Child Psychopathology - Week 9 Notes

Objectives

  • Develop an understanding of the challenges associated with identifying psychopathology in youth.
  • Learn about the epidemiology of mental health problems across childhood.
  • Learn about the classification and aetiology of some psychological disorders that commonly present during childhood.
  • Gain knowledge about the central tenets of the Developmental Psychopathology framework.

Determining Abnormality in Youth

  • Frequency & Intensity: Consider the frequency and intensity of cognitions, physiological signs, behaviors, and emotional responses.
  • Deviation from Norms: Evaluate how much the behavior deviates from expected norms.
  • Contextual Appropriateness: Determine if the behavior is appropriate for the context, considering:
    • Developmental context: developmental stage.
    • Family context.
    • Cultural context.
    • Historical context.
  • Impact on Functioning: Assess the impact of the behavior on the child's overall functioning.

Psychopathology in Youth - Epidemiological Considerations

  • Mental health difficulties are common in youth.
  • Lifetime prevalence:
    • Around 20%20\% of individuals experience a psychological disorder during childhood.
  • Recent Australian Bureau of Statistics (ABS) data:
    • 39%39\% of those aged 16–24 years had a ‘12-month mental disorder,’ up from 26%26\% in 2007.

Types of Difficulties

  • Prevalence of many mental health difficulties is higher than in the general population for certain groups:
    • Australian Aboriginal and Torres Strait Islander youth
    • Youth from culturally and linguistically diverse (CALD) backgrounds
    • LGBTIQA+ youth
    • Those living in rural/remote locations

Comorbidity

  • Around 40%40\% of children with one mental health disorder also have another.
  • Adolescents with Oppositional Defiant Disorder
  • Children with Autism Spectrum Disorder
    • Around 90%90\% meet criteria for another disorder (anxiety disorders, depression, substance use disorders, ADHD).
  • Adolescents with Depression
    • 40−60%40-60\% have at least one other anxiety disorder.
  • Children with an Anxiety Disorder
    • Up to 80%80\%: clinically significant anxiety symptoms;
    • 40−60%40-60\%: an anxiety disorder.
  • High comorbidity
    • Shared aetiology?
    • Challenges with drawing categorical boundaries?
    • Impairments associated with one disorder become risk factors for another?

Prevalence by Age

  • Depression, Anxiety Disorders, Eating disorders:
    • Higher prevalence in adolescents than younger children.
  • The opposite for some disorders – e.g., ADHD, ODD.
  • Overall prevalence: adolescents > younger children

Prevalence by Sex

  • Depression, Anxiety Disorders, PTSD, and Eating Disorders:
    • All more prevalent in girls.
  • ODD and ADHD, ASD, Specific Learning Disorders:
    • Occur more frequently in boys.

Interactions Between Sex and Age

  • Depression:
    • Equal prevalence in pre-adolescents
    • Girls > Boys in adolescence
  • ODD:
    • Boys > Girls in pre-adolescents
    • Equal prevalence in adolescence

Trends in Prevalence

  • Depression in Adolescents (2005 vs. 2015):
    • 9%9\% for those born in the 1990s
    • 15%15\% for ‘millennials’.
  • Anxiety Disorders across Childhood:
    • A 51%51\% increase in reported prevalence between 2004 and 2017.
  • Autism Spectrum Disorder:
    • From 1 per 5,000 in 1990 to 1 in 88 in 2012 to 1 in 54 in 2016 to 1 in 31 in 2022.

Increasing Prevalence - Possible Explanations:

  • Increased awareness/understanding?
  • Decreased stigma?
  • Changed diagnostic criteria?
  • Risk factors more prevalent?

Access to Services

  • Relatively few youth access services.
  • Only 56%56\% of those with mental health difficulties had used services for emotional and behavioral problems in the past 12 months.

Barriers to Access

  • Stigma (parents, children)
  • Availability/Accessibility
  • Under-identification:
    • “She’s just a moody teenager.”
    • “He’s just shy.”
    • “I was like that at his age; he’ll grow out of it.”

Adult Disorders: Origins in Childhood

  • Half of adults with mental health disorders had an onset of the disorder by 14 years of age, and 75%75\% before 24 years.

