UOW PSYC251 Lecture 3 PDF

UOW PSYC251 Lecture 3 Mala Khare  Today’s agenda Behavioural Problems in children and Adolescents Developmental disorders– – ADHD, Autism Consultation  Behavioural Problems in children and Adolescents  Conduct Disorder And Opposition...

UOW PSYC251 Lecture 3 Mala Khare  Today’s agenda Behavioural Problems in children and Adolescents Developmental disorders– – ADHD, Autism Consultation  Behavioural Problems in children and Adolescents  Conduct Disorder And Oppositional Defiant Behavior 4  Conduct Disorder is a relentless pattern of conduct in which the basic rights of others & key age-appropriate societal norms or rules are violated. – children who display a broad range of behaviors that bring them into conflict with their environment. Oppositional Defiant Disorder is a pattern of negativistic, aggressive, & defiant behavior without the more serious violations of the basic rights of others that are seen in CD 5 DSM V Conduct Disorder Criteria A. Repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate social norms or rules are violated At least 3 of the 15: Aggression to people and animals 1. bullies, threatens, intimidates 2. Initiates physical fights 3. Used a weapon to cause serious harm 4. Physically cruel to people 5. Physically cruel to animals 6. Stolen while confronting a victim 7. Forced someone into sexual activity Destruction of property 8. Fire setting  DSM V Conduct Disorder Criteria 9. Destroyed property in other ways Deceitfulness or Theft 10. Broken into someone’s house, building or car 11. ‘cons’ / lies to others 12. Stolen without confronting victim Serious Violation of Rules 13. Stays out at night without parental permission (before age 13) 14. Run away from home over night 2+ or 1x (lengthy) 15. Often truant from school (before age 13) B. Clinically significant impairment C. If >18 years, criteria not met for antisocial PD Adult Criminality & Childhood Animal Abuse Felthous & Kellert Studies- —Compared criminals to non-criminals & psychiatric to “normal” —Significant association between acts of cruelty to animals in childhood & serious, recurrent aggression against people as an adult; most aggressive criminals committed more severe acts of animal cruelty Ascione:—48% of individuals incarcerated for sexual homicide abused animals as children —46% of convicted rapists abused animals as children  Oppositional Defiant Behavior as A DSM V Diagnostic Category ODD is defined as "a recurrent pattern of negativistic, defiant, disobedient, & hostile behavior toward authority figures". The disorder is reflected in behaviors such as frequent temper tantrums, arguing, defiance, non- compliance, externalizing blame, vindictiveness, & a range of other problem behaviors. 9  Specific DSM V ODD Criteria A. Recurrent pattern of negativistic, defiant, disobedient and hostile behaviour towards authority figures > 6 months. 3 subtypes o Angry / irritable mood (loses temper, easily annoyed, angry and resentful) o Argumentative / defiant behaviour (argues with authority figures, actively defies rules, deliberately annoys others, blames others) o Vindictiveness (spiteful or vindictive 2+ x within last 6 months) B. Clinically significant impairment or distress C. Differential diagnosis (psychosis, depression, bipolar, substance use) 10  DSM V ODD Criteria Severity: Mild – symptoms confined to 1 setting Moderate – some symptoms in at least 2 settings Severe – some symptoms in 3+ settings The symptoms: – cause clinically significant distress or impair work, school or social functioning. – do not occur in the course of a Mood or Psychotic Disorder. – do not fulfill criteria for Conduct Disorder. 11 No clear causes, but some factors are: Genetic factors likely for both ODD & CD – Inattention, hyperactivity, aggressiveness & novelty seeking Temperament Family's reactions to child's temperament A biochemical or neurological factor No clear causes, but some factors are: A genetic component that when coupled with certain environmental conditions increase the risk. Such as: – Exposure to violence – Substance abuse – Parents with a history of ADHD, ODD or conduct problems Risk factors for CD: Parent with mood or substance abuse disorder Being abused or neglected Harsh or inconsistent discipline Lack of supervision Poor relationship with one or both parents Family instability such as occurs with divorce, multiple moves, or changing schools or child care providers frequently Financial problems in the family  Conduct Disorder Earlier onset usually predicts more serious impairment  Treatment ODD Parent Management Training Programs to help parents & others manage the child’s behaviour. Individual therapy - anger management. Family therapy Cognitive Problem-Solving Skills Training Social Skills Training to increase flexibility & improve social skills & frustration tolerance with peers. Medication for ADHD, anxiety, mood disorders  CD and ODD Prevalence – 2%-6% for CD – 12% for ODD Gender differences – in childhood, antisocial behavior 3-4 times more common in boys – differences