Abnormal Child Psychology Flashcards

Finishing Body Dysmorphic Disorder (BDD) and Introduction to Maltreatment

Body Dysmorphic Disorder (BDD)

• Last Class Review:
  • Body Dysmorphic Disorder (BDD) in children leads to:
    • High levels of stress.
    • Psychosocial problems.
    • Functional impairment.
    • Desire for plastic surgery.
  • Comorbidities:
    • Earlier age of onset is associated with higher risks of:
      • Negative developmental impact.
      • Comorbid disorders.
      • Higher risk of suicide.

BDD: Similarities and Differences Compared to OCD

• Similarities to OCD:
  • Obsessive, intrusive, repetitive thoughts.
  • Excessive time dedicated to rituals (e.g., mirror checking, grooming).
  • Age of onset.
  • Associated anxiety and emotional distress.
  • Approximately 10% of BDD patients attempt suicide.
• Differences:
  • Underlying Core Beliefs:
    • BDD: Focuses on the unacceptability of the self (e.g., being unlovable, inadequate, worthless).
    • Moral repugnance is unusual in BDD.
  • Insight:
    • BDD patients have poorer insight.
    • Approximately 2% of OCD patients are currently delusional, compared to 27%-39% of BDD patients.
  • Anxiety Relief:
    • Compulsive behavior doesn’t relieve anxiety in BDD.
  • 25% of BDD patients attempt suicide.

Body Dysmorphic Disorder: Areas of Focus

• Most Common Areas of Focus:
  • Head and Face: 55%
  • Skin: 20%
  • Arms/Legs: 7%
  • Genitalia: 5%
  • Overall Body: 13%

BDD: Common Behaviors

• Obsessive mirror checking.
• Looking in reflective surfaces.
• Excessive grooming/primping.
• Camouflaging (e.g., hats, clothes, scarves, wigs, masks).
• Avoidance behaviors.
• Comparing body parts.
• Social media comparisons/unrealistic expectations.
• Reassurance seeking.

BDD: Child Sample Study

• Sample: Thirty-three children and adolescents.
  • Bodily preoccupations most often focused on:
    • Skin (61%).
    • Hair (55%).
  • All had compulsive behaviors:
    • Camouflaging (e.g., with clothing): 94%.
    • Comparing: 87%.
    • Mirror checking: 85%.
  • Impairment in:
    • Social functioning: 94%.
    • Academic functioning: 85%.
  • Psychiatric hospitalizations: 38%.
  • Suicide attempt: 21%.

BDD: Treatment Outcomes in the Sample

• Ten (53%) of 19 subjects treated with SSRIs showed significant improvement in symptoms.
• Twelve (36%) subjects received surgical, dermatological, or dental treatment, with poor outcomes.

BDD Clinical Interview & Assessment

• Body Dysmorphic Disorder Questionnaire (BDDQ):
  • Asks about concerns with physical appearance.
  • Asks to list disliked body areas:
    • Examples: skin issues (acne, scars, wrinkles), hair, nose shape/size, mouth, jaw, lips, stomach, hips, genitals, breasts, etc.
  • Questions about the impact of appearance concerns on life:
    • Upset levels.
    • Interference with social activities/relationships.
    • Problems with school/work/activities.
    • Avoidance of situations due to appearance.
  • Time spent thinking about appearance (e.g., less than 1 hour, 1-3 hours, more than 3 hours).
• Treatment:
  • SSRIs
  • ERP Therapy

BDD: DSM-5 Criteria

• Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
• Repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing appearance) in response to appearance concerns.
• The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.
• Specify if:
  • With muscle dysmorphia: The individual is preoccupied with the idea that their body build is too small or insufficiently muscular.
  • Indicate degree of insight regarding BDD beliefs:
    • With good or fair insight.
    • With poor insight.
    • With absent insight/delusional beliefs.

Maltreatment in Childhood and Adolescence: Overview

• Overview of Maltreatment.
• Effects of Maltreatment.
• Post-traumatic Stress Disorder.
• Social and Emotional Deprivation.

