Developmental Psychopathology Unit 2 PDF

Chapter 11 Fears vs. anxiety - Anxiety - Apprehension about potential future threat - Fear - Response to an immediate threat Fear - Basic emotion found across species - Autonomic nervous system activation - “Fight or flight” - Adaptive value -...

Chapter 11 Fears vs. anxiety - Anxiety - Apprehension about potential future threat - Fear - Response to an immediate threat Fear - Basic emotion found across species - Autonomic nervous system activation - “Fight or flight” - Adaptive value - When fear unexpectedly occurs in the absence of any obvious danger or threat = panic Fear and psychological arousal - Limbic system - especially amygdala - Autonomic nervous system - sympathetic and parasympathetic nervous system response The components of fear and panic - cognitive/subjective - “I'm going to die” - Psychological - Heart rate - Breathing - Sweating - Behavioral - Strong urge to escape Anxiety - More oriented to the future and much more diffuse - Also can be adaptive - Help us plan and prepare for a possible threat - Mild to moderate levels of anxiety improve performance Three components of anxiety - Cognitive/subjective - Negative mood - Worry - Self-preoccupation - Unable to predict and control threat - Psychological - Muscle tension - Chronic over-arousal  - Behavioral - Avoid situations that might be dangerous The many symptoms of anxiety - See chapter 11 slide 11 Normal fears, anxieties, worries, and rituals - Mild to moderate fear and anxiety are norm and can be adaptive - Emotions and rituals that increase feelings of control are common in children and teens - Normal fears - Fears that are normal at one age can be debilitating a few years later - A fear defined as normal depends on its effect on the child and how long it lasts - The number and types of fears change over time Anxiety disorders - Fears or anxieties - Unrealistic, irrational - Excessive, debilitating - Distress and/or impairment DSM-5 Anxiety disorders - Separation anxiety disorder - Social anxiety disorder - Selective mutism - School refusal - Generalized anxiety disorder - Specific phobia - Panic disorder - Agoraphobia - OCD Separation Anxiety Disorder (SAD) - Separation anxiety is important for a young child’s survival - It is normal from about age 7 months through the preschool years - Lack of separation anxiety at this age may suggest insecure attachment - SAD is distinguished by: - Age-inappropriate, excessive, and disabling anxiety about being apart from parents or away from home Prevalence and Comorbidity - Sad is one of the two most common childhood anxiety disorders - Occurs in 4-10% of children - More prevalent in girls than boys  - More than ⅔ of children with SAD have another anxiety disorder and about half have developed a depressive disorder Onset, course, and outcome - SAD has the earliest reported age of onset of the anxiety disorders (7-8 years of age) and the youngest age a referral - Tends to progress from mild to severe - Associated with major stress - Examples: may onset shortly after moving to a new neighborhood or entering a new school - SAD persists into adulthood for more than ⅓ of affected children and adolescents Social anxiety disorder (social phobia) - A marked, persistent fear of social or performance requirements that expose the child to scrutiny and possible embarrassment - DSM-5 criteria - Marked fear or anxiety about one or more social situations involving exposure to possible scrutiny by others - Concern about humiliation, embarrassment, rejection, or offending of other - Situations almost always provoke fear or anxiety - Avoidance or endured with intense fear - Out of proportion to actual threat - Persistent, at least 6 months - Significant distress or impairment Prevalence, comorbidity, and course - Lifetime prevalence of 6-12% of children - Twice as common in girls - Two-thirds also have another anxiety disorder - 20% also suffer from major depression and may self-medicate with alcohol and other drugs - Most common age of onset is early to mid-adolescence, and is rare under age 10 Selective mutism - Failure to talk to specific social situations, even though they may speak loudly and frequently at home or other settings - Estimated to occur in 0.7% of children - Average age of onset is 3-4 years - May be an extreme type of social phobia, or a precursor to it, but there are differences between the two disorders School reluctance and refusal - School refusal behavior - Refusal to attend classes or difficulty remaining in school for an entire day  - Occurs most often in age 5-11 - Fear of school may be due to a fear of leaving parents (separation anxiety), social anxiety, or other reasons (e.g., bullying, test anxiety) - Serious long-term consequences if untreated Generalized anxiety disorder (GAD) - DSM-5 criteria - Excessive anxiety and worry, more days than not for at least 6 months, about numerous events or activities - Difficulty controlling the worry - At least one of: restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance - Significant distress or impairment - Not attributed to psychological effects of a substance or medical condition - Not better explained by another mental disorder Prevalence and comorbidity - National survey: lifetime prevalence rate 2.2% - Equally common in boys and girls - Accompanied by high rates of other anxiety disorders and depression Onset, course, and outcome - Average age of onset is early adolescence - Older children have more symptoms - Symptoms tend to persist over time Specific Phobia - DSM-5 criteria - Marked fear or anxiety about a specific object or situation - object/situation almost always provokes immediate fear - Actively avoided or endured with intense fear - Out of proportion to the actual danger posed - Fear is persistent, lasting at least 6 months - Significant distress or impairment Subtypes - Animal - Natural environment - Situational - Blood-injection-injury - Disgust response - Unique psychological response - Other - Choking, vomiting, costumed characters, loud noises Prevalence and outcomes - Prevalence and comorbidity - About 20% of children are affected at some point in their lives, although few are referred for treatment - More common in girls - Onset, course, and outcome - Onset at 7–9 years - phobias involving animals, darkness, insects, blood, and injury - Clinical phobias are more likely than normal fears to persist over time - Evidence that if treated early, children are less likely to develop additional anxiety disorders in the future Panic Attacks - Abrupt surge of intense fear or discomfort that reaches a peak within minutes - Must contain at least 4 of the following symptoms: - Heart palpitations - Tingling in the hands or feet - Shortness of breath - Sweating - Hot or cold flashes - Trembling - Nausea - Chest pains - Choking sensation - Dizziness - A feeling of unreality - Fear of losing control or going crazy - Fear of dying - Rare in young children but common in adolescence - Young children may lack the cognitive ability to make catastrophic misinterpretations - Are related to pubertal development - The KEY is that people catastrophically misinterpret their bodily sensations Panic Disorder - Recurrent, unexpected panic attacks - A month or more of one of the following after at least one of the attacks - (a) persistent concern about having additional attacks or consequences of the attack - (b) significant change in behavior related to the attack - Not attributed to physiological effects of a substance or medical condition - Not better explained by another mental disorder Agoraphobia - DSM-5 criteria - Marked fear or anxiety about 2 (or more): - Public transportation - Open spaces - Enclosed spaces - Standing in line or in a crowd - Being outside of the home alone - Person is afraid because escape might be difficult or help unavailable, if panic-like or other embarrassing symptoms may occur - Situations almost always provoke fear - Actively avoided, required companion, or endured with intense fear - Out of proportion to actual danger - Persistent, at least 6 months - Significant distress or impairment Prevalence, comorbidity, and course - Panic attacks are common (16% of teens) - Panic disorder is less common (about 2.5% of teens 13–17 years) - Panic attacks are more common in adolescent females than adolescent males - Comorbidity is adolescents with panic disorder - Most commonly have another anxiety disorder or depression - At risk for suicidal behavior; alcohol or drug abuse - Onset, course, and outcome - Age of onset for first panic attack 15–19 years; 95% of panic disorder adolescent are post-pubertal - Lowest remission rare of ant of the anxiety disorders Obsessive-compulsive disorder - Obsessions - Recurrent and persistent thoughts, ideas, impulses, or images that are experienced as intrusive and unwanted (cause anxiety or distress) - Attempts to ignore, suppress, or neutralize with thought or action - Compulsions - Repetitive behaviors or mental acts that feel driven to preform in responses to obsession or according to rigid rules - Aimed at preventing or reducing anxiety or distress, or preventing dreaded situation; however, not connected in a realistic way or clearly excessive - DSM-5 criteria - Recurrent obsessions, compulsions or both - Time consuming (more than 1 hr/day) or significant distress or impairment - Not attributed to psychological effects of a substance or medical condition - Not better explained by another mental disorder Important features of obsessions - Obsession are undesirable and intrusive - Try to ignore and resist them, but they keep coming back - Most common forms: - Thoughts, urges, images, ideas, doubts - Most common themes: - Contamination, violence and aggression, doubt, “just right,” orderliness, religion, and sexuality, perfectionism Important features of compulsions - Seen as unreasonable, but feel they must do them in order to avoid harm or decrease anxiety - Sometimes turn into elaborate rituals - Common forms: - Cleaning, checking, repeating, ordering or arranging, counting Prevalence, comorbidity, and course - Prevalence and comorbidity - Lifetime prevalence in children and adolescents is 1-2.5% - Clinic-based studies find it twice as common in boys - Comorbidities most common are other anxiety disorders, depressive disorders, disruptive behavior disorders - Substance-use; learning and eating disorders; vocal and motor tics are also overrepresented - Onset, course, and outcome - Average age of onset 9–12 years with peaks in early childhood and early adolescence - Chronic disorders - as many as two-thirds continue to have OCD 2–14 years after initial diagnosis Associated characteristics - Children with anxiety disorders display a number of associated characteristics - Cognitive disturbances - Physical symptoms - Social and emotional deficits - Depression Cognitive disturbances - Disturbance is how information