PSYC 3220 Child Psychopathology Lecture Notes Fall 2024 PDF

PSYC 3220 Child Psychopathology Notes Instructor Dr. Carlin Miller Fall 2024 Week 1 - Introduction (Chapter 1) - (Research Issues Chapter 3) Week 2 - (Major Theories Processes Chapter 2) - (Processes of Assessment, Treatm...

PSYC 3220 Child Psychopathology Notes Instructor Dr. Carlin Miller Fall 2024 Week 1 - Introduction (Chapter 1) - (Research Issues Chapter 3) Week 2 - (Major Theories Processes Chapter 2) - (Processes of Assessment, Treatment, & Diagnosis Chapter 4) Week 3 - Counter Narratives in Child Psychopathology - DSM-5-TR Issues Week 5 - ADHD (Chapter 8) - Tic Disorders (Chapter 8) Week 6 - Disruptive, Impulse-control and Conduct Problems (Chapter 9) Week 7 - Depressive Disorders Non-Suicidal Self-Injury and Suicidal Behaviour (Chapter 10) Week 8 - Anxiety Disorders and Obsessive-Compulsive and related disorders (Chapter 11) Week 10 - Trauma and stressor-related disorders (Textbook chapter 12) - Feeding and eating disorders (Textbook chapter 14) Week 11 - Health-related disorders - Elimination disorders Week 12 - Substance use disorders Counter Narratives in Child Psychopathology Aren't Mental health problems a modern condition? - Greek and Roman empires - War heroes were a burden - Abuse was really common They would see it as possession by the demon - John Locke (Beginning of people being seen as emotionally sensitive, esp children). - Nina Holingswotth (Suggested the problems were adults in poor behaviour management) - Benjamin Rush (Came up with this idea of moral insanity). - Dorothea Dix (Beginning mid 19 century, she started to set up institutions that were intended to help others). - These are all 5 white people (Beginning of mental health) Chapter 1 Reading/Textbook Notes Introduction to Psychopathology in Children and Adolescents Historical Views and Breakthroughs: - Early psychological attributions were influenced by the belief that disorders resided within individuals. - Eugenics and other outdated views contributed to harmful societal attitudes and the segregation of children with mental disabilities. - The 19th century saw the rise of more humane approaches, particularly influenced by figures such as John Locke. Defining Psychopathology: - Psychopathology is understood as patterns of behavioral, cognitive, emotional, or physical symptoms that are distressing and impair function. - It includes discussions on competence, which refers to a child's ability to adapt in different environments. Risk and Resilience: - This section examines the concept of resilience, the ability to withstand stress and adversity. - Discusses factors that influence resilience, such as intelligence, support systems, and community involvement. Key Factors Affecting Psychopathology:  - Socioeconomic disadvantage, gender differences, race, and child maltreatment are central to understanding different rates and expressions of psychopathology in children CHILD PSYCHOPATHOLOGY RESEARCH WHY IS SCIENCE IGNORED? - Experts disagree with each other This is normal Research subject at hand with curiosity: TV in young children causes ADHD. - With this, children with attention problems, parents put them in front of it so they know it's a safe place, but their attention becomes worse. - Science has been ignored in american politics - Media wants a soundbite With human beings we are chaotic beings, people want information short and straightforward. The media is not set up to have 12 lines, nobody would read them. - Conflicts in findings Data and research keeps on changing which can possibly make it inaccurate. In child psychopathology the findings are shifting and changing all the time. - Recommendations are constantly shifting - N=1 prob We are all individuals who are unique, and know people who are fully unique. It is not always possible that you are an outlander, people usually fit within a group. - EX: most people are right handed because most of the population are right handed. - EX: having eyes and other facial aspects, because its a genetic disposition. We are unique but we can always find exceptions. - Solutions and answers are often complex Ignoring science because science is hard. Thinking about ADHD, autism because it's too complex. - Many people don’t understand the research process Human behaviour research process is different from any other research process. ETHICS OF RESEARCH WITH CHILDREN - Informed consent/assent The person performing consent isn't the child, it is the caregivers, but then you have to get the child to say yes. Children in Canada at 13 years old are allowed to provide informed consent for health based research. - Voluntary participation: Both from a parent and child perspective. - Confidentiality Needs to stay within the research space, this can get tricky within the clinical research area, it can be reported under circumstances.  - Non-harm Non-malfisents (the idea that there is no harm to participants) EPIDEMIOLOGY WHAT IS IT? - A public health ideology - Tell us how often a disorder happens - Who does it happen to? - What are the risk factors for this disorder? - What are the common comorbidities? Females who have ADHD who also have an anxiety disorder - The rates of the disorder depend on the factors? - What diagnostic to use? - Are they getting treatment for a specific disorder? - 10-20 of children meet criteria for a mental health disorder at any given time. Chronic Non chronic - Many more of supplemental symptoms meaning they don't have it but they're leading down that road. - Half have an undiagnosed mental health disorder. PSYCHOMETRIC CONSIDERATIONS - Standardization Test the same way every time. Ensures part of the validity and reliability process. The results that we get arent the results of another factor. - Reliability Idea that do we get the same results Method reliability - Validity Assumes reliability. Is this real? TYPES OF DATA COLLECTION - REPORTING Interviewing, questionnaire forms. Peer evaluations, parent interviews, teachers. One way to get information - PSYCHOPHYSIOLOGICAL DATA Something rarely used with kids. Apple watch, fit bit tracks that as well. Used for research. Adults with anxiety disorders are not common. - NEUROIMAGING (No data that is perfectly objective) STRUCTURAL Scans - What is where and how it is, CT, ex-ray FUNCTIONAL - The brain in action - Thinking , sleeping, breathing doing, imagining - Neuroimaging is expensive and only used for research.  - OBSERVATIONS NATURALISTIC - Watching someone in their own environment - Shows us how people behave in the places they inhabit - Shows how people act in a natural environment STRUCTURED - Places like clinical, lab places. - Giving a task for the child. - Highly structured setting - TESTING Academic achievement test IQ test Don't always give us the whole story - After putting everything together, we can determine something about child psychopathology. RESEARCH DESIGN - EXPERIMENTAL VS. QUASI-EXPERIMENTAL Research on Child psychopathology is not usually experimental because you can't randomly assign participants. Experimental research is very uncommon. Most of the time it is Quasi-experimental design with controlled variables. - The problem is we can't test direction effects, but can develop hypotheses. - PROSPECTIVE VS. RETROSPECTIVE A prospective study we enroll a lot people early on (Recruitment) - Following them based on the variables of interest The problem with Prospective research design, it is very expensive, and time consuming because you have to keep up with your research participants. With retrospective research design it looks at the beginning of data. The problem with this is memory being asked what happened in the past. They are problematic because there is no memory of what happens and it is cost-efficient. - SINGLE CASE EXPERIMENTAL DESIGNS VS. BETWEEN GROUP COMPARISONS Single case designs we enroll someone and collect multiple data collections at multiple different times. Withdraw the treatment, testing, add the therapy, change in environment (ON & OFF EFFECT) More common in rare disorders. For group comparisons, disorders can be compared from past, present and future. - Collecting a pair of samples to pair groups. - CROSS-SECTIONAL VS. LONGITUDINAL STUDIES Cross- sectional collects data at one point in time. Becoming very hard to publish. DUNEDIN LONGITUDINAL STUDY - Is a city, far end of the world. - To get there from LA is a 14 hours flight.  - Hundred thousand people - Started in 1971 and 1972. - Participants were born in 1972-1973. - They recruited more than a thousand people Are you part of the sample? (This question is very common) - They are still collecting data till this day, contacting participants - They have maintained this sample, and have data from 6 month intervals to middle aged now. - Used to support the legalization of marjuna in the state of colorado. - Not just child mental health it's everything. Chapter 3 Reading/Textbook Notes Research Scientific Approach: - Emphasizes the importance of evidence-based practice in understanding and treating psychopathology. - Discusses the research process and the necessity of systematic inquiry, including the formulation of hypotheses and the use of control groups. Methods of Studying Behavior: - Covers different research methods, such as longitudinal studies, cross-sectional studies, and case-control studies. - Ethical concerns are paramount, including ensuring confidentiality and informed consent in child research. Research Strategies: - Experimental designs allow researchers to isolate cause-and-effect relationships. - Correlational studies are useful in identifying associations between different factors without establishing causation. Challenges in Research: - Challenges in distinguishing valid from invalid claims, as well as the skepticism toward scientific research in child psychopathology. Theories and Causes of Child Psychopathology Major assumptions in developmental psychopathology - Developed by Dante Cicchetti - Normal