Psych Test - Chapter 20: Somatic Symptom & Dissociative Disorders PDF

Psych Test **Chapter 20: Somatic Symptom and Dissociative Disorders:** **Introduction:** - Somatic symptom disorders are characterized by physical symptoms suggesting medical disease but without demonstratable organic pathology or a known pathophysiological mechanism of account for...

Psych Test **Chapter 20: Somatic Symptom and Dissociative Disorders:** **Introduction:** - Somatic symptom disorders are characterized by physical symptoms suggesting medical disease but without demonstratable organic pathology or a known pathophysiological mechanism of account for them - Dissociative disorders are defined by a disruption in the usually integrated functions of consciousness, memory, and identity **Historical Aspects:** - Somatic symptom disorders have been identified as hysterical neuroses and were thought to occur in response to occur in response to repressed severe anxiety - Hysterical neurosis: witchcraft, demonology, sorcery, dysfunction of the nervous system, & unexpressed/repressed emotion - Freud viewed dissociation as a type of repression, an active defense mechanism used to remove threatening or unacceptable mental contents from conscious awareness - Recall of repressed memories under hypnosis; led to idea that unexpressed emotion can be "converted" into physical symptoms **Epidemiological Statistics:** - Somatic symptom disorders: - Originally thought to be more prevalent in females; however, this may be attributable to the fact that females tend to report somatic symptoms more often than males - Conversion disorders are more commonly found in: - Women than in men - Adolescents and young adults - Illness anxiety disorder: (hypochondriac) - Equally common among men and women - Most commonly occurs in early adulthood - More research is needed - Dissociative disorders are statistically quite rare - Brief episodes of depersonalization symptoms appear to be common in young adults, particularly in times of severe stress, sleep deprivation, travel to unfamiliar places, or when under the influence of substances **Somatic Symptom Disorders:** - Psychological factors affecting medical conditions: - Psychological factors may play a role in virtually any medical condition - With this diagnosis, there is evidence of a general medical condition that has been precipitated by or is being perpetuated by psychological or behavioral circumstances - Don't care about why the symptom is there only cares about the specific symptom like ringing in the ears - Drug abuse and dependence are common complications of somatic symptom disorder - Exaggeration of real s/s - You enforced the mental health issue b/c you ignored the somatic s/s - As a healthcare provider sometimes, you say "Fine! Here are some meds go away!" - Personality characteristics: heightened emotionality, strong dependency needs, and a preoccupation with symptoms and oneself - Validation in I can\'t take care of myself there is something wrong with me - When you give med or CT then we are enabling validation - Types of somatic symptom disorders: - A syndrome of multiple somatic symptoms that cannot be explained medically and is associated with psychosocial distress and long-term seeking of assistance from health-care professionals - The disorder is chronic, and anxiety, depression, and suicidal ideation are frequently manifested - Illness anxiety disorder: - unrealistic or inaccurate interpretation of physical symptoms or sensations, leading to preoccupation and fear of having a serious disease - The behavioral response to even the slightest in feeing or sensation of unrealistic and exaggerated - Anxiety and depression are common, and obsessive-compulsive traits frequently accompany the disorder - Conversion disorder: - A loss of or chnage in body function that cannot be explained by any known medical disorder or pathophysiological mechanism - Paralysis, blindness, hearing loss, stuttering - Not fake symptoms- need to rule out medical problem - The most obvious and "classic" conversion symptoms are those that suggest neurological disease - Some instances of conversion disorder may be precipitates by psychological stress - Factitious Disorder: - Conscious, intentional feigning of physical and/or psychological symptoms - Individual pretends to be ill to receive emotional care and support commonly associated with the role of "patient" - Imposed on Self or Imposed on Another - Previously Munchausen syndrome or Munchausen by Proxy - They like the feeling of how people are when they have a sick kid like "what can I do for you?" "I'm