decrease/disappear by age 15 – boys remain more violence-prone throughout lifespan; girls use more indirect & relational forms of aggression  CD and ODD Relationship between ODD & CD is unclear ODD is commonly a precursor for CD, but not necessarily Impoverished self-regulation of affect & behavior underlie both disorders Maintained by a range of bio psychosocial influences Socio-economic adversity, a disadvantaged neighbourhood Parental maladaptive behavior Family instability Physical & sexual abuse School Violence Modern phenomenon Report of the Review Panel (2007): 45 school shootings from 1966- 2007 Significant number of shooters had experienced bullying & ‘retaliated’ School Violence: Warning signs associated with shooters 7. Homicidal ideation 1. Violent fantasy content 8. Stalking behaviour 2. Anger problems 9. Disciplinary problems 3. Fascination with 10. Admiration of other weapons murderers 4. Fighting 11. Interest in previous shooting situations 5. Loner-schizoid 6. Suicidal ideation Preventing School Violence Intervention should start at the basic level: Parents – help develop pro-social behaviour – Eliminate access to firearms, alcohol & drugs School – Identify children with problems – Teach conflict resolution skills – Clear rule structures  Parenting Styles PERMISSIVE AUTHORITARIAN AUTHORATATIVE Outcome of authoritarian parenting style for the child Ongoing problems in areas of – Self-confidence & competence, self-perception, behaviour, psychological distress Pile-hammered into obedience Deviant peer groups become the focus of coping through rebellion & escape Social abilities, academic abilities & value, & self- reliance suffer as a result Likelihood of future internalised distress heightened Outcome of permissive parenting style for the child Higher frequency & intensity of alcohol & other drug (AOD), conduct & other problem behaviours Frequent disengagement from school Poor knowledge-skill base for – Problem solving/conflict resolution – Formulation of social mores & customs as their own However, the peer group can have a positive & supportive influence  Outcome of authoritative parenting style for the child Better adjusted & more competent Increased confidence in their abilities Increased competence of children leads to higher levels of achievement Decreased likelihood of problem behaviour, psychosocial impairment & depression Can strengthen resilience against risk-laden barriers  Authoritative Parenting If Authoritative Parenting in associated with the best outcomes for children, why doesn’t everyone do it?  Authoritative Parenting – Is a skill, usually learnt from one’s own experience – It requires executive functions such as inhibition, emotional regulation & planning. – It requires time & energy – It requires a belief in one’s competence & right to authority – It is based on RELATIONSHIP – It is effected by TRAUMA  Trauma & parenting Traumatized adults find authoritative parenting particularly difficult Difficulty in affect regulation Difficulty in executive function – developmental trauma Difficulty in believing one’s own right to authority Fears about being incompetent or “a victim” Fight/flight/freeze can be easily triggered – can lead to aggression & abuse What is the point of “Behavior Management”? Why Behavior Management? Safety Allows relationships to develop Facilitates learning Prevents placement breakdown Teaches societal norms Teaches emotional regulation Teaches respect for others & self Limits as a means to controlling anxiety – “I can trust adults to be in charge” USING LIMITS TO MANAGE ANXIETY…  Parenting RELATIONSHIP Setting limits shows the child they will be cared for & they are free to be a child It is a teaching opportunity However, saying “no” also places strain on the relationship Successful limit setting relies on building & maintaining a relationship of trust – Predictability – Reliability – Honesty  Roles in Setting Limits ADULT CHILD – Set rules & – Contribute to expectations. rules & – Clearly communicate expectations if them. appropriate. – Encourage – Comply compliance. – Apply appropriate consequences to allow learning.  What is the difference between “Behavior Management” and “Punishment”? Good discipline has little to do with punishment Punishment can include: Physical pain Humiliation Isolation Revenge Threats  The Dark Side to Punishment Punishment can damage the foundation of relationship of your House of Reparative Care. It can reinforce the world view that “adults are untrustworthy and I need to look after myself”. Ineffective Limit Setting 1. Angry Orders 2. Threats and warnings 3. Lecturing 4. Name calling 5. Martyrdom 6. Comparisons 7. Sarcasm  Effective Limit Setting § Reasonable limits provide a secure structure within which children can make choices & act with freedom. § Unreasonable limits over-regulate the child or are so broad as to be meaningless. § Setting limits in a way that the child perceives as a threat, to themselves or their relationship with you, usually leads to acting out behaviour.  