Impact of Childhood Mental Health Disorders

  • Distress
  • Functional impairment (child, family)
  • Cascading effects on development

Categorical Approaches to Classification in Childhood

  • DC:0-5
  • DSM-5
  • ICD-11

DSM-5 and ‘Development’

  • Same criteria as for adults, for the most part
  • Some disorders: developmental specifiers (e.g., depression)
  • Some disorders: behaviors need to be “inconsistent with developmental level” (e.g., ODD)
  • PTSD: a Preschool Subtype
  • Some disorders – most likely manifest during childhood (e.g., separation anxiety disorder)
  • Neurodevelopmental Disorders – by definition, childhood-onset of symptoms

DSM-5 Neurodevelopmental Disorders

  • A group of disorders with onset in childhood, though not always diagnosed early.
  • A range of developmental deficits (e.g., motor, communication, social, cognitive) impacting functioning across domains (e.g., social, academic, daily living, family).
  • High heritability.
  • More common in boys than girls.
  • Typically multifactorial in origin (singular causes rare).
  • High levels of comorbidity.

Specific Neurodevelopmental Disorders

  • Intellectual Disability (Intellectual Developmental Disorder) & Global Developmental Delay
  • Communication Disorders:
    • Language Disorder
    • Speech Sound Disorder
    • Social (Pragmatic) Communication Disorder
    • Childhood Onset Fluency Disorder (Stuttering)
  • Specific Learning Disorders (in Reading, Writing, Mathematics)
  • Autism Spectrum Disorder
  • Attention Deficit Hyperactivity Disorder
  • Motor Disorders:
    • Developmental Coordination Disorder
    • Stereotypic Movement Disorder
    • Tic Disorders

Intellectual Disability - Key Criteria

  • Deficits in intellectual functions such as reasoning, problem-solving, planning, abstract thinking, judgement, academic learning, and learning from experience, confirmed by both clinical assessment and individualised, standardised intelligence testing, AND
  • Deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility.
  • Without ongoing support, the adaptive deficits limit functioning in one or more activities of daily life, such as communication, social participation, and independent living, across multiple environments, such as home, school, work, and community.
    • Across Conceptual, Social, and Practical domains, AND
  • Onset of intellectual and adaptive deficits was during the developmental period
  • Severity: based on IQ and adaptive functioning across Conceptual, Social, Practical domains

Intellectual Disability - Additional Information

  • Prevalence: 1−3%1-3\% of the population.
  • More common among males (1.5:11.5:1).
  • At least 500 causes known.
  • Many cases of ID are of unknown aetiology.
  • Specific aetiologies found for about 25%25\% of those with mild-moderate ID; around 70%70\% of those with severe/profound ID.
  • High prevalence in people with Autism (30%30\%).

Intellectual Disability – Risk Factors

  • Prenatal and birth complications:
    • Prenatal exposures (e.g., Alcohol, Lead)
    • Prenatal iodine deficiency
    • Maternal infections (e.g., Rubella, Cytomegalovirus; CMV)
    • Complications of birth/prematurity (e.g., hypoxia, periventricular haemorrhage)
  • Environmental factors:
    • Severe malnourishment
    • Post-natal exposure to toxic substances (e.g., Lead, Radiation, Mercury)
  • Medical conditions/Treatments:
    • Neurological disorders – e.g. Epilepsy
    • Metabolic conditions – e.g. Phenylketonuria
    • Brain radiation
    • Acquired brain injury – e.g. Infections, TBI, Stroke
  • Chromosomal abnormalities/Genetic conditions:
    • Down Syndrome, Fragile X Syndrome, Prader-Willi Syndrome

Autism Spectrum Disorder – Key Diagnostic Criteria

  • A. Persistent deficits in social communication and social interaction
  • B. Restricted, repetitive patterns of behavior, interests, or activities
  • C. Symptoms present in the early developmental period (but may not become fully manifest until social demands exceed limited capacities or may be masked by learned strategies in later life).