is perceived and processed - Intelligence and academic achievement - Despite normal intelligence, deficits are seen in memory, attention, and speech or language - High levels of anxiety can interfere with academic performance - Those with social anxiety disorder may drop out of school prematurely  - Threat-related attentional biases - Selective attention is given to potentially threatening information - Cognitive errors and biases - Perceptions of threats activate danger-confirming thoughts - Children with conduct problems select aggressive solutions in response to a perceived threat while anxious children select avoidant solutions - Children with anxiety disorders see themselves as having less control over anxiety-related events than other children Physical symptoms - Physical symptoms key to the experience of anxiety - Somatic complaints, such as stomachaches or headaches, are more common in children with GAD, panic disorder, and SAD than in those with a specific phobia - 90% with anxiety disorders have sleep-related problems, e.g., insomnia or trouble sleeping alone Social and Emotional Deficits - Anxious children - Display low social performance and high social anxiety - See themselves as shy and socially withdrawn, and report low self-esteem, loneliness, and difficulty initiating and maintaining friendships Clark and Wilson (1991) Tripartite Model Gender, Ethnicity, and Culture - Higher incidence of anxiety disorders in girls suggests genetic influences and related neurobiological differences - And varying social roles and experiences - The experience of anxiety is pervasive across cultures - Ethnicity and culture may affect the expression, developmental course, and interpretation of anxiety symptoms Theories and Causes - Early Theories - Classical psychoanalytic theory  - Anxieties and phobias seen as defenses against unconscious conflicts rooted in the child’s early upbringing - Behavioral and learning theories - Fears and anxieties learned through classical conditioning and maintained through operant conditioning (two-factor theory) - Bowlby’s theory of attachment - Fearfulness is biologically rooted in the emotional attachment needed for survival - Early insecure attachments leads children to view the environment as undependable, unavailable, hostile, and threatening Temperament - Variations in behavioral reactions to novelty results in part from inherited differences in the neurochemistry of certain brain structures - Amygdala - primary function is to react to unfamiliar or unexpected events - Behavioral inhibition (BI): a low threshold for novel and unexpected stimuli - Places and individual at greater risk for anxiety disorders Family and Genetic risk - Family and twin studies suggest - About ⅓ of the variance in childhood anxiety symptoms is genetic - Genes are linked to bread anxiety-related traits (e.g., behavioral inhibition) - No strong direct link between specific genetic markers and specific types of anxiety disorders Neurobiological factors - The entire anxiety response system is controlled by several interrelated systems - Sympathetic nervous system - Hypothalamic-pituitary-adrenal (HPA) axis - Limbic system (amygdala; hippocampus) - An overactive behavioral inhibition system (BIS) - BIS may be shaped by early life stressors - Brain abnormalities have been implicated in children who are anxious and/or behaviorally inhibited - Primary neurotransmitter system implicated in anxiety disorders - Y-aminobutyric acidergic (GABA-ergic) system Error-related Negativity (ERN) - ERN is an event-related potential measured from EEG - Changes in electrical potential at the scalp results in the peak you see when you are engaged in a task and make a mistake - ERN at age 6 have been shown to predict new onset anxiety disorders are age 9 Family and SES Factors - Parenting practices  - Parents of anxious children are seen as overinvolved, intrusive, or limiting child’s independence - Prolonged exposure to high doses of family dysfunction associated with extreme trajectories of anxious behavior - Low SES - Insecure early attachment Behavior Therapy - Main technique is gradual exposure to feared stimulus - While providing children with ways of coping other than escape and avoidance - Systematic desensitization - New evidence suggests not as effective as exposure without relaxation - Can be done in an intensive form over the course of 1 day or 1 week - often quite effective - Response prevention prevents child from escaping, avoiding, or engaging in compulsions (ExRP) - Modeling and reinforced practice CBT - The most effective procedure for treating most anxiety disorders - Almost always used with exposure-based treatments - Coping Cat is one common protocol use with child anxiety disorders - solid evidence base - Skill training combined with exposure combats both problematic thinking and avoidance - Computer-based CBT has also been shown to be effective Family Interventions - Child-focused treatments may have spillover effects into the family - Addressing children’s anxiety disorders in a family context may result in more dramatic and lasting effects - Family treatment for OCD - Provides education about the disorder - Helps families cope with their feelings - Focuses on limiting accommodation Medications - Medications can reduce symptoms, especially OCD - The most common and effective medications are selective serotonin reuptake inhibitors (SSRIs), especially for OCD - Medications are most