PSYC 412 - Child Psychopathology Lecture Notes PDF

Lecture 2: Intro to Child Psychopathology (CH1) What is unique about understanding and treating psychopathology in Youth? ​ Some disorders are only diagnosed with childhood onset – auitsm, ADHD ○​ Some disorders have to have continuity for it to be diagnosed ​ Indicators of a significan...

Lecture 2: Intro to Child Psychopathology (CH1) What is unique about understanding and treating psychopathology in Youth? ​ Some disorders are only diagnosed with childhood onset – auitsm, ADHD ○​ Some disorders have to have continuity for it to be diagnosed ​ Indicators of a significant emotional or behavioral problem may be diffenret ○​ Like if 25-year-old is sexually active it is normal but for a 9-year-old it is concerning ○​ A kid may show distress differently ​ Presentation over time might change ○​ As people develop(socially/cognitively) and context changes, the presentation changes ​ Developmental differences may lead to differences in efficacy in treatment ○​ Cognitive therapy ○​ Medication ○​ For example for an adult having depressin it would focus more ont he individual, but ina child it is important to involve family ​ Who advocates for youth? – kids are often brough by their parents, kids may not want treatment Abnormal or no? ​ Norm violation → depends on what your reference group is ○​ For canada/US actually → having a child at 19 is abnormal, younger than the norm ○​ But in countries like india, kenya, bangladesh → 19 is the norm age of having children so it is normal ○​ Eating insenstc for example – some places, like mexico it is common but in the US it is not common ​ Statistical Rarity → what percentage of the people have this thing ○​ Normal distribution for IQ – 68% percent of people have an 100 IQ ○​ For example young sheldon’s intelligence is statistically rare but we don’t think negative of him ○​ Lifetime prevalence of any disorder by age 75 – 47& ○​ Anxiety disorders are not very uncommon BUT significant impairment ​ But young sheldon is highly uncommon - no impairment ​ Personal Discomfort ​ Maladaptive Behavior ​ Deviation from an Ideal ○​ In north america kids are expected to become really advanced/skilled in a very early age ​ So Ideal = kid being ahead on developmental tasks ○​ But is this realistic? Creating more problems? ​ They are pushed too much and making them feel bad about having leisure time  ​ Baby Einstein ○​ We wouldn’t say this is maladaptive, even though it is different than the socailizaiton norm, it is not causing maladaptive behavior or personal discomfort, may even help them in terms of development ​ SO: Defines as a pattern of symptoms associated with ○​ Distress ○​ Disability ○​ Increased risk for further suffering or harm ​ These can be defined as adaptational failure ​ Meaning that kids aren’t progressing towards the typical trajectory of milestones / typical behavior as a benchmark ​ Noticing this adaptational failure is important!! It can later on lead to a potential diagnosis of something Developmental Benchmarks DDST – Denver Development Screeing Test: a commonly used tool in pediatric units of hospitals This shows when kids reach certain milestones, and shows in which percentile they are. This percentile sort of represents how many kids also reach that milestone at that age. And if you’re consistently in the dark bars → always later than your peers, it might be an indication that something is going on. Normal Development as a Benchmark – developmental psychopathology framework ​ Broad approach to disorder of youth ​ Stresses importance of developmental processes and tasks ​ To understand maladaptive behavior, one must view it in relation to what is considered normative The Scope of the Problem: Broad Prevalence This shows how childhood and adolescence is such an important time where disorders show themselves. Lifespan Implications ​ Impact is most severe when problems go untreated for extended periods of time ​ Abt 20% of children with the most chronic and serious disorders face life-long difficulties ​ Lifelong consequences associated with child psychopathology are costly The Scope of the Problem – Inadequate Services ​ High demand but now enough services, also symptoms might go under the radar ​ The first point of contact is often a medical doctor ​ Disparities in racial/ethnic health care ○​ They use it less due to barriers like stigma, or simply don’t have access Who Develops Psychopathology – introduction to epidemiology ​ Gender – social & biological ○​ Boys more likely to have ADHD or conduct problems, girls more depression ○​ Difference in timing ○​ Boys in childhood, girls in adolescence generally  ​ LGBTQ+ Youth → more likely to vşictimized by their peers and family members ○​ Higher rates of mental healthy problems from discrimination and maltreatment ​ Poverts and Socioecnomic (SES) disadvantage ○​ Yearly snaoshots underestimate the number of youth who live in poverty → poverty is linked to MANY disorders ○​ We can see that ⅓ of canadian children lived in poverty in at least 1 of the last five years ​ Racial/Ethnic Disparities in mental Health ○​ They tend to be on the lower side of the SES ○​ Differences in assessment – black vs white kids ​ Black youth are mpre likely to be diagnosed with disruptive behavior disorder/psychohsis and less likely to be diagnosed with mood and substance use disorders than white kids ​ Bias in diagnostic practives ​ Culture ○​ Meaning of behavior varies & expression of symptoms vaires ​ Social anxiety – fear of evalution others – so this is more of an important disorder for collectivistic cultures ​ Taijin kyofusho – a japanese type fo social anxiety → incapacitating fear of offending or harmin others through one’s social awkwardness Models of Etiology & Maintenance of Disorder ​ Diathesis-stress model ○​ Diathesiis – an underlying vulnerability or tendency to develop a disorder ○​ Stess – a situation or challenge that calls on resources The girl in the beginning needs a looooot to actually get to the depression finish line, but the last guy is so close to the finish line - he has more vulnerability, so it takes less of a traumatic experience to get him depressed. Strengths of the Diathhesis-Stress Model ​ Organizes thinking about nature and nurture behavşor & emotions are complicated  ○​ Almost no disorders caused by just genes or just stress – dual contribution ○​ Can have muliptel interacting diatheses x stress Developmental Pathways – the sequence and timing of particular behaviors as well as the relationships between behaviors over time – 2 common types 1.​ Multifinality → certain charred behaviors might lead to different outcomes, multiple “finales 2.​ Equifinality → many different factors can contribute to similar outcomes Lecture 3: Perspective on Development & Psychopathology(CH 2) Etiology (for our purposes) → the study of the causes of childhood disorder Developmental Psychopathology Perspective ​ Abnormal development is multiplu determined ○​ We must look past current symptoms and consider developmental pathways interacting events ○​ Holistic understamdimng ​ Children and environments are indterdependent ○​ Both children & environment are active contributors ○​ Ex: baby cries a lot, people around them tend to be upset but if baby happy all the time, people around them are happy to ​ Abnormal development involves continuities and discontinuties ○​ Continuous – like a change in degree, things are moving incrementally ​ Gradual & quantitative cahnges ○​ Discontinous → stage theories, changes are more qualitative Not hitting developmental milestones being a sign of “abnormalitiy” → example od a discontinous development Organization of Development → early patterns of adaptation evolve with structure over time ​ Sensitive periods → think of fetal development, stressors in sensitive periods affect a lot ○​ Kids raised by wolves example – because he had no