sorry" - Gypsy rose purposely causing physical symptoms - Maya's story: Doctors blamed the family for purposely causing symptoms when maya was actually sick - Many of them are mentally ill themselves, they need control, always want the kid or person to depend on them - Predisposing factors associated with somatic symptom disorders: - Genetic: Hereditary factors are possibly associated with somatic symptom disorder, conversion disorder and illness anxiety disorder. - Biochemical: Decreased levels of serotonin and endorphins may play a role in the etiology of somatic symptom disorder, predominantly pain - Neuroanatomical: brain dysfunction (impaired information processing) has been implicated as a factor in factitious disorder - Psychodynamic theory: Suggests that illness associated with anxiety disorder is an ego defense mechanism. Physical complaints are the expression of low self-esteem and feelings of worthlessness - Conversion disorder may represent emotions associated with a traumatic event that are too unacceptable to express and so are acceptable "converted" into physical symptoms - Family dynamics: in dysfunctional families, when a child becomes ill, focus shifts from the open conflict to the child's illness and leaves unresolved underlying issues that the family is unable to confront openly - Somatization brings some stability to the family and positive reinforcement to the child (called tertiary gain) - Learning Theory: Somatic complaints are often reinforced when the sick person learns that they - May avoid stressful obligations or be excused from troublesome duties (primary gain) - May become the prominent focus of attention because of the illness (secondary gain) - May relieve conflict within family because concern is shifted to the ill person and away from the real issue (tertiary gain) - Illness anxiety disorder: experience with serious or life-threatening physical illness, either personal or that of close relatives, can predispose the person to illness anxiety disorder **Dissociative Disorders:** - Depersonalization- Derealization Disorder: - Characterized by a temporary change in the quality of self-awarness, which often takes the form of: - Feelings of unreality - Changes in body image - Feeings of detachment from the environment - A sense of observing oneself from outside the body - Depersonalization: is defined as a disturbance in the perception of oneself (you yourself is disconnected from reality) - Derealization: is described as an alteration in the perception of the external environment (experience that reality is not real) - Symptoms of this disorder are often accompanied by: - Anxiety and depression - Fear of going insane - Obsessive thoughts - Somatic complaints - Disturbance in the subjective sense of time - This is like sitting in a room in my brain and watching life through a TV - Dissociative Amnesia: - A specific subtype of dissociative amnesia is with dissociative fugue, in which there is sudden, unexpected travel away from home with the inability to recall some or all of one's past - Types of Disturbances in recall: - Localized amnesia - Selective amnesia - Generalized - Dissociative Identity Disorder: - Characterized by the existence of two or more personalities within a single individual (previously known as multiple personality disorder) - Transition from one personality to another usually sudden, often dramatic, and usually precipitated by stress - Primary person is unaware of alter personalities - Psychological trauma: - Evidence points to the etiology of DID as traumatic experience(s) that overwhelm the capacity to cope by any means other than dissociation - Most often identified experiences of sever physical, sexual, or psychological abuse by a significant other in the child's life - DID is thought to serve as a survival strategy for the child in this traumatic environment - Predisposing Factors to dissociative disorder: - Genetics: preliminary research does not show evidence of significant genetic contribution - Neurobiological: dissociative amneisa may be related to neurophysiological dysfunction, EEG abnormalities have been observed in some clients with DID (not conclusive) - Psychodynamic theory (Freud): dissociation is the repression of distressing mental contents from conscious awareness; current stance is that dissociative behaviors are a defense against unresolved painful issues - Somatic symptom disorders: Treatment strategies: - Individual psychotherapy - Group psychotherapy - Cognitive behavior therapy and psychoeducation - Psychopharmacology: treat the underlying depression or anxiety - Mental