Untitled Quiz

Fear vs. Anxiety

• Anxiety is apprehension about potential future threat.
• Fear is a response to an immediate threat.
• Both fear and anxiety are basic emotions found across species.
• Fear activates the autonomic nervous system for a “fight or flight” response.
• Fear is adaptive but when it occurs unexpectedly without a clear reason, it’s called panic.
• Anxiety can also be adaptive, helping plan and prepare for threats.
• Mild to moderate anxiety can improve performance.

Fear

• The limbic system, particularly the amygdala plays a key role in fear response.
• Fear manifests in cognitive, psychological, and behavioral components.
• Cognitive: "I'm going to die".
• Physiological: increased heart rate, breathing, sweating.
• Behavioral: strong urge to escape.

Anxiety

• More oriented to the future and diffuse.
• Three key aspects:
  • Cognitive/subjective: negative mood, worry, self-preoccupation, struggle with control.
  • Physiological: muscle tension, chronic overarousal.
  • Behavioral: avoidance of potential danger.

Normal Fears and Anxieties

• Mild to moderate fear and anxiety are normal and adaptive.
• Children and teenagers often have rituals to increase control.
• Normal fears change with age, what's normal at one age may be debilitating later.

Anxiety Disorders

• Fears and anxieties become unrealistic, irrational, excessive, and debilitating.
• Cause distress and/or impairment in daily life.

DSM-5 Anxiety Disorders

• Separation Anxiety Disorder (SAD)
• Social Anxiety Disorder
• Selective Mutism
• School Refusal
• Generalized Anxiety Disorder (GAD)
• Specific Phobia
• Panic Disorder
• Agoraphobia
• Obsessive-Compulsive Disorder (OCD)

Separation Anxiety Disorder

• Normal for children from 7 months to preschool years.
• Lack of separation anxiety may indicate insecure attachment.
• SAD is characterized by age-inappropriate, excessive, and disabling anxiety about being apart from parents.
• One of the two most common childhood anxiety disorders.
• Affects 4-10% of children, more prevalent in girls.
• Often occurs alongside other anxiety disorders and depression.
• Earliest reported age of onset for anxiety disorders (7-8 years).

Social Anxiety Disorder

• Marked fear of social or performance situations that involve scrutiny and potential embarrassment.
• Characterized by fear of humiliation, embarrassment, rejection, or offending others.
• These situations almost always provoke anxiety and fear, leading to avoidance or enduring them with intense fear.
• Fear is out of proportion to the actual threat.
• Lasting at least 6 months with significant distress or impairment.
• Affects 6-12% of children, twice as common in girls.
• Often coexists with other anxiety disorders, depression, and substance abuse.
• Most common onset is early to mid-adolescence rare before age 10.

Selective Mutism

• Failure to speak in specific social situations despite speaking freely elsewhere.
• Affects 0.7% of children, with average onset at 3-4 years.
• May be a severe form of social phobia or a precursor, but with distinct differences.

School Reluctance and Refusal

• Refusal to attend or remain in school for the whole day.
• Occurs most often in ages 5-11.
• Fear of school may be due to separation from parents, social anxiety, bullying, or test anxiety.
• Has serious long-term consequences if left untreated.

Generalized Anxiety Disorder

• Excessive anxiety and worry, more days than not for at least 6 months, about numerous events or activities.
• Difficulty controlling the worry.
• Includes symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance.
• Causes significant distress or impairment.
• Not attributed to substance or medical condition.
• Not better explained by another mental disorder.
• Lifetime prevalence rate of 2.2%.
• Equally common in boys and girls, and often accompanied by other anxiety disorders and depression.
• Average age of onset is early adolescence.

Specific Phobia

• Marked fear or anxiety about a specific object or situation.
• Almost always provokes immediate fear.
• Actively avoided or endured with intense fear.
• Fear is out of proportion to the actual danger posed.
• Fear is persistent, lasting at least 6 months.
• Causes significant distress or impairment.
• Subtypes: animals, natural environment, situational, blood-injection-injury, and others.
• Affects 20% of children but few seek treatment.
• More common in girls.
• Onset at 7-9 years, often involving animals, darkness, insects, blood, or injury.
• Early treatment can reduce the risk of developing other anxiety disorders.