language/social etc input during sensitive periods he didn’t develop “normally”, he displayed animal like behavior ​ Development is a process of increasing differentiation and integration – current abilities/limitationsa re influenced by prior accomplishmemnt An Integrative approach – ther ei sno single theorotcail orientation explaining various behaviorws or disorders – multit-theorotical approach Biological perspectives ​ Neurobiological perspective ○​ Brain = underlying cause of psychological disorders ○​ The fetal brain developes from all-purpose cells into a complex organ ​ Neural plasticity → the brain’s anatomical differentiation is use-dependent ○​ One’s that are used – are strength, unused are pruned ​ Experience!! ​ Maturation of the brain ○​ Sensory & motor skills mature during first 3 years ○​ Perceptual and instinctive centers – affected by early childhood experiences ○​ Prefrontal cortec & cerebellum are not rewired until 5-7 years old ○​ Major reconstrucnting occurs from age 9-11 due to pubertal devlopemtn in adolescence So what are these examples of? → sensitive periods in development Genetive Contributions Expression of genetic influences = malleable & responsive to social environment Genetic influence my take a while to show up. ​ Behavioral genetics → investigate connection between a genetic predispoisitona nd observed behavior – lots of twin studies ​ Molecular genetics → identify specific genes for childhood disorders – longterm goals is to determine how genetic mutations alter how genes function Genetic influences are probabilistic, not deterministic. Most forms of abnormal behavior are polygenic Gene-environmentg Correlations → Ways that a person’s genes and their environment are systematically interrelated 1.​ Passive → simple association of your genes & the environment you’re in 2.​ Evocative → the function of who you’re as a result of yoru genes, evoke or elicit reactions from the environment a.​ Like the positive temperament eliciting positive reactions from the environment 3.​ Active → my genes are pushing me to seek out certain experiences in my environment Example – Ken has very strong verbal abilities ​ His parents have strong verbal abilities, they read to him a lot etc – passive ​ His teachers notice this, place him in honors, AP english etch – evocative ​ He seeks out books and reading materials that challenge him – active Active increases as you get older. Evocative stays the same. Passive decreases as you get older. Why? Along with maturity – comes increases amount of control of your environment so it is mormal that passive decreases and active increase Why is evocative same → your traits will always elicit reactions from people, you’re always being influence of the environment and the environment is influenced by you Neurobiological Contributions ​ Neurotransmitters → make biochemical connections ○​ The ones involved in psychopathology: serotonin, GABA, norephinphrine, dopamine ​ Psychoactive drugs with these are used in treatments We can see multifinality & equifinality here Psychological Perspectives → transactions, emotions, behavioral and cognitive processes are considered ​ Emotional influences → emotions and affective expression ○​ Core elements of human psychological experience & central feature of infant activity and regulation ○​ Infants act a lot based on primary emotions ○​ Emotion reactivity & regulation ​ Emotion reactivity: individual difference in the threshold & intensity of emotional experience ​ Emotion regulation: enhancing, maintaining, or inhibiting emotional arousal ○​ Temperament → shapes individual’s approach to their environment & vice versa 1.​ Surgency → positive affect and approach a.​ Precursor to extroversion 2.​ Effortful Control → fearful/inhibitied/cautious a.​ Can be good in terms of regulation but can also increase anxiety 3.​ Negative affectivity → negative affect or irritability, mood ​ High self-regulation → a good formula for healthy adjustment Behavioral & Cognitive Influence ​ Applied Behavior Analysis (ABA) → explains behavior as a function of antecedents and then consequences ○​ Might not care about developmental pathways ○​ 4 primary operant conditioning ○​ Positive and negative reimnforcement + positive and negative punsihment ​ Classical Conditioning – pavlos ​ Cognitive theorist → how thought patterns develop over time ○​ Observational learning, how do people learn from others ​ Social - cognitive theorists ○​ Bendura’s Social Learning Theory → children learn by observing others ​ Seeing others get rewarded doesn’t affect us but punished does Infant-caregiver attachment ​ Attachment → the process of estabkisign and maintaining emotion bond with parent/caregiver  ​ Internal working model of relationships comes from a child’s intiiak crucial relationships ○​ Secure base - home person ​ The Strange situation ○​ The reunion! – parent comes back and the baby calms – secure attachment The family & peer context ​ It is important to not look at child psychopatholgoy from too much of an individualistic context ​ The family system - complex family relatiomnships - subsystems (mother-child & marital couple) ​ Less attention is given o roles of siblings and fathers ​ Family systems theorists argue that understanding or predicting the behavior of a particular family member cannot be done in isolation from other family members ​ How the family deals with typical and atypical stress – crucial to a child’s adjustment and adaptation ○​ Major family & indiviudal issues interfere with consistent and predictable childcare Family, social & cultural perspectives → social and environemntla contexts!! ​ proximal(close) and distal(events) ​ Shared & non-shared environment  ○​ Like twin studies – shared enviornment is like house, parents etc but maybe one of you dances but one plays basketball ​ Bronfenbrenner’s Bioecological Systems Theory ○​ A child is affected by 5 components of the enviornment ​ Microsystem – Family ​ People & context and in direct and frequent contact with child ​ Parents-siblings-teachers-school peers ​ Mesosystem – Connections of people around the child, like father and school teacher ​ Interactions of different people in the microsystem ​ Exosystem –social settings that don’t involve the child, like if mother loose a job, it effects wife-husband dynamic ​ Macrosystem – Overarching culture – religion, social norms ​ Society, culture ​ Chronosystem – Time – that changes everything overitme ​ Divorce, covid-19 influence etc ○​ Recognizies gene-environment connection ○​ Strengths ​ Shows complex layers by conceptualizing it as a product of biological and enviornmental forces interacting ○​ Weaknesses ​ Hard to provide a coherent picture of development ​ Reconceptualiztion of the model – Culture moved from macrosytem to a factor that influences all levels Lecture 4: Stats 4 Success Descriptive vs Inferential Statistics ​ Descriptive ○​ Central tendency – mean, median, mode ○​ Measures of spread – variance, standard deviation ○​ Describe a data set but don’t allow to say anything abt people who were not included in ur data set ​ Inferential – to compare groups ○​ Is the difference bw groups we observed dependable or by chance ○​ Is there really a difference int he underlying population? ○​ Hypothesis Testing ​ Null hypothesis vs alternative hypothesis ​ P-value Basic Statistical tests tht developmental psychologists use? 1.​ Difference between groups a.​ T-tests(two groups) b.​ ANOVA(more than two groups) 2.​ Are continuous variables related to each other? a.​ Correlation(r) – relation between two continuous variables i.​ No causality b.​ If we have more than 2 variables i.​ Multiple regression ii.​ Multiple IVs and DVs iii.