development informs our understanding of atypical development - Behaviour is multiply determined Evocative Effects - These occur when a child’s genetically influenced behaviors or characteristics evoke specific responses from their environment. - Example: A child who is naturally outgoing and energetic (a trait influenced by genetics) might elicit more social interaction and positive attention from teachers and peers, reinforcing their sociable behavior. Passive Environmental Effects:  - These arise from the environment that parents create for the child, which is influenced by the parents' own genetics. Since parents provide both the genes and the environment, these effects are "passive." - Example: Parents who are intellectually inclined (and pass down genetic predispositions for intelligence) may fill the home with books and educational materials, fostering a rich learning environment that enhances the child’s intellectual development. - Child and the environment are interdependent They're interacting with each other This is important because kids shape their own environment Babies and toddlers, school age, young adults shape their botnets and the behaviours Disorders do not exist within the child they exist in the set - Behaviours occur in continuity and discontinuity Warning us about something that is coming in the near future With continuity sometimes behaviours are connected over time Major Theories - SYSTEMS THEORY (BRONFENBRENNER) Russian worked with stanford The idea that we all exist in a series of constives influences Things come and interact in the little circle Microsystems (Directly interacting with the world 1-1) Mesosystems Macrosystems Biological models, cultural (Chronosystems) Consecutive circles (Moving through time) Any time we look at a child with a disorder or not we need to consider what is this childs context like. (Think about the systems in which the child exist) - BEHAVIORAL MODELS (PAVLOV, WATSON, SKINNER) Behaviour is observable Behaviour has an empirical basis (Its measurable) Behaviour is culturally relativistic (Different people from different cultures have different behaviours) Concerned about the antecedent (What happened before; plays a role in the behaviour) and the consequence (What happens after; whether the behaviour will happen again) Social learning and socio- cognitive models - BANDURA Canadian at stanford Said that we learn from our own experiences, and we learn from watching the experiences of someone else and we develop our own internal working models These internal working models become like scripts for how we go through our days.  The Bobo doll Experiment (The idea so kids can work out their aggression, but he learned that they were just watching others) - DODGE The idea of a hostile attribution bias (For some people Internal working models can go through a negative lens) Our past experiences and the past experiences of others influence our present experiences, and of others which in turn influences what will happen down the road. Biological foundations - Brain development, structure and function Continues to develop and then decline up until the last breath has been taken The oldest parts of the brain (The back of the brain) The front of the brain (Frontal cortex) Early 30s brain starts to diminish - Neurotransmitters Chemical signs involved in communication within the brain 1. GABA: Tied up with anxiety disorders 2. Dopamine: Tied up in ADHD, Schizophrenia, and Parkisons disorder, mood disorders 3. Serotonin: Tied Mood disorders, OCD and schizophrenia - The brain influences all aspects of human behaviour, cognition, human emotion TEMPERAMENT (ROTHBART) - Took the work of Thomas and Chess, and made it better - Looked at how kids respond to environmental events (Surprises, demands, feelings) - What we measure is the biological precursor of behaviour. - Temperament is what becomes personality over the life span - The Heritability of temperament is about 50% (½) of our temperament when we come into the world is fully genetic and the other half is formed by intereuro experiences. (Half is heritable and half is environmental) 1. Positive Affect and Approach - Some babies and toddlers just seem happy all the time and some are more serious, and have a stronger much approach instinct - Positive Affect and Approach don't go together 2. Fearful inhibition - Waiting, watching, hanging back - Inhibition means not acting because they are afraid. 3. Negative Affect and Irritability - Emotional little people - The negative response to environmental events (Mad, cranky, irritable) - The reasons for thinking of temperament is that half of the way we behave is genetic and 100% is influenced by the environment. ATTACHMENT (BOWLBY) - Wrote and theorized about attachment (How connected a baby, toddles, ect, is how connected they feel to an attachment figure) - When attachment goes well the baby cries and the parent fixers it up - Strong attachment - This assumes that early relationships relate to future relationships  - Attachment continues to develop over time, in most cases, 15-17 year olds don't spend too much time with their family, as a result kids will end up attached later on. (Over time this attachment series of behaviours, - Babies are programmed to cry when they are in pain, uncomfortable (Attachment of Elicit Behaviour) - Attachment can be broken and repaired - This idea that early relationships are important influences in our future relationships. Genetics and epigenetics influences - Nature and nurture are not separable (It's always both) They are interacting with each other Sensitive to different environmental events Passive genetic influence Passive environmental influence Genetics trusts to something and the environment responds to it Active condition - Pick what is good for our genetic influence - People should always find niches that are a good fit for them. - Multiple ways to model genetic and environmental interactions - Epigenetics Genes are like light switches, there not always on all the time (Millions of environmental events happening) When the environment turns on a light switch that's when the gene becomes active (intergenerational trauma) Genetic codes can set some boundaries Cannot escape genes and our descends make up for our experiences Chapter 2 Continued Reading Notes Ipad-Laptop - 2.2 Theoretical Foundations A theory allows us to make educated guesses and predictions about behaviour that are based on existing knowledge, and it allows us to explore these possible explanations empirically. Developmental psychopathology provides a useful framework for organizing the study of child psychopathology around milestones and sequences in physical, cognitive, social-emotional, and educational development. Three underlying assumptions about child development are emphasized; It is multiply determined, the child and the environment are interdependent, and atypical development involves continuities and discontinuities of behaviour patterns over time. The complexity of child psychopathology requires consideration of the full range of biological,psychological, and sociocultural factors that influence children’s development. Epigenetics is defined as the study of how behaviours and environment can cause changes that affect the way an individual's genes work. Section Review  - What is the purpose of having a theory, or case conceptualization, of human behaviour? - Identify the three assumptions of child development - Define Epigenetics 2.3 Developmental Considerations: - Adaptational failure is the failure to master or progress in accomplishing developmental milestones. - Children's behaviours and their environment are interconnected. - The organization of development perspective looks closely at the psychological processes that may explain how these systems influence each other. Early patterns of adaptation, such as infant eye contact and speech sounds, evolve with structure over time and transform into higher-order functions such as speech and language. - Sensitive periods are windows of time during which environmental influences on development, both good and bad, are enhanced. - Children's development is organized, which means that early patterns of adaptation evolve over time and transform into higher-order functions in a structured, predictable manner. - Section Review Define adaptational failure Explain how sensitive periods affect child development. 2.4 Biological Perspectives - Considers brain and nervous system function as underlying causes of psychological disorders in children and adults. - The brain stem commands heartbeat and breathing, the cerebellum controls and coordinates sensorimotor integration, and the cortex is where thought and perception originate. - During early childhood, synapse multiply; then selective pruning reduces shapes and differentiates important brain functions. - Neural Plasticity and the Role of Experience The brain shows neural plasticity throughout the course of development. Neural Plasticity or malle-ability, means the brain's anatomical differentiation is use-dependent: Nature provides the basic processes, whereas nurture provides the experiences needed to select the most adaptive network of connections, based on the use and function of each. Children's early caregiving experiences play an important role in designing the parts of the brain involved in emotion, personality, and behaviour. Brain Maturations is an organized, hierarchical process that builds on earlier function, with brain structures restructuring and growing throughout the lifespan. - Primitive areas of the brain, which govern basic sensory and motor skills, mature first and undergo the most restructuring, during the first three years of life. - Genetic Contributions Nature of genes Any trait results from the interaction of environmental and genetic factors Genes contain genetic information from each parent. - The Nature of Genes  By itself it does not produce a behaviour, an emotion or even a thought, raither