01.11.2024

• course objectives sound very interesting

  • clinical applications

  • concepts of psychopathology (different types)

  • factors of risk and resilience

  • emphasis on compassionate understanding and individual differences in developing psychopathology vs. “healthy” minds

• textbook: 8th edition (2024) Child Psychopathology — Mash, Wolfe, Williams (e-text)

Children’s Mental Health Pre-Pandemic

• 1/5-1/8 of children have MH problems in US

• 10-20% have at least one psychological disorder

• 50-75% of children who need MH services do not receive any

• many disorders extend across the lifespan

  • disparities— social injustice

Effects of Global Pandemic

• existing national surveys show increased rates of distress and impairment

• well-replicated finding of increased psych ER visits

• exacerbated existing problems

  • women, BIPOC

01.18.24

Big Picture Concepts

• developmental psychopathology

• deficit models predominate: children’s strengths are often overlooked in research, diagnoses, and treatment

  • deficit-oriented field (minimize children to their disorders)

• knowledge of child psychopathology is extremely biased

  • primarily based on western culture (US)

• gender differences are vital

  • development and expression of child psychopathology

  • ex. until 1990s, all research on anti-social behavior was done on boys only

• social adversity has effects on development and persistence of psychological symptoms

  • can change stress response

Jeffrey Case Study

• old man was killed, three teenagers were involved

  • possible problems that led to this

    • substance use

    • lack of impulse control

    • exposure to violence

    • lack of empathy

    • drug use (modeling from parents as well)

  • risk processes fully given next lecture*

Background of Traditional Theoretical Perspectives

• etiology

• pre-19th century explanations: focused on adults (children = miniature adults), and based on supernatural ideas

• medical model

• psychoanalysis

• behaviorism

• limitations of these perspectives

  • tend to ignore issues of normal development

  • tend to focus on singular causes

• developmental psychopathology perspective

  • how normal development can become compromised

    • starts with competence as a building block: how well child uses external and internal resources to successfully adapt to the environment

      • psychopathology = adaptive failures

Age-Salient Adaptive/Developmental Tasks

• must be mastered by children of different age groups

  • 0-1 yrs: regulation of sleep, eating, and arousal; formation of normal attachment relationships

  • 1-2.5 yrs: exploration and autonomy (taste, touch); mastery of object world; simple impulse control, emerging self-regulation bound to specific situations

  • 3-6 yrs (preschool): fundamental skills that help them adapt, rapid brain development especially in executive functioning, flexible internal control (internalizing some rules that they carry with them), self-initiative (carrying out tasks), effective peer interaction, perspective-taking (others have different thoughts and feelings than them)

  • 6-12 yrs: school adjustment, establish friendships with same-gender peers, sense of efficacy (confident working toward goals that are important to themselves and/or others), empathic concern for others

  • 13+ yrs: identity, abstract thinking, same and opposite sex friendships

• developmental tasks are broadly integrative: cuts across affective, social, and cognitive domains of functioning

• adaptive failures have cumulative, snowballing effects across time

  • cascades

  • lack of competence, internal control = inability to regulate themselves in school (bad impression from teachers, at risk for peer rejection, at risk for academic failure)

    • predict effects across the life span (failure to meet adaptive challenges can have lifelong implications)

• ex. 3 y/o thought the sun moved in the sky because it was following him = egocentrism

  • theory of mind

    • associated with ASD

Video in class (gender differences)

• key messages

  • the way boys and girls are socialized when it comes to emotional expression is highly impacted by their home life and environment

• fraternal twins (M and F)

• daughters are emotionally expressive toward their dad, who is away for his job

  • on the other hand, brother rejects talking to dad

    • acts out: more aggressive, irritable, disruptive, disobedient

• parents treat their children differently depending on gender

  • do not want boys to be “weak”

  • more likely to have feeling talk with girls rather than boys

  • mothers are accepting of boys’ reactions to anger

• girls visibly reacted to disturbing pictures, boys did not but polygraph show a salient reaction