​ Unique association of each IV with the DV Risk factors → increase the chance of a negative outcome ​ Low SES, children maltreatment Portective factors → decrease the chance of a negative outcome ​ Secure attachment A = protective B = protective-stabilizing The protective factor stabilzies your well being C = Protective-enhancing You do even better in high adversity condiitons D= Protective-reactive It protects very well when the risk factor is low, but wellbeing does go doen as risk gets higher, Main Effects & Interactions ​ Often we have more than one IV – conduct disorder & SES ​ Main Effect — association bw IV and DV ​ Interaction/Moderation – association bw one IV and the DV varies as a function of the other variable ○​ The association bw an IV and the DV depends on the value of the other IV Like does the impact of stress on depression get stronger/weaker depending on how much social support we have  The degree to which girls have a higher chance of depression increases as puberty goes on Mediator Variables → impact the process, mechanism, or means through which a variable produces a particular outcome ​ Gets into more causal mechanisms ​ Mediation focuses on WHY the 2 are related ○​ Middle factor in causal chain of events ​ We still can have direct effects even when there is a mediator ○​ Direct effects are like straight lines ​ Indirect effect → mom negative mood is indirectly associated with more child behavior problems through its impact on discipline ○​ The indirect effect is a curve dline going through all 3 Lecture 5: Methods 4 Success What types of Measures do developmental psychopathologists use? ​ Psychological systems ​ Predictors ​ Behaivoral - physiological - neural - cognitive ​ Why would we event want to measure? ○​ We want to be able to gave this common language to talk to other psychologists ○​ For diagnosis-treatment planning-monitoring Assesment – how do we do it? ​ Interviews – data says structured & semi-structured are more valid than unstructured ○​ Unstructured → clinician asks you questions and arrives at diagnosis ​ Common approach ​ The garden of forking paths ​ Lots of challanges: ​ Less comprhensices ​ Biasses ○​ Confirmatory biases – asking certain questions that leads to somewhere ○​ Availianlity heuristics – they base decision one examples that come to mind easily ○​ Structured → interviewer has a set of questions that they have to ask the respondent ​ Questions are fixed and interviewer has very little flexibility ​ Can be administered by computer ○​ Semi-structured → interviewer has a set of questions that they have to ask the respondent ​ Also ability to ask follow-up questions ​ Interviewwre has a lot of latitude in asking questions ​ Clinical judgement involved ○​ Disadvantages of structured & semi-structured interviews ​ They are considered the gold standard BUT feasbility is a weakness ​ K-SADS → Kiddie schedule of affective disorders & schizophrenia ○​ Good coverage across many sorts of disorders ○​ Screener tell you what to follow up – they give questions that correspond to DSM5 criteria ○​ It would take SO much time ot ask about EVERY specific disorder, so there are rules to skip some sections ​ But this involves training!!  ​ Rating Scales → questions eiter self reported, or by teacher or by parent ○​ CDI – Children’s depression inventory ○​ Used to measure psychopathology continoulsy ​ Number or severity of symptoms ​ Wide range of possible scores ○​ Clinical’s office doesn’t care much about those scores, they make cut offs ○​ Shorter & no interviewer ○​ Assumption that they are less good than interviews – but we shouldnt rely on 1 assessment tools, we need a few working together ○​ Can be given to anyone, so an easy and quick way ○​ Elevation on rating scale does not equal diagnosis ​ Observations → go into a naturalistic setting to see the behavior of interest in person ○​ Naturalistic → the clinicians going into the kids home/classroom ​ For rare behavior, seeimng that behavior in the 1 hour you are in the class might not worj ○​ Structured → in a clinic/controlled lab setting ​ A lot of control might not translate to the real world ○​ Challenges: ​ feasbility/external validity ​ Presence of an observer may change behavior A typical, thorough ADHD Assessment Why go through all this? ​ For example why IQ – to rule out alternative explanations, to actually find the rootcause ○​ Such as learning disabilities/intellectual devlopment disorders etcetc as a root cause of inattention and hyperactivity Different Informants When Collecting Data on Child Psychopathology ​ Use of informants → rating scales and interviews rely on someone’s report of symptoms ○​ Parent-children-teachers ○​ The demands of the environment are different and can lead to difference behaviors ​ Informants often do not agree – because they see these kids in different contexts ○​ What is typical - atypical? Normal vs abnormal? ​ Parents might not be able to identify what is normal and what is not, whereas teachers can since they have seen a bunch of children ○​ Ex: Parent mental health can affect – maternal depression might lead to over reporting kids behavior ​ Using data from multiple informants – combine ratings ○​ “Or” rule → symptom is present if any informant says it is ​ The disorder is diagnsoed ○​ “And” rule → symptom is present only if all informants agree ​ This rule might not cut off for the disorder ○​ So how to combine? ​ Clinicians have to use their judgment to understand where and how to apply these rules Lecture 6: Methods 4 Success Continued Properties of Good Measures ​ Reliability – consistency ○​ If I give you a checklist with 10 symptoms, you have to respons to all the symptom consistenly ​ Validity → are we measuring what we think we are measuring ​ Relaibiltiy is a necessary condition for validit ○​ Less reliable = more error Reliability ​ Internal consistency → if those items are a reliable measure of the construct, people’s answers to those wuestions should ebs strongly positively related ​ Test-retest reliability → focusing on change over time ○​ Do we get similar answer on different measurement occasions ○​ But there are some constructs should change over time such as ADHD symptoms at age 8 and at age 20 ​ Inter-rater reliability → agreement bw two people judging whether sth is present or occurring ○​ Diagnosis ​ Other less common types ○​ Parallel-form reliability → different versions of the same exam measuring the same thing but the questions are different, if the scores are highly associated, higher parallel-form reliability ○​ Split-half reliabitliy → cut the scale in half and compare the scores from the first 50 items and last 50 items – if similar score, good split half reliability Validity ​ Convergent valididity → we made our scale, is it related to other measures of the same construct ​ Dicriminant validity → our scale is different from scores of other constructs ​ Face validity → does this appear to measure what it is supposed to measure ○​ will the average readers read the items scale and realize it is ADHD symptoms Measurement invariance – fairness of a measure ​ When measurement invaraince is not upheld, there’s some unfairness in testing ​ We want invaried scales Correlational Study Design ​ Cross-sectional → surveying a group at one time point, of age 7-8-9. ○​ Cheap, practical ○​ Different cohorts are compared at a given time ○​ BUT can’t understand how individual people change with age ​ Age effects are confounded with cohort effects ​ Longitudinal Design → A single cohort of 7 year olds and I follow them when they become 8 and 9 ○​ Can make within-subject comparsion ○​ No cohort effects ○​ BUT time consuming, people dop out  ​ Age effects confounded with time of measurement effects ​ Sequential Design → I have multiple cohorts that I am following longitudanlly Help disentangle age effects from cohort effects & time of measurement effects BUT – huge sample size, so time consuming, expensive, so complex Experimental Design → in the context of evidence-based treatment ​ Well established treatments: ○​ A large series of single case study