Panic Attacks

• Abrupt surge of intense fear or discomfort that peaks within minutes.
• Includes at least 4 of the following symptoms: heart palpitations, tingling, shortness of breath, sweating, hot or cold flashes, trembling, nausea, chest pain, choking, dizziness, feeling unreal, fear of losing control or going crazy, and fear of dying.
• Rare in young children, but common in adolescence.
• Linked to pubertal development.
• Key aspect is the person's catastrophic misinterpretation of bodily sensations.

Panic Disorder

• Recurrent, unexpected panic attacks.
• Persistence of concern about future attacks or consequences for at least a month after one attack.
• Significant behavioral changes related to the attack for at least a month.
• Not attributable to substance or medical condition.
• Not better explained by another mental disorder.

Agoraphobia

• Marked fear or anxiety about at least two of the following: public transportation, open spaces, enclosed spaces, standing in line or in a crowd, being outside of the home alone.
• Fear stems from concern about difficulty escaping, help being unavailable, or experiencing panic-like or embarrassing symptoms.
• Situations almost always provoke fear.
• Actively avoided, requiring a companion, or endured with intense fear.
• Fear is out of proportion to the actual danger posed.
• Persistent, lasting at least 6 months.
• Causes significant distress or impairment.
• Panic attacks are common in teens (16%), panic disorder is less common (2.5% of teens 13-17 years).
• Panic attacks are more common in adolescent females.
• Often coexists with other anxiety disorders or depression.
• At risk for suicidal behavior and substance abuse.
• Onset of first panic attack: 15-19 years, 95% of panic disorder cases happen after puberty.
• Lowest remission rate among anxiety disorders.

Obsessive-Compulsive Disorder

• Characterized by obsessions and compulsions.
• Obsessions: recurrent and persistent thoughts, ideas, impulses, or images that are intrusive and unwanted, causing anxiety or distress.
• Compulsions: repetitive behaviors or mental acts that feel driven to perform in response to obsessions or rigid rules, aiming to prevent or reduce anxiety or distress, or prevent dreaded situations.
• Time consuming (more than 1 hour/day) or causing significant distress or impairment.
• Not attributed to substance or medical condition.
• Not better explained by another mental disorder.
• Affects 1-2.5% of children and adolescents.
• Twice as common in boys in clinic-based studies.
• Often coexists with other anxiety disorders, depressive disorders, and disruptive behavior disorders.
• Average onset is 9-12 years, with peaks in early childhood and early adolescence.
• Chronic disorder: two-thirds continue to have OCD 2-14 years after diagnosis.

Associated Characteristics of Anxiety Disorders

• Includes cognitive disturbances, physical symptoms, social and emotional deficits, and depression.

Cognitive Disturbances

• Disturbed information perception and processing.
• Intellectual deficits: despite normal intelligence, difficulties in memory, attention and speech.
• High anxiety interferes with academic performance.
• Social anxiety can lead to school dropout.
• Threat-related attentional biases: selective attention to potentially threatening information.
• Cognitive errors and biases: perception of threats leads to danger-confirming thoughts.

Physical Symptoms

• Somatic complaints like stomach aches or headaches are more common in GAD, panic disorder, and SAD.
• 90% of children with anxiety disorders have sleep problems.

Social and Emotional Deficits

• Display low social performance and high social anxiety.
• See themselves as shy and socially withdrawn.
• Report low self-esteem, loneliness, and difficulties initiating and maintaining friendships.

Clark and Wilson's Tripartite Model

• Model explains the shared and distinct features of anxiety and depression.
• Shared: negative affect
• Anxiety: fear, worry, and avoidance
• Depression: worthlessness, hopelessness, and anhedonia

Gender, Ethnicity and Culture

• Higher incidence of anxiety disorders in girls suggests genetic influences and neurobiological differences, but also varying social roles and experiences.
• Anxiety is pervasive across cultures.
• Ethnicity and culture impact expression, developmental course, and interpretation of anxiety symptoms.