effective when combined with CBT - CBT is the first line of treatment Prevention and stepped-care approaches  - Programs focusing on behaviorally inhibited children with anxious parents - Intervention depends on level of severity - Guided self-help, parenting books, internet programs - Brief CBT, groups - Individual CBT medication Chapter 10 Terminology - Mood disorder = affective disorder - Depression - pervasive, unhappy mood - Dysphoria - prolonged sadness - Anhedonia - loss of interest, pleasure, joy - Irritability - easy annoyance and “touchiness” - Mania - abnormally elevated and expansive mood, increased goal-directed activity and energy, feelings of euphoria - Euphoria - exaggerated sense of well-being - Expansive - over the top, flamboyant Overview of Mood Disorders - Extreme, persistent, or poorly regulated mood states (episodes) - The spectrum runs from severe depression to extreme mania - DSM-5 divides mood disorders into two general categories - Depressive Disorders: Excessive unhappiness (dysphoria) and loss of interest in activities (anhedonia) - Bipolar disorder: mood swings from deep sadness to high elation (euphoria) and expansive mood Mood disorders - Most people’s moods come and go - Mood disorders are different - More severe alterations - Much longer - Distress or impairment is present - Main feature is extreme mood - Depression - extraordinary sadness and dejection - Mania - Intense and unrealistic excitement and euphoria Types of Mood Disorders - Unipolar depressive disorder - Only depressive episodes - Depression or loss of interest for at least 2 weeks  - Bipolar depressive disorder - Manic and depressive episodes - Markedly euphoric mood, often interrupted by intense irritability, for at least 1 week Depressive Disorder - Mood disorders characterized by pervasive unhappiness - More severe than the occasional blues or mood swings everyone experiences - Children who are depressed cannot shake their sadness - it interferes with their daily routines, social relationships, school performance, and overall functioning - Often accompanied by anxiety or conduct disorders - Often goes unrecognized and untreated Depression and development - Experiences and expression of depression change with age - In children under age 7 (as young as 3-5) - Tends to be diffuse and less easily identified - Anaclitic depression (Spitz) - infants - Infants raised in clean but emotionally child institutional environment show depression-like reactions - Similar symptoms can occur in infants raised in severely disturbed families - Preschoolers - May appear extremely somber and tearful, lacking exuberance - May display excessive clinging and whiny behavior - School-aged children - The above, plus increasing irritability, disruptive behavior, and tantrums - Preteens - The above, plus self-blame, low self-esteem, persistent sadness, and social inhibition Anatomy of Depression - Depression (symptom): feeling sad or miserable - Occurs without existence of serious problem, and is common at all ages - Depression (syndrome): a group of symptoms that occur together more often than by chance - Depression (disorder) - Major depressive disorder (MDD) - Persistent Depressive disorder (P-DD/Dysthymia) - Disruptive Mood Dysregulation Disorder (DMDD) Major Depressive Disorder (MDD) - Diagnosis in children - Same criteria for school-age children and adolescents  - Depression is easily overlooked because other behaviors attract more attention - Some features (e.g., irritable mood) are more common in children and adolescents than in adults Prevalence - Between 2% and 8% of children ages 4-18 experience MDD - Depression is rare among preschool and school-age children (1-2%) - Increases two- to threefold by adolescents - The sharp increase in adolescence may result from biological maturation at puberty interacting with developmental changes Comorbidity - As many as 90% of young people with depression have one or more other disorders; 50% have two or more - Most common comorbid disorders include: - Anxiety disorder (especially generalized anxiety disorders, specific phobia, and separation anxiety disorder) - Depression and anxiety are more visible as separate, co-occurring disorders: - As severity of the disorder increases and the child gets older - Other common comorbid disorders are: - Persistent depressive disorder, conduct problems, ADHD, and substance-use disorder - 60% of adolescents with MDD have comorbid personality disorders, especially borderline personality disorder - Pathways to comorbid conditions may differ by disorder/sex Onset, course, and outcome  - Onset may be gradual or sudden - Usually a history of milder episodes that do not meet diagnostic criteria - Age of onset, usually between 13-15 - Average episode lasts eight months - Longer duration if a parent has a history of depression - Most children eventually recover from initial episode, but the disorder does not go away - Change of recurrence is 25% within one year, 40% within two years, and 70% within five years - About one-thrid develop bipolar disorder within five years after onset of depression (bipolar switch) Persistent Depressive Disorder [P-DD] (Dysthymia) - Is characterized by symptoms of depressed mood that occurs on most days, and persist for at least one year - Child with P-DD also display at least two somatic or cognitive symptoms - Symptoms are less severe, but more chronic than MDD Persistent Depressive Disorder - Characterized by