Structural Family Therapy Hierarchy: Authority needs to be with adults Inverted hierarchy (where children hold parents to ransom) is dysfunctional where: Children do not follow instructions Children speak disrespectfully to adults Adults do not spend time alone as a couple Adults avoid foods/situations etc. just to keep the children from misbehaving, even if these things are important for the children There are few, if any, rules that are reinforced Adults report feeling helpless or bullied Change inverted hierarchy The real work lies in getting the parents to – Understand that they have a right to be in charge – Establish this in an assertive, not aggressive, way with the children Developmental Disorders ADHD, Autism Developmental Disorders — Diagnosed 1st in infancy, childhood, or adolescence — significant dysfunction during childhood — Learning Disorder — Pervasive Developmental Disorders — Attention Deficit Hyperactivity Disorder — Note: most of these conditions persist into adulthood Learning Disorders — Problems related to academic performance in reading, mathematics, and writing — Performance is substantially below what would be expected  Reading Disorder Dyslexia – Word recognition – Reading comprehension – Spelling Tends to persist into adulthood 2% - 8% of school aged kids “Dyslexia is difficulty with language. Intelligence is not the problem; the problem is language. People who are dyslexic may have difficulty with reading, spelling, understanding language they hear, or expressing themselves clearly in speaking or in writing. An unexpected gap exists between their potential for learning and their school achievement.” (International Dyslexia Association, 1993)  Disorder of Written Expression Overlaps with Dyslexia/Reading Disorder Sometimes referred to as Dysgraphia – a neurological-based writing disability in which a person finds it hard to form letters or write within a defined space. Key (DSM) features are grammar, punctuation, spelling and organisation of paragraph errors AND severe interference with academic achievement or daily activities that require writing skills Mathematics Disorder Dyscalculia – a mathematical disability in which a person has unusual difficulty solving arithmetic problems and grasping math concepts. Difficulties in: – Recalling arithmetic facts – Counting objects correctly & quickly – Aligning numbers in a column  Causes of Learning Disorder: biopsychosocial Multiple interacting causes comprising – Genetic: evidence that dyslexia linked to chromosome 6 – Biological: abnormalities of the temporoparietal cortex important in phonological awareness, an aspect of language processing – Psychological: perceptual deficits in rapid visual processing – Behavioural: attending and conforming – Environmental: educational opportunities, peer & family support Pervasive — Pervasive – refers to the Developmental problems that span the Disorders person’s entire life — Problems occur in language, socialization, & cognition — Examples of PDD: — Autistic disorder — Asperger’s syndrome  Autism and Aspergers can be viewed as a single related disorder, albeit on a spectrum or dimension  WHAT IS AUTISM? “Auto” – children are “locked within themselves.” Kanner (1943)- early infantile autism Till 1980 considered to be an emotional disturbance  Autistic Disorder — Neurological disorder — Affects the normal functioning of the brain — Developmental disability — Appears during 1st 3 years of life — Can be diagnosed from about 18 months onwards but can appear normal until around the age of 30 months — adversely affects a child's educational performance Autistic Disorder — Autism occurs worldwide — No known racial, ethnic, or social boundaries — No relation to family income, lifestyle — It is four times more prevalent in boys than in girls. Autistic Disorder — Impact development in the areas of — Verbal & non-verbal communication skills — 50% never acquire useful speech — Social interaction — Unable to form relationships with others — Restricted patterns of behavior, interest, and activities Triad of social impairment 1. Social relationships (Indifference, avoidance) 2. Communication (Absence of desire to reciprocate) 3. Imaginative and pretend abilities (Lack of pretend play, ToM)  ALL 3 have to be present – Taken singly these traits are NOT unique to autism Theory of Mind & Autism Autistic Disorder: Facts and Statistics Prevalence and Features of Autism – Affects 2 to 20 persons for every 10,000 Autism and Intellectual Functioning – 50% have IQs in the severe-to-profound – 25% test in the mild-to-moderate IQ range – Rest- can have average & high IQ range Reliable indicators of good prognosis – Language ability and IQ  Common traits — Difficulty in mixing with others — Preference to being alone; aloof manner — Not wanting to cuddle or be cuddled — Little or no eye contact — Laughing/or crying — for reasons not apparent to others — Difficulty in expressing needs ( gestures or pointing instead of words) — Tantrums Common traits — Non responsive to verbal cues — Act deaf- but hearing tests normal — Repeating words/ phrases — not normal, responsive language Uneven gross/fine motor skills — Noticeable physical over-activity or extreme under-activity — Apparent over-sensitivity or under-sensitivity to pain — No real fears of danger Common traits — Unresponsive to normal teaching methods — Sustained odd play — Insist ‘sameness’ — resistance to change — Spinning objects — Obsessive attachment to objects Autistic traits — Persist into adulthood, but vary in severity. — Some function well, earning college degrees & living independently. — Others never develop the skills of daily living, & may be incorrectly diagnosed with a variety of psychiatric illnesses.  