Theories and Causes of Anxiety Disorders

• Psychoanalytic: anxieties and phobias are defense mechanisms against unconscious conflicts rooted in early upbringing.
• Behavioral and Learning: fears and anxieties learned through classical conditioning and maintained through operant conditioning (two-factor theory).
• Bowlby's Attachment Theory: fearfulness stems from the emotional attachment needed for survival, insecure attachment leads to a perception of the environment as undependable, unavailable, hostile, and threatening.

Temperament

• Variations in behavioral responses to novelty, influenced by inherited differences in neurochemistry of certain brain structures.
• Amygdala: reacts to unfamiliar or unexpected events.
• Behavioral inhibition (BI): low threshold for novel and unexpected stimuli, greater risk of anxiety disorders.

Family and Genetic Risk

• Genetic component: ⅓ of variance in childhood anxiety symptoms is genetic.
• Genes linked to broader anxiety-related traits, like behavioral inhibition.
• No direct link between specific genes and specific anxiety disorders.

Neurobiological Factors

• Entire anxiety response system controlled by:
  • Sympathetic nervous system
  • Hypothalamic-pituitary-adrenal (HPA) axis
  • Limbic system (amygdala; hippocampus)
• Overactive behavioral inhibition system (BIS), possibly shaped by early life stressors.
• Brain abnormalities implicated in anxious and behaviorally inhibited children.
• Relevant neurotransmitter system: Y-aminobutyric acidergic (GABA-ergic) system.

Error-Related Negativity (ERN)

• Measured from EEG, reflects electrical changes at the scalp when making mistakes during tasks.
• Changes in ERN at age 6 can predict new onset anxiety disorders at age 9.

Family and SES Factors

• Parenting practices: Overinvolvement, intrusiveness, limitation of child’s independence associated with anxious children.
• Family dysfunction: Prolonged exposure to high levels of family dysfunction linked to anxious behaviors.
• Low SES: Associated with increased risk of anxiety disorders.
• Insecure early attachment: Impacts development of anxiety.

Treatment of Anxiety Disorders

• Behavior Therapy: Gradual exposure to feared stimuli with coping strategies besides escape or avoidance.
• Systematic Desensitization: New evidence suggests exposure without relaxation is more effective.
• Intensive exposure therapy: Effective in 1 day or 1 week.
• Response prevention: Prevents escape, avoidance, or compulsions (ExRP).
• Modeling and reinforced practice: Learning by observing and practicing.

CBT

• Most effective treatment for anxiety disorders.
• Combined with exposure-based treatments.
• Coping Cat: protocol for child anxiety disorders, combines skill training with exposure.
• Computer-based CBT is also effective.

Family Interventions

• Addressing children’s anxiety disorders within the family context can lead to greater impact and lasting effects.
• Provides education about the disorder.
• Helps families cope with their feelings.
• Focuses on limiting accommodations (OCD).

Medications

• Can reduce symptoms, especially for OCD.
• Most common: selective serotonin reuptake inhibitors (SSRIs).
• Most effective when combined with CBT.

Prevention and Stepped Care Approaches

• Programs for behaviorally inhibited children with anxious parents.
• Intervention depends on severity:
  • Guided self-help, parenting books, internet programs
  • Brief CBT, groups
  • Individual CBT and medications.

Terminology

• Mood disorder = affective disorder
• Depression: pervasive, unhappy mood
• Dysphoria: prolonged sadness
• Anhedonia: loss of interest, pleasure, joy
• Irritability: easy annoyance and “touchiness”
• Mania: abnormally elevated and expansive mood, increased goal-directed activity and energy, feelings of euphoria.
  • Euphoria: exaggerated sense of well-being
  • Expansive: over the top, flamboyant

Overview of Mood Disorders

• Extreme, persistent, or poorly regulated mood states (episodes).
• Spectrum from severe depression to extreme mania.
• DSM-5 divides mood disorders into:
  • Depressive Disorders: excessive unhappiness and loss of interest.
  • Bipolar Disorder: mood swings between sadness and elation/ expansiveness.