it produces a protein. Gene-Environment interaction (GxE) in child psychopathology - Child psychopathology is the result of complex interchanges between nature and nurture and is affected not only by genetic and environmental influences, but also by the timing of when they meet. - Biological changes to genetic structure result from epigenetic mechanisms which involve changes in gene activity resulting from a variety of environmental factors. The environment can turn genes on and off. - Helps explain why some people exhibit disorders and others do not, in the face of similar environmental events. - Epigenetic alterations may be reversible through pharmacological and behavioural interventions. Behavioural Genetics: A branch of genetics that investigates possible connections between a genetic predisposition and observed behaviour, taking into account environmental and genetic influences. Molecular Genetics - Supports the influence of genes on child psychopathology. - Assess the association between variations in DNA sequences and variations in a particular trait or trait. - Have been used to search for specific genes for childhood disorders, (ex: autism, ADHD, and learning disabilities. - Neurobiological Contributions Brain structure and function - Divided into the brainstem and the forebrain (telencephalon). - The brainstem, located at the base of the brain. Handles most of the automatic functions necessary to stay alive. - Lowest part of the brain stem, called hindbrain, contains the medulla, the pons, and the cerebellum. - The hindbrain provides an essential regulator of autonomic activities such as (breathing, heartbeat and digestion), the cerebellum controls motor coordination. - The brain stem also contains the midbrain, which coordinates the movement with sensory input. - The midbrain houses the reticular activating system (RAS), which contributes to processes of arousal and tension. - At the top of the brainstem is the diencephalon, located just below the forebrain. It contains the thalamus and hypothalamus, which are both essential to the regularity of behaviour and emotions. It functions primarily as a relay between the forebrain and the lower areas of the brain stem. - At the base of the forebrain is the limbic, or broader, system. It contains a number of structures that are suspected causes of psychopathology. Such as the hippocampus, cingulate gyrus, septum, and amygdala. (These structures regulate emotional experiences and expressions and play an important role in learning and impulse control).  - The Limbic system also regulates the basic drives of sex, aggression, hunger, and thirst. - The Basal ganglia, which includes the caudate nucleus. (This regulates, organizes and filters information related to cognition, emotions, mood, and motor function -this is implicated in ADHD). - The cerebral cortex, (the largest part of the forebrain) gives us human qualities and allows us to plan as well as to reason and to create. - The cerebral cortex is divided into two hemispheres that look alike but have different functions. (The left hemisphere plays a role in verbal and other cognitive processes, the right hemisphere is better at social perception and creativity). - The frontal lobes contain the functions of our thinking and reasoning abilities, including memory. (These functions enable us to make sense of social relationships, customs, and to relate to the world and others around us). The Endocrine System - Linked to anxiety, and mood disorders in children and adults. - Several endocrine glands, (each produces a specific hormone that releases into the bloodstream). - The adrenal gland (located on top of the kidneys) are important because they produce epinephrine (also known as adrenaline in response to stress). - Epinephrine (adrenaline) energises us and prepares our bodies for possible threats or challenges. - The thyroid gland produces the hormone thyroxine, which is needed for energy metabolism and growth and is implicated in certain eating disorders. - The pituitary gland, located deep within the brain, controls the body's functions by regulating a variety of hormones, including estrogen and testosterone. - The endocrine system is related to the immune system, which protects us from disease and other biological threats. - Cortisol - A stress hormone. - The hypothalamus control center, coupled with the pituitary and adrenal glands, make up a regulatory system in the brain known as the hypothalamic-pituitary-adrenal (HPA) axis. Neurotransmitters - Similar to biochemical currents in the brain. (These currents develop in an organized fashion to make meaningful connections that serve larger functions such as thinking and feeling. - Neurons that are more sensitive to one type of neurotransmitter, such as serotonin, tend to cluster together and form brain circuits. - Brain Circuits - paths from one part of the brain to another. Brain circuits and neurotransmitters relate to particular psychological disorders, permitting more targeted treatments. - Psychoactive drugs work by either increasing or decreasing the flow of various neurotransmitters.  - Major Neurotransmitters and Their Implicated Roles in Psychopathology Benzodiazepine - GABA - Reduces arousal and moderates emotional responses, such as anger, hostility, and aggression. - Is linked to feelings of anxiety and discomfort. - Implicated in Anxiety disorders. Dopamine - May act as a switch that turns on various brain circuits, allowing other neurotransmitters to inhibit or facilitate emotions or behaviour. - Is involved in exploratory, extroverted, and pleasure-seeking activity. - Implicated in Schizophrenia, Mood disorders, ADHD. Norepinephrine - Facilities or controls emergency reactions and alarm responses - Plays a role in emotional and behavioural regulation. - Not directly involved in specific disorders (acts generally to regulate or modulate behavioural tendencies). Serotonin - Plays a role in information and motor coordination. - Inhibits children's tendency to explore their surroundings. - Moderates and regulates a number of critical behaviours, such as eating, sleeping, and expressing anger. Biological Perspectives - Brain function undergoes continual changes, described as neural plasticity, as they adapt to environmental demands. - Neural plasticity, or malleability, means the brain's anatomical differentiation is use dependent: Nature provides the basic processes, whereas nurture provides the experiences needed to select the most adaptive network of connections, based on the use and function of each. - Genetic influences depend on the environment. Genetic endowment influences behaviour, emotions, and thoughts; environmental events are necessary for this influence to be expressed. - Neurobiological contributions to child psychopathology include knowledge of brain structures, the endocrine system, and neurotransmitters, all of which perform their functions in an integrated harmonious fashion. What is neural plasticity? What is epigenetics? 2.5 Psychological Perspectives - Emotional Influences Emotions and affective expression are core elements for human psychological experience. Emotional reactions assist us in our fight-or-flight response. Emotions give special value to events and make actions most likely to occur. Emotions tell us what to pay attention to and what to ignore, what to approach and what to avoid. They are backed up by powerful stress-regulating hormones (cortisol).  Children's emotional experiences, expressions, and regulation affect the quality of their social interactions and relationships (foundation of early personality development). Children have a natural tendency to attend to emotional cues from others, which helps them learn to interpret and regulate their own emotions. Children look to the emotional expression and cues of their caregivers to provide them with the information needed to formulate basic understanding of what's going on. Primary form of communication for children that permits them to explore the works with increasing independence. - Emotion Reactivity and Regulation The emotional process is divided into two dimensions: emotion reactivity and emotion regulation. Emotion Reactivity- individual differences in the threshold and intensity of emotional experience, which provide clues to an individual's level of distress, and sensitivity to the environment. Emotion Regulation - involves enhancing, maintaining, or inhibiting emotional arousal, which is usually done for a specific purpose or goal. Concerns in regulation (involve weak or absent control structures) and concerns in dysregulation (existing control structures operate atypical). - Temperament and Early Personality Styles Temperament - the child's organised style of behaviour that appears early in development, and can shape the child's approach to their environment, vice versa. Temperament is established during early brain development Three primary dimensions of temperament are linked to child development: 1. Positive affect and approach - Describes the easy child, who is approachable and adaptive to their environment and possesses the ability to regulate basic functioning of eating, and sleeping. 2. Fearful or inhibited - The slow-to-warm-up child, who is cautious in their approach to novel or challenging situations. They may show distress or negativity toward some situations. 