• okay to be a tomboy but not a tomgirl: things associated with girls are inferior

• facilitation of speaking with boy: safe space, engaged in action play, let boy lead the talking, shared own feelings

01.23.24

• preexisting factor that increases the chance that a child will develop a behavioral pattern

• hereditary influences

  • comparison of groups that differ in levels of genetic risk (twin or adoption studies)

  • analyses of specific genetic variants thought to increase risk

• teratogens: harmful substances that pass placental barrier during fetal gestation

  • alcohol, tobacco, malnutrition, prenatal maternal stress

• abnormalities in brain structure and function

• disturbances in neuroendocrine function

  • HPA axis main system of stress regulation

  • cortisol is stress hormone that when abnormally high or low is linked to psychopathology

• perinatal

  • low birth weight, anoxia (oxygen deprivation during birth)

• dispositional risk factors

  • fairly stable

  • appear earlier in life

  • potentiate risker reactions with the social world

  • difficult temperament

    • high levels of irritability and resistance to control

    • high levels of behavioral inhibition

      • toddlers who freeze with anxiety in novel social situations and stay frozen for long periods of time

  • negative self-evaluation

  • poor self-regulation

    • problems with executive functioning manifesting in impulsive behavior

    • task organization and persistence

    • predict adjustment problems across lifespan

  • deficient or social cognition: ability to understand others is delayed

    • deviant social cognition: abnormal and maladaptive ideas about other people’s ideas

  • low intelligence

• social/ecological risk factors

  • family adversity

  • economic hardship

  • poor peer relations

    • low levels of peer acceptance

    • hang out with bad friends

  • exposure to community and political violence

  • poor schooling

  • peer victimization

    • discrimination

• 10,000 children are killed by guns per year

• Jeffrey case risk factors

  • grandmother was teen mom (15 y/o), substances

  • mom did drugs, physically abused by partner during pregnancy

  • anoxia

  • extremely fussy as infant

  • impulsive in school, bad impressions in school

  • rejected and victimized by peers

  • in and out of foster care

  • chronic poverty

  • dad is felon

• multiple risks in different domains that lead to cascades

• parameters of risk: exposure and timing effects

• sensitive periods for development

• dose of exposure explains difference in resilience

• risks to development cluster

• after 4 or more risks → risk for psychopathology increases exponentially

• transformational models of risk

• transactional model of development

  • hypothetical negative sequence

• epigenetics: environmental experiences that trigger biological changes (changes in gene expression result from alterations in gene structure linked to environmental influences)

  • rat licking example: rats licked showed low levels of stress

  • traumatic events can alter structure of DNA that make it difficult to manage future stressors

01.24.24 Discussion

Week 3: Resilience and Research Methods

*Exam 1 on Thursday, Feb 8 — exam review sheet will be sent out by prof

• resilience

  • showing resilience in one domain does not mean it is attributable to every sphere

  • varies according to the type of stress and context

• risk factors

  • typically involves acute, stressful situations as well as chronic adversity

  • examples include community violence, parental divorce, chronic poverty

  • especially negative in absence of compensatory resources

    • constructive activities outside of home, loving friends and family

• neuroendocrinology

  • specific forms of stress are more impactful than others

  • vary by critical periods

  • resilience vs. protective factors: resilience is combination of protective factors, regulatory skills developed, end result or outcome of these factors

  • dha is example of biological resilience

• variables

  • mediator

  • comorbid

  • correlated

  • moderator

• mediator vs. moderator

  • moderator weakens or strengthens relationship, can change direction

    • cannot be predicted

  • mediator is middle ground that falls in between two factors

• epidemiological research

  • prevalence rate = all cases divided by population at risk

  • incidence rate = new cases divided by population at risk

• correlates

  • variables that are associated with each other with no clear proof of which precedes the other (association, relationship between two factors)