Mood Disorders vs. Normal Moods

• Mood disorders are different from normal mood swings:
  • More severe alterations
  • Last much longer
  • Distress and impairment are present.
• Main feature is extreme mood:
  • Depression: extraordinary sadness and dejection
  • Mania: Intense and unrealistic excitement and euphoria

Types of Mood Disorders

• Unipolar Depressive Disorder: only depressive episodes.
• Bipolar Depressive Disorder: manic and depressive episodes.

Depressive Disorder

• Characterized by pervasive unhappiness, more severe than occasional blues.
• Interferes with daily routines, social relationships, academic performance, and overall functioning.
• Often accompanied by anxiety or conduct disorders.
• Frequently overlooked and untreated.

Depression and Development

• Expression of depression changes with age:
  • Children under 7: diffuse and less easily identified.
    • Anaclitic depression (Spitz): Infants raised in emotionally deprived environments show depression-like reactions.
  • Preschoolers: somber, tearful, lack exuberance, clingy, whiny.
  • School-aged children: above, plus irritability, disruptive behavior, tantrums.
  • Preteens: above, plus self-blame, low self-esteem, persistent sadness, social inhibition.

Anatomy of Depression

• Depression (symptom): feeling sad or miserable without reason, common at all ages.
• Depression (syndrome): group of symptoms that occur together more often than by chance.
• Depression (disorder):
  • Major Depressive Disorder (MDD)
  • Persistent Depressive Disorder (P-DD/Dysthymia)
  • Disruptive Mood Dysregulation Disorder (DMDD)

Major Depressive Disorder

• Criteria for diagnosis are the same for school-age children and adolescents.
• Depression may be missed as other behaviors are more attention-grabbing.
• Specific features like irritability are more common in children and adolescents.
• Affects 2-8% of children ages 4-18.
• Rare in preschool and school-aged children, but increases significantly by adolescence.
• Increase in adolescence may be due to biological maturation interacting with developmental changes.

Comorbidity

• 90% of young people with depression have one or more other disorders; 50% have two or more.
• Most common: anxiety disorders, persistent depressive disorder, conduct problems, ADHD, substance use disorder, and personality disorders (especially borderline).
• Comorbid conditions may vary by disorder and sex.

Onset, Course, and Outcome

• May be gradual or sudden.
• Often a history of milder episodes.
• Age of onset typically between 13-15.
• Average episode length is eight months.
• Longer duration if a parent has a history of depression.
• Most children recover but have a high risk of recurrence.
• About one-third develop bipolar disorder within 5 years after depression onset (bipolar switch).

Persistent Depressive Disorder

• Symptoms of depressed mood occur on most days and persist for at least one year.
• At least two somatic or cognitive symptoms present.
• Less severe but more chronic than MDD.
• Characterized by poor emotion regulation: constant sadness, feeling unloved, self-deprecation, low self-esteem, anxiety, irritability, anger, and temper tantrums.
• Children with both MDD and P-DD are more severely impaired.
• P-DD rates are lower than MDD (1% of children, 5% of adolescents).
• Most common comorbid disorder is MDD, nearly 70% of children with P-DD may experience an episode of major depression.
• About 50% of children with P-DD also have nonaffective disorders like anxiety disorders, conduct disorders, or ADHD.

Onset, Course, and Outcome

• Most common age of onset: 11-12 years.
• Childhood-onset P-DD can last 2-5 years.
• High risk for developing other disorders: MDD, anxiety disorders, conduct disorder.
• Adolescents with P-DD receive less social support than those with MDD.

Disruptive Mood Dysregulation Disorder

• Chronic, severe, persistent irritability: temper outbursts and irritable or angry mood.
• New to DSM-5, created due to concerns about overdiagnosis of bipolar disorder in young children.
• Characterized by chronic irritability and frequent, severe temper outbursts out of proportion to the situation.
• Does not experience the manic or hypomanic episodes of bipolar disorder.
• Not typically developing adult bipolar disorder, but at elevated risk for depression and anxiety as adults.