designs ​ Single case experimental designs → examine the effect of a treatment on a signle chidl’s behavior ​ Repeated measure of behavior ​ Replciation of treamtnet effects ​ A-B-A-B Reversaş designs ○​ Baseline - intervention on repeat ○​ Give a sense of wheter the thing we are doing is actually working ​ Advantages → internal validity, temporal ordering, A changes B ​ Disadvantages → external validity not there, can be hard to interpret, ethics of removing the intervention ○​ At least 2 between group design experiment → randomizes control trial (RCT) – seen as high stadnard ​ A therapy expriment ​ Experimental and control conditions ​ Random assignment – helps us establish internal validity ​ Powerful test of intervention efficacy, test theory ​ If desgined carefully, can let researcher establish cause ​ Disadvanagtes: ​ Drop out is a huge concern ○​ Attrition bias – people with certain characteristics are more likely to drop out ​ Like low SES drop out more – potentially impacting the results of the study  ​ External validity problems – like most experiments are in universitity – WEIRD samples ○​ Conducted in clinics with non-comorbid teens whereaas in reality teens have a lot of comorbidity ​ Efficacy – does it work in clinical trials/uni ​ Effectivenes – does it work in clinical practice, outside of clinic ​ Efficient → contribute to more efficient use of resources, feasibility, financial side **Shifting to systematic review of the literature followed by a committe reviewing evidence ​ Also meta-analaysis → study of studies Nosology → classification of disease ​ In developemntal psychopathology – the organiztion of behavioral and emotional dysfunction into meaningdul groupings ​ Dimensional vs Categorical Classification ○​ Categorical → someone who has that disroders is fundamentally different than someone who does not ​ In reality we sometimes need to oversimplfly it, there might be overlap but still considered not depressed ​ DSM has a hybrid approach – mainly categorical tho ​ It is categorical in terms of you either have the disorder or not ○​ Dimensional → present in varying degrees ​ DSM also is kinda dimensional because it talks about severity ​ RDoC → research Domain criteria – rather than diagnostic categories, move towards assesing ley dimensions Lecture 7: ADHD – Attention Deficit Hyperactivity Disorder Is ADHD real? – many people argue that it is a social construct of western culture ​ Unrealistic expactiation of kids ​ Skepticsm of pharmaceutical industry ​ OFCOURSE very real ​ Prevalence of adhd is similar worldwide ​ In north american med used to treat ADHD is higher than the reslt of the world ​ Presenf of ADHD is asociated with – problems with peers, school failure, mortality Definition: core characteristics of ADHD ​ Inattention → having difficulty sustaining attention, particularly for repeitice, structured and less-enjoyable task ○​ But when they are asked of enjoyable tasks they actually can lock in very much ​ Hyperactivity/Impulsivity ○​ Hyperactivity → inability to volutnarily inhibit ongoing behavior ○​ Impulsivity → şnabiltiy to control immediate reactions or to think before acting DSM-5 Criteria: – we want symptoms for at least 6 months ​ Inattention symptoms: – 9 symtpoms ○​ Fail to give close attention ○​ Often loses things ○​ Does not seem to listen when spoken directly ​ Hyperactivity/Impulsivity symptoms: – 9 symtpoms ○​ Often fidgets ○​ Talks excessively ○​ Blurts out DSM-5 Criteria - subtypes 1.​ Primarily Inattentive - ADHD-PI a.​ At least 6 inattentive symptoms b.​ 5 or fewer hyperacitve/impulsive 2.​ Primarily Hyperactive – ADHD HI a.​ 6 or more hyperactive symptoms b.​ 5 or less inattentive 3.​ Combined – ADHD-C a.​ If hit the cut off of both b.​ Most often referred for treamtnet ADHD is really seen as a neurodevelopmental disorder – so diagnsotic criteria actually changes as age changes ​ For example for teens older 17 – the cut off of 6 decreases to 5 Additional criteria: ​ At least 6 months ​ Persistent, impairment and non-normative ​ Several symptoms were present prior to age 12 – people dont just develop ADHD at young adulthood ​ Severy symptoms present in at least 2 settings – if present in school but NOTHING at home, inconsistent with the symptoms Specify current severity → Mild - Moderate - Severe ​ Mild → none or barely any symptoms above and beyond the diagnostic threshold ○​ Minor impairments ​ Moderate → in between ​ Severe → many symptoms above and beyond the threshold ○​ Sever imparaiments ADHD: categorical or dimensional ​ DSM treats ADHD as categorical – but research evidence suggests it’s dimensional ○​ This is one of the weaknesses of DSM, you still experiencet eh symptoms but because you don’t cut off the threshod you don’t get diagnosed ​ DSM crtierai shape our understanding of ADHD → informs how we think abt the disorder – research continues to define the ADHD and the diagnostic criterai gets updated ○​ But DSM can get lagged behind new research findings Assessment of ADHD ​ Rating scales & interviews ○​ Parent report ○​ Teacher report!!! Very important ​ Normative framework fro placing children’s behavior ○​ Often don’t directly ask youth – especially younger kids ​ Not reliable – children tendt to underreport their own symptoms ​ KSADS – semistructued interviews ○​ To people in the family ​ Difficulty sustaining attention on tasks or play acgtivities ​ Difficulty remaining seated ​ SNAP-IV ADHD – parent/teacher report version Combining reports from parents & teachers ​ Research says looking at JUST parents or JUST teachers results in diagnosis of just inattentive or just hyperacrtive BUT when those report are combined → the cases become combined cases ​ We might see different types of symptoms in different settings Might ADHD be multiple disorders? ​ There are a lot of different presentations of ADHD ○​ Might that be evidence that we are talking abt different things? ​ Sluggish Cognitive Tempo / Cognitive Disengagement Syndrome ○​ This is often misdiagnosed as ADHD and refers to people who dealth with inattenttive symptoms but have never had probelsm with hyperactivity or impulsivity in their lives ○​ This is NOT in the DSM – you cannot diagnose this ○​ These symptoms are more coherent among themselves ○​ Separate from ADHD, anxierty, depression symtpoms ○​ Shows reasonable tes-retest reliability over short time and long time ○​ Again an example where DSM lags behind research/RDoC Epidemiology of ADHD ​ Prevalance of ADHD – generallly around 8-10% know this ○​ Point prevalance -> 5-9% of school age in N. America ○​ 6-month prevalence → 10.5% of chidlren aged 4-11 years ○​ Adolescents → lifetime prevalence → 8.7% ​ Cultural and contextual different – but chidlren in many cultures do meet digansitoci criteria for ADHD ​ Slightly more prevalent among chidlrent in povert/low SES ​ Racial differences are not clear ​ Diagnostic rates vary by gender ○​ In community → 3 boys:1 girl ○​ In clinics → 6 boys: 1 girl ○​ Why? → symptom presentation varies by gender ​ Girls might be underdiagnosed – especially innattetive girls ​ Hyperactive girls might be get diagnosed becasue they don’t fit the social norm of being a girl Lecture 8: ADHD Continued Developmental course: 1.​ Infancy – origin should be present at birth a.​ BUT no reliable and valid measures to asses below age 3 2.​ Preschool – if symptoms last for abt a yet – child is likely to continue to have challenges a.​ The diagnostics cut off is 6 months tho 3.