• risk factors precede outcome, increase chance of negative outcome

  • protective decrease

• randomized controlled trials (RTC)

  • patients, treatment and control groups, follow up for both, compare results

  • placebo incorporation

  • randomization to reduce bias

• efficacy vs. effectiveness

  • efficacy = the degree to which something works (lab or research environment), effectiveness = how effective it is in the real world

  • common argument is the non-translational value of certain treatments (works for one and not the other)

• standardization

  • ex. study that investigates if new psychedelic treatment is effective, need to screen participants

• reliability and validity

  • interrater reliability

  • validity = accuracy

  • reliable but not valid, valid but not reliable, valid and reliable

• retrospective, prospective, longitudinal

  • prospective

  • retrospective: asked info relevant to earlier period of time

• non-experimental and experimental research

  • N-E: interview, no manipulation of variables

  • true experiments = those in which researchers have maximum control over independent variables, subjects are randomly assigned to groups and possible sources of bias are controlled

• co-variance to parce out variance

• correlational studies

• case studies: involve intensive and usually anecdotal observations and analyses of an individual child

  • Albert example (died early of encephalitis)

• single-case experimental design: repeated measures over time, replication of treatment effects within the same subject, subject serving as his or her own control

• between-group comparison design

• cross-sectional studies: individuals at different ages or stages of development are studied at the same point in time

• longitudinal studies: same individuals are studied at different ages or stages of development

• qualitative research vs. quantitative

Group Work!

• create research study with varying methods and design

• answer questions regarding hypothesis, method, design,

• resilience, observational and longitudinal

  • children that experience natural disasters

  • start with age 4, then go to age 8 and 12

• Children that experience natural disasters who are subject to home displacement score lower on resiliency measures.

• Method: interview children aged 4 and have them answer questions, resilience scale

• Design: structure of study →

• how design/method can adequately test the hypothesis: using narrative accounts to get a better idea of how the children feel, speaking to parents as well to increase validity and see if there is a discrepancy between child’s viewpoint and parents’

• Limitations: children’s individual openness to being interviewed and their honesty with answering the questions, finding participants with this context who experienced the same thing, ethical concern might involve interfering with children’s recovery process

01.25.24

Cookie Video

• hypothetical scene in which child is faced with “dilemma” of either sneakily having cookie before supper or being good and waiting → child uses dolls and kills mother

  • example of deviant social cognition style where aggression is heightened

Transactional Process Video

• iliciting aggression from a child who is not initially aggressive, hard to differentiate between actor and reactor

Pathways of Risk

• equifinality:

• multifinality: different clinical outcomes may reflect common risk factors

  • ex. children who experience familial neglect can develop personality disorder or be on a resilient pathway

Vulnerability and Protection

• many children exposed to common risk factors, how to explain why some develop behavior disorders while others develop normally

• vulnerability and protection only operate in the context of risk in development

• vulnerability: any factor that intensifies the effects of risk

  • genetic and caregiving risk are sources of vulnerability

• protective factors: attributes of individuals, environments, or events that mitigate the chances that a child will develop a behavior disorder

Resilience

• person-centered, individuals that show adequate adaptive confidence despite exposure to adversity

• myths

  • individual trait (either resilient or not)

  • resilient individuals have extraordinary coping powers

• dynamic process

  • waxes and wanes across development according to balance of risk and protective factors

• ex. 9 y/o had to be resilient and manage own diabetic symptoms, parentification, at age 12 suffered from depression

• Kauai study (one of the most famous resilience studies)

  • traced long-term development of entire birth cohort of children born on Kauai in 1955

  • tremendous amount of poverty on island

  • most people who lived there stayed there

  • prenatally at birth, then followed up ages 2, 10, 18, 32

  • home observations of parent-child interactions, interviews, school records, teacher reviews of children

  • main q: what pathways led boys and girls who experienced significant childhood adversity to show successful adaptations in adulthood?