Associated Characteristics of Depressive Disorders

• Intellectual and academic functioning: difficulty concentrating, loss of interest, slowness of thought and movement negatively impacts intellectual and academic functioning.
• Cognitive biases and distortions: selective attention to negative information, feelings of worthlessness, negative beliefs, attributions and failure, self-critical and automatic thoughts, depressive ruminative style, pessimistic outlook, and negative self-esteem.
• Social, peer, and family problems: Few close friendships, loneliness, impaired social skills, social withdrawal, ineffective coping in social situations, co-rumination, less supportive and more conflicted relationships with parents and siblings, social isolation from family.

Depression and Suicide

• Most youngsters experience suicidal thoughts, one-third who think about it attempt it.

Behavioral Theories of Depression

• Learning, environmental consequences, skills and deficits influence the onset and maintenance of depression.
• Lack of response-contingent positive reinforcement: decrease in positive rewards and increase in negative events leads to depression, then fewer constructive behaviors, perpetuating the cycle.

Cognitive Theories of Depression

• Relationship between negative thinking and mood.
• Depressogenic cognitions: negative perceptual and attributional styles are associated with depressive symptoms.
• Beck's cognitive model: depressed individuals interpret life events negatively.
  • Biased and negative beliefs act as filters.
  • Three areas of cognitive problems:
    • Information-processing biases
    • Negative outlook about oneself, the world, and the future (negative cognitive triad)
    • Negative automatic thoughts and dysfunctional beliefs (schemas)

Helplessness Theory

• Pessimistic attributional style: attributing negative events to internal, global, and stable causes.
• Pessimistic attribution style + uncontrollable negative events = depression

Learned Helplessness Theory

• Depression results when individuals feel they have no control over their life's reinforcements.

Other Theories of Depression

• Interpersonal models
• Socio-environmental models: diathesis-stress model
• Neurobiological models

Causes of Depression

• Multiple pathways to depression are likely:
  • Genetic risk influences: neurobiological processes and early temperament characterized by oversensitivity to negative stimuli, high negative emotionality, and disposition to negative affect. These are shaped by negative experiences in family and with peers.

Biological Markers and Correlates

• Heritability (30%-80%) and genetic risk: focus on chromosomes or regions, genes involved in serotonin reuptake are critical.
• Decreased response to reward.
• Sensitivity to stress: elevated amygdala activity, hippocampus and stress response, HPA-axis and cortisol response.

Family Influences

• When children are depressed: families display more critical and punitive behavior towards the depressed child.
• When parents are depressed: depression impacts the parent's ability to meet the child's needs, increasing the child's risk for depression, phobias, panic disorder, and alcohol dependence.

Stressful Life Events

• Triggers for depression:
  • Interpersonal stress and losses, like death, abandonment, rejection.
  • Life changes, like moving.
  • Violent family or neighborhood environment.
  • Daily hassles and other non-severe stressful life events.

Emotional Regulation

• Children experiencing prolonged emotional distress, sadness, or exposure to maternal negative moods may have difficulty regulating negative emotions and are prone to depression.
• They may use avoidance or negative behaviors to regulate distress rather than problem-focused and adaptable coping strategies.

Treatment of Depression

• Psychosocial Interventions:
  • Behavior Therapy: Increase pleasurable activities and events, develop reinforcement-seeking skills.
  • Cognitive Therapy: Identify, challenge, and modify negative thought processes.
  • Cognitive-behavioral Therapy (CBT): Combines behavioral and cognitive therapies.
  • Interpersonal Psychotherapy for Adolescent Depression (IPT-A): Focus on depressive symptoms and their social context.

Challenging Negative Thoughts:

• Is there substantial evidence for my thought?

Medications

• Can reduce symptoms, especially for OCD.
• Most common: selective serotonin reuptake inhibitors (SSRIs).
• Medications are most effective when combined with CBT.