health disorders are diagnosed when we look past what is normal for that person!! - Dissociative Disorders: Treatment Strategies: - Individual psychotherapy - Hypnosis: don't use as much anymore, alternative tx - Supportive care - Cognitive therapy - Group therapy - Integration therapy (DID) - Psychopharmacology: treatment underlying - Application of the nursing process: ASSESSMENT - Medical History: "doctor shopping": doesn't mean that they are just looking for meds - Current Symptoms: Appraisal of symptoms: "nothing helps, and nobody cares", "nobody listening" - Psychiatric History: recent stressors and/or long-term stressors, thorough mental status exam - PLANNING AND IMPLEMENTATION: - Nursing care of the individual with a somatic symptom disorder is aimed at relief of discomfort from the physical symptoms - Assistance is provided to determine strategies for coping with stress by means other than preoccupation with physical symptoms - Nursing care for the client with a dissociative disorder is aimed at restoring normal thought processes - Assistance is provided to the client to determine strategies for coping with stress by means other than dissociation from the environment. **Survivors of Abuse or Neglect:** **Predisposing Factors: Biological theories** - **Neurophysiological:** - Lower volume of amygdala: fear, immediate processor of every sensory thing we experience - Decreased connectivity between amygdala and prefrontal cortex - Limbic prefrontal cortex grey matter volume and connection to amygdala - Striatum dysfunction - **Biochemical** - Role of serotonin: calms down our flight or fight - Increased dopamine release - Testosterone and cortisol levels - Complex interaction with serotonin - GABA (inhibitory) and glutamate (excitatory): modulate serotonin influenced violence - Proactive aggression: just for the fun of it, nobody triggered it, im going to get you back - Reactive aggression: something triggered it, not always known what triggered it - **Genetic:** - At least 40 genes associated - Trauma can alter genetic expression - 50% heritibility - ADHD and depression share common DNA variants - Possible X-chromosome linked mutations od MAO-A gene - Serotonin transporter gene - **Brain Structure/ function:** - Tumors- limbic system and temporal lobe - Brain trauma- cerebral changes - Disease process - Epilepsy esp in the temporal lobe - Encephalopathy and medications that impact this - **Psychodynamic Theory** - Unmet needs of satisfaction and security results in underdeveloped ego and weak superego - Frustration met with aggression and violence - Feeling of power and prestige boost self-image and validates a lacking significance - Underdeveloped ego cannot id behaviors and weak superego unable to produce guilt - **Learning Theory** - Imitation of role models perceived as prestigious, powerful, or influential - Aggressive behavior produces positive reinforcement - Susceptibility to negative role modeling - **Sociocultural** - Accepted as primary influence for aggressive behavior - American society's acceptance of forms of aggression & violence in problem-solving - War, physical discipline of children, law enforcement - Other society influences: Relative deprivation, marginalization, subcultures, Poverty, prolonged unemployment, lack of access to resources, Family breakdown, exposure to violence in family and/ or community **Nursing Process: Intimate partner violence (IPV)** - Domestic violence, spousal abuse, battering - 9% of all homicides are committed by an intimate partner - **IPV** - A pattern of abusive behavior that is used by an intimate partner to gain or maintain power and control over the other partner - Physical, sexual, emotional, economic, or psychological actions or threats - Intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound - [Battering]: a pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence of an intimate partner. **IPV: Victim profile** - No distinction in age, race, religion, culture, education or socioeconomic level - Low self-esteem - Women adhere to feminine sex-role stereotypes & accept relationships as male dominant - Accept blame for abuse - Grew up in abusive homes & left at a young age through marriage - Learned Helplessness: progressive inability to act on her own behalf when perceived outcome is unpredictable **IPV: Perpetrator (victimizer) profile** - Low self-esteem - Pathologically jealous & possessive - "Dual personality": one to the world & one at home/ to partner - Limited ability to cope with stress - Often ignore young children but may become targets of aggression as they grow & especially if they attempt to protect abused parent - Frequent degradation, insulting, and humiliating behavior toward partner - Achieves power and control through intimidation tactics - Goal to keep partner dependent **Cycle of Battering: Tension-building phase** - Senses declining tolerance for frustrations - Becomes angry with little provocation but apologizes quickly - Victim becomes increasingly nurturing & compliant in effort to prevent escalation of anger - Minor battering incidents - Abuser fears partner will leave; jealously & possessiveness increases - Battering incidents become more frequent & intense - Victim is walking on eggshells all the time **Cycle of Battering: Acute battering phase** - Most violence and shortest duration (up to 24 hours) - Begins with abuser justifying their behavior to self but ends with a feeling of loss of control - Victim may intentionally provoke behavior in effort to release unbearable tension - Victim ay feel only option is to find safe place to hide - Potential dissociation from body; many victims can describe incidents in detail - Abuser minimizes severity of abuse - Help is sought only if injury is severe or if in fear for life of self or children - Isolate to let injuries heal **Cycle of Battering: Loving, Respite (Honeymoon) Phase** - Abuser becomes extremely loving, kind, & contrite; promises "never again" and begs forgiveness - Abuser plays on victim's feelings of guilt & victim wants to believe cycle will end - Victim relives original dream of ideal love & chooses this vision of abusive partner - Victim holds this phase as view of the relationship - Victim & abuser become locked in an intense, symbiotic relationship **IPV: Why they stay** - Fear of retaliation (most common reason) - Fear of losing custody of children - Physical or financial dependence - Lack of support network - Cultural/ religious reasons - Hopefulness - Lack of attention to danger [Abuse often doesn't stop once they leave] Risk of being killed increases by 75% after leaving an abusive relationship **Child abuse** - Erik Erikson (1963) "the worst sin is the mutilation of a child's spirit" - [Child Abuse Prevention & Treatment Act ] - **[Physical abuse]**: "any nonaccidental physical injury as a result of punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting, burning or otherwise harming a child that is inflicted by a parent, caregiver, or other person who has responsibility for the child" - **[Sexual abuse]**: Employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing any visual depiction of such conduct; or the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other forms of sexual exploitation of children, or incest with children - **[Emotional abuse]**: Emotional injury resulting from belittling, rejecting, ignoring, blaming, isolating, use of harsh or inconsistent discipline **Childhood Physical abuse** [Signs in children] - Unexplained burns, bites, bruises, broken bones, or black eyes - Fading bruises or other marks noticeable after an absence from school - Seems frightened of parents; protests or cries when time to go home - Shrinks at approach of adults - Reports injury by parent or another adult caretaker - Abuses animals or pets - Sudden change in behavior - Offers conflicting, unconvincing, or no explanation of child's injury - Describes child as "evil" or in other negative ways - Uses harsh, physical discipline - History of being abused as a child - History of abusing animals or pets **Childhood Emotional Abuse** - [Signs in the child] - Extremes in behavior - Behavior is either inappropriately adult or infantile - Delay in physical or emotional development - Attempted suicide - Reports lack of attachment to a parent/ caregiver - [Signs in parent/ caregiver] - Constantly blames, belittles, or berates the child - Unconcerned about the child & refuses to consider offers of help for child's problems - Overtly rejects the child **Childhood Physical & Emotional Neglect** - [Signs in children] - Frequently absent from school - Begs for or steals food or money - Lacks needed medical, dental, or other healthcare - Consistently dirty/ severe body odor - Lacks appropriate clothing for weather - Abuses alcohol or drugs - Reports no one at home to provide care - [Signs in parents/caregivers] - Appears indifferent to child - Behaves irrationally or bizarre - Seems apathetic or depressed - Abuses drugs or alcohol **Childhood sexual abuse** - [Signs in the child] - Difficulty walking or sitting - Suddenly refuses to change for gym or physical activities - Nightmares and/or bedwetting (nocturnal enuresis) - Sudden changes