3. Negative affect or irritability - The difficult child, who is negative or intense in mood, not adaptable. They show distress when faced with challenging situations. Personality disorders - are rarely diagnosed until late adolescence or early adulthood, which is evident to the person's pattern of behaviour or inner experience is enduring and problematic. - Behavioural and Cognitive Influences Principles of learning and cognition, which shape children's behaviour and their interpretation of things around them. Applied behaviour analysis - focuses on observable behaviour and rejects the notion that cognitive mediation is necessary for explaining behaviour. Social learning theory - cognitive process and explanations. Major behavioral and cognitive theories - Applied Behaviour Analysis (ABA) - examines the relationships between behaviour and its antecedents and consequences which is also known as a functional approach to behaviour. It describes and  tests functional relationships between stimuli, responses, and consequences. It is based on four primary operant learning principles, (Positive and negative reinforcement, extinction and punishment). - Classical Conditioning - Explains the acquisition of deviant behaviour on the basis of paired association between neutral stimulus and unconditioned stimuli. - Social learning and cognition - not only overt behaviours, but also the role of possible cognitive mediators that may influence the behaviours directly or indirectly. Also incorporates the roles of social cognition - (relates to how children think about themselves and others, resulting in the formation of mental representation of themselves). Identify the three dimensions of temperament. Explain the role of emotional reactivity and regulation in child development. List the three major behavioural approaches to child psychopathology. 2.6 Family, Social, and Cultural Perspectives - Proximal (Close-by) - Distal (Further-removed) - Environmental influences include shared and non shared types. - Shared environment - environmental factors that produce similarities in developmental outcomes among siblings in the same family. - Nonshared environment - environmental factors that produce behavioural differences among siblings. - Infant-Caregiver Attachment Refers to the processes of establishing and maintaining an emotional bond with parents or other individuals. This process is ongoing, typically beginning between 6 and 12 months of age. Bronfenbrenner’s ecological model of environmental influences - The Family and Peer Context Family systems theorists argue that it is difficult to understand or predict the behaviour of a particular family member, such as a child , in isolation from other family members. - Define shared vs nonshared environment as it relates to environmental influences. - Define attachment. - True/False: The family systems perspective is becoming more mainstream and regarded within the context of child psychopathology. ASSESSMENT, DIAGNOSIS, AND TREATMENT WHAT IS “DIFFERENTIAL DIAGNOSIS"? - Us saying which disorder is most likely to fit this person, and what other disorders are still under consideration. - What we can possibly rule in, rule out, and what we still need to consider. LABELS CAUSE KNOWN PROBLEMS  - So, why use them? Labels can be problematic 1. Because they provide access to services 2. Shorthand between one clinician to another 3. We like to make categories and then put them into those categories (normal human condition) - They bring stigma, and expectations, minimizes any context of the disorder - Using a label that doesn't acknowledge the system the human is functioning PURPOSES OF ASSESSMENT - Understanding the nature of the referral Why are they there? The problems? Prediction? - Linking diagnosis with treatment - Idiographic vs. nomothetic perspectives Diagnosis is nomothetic - rules, policies, assumptions that underlie how humans are, describing people across groups under these terms. Comparing this child a lot of people Diagnosis and Assessment are Idiographic - person at the centre of this who is very individual HOW TO THINK ABOUT DEMOGRAPHICS IN CLINICAL PROCESSES (Who) - Age Because everyone is different from each other at every age. Puberty (part of developmental psychopathology, very normal) - Girls who go through precocious puberty are female. - Gender/sex/identity Sex and gender pattern of diagnosis Males are more likely to be diagnosed with an externalized disorder than females. Girls are at higher risk for internalizing psychopathology. Boys are likely to be referred, girls are more overlooked Gender atypical (girls, being quiet, polite) (males being, strong, stoic) What looks like ADHD in a male can be looked at differently in a Female. - Culture/race/ethnicity Hallows in this area People of colour are more likely to be misdiagnosed When we don't take culture into account diagnosis is likely to be less valid Different cultural groups describes symptoms differently (stimage associated with them, negative interpretation) Understanding the impact it has the more accurate the diagnostic strategy and more effective the strategy will be. - SES A huge risk factor in child psychopathology Kids growing up in poverty are massively increased risk for massive problem (more likely to be labeled inaccurately) Thinking about the terms of the recommendations that are made ASSESSMENT (IDIOGRAPHIC APPROACH) - Multiple sources of information  Talking to the child, parents, teachers, assorted others, observe and get information from peers - Multiple formats for data collection Information about their strengths and weaknesses. Finding ways to get interventions for the child. Doing a observation (reporting how severe the symptoms are) Better to see the child in a natural environment (naturalistic observation) Interviewing (May Include the child in the interview) What is the reason there there (Referral) What does the parent expect to get from assessment and intervention Get a developmental and medical history (can be from prenatal time, perinatal, and personal tal period) Medical history - What else happened School history Family structure Social history Psycho education of possession Checklists, questionnaires (CCBL) Own self-report - Each clinician has a unique style that likely reflects training and preferred treatment modality HOW WE GATHER INFORMATION (NOMOTHETIC APPROACH) - Observations - Interviews - Checklists/rating scales - Testing WHAT DO YOU MEAN BY “TESTING?” - Intelligence testing CAN HAVE INHERENT BIAS MAY PROVIDE MISS INFORMATION FOR SOME PEOPLE IN GRD 2 in ontario everyone takes the intelligence test Harder for boys than girls Harder for kids from racialized and poor families Harder for children for disability - Developmental scales Tests for babies and toddlers (Bailey) Not so much about getting a score, there is use to figure out whos gonna need a lot of intervention Hearing impairment, deaf, blind - Achievement tests Most of the time academic testing (reading, writing comprehension, math, oral language) Highly predictive in long term success in education - Neuropsychological assessment tools Two ways to use them 1. Measures connecting behaviour with brain 2. Child clinical psychologists use scores on all the cognitive tests - Planning  - Memory - Language - Organization - Visual-spatial Connect the brain's functioning to assessments - Projectives Ink-blot testing To give people ambiguous stimuli (Ask them to describe what they see) The purpose is to get the person's subconscious and unconscious thoughts. Unfortunately the liability and reliability is low They were used more in the past, bearley anymore. Not valid DSM-5 TR - How we do diagnosis (Cook Book) - Diagnostic Statistical Manual - DSM 1 and 2 didn't have childhood disorder psychoanalytic in nature - Came out in 2013 (TR- test revision to make it more clear, came out in 2022) - This version recognized the disorders - It was controversial to the point that the national institute of health (NIH) - they won't fund any studies that use the DSM - Problems that the NIH found Does Not acknowledge the interaction between the person and the environment (If you have a given disorder, that disorder resides in your environment) Chapter on children and adolescents is not big (very few hints how to diagnosis depression in 7 year olds) Childhood disorders aren't outgrown yet but they don't reflect that. Don't get much consideration that mental health is continuous and discontinuous across the lifespace. Limited validity for some of the disorders in the DSM PROBLEMS WITH NORMALITY - A big problem - Because we tend to see anything we dont like as a normal - And anything that fits with our world we tend to see as normal - Toddlers - trying to make their way of the world - Insecure and attached child - shy children that may be seen as having problems but they don't necessarily have these problems. - Oppositional adolescence - Overly dramatic, impulsive youth - Includes a lot of problematic behaviours. What’s the big deal with evidence- based treatment? - Cognitive-Based therapy was the best back then - Treatment that is supported by research  - Mindfulness-Based Therapy - Effective for keeping anxiety and depressive disorders at bay once they are in control, good for lowering stress under certain circumstances, meditations. - Very specific kind of treatment for a specific kind of problem. - EX: Adolescents with mood disorder = evidence base standard for youth is CBT and medication (SSRIs) - Assumes that the clinician can follow the manual because it's been tested and validated. - Best practices also assume that multiple groups have tested this kind of treatment in multiple settings. - Multiple prescriptions, researchers and expert judgment. - Most physiotherapy is not evidence based, this is the number 1 reason why some people don't get better. (This is problematic because there aren't any practicing mental health professionals). - What are the particular problems of treating children and adolescents? Kids - not in charge, if the kid isn't interested they'll get away with it. The patient is often not the reason for saying that they wanna go (The parent or the teacher is the drive of force) Parents are always in the background. Parents might be defensive. Parents might not be willing to sit with them, or take them for medication checks. Confidentiality and Consent - The clinician won't tell anyone you say unless there is a serious reason to break it. (They are strictly laid out) - Parents don't like it, when the parents don't like it when they dont get information for their children. - In families where they are