​ Elementary school – age where a lot of kids are getting first identified of ADHD Under the age of 17 – 6/9 symptoms, 17 and over – 5/9 symptoms Prognosis → previously thpugh that syöptoms of ADHD resolved in adoelscve ​ The symptoms do go down a little bit, but still it is worse than non-ADHD people Adult outcome of ADHD ​ Recruiting 200 boys, referred to clinic – old study, DSM3 wasn't even out ○​ Followed up when they were 41 years old ○​ Compared with 130 people with no ADHD ​ Probands(people with ADHD) did not differ on SES/IQ so dropout was random – but comparisons(no ADHD) tended to have higher SES and higher IQ ​ Findings: We see a lot of differences in education, divorce and even mortality – can be related to SES levels Mortality why higher?? → more risk taking behavior with ADHD so maybe accidents & comorbidity Comorbidity ​ Up to 80% of children with ADHD aslo have a co-occuring psychogloical disorder ○​ Oppositional deficient disroder(ODD) and conduct disroder(CD) – 50%  ○​ Anxiety disorders – 20-50% ○​ Depression – 20-30% ○​ Tic disorders - 20% Correlates of ADHD ​ Is NOT associated with decreased intellectual ability – academic functioning is impaired ​ Formal speech & language disorders – speech production errors/lang abilities ​ Deficits in interpersonal functioning – with family & peers ​ Exacerbated by co-occurring issues Etiology of ADHD ​ Heritability – 75% ​ Environmental influences – maternal use of cigarettes/stress even etc ​ In general = bio + genetics ○​ Genes have an extra strong influence Treating ADHD – Guest Lecturer ​ Medication – since 1930 ○​ Desxtroamphetmainie and methylphenidate(concerta) ○​ Increases activity in the prefrontal cortex ○​ Side effect – slowing growth, increase in heart rate or difficulty falling asleep ○​ There is evidence sayinbg it is beneficial BUT ​ 20% might not improve ​ Might be not a fixed solution for peer relations/family ​ Tolerance may occur – same dose might not work anymore ​ Some parents have their children not be on medication on summer ​ Parent Training → goal is to supporting caregivers in managing challenging child behavior & promoting positive behaviors ○​ Very parent-focused – you might never meet the child ○​ Often times parents thinks they will become an expert in 1 session – but it takes more time, frist you learn abt ADHD then how to manage it ○​ Many types of parent training ​ Defiant Children's book – standard approach ​ Supporting caregivers of children with adhd – more integrated approach with feelings and mood and etc ​ Since ADHD has a big genetic component, this also is giving parents support in navigating their own ADHD ​ These are clinician guided, 10-15 session program  Parent-focused program structure 1.​ Psychoeducation – providing parents education abt ADHD in childhood The parents are walked through this. Potential stigma, what is affecting ADHD etcetc 2.​ Improve parent-child relationship → emphasis the child with positive attention and affirmation a.​ Children with ADHD often gets negative attention, we want to change that to increase the behaviors we want to see b.​ Parent-child relationship – special time: i.​ Task for parent for 10 minutes a day where they provide their child with positive attention & affirmation, point out strengths and ignore minor misbehavior ii.​ Vitamin analogy – vitamin for the parent-child relationship, a foundation for the future iii.​ Parent thought record – opportunity for parents to monitor their mood and feelings as a caregiver 1.​ Purpose: look at connections of the parents’ stress 3.​ Behavioral Strategies → how parents can enhance their routine and navigate better a.​ Behavior charts & reward positive behavior b.​ Routine and structure building c.​ Time-outs and privilege removal for misbehavior d.​ Establishing routines – putting a list/piece of paper like on the fridge or sth 4.​ Communication strategies → how to give effective commands a.​ Encouraging firm and assertive communication when necessary – especially in misbehaving b.​ What you say should be direct and not a question c.​ Eliminate distractions so the child is paying attention to the parent Big takeaways → programs focus on increasing positive attention and decrease behavior we don’t want to see and teaching communication + behavioral strategies The Evidence: – how effective? – Overall meta-analyses and systematic reviews point to benefits for children and for parents ​ Coates et al. 2015 – meta-analytic finding: significantly reduce ADHD symtpoms in children ​ Dekkers et al 2022 – meta-analysis of 29 randomized control trials ○​ Effects on parents – parent-child relationship quality, parent mental health etc ​ However, these effects may not be sustained over time – Lee et al. 2012 ○​ Moderate effects sizes at post-treatment – small at follow-up ○​ More follow-up sessions may be beneficial Other Interventions ​ Organization skills training – more in the academic domain ○​ Ways to improve functioning in the school system ​ Cognitive interventions Treatment Studies – Chronis Tuscano et al 2013 ​ Mothers of Children with ADHD ○​ Targeting maternal depressive symptoms & parenting children with ADHD ○​ Randomized into two groups ​ Standard parent training → behavioral strategies, routine building ​ Integrated intervention → standard + relaxation, mood, CBT, STRESS Big takeaways: ​ Integrated intervention post-treatment → small to moderate impacts compared to behavioral parent training ○​ BUT this effect wasn’t sustained ​ So, the ones with the standard parenting were doing better positive parenting MTA Study: Participants ​ 6 sites ​ 579 youths enrolled ​ Age 7-9 ​ 80% male ​ ADHD-C diagnosis ○​ Parent & parent teacher report Design: Treatments: 1.​ Medication management  2.​ Psychosocial treatment a.​ Parent + educational interventions 3.​ Combination treatment (medication + psychosocial) 4.​ Communtiy treatment as usual a.​ Could be nothing or any of the above Results: ​ Core symptoms of ADHD Medication & combined treatment worked better in terms of reducing core symptoms. ​ Parent-child conflict Psychosocial & combined treatment worked better in therms of parent-child conflict. Overall: combined treatment worked better. Long-term patterns of remission from MTA study → several of follow-ups with MTA sample 2 years post-intervention  ​ The interventions helped, but do symptoms and impairment return across time? ○​ Increases over time but overall very little full and sustained recovery ○​ Many fluctuate in symptoms and impairment x time ○​ Some symptoms/impairment emerges through adulthood Lecture 9: Disruptive Behavior Disorders Examples of clinical presentations: The range! Core Features ​ Age inappropriate ○​ Violating family expectations, societal norms etc ​ Issues of self control/emotional control ​ 2 diagnoses: Oppositional Defiant Disorder(ODD) & Conduct Disorder ○​ Some conduct symtpoms/ soem defiance might be normative, that’s why “age inappropriate” is important to check ​ In adolescence some conflict is normal etcetc ​ Sometimes some conflict might also be effective Overt destructive: particularly risky, bullying etc Oppositional Defiant Disorder (ODD) ​ A pattern of angry mood, argumentative defiant behavior or vindictiveness ○​ Lastingn at least 6 months ○​ Evidenced by at least 4 symptoms ○​ And exhibited during interaction with at least one individual who is not a sibling ​ Symptoms: ○​ Negative affect ​ Lose temper ​ Easily annoyed ​ Often angry ○​ Defiant/headsttrong behavior​ ​ Argues with adults ​ Refused reuqiest ​ Blames others ​ Deliberately annoys others ○​ Hurtful behavior – less common, more sever ​ Has been spiteful or vindictive at least twice in the last 6 months ​ Diagnostic Criteria ○​ 4 of behaviors are present ​ For children younger than 5-years- age → behavior should be occurring on most days for a period of at least 6 months ​ Older than 5 years age → at least once a week for a period of 6 months ​ Why this difference? → under 5 children are still developing so these behavior might be more common, over 5 tho it is elss common so 1 a week is more often than normal ○​ More than normative!! – abt gender, culture etc ○​ You either have it or not, if you have it: ​ Mild – occurs in 1 setting ​ Moderate – at least 2 settings ​ Sever – present in 3 settings ​ Brief aside abt siblings – fighting between siblings