in appetite - Bizarre, sophisticated, or unusual sexual knowledge or behavior - Becomes pregnant or contracts STI under age 14 - Run away - Reports sexual abuse by parent or another adult - Attaches very quickly to strangers or new adults in their environment - [Sexual exploitation of a child] - Child is induced or coerced into engaging in sexually explicit conduct for the purpose of promoting any performance - Child being used for the sexual pleasure of an adult or other person - Often victims of childhood abuse - Active substance use - Currently experiencing a stressful life situation - Few support systems; commonly isolated from others - Lacks adaptive coping strategies, angers easily, difficulty trusting others - Expecting child to be perfect: may exaggerate any mild difference the child manifests as "normal" - [Signs in parent/caregiver] - Unduly protective of child or severely limits contact with other children, esp. opposite sex - Secretive & isolated - Jealous & controlling with family members - Most research has been in father-daughter incest - If reported in one child in a household, suspect all children - As adults: - Lack of trusting relationships, low self-esteem, poor sense of identity, alterations in consenting sexual activity - Increased findings in inflammatory markers **Sexual violence** - Includes any act of sexual coercion including penetration, unwanted sexual experiences, noncontact unwanted sexual experiences, and rape per definitions of rape - [Never use the word reportedly and allegedly in documented, use reports, stats] - [Profile of Perpetrator] - Not distinguishable by physical traits or intelligence - Increased likelihood if experienced childhood abuse - Rapes are often premeditated - Ignore or violate rights of others - Underlying motives - [Profile of Victims] - Highest risks: Below 34 years old, lower income, never married **Sexual violence: Psychological responses Rape Trauma Syndrome** - Immediate presentations - [Expressed Response Pattern]: expresses feeling of fear, anger, & anxiety through crying, sobbing, restlessness, & tension- mental breakdowns - [Controlled Response Pattern]: feelings are masked or hidden with calm, composed, or subdued affect- shuts down, like nothing happened - In following days to weeks - Contusions/ abrasions on body - Headaches, fatigue, sleep pattern disturbances - Stomach pains, nausea/ vomiting - Vaginal discharge/ itching, burning upon urination, rectal bleeding and pain - Rage, humiliation, embarrassment, desire for revenge, and self-blame - Fear of physical violence/ death - At risk for PTSD symptoms to develop **Sexual Violence: Other Psychological responses** - [Compound Rape Reaction] - Rape trauma syndrome symptoms with added depression, suicidal ideation, substance use, psychotic behaviors - [Silent Rape Reaction] - Tells no one about the assault - Anxiety is suppressed; emotional burden may become overwhelming - Unresolved trauma may not be revealed until forced to face another sexual crisis **Sexual Violence: Outcomes** - [Sexual Assault] - No longer experiencing panic anxiety - Demonstrates a degree of trust in the primary nurse - Received immediate attention to physical injuries - Initiated behaviors consistent with grief response - [Physically Battered] - Received immediate attention to physical injuries - Verbalizes assurance of immediate safety - Discusses life situation with primary nurse - Verbalizes choices from which they can receive assistance - [Child Abuse] - Received immediate attention to physical injuries - Trust in primary nurse by disclosing abuse through play therapy - Decrease in regressive behaviors **Sexual violence: interventions** - Communicate: - "You are safe" - "I'm sorry that it happened" - "I'm glad you survived" - "It's not your fault. No one deserves to be treated this way" - "You did the best you could" - Explain every assessment procedure and why it is being conducted - Maintain a caring, non-judgmental manner throughout all aspects of data collection - Assure adequate privacy for all interventions - Encourage victim to give details of assault - Specific nursing documentation is required but always use "Patient/client reports" rather than "patient alleges" **Sexual violence: evaluation Questions** - Has the individual been reassured of his or her safety? - Is this evidenced by a decrease in panic anxiety? - Have wounds been properly cared for and provisions made for follow-up care? - Have emotional needs been attended to? - Trust established with at least one person to whom the client feels comfortable relating the abusive incident? - Have