poor emotion regulation - Constant feelings of sadness, being unloved or forlorn, self-deprecation, low self-esteem, anxiety, irritability, anger, and temper tantrums - Children with both MDD and P-DD are more severely impaired than children with just one disorder (“double depression”) Prevalence - Rates of P-DD are lower than MDD - Approximately 1% of children and 5% of adolescents display P-DD - Most common comorbid disorder is MDD - Nearly 70% of children with P-DD may have an episode of major depression - About 50% of children with P-DD… - Also have one or more nonaffective disorders that preceded dysthymia, e.g., anxiety disorders, conduct disorders, or ADHD Onset, Course, and Outcome - Most common age of onset 11–12 years - Childhood-onset dysthymia has prolonged duration, generally 2–5 years - Most recover, but are at high risk for developing other disorders: - MDD, anxiety disorders, and conduct disorder - Adolescent with P-DD receive less social support than those with MDD Disruptive Mood Dysregulation Disorder (DMDD) - Chronic, severe, persistent, irritability - Temper outbursts - Irritable or angry mood  - New to DSM-5 - Created in response to… - Increased focus on irritability as an important clinical feature - Concerns about over-diagnosis of bipolar disorder in young children Disruptive Mood Dysregulation Disorder (DMDD) - Child is chronically irritable and experiences frequent, severe temper outbursts that seem grossly out of proportion to the situation at hand - These children do not experience the episodic mania or hypomania characteristics of bipolar disorder, and they do not typically develop adult bipolar disorder, although they are at elevated risk for depression and anxiety as adults Associated Characteristics of Depressive Disorders - Intellectual and academic functioning - Difficulty concentrating, loss of interest, and slowness of thought and movement may have a harmful effect on intellectual and academic functioning - Lower scores on tests, poorer teacher ratings, and lower levels o grade attainment - Interferences with academic performance, but not necessarily related to intellectual deficits - May especially have problems on tasks requiring attention, coordination, and speed Cognitive Biases and Distortions - Selective attentional biases - Feelings of worthlessness, negative beliefs, attributions and failure, self-critical and automatic thoughts - Depressive ruminative style; pessimistic outlook; and negative self-esteem - Negative thinking and faulty conclusions generalized across situations, hopelessness, and suicidal ideation Social, peer, and family problems - Social and peer problems - Few close friendships, feeling loneliness, and impaired social skills - Social withdrawal and ineffective styles of coping in social situations - Co-rumination - Family problems - child with depression: - Has less supportive and more conflicted relationships with parents and siblings - Feels socially isolated from family and prefers to be alone Depression and suicide - Most youngsters with depression think about suicide, and as many as one-thrid who tink about it, attempt it Behavioral theories - Emphasize the importance of learning, environmental consequences, and skills and deficits during the onset and maintenance of depression - Depression is related to a lack of response-contingent positive reinforcement - Decrease in positive/rewards, more negative events → feel depressed → perform fewer constructive behaviors → cycle repeats Cognitive theories - Focus on relationship between negative thinking and mood - Emphasize “depressogenic” cognitions - Negative perceptual and attributional styles and beliefs associated with depressive symptoms - Beck’s cognitive model: depressed individuals make negative interpretations about life events - Biased and negative beliefs are used interpretive filters for understanding events - Three areas of cognitive problems - Information-processing biases - Negative outlook regarding oneself, the world, and the future (negative cognitive triad) - Negative automatic thoughts and dysfunctional beliefs (also known as core beliefs of schemas) Helplessness Theory - Pessimistic attributional style - Attribute negative events to causes that are internal, global, and stable - Pessimistic attribution style + uncontrollable negative events = depression Cognitive theory: learned helplessness - Depression results when: - One feels they have no control over the reinforcements in their life - Seligman’s famous dog sturdy Other Theories of Depression - Interpersonal models - Socio-environmental models - Diathesis-stress model - Neurobiological models Causes of Depression - Due to the many interacting influences, multiple pathways to depression are likely - Genetic risk influences neurobiological processes and is reflected in early temperament characterized by: - Oversensitivity to negative stimuli - High negative emotionality  - Disposition to feeling negative affect - These early dispositions are further shaped by negative experiences in the family and with peers Biological Markers and Correlates - Heritability (30%-80%) and genetic risk - Focus on general chromosomes or regions - Genes involved in serotonin reuptake seem to be particularly important - Decreased response to reward - Sensitivity to stress - Elevated amygdala activity - Hippocampus and stress response - HPA-axis and cortisol response Family Influences - When children are depression - Families display