Interpersonal Psychotherapy (IPT)

• A short-term therapy developed for adult depression
• Focuses on interpersonal factors that may contribute to psychological problems
• Emphasizes interpersonal rather than intrapsychic factors
• Aims to improve interpersonal skills and communication

IPT Basic Principles

• Identifies specific problem areas for intervention
• These include: grief, interpersonal role disputes, role transitions, and interpersonal deficits
• Emphasizes effective communication and problem-solving techniques
• Practices these techniques in session and encourages experimentation outside of session

Medications for Depression in Youth

• Tricyclic antidepressants are not effective for youth and have potential cardiovascular side effects
• SSRIs are commonly prescribed for childhood depression
• Support for efficacy exists, but potential side effects include suicidal thoughts, self-harm, and long-term effects on the developing brain
• Up to 60% of depressed youngsters may respond to a placebo.

Bipolar Disorder (BD)

• Characterized by alternating periods of elevated mood and depression
• Elevated moods can range from elation to anger and hostility.

Bipolar Disorder in Young People

• Often experience significant impairment in functioning including hospitalization, depression, medication treatment, disruptive behaviors, and anxiety disorders
• May experience psychotic symptoms and suicidal thoughts/attempts.

Bipolar Disorder Symptoms

• Include restlessness, agitation, sleeplessness, pressured speech, flight of ideas, racing thoughts, sexual disinhibition, surges of energy, and grandiose beliefs.
• Atypical symptoms in youth may include: volatile mood swings, psychomotor agitation, and mental excitation.

Bipolar Disorder Types

• Bipolar I disorder includes manic episodes that cycle with major depressive episodes.
• Bipolar II disorder includes hypomanic episodes that cycle with major depressive episodes.
• Cyclothymic disorder includes hypomanic episodes that cycle with dysthymia.

Bipolar Disorder Prevalence

• Lifetime estimates range from 0.5-2.5% of youths aged 7-21 years old.
• Accurate diagnosis can be challenging.
• Bipolar II and Cyclothymic disorders are more common in youth than Bipolar I disorder.
• Rapid cycling episodes are frequent.
• Extremely rare in young children, but rates increase significantly after puberty.

Bipolar Disorder Comorbidity

• High rates of co-occurring mental health disorders are common.
• Most common include: separation anxiety disorder, generalized anxiety disorder, ADHD, conduct disorders, and substance use disorders.
• Suicidal thoughts and ideation are also common.
• Co-occurring medical problems include: cardiovascular and metabolic disorders, epilepsy, and migraine headaches.

Bipolar Disorder Onset, Course, and Outcome

• About 60% experience a first episode before age 19.
• Onset before age 10 is extremely rare.
• Adolescents with mania often have: psychotic symptoms, unstable moods, and severe behavioral deterioration.
• Earlier onset is often associated with a chronic course and resistance to treatment.
• Long-term prognosis is poor.

Bipolar Disorder Causes

• Limited research into the causes of BP in children and adolescents.
• Adult research suggests a combination of genetic vulnerability and environmental factors (e.g., life stress, family disturbances)
• Multiple genes may be involved, but genetic predisposition does not guarantee development of BP.
• Brain imaging studies suggest mood fluctuations are related to abnormalities in brain regions associated with emotional regulation: prefrontal and anterior cingulate cortex, hippocampus, amygdala, thalamus, and basal ganglia.

Bipolar Disorder Treatment

• No cure exists.
• Multimodal treatment plans include:
• Symptom monitoring
• Patient and family education
• Matching treatments to individual needs
• Medication administration (e.g., lithium)
• Psychotherapeutic interventions to address symptoms and psychosocial impairments.

Trauma and Stress-Related Disorders

• New category in the DSM-5, previously categorized as anxiety disorders.

Trauma and Stress

• Traumatic events: exposure to actual or threatened harm or fear of death or injury, considered extreme or uncommon stressors.
• Stressful events: more common and less extreme than traumatic events.