available support systems been identified and notified? - Have options for immediate circumstances been presented? - Is the individual able to conduct activities of daily living satisfactorily? - Have physical wounds healed properly? - Is the client appropriately progressing through the behaviors of grieving? - Free of sleep disturbances; psychosomatic symptoms; regressive behaviors; psychosexual disturbances? - Is the individual free from problems with interpersonal relationships? - Has the individual considered the alternatives for change in his or her personal life? - Has a decision been made relative to the choices available? - Is he or she satisfied with the decision that has been made? **Sexual Violence: Forensic Nursing** - Sexual Assault Nurse Examiner (SANE) Nurses - Specialized nursing to provide care, evaluation, and advocacy for victims - Investigate wounds & reports - Evidence collection & preservation - Testify in court **Trauma-Informed Care (TIC)** - Not a set of specific interventions but a framework for developing interventions to incorporate into care - Understanding that everyone's response to trauma is different and rooted in "fight or flight" (autonomic nervous system) response - This response impacts & disrupts the function of body systems; most notably is memory & emotional regulation - Goal is to accommodate the vulnerabilities of trauma survivors by adapting services to avoid inadvertent *[re-traumatization]* and facilitating consumer empowerment in health care. - Don't go in a room w/o knocking, don't assume someone wants their door shut, don't touch a patient w/o asking **Four R's of TIC** - **Realize** the widespread impact of trauma - Screen for trauma history - Understand potential paths for recovery - **Recognize** the signs & symptoms of trauma in patients, families, staff, & others involved - **Respond** by fully integrating knowledge about trauma into policies, procedures, & practices - **Resist** re-traumatization - Behaviors include trustworthiness, transparency, assuring patient safety, collaboration, & empowerment **TIC: Sanctuary Model** - Institutional model designed for children exposed to interpersonal violence, abuse, and trauma - Residential settings, public schools, shelters, group homes, community based, acute care, and juvenile justice - [Seven Cultural Pillars] - Nonviolence - Emotional intelligence - Inquiry & social learning - Shared governance - Open communication - Social responsibility - Growth & change - Treatment modalities **[Crisis Interventions]** - Goal: help survivors return to previous lifestyle as quickly as possible - Patient should be involved in all planning of interventions and aftercare - Usually, time limited 6-8 weeks - Focus on coping strategies - [Safe House or Shelter] - [Family Therapy] - Changing family functional/ interactional patterns **[Chapter 23: Children and Adolescents]** Disorders to be reviewed: - Disorders: - Separation Anxiety - Intellectual Developmental Disorder (IDD) - Autism Spectrum Disorder (ASD) - Attention-Deficit Hyperactivity Disorder (ADHD) - Tourette's Disorder - Oppositional Defiant Disorder (ODD) - Conduct Disorder - Introduction - Some disorders in this chapter may not be recognized until later in life but symptoms appear in childhood - It is often difficult to determine whether a child's behavior indicates emotional problems. - An emotional problem is likely when behaviors: - Are not age appropriate - Deviate from cultural norms - Interfere with adaptive functioning - Separation Anxiety Disorder - The essential feature of separation anxiety disorder is excessive fear or anxiety concerning separation from those to whom the individual is attached - The anxiety exceeds that which is expected for the person's developmental level and interferes with social, academic, occupational, or other areas of functioning. - Most commonly diagnosed age 5-6 y/o, upon starting school - Separation Anxiety Disorder: Predisposing Factors - Biological influences, Genetics, Temperament, Environmental influences, Stressful life events, Family influences, Parental overprotection, Insecure parent--child attachment, Maternal depression - Separation Anxiety Disorder: Treatment Approaches - Behavioral therapy - Group family - Family therapy - pyschopharmacology - Intellectual Developmental Disorder - Intellectual Developmental Disorder (IDD) - Known as "IDD" or "ID" - Onset prior to age 18 year - Characterized by deficits in general mental abilities- reasoning, problem solving, planning, abstract thinking, judgment, learning in both academic & from experience. - IDD: Diagnostic Features - **General intellectual functioning** - Clinical assessment **AND** Performance on IQ tests (not diagnostic). - **Adaptive functioning (diagnostic)** - Ability to adapt to requirements of activities of daily living and the expectations of their age and cultural group. - IDD: Determining Severity - Severity Levels: Mild, Moderate, Severe, & Profound - Level of severity is defined by: - Severity of impairment in adaptive functioning - IQ scores are no longer part of severity assessment but can be an influencing factor - [Domains of Adaptive Functioning] - Conceptual - Social - Practical - IDD: Predisposing Factors - Genetic factors (5%) - Pregnancy and perinatal factors (10%) - Disruptions in embryonic development (30%) - Acquired medical conditions (5%) - Sociocultural & other Mental Disorders (15%) - IDD: Psychosocial Interventions - Behavioral - Generalized behavioral interventions - Social skills training - Parent training - Early intensive behavioral intervention (EIBI) - Complementary - Psychotherapy - Educational Support - Adaptive Skills Training - Occupational Training - Speech Therapy - Vocational Training - IDD: Psychopharmacological Treatments - Antipsychotics - Comorbid ADHD occurs at higher rates in ID but response is\ lower in decreasing hyperactivity/ irritability & less tolerable - Must consider common characteristics of ID\ Stimulants - Used for comorbid anxiety & depression - Unclear how these may impact behavioral problem - Antidepressants - Autism Spectrum Disorder (ASD) - Characterized by a wide range of social difficulties, communication impairments, and restricted/ repetitive behaviors. - Persistent impairment in reciprocal social communication or interactions and restricted or repetitive patterns of behavior, interests and/or activities - Prevalence is about 1 in 54 children. - ASD: Diagnostic Features - Persistent deficits in social communication & interaction across multiple contexts: - Social-emotional reciprocity - Nonverbal communication - Developing, maintaining, and understanding relationships - Restricted, repetitive patterns of behavior, interests, or activities - ASD: Levels of Severity - Level 1: Requiring support - Level 2: Requiring substantial support - Level 3: Requiring very substantial support - ASD: Predisposing Factors - Neurological implications - Abnormalities in brain function or structure - Role of neurotransmitters under investigation - Genetics - Familial association - Chromosomal involvement - Prenatal & perinatal influences - maternal asthma or allergies - ASD: Psychopharmacological Intervention - FDA Approved Medications - Risperidone - Aripiprazole - Dose based on\ child's weight and\ response - Targeted symptoms - Aggression - Deliberate self-injury - Temper tantrums - ASD: Nonpharmacological Interventions - Behavioral and communication therapy - Family therapy - Education therapy - Attention Deficit Hyperactivity Disorder (ADHD) - ADHD: Diagnostic Features - [Inattention ] - Poor attention to details or careless mistakes - Impaired tasks completion - Seems to listen when spoken to directly - Impaired ability to maintain attention in activities - Poor organizational skills - Avoids/ reluctant engage in certain tasks - Loses important/ required items - Easily distracted - Forgetful in daily activities. - [Hyperactivity- Impulsivity] - Fidgets or "squirms" - Unable to remaining seated expected (leaves seat) - Runs or climbs in situations where not appropriate - Unable to play quietly - Behavior is \"on the go\" or as if \"driven by a motor\". - Excessive talking - Blurts out or answers questions before completed - Difficulty waiting their turn. - Frequently interrupts or intrudes on others - ADHD: What we see - Behavior pattern includes symptoms of inattention and/or hyperactivity and impulsivity with an onset prior to 12 y/o. - Subsets are predominately inattentive, predominately hyperactive/ impulsive, and combined type - Hyperactivity: - Excessive psychomotor activity that may be purposeful or aimless, accompanied by movements/ speech that can be more rapid than normal. - Inattention/ distractibility are common with hyperactive behavior. - Impulsivity: - Acting without reflection or thought to the consequences of the behavior; urges to act (and the inability to resist acting) - Signs of Impaired Executive Function - Interrupt others often - Difficulty stopping or changing ongoing behavior - Difficulty returning to an activity after interruption - Impatient - Excessive touching/ moving objects - Difficulty with delayed gratification - Disinhibition that decreases with age - Difficulties with motor coordination & sequencing - Impaired working memory and recall - Impaired planning ability - Difficulty following strict or command directions - Impaired emotional regulation ("meltdowns") - ADHD: Common Comorbidities - Oppositional defiant disorder (50%) - Conduct disorder - Anxiety (20%) - Depression (30%) - Bipolar disorder (20%) - Substance use disorders - Frontal lobe epilepsy (89.4%) - Disruptive Mood Dysregulation Disorder (DMDD) - ADHD: Predisposing Factors - [Genetic] - Biochemical Theories (Still under investigation) - Anatomical: Decreased volume/ activity in prefrontal cortex & other areas - [Prenatal, perinatal, & postnatal factors] - Maternal smoking, exposure to toxic substances, maternal infections - Low birth weight, trauma, early infancy infections, brain injuries - [Environmental Influences] - Disorganized/ chaotic environments, early life trauma - [Psychosocial Influences] - Single-parent, young maternal age, parental antisocial behavior, maternal depression, & low socioeconomic status - ADHD: Psychopharmacological Interventions - Central Nervous System Stimulants - Examples: Dextroamphetamine, methamphetamine, lisdexamfetamine, methylphenidate, dexmethylphenidate, dextroamphetamine/amphetamine mixture - Side effects: Insomnia, anorexia, weight loss, tachycardia, decrease in rate of growth and development - ADHD: Nonpharmacological Intervention - Trigeminal nerve stimulation - Neurofeedback Cognitive training - Cognitive behavioral therapy - Child or parent training - Dietary omega fatty acid supplementation - Tourette's Disorder - The essential feature of Tourette disorder is the presence of multiple motor tics and one or more vocal tics. - May appear simultaneously or at different periods during the illness. - May cause distress or interfere with social, occupational, or other important areas of functioning. - Peak severity pre-teen & teen year - Onset may be as early as 2 years but occurs most commonly around age 6 or 7 years. - Tourette's: Predisposing Factors - Tourette's: Pharmacological & Nonpharmacological Interventions - Biological: genetic, biochemical, structural - Environmental: complications in pregnancy, low birth weight, infection, head trauma - Most effective when combined with other therapy, such as: - Behavioral therapy - Individual counseling or psychotherapy - Family therapy - Common medications used for Tourette disorder - Antipsychotics: Haloperidol & Risperdal - Alpha agonists - Oppositional Defiant Disorder (ODD) - [Leading cause of referral for mental health & SpecEd services] - Recurrent pattern of defiance, hostility antagonizing & blaming others for their mistakes - Average age of onset 6 years old but symptoms may start much earlier & Rarely begin later than early adolescence - Primarily due to parenting or other immediate environmental features of early childhood (hostile or overly controlling parenting styles) - ODD: Predisposing Factors - Biological - Role has not been fully established - Family influences - If power and control are issues for parents, or if they exercise authority for their own needs, a power struggle can be established between the parents and the child, which sets the stage for the development of ODD - ODD: Treatment Strategies - Family based interventions - Social training interventions - Pharmacological interventions - Conduct Disorder - Persistent pattern of behavior in which the basic rights of others and major age-appropriate societal norms or rules are violated. - Physical aggression is common & peer relationships are disturbed. - Prevalence estimates range 2%-10%; rises from childhood to adolescence - **More common in males** than females; especially with child-onset - Common comorbidities: - ADHD, mood disorders, learning disorders, and substance use disorders. - Conduct Disorder: Diagnostic Features - 4 Symptom/ Behavior Categories (total of 15 criteria) - Conduct Disorder: What we see - Typically lacking in guilt or remorse for actions - Frequently minimize their behavior re severity - Behaviors often include proactive aggression and confrontational aggression - Adolescent females are more likely to have issues with substance misuse - Rates of suicide attempts and suicidal ideation are higher than expected - Often have significant abuse/ neglect history - Conduct Disorder: Predisposing Factors - Biological - Genetics - Temperament - Neurobiological factor - Psychosocial - Peer relationships - Family Influences - Conduct Disorder: Treatment Strategies - Family based intervention - Social training interventions - Pharmacological interventions