two parents, sometimes they won't be on the same page. Parents think that one is responsible for the problems, interventions (The problem we run into is that its always someone else's fault). THEORETICAL APPROACHES TO TREATMENT - Psychodynamic Very concerned with the unconscious and subconscious Focus on becoming aware of our unconscious and subconscious thoughts Emphasis on early relationships playing on how well developed, this is important because relationships are what set the ground for future relationships. Uncovering the damage done in early relationships and how it counts later on. - Behavioural Dysfunction is learned Rewarded for certain behaviours, and punished for certain behaviours. Use learning paradigms to change behaviour and thoughts. Making things harder to engage this approach. Positive reinforcement, modeling, desentization, timeout - Cognitive Assume that people have dysfunction because of the way you think about events. (Faulty cognitions)  How we think about experiences is the important part, changing cognitions that are hurtful, problematic ect. (This includes how we talk to ourselves) People who are more positive and optimistic live longer, have more friends, learn more, and have more success (cognitive pairing) - CBT Start to identify the faulty cognitions Work on replacement and framing Opportunities for positive reinforcement. Identifying the cognition, working on behaviours to counter those thoughts (exercise, more time with friends, being outside). - Client-centered Unconditional positive regard (people like to be liked) As soon as you feel that your therapist doesn't like you, therapy won't work. Non-judgmental interactions, working on those foundational relationships issues. - Family Systems approach Nearly all kids exist in a system Appropriate for schools, classrooms, neighbourhood approaches Assumes that the is not occurring within the individual, it can be the system. By being aware that the dynamic is within the problem. The problem is in the interaction patterns. Working on the system, communication styles, contingencies in the environment - Biological Medication approach Less common in kids than adults (except with ADHD) Medication only does so much, you have to have changes in behaviour and cognition. Biological treatments that have developed for adults and wont be used for kids. Drugs like ketamine, hallucinogens (Not for kids). Chapter 4 Reading/Textbook Notes Assessment, Diagnosis and Treatment 4.1 Clinical Issues - The Decision-Making Process Aimed at finding answers to both immediate and long-term questions about the nature and course of the child's disorder and its optimal treatment. Begins with a Clinical Assessment - systematic, problem-solving strategies to understand children with disturbances and their family and school environments. - Strategies include an assessment of the child's behavioural, emotional, and cognitive functioning, as well as the role of the environmental factors.  -They are meaningful to the extent that they result in better understanding of functioning as well as practical and effective interventions. - Idiographic case formulation - detailed understanding of the child and the family as a unique entity. - Nomothetic formulation - emphasis general inferences to large groups of individuals (children with depressive disorders). - Developmental Considerations Age, Gender, and Culture - Gender Patterns for Selected Concerns of Childhood and Adolescence More commonly reported among Males - ADHD - Childhood conduct disorder - Intellectual disability - Autism Spectrum disorder - Language disorder - Specific learning disorder - Enuresis More Commonly Reported among Females - Anxiety disorders - Adolescent depression - Eating disorders - Sexual abuse Equally Reported among Males and Females - Adolescent conduct disorder - Childhood depression - Feeding disorder - Physical abuse and neglect - Culture can include ethnicity, language,religious or spiritual beliefs, race, gender, SES, age, sexual orientation, geographic origin, group history, education, and upbringing. - Cultural syndromes - A pattern of co-occurring, invariant symptoms associated with a particular cultural group, community or context. Purpose of Assessment - These purposes guide the assessment process. - Three common purposes of assessment: Description and Diagnosis Prognosis Treatment Planning Description and Diagnosis 1. Provide a clinical description - Summarizes the unique behaviours, thoughts, and feelings that together make up the features of the child's psychological disorder. Attempts to establish basic information about the child and sometimes parents/adults concerns at presentation.  2. Diagnosis - Analyzing information and drawing conclusions about the nature or cause of the problem, or assigning a formal diagnostic label for a disorder. There are two separate meanings: - Taxonomic Diagnosis - focuses on the formal assignment of cases to specific categories drawn from a system of classification such as the DSM-5-TR. - Problem-solving analysis - similar to clinical assessment and views diagnosis as a process of gathering information that is used to understand the nature of an individual's problem, possible causes, treatment options, and outcomes. Prognosis and Treatment Planning - Prognosis - is the formulation of prediction about future behaviour under specified conditions. - Any decision to treat a child's particular problem must be based on developmental understanding and informed prognosis. - Treatment planning and evaluation - means using assessment information to generate a plan to address the child's mental health consent and to evaluate the effectiveness of the treatment. Clinical Issues - Clinical assessment is directed at differentiating, defining, and measuring the child's behaviours, cognitions, and emotions of concern, the environmental circumstances that may contribute to these concerns, and the child's strengths and competencies. - Assessments are meaningful to the extent that they result in effective interventions; a collaborative and continuing partnership must exist between assessment and interventions. - Age, gender, and culture influence how children symptoms and behaviour are expressed and recognized, and have implications for selecting the most appropriate methods of assessment. - The age inappropriateness, the severity, and the pattern of symptoms, rather than individual symptoms, usually define childhood disorders. The extent to which the symptoms result in impairment in the child's functioning is also a key consideration. - Three purposes of assessment: 1. Description and Diagnosis - Determine the nature and possible causes of the child’s mental health concern. 2. Prognosis - Predicts future behaviour under specific conditions. 3. Treatment planning and Evaluation  - What are the three factors described in the text that define childhood disorders? - Define cultural humility. 4.2 Assessing Disorder - Many clinical settings use a multidisciplinary team approach to assessment. - Multidisciplinary teams - Include a psychologist, psychiatrist, a primary care physician, an educational specialist, ect. - The clinical assessment of children experiencing difficulties relies on multimethod assessment approach - the importance of obtaining information from different informants in a variety of settings and using a variety of methods that may include interviews, observations, questionnaires, and tests - Clinical Interviews The clinical interview and the assessment procedure is usually used with parents and children. Allow professionals to gather information in a flexible manner over manny sessions. They use a flexible conversational style. Discussing ality beforehand. May observe nonverbal communications by the child and parents, such as facial expressions, body posture, voice, mannerism, and motor behaviour. (Helps with insight on the parent-child relationship) Often uses video games, crafts, and similar enticements to help the child feel more comfortable. Considering the office environment to be child-friendly in decor and ambiance. - Developmental and Family History Initial assessment often include a developmental history or family history - information is obtained from the parents regarding potentially significant developmental milestones and historical events that might impact the child's current difficulties. Often this information is gathered via a back-ground questionnaire or interview. Semi-structured Interviews - Specific questions designed to elicit information in a relatively consistent manner regardless of who is conducting the interview. - Behavioural Assessment A strategy for evaluating the child's thoughts, feelings and behaviours in specific settings, and then using this information to formulate hypothesis about the nature of the problem and what can be done about it. Observing the child's behaviour, rather than inferring with how children think, behave or feel on the basis of their descriptions of inkblots or the picture they draw. When using behaviour assessment, usually what is identified is target behaviours- primary concerns, with the goal of then determining what specific factors may be influencing these behaviours.  