Autism Spectrum Disorder – Risk Factors

  • Prevalence: around 1/50; Males:Females = 4:1
    • Though ??under-recognition in women/girls
  • Aetiology poorly understood (despite extensive research into prenatal biological/environmental factors)
  • Known correlates include:
    • Some genetic disorders
    • Strong genetic component
    • Differences in early brain development (Early brain overgrowth - marked in frontal areas; reduced cortical pruning; Atypical patterns of activation/connectivity - various regions & networks)
    • Some findings related to:
      • Advanced parental (esp. paternal) age
      • Prenatal Vitamins
      • Prenatal BPA exposure

Attention Deficit Hyperactivity Disorder (ADHD)

  • “a persistent pattern of inattention and/or hyperactivity- impulsivity that interferes with functioning or development”

Inattention Symptoms (ADHD)

  • Fails to give close attention to details / makes careless mistakes in schoolwork, work, or other activities
  • Has difficulty sustaining attention in tasks or play activities
  • Does not seem to listen when spoken to directly
  • Does not follow through on instructions & fails to finish schoolwork, chores or duties in the workplace
  • Has difficulty organizing tasks and activities
  • Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
  • Loses things necessary for tasks or activities
  • Is easily distracted by extraneous stimuli
  • Is forgetful in daily activities

Hyperactivity/Impulsivity Symptoms (ADHD)

  • Fidgets with or taps hands or feet or squirms in seat
  • Leaves seat in situations when remaining seated is expected
  • Runs about or climbs excessively in situations in which it is inappropriate
  • Unable to play or engage in leisure activities quietly
  • “On the go” acting as if “driven by a motor”
  • Talks excessively
  • Blurts out an answer before a question has been completed
  • Has difficulty waiting turn
  • Interrupts or intrudes on others

Presentations (ADHD)

  • Predominantly Inattentive
  • Combined (75% of children with ADHD)
  • Predominantly Hyperactive/Impulsive

ADHD - Prevalence

  • Childhood prevalence: 5−7%5-7\%.
  • Boys: Girls = 3:1
  • But sex differences hold only for combined and hyperactive subtypes.

ADHD – Risk Factors

  • Genetics:
    • Strong Heritability (>70\%)
    • Multiple genes; Particularly those involved in dopamine and serotonin pathways
    • High prevalence associated with some genetic conditions – e.g., Fragile X
  • Neurobiological findings:
    • Differences in regions involved in attention and executive and inhibitory control
    • Structural differences: especially in prefrontal areas
    • Neurochemical differences: Lowered Dopamine and Norepinephrine (Noradrenaline) levels (reuptake problems)
  • Environmental factors Include:
    • Maternal smoking & alcohol during pregnancy
    • Low birth weight & prematurity
    • Toxins – e.g., lead, other pollutants
    • Higher prevalence in context of psychosocial adversity

Neurodiversity

  • A paradigm shift - led from within Autism field
  • Increasing attention to voices of those with lived experience
  • Criticisms of:
    • deficit-focused models/research
    • ‘medical models’
    • interventions that appear to have the goal of ‘normalcy’
  • Increasing attention to:
    • strengths of neurodivergent individuals
    • questions about “goodness of fit” between neurodivergent individuals and their environment/context
  • Not described as helpful by all
  • ‘Neurodiversity’ a term coined in late 1990s

Neurodiversity - Definitions

  • Neurodiversity: The range of natural diversity that exists in human neurodevelopment.
  • Neurotypical: A person or people whose neurodevelopment falls within the range usually considered to constitute 'typical' development.
  • Neurodivergent: A person or people whose neurodevelopment falls outside of (or 'diverges' from) the range usually considered to constitute "typical" development (e.g. a group of autistic people is a group of 'neurodivergent' people).
  • Neurodiverse: A collective term for groups including mixed neurodevelopment (e.g. a group of autistic and nonautistic people is a 'neurodiverse' group).

Disruptive, Impulse-Control, and Conduct Disorders

  • Prevalence in childhood – around 6%6\%.
  • Boys > Girls
  • “…conditions involving problems in the self-control of emotions and behaviors.
  • While other disorders in DSM-5 may also involve problems in emotional and/or behavioral regulation, the disorders in this chapter are unique in that these problems are manifested in behaviors that violate the rights of others (e.g., aggression, destruction of property) and/or that bring the individual into significant conflict with societal norms or authority figures…”

Specific Disruptive, Impulse-Control, and Conduct Disorders

  • Oppositional Defiant Disorder
  • Conduct Disorder
  • Intermittent Explosive Disorder
  • Pyromania
  • Kleptomania
  • Antisocial Personality Disorder
  • Other Specified and Unspecified Disruptive, Impulse-Control, and Conduct Disorders