Children do not "outgrow" autism but symptoms may lessen as the child develops and receives treatment. Autism can be MANAGED  Asperger's syndrome is similar to autism but usually does not involve language or cognitive impairment Boys more likely to be affected (9:1) Better long-term outcome than for autism – NOT intellectually disabled Usually diagnosed at age 6 or over Signs of Asperger Syndrome — Difficulty making friends — Difficulty reading or communicating through nonverbal social cues, such as facial expressions — Not understanding that others have feelings different from his or her own  Signs of Asperger Syndrome — Obsessive focus on a narrow interest, such as reciting train schedules — Awkward motor skills — Inflexibility about routines, especially when changes occur spontaneously — Mechanical, almost robotic patterns of speech  Signs of Asperger Syndrome difficulty reading nonverbal cues (body language) and very often difficulty determining proper body space overly sensitive to sounds, tastes, smells, and sights, the person with AS may prefer soft clothing, certain foods, and be bothered by sounds or lights no one else seems to hear or see — Many persons with Asperger’s disorder probably go undiagnosed, with estimates of prevalence between one and two per 10,000. — Little research on the cause of this disorder exists, though there is probably a genetic component that is related to both autism and Asperger’s. Remember Even "normal" children exhibit some of these behaviors from time to time. The symptoms of autism & Asperger's, by contrast, are persistent & debilitating General agreement Children with Autism are born with the disorder or born with the potential to develop it. Can be diagnosed from about 18 months onwards Toddlers- watch for a cluster of symptoms — — No pointing by 1 year — No babbling by 1 year; no single words by 16 months; no 2 word phrases by 2 years — Any loss of language skills at any time — No pretend playing — No response to own name, indifference to others Toddlers- watch for a cluster of symptoms — Little or no eye contact — Extremely short attention span — Repetitive body movements, e.g., hand flapping, rocking — Oversensitivity to certain sounds, textures or smells Toddlers- watch for a cluster of symptoms Little interest in making friends Unusually strong resistance to changes in routine Intense tantrum Fixations on a single object, such as a spinning fan  Why does it happen……. — There is no known single cause for autism —Historical Views -Bad parenting — Both genetic and environmental factors are being studied as possible causative factors. children with a small head at birth, followed by a sudden & excessive increase in head circumference during their 1st yr, seemed to be more at risk of subsequently developing symptoms of autism. The more excessive the growth, the more severe the later symptoms of autism were likely to be  Genetic factors Abnormalities in brain structure or function – Brain scans show differences in the shape & structure Other family members often have some autistic features, such as aloofness, few friends, etc.  Genetic factors The chance of a sibling also having autism is 5- to 10- times higher than normal Twin studies show that if one identical twin has classical autism, 60-90% of twins will have autistic symptoms Why does it happen……. — Children with autism have impairments in the midbrain, cerebellum and cortical areas Abnormalities of the cerebellum ( area which modulates sensory inputs) demonstrate extreme sensitivity to the sound and touch Why does it happen……. — Neurobiological evidence of brain damage in the amygdala (region that controls emotions- anxiety & fear) has indicated a possible connection with autism. — It is believed that the amygdala in children with autism is enlarged, causing high anxiety & fear, & that the continued release of cortisol eventually damages the neurons in the amygdala — lower levels of oxytocin in their blood — giving this chemical to children improved their ability to process emotional information  Psychogenic theories have been discredited  5% - 17 % report to make good adjustment, lead relatively independent adult lives, albeit with some residual social deficits.  