more critical and punitive behavior toward the depressed child than towards other children - When parents are depressed - Depression interferes with the parent’s ability to meet the needs of the child - Child experiences higher rates of depression, phobias, panic disorder, and alcohol dependence as adolescents and adults Stressful life events - Triggers for depression may involve: - Interpersonal stress and actual or perceived personal losses (e.g., death of a loved one, abandonment, rejection by a friend) - Life changes (e.g., moving to a new neighborhood) - Violent family or neighborhood environment - Daily hassles and other non-severe stressful life events Emotional Regulation - Children who experience prolonged periods of emotional distress and sadness, or who are exposed to maternal negative moods - May have problems regulating negative emotional states and may be prone to depression - May use avoidance or negative behavior to regulate distress, rather than problem-focused and adaptive coping strategies Treatment of Depression Psychosocial Interventions - Behavior Therapy - Focuses on increasing pleasurable activities and events, and providing the youngster with the skills necessary to obtain more reinforcement - Cognitive Therapy - Teaches depressed youngsters to identify, challenge, and modify negative thought processes - Cognitive-behavioral therapy (CBT) - Psychosocial intervention combining behavioral and cognitive therapies - Interpersonal psychotherapy for adolescent depression (IPT-A) - Focus is on depressive symptoms and social context in which they occur Challenging negative thoughts - Is there substantial evidence for my though? - Is there evidence contrary to my thought? - Am I attempting to interpret this situation without all the evidence? - What would a friend think about this situation? - If I look at the situation positively, how is it different? - Will this matter a year from now? How about five years from now? What is Interpersonal Psychotherapy - Interpersonal psychotherapy (IPT) is a brief, time limited psychotherapy that was initially developed in the late 1960s for the treatment of adult depression - IPT is based on the belief that interpersonal factors may contribute heavily to psychological problems - IPT is commonly distinguished from other forms of therapy in its emphasis on the interpersonal rather than the intrapsychic - IPT focuses on the interpersonal context and on building interpersonal skills IPT Basic Principles - The primary strategies for achieving treatment goals include the following: - Identifying a specific problem area  - The four problem areas include - Grief - Interpersonal role disputes (e.g., parent-child conflict) - Role transitions (e.g., transitioning from a high school student to a college student) - Interpersonal deficits - Identifying effective communication and problem-solving techniques to use within the problem area - Practicing in session and eventually experimenting outside the session with the use of these techniques in the context of significant relationships Medications - Tricyclic antidepressants consistently fail to demonstrate any advantage over placebo in treating depression in youth - They have potentially serious cardiovascular side effects as well - SSRI (e.g., Prozac, Zoloft, and Celexa) are the most commonly prescribed medications for treating childhood depression - Despite support for their efficacy, side effects may include suicidal thoughts and self-harm - And there is a lack of information about long-term effects on the developing brain - Up to 60% of depressed youngsters respond to placebo Bipolar Disorder (BD) - Features a striking period of unusually and persistently elevated, expansive, or irritable mood, alternating with or accompanied by one or more major depressive episodes - Elation and euphoria can quickly change to anger and hostility, particularly if the desired behavior is impeded Bipolar Disorder in Young People - Young people with BD display: - Significant impairment in functioning, including previous hospitalization, MDD, medication treatment, co-occurring disruptive behavior and anxiety disorders - History of psychotic symptoms, and suicidal ideation/attempts are common Bipolar Disorder Symptoms - Symptoms include restlessness, agitation, sleeplessness, pressured speech, flight of ideas, racing thoughts, sexual disinhibition, surges of energy, and grandiose beliefs - Youngsters with mania may also present with atypical symptoms - volatile and erratic changes in mood, psychomotor agitation, and mental excitation - Irritability, belligerence, and mixed manic-depressive feature occur more frequently than euphoria Bipolar Disorder Types - Three subtypes  - Bipolar I disorder - manic episodes cycle with major depressive episodes - Bipolar II disorder - hypomanic episodes cycle with major depressive episodes - Cyclothymic disorder - hypomanic episodes cycle with dysthymia Prevalence - Lifetime estimates of BP range from 0.5-2.5% of youths 7–21 years old - It is difficult to make an accurate diagnosis - In youngsters, milder bipolar II and Cyclothymic disorder are more likely than bipolar I - Rapid cycling episodes are common - Extremely rare in young children - Rate increases (nearly as high as that for adults) after puberty Comorbidity - High rates of co-occurring disorders are extremely common - Most typical are separation anxiety disorder, generalized anxiety disorder, ADHD, and conduct disorders - Substance use disorder - Suicidal thoughts and ideation - Co-occurring medical problems - Cardiovascular and metabolic disorders, epilepsy, and migraine headaches Onset, course, outcome - About 60% of patients with BP have a first episode prior to age 19 - Onset before age 10 is extremely rare - Adolescents with mania typical have: - Psychotic symptoms, unstable moods, and severe deterioration in behavior - Earlier onset is related to chronic course and is more resistant to treatment - Long-term prognosis is poor Causes - Few studies have looked at the causes of BP in children and adolescents - Research with adults suggests that BP is the result of a genetic vulnerability tn combination with environmental factors (e.g., life stress and family disturbances) - Multiple genes may be involved - Genetic predisposition does not necessarily mean a person will develop BP - Brain imagining studies suggest mood fluctuations are related to abnormalities in areas of the brain related to emotional regulation - Prefrontal and anterior cingulate cortex, hippocampus, amygdala, thalamus, and basal ganglia Treatment - There is no cure to BP - A multimodal plan includes - Monitoring symptoms closely  - Educating the patient and the family - Matching treatments to individuals - Administering medications, e.g., lithium - Addressing symptoms and related psychosocial impairments with psychotherapeutic interventions Chapter 12 Trauma and Stressor-Related Disorders Trauma and Stress - Traumatic events: exposure to actual or threatened harm or fear of death or injury, considered “uncommon” or extreme stressor - Stressful events = more common and less extreme than traumatic events How Stress effects Children - Stress can be strengthening if it does not exceed the child’s ability to cope - Manageable - typically mild, predictable, and brief - Degree of parental support is crucial What happens when stress becomes too high to manage - Allostatic load: progressive “wear and tear” on biological systems due to chronic stress - Stressful events affect each child in different and unique ways - Hyperresponsive reaction - Hyporesponsive reaction Maltreatment - Maltreatment is one of the most impactful types of childhood stress and trauma - Four primary types of maltreatment - Neglect, physical abuse, sexual abuse, emotional (psychological) abuse Neglect - Failure to provide for a child’s basic physical, educational, and emotional needs - Three forms of neglect - Physical neglect - Educational neglect - Emotional neglect - Outcomes may include: health problems, vacillation between high activity and extreme passivity, little enthusiasm, poor impulse control, high levels of dependence Physical abuse - Multiple acts of physical aggression - Often the unintentional results of over-discipline or severe physical punishment - Outcomes may include disruptiveness and aggression Emotional (psychological) abuse - Repeated acts or omissions that have caused, or could cause, serious cognitive, emotional, or mental disorders - Might include extreme forms of punishment, verbal threats, habitual scapegoating, belittling, and name-calling - Tends to be present in all other forms of abuse, so its specific consequences are less well understood Sexual Abuse - Sexual abuse includes sexual touching, rape, incest, sodomy, exhibitionism, and commercial exploitation - Outcome may include: health problems, anger, anxiety, depression, difficulty with attention, withdrawal, temporary regression, acting out, sexualized behavior - Depends on: duration, frequency of abuse, use of force, a close relationship to perpetrator, response of important others - Emergence of symptoms may be delayed Characteristics of Children who suffer maltreatment - Child maltreatment is NEVER the fault of the child - Children’s age and sex are related to risk of maltreatment - Younger children are at greater risk for physical neglect - Toddlers, preschoolers, and young adolescents are more at risk for physical and emotional abuse - 80% of sexual abuse victims are female, and sexual abuse is more common in youths 12+ - Racial difference in rates of abuse likely a function of poverty, stress, and disadvantage Maltreated Children Face Paradoxical Dilemmas - The victim wants the violence to stop but also wants to belong - Affection and attention may coexist with violence and abuse - The intensity of violence tends to increase over time, but may also decrease or even stop all together What children need for health development: foundational and expectable environment - Children need both control and direction and stimulation and sensitivity - Protective and nurturing adults - Opportunities for socialization - Supportive family and peer contact - Opportunities to master their environment Importance of health families - the building blocks of prevention - In order to provide that environment, parents need: - Knowledge of child development and expectations - Adequate coping skills for parental stress - Opportunities to develop attachment and communication - Adequate parental knowledge of home management - Provision of necessary social and health services Risk factors - Little exposure to positive parental models and support - Greater degree of stress - Information processing disturbances - Lack of knowledge of development - Chronic social isolation - more common in neglectful families - Neglectful parents disengage under stress, abusive parents become emotionally reactive - Racism and