Maltreatment: Facts

• Approximately 3.5 million kids are referred to child protective services for suspected maltreatment annually.
• Approximately 675,000 of these reported cases are substantiated.
• 1% of children and adolescents are abused or neglected each year.
• This estimate does not include the vast number of maltreated youths who are never reported.

Maltreatment: Economic Impact

• Over the course of a child’s lifetime, the cost of maltreatment ranges from 210,000 to 831,000 per victim.
• The estimated financial cost of child maltreatment in the United States is approximately 428 billion each year.
• Includes:
  • Direct financial costs.
  • Indirect financial costs.

Maltreatment: Definition

• First definition presented in the Child Abuse Prevention and Treatment Act of 1974 (PL 93–247):
  • “The physical or mental injury, sexual abuse, exploitation, negligent treatment, or maltreatment of a child under the age of 18 by a person who is responsible for the child’s welfare under circumstances which indicate that the child’s health or welfare is harmed or threatened.”
• Four types of child maltreatment:
  • Neglect.
  • Physical abuse.
  • Sexual abuse.
  • Psychological abuse.
• Children who experience maltreatment are diagnosed based on the signs of symptoms they display.

Maltreatment: Role of Parents and Caregivers

• Children depend on parents and other caregivers for protection, nurturance, and direction.
• As a biological predisposition, humans are bound to form attachments with their caregivers and seek them out at times of stress.
• Without reliable, capable caregivers, kids find it difficult to cope effectively with their surroundings.
• It’s traumatic.

Child Neglect: DSM-5 Definition

• An action by a parent or caregiver that deprives the child of basic age-appropriate needs and thereby results (or has reasonable potential to result) in physical or psychological harm to the child.
• Includes:
  • Abandonment.
  • Lack of appropriate supervision.
  • Failure to attend to necessary emotional or psychological needs.
  • Failure to provide necessary education, medical care, nourishment, shelter, and/or clothing.

Early Psychosocial Development (Erikson)

• Infant - 18 months: Trust vs. Mistrust
• 18 months - 3 years: Autonomy vs. Shame/Doubt
• 3-5 years: Initiative vs. Guilt
• 5-13 years: Industry vs. Inferiority
• 13-21 years: Identity vs. Confusion
• 21-39 years: Intimacy vs. Isolation
• 40-65 years: Generativity vs. Stagnation
• 65 and older: Integrity vs. Despair

Neglect: Socio-Emotional Deprivation

• Characterized by disregard for the child's basic emotional needs can lead to severe global psychosocial and cognitive dysfunction and deviant developmental trajectories of brain maturation.

Two DSM-5 Diagnosed Disorders Related to Social-Emotional Deprivation

• Reactive Attachment Disorder (RAD).
• Disinhibited Social Engagement Disorder (DSED).
• Mostly seen in:
  • Orphanages
  • Foster care
  • Group Homes
• Rarer:
  • Severely neglected at home.

Social-Emotional Deprivation in Infancy

• May spend early years in institutionalized care, which may be pathogenic.
• Institutions/Orphanages:
  • High child-to-caregiver ratios ranging from 1:8 to 1:31.
  • Many located in countries ruled, plagued by war or disease financial instability and violence.
  • High caregiver turnover, with children exposed to 50 to 100 caregivers during their first 18 months of life.
  • Many of the children raised in these centers spend long periods of time in isolation and in crib/bed for the majority of time.
  • Caregivers focus mainly on children's’ physical health not social and emotional well-being.
  • Some provide adequate physical care and cognitive stimulation; conditions of other orphanages have been described as abusive and deplorable.

History of Research on Deprivation

• Anna Freud:
  • Observed World War II children separated from parents.
  • Opened the Hampstead War Nursery in England.
  • Published some of the first papers describing the harmful effects of maternal deprivation on these children’s emotional health.
• In 1946, René Spitz and Katherine Wolf conducted an observational study of institutionalized orphan babies in the United States.
  • Although their physical needs were met, they were largely confined to their cribs and provided little contact with staff.

