chapter sixteen psychological disorders of childhood

CHAPTER SIXTEENCHAPTER SIXTEENPsychological Disorders Psychological Disorders

of Childhoodof Childhood

Childhood DisordersChildhood Disorders Childhood psychopathology

Internalizing Disorders

Externalizing Disorders

ADHD, ODD, CD

Epidemiology

Etiology

Treatment

Childhood disorders outcome summary

Defining Defining Childhood Childhood

PsychopathologyPsychopathology Definitions of “normal” depend on age

Classification of many childhood disorders rests on our knowledge of normal childhood behavior

Childhood DisordersChildhood Disorders


problems in conforming to expected norms; often causes problems for others


experience of subjective distress; others often unaware of their difficulties




ADHD, ODD, CD

Epidemiology

Etiology

Treatment


Diagnosing Internalizing Diagnosing Internalizing Disorders: Depression and Disorders: Depression and

AnxietyAnxiety Children can be diagnosed with “adult”

anxiety disorders (e.g., MDD, OCD, GAD)

Specific symptoms may differ from adults

Some symptoms may be absent due to children’s developmental differences

Difficulty in obtaining reliable information due to problems with self-reports

General symptoms Excessive distress associated with

separation Worry for separation and/or harm to

attachment figure School refusal Nightmares & complaints of physical

symptoms

Onset: before 18 years old

Duration: at least 4 weeks

Impairment

Separation Anxiety DisorderSeparation Anxiety Disorder

SAD is the most common anxiety disorder of childhood occurring in about 6% to 12% of all children

Equally common in boys and girls

About 80% to 90% of all children with SAD have another disorder (e.g., GAD, depression)

Children showing school refusal due to SAD tend to be younger, female, of lower SES, and from single parent families.

Separation Anxiety Disorder: Separation Anxiety Disorder: Prevalence & ComorbidityPrevalence & Comorbidity




ADHD, ODD, CD

Epidemiology

Etiology

Treatment


Externalizing Disorders:Externalizing Disorders:Key FeaturesKey Features

rule violations

negativity, anger & aggression

impulsivity

hyperactivity

deficits in attention

Diagnosing Externalizing Diagnosing Externalizing DisordersDisorders

DSM-IV-TR divides externalizing disorders in to three major subtypes:

Attention deficit/hyperactivity disorder (ADHD)

Oppositional defiant disorder (ODD)

Conduct disorder (CD)

ADHD Diagnostic CriteriaADHD Diagnostic Criteria

Key features: hyperactivity, attention deficit and impulsivity symptoms begin before age 7 6 of 9 DSM-IV symptoms for 6 months symptoms visible across settings

Three subtypes Predominantly Inattentive Type Predominantly Hyperactive-Impulsive

Type Combined Type

ODD Diagnostic CriteriaODD Diagnostic Criteria

A pattern of negativistic, hostