Childhood Disorders PDF

Childhood Disorders Learning objectives 1. Differentiate between critical biological, psychological, and social factors that extinguish a child from adult mental illness (in both child and adult psychopathology) 2. Explain the biopsychosocial models of specific childhood disorders 3. Identify what m...

Childhood Disorders Learning objectives 1. Differentiate between critical biological, psychological, and social factors that extinguish a child from adult mental illness (in both child and adult psychopathology) 2. Explain the biopsychosocial models of specific childhood disorders 3. Identify what makes the prospect of treating a child's mental illness different from adult psychological disorders 4. Identify the most common forms of childhood disorders Anxiety, Depression, ADHD and Conduct Disorder 5. Identify special issues regarding treatment for children → note: create a biopsychosocial grid on childhood vs. adult development Connections i am seeing: importance of early intervention in childhood disorders (depression before reaching 4 periods of depression, CD → intervening on proper coping and planning before escalation) Adhd and conduct disorder overlap → explaining factors as to why adhd is highly commorbid with Conduct disorder How childhood developement in contrast to adults, play a role in mental disorders (e.g. lack of theory of mind in conduct disorder) or how they rely on adults in lives to help their disorder (e.g. interventions or parental behaviours as etiology to CD) Childhood Disorders 1 Additional required videos This is not tested however here are the notes: CBT Skill: Problem Solving STEPS identifying numerous solutions → adult supports child to solve themselves STEPS: S → what is the situation/problem that needs to be solved not always clear T → think of possible solutions E → evaluate the solutions (pros and cons) P → pick one S→ see if it worked Possibly tested? Classic Research on child temperment is said that → certain reactions in 4 month olds can predict future shyness or sociability average is often not very shy or outgoing? one kid with increased mobility and excitation then transitions to irratability when looking at hanging mobile → he passed his threshold (starts crying/great distress to stimuli) → is likely to be more of a shy, timid child in the future parents often misinterpret this behaviour when infact that child was born with that neurochemistry to make it likely to react that certain way. Incontrast → very calm when looking at mobile/ lack of tension → more outgoing, socially, spontaneous, nonfearful. brain activity measured → shy = greater activity in one side and outgoing → other side is active. but in average temperment = pretty equal activity in both hemispheres. (underlying chemistry and physology). Childhood Disorders 2 genes aren’t our destiny → but also how parents respond to childs reactions. Chapter 15 → will not cover/be tested on learning disabilities or ASD Lecture Notes Developmental Psychopathology Study of the origins and course of individual maladaptation (disorder) in the context of typical growth processes Epidemiology Point Prevalence 15% of children (4-17yrs) at any one point have a clinically significant mental health issue Anxiety is the most common form This statistic is likely an underestimate as many either don’t meet the diagnostic criteria, self-presentation concerns (when kids are asked how they are feeling, they say “fine” or “okay” even when they are not) → this also leads to how we see suicide in youth “come out of nowhere”. As many people in their day-to-day life, don’t see the signs of suicidality. This is very common. Trends Anxiety and depression are increasing in girls Over > 50% of children have a comorbid disorder Less than boys (2:1) Etiology Bio/Psycho note → whenever you see bio/psycho often referring to temperament Genes Genes are often related to anxiety disorders through Temperament → specifically the trait of Behavioural Inhibition Childhood Disorders 9 This trait is very stable overtime → some behaviour becomes quite predictable due to this trait Behavioural Inhibition → tendency to avoid novel, new, and unfamiliar situations (e.g. toys, people, classes etc). you see differences in autonomic reactivity → cortisol heightened. There is much a lower threshold for stress in the child. One reason for this reactivity is possibly they are more easily conditioned to anxiety because of high reactivity the pairing of a conditioned response and stimuli happens much easier, then avoid that stimulus/pairing → increasing the operant conditioning by negatively reinforcing/avoiding. Social 1. Family Early relationships (where there is high anxiety there is often poorer adaptive coping skills) caregivers who show higher anxiety also show this poorer coping skills Parents can be considered as either: Anxiety sensitizers (vs.) or Anxiety suppressors Anxiety sensitizers → the parent is very sensitive to child's anxiety and they increase the child's anxious reaction, to their own anxiety. Anxiety Suppressor → does not react to child's anxiety, therefor teaching child not to react to anxiety. → these are a matter of reinforcement E.g. a child wakes up from an upset stomach or scared something bad might happen (having an anxiety reaction). an anxiety sensitizer → “oh no what’s wrong, we should keep you home from school, something might be bad or is going to happen” by doing so, parent is sensitizing the child to the anxiety, you are encouraging and positively reinforcing the anxiety reaction Childhood Disorders 10 an anxiety suppressor → “okay, that happens sometimes. You’re scared something bad is going to happen, i get it well we will see”. someone who does not react with a bunch of (over)attention to the child or anxiety, or anxiety of their own. the suppressor is more likely to keep the child’s anxiety at bay whereas the sensitizer is more likely to facilitate/cultivate the child’s development of an anxiety disorder 2. Environment an unusual level of stress, threat exposure (e.g. living in a dangerous neighbourhood, frequent experience of war/bombings, gang activity, maltreatment, domestic violence) Anxiety Disorder Treatment for Children Biological you can use SSRI’s, but it’s empirically much better and longer lasting if you use (+CBT) alongside SSRI’s. However SSRI’s (bio based treatment) still aren’t the best for treating anxiety disorders as it doesn’t allow child to habituate to the anxiety. But if SSRI’s are necessary to get the child through treatment, that’s fine. Psychosocial Behavioural Therapy → exposure therapy Child CBT + Parent/family treatment is 2x as effective as child alone CBT therapy e.g. PCIT→ parent-child interaction therapy there is a very intense attention the child is giving the child, therapist is on the other side of glass communicating with parent through microphone + earpiece in parent, to help parents practice the things they can say to improve or strengthen the attachment and relationship before incorporating more of the requirements/difficult therapeutic tasks from the child. Strong bond is really important first. Childhood Disorders 11 Childhood Depression Criteria for Diagnosis: Same as adult criteria except for one important difference → children can show irritability instead of depression/being depressed. one implication of this: parents or adults may not know this, and think that child’s irritability is being moody or some kind of external disorder (moodiness), missing that it could be depression. Epidemiology Rates of Depression in different Ages include: 1% preschoolers 2-4% grade school 8-15% Adolescents Rates in the Sexes: Childhood - approximately equally, (slightly more males than females) Adolescence - Girls > boys = 2:1 very likely of biopsychosocial reasons that contribute to this ratio. Course of Depression in Childhood: Average Major Depressive Episode (MDE) is the same as an adult → 7-9 months quite long for a child’s life After 2 years, 90% of children with depression recover However similar to adults it does recur/is recurrent → Relative to MDE in adults we don’t want to hit 4 recurrent episodes. This is why it's especially critical to have early intervention for children/adolescents (and everyone) Etiology Psychological factors to developing depression: Childhood Disorders 12 Same as for adults except for perfectionism → this trait is seen a bit in adults but even more greatly in children. Social Factors to developing depression: when a child has a depressed parent they are 2-3x more likely to develop depression which increases their risk to 15% to 45% lifetime risk The reason for this gap of 15-45% is that studies find different results so we must say between 15-45%. There may be different reasons for different rates, but we can’t say definitively what. if the parent is critical to the child this is also a big factor for relapse in depression similar to adults Etiology/Presentation of childhood depression: Psychological Again, important to ask how child psychology/child development is different from adults, which plays into the disorders. Adolescence in Formal Operations Stage Having Abstract, complex thought Thoughts: “life is meaningless, existential view on everything” this is a very typical psychological event for someone to go through in life, but has the potential to be a trap for depression. Egocentrism We see this is children and adolescence Thoughts: “Nobody understands me, I'm the only one going through this level of pain” This can encourage kids to isolate themselves further which can worsen depression. Cognitive inflexibility Thoughts: “Nothing will ever change, it will be like this forever” Childhood Disorders 13 adults have this to some degree, but this is certainly characteristic of the formal operations period which feeds very strongly into a depressive disorder. Presentation of childhood Depression Children with depression tend to present with more somatic or physical complains they tend to have a sick stomach or headaches or they feel shaky. There is more psychomotor retardation and there is a greater overlap with anxiety Adolescents on the other hand show more hopelessness, hypersomnia (sleep a lot), and show more differences in weight changes either gaining or loosing a lot of weight (due to changing their eating behaviour substantially) Depression and suicide This is critical in children as well Ages 12-17: Suicide is the 2nd leading cause of death Ages 5-14: Suicide is the 5th leading cause of death 5 year olds attempting suicide is rare, before we use to really only see suicide in adolescence (12-17), however the age of suicide rates has been continuing to reach younger kids Treatment for depression in Children Biological Treatment SSRIs and Suidide in youth (specifically in adolescence)? the fear is that SSRIs can increase the risk of suicide in adolescence we do see slightly higher rates of this (suicide in adolescence on SSRI’s) There was a blackbox warning of this due to this, but in reference to what we know about the riskiest time for suicide (in mood disorders unit) → it’s Childhood Disorders 14 when the individual begins to feel better. and What SSRI’s Do? they help you get better. Therefore 1 possible explanation for increase risk of suicide in youth on SSRI’s is: the person hasn’t developed different forms of thinking yet or ways of behaving in their lives so their quality of life isn’t improving, BUT they are gaining more physiological energy in order to enact their plans Psychological treatment CBT and particularly Behavioural Activation behavioural activation is the “special ingredient” here → as it is making you get up and get out of the house and do stuff you don’t want to do and in doing so you are changing your life and filling your life with things that make your life meaningful to you. Social Treatment Interpersonal Therapy (ITP) Externalizing Disorders in Children Where children externalize through their behavious, actions, speech, thought processess, emotions ADHD Epidemiology 1-7% of population likely meets criteria for disorder 4:1 ratio of Males:Females are diagnosed with the disorder 60% of children with the disorder continue to have ADHD as adults Symptoms 1. Hyperactivity 2. Forgetfulness 3. Poor Impulse Control 4. Distractability Childhood Disorders 15 5. “run by a motor” → seeming as if you are run by a motor Nature of ADHD It is a chronic neurological disorders There is no known medical cure However, there are variety of treatments to manage symptoms the diagnosis itself has been quite controversial, in part → because what we are require of children (for example) in school systems, is to have them sit at a desk for hours at a time and have brief times to run around outside. This is said to effect boys, more as they are more likely to act out, then get into trouble, then when this repeated mismatch of expectations and capabilities happens the boys (and girls) can be diagnosed with this disorder when in actuality it’s that the enviroment doesn’t fit them quite right. this isn’t ofcourse the case for everyone but some. Subtypes 1. Inattentive forgetting, not paying attention, not being aware 2. Hyperactive-impulsive run by a motor, doesn’t think before doing things 3. Combination includes both 1 and 2 ADHD presentation/symptoms Etiology of ADHD Biological components: Genes about >30% of individuals with diagnosis have family members with ADHD Neurotransmitters Low level of DA (dopamine) Pre-perinatal stress Childhood Disorders 16 including pregnant mother using cocaine Birth complications (always thinking of hypoxia and it’s effect on neural development) Psychosocial components: Not much of these are known or found about psychosocial etiology or stand out as consitently contibuting to the development of the disorder → as it’s highly a neurological disorder there is the possibility that family adversity & disorganization may contribue however it is a weak correlation between this and childhood ADHD But it’s important to remember the directional relationship of this → correlation does NOT equal causation. A can lead to B, or B can lead to A. (e.g. a child having ADHD can increase family adversity as it’s difficult to manage and it’s chronic (happening all the time) and can lead to higher disorganziation in many ways in a familys system/functioning. Or it’s something else entirely! Biological Presentation of Hyperactivity and Impulse control Poor connections between amygdala & PFC (impulse control) → this is common childhood anyway, but even more so in children with ADHD the PFC can’t keep the reigns on the amygdala and the amygdala is just doing whatever it wants to do. Underactive Behavioural Inhibition System (BIS) In contrast to kids with anxiety, it tends to be lower or less active in kids with ADHD Underarousal Theory as seen in relation to adults involved in substance use There seems to also be this underarousal in kids with adhd Biological Presentation of Innattention Striatum + Frontal lobes + Posterior Periventricular region Childhood Disorders 17 note: posterior perventricular region is made up of white matter together they increase someones ability to control and direct their attention where they want too These areas are less active in children and adults with ADHD This system is also highly connected with sensory cortices (all your sensory information is very much connected to this path) Meaning → if this system are underactivated, when sensory input comes in you are not able to identify which piece of sensory information you should be/is most important to attend too at that moment. These 3 structures act as a gate meaning: they filter out irrelevent “noise” (think about when a neurotypical is listening to a lecture they are filtering out other input such as sensations of clothing, or other surrounding stimuli → putting all info into 1 thing not the ticking of a clock) but in ADHD as these are underactive → you are recieving all this information (hunger, clock ticking, sounds, lights etc.) and you are not able to identify or filter our the ones not relevent to what you are doing at the moment. which is quite difficult. To Recap/continue: There are under-functionig “gates” unable to filter out increasing stimuli the Sensory cortices are flooded with incoming messages → there is high blood flow there, especially to vision and sound input areas which means visual and auditory info neurotypicals don’t usually attend to, is coming in as if it were all equally important. Childhood Disorders 18 Treatment for ADHD Biological 1. Methylphenidate (Ritalin, Concerta) most commonly used works to redistrubute blood flow in brain → parts of the brain that are overactive subtle down and parts of the brain that are underactive settle up. It increases the function of striatum, frontal lobes, and posterior periventricular region so they are able to act as a gate and keep out irrelevent information so one can focus on relevent information increases the availbility of DA (dopamine) A person develops increased focus, inhibitory control, regulation of extraneous motor behaviour (e.g. fidgeting) It seems to reducce symptoms in 60-80% of school age children. (which is enticing/sounds great for many children who get into trouble often at school) but also means about 40% don’t respond to it. Perscriptions have increased 600% for these perscriptions between 19852002 (probably more after 2002 too) it’s also known these medicatons are used recreationally, and how much more we are using these medications for kids. Childhood Disorders 19 the question of are we overmedicating children? → answer is we don’t know. It does seem to help many get less in trouble, but there are also other interventions that can help e.g. going outside more ALONGSIDE medication or as a first step if there is concern of overmedicating. Psychosocial Treatment Cognitive interventions are NOT successful you can’t ask a kid to just sit down and stop being difficult, as it’s not a result of the child being defiant or difficult (as often believed by the adult) → but becuase they genuinely can’t. They don’t have the ability to inhibit their impulses or level of functionig they need to complete the task you or they want to do. Behavioural Parent (and teacher) training → does seem to make a difference behavioural programs need to emphasize attention, self control and obeying rules again you need to do this in very small baby steps, so you don’t set the child up for failure. as by the time they have gotten into treatment, the child has been “failing” for a while so you want to help them see ways they can ‘train’ themselves. But.. Medication is still what’s most effective it is important to teach other skills alongside medication (e.g. social skills) for longer term improvement Kids with ADHD have higher rates of rejection from peers, hence the importance of developing those other skills. Conduct Disorder (CD) Childhood Disorders 20 characterized by a violation of rules and disregard for basic rights of others Some of major symptoms include: 1. Agression to people and animals 2. Destruction of property 3. Deceitfulness or theft 4. Serious violation of rules Epidemiology of CD It is highly comorbid with ADHD think of the brain differnces and lack of impulse control Substance abuse Anxiety and depression also common Prevelence among ages 4-16 8% Boys 3% Girls Two Courses this disorder can take 1. Childhood onset: Male >female with this course considered “life course persistent” meaning it shows up at about 3 years old but tends to continue into adulthood 2. “Adolescence limited”: Male = female with this course considered “adolescence limited” → meaning they grow out of it once their adults. genderally thought of as a Maturity Gap → their bodies are developing faster then their minds Etiology Childhood Disorders 21 Biological: Genes 50% of heritability NOT for conduct disorder but for Antisocial behaviour 20% heritability based on shared environment 30% Person-specific (non-shared environmental factors) Decreased functioning of MAOA → leads to greater aggression Biopsychological: Genes: what is specifically inherited genetically? 1. A Collous-unemotional style is inherited → a trait that you don’t really care about how others are reacting to things and you don’t tend to get worked up emotionally, yourself. 2. Executive dysfunction Poor problem-solving and planning ability → lead to poorly thought out, maladaptive reactions to distress and conflict. Again why it’s really important to intervene early to help children learn to better problem solve and plan so they can achieve their goals that (hopefully) don’t involve hurting other people. 