A common and simple framework for organizing findings in behavioural assessment has been dubbed the “ABCs of assessment”: - A: Antecedents, or the events that immediately precede a behaviour - B: Behaviours of interest - C: Consequences, or the events that follow a behaviour. Behaviour analysis or functional analysis of behaviour - A more general approach to systematically organizing and using assessment information in terms of antecedents, behaviours, and consequences. - Checklist and Rating Scales Reports concerning child behaviour and adjustment can be obtained using global checklists and problem-focused rating scales. The child checklist (CBCL) developed by Thomas Anchenbach and his colleagues is a leading checklist for assessing behavioural concerns in children and adolescents ages 6-18. - Widely used in treatment settings and schools, and its reliability and validity has been documented in numerous ways. - Used to assess children in 80 or more cultural groups throughout the world. - They focus mainly on specific disorders. - Behavioural Observation and Recording Parents or other observers record baseline (prior to intervention) Portable electronic devices (ex: behaviour-tracking apps on cellular phones) that cue the parent or older child to recond ad rate the intensity of specific symptoms or behaviours. Role-Play simulation - to see how the child and family might behave in daily situations encountered at home or school. - Psychological Testing A test is a task or set of tasks given under standard conditions with the purpose of measuring some aspect of the child's knowledge, skill or personality. Most, undergo a process called standardization- allows for individuals undergoing the test at different times to receive the same testing conditions. - Developmental Testing Are used to assess infants and young children, and are generally carried out for the purposes of screening, diagnosis, and evaluation of early development. Screening - identifying children at risk. Who are then referred for more thorough evaluations. - Cognitive and Achievement Testing Important in clinical assessments for a wide range of childhood disorders. Used to identify children who may have difficulty succeeding in a regular classroom to plan interventions. The Wechsler Intelligence Scale for Children (WISC-V)  - Most popular - Made up of 10 mandatory and 6 supplementary subsets that span the age range of 6-16 years old. - Does not represent different types of intelligence. - Projective Testing Present the child with ambiguous stimuli such as inkblots or pictures of people, and the child is asked to describe what they see. Children will project their own personality unconscious fears, needs, and inner conflicts onto the ambiguous stimuli of other people and things. - Neuropsychological Tests Attempts to link brain functioning with objective measures of behaviour known to depend on an intact central nervous system. - Assessing Disorders Clinical assessment relies on a multimethod assessment approach, which emphasizes obtaining information from different informants in a variety of settings, using a variety of methods. The clinical interview counts to be the most universally used assessment procedure with parents and children. In unstructured interviews, interviews use their preferred style and format to pursue various questions in an informal and flexible manner. Semi-Structured interviews include specific questions designed to elicit information in a relatively consistent manner. Behavioral assessment evaluates the child's thoughts, feelings, and behaviours in specific settings and uses this information to formulate hypotheses about the nature of the concern and what can be done about it. - Identify at least three methods in a multimethod clinical assessment. - Compare and contrast unstructured vs semi-structured interviews. 4.3 Classification and Diagnosis - Classification - A system for representing the major categories or dimensions of child psychopathology, and the boundaries and relations among them. - Two related strategies for determining the best plan for a given individual: 1. Idiographic Strategy - To highlight a child's unique circumstances, personality, cultural background, and other features that pertain to their situation. 2. Nomothetic Strategy - Attempt to name or classify the concern using an existing system for diagnosis, such as the DSM-5-TR. - Categories and Dimensions Categorical classification systems such as the DSM-5-TR are based on informed professional consensus, an approach that has dominated countries to dominate the field of child and adult psychopathology. Dimensional classification approach assumes that many independent dimensions or traits of behaviour exist, and that all children possess them to a certain degree.  - The Diagnostic and Statistical Manual of Mental Disorder (DSM-5-TR) DSM-5-TR Disorders - Published in 2013 - Includes a new diagnosis (prolonged grief disorder). - Includes impact of racism and discrimination on the diagnosis and manifestations of mental disorders. DSM-5-TR Specifiers - Used to describe more homogeneous subgroupings of individuals with the disorder who share particular features and to communicate information that is relevant to treatment of the disorder. - May be used to note general medical conditions relevant to the understanding or management of the individual's mental disorder. Classification refers to a system for representing the major categories of child psychopathology and the relations among them. Diagnosis refers to the assignment of cases to categories of the classification system. Childhood disorders have been classified using categories and dimensions. Categorical classification systems such as the DSM-5-TR have been based primarily on informed professional consensus and overt symptoms. Dimensional classification approaches assume that many independent dimensions of traits exist and that all children possess these to varying degrees. - Describe one advantage to using the DSM-5-TR diagnosis, aka “labels” - What are DSM-5-TR specifiers? 4.4 Treatment and Prevention - Intervention - is a concept that highlights many different theories and practices directed at helping the child and family adapt more effectively to their current and future circumstances. - Prevention - are directed at decreasing the chances that undesired future outcomes will occur. - Treatment (Therapy) - Corrective actions that will permit successful adaptation by eliminating or reducing the impact of an undersidered concern or outcome that has already occurred. - Maintenance - efforts to increase adherents to treatment over time to prevent relapse or recurrence of a concern. - Cultural Considerations The cultural compatibility hypothesis - states that treatment is likely to be more effective when it is compatible with the cultural patterns of the child and family. - Treatment Goals Outcomes Related to Child Functioning: - Reduction or elimination or symptoms, reduced degree of impairment in functioning, enhanced social competence, improved academic performance. Outcomes Related to Family Functioning  - Reduction in family dysfunction, improved martial and sibling relationships, reduction in stress, improvement in quality of life, reduction in burden of care, enhanced family support. Outcomes of Societal Importance - Improvement in the child participation in school-related activities (increased attendance, reduced truancy, reduction in school dropout rates), decreased involvement in the juvenile system, reduced need for special services, reduction in accidental injuries or substance abuse, enhancement of physical and mental health, reductions in mental health care costs. - Ethical and Legal Considerations 1. Children are inherently more vulnerable than adults 2. Children's abilities are more variable and change over time. 3. Children are more reliant upon others and upon their environment. 4. Ethical principles and practices in the treatment of adults must be modified in response to the child's current developmental abilities and legal status. Two laws that have had an influence on services of children with disabilities are the Education for All Handicapped Children Act (1975). The following are two of the many purposes of these laws. 1. To ensure that all children with disabilities have available to them a free, appropriate public education that emphasizes special education and related services designed to meet their unique needs and prepare them for employment and independent living. 2. To ensure that the rights of children with disabilities and of the parents of such children are protected. - General Approaches to Treatment Psychodynamic Treatments - Underlying unconscious and conscious conflicts. - Helping the child develop an awareness of unconscious factors that may be contributing to their concerns. Behavioural Treatments - Assume that many child behaviours are learned. - The focus of the treatment is on re-educating the child, using procedures derived from theories of learning or from research. - Procedures Include: positive reinforcement, time-out, modeling, and systematic desensitization. Cognitive Treatments - View problematic child behaviour as the result of deficits and/or distortions in the child's, thinking, including perceptual biases, irrational beliefs, and faulty interpretations. Cognitive-Behavioural Treatments - View psychological disturbances as the result of both faulty thought patterns, and faulty learning and environmental experiences. Client-Centered Treatments - The result of social or environmental circumstances that are imposed on the child and interfere with their basic capacity for personal growth and adaptive functioning.  