is common ○​ This aggression is harmful – may lead to maladadptive behaviors ​ Assesment of ODD ○​ Interviews and Checklists: K-SADS ○​ Observation ​ Disruptive Behavior Diagnositc Observatipn Schedule (DB-DOS) ​ Preschoolers interacting in 3 contexts ​ Presses for disruptive behavior Conduct Disorder (CD) → a repetitive and persistent pattern of violating basic rights of others and/or age-appropriate societal norms or rules including: ​ Agression to people and animals ​ Destruction of property ​ decetifulness/theft ​ Serious violation of rules Similar to anything? → antisocial personality disroder – you don’t diagnose before age of 18, so this is like a children version of it not the same tho ​ 15 symptoms → need 3 in past year 1 in past 6 motnhs ​ Specifiers ○​ Onset ​ Childhood-onset – onset of at least one symptom before age 10 ​ Severity: Mild - moderate - severe ​ Per diagnostic criteria, there are many possible combinations of symptoms ○​ Bullies, threatens or intimidates, physical fights VS cruel to animals, forced into sexual activity etc ​ What do we notice comparing these 2 different lids with CD? ○​ All purpose bucket for kids that behave badly ○​ All have the same diagnosis but they engage in a lot of different behaviors Question 3 Symtpom Cutoff → different potential combinations of symptoms and how severe they are The X axis shows severity, the Y axis shows number of ysmtpoms. The DSM cut off is 3+ symptoms, but a 2 symptom case person might have more severe cases. Limitations of DSM!!  ​ Additional specifier – new to DSM5 ○​ Limited prosocial emotions specifier: two of the following characteristics persistently present over the last 12 months and in multiple relationships and settings – we refer to these characteristics collectively as callous and unemotional(CU) ​ Lack of remorse ​ Callous, lack of mepahty ​ Unconcerned abt performance ​ Shallow or deficient affect ​ CU Traits – verys mall subset of youth have these traits – 2% ​ When youth have CU traits, CD is earlier onset, aggression is more severe and more instrumental ​ CU associated with insensitivity to punishment ○​ Harder to treat ○​ They don’t respons to operant conditioning as usual ​ Can Conduct Disorder and ODD be diagnosed at the same time? → YES ○​ In older DSM you couldn’t, you would only get diagnosed of CD ​ So ODD was seen as a subtype of CD ○​ But in current DSM — yes they can be ○​ Nearly half of all children with CD have not been diagnosed with ODD ​ Also nearly half of children with ODD do not progress to more sever CD Lecture 10: Disruptive Behavior Disorders Continued Epidemiology and Correlates ​ Prevalence fo CD and ODD ○​ Lifetime prevalence ​ ODD – 12% – genders very similar ​ CD – 8% – gender very similar ○​ 6 month prevalance ​ ODD – 7.6% ​ CD – 1.3% ○​ Cultural contextual differences ○​ Strongly associated with poverty!!! ○​ Exposure to violence!!! ○​ CD diagnosis should onlybe applied when the ebhavior in question is not simply a reaction to the immediate social context Poverty and Disruptive Behavior Disorder ​ Social causation → stress of poverty leads to an increase in childhood psychopathology ​ Social selection → families with genetic predisposition drift down towards poverty Great Smoky Mountain Study – longitudinal study of epidemiology of childhood psychiatric disorder ​ Significant positive assocaition bw poverty and disruptive behavior ​ Sample included a significant number of indigenous youth, many of whom lived on a reservation ​ Part way through the study → a casino opened on the reservation ○​ Led to 4 groups: ​ Persistently poor ​ Ex-poor ​ Never poor ○​ This lead to a naturaly experiment for test of social causation & selection theory: ​ If social causation is true – increase in income should reduce symptoms ​ If selection is true – increased income should have no effect Youth whose families were no longer poor’s disruptive behaviors decreases → supports social causation theory Follow up analysis why→ psossible mediators of the association bw increase in income and decrease in ebhavioral ​ Improved parental supervision – full mediator ○​ 100% – the increased income completely led to this – hence fewer disruptive behavior problems Gender Condisderations → conduct problems are 2-4 times more common in male children ​ Behaviors is more common in boys, but diagnosis is similar between boys and girls ​ Early-onset persisten CD → 10 male: 1 female ​ Adolscenet-limited CD → 2 male: 1 female or none diff  Developmental Course Early-onset/ life-course consistent pathway Late-onset pathway/adolescnet-limited ​ High aggression in childhood ​ Thorugohut a period of adolescence ​ Diversification: kids are adding new ​ Less extreme less violent and less forms of disruptive behavior over time rather than only replacing old forms of behavior new ones ○​ If I used to bite, now I bite and punch likely to persist Boys are more physical aggression – girls are more relational aggression ​ But difference is small and not meaningful ​ Boys antisocial behavior is more overt – may get them noticed at an early age ODD/CD & Comorbid Psychopathology ​ ADHD – 35% + of youth with ODD also have ADHD ○​ More than 50% of children with CD also have ADHD ​ Depression and anxiety – 50% of chidlren with ODD and CD also have depression and anxiety Correlates of ODD/CD ​ Cognitive and verbal challenges ○​ Not associated with intellectual impatient, verbal deficits ​ Academic functioning ○​ Underachivement, suspension etc ○​ May lead to mood problems – anxiety/derpession ​ Antisocial personality disorder – up to 40% of kids with CD develop APD as adults ​ Family functioning – high levels of conflict, lack of cohesion ​ Peer problems ○​ Agressive behaviors, rejection ○​ Significant ehealth risks – STD, phusial injuries, substance use ○​ Boys with conduct provelsm are 3-4 times more likely to die before the age of 30 Developmental course ​ Infants ○​ Difficulty temperament ○​ Dussy ○​ Increased link to ODD in boys ​ Preeschoolers ○​ 2 diagnositc challenges ​ impossible/imrpobably symptoms ​ Truancy, staying out all night ○​ Normative misbehaviors – noncomplianece, temper loss and aggression are common ​ These behaaviors due tend to go down as they grow older How do we distinguish typical misbehavior from that representing a significant problem? ​ Frequency – severity – flexiblity – expectability – pervasiveness Etiology and Maintenance I: Genes and Parenting Heritabiltiy of disruptive Behaviors ​ Adaption and twins studies indicate that – 50% or more of the variance in antisocial behavior is hereditary Prenatal factors & brith complications ​ Low brith weight – malnutrition — lead posigin – mother’s use of substance Chilhood maltreatment → universal risk factor for antisocial behavior ​ But most people who are maltreatefd do not develop sever anti social behavior ​ Gene-environemtn interacitson ○​ MAOA enzyme that metabolized/makes it inactive neurotransmitters such as dopamine and norepinhephrine ​ Low MAOA → increase aggression ​ MAOA activity is linked to a specigc gene – X chromosome Coercion Theory – conditioning principles ​ Cycle of icnreasingly negative interactions ○​ delay/escape strategies – children do obnoxious stuff to get out of doing sth that they dont want to do ○​ Inconsistency from parents ○​ Manages to be reinforcing to all ​ Parenting behaviors are associated with an increase in disruptive nbehavior Etiology and Maintenance II: Cognition and Learning Social Information Processing → a series of cognitive steps that taek a person from a situation to action ​ Processing problems: ○​ Encoding – what do I pay attention ​ Relatively little is known​ ○​ Interpretation – what does it mean ​ Hostile Attribution bias → children with aggressive behavior problems are more likely to think the other child dit it on purpose ○​ Response Search –what can I do ​ Split second process of idea generation ​ Higher aggression