History: Spitz and Wolf Study

• The researchers compared these orphans to another group of infants raised in a prison nursery where their mothers were incarcerated.
• By 1 year, orphanage children were:
  • Less playful, interested in their surroundings
  • Less responsive to staff
  • Did not seek contact comfort.
  • Developed infections more.
  • Didn’t meet developmental milestones (weight, growth patterns).

Post WW II: John Bowlby’s Research

• John Bowlby (1951) was asked by the World Health Organization to review research on the developmental outcomes of children who experienced deprivation in postwar Europe.
• Bowlby met with researchers and clinicians who worked with kids raised in orphanages, group homes, and other institutions.
• Described these children as “listless, quiet, unhappy, and unresponsive.”
• Bowlby concluded: “A warm, intimate, and continuous relationship” between infants and a primary caregiver was essential to children’s physical, cognitive, and social–emotional development.”

Reactive Attachment Disorder (RAD)

• Pathogenic care.
• In the United States, RAD is most often seen among international adoptees who spent their first 12 to 24 months of life in low-quality orphanages.
• Extreme neglect and in young children who have lived in multiple foster homes during their first year of life
• Lack of attachment to a single caregiver early in life.
• Not to be confused with insecure or disorganized attachment, in which children do form attachment relationships, but they are less than optimal.

Reactive Attachment Disorder (RAD): DSM-5

• Classified as a Trauma and Stressor-Related condition of early Childhood.
• Rare and almost exclusively in infants and young children who experience extreme deprivation.
• Disturbed or developmentally inappropriate attachment behaviors.
• Do not seek or respond to comfort from caregivers when distressed.
• Emotionally withdrawn.
• Negative affect toward their caregivers (seldom smile, hug, or kiss).
• Present as sad, anxious, or irritable.
• Should not be Dx before 9 months old.
• The Bucharest Early Intervention Project showed that orphans adopted prior to 24 months did not develop RAD; however, one-third of children who remained in the orphanage developed RAD signs and symptoms.

Bucharest Early Intervention Project

• Fall of 2000, examined the effects of early institutionalization on brain and behavior development and the impact of high-quality foster care as an intervention.
• For over 2 decades, the leader of Romania, tried to increase the workforce and ordered couples to have multiple children.
  • If less than 5 oppressive taxes.
• Regime dissolved, and 170,000 children were in orphanages because parents could not afford their care.

Bucharest Early Intervention Project: Issues in Romanian Orphanages

• Undernourished.
• High staff to child ratios.
• Children left in cribs for extended periods.
• Little to no social interaction between children and staff.
• No foster system to help them.
• The new Romanian government requested assistance from the international community.

Bucharest Early Intervention Project: Study Design

• Found foster parents in the US and UK to care for infants living in the Romanian orphanages.
• Not enough for all infants.
• Researchers randomly assigned infants into three groups:
  • (1) Children raised in Romanian orphanages.
  • (2) Children initially raised in Romanian orphanages but placed in foster homes before age 24 months.
  • (3) Romanian children living with their biological families.
• Examined children’s development until age 54 months to determine their outcomes.

Bucharest Early Intervention Project: Findings

• RAD is associated with a lack of attachment in infancy and early childhood.
• At age 24 months:
  • 100% of the noninstitutionalized children (i.e., adoptees and children living with their biological parents) showed a clear attachment to their primary caregiver.
  • 3.2% of institutionalized children showed a clear attachment pattern.
  • 9.5% of institutionalized children showed no attachment behavior toward caregivers and no differentiation between familiar and unfamiliar adults whatsoever.
  • An additional 25.3% of institutionalized infants showed only slight preference for their caregiver over a stranger but no positive emotions when interacting with their caregiver.
• Severity of RAD was inversely associated with the quality of care
• The more sensitive and responsive the care, the fewer symptoms.

Treatment for RAD: Attachment and Biobehavioral Catch-Up (ABC)

• The Attachment and Biobehavioral Catch-Up (ABC) intervention consists of ten 1-hour sessions for parent–child dyads.
• Goals:
  • Cultivate nurturance: Parents are taught to meet their infants’ needs even when these needs are not clearly communicated.
  • Improve synchrony: The serve and return of parent–child interactions.
  • Parents are encouraged to give their infants greater autonomy and to be responsive to their needs and signals.
  • Reduce intrusive or frightening behavior in the caregiver: Caregivers who have experienced abusive or neglectful parenting themselves may have difficulty meeting their children’s needs.