3. Testosterone imbalance increased testosterone 4. Sensation-seeking chronic underarousal → which leads to seeking-stimuli to keep oneself excited enough another correlation to ADHD → underarousal theory Psychological: Empathy and perspective-taking deficits → lack of theory of mind Hostile attributional bias Childhood Disorders 22 Something that is neutral or vague happens (e.g. no intention of being mean), people with more hostile attribution bias assume people are doing things to hurt them → are more likely to develop Conduct disorder Social: Modelling → behaving like others they observe Inter-parent discord high levels of problems, arguments, stress, tension, aggression → can promote development of disorder Overly harsh discipline → discipline doesn’t fit the act Inconsistent contingencies e.g. you are allowed to do one thing one day, but another day you do the same thing and get in trouble; parents rules and conscequences are inconsistent are often based on caregivers mood/how they feel that day. Low family/caregiver involvement, weak bonding, poor monitoring we see from these parental styles including high levels of neglect and high levels of criticism/harshness → lead to possible development of CD. Differential attending/rewarding this is an interaction between parent and child → child misbehaves, parent suddenly attends to the child but very negatively. THEN, the child does something not problematic and the parent doesn’t give attention to child at all or their behaviour = leading to the child being rewarded for engaging in problematic behaviour through attention This demonstrates role of operant conditioning, as problematic behaviour is being reinforced (positive reinforcement? Maybe?). it’s very hard not to reinforce poor behaviour with attention → so there are certain ways to work on this in treatment: Childhood Disorders 23 e.g. identifying things caregiver shouldn’t attend to that are low level, low grade misbehaviour so that you can attend to behaviour that must be attended too. Treatments for Conduct Disorder Biological Stimulant Medication? It has been considered and sometimes works Similarly to ADHD, findings are consistent with theory and evidence on low arousal This increases arousal and decreases poor behaviour Social Harsh discipline → increases delinquency e.g. someone saying “why don’t you just punish the child more strongly and they will stop” the problem with this: using really harsh punishment on a child who has all these other factors for developing CD, it promotes it and encourages more misbehaviour. Family intervention Parent management training is huge → teaches parents how to deal with their own emotions and how to respond to their childs behaviour. Really teaches them (similarly to Parent Child interaction therapy), to really attend to the behaviour they want to see and not attend to behaviour they don’t want to see. Multisystemic treatment (MST) Very Important for treating conduct disorder inolves child, family, school, peer group, community, neighbourhood etc. Is highly resource intensive (involves many people and resources to do)→ but is often used instead of incarceration Childhood Disorders 24 → (likely due to) continuous and highly problematic ongoing behaviour where they either do this treatment or are incarcerated It tends to work but just takes alot of resources which leads to not many kids recieving the treatment Parent Management Training for CD Relationship bulding is the primary factor here you want to increase the positive feelings in the relationship and for the kid to reinvest into the relationship → meaning the caregiver needs to highly highly invest and gives lot’s of positive feedback and positive reinforcement for the kid engaging. you want the kid to care about, what you (the caregiver) think about whats happening. Attending & Active Ignoring Caregiver → gives attention/attending to what you want to see. And actively ignoring → some of the more minor misbehaviour (e.g. fussiness, swearing), but attend to major rule violation (e.g. hurting someone, damaging property). Effective instructions More direct instructions over more vague direct is much more effective → short, clear instructions e.g. clean your room vs. pick your clothes up off the floor and put them into the laundry room in the washer, then put books up off the floor and onto bookshelf. Praise/Reward System (shaping behaviour) find what is rewarding to the person (e.g. privalages like staying up a bit later, choose what they eat that week, or some screen time). They can be tiny things When they complete the little behaviours you want them to do they are rewarded quickly. (e.g. marble jar and later cash it out, but they need Childhood Disorders 25 immediate rewards so they immedietly experience the benefits of doing what you want them to do/desired behaviour). Consequences → not punishment but privilege removel, attention withdrawl. e.g. not using phone, or not watch tv, or see friends these become known to child as priveleges that can be taken away rather than rights. Examples of programs that impliment Parent Management Training for CD Incredible Years Triple P Multisystemic Therapy for CD involves aspects of CBT, Case management, family systems treatment There has to be the right “fit” between problem and systemic context when misbehaviour is happening its because there is a “fit” → meaning it’s working and rewarding them in that context in their lives. What has to happen that context and those rewards have to change → you change the expereinces they have so the misbehaviour is no longer rewarding. you need to encourage really responsible behaviour in family members which can be difficult Requires so much daily/weely effort from family (alongside other individuals) but it works! Childhood Disorders 26