How Stress Affects Children

• Can be strengthening if it does not exceed the child's coping abilities.
• Manageable stress is mild, predictable, and brief.
• Parental support is crucial.

Stress Overload

• Allostatic load: chronic stress leads to progressive wear and tear on biological systems.
• Stressful events affect children in unique ways:
• Hyperresponsive reaction: overly sensitive to stress.
• Hyporesponsive reaction: blunted response to stress.

Maltreatment

• One of the most impactful types of childhood stress and trauma.
• Four main types: neglect, physical abuse, sexual abuse, and emotional (psychological) abuse.

Neglect

• Failure to provide for a child's basic physical, educational, and emotional needs.
• Three forms: physical, educational, and emotional neglect.
• Outcomes: health problems, fluctuating activity levels, lack of enthusiasm, poor impulse control, and high dependence.

Physical Abuse

• Multiple acts of physical aggression.
• Often unintended results of over-discipline or severe physical punishment.
• Outcomes: disruptiveness and aggression.

Emotional (Psychological) Abuse

• Repeated acts or omissions causing or potentially causing cognitive, emotional, or mental disorders.
• Includes: extreme punishment, verbal threats, scapegoating, belittling, and name-calling.
• Often present in other forms of abuse, making it challenging to isolate its specific consequences.

Sexual Abuse

• Includes: sexual touching, rape, incest, sodomy, exhibitionism, and commercial exploitation.
• Outcomes likely include: health problems, anger, anxiety, depression, attention difficulties, withdrawal, temporary regression, acting out, and sexualized behavior.
• Degree of severity depends on: duration, frequency, use of force, closeness to perpetrator, and support from significant others.
• Symptom emergence may be delayed.

Characteristics of Children Who Suffer Maltreatment

• Maltreatment is never the child's fault.
• Child’s age and sex are linked to abuse risk:
• Younger children are more at risk for physical neglect.
• Toddlers, preschoolers, and young adolescents are more prone to physical and emotional abuse.
• 80% of sexual abuse victims are female, and sexual abuse is more common in youths 12 and older.
• Racial differences in abuse rates may be due to poverty, stress, and disadvantage.

Maltreated Children Face Paradoxical Dilemmas

• Victims desire an end to the violence but also want to belong.
• Affection and attention may coexist with violence and abuse.
• The intensity of violence can increase over time, but may also decrease or stop altogether.

What Children Need for Healthy Development

• Foundational and expectable environment:
• Control and direction alongside stimulation and sensitivity.
• Protective and nurturing adults.
• Opportunities for socialization.
• Supportive family and peer contact.
• Opportunities to master their environment.

Importance of Healthy Families - Building Blocks of Prevention

• Parents need:
• Knowledge of child development and expectations.
• Adequate coping skills for parental stress.
• Opportunities to develop attachment and communication.
• Adequate parental knowledge of home management.
• Provision of necessary social and health services.

Risk Factors

• Limited exposure to positive parental models and support.
• Higher levels of stress.
• Information processing disturbances.
• Lack of knowledge of development.
• Chronic social isolation - more common in neglectful families.
• Neglectful parents disengage under stress, while abusive parents become emotionally reactive.
• Racism and inequality.
• Substance abuse and personality disorders.
• Long-held social customs that endorse the use of physical force to resolve child conflicts.

An Integrated Model of Physical Child Abuse

• Multifaceted factors contributing to abuse:
• Antecedents: factors that may contribute to abuse.
• Triggering events: events that may set off the abuse.
• Child characteristics: factors related to the child that may influence abuse.
• Social support and services: the presence or lack of support and services for the family.

Trauma and Stress-Related Disorders

• New category in the DSM-5, previously categorized as anxiety disorders.

Reactive Attachment Disorder (RAD)

• Characterized by:
• Failure to seek comfort from caregivers and failure to respond to caregivers' efforts to provide comfort.
• Minimally responsive to others socially and emotionally, limited positive affect, and unexplained irritability, sadness, or fearfulness.
• Experiences a pattern of insufficient care.
• Emotional disturbances developed following inadequate care.