Oppositional Defiant Disorder – Key Diagnostic Criteria

  • Angry/irritable mood – often…
    • loses temper
    • touchy or easily annoyed
  • angry and resentful
  • Argumentative/Defiant Behaviour – often …
    • argues with authority figures (for children/adolescents: with adults
    • actively defies/refuses to comply with requests from authority figures / with rules
    • deliberately annoys others
    • blames others for his/her mistakes or misbehaviour
  • Vindictiveness
    • Spiteful or vindictive

Conduct Disorder – Key Diagnostic Criteria

  • Aggression to people and animals
    • often bullies, threatens, or intimidates others
    • often initiates physical fights
    • has used a weapon that can cause serious physical harm to others
    • has been physically cruel to people
    • has been physically cruel to animals
    • has stolen while confronting a victim
  • Destruction of property
    • deliberately engaged in fire setting with intention of causing serious damage
    • deliberately destroyed others' property (other than by fire setting)
  • Deceitfulness or theft
    • has broken into someone else’s house, building, or car
    • often lies to obtain goods/favours / to avoid obligations (i.e., “cons” others)
    • has stolen items of nontrivial value without confronting a victim
  • Serious violations of rules
    • often stays out @ night despite parental prohibitions (from <13 years)
    • run away from home overnight at least 2x (or once, with delayed return)
    • often truant from school, beginning before age 13 years

Childhood Onset vs. Adolescent Onset Subtypes (Conduct Disorder)

Parenting Practices and Disruptive Behavior Disorders

  • Low supervision & involvement
  • Inflexible/rigid discipline
  • Inconsistent discipline
  • Initiation & reciprocation of aggressive/aversive behavior
  • Irritable/explosive discipline
  • Positive reinforcement of challenging behavior
  • Failure to attend to prosocial behavior
  • Attribution of challenging behavior to intentionality; stable global causes

Categorical Descriptions - Advantages:

  • Provide a shared language to aid understanding
  • Guide intervention
  • Facilitate access to funding and services
  • Provide validation/legitimacy; help to avoid conceptualizations of ‘blame’

Categorical Descriptions - Challenges:

  • ‘Sub-clinical’ presentations less readily described/gain less attention
  • Locates problem ‘within the child’
  • Children are a ‘work in progress’
  • Role of labels in shaping subsequent development
  • Instability of diagnosis

Developmental Continuities and Discontinuities

  • Developmentally transient problems
  • Homotypic continuity (continuation of the same disorder/same symptom profile from childhood through to adulthood)
  • Heterotypic continuity (the manifestation of psychopathology changes across development)

Developmental Factors Impacting Diagnosis

  • Younger children can struggle to reflect on/describe internal experiences
  • Looking for behavioral indicators; relying on others’ reports
  • Parent-child concordance poor (especially for ‘internalising’)
  • Establishing distress and impairment – subjectivity; who do we ask?
  • High levels of comorbidity
  • Wide range of what is typical for any given age
  • Heterogeneity of presentations within & across developmental stages

The Developmental Psychopathology Framework

  • A broad integrative, cross-disorder approach to studying the developmental processes and pathways that lead to adaptive and maladaptive behavior across the lifespan
  • Key figures include: Dante Cicchetti, Michael Rutter; Alan Sroufe, Ann Masten

Developmental Psychopathology – Key Concepts

  • Systems Principle
  • Multiple-Levels Principle
  • Normative Principle
  • Developmental Pathways

Systems Principle

Children are embedded within systemic contexts
  • Children influence and are influenced by their environment

Multiple Levels Principle

  • Psychological, Social-Contextual, Biological
    • Individual developmental trajectories are determined by dynamic interactions between changing systems within and outside the person across multiple levels of functioning, from epigenetic and neurobiological, to cultural and societal – a multi-level perspective

Developmental Cascades

  • Maternal smoking; Premature birth; Neurobiological impacts
  • Child ADHD - prominent impulsivity and irritability
  • Aversive interactions with peers
  • Challenges with schoolwork
  • Negative impacts on self-concept
  • Social skills development negatively affected
  • Social withdrawal
  • Depression
  • Substance abuse