Attention Deficit Hyperactivity Disorder (ADHD) ADHD- An Overview Central features: Inattention over activity impulsivity – Associated with behavioral, cognitive, social, & academic problems  ADHD — DSM — Cluster 1 – Symptoms of inattention — Cluster 2 – Symptoms of hyperactivity and impulsivity cluster — Either cluster 1 or 2 must be present for a diagnosis —Combined Symptoms of Inattention Symptoms of Hyperactivity Fails to give close attention to details Fidgets with hands or feet or squirms in or makes careless mistakes seat Leaves seat in classroom or in other Has difficulty sustaining attention in situations in which remaining seated is tasks or play activities expected Does not seem to listen when spoken to Runs about or climbs too much in directly situations in which it is inappropriate Has difficulty playing quietly Does not follow through on Is 'on the go' or acts as if 'driven by a instructions & fails to finish motor' schoolwork, chores, or duties Has difficulty organizing tasks Symptoms of Impulsivity Avoids tasks that require sustained Blurts out answers before questions mental effort (such as homework) have been completed Loses things necessary for tasks or Has difficulty waiting his or her turn activities (toys, school assignments, pencils, books, or tools) Interrupts or intrudes on others (such Is easily distracted by outside stimuli as butting into conversations or games) Is forgetful in daily activities ADHD: Facts and Statistics — Prevalence —Occurs in 4%-12% of children who are 6 to 12 years old —68% of children with ADHD have problems as adults — Gender Differences —Boys outnumber girls 4 to 1 ADHD — Symptoms are usually present around age 3 or 4 — Deficits become more serious as children grow older as they are expected to "be more responsible" by handling such tasks independently with little oversight. — More responsibility- more sense of "incompetence" Assessment IQ/Achievement testing to screen for learning disabilities (50% comorbidity) Behavioral observations at home and school No medical screen, cognitive test, or brain imaging technique can detect ADHD Children with ADHD can focus long enough to watch TV, play videogames or sit still at the doctor’s office. Developmental Course Problems often continue into adulthood – those adults with ADHD may experience a great deal of boredom, work difficulties, impaired social relations, depression, low self-concept, and substance abuse Better outcomes for youth with less severe symptoms, support, supervision, and access to resources  Developmental Course — Inattention remains stable — Hyperactivity declines with age — When ADHD co-occurs with conduct disorder, chronic criminality and serious substance use can result — When ADHD co-occurs with depression, risk of suicide ADHD: Biological Contributions — Genetic Contributions — ADHD runs in families — Familial ADHD may involve deficits on chromosome 20 — The Role of Toxins — Lead poisoning before age 3 years — No scientific basis to believe allergens & food additives cause ADHD — Maternal smoking increases risk of having a child with ADHD ADHD: Biological Contributions — Neurobiological Contributions: Brain Dysfunction and Damage —Inactivity of the frontal cortex & basal ganglia —Right hemisphere malfunction —Abnormal frontal lobe development & functioning —Yet to identify a precise neurobiological mechanism for ADHD Red areas within brain represent metabolic activity. Non ADHD ADHD ADD brain metabolically less active or under stimulated Metabolic activity is partly responsible for ability to focus & concentrate & is the result of brain chemicals (dopamine, serotonin, etc.). Higher levels of brain chemicals increase the metabolic activity. – Relies on external factors to become stimulated enough to focus & concentrate. – Verbal &/or physical impulsivity or activity that is part of the ADD is necessary to stimulate the brain. ADHD: Psychosocial Contributions — Psychosocial Factors Can Influence the Disorder Itself —Constant negative feedback from teachers, parents, & peers —Rejection from peers leading to social isolation —Such factors foster low self-image  Deficits in Executive Functioning The Current view is that ADHD is a deficit not of capacity but of self regulation, disinhibition and planning. These are linked to Executive Functions: – Planning – Shifting set – Problem solving – Response inhibition Biological Treatment of ADHD — Goal: —Reduce impulsivity/hyperactivity —Improve attention — Stimulant Medications —Medication increases metabolic activity (brain) & reduces need for external stimulation. —Reduce the core symptoms of ADHD in 70% of cases —Ritalin, Dexedrine  Biological Treatment of ADHD — Effects of Medications —Improve compliance & decrease negative behaviors in many children —Negative side effects include insomnia, drowsiness, & irritability —Beneficial effects are not lasting following drug discontinuation Behavioral and Combined Treatment of ADHD —Classroom behavior modification techniques & academic interventions —Special educational placement —Increase appropriate behaviors & decrease inappropriate behaviors —Involve reinforcement programs —Parent training — Recommended Combined Bio-Psycho-Social Treatments