS and lessen the severity of presentation

Treatment of PTSD:

• Cognitive behavioral therapy (CBT) has strangest evidence for sucess

  • Parental involvement is important

  • Trauma-focused CBT combines sessions for childre-only, parent-only and sessions for both together

  • Acronym PRACTICE describes components of TF-CBT model

    • It’s about helping them understand and work through their emotions, and to help them learn how to cope with their trauma

Forms of Child Maltreatment:

• Physical abuse

• Sexual abuse

• Psychological abuse

• Neglect (most common form)

  • Maltreatment encompasses all of these:

• Physical abuse:

  • An intentional use of physical force that results in injury

  • Can result from discipline

  • Probably easier to detect than other forms of maltreatment

  • Nature and severity of injuries can vary considerably

• Sexual abuse

  • Refers to sexual experiences between youth and older persons or to the sexual exploitatian of the young, such as in pornographic fim

  • More common in girls than boys

• psychological /emotional abuse

  • Might include blaming, isolating

  • Defined as persistent and extreme actions or neglect that thwart the child's basic emotional needs and that are damaging to the behavioral, cognitive, affective, or physical functioning of the child

• Neglect 

  • Failure to provide for a child's basic needs (physical)

  • Not enrolling children in school

  • Letting the child do whatever they want throughout the day

  • Ignoring the child for long periods of time

    • Requires sensitivity to family and cultural values and to economic and SES

Who perpetuates maltreatment?

• 81.6% of perpetrators are parents

• 69% are mothers (acting alone 40.8% or in combo with the father 28.2%)

• 13% are non-parents

  • 4.7% of those are relative

  • 2.9% are a parent partner

  • Majority of parents who maltreat their children were abused themselves, but majority of children who were maltreated do not go on to maltreat themselves

Interventions for maltreatment:

• Strong emphasis on prevention

• Programs include:

  • Nurse-family partnership (NFP)

  • SEEK program

  • Incredible Years (IY)