Example of Why Not Using Evidence-Based Practice (EBP) is a Serious Problem: Rebirthing Therapy

• Developed by Leonard Orr (NO background in medicine or psychology).
• Uses breathwork and holding to help the child remember their birth, and any traumas they were exposed to as a young child.
• The main method taught by Orr is one that includes breathing in and out continuously, without stopping to pause.
• Patient can be wrapped in blankets and tightly held by multiple people.
• The session can last up to 2 hours.

Disinhibited Social Engagement Disorder (DSED)

• Child displays a pattern of culturally and developmentally inappropriate, overly familiar, behavior with strangers.
• Beginning at age 6 or 7 months, most children begin to show wariness of strangers—children with DSED do not.
• Child will readily approach and interact with unfamiliar adults.
• Unlike their same-age peers, children with DSED do not “check back” with their caregivers to make sure that they are safe and that their caregivers know their whereabouts.
• Will often talk to strangers, sit on their lap or hold their hand, and wander off without their caregivers’ knowledge or permission.

Disinhibited Social Engagement Disorder (DSED): Research Findings

• Researchers who conducted the BEIP examined symptoms of indiscriminately friendly behavior among infants placed in Romanian orphanages:
  • 31.8% showed features of DSED.
• DSED signs and symptoms were not consistently associated with the quality of care.
• Not an attachment disorder; securely attached infants sometimes showed DSED.
• DSED displayed difficulty with attention and social inhibition later in childhood.

Causes of DSED

• Lack of social inhibition – Not an attachment disorder
• High number of caregivers between 6-24 months.
• Late infancy-early childhood is a sensitive period to develop social inhibition.
• Stranger danger isn’t learned.

Treatment for DSED

• Studies strongly suggest infants adopted into nurturing homes within the first 6 months don’t develop symptoms.
• Prevention is the best approach.

Treatment for DSED: Play and Creative Arts Therapy

• Children naturally develop attachments through play and creative expression.
• Play therapy creates an opportunity to bond with a caregiver who joins the session.
• Creative arts therapy is also interactive and experiential for the child and caregiver.
• Both provide sensory experiences.
• Can be done non-verbally - good for young children.
• This is important because young children are not always willing to or able to verbally discuss trauma.

Physical Abuse

• Nonaccidental physical injury to a child, ranging from minor bruises to severe fractures or death.
• Such injury is considered abuse regardless of whether the caregiver intended to hurt the child.
• Physical discipline such as spanking or paddling is not considered abuse as long as it is reasonable and causes no bodily injury to the child.

Psychological Abuse

• Repeated acts or omissions by the parents or caregivers that have caused or could cause serious behavioral, cognitive, emotional, or mental disorders.
• It includes five broad types of behavior:
  • Spurning: Verbal and nonverbal acts that reject or degrade a child (e.g., ridiculing a child for showing emotions, humiliating a child in public, or showing extreme favoritism to one child at the expense of another).
  • Terrorizing: Threatening to hurt or abandon a child or his or her loved one (e.g., allowing a child to witness domestic violence, threatening to harm their pet).
  • Isolating: Denying opportunities to interact with peers or adults outside the home (e.g., refusing to allow them to play with friends or have legal visitation with a parent).
  • Exploiting: Encouraging a child to adopt maladaptive or antisocial behaviors (e.g., allowing a child to witness illegal acts or using the child to sell or transport drugs).
  • Denying emotional responsiveness/neglect: Ignoring the child’s bids for attention and emotional interactions (e.g., acting cold or emotionally distant, rarely showing affection, or refusing to give a child comfort when he is distressed).

Psychological Abuse: Childhood Emotional Neglect (CEN)

• Childhood Emotional Neglect (CEN) is a form of psychological abuse where a child’s primary caretakers (usually his parents) fail to respond enough to the child’s emotional needs.
• Happens often in normal homes all over the world, even when the parents are physically present, and all the child’s material needs are met.