inequality - Substance abuse, personality disorders - Long-held social customs that endure the use of physical force to resolve child conflict An integrated model of physical child abuse Trauma and stress-related disorders - New category in the DSM-5 - Previously categorized as anxiety disorders Reactive attachment disorder (RAD) - Criterion A: Failure to show consistent effect to seek comfort from their caregiver and failure to respond to caregivers’ efforts to provide comfort - Criterion B: 1.) minimal social and emotional responsiveness to others; 2.) limited positive affect; 3.) unexplained irritability, sadness, or fearfulness even during nonthreatening interactions with caregivers  - Criterion C: experienced a pattern of extremes of insufficient care - Criterion D: Emotional disturbances developed following the lack of adequate care Disinhibited social engagement disorder (DSED) - Criterion A: Shows a pattern of overly familiar and culturally inappropriate behavior with strangers - Criterion B: behaviors are not limited to impulsivity (as in ADHD) but include socially disinhibited behavior - Criterion C: Experienced a pattern of extremes of insufficient care Characteristics of RAD and DSED - Ages 9 months to 5 years - Typically accompanied by cognitive and socioemotional delays - DSED is more persistent than RAD - Little is known about causes, beyond early adequate care Post-traumatic Stress Disorder (PTSD) (Adults and Children Over the Age of 6) - Criterion A: Exposure to actual or threatened death, serious injury, or sexual violence - Directly experiencing, witnessing, or learning about - Experiencing repeated or extreme exposure to details of a traumatic event (usually work-related) - Criterion B: Re-experiencing - Criterion C: Avoidance - Criterion D: Negative cognition or mood - Criterion E: Arousal PTSD Symptom Expression in Children - Separate diagnostic criteria for children under 6 - Criterion A: Repeated exposure to details removed - Criterion B: Reexperiencing - For children, trauma themes or trauma reenactment may occur in play - More likely to experience nightmares vs. flashbacks - Criterion C and D combined into one category Prevalence and Course - About two-thirds of children experience one or more potentially traumatic events by age 16 - Prevalence of PTSD in adolescents: 3.7% (boys) and 6.3% (girls) - Severity of trauma predicts the likelihood of developing PTSD - Prevalence of PTSD symptoms is greater in children exposed to life-threatening events or prolonged interpersonal trauma Associated Problems and Adult Outcomes - PTSD can become chronic psychiatric disorder  - Particularly if untreated - Persistent mood and affect disturbances - Emotional and behavioral problem - Girls tend to exhibit more internalizing symptoms - Boys tend to exhibit more externalizing symptoms Acute Stress Disorder - Similar to PTSD, but earlier onset (within 1 month of trauma) and shorter course - Occurs following trauma in 10% to 20% of children - Diagnostic category for use when symptoms develop shortly after traumatic event and last for at least 2 days - Enables people to receive treatment immediately - Diagnosis can change to PTSD if symptoms persist Adjustment Disorder - Psychological response to common stressor - Can be in response to single or multiple events - Occurs within 3 months of stressor - Results in clinically significant behavioral or emotional symptoms - Must be greater than expected - Symptoms disappear when stressor ends or person adapts Stress and Mental Health Etiology - Trauma exposure - Developmental level - Pre-disaster characteristic (e.g., anxiety level) - Cognitive appraisal - Coping style - Aspects of traumatic experience Causes: Poor emotion Regulation - Maltreated infants/toddlers have difficulty establishing reciprocal, consistent interactions with caregivers - Exhibit insecure-disorganized attachment - Have difficulty understanding, labeling, and regulating internal emotional states - Learn to inhibit emotional expression and regulation, remaining more fearful and on alert Causes: Emerging View of Self and Others - Maltreated children’s emerging views of self and their surroundings are not fostered by healthy parental guidance and control - Emotional and behavioral problems are likely to appear - Negative representational models of self and others develop based on the sense of inner “badness”, self-blame, shame, or rage - Feelings of powerlessness and betrayal are internalized as part of the child’s self-identity Causes: neurobiological development - Children and adults with history of child abuse show long-term alternation in the hypothalamic-pituitary-adrenal (HPA) axis and norepinephrine systems - These alterations have a significant effect on responsiveness to stress - Affected brain areas: - Hippocampus (learning and memory) - Prefrontal cortex (planning and decision-making) - Amygdala (emotion regulation) - Acute and chronic forms of stress associated with maltreatment may cause changes in brain development and structure from an early age - The neuroendocrine system becomes highly sensitive to stress - Release of cortisol to produce fight or flight response - Elevated levels of stress hormones can impact brain development. Structure, and function - With chronic exposure to stress, cortisol levels can become depleted and the stress response system cab behave unpredictably - Causes neurobiological changes that may account for later psychiatric problems