Normative Principle

Understanding psychopathology in a developing person requires an understanding of normative development

Developmental Tasks

  • At each stage of development, there are stage-salient issues (developmental tasks) to be confronted and mastered (across domains)
  • Whether these are resolved in adaptive or maladaptive ways influences future adaptation
  • Psychopathology as adaptational failure

Examples of Developmental Tasks by Stage

  • Prenatal Period à Infancy/Toddlerhood
    • Physical growth
    • Brain development
    • Establishing an attachment to one or more specific caregivers
    • Differentiation of self from environment
    • Acquiring functional language
    • Learning to walk
  • Preschool à Middle Childhood
    • Separation from caregivers
    • Regulating emotions and behaviours
    • Acquiring academic skills
    • Developing peer relationships
    • Rule-governed behavior
  • Adolescence
    • Establishing autonomy from parents
    • Consolidating close peer relationships
    • Preparing for a job/career/further education
    • Exploring & developing various aspects of identity

Developmental Pathways

Multiple factors (individual and systemic) interact dynamically and bi-directionally to influence the course of an individual’s development. There are individual risk factors, vulnerabilities, and protective factors for each child. Genetic, biological, and systemic factors interact to influence - but not to determine - outcomes: Probabilistic Epigenesis

Developmental Pathways: Multifinality

  • Various pathways may stem from similar beginnings

Developmental Pathways: Equifinality

Differing beginnings leading to similar outcomes

Vulnerabilities and Risk Factors

  • Vulnerability: A biologically-based factor or trait that renders individuals more susceptible to developing psychopathology in the face of risk factors – e.g.:
    • A genetic predisposition
    • A ‘difficult’ temperament
  • Risk Factor: An environmental experience or circumstance that increases the likelihood that someone will have difficulty with adaptation – e.g.:
    • Poverty
    • Parental psychopathology
    • Community violence
    • Family violence
    • Child maltreatment

ACEs (Adverse Childhood Experiences Study)

  • The three types of ACEs include
    • ABUSE
      • Physical
      • Emotional
      • Sexual
    • NEGLECT
      • Emotional
      • Physical
    • HOUSEHOLD DYSFUNCTION
      • Mental Illness
      • Incarcerated Relative
      • Mother treated violently
      • Substance Abuse
      • Divorce

Exposure to ACEs is common

  • Of 17,000 ACE study participants:
  • 64% have experienced at least 1 ACE
  • 36% O ACEs
  • 26% 1 ACE
  • 16% 2 ACEs
  • 9.5% 3 ACEs
  • 12.4% 4+ ACEs

Types of Experiences (ACEs)

  • percentage of study participants that experienced a specific ACE
  • Child Maltreatment or Developmental Trauma
  • Adverse Childhood Experiences
  • Social Conditions / Local Context
  • Generational Embodiment / Historical Trauma

Protective Factors

  • Factors that promote or maintain healthy development (in face of risk). Internal resources or external /environmental resources.
  • Across disorders, examples that consistently emerge include:
    • Good intellectual functioning
    • An ‘easy’ temperament
    • High self-efficacy
    • An authoritative parenting style
    • A positive stable relationship with a caregiving figure
    • Positive connections with adults outside the family
    • A talent or hobby valued by adults/peers

Resilience

  • In the face of risk factors and vulnerabilities, some will show resilience
  • Resilience = successful adaptation despite exposure to considerable risk
  • Is not a static trait
  • Can vary across contexts and across time

Case Formulation in the Child/Adolescent Context

  • Case formulations need attention to:
    • Developmental factors
    • Systemic considerations unique to youth (e.g., parenting; developmental transitions; school)

Case example

  • A Basic Formulation
    • Presenting
      Difficulties separating from caregivers across settings (Separation Anxiety)
    • Physical aggression
    • Predisposing
      Family history of anxiety - possible biological contribution
      Prematurity
    • Precipitating
      Starting school
      Returning to normalcy’ post COVID-19 lockdowns
    • Perpetuating
      Parental protective (avoidance- promoting) behaviour
      ?Language/ Learning difficulties
  • Protective
    Caring, Supportive, Help-seeking parents
    A specific skill/talent (piano)
    Supportive teachers
    One developing friendship at school