Family Treatments - Challenge the view of psychopathology as residing only within the individual child, and instead, view child psychopathology as determined by variables operating in the larger family systems. - Combined Treatments The use of two or more interventions, each of which can stand on its own as a treatment strategy. - Treatment and Prevention Interventions for childhood disorders cover a wide range of strategies related to prevention, treatment, and maintenance. Treatment goals now include outcomes related to child and family functioning as well as those of societal importance. Both ethically and legally, clinicians who work with children are required to think not only about the impact that their actions will have on the children they see, but also on the responsibilities, rights, and relationships that connect children to their parents. A tremendous number and diversity of treatments for children and families now exist, including psychodynamic, behavioural, cognitive, cognitive-behavioural, client-centered, family, biological, and combined approaches. - What is the purpose of a treatment goal? - Define evidence-based practice. Lecture 5 - Counter Narratives in Child Psychopathology Promoting resiliency in all children (5 Categories important for all) - Developmental needs are shaped by human development and evolution. - What we need is shaped over periods of time - Society has changed massively over the last 100 years - 1920 - Western Canada was not settled yet, different times - 1820 - Industrial revolution hasn't happened yet - All these changes mean, life hasn't changed has more rapidly than evolution can adapt to - We live in a 24/hr news cycle, and a world around social media Sleep - Babies - 16-18 hours a day - Toddlers - 11-14 hours a day - Preschollers - 10-12 hours a day - Young teens - 8-10 hours - Emerging adults - 8-10 hours on average When people dont sleep enough it damages attention (ability to stay focus on one thing) Sleep helps the brain organize new knowledge For children it is problematic because it impacts growth Sleep impacts metabolism (Body weight can be highly correlated with sleep deprivation) Good Sleep looks like:  - Bedroom only for sleep and sex - Low stimulation - No tv, computer - Dark, quiet and cool 19 degree or below - Promoting melatonin secretion: Walking away from the screen an hour before going to sleep. Diet/Nutrition - Canada food guide (½ fruits and veggies, ¼ whole grains and ¼ should be protein (lean meats, non animal sources of meet) - Treats, sweeteners, sweets are good in small quantities. - Evidence to suggest is that vitamins and minerals make a big difference in growth and mental health. - North American Canadian Public meets less than 20% of the Canada Food Guide. (It's not easy) Physical Activity - Evolution set us up to be active species - With kids, preschoolers need physical activity most of the day in non organized structured play. - With adolescents, hours of physical activity a day, non structured or programmed activities but rather activities that are part of their day. - Kids should get aerobic, cardiac activity 3x a week. - We want kids to have at least 3x per week that they are building muscles (climbing walls, trees, rocks) - Kids should be involved in bone strengthening activities 3x a week - Balance as well (If we can get all this in a regular base, by the time they are older they are at lower risk for physical and mental health) - People who are more into physical health have better mental health with mood disorders and anxiety disorders. Screen time - Little kids have early exposure to screen time. - Recommendation under 2 years old, no child should have screen time with the consideration of video calling (Inherently social activity) - 2-5 years old (hour a day) -sitting with someone (coeviewing) -social environment - School age - teens (2 hours for school and homework) Not all screen time is equal - Social interactions that is happening in a virtual space is good for development Social Relationships - All of us need some social interaction but not the same amount of it. - Everyone has social needs. - Development needs to be a part of that process - Parallel Play Pile of toys in front of kids - Over time we become more and more engaged with our peers. - Adolescence - We turn our backs to our families of origin  - Most kids become more autonomous over time (moving away, relationships) Challenging the predominate narratives - Indigenous models of psychology and psychopathology - Blume wrote a textbook on psychology as a discipline Comparing perspectives - Western/Colonial models Individuality is central - the focus, not the community. Goals for what is considered a successful life: - Autonomy (graduating, moving out, having children, leave where you came from and go somewhere), acquisition of material wealth (american dream,) , and personal accomplishment (getting educated, job, promoted, ect) Life problems = abnormality - (unhappy marriage, difficulty completing education, mental health problems) Time is linear - It slows from the day we are conceived, until the day we take our last breath Relationships are hierarchical - mothers and fathers have authority over their children, city governments have control over communities, police have the authority to arrest us. We have people at the top and people at the bottom. Marginalization of the other - The other is less important then our own individual self. - Indigenous Models Creation is the center not the individual Goal: Balanced relationships with Creation and other people Life problems = learning opportunities (if you become anxious, this is an opportunity for you to find new ways to cope, sources of support). Time is cyclical in nature (We come back to things over and over again) Seeing events in human society coming again and again Relationships are egalitarian - Two people who each come to the clinical experience with knowledge, experiences to each, learn things about each other, experience a new interest or point of joy, Cultural curiosity/cultural humility - Someone you meet with different cultures and you say “tell me more” its important because we benefited from their marginalization  - Indigenous model - treatment process rarely focus on the individual, it's always seen as a community opportunity or problem So, what does this mean for psychopathology? - Focus is on systems and relationships - Obstacles are seen as teachers - Expanded treatment partners - Wisdom is non- hierarchical Addressing the harms from colonial models - Intergenerational trauma Damage done to people of generations ago whether harm was in slavent, concentration camps, intergenerational trauma has impacts over time. African American Community - Impact of slavery, marginalization of people based on colour. Trauma that started generations and generations ago counties through families, some of that is in the systems that people have set up that support the colonizers. - Stigma Idea of Marginalization, because you don't fit with the dominant narrative - Limited access to care Very few mental health resources - Assumptions of pan-Indigeneity Assume indigenous cultures are all one group, in Canada they are not monolithic. - Legacy of ignoring personal belief systems Personal beliefs systems have to say about psychopathology What does treatment look like? - Focus on reconciliation between the person in distress and creation Creation Individuals with systems, family, and self, its an important part of any treatment approach. Between Groups with other groups (families and community organizations) Processes across time and seeking to correct process that are damaged - Involvement of knowledge keepers and traditional medicines (knowledge keepers are: This person holds traditional knowledge and teachings, they have been taught how to care for these teachings and when it is and is not appropriate to share this knowledge with others). - Identifying sources of fears and anger (Healing fear and anger, even if they are not part of the disorder) - Rebuilding and replacing systems that care causing distress DSM Issues - History of the DSM DSM-I (1952), when it came out it was focused on only adults, no disorders in children and DSM-II (1968), there is a big behavioural emphasis, the behaviourists and psychoanalysts would fight all the time, most places have less psychoanalytic thought. It's very descriptive, only 60 diagnoses, still no disorders diagnosed in children. DSM-III (1980), Ronal Regan is the president of the US, the first diagnostic manual that had specific symptoms, this improved the reliability of the DSM, it was a massive improvement. multiaxial classification system, acute disorders, at that time they used works like “mental retardation” DSM-III-R (1987) the R, is a whole scale revision, attempting to clarify and refine the diagnostic criteria, the beginning of the prototypical model of disorders. (you need to have 6/9 symptoms to have this disorder), major improvement. This is important with kids, because they are developing and every disorder looks different in every child, it benefited the whole field and kids, it wasn't well received. DSM-IV (1994), keeps the personality and mental retardation separate, being diagnosed with something like cancer could have real consequences for your mental health. The problem is, they ignored human development. and DSM-IV-TR (1998), The problem is, they ignored human development. They didn't change any diagnostic criteria just updated the text, (The model assumes the disorder is within the person, the person is depressed, not the environment in which they lived increased the likelihood in which they experienced). Developing the DSM-5 (2013) - Clinically derived Diagnostic system Experts get together and ask what constitutes within the disorders - consensus problems This DSM lacked reliability that wasn't tested  - Development started in 2006 Lists about 500 disorders + 60-70 under investigations The disorders were re-organized - Practitioner and research concerns This DSM lacked reliability that wasn't tested - NIH response They rejected it, largest single funder of all research) - Now on DSM-5 TR (2022) DSM-5 - What is psychopathology? - ~ 400 disorders - Comorbidity - presence of two identifiable disorders, co-occurring disorders, the DSM allows to be diagnosed with comorbidity. This is the different t Prevalence Different perspective from ICD (only allow you to diagnose 1 disorder, and have features of other disorders). Problem for science vs. clinical practice (symptoms, are overlapping) Creates research problems, we need huge samples for people with comorbidity. Changes with DSM-5 - Neurodevelopmental disorders Includes ADHD, but then there's a whole section on impulse controls, but ADHD is an impulse control disorder. - Bipolar disorder - Depressive disorders - Obsessive-compulsive disorders - Traumatic stress disorders - Substance disorders Misuse, abuse - ADHD - New personality disorders system New way of diagnosing Seen as dimensional Borderline personality disorders - we