children think of less ideas of responses ​ More aggressive and less prosocial ○​ Response decision – what will I do ​ Aggressive children are more likely to think that aggressive responses will be more likely to be successful ​ Self efficacy – agressisve children perceive themselvesl as being able to carry out these behvaiors ​ They will pick the more aggressive ○​ Enactment – how well did I do it ​ Highly aggressive children are doing these aggressive beahviors How do these patterns develop? ​ Parents – genetic heritabligy ○​ They might see aggression as a competent response, also have hsıotile attribution bias etc ​ Peers – may be reinforcing behaviours Treatmetn of DBD: Problem-solving, Skills Training, and Parent management Training ​ Effective treamtnets: ○​ Parent management training(PMT) → Mesosystem ​ Operant conditioning ​ Reinforce positives!! – so kids will shoe fewer negative behavior ​ Attention!! Is a very good reinforcer! ​ Component of pscyhoeducation ​ Clear communication skills ​ Picking consequences ​ Teach parents to learn to observe child’s behavior ​ ABC model ​ Antecedent - behavior - consequence ​ Time outs!! – removal of positive reinfrocemtn for a brief period fo time ​ Recent suggest that these do decrease negative behavior, no relation in terms of long-term ​ Efficacy ​ Effective in younger kids compared to older ○​ Problem-solving skills training (PSST) → center of microsystem ​ To reduce behavior problems ​ Related to social-information processing ​ Targeting the upstream cognitive processes, thinking ​ Interested in encoding, interpretations etcetc ​ Can I help them have more prosocial responses etc ​ STEPS model ​ Anger Coping Program → goal is to inhibit early angry and aggressive reactions ○​ Focuses on specific cognitive biases ○​ Distorted perceptions of aggressiveness ○​ Response search and selection – rely heavily on direct action rathe than verbal solutions ○​ Faulty emotional identification – help people recognize the full range of emotions people are actually hvaving  ○​ 3 main steps: inhibit early aggression + relabel stimuli perceives as threatening + geenrating alternative coping responses ​ Generally work but maybe not in certain situations ○​ In the real world, problematic behaviors may be reinforced – coercive cycle etc ○​ We might need more family level approaches for an holistic approach ○​ Multisystemic therapy (MST) → microsystem & exosystem ​ Targeting many different aspects of the system ​ Often used in severe cases of disruptive behaviors ​ Recognizes that disorders are caused by multiple risk factors and multiple levels of the ecological system ​ More intervention ​ Evidence based practivcess – integration of multiple methods ​ Intensive services overcome barriers to service access – like a 24/7 avaiiablae therapist ​ Efficacy – good in chronic and vioelnt juvenile offenders, youth in psychiatric crisis ​ Littell – metanalysis ​ We know that it works well but mixed evidence in terms of whether MST works better than other existing evidence based treatments – depends on outcome/place it is done ​ Family functioning is a mediator!! Lecture 11: Substance Use, Anxiety & OCD Substance Use Disorders → problematic pattern of use, significant impairment – at least 2 symptoms occuring within a 12-month period ​ 10 different substances: ○​ Alcohol - cannabis - opiods – hallucionogens – inhalants… ​ Symptoms – a lot 11: ○​ Risky ebahvior – durnk driving ○​ Tolerance - a need for markedly increased amount of substance to achieve desired effect etc ○​ … ​ We need 2 of these symptoms ​ Severity ratings – just about the number of symptoms you have ○​ Mild - morderate - severe ​ We have a number of specifiers: ○​ Early remission – over 3 months but less than a year, but you don’t fit the DSM diagnosis criteria ​ So how can someone have cravings but not be diagnosed?  ​ Psychological cravings might not actually go away at all – so we wouldn’t call it an active disorder ○​ Sustained remission – any period of over 12 months without meeting any of the symptoms other than cravings Adolescence is a risk period for Substance use problems ​ Earlier use = higher risk for problematic use ○​ 15% start drinking by 14 develop alcohol use disorder ○​ Onset is not necesarrily a causal factor, might increase chances tho ​ A risk marker ​ Substance use in adolescence is associated with the three leading causes of death for adolescents ○​ Accidents ○​ Suicide ○​ Interpersonal violence Prevalence – experimentation is very common ​ ⅔ of grade 12 students had tried alcohol in the past year ​ Lifetime prevalence of any substance use disroder ○​ From age 13-18 – 11.4%, 17-18 – 22.3% ​ Monitoring the future study!! – to track substance use ○​ So substance use among adolescents in the last 5 years ​ So actually there is a pretty steep decrease – COVID let to lower use of substance!! Treatment Models ​ Early brief Interventions → norm-based interventions ○​ alcoholEdu for college ○​ Norms about drinking ​ Injunctive norms – how much others approve/disapprove of drinking ​ Descriptive norms – how much others actually drink ○​ Why do we care abt drinking norms? – if we have an idea of others drinking habits, we will arrange our own behavior accordingly ​ People assumes way more than reality – because if we have an inflated view that people drink a lot, we might want ot drink more – so being shown of the reality helps ○​ Individualized feedback about actual drinking norms – changes in perceived norms may mediate ○​ Meta analysis found that these studies work ​ Outpatient treatment → family therapy, Alcoholics Anonymous ○​ Multidimensional Family Therapy ​ Targeting Adolescent & Parents ​ Family therapy results in better otucome compared to control  ○​ Alcoholics Anonymous(AA) – very popular ​ Involve acknowledging that alcohol is a problem, recommend abstinence, supported by a peer ​ Easily accessible ​ 3 Hypotheses of why this works: ​ The more you go to AA, the less you use substances ​ Lower substance use leads to more AA attendance ​ Having a good prognosis, more motivated, better outlook leads to more AA and hence less substance use ​ Not a lot of good research – because anonymity is very important ​ Few research suggest it actually is not good, but these research are very poorly done ​ A more recent study – found that people that went to AA used less post treatment, but did not predict AA involvement at year 2, good prognosis also did not meaning lower alcohol so ONLY hypothesis 1 was supported ​ Residential inpatient treatment → short duration, treamtnet facility ○​ Range of treatment programs ○​ Often followed by outpatients treatment ○​ Mostly adults, not much in youth Anxiety Disorders Internalizing problems → general term that refers to both anxiety and mood type symtpoms //anxiety disorders & mood disorders ​ Developmental psychopathology framework – fear and sadness are important emotions, but “normal” fears come and go over development SO once it becomes “abnormal” we evaluate Anxiety disorders – a future-oriented concern, becomes more problematic when it is out of proportion depending on context, it is a natural thing otherwise ​ Asspciated with significant impairment ​ Social impairment ○​ Excluded, victimized etc ​ Academic impairment ​ Low rates of service utilization – often going untreated ○​ Girls with anxiety are more likely to get reatment and older kids are more likely to  ○​ But in general veryvery little treatment compared to other disorders ​ SOME fear and anxiety is NORMAL ○​ All 1-year olds become distressed when seperated from mom ○​ Most children have short lived fears etcetc ​ Some anxiety is adaptive – stranger anxiety in young childnre, ○​ Test anciety – excessive checking of homework etcetc ○​ 0 anxiety or SO MUCH anciety is bad for performance, but a mid level of anxiety might help perfomance in a good way ​ It may not be as upsetting to adults ○​ Anxiety in kids may not be serving distribution in the family context, so they might not be getting treatment ​ Anxiety is future oriented whereas fear is present-oriented ○​ Strong negtaive emotion/tension displayed ​ Physical sensations, cognitive shifts, behaviroal patterns ​ Diagnoses – many specific diagnoses ○​ Vary on content of threat/symptoms ​ DSM-5 → anxiety disorders now seperated from OCD ○​ There is intense anxiety associated with OCD Lecture 12: Anxiety continued & OCD **for the exam we are expected to know diagnostics criteria, not word for word but should be able to recognize symptoms, differentiate things etcetc Specific Phobia → fear of specific situations and things ​ Diagnosis specifiers ○​ Animal ○​ Natural environemnt ○​ Blood ○​ Situations ○​ Other… ​ Prevalence – 20%, but very few are referred to treatment ​ More common in boys ​ Common age of onset 7-9 years old ○​ Clinical levels persist more Separation Anxiety → separation from or harm coming to loved ones ​ Has to be out of proportion depending ond evelopmental stage ​ Frequency & intensity is important ​ Parents getting harmed is a big driver ​ 4% ​ More prevalent in girls ​ Comorbid!! – with other anxiety & depression ​ 33% some form of separation anxiety persist through adulthood Social Anxiety → fear of negative evalution by others ​ In peer settings, not just adults Selective Mutism → we don’t think that children with this is anxious by nature ​ Failure to speak in specific situations and contexts in which speaking is expected – even though they may speak in other settings ​ Reclassified as an anxiety disorder in DSM-5 Generalized anxiety disorder → Excessive, uncontrollable anxiety and worry ​ Worry is the key word ​ Can be episodic or almost continuous ​ Escessive about minor everyday occurrences ​ Somatic – physical symptoms as well ​ Prevalance – 2.2% lifetime ○​ Eqaully common in boys and girls ​ Comorbid – other anxiety and depression ​ Onset in early adolescence ​ Tend to see persistence over time – making it difficult to treat Panic Disorder ​ Panick attack → period of intense fear or discomfort that develops abruptly ○​ Sweating, shortness of breath, nausea, like your chocking ○​ People can have a panic attack but not have a panic disorder ​ DSM-5 Criteria for Panic Disorder ○​ Recurrent, unexpected panic attacks ○​ At least 1 attach followed by one month+ of the following ​ Persistent concern abt having additional attacks ​ Worry about the implications of the attack or its consequences ​ A significant change in behavior related to the attacks Obsessive-Compulsive Disorder (OCD) ​ Obsessions → Recurrent, persistent thoughts impulses or even mental images that we can see as intrusive, inappropriate that cause anxiety/distress ○​ Person attempts to ignore or suppress the thoughts or to neutralize them with another thought or action  ○​ Person recognizes that the thoughts are a product of their own minds ○​ Common obsession: ​ Contamination ​ harm/sefl harm ​ Symmetry ​ Compulsions → repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, must be applied rigidly ○​ Aimed at preventing the stress, or prevening soome dreaded situations ○​ However, these behaviors are not connected in a realistic way with what they are designed to prevent ​ Locking and unlocking 15 times is excessive ○​ Common compulsions: ​ Counting - checking - washing ​ To meet criteria, person has to have obsessions OR compulsions ○​ You don’t need both ​ Os and Cs are time consuming ​ Specifiers – around levels of insight ○​ Good → you recognize that these Os or Cs are not inline with reality, so you are distressed by your own compulsions ○​ Poor → you might not make this connection ○​ Absent → you fully believe in the connection and fully believe that your compulsions are absolutely necessary in neutralization ○​ Tick-related or not is also a specifiers Anxiety disorders: Epidemiology, Correlates and Course ​ Prevalence ○​ Lifetime of any anxiety disorder → 32% ○​ OCD – 1% ish ○​ Selective mutism – 0.7% → rarest ​ Gender ○​ Overall girls are more likely ​ 2 female: 1 male ○​ Differences start around ages 8-10 ○​ OCD follows the opposite trend 2 male: 1 female ​ SES & Ethnicity ○​ Present across SES & ethnicit ○​ Context ○​ Lower SES is higher risk in basically any disorder ○​ Race-based rejection sensitity – based on past experiences like racism etc – might provoke anxiety ​ Comorbidity – Very common  ○​ Selective mutism – 80% with another anxiety disorder, 69% meets with social anxiety disorder ○​ Depression – up to 80% comorbodity ​ Internalizing, mood & anxiety highly related ○​ Anixety sympotms/disorders often PRECEDE depressive symptoms and depressive disorders ○​ Symtpom overlap ​ GAD & MDD – fatigue, sleepless, irritablity etcetc ​ Negative affectiveiy – extent to which person feels distress ​ Positive affectivity is INDEPENDENT – only related to depression NOT anxiety ​ Clinical Correlates ○​ Academic difficulties ​ Impact of worry on concentration ​ Academic functioning ​ School refusal – seperation/social anxiety ​ Selective mutism ○​ Social difficulties ​ Rejected by peer group age ​ Peer victimization Developmental course ​ Young children may not realize that their fear are excessive ​ May become more embarassed ​ Not be able to tell you how they are feeling Prognosis of Anxiety Disorders → research is ongoing to determine what the long-term outcomes of anxiety disorder are ​ Homotypic continuity → something staying the same overtime ​ Heterotypic continuity → social anxiety getting replaced by GAD or depression i.e Etiology and Maintenance of Anxiety Disorders I: Heritability and Learning ​ Heritability of anxiety → Tendencies towards anxiety are inherited ○​ Tendency to be anxious but kids may not always display the same types of anxiety with their parents ○​ Children of parents with anxiety disorders are 5x more likely to have anxiety ○​ Twin studies indicate 33% of variability in anxiety is heritable ​ Identical twisn can hve different types of anxiety disorders ​ Biological predisposition of anxiety → diathesis-stress model ○​ Inherit a general vulnerability/diathesis to anxiety disorders ○​ Temparement ○​ Environment plays a role as well Two-stage model of fear acquisition – etiological and maintenance model for specific phobia 1.​ Stage 1: fear develops through classical conditioning 2.​ Stage 2: avoidance behavior maintained through operant conditioning a.​ Avoidant behaviro provides relief from anxiety b.​ Negative reinforcement Maintenance Model of OCD We have the obsession. We put importance to it. We want to get rid of if → neutralize So the distress decreases. But this decrease in distress leads to the idea that this “obsession” was really important in the first place. Continuous cycle. Unwanted intrusive thoughts are typical – 300 undergrads ​ Running var off the road, cutting of finger etc etc ​ Difference is not in wheter you have unusual obtrusive thoughts, difference is how important you think they are & what you do after you have them Course of OCD ​ Average age of onset 9-12 years old ​ Bimodal distribution – 2 different peak onset periods ○​ Early childhood – boys are overrepresented ○​ Late adolescence/early adulthood ​ A lot of continuity overtime – 50-60% meet criteria 2-14 years later ​ Placebo ​ Combined> CBT, SSRI – so combined is best outcome ​ CBT=SSRI ​ Anxiety diagnosis was a moderator!! → meaning that impact of the intervention differed depending on the diagnoses the youth had ​ SAD → SSRI>CBT ​ GAD → CBT>SSRI ○​ Became CAMELS – follow up study – similar family level associations ​ Pediatric OCD trials (POTS) ○​ 112 youth ○​ SSRI only, pill placebo, CBT, SSRI+CBT ○​ Combined> CBT, meds, Placebo ○​ CBT=meds ○​ CBT, Meds > Placebo ○​ BUT this study was done at two different sites ​ Site was a moderator!! ​ Duke – people in combined are better than CBT ​ Penn – combined is not better than CBT