  • both qualitative and quantitative data

  • resilient group

    • 4+ risk factors before age 2, but functioned normally at 10 and 18

      • poor, significant % had anoxia, low birth weight, alcoholic or mentally ill parents

  • non-resilient group

    • matched for age, sex, and risk status, reflections of impairment

  • resilient functioning reflects “ordinary magic”

  • temperament (resilient = calmer, more agreeable)

  • peer relations (better self-concepts and relations)

  • family size (on avg 6-8 kids, smaller family sizes were protective factor)

  • quality of parent-child relationship

  • found emotional support outside family

• watch social connections video, come back to class on tuesday with two take home msgs

Traumatic Stress Video

• studies show that ppl tend to end up as happy as they were before their trauma (bouncing back/resilience)

• set point is level of happiness that is returned to

• Dr. Dennis Charney: studied people who bounced back from massive traumatic events

• Bob Shoemaker, former Navy pilot, prisoner of war

  • combat duty in Vietnam, just married and had a son

  • broke back during flight, shuttled between North and South

  • was tortured in Vietnamese prisons for years, held in solitary confinement

  • spent his time designing a home in his mind that kept him hopeful

  • created form of communication (tap code) to speak with fellow prisoners to keep spirits alive

    • crucial to his survival, resilience cannot be obtained alone, emphasizes the importance of social bonds

  • released after 8 years of captivity, spirit unbroken

  • looked at it as time of growth, said he would not erase this experience

01.31.24 Discussion

• categorical vs. dimensional approaches

  • disorders in DSM/ICD are defined categorically

  • diagnostic criteria provided for each disorder

  • dimensional approach assumes a number of independent dimensions or traits exist and that all children possess these

    • example is big 5

• DSM5 (2013)

  • introduces category of neurodevelopmental disorders

  • inclusion of child/adol issues, deeper knowledge

  • specifiers

  • based on symptoms rather than underlying etiology

    • neural bases can help with targeting treatment

• ABC’s of behavioral assessment

  • antecedents, behaviors, consequences

• diathesis?

• transactional view: environment and child

• categories and sub-threshold populations — not true

• external validity = generalization ability

• differential susceptibility model: resilience, innate ability

  • dandelion flat trajectory, orchid highly susceptible to environment

02.01.24 Lecture

• classification: grouping for scientific study

• diagnosis: narrower; grouping for clinical purposes

  • needed for approval from insurance, foundation for comparing with others (labeling) can be helpful for strategizing

  • researchers need to communicate (plus other professionals)

• good diagnostic systems

  • clinical utility: clarity of criteria, clear rules for diagnosis compared to other disorders, comprehensive system that covers a broad range

• clinically-derived categorical systems

  • based on experts’ consensual opinions

  • experts on specific disorders argue opinions about primary and associated features

    • quantity of systems

  • opinions informed by clinical research and practice

• DSM

  • medical model document

  • ICD published by WHO used in other places in the world

  • DSM-IV was multi-axial structure

    • clinical disorder

    • intellectual disability of personality disorder

    • relevant current medical conditions relevant

    • psychosocial or environmental stressors

    • global assess function (rating of adaptive functioning from 0-100)

• DSM-V

  • explicit harmonization with ICD

  • procedures for establishing reliability

  • no axes

  • specifiers replaced subtypes

    • provide additional clinical information

  • lifespan perspective

  • structural organization of diagnoses

Alan case study

• age 8, referred by CPS, lived in emergency foster care

• according to teachers: on verge of being expelled due to high levels of aggression with peers, extremely disruptive belligerent inattentive impulsive, crashing and burning academically

• at home: only child of single mom living in deep poverty in rural New England

• convinced mom to seek psychiatric care to avoid suicide

  • stressed by Alan’s misbehavior, which has been a problem since his toddler years

• dad has long history of abusive behavior toward Alan and mom, incarcerated for antisocial behavior, moved to another state to start new family