say they have a significant amount of symptoms associated with it, this creates a series of problems for many clients. - These changes, with the DSM-5-TR have been questioned. ATTENTION-DEFICIT/ HYPERACTIVITY DISORDER - ADHD IS NOT A NEW DISORDER 1770 medical textbook - Description, german med school - Registered symptoms - Cryton (british physician), medical disorder not behavioural disorder George Still (1902)  - Boys with impaired volitions, and marked inhabited to concentrate and sustain attention - Impaired behaviour control and difficulty concentrating (british med journal) Attributed defects in moral control Equine encephalitis - Viral illness, communicated today by mosquitoes Beginning of medication - LABELING ADHD SYMPTOMS 1930s –1950s - Minimal brain dysfunction/damage (A good label for people who had these symptoms after having Equine encephalitis) MBD DSM-II (1968) - The label changed, it was called hyper-connect reaction (linking back to the psychoanalytic school of thought) of childhood - Too much movement (Hyperactivity to some event or trauma in childhood) DSM-III (1980) - ADD pops up - ADDRT - There are subclinical descriptions of these disorder DSM-III-R (1987) - ADD is gone (never exists again) - First ADHD disorder - Weird label (UADD) DSM-IV (1994) and DSM-IV TR (1998) - The point where we only had ADHD but there was subtypes - Had NOS with every single disorder - How they diagnosed people who were a little under the threshold - DSM-5 TR SYMPTOMS Symptoms did NOT change from DSM-IV At least 6 symptoms: - Inattention and/or Hyperactivity-Impulsivity, there are 9 in each common Specify presentation - Is it a combined type presentation with inattention?? Specify current level severity - Mild, moderate, or severe Symptoms before 12 years old - Previous iterations of ADHD diagnostic criteria used to be 7, - This change happened because in the MTA data it was pretty clear for girls to have later on onset. Symptoms present in more than one setting - ADHD cannot be a disorder only happening in one place - There doesn't have to be impairment in every setting.  - Lots of kids with ADHD have problems in school and their just fine on a sports team, maybe because they are physically active - WHAT WE KNOW Prevalence - 7%-11% of the population in North American samples Sex differences - 5%-10% times common in boys on a diagnostic level compared to girls Adults - Partial remission of symptoms by adulthood. - They can get picked up in assessment. Etiology - Migration hypothesis The more hyperactive, and less attentive to onset the more likely you are to say that you're out of here. This is the reason why there are lower rates of ADHD in Asia and higher rates across North and central america. - Cross cultural studies suggest ADHD exists everywhere but can be dealt with differently everywhere - Evidence for biological risk factors - Causes of disorders ADHD promotes high levels of sexual activity and doesn't necessarily monitor their impulses - ETIOLOGY OF ADHD Neural substrata - Parts of the brain that are more likely to be different in people with ADHD than with people without ADHD. - Brain functions don't work the same way to connect the same way. - There are people who don't have ADHD but have these differences. (People with the genetic code for ADHD but don't have it) Prefrontal cortex - implicated in ADHD, less likely to become active at a time you would want it to be less active Cerebellum - Part of the brain being involved in coordination (run, walking) but also timing (time perception) - Does Not up or down regulate the way it should with people with ADHD. - Subcortical structures: symmetrical or asymmetrical in some way 2 Cerebral Hemispheres (Corpus Callosum) - Band of fibres connecting left to right in the brain Neurotransmitters involved in ADHD 1. Dopamine  - Involved in reward (phone, laptop, watching tv, physical connection, ect) - They don't have enough circulating dopamine in the reward centers of the brain 2. Norepinephrine - Communication Genetic risk - Highly heritable disorder - Heritability = 70%-85% - The most heritable of all the psychiatric disorders because there are multiple genes, - 2 flavours of risks of genes 1. DRD4 - Codes for Dopamine receptors 2. DAT1 - Codes for dopamine transporter molecules Prenatal influences - No evidence that its the cause - Increases or lower risks of ADHD - Babies born early or small, are more likely to grow up with ADHD (experience hemorrhages, and microhemorrhages) - Brain Injury has an increased risk for ADHD - Prenatal exposure to nicotine and alcohol particularly in the offspring of women who has ADHD themselves (this is the huge risk factor) Diet? - It doesn't cause ADHD - It may make a difference in symptom presentation - 1970s - A doctor says ADHD is caused by sugar consumption (Does Not cause ADHD) - Sugar makes people hyperactive (Placebo effect) - This is a fight between the parent and the child - There is evidence that diets that are limited in nutritional value might make symptoms in ADHD worse Lead - Flint Water Crisis (lead is still around) - Levels of lead increase the risk of ADHD - Its not a huge one but its still important - Lead paint left in lower housing, old housing,ect - Babies are more exposed to lead based paint Psychosocial factors - Not causes of ADHD (growing up in a chaotic homes, how much tv is consumed but may make the in attention worse) - Parental psychopathology can be the underlying genetic shared risks - More like moderators - DEVELOPMENTAL COURSE Early childhood - A hard early childhood  - 2,3,4 kids sitting down to play with toys - Start to see some of the behaviours - All toddlers and many preschoolers appear to be more hyperactive but this is the nature of it - It is only ADHD when the symptoms persist - A lot of hyperactivity - More likely to see walking running before others, difficult temperament, beginning of emotional reactivity School-age - Most diagnoses happen - Teachers have very tightly a tuned norms for what kids should look like - 2-3 in every single classroom in a school - Attention symptoms start becoming more prominent because we expect kids to sit down, read, do math, ect - Learning problems and social problems are also developing with kids with ADHD - Half the kids with ADHD will have ODD or conduct disorder Adolescence and emerging adulthood - 5 longitudinal studies (half the people with ADHD will go through a decrease in symptoms between puberty and middle adulthood, this means that half will continues to meet diagnostic criteria - We have to rely on retrospective research but it is garbage - By the time we get here and make this diagnosis. Profiles of persistence/remission - More severe less likely for good outcome - Great variability and outcomes, some completely grow out of symptoms, - Some people will grow and have symptoms but they never cause a problem for them. - Hyperactive and impulsive symptoms tend to diminish over time. - In attention is static, everyone is improving until they hit middle age. - The more severe your symptoms were in childhood the less persistent - Affective intervention predicts better outcomes, especially if you continue to manage with treatment controls. - Having higher IQ, the smarter you are the better you'll do in life - Family support in terms of outcomes - Parenting styles are a big factor with ADHD, more authoritative parenting style - Peers make a difference - CO-OCCURRING DISORDERS (comorbidity with ADHD) Learning disorders - ⅓ of people with ADHD have a learning disorders because of some underlying shared genetic risk Disruptive/impulsive behaviour disorders  - Oppositional default (ODD) and conduct (CD) ½, then ½ develop conduct disorder. - Genetic risk is shared and runs on the same genes as DRD4 and DAT1. - Very problematic Internalizing disorders - Anxiety disorder - Mood disorders - Depressive disorders - Overlap of 20%-20% - Bipolar used to be here because of Dr. Beaterman Substance use disorders - Parents worry that if they use a medication that there is a risk for substance use disorder but there is no data or research. - People with ADHD are at high risk for substance use disorders Personality disorders - Comorbid with ADHD with borderline and ASPD Autism spectrum disorders - Before DSM-5 this wasn't allowed with comorbidity - Very challenging to treat, more because of the issue with ASD. - ASSESSMENT ISSUES What approach/s to use? - broads based needs assessment with a clinical interview. - Secondary reporter such as a parent is important. - We want other sources of info such as report cards, to get evidence of impairment, including driving infractions or difficulties with employment. - Development is also considered. - We also want to rule out other disorders that may overlap with ADHD. ex. Inattention is a symptom of many disorders. Who to interview? - We want to interview a variety of people to see how they function in the real world. Rating scales help with this. - Observation through how they do with the interviewer themselves or through testing and in the waiting room. - Medical history is needed. - How school impacts home. Teachers offer a very different perspective as they dont know a lot about the child but can compare the child to other kids they have taught. Teachers can also observe peer interactions when parents may not be able to. Rating scales Observation What probably isn’t necessary unless there are issues related to comorbidity What is a waste of time/money - What isn't necessary? Neuropsych testing unless comorbidity exists. Academic achievement testing is a maybe but you can get the info from report cards.  - Continuous performance testing is not particularly good at picking up ADHD. Neurological and medical tests are not warranted for ADHD. - TREATMENT ISSUES What did we learn from MTA study? - Multimodal treatment of ADHD. prior to this were 5 longitudinal studies on ADHD. MTA had 550 kids with ADHD randomly assigned to 1 of 4 treatment conditions. - Highly structur