Disinhibited Social Engagement Disorder (DSED)

• Characterized by:
• Overly familiar and culturally inappropriate behavior with strangers.
• Behaviors go beyond mere impulsivity and include socially disinhibited behavior.
• Experiences a pattern of extreme insufficient care.

Characteristics of RAD and DSED

• Typically diagnosed between 9 months and 5 years old.
• Often accompanied by delays in cognitive and socioemotional development.
• DSED tends to be more persistent than RAD.
• Little known about their causes beyond early inadequate care.

Post-Traumatic Stress Disorder (PTSD) (Adults and Children over the Age of 6)

• Characterized by:
• Exposure to actual or threatened death, serious injury, or sexual violence through directly experiencing, witnessing, learning about, or experiencing repeated exposure to details of a traumatic event.
• Re-experiencing the traumatic event.
• Avoidance of trauma-related stimuli.
• Negative cognitions and moods.
• Increased arousal and reactivity.

PTSD Symptom Expression in Children

• Separate diagnostic criteria for children under 6.
• Repeated exposure to details is removed.
• Re-experiencing: trauma themes or reenactment in play, nightmares instead of flashbacks.

Prevalence and Course

• Approximately two-thirds of children experience one or more potentially traumatic events by age 16.
• Prevalence of PTSD in adolescents: 3.7% (boys) and 6.3% (girls).
• Trauma severity predicts PTSD likelihood.
• PTSD symptoms are more common in children exposed to life-threatening events or prolonged interpersonal trauma.

Associated Problems and Adult Outcomes

• PTSD can become a chronic psychiatric disorder if left untreated.
• Persistent mood and affect disturbances.
• Emotional and behavioral issues.
• Girls tend to exhibit more internalizing symptoms.
• Boys tend to exhibit more externalizing symptoms.

Acute Stress Disorder

• Similar to PTSD but with earlier onset (within 1 month of trauma) and a shorter course.
• Occurs in 10-20% of children following trauma.
• Diagnostic category is used when symptoms develop shortly after a traumatic event and last at least 2 days.
• Allows for immediate treatment.
• Diagnosis can shift to PTSD if symptoms persist.

Adjustment Disorder

• Psychological response to a common stressor.
• Can be in response to singular or multiple events.
• Occurs within 3 months of the stressor.
• Results in clinically significant behavioral or emotional symptoms, which must exceed what is expected.
• Symptoms disappear when the stressor ends or the individual adapts.

Stress and Mental Health: Etiology

• Trauma exposure.
• Developmental level.
• Pre-disaster characteristics (e.g., anxiety levels).
• Cognitive appraisal of the situation.
• Coping styles.
• Aspects of the traumatic experience.

Causes: Poor Emotion Regulation

• Maltreatment in infancy and toddlerhood affects the development of reciprocal interactions with caregivers.
• Insecure-disorganized attachment develops.
• Difficulty understanding, labeling, and regulating internal emotional states occurs leading to:
• Inhibition of emotional expression and regulation.
• Increased fear and alertness.

Causes: Emerging Views of Self and Others

• Maltreatment hinders the development of healthy views of self and surroundings.
• Emotional and behavioral problems arise.
• Negative representational models of self and others develop leading to:
• Feelings of inner "badness," self-blame, shame, or rage.
• Powerlessness and betrayal are internalized as part of self-identity.

Causes: Neurobiological Development

• Children and adults with a history of child abuse exhibit long-term alterations in the hypothalamic-pituitary-adrenal (HPA) axis and norepinephrine systems, significantly impacting stress responsiveness.
• Affected brain areas include: hippocampus (learning and memory), prefrontal cortex (planning and decision-making), and amygdala (emotion regulation).
• Acute and chronic stress associated with maltreatment can cause changes in brain development and structure from an early age.
• The neuroendocrine system becomes highly sensitive to stress, leading to the release of cortisol (fight-or-flight response) and elevated stress hormone levels that can impact brain development.