• mom lets bad behavior build up and then explodes in rage

• threw Alan really hard against the wall after one event of misbehavior

• Alan’s diagnosis dsm 4

  • axis 1: ADHD, oppositional defiant disorder

  • axis 2

  • axis 3

  • axis 4: lots of factors

  • axis 4: 50

• Alan’s diagnosis dsm 5

  • ADHD combined with presentation of severe

  • severe oppositional defiant disorder

  • numbered codes for environmental and social factors

    • ex. academic problems, low income, parent-child relational problem

Strengths of categorical systems

• reliability

• comprehensive

Weaknesses

• use of adult criteria to define child cases

• comorbidity: most children who suffer from one disorder also manifest other disorders

  • extremely common across lifespan

  • rule rather than exception

  • think about knowledge about disorders that cluster

• problems with the use of categorical symptom cutoffs

  • who is in/out

  • most disorders are dimensional → no sharp cutoffs

    • NIH incorporated dimensional ideas as alternative (biological reductionism?)

  • inattention to context, remain important unmet needs

Diagnostic labeling

• potential cons

  • having a diagnosis could foster a negative self-image

  • self-fulfilling prophecies

  • stigma and peer victimization

  • increase distress

• potential pros

  • naming disorder can foster relief, hope, and appropriate treatment

  • naming disorder can promote understanding and support

    • can reframe in ways that lift blame from child and their environment and promote constructive behavior

  • insurance benefits for treatment

Video in class (DJ)

• BPD in young child on lots of medications (atypicals)

• side effects: incessant eating, drooling

• repetitive behaviors that meds do not change

• adolescent psychiatry difficulties

• meds are not verifiably safe for children— only for adults

  • question of safety vs. mitigating disruptive behavior

02.06.24

Assessment and Treatment

• assessment = first phase

• children have little control over referral and treatment decisions

• clinicians must know how to deal with ppl across all ages

Treatment goals

• designed to reduce risk

• enhance protective factors and individual strengths

• treatments should be empirically validated to suit child’s presenting complaint

• cultural variations in families

Returning to Alan case

• pervasive symptoms → assess using multiple informants, settings, methods

• establish rapport with Alan, interview him and learn how he viewed his own difficulties (he blamed others for problems at home and school)

• intelligence assessment (Wexler scale), 90 min, Alan took even longer because Alan was impulsive and inattentive

  • avg IQ score → capacity to learn; he could have scored even higher under better circumstances

• standardized achievement test → scored in 20th percentile

• psychological impairments and life stressors were holding him back

• interview with teacher: good sense of humor, liked to entertain class, completed standardized behavioral test → scored high on externalizing behavior

• direct observations: observed interaction with peers on playground (“visitor” to class), 45 min, Alan got into 9 fights

• interviewed mom: recent history, mother and teacher agree on his behavior problems

  • self-report measure on MMPI (personality inventory): mom scored depression, anxiety, personality disorder

• direct observation of mom and Alan

  • free play, forced compliance test (adds stress, Alan’s mom commands him about 50 times and ignored by Alan, angry and yelling, ineffective strategies of discipline), playful art task (harmony restored, left smiling)

• treatment plan

  • school setting: behavioral management plan with clear positive goals for Alan to work toward each day attached to tangible rewards and consequences

  • tutor

  • improve emotion regulation skills

  • therapist worked with him to identify triggering situations, incorporated pros and cons of responding aggressively (mindfulness), keeping trouble at bay and making friends posited as Alan’s goals

  • psychiatrist diagnosis: ADHD, meds consult, standard dose of Ritalin

  • mother: therapist, CBT, standard parent management therapy carried out with both Alan and mom, social worker who connected her with community resources (for food, bill assistance)

• treatment outcomes and lessons learned

  • still did not reach threshold that would signify a total repair

  • severe behavioral disorders require extended and comprehensive treatments (years)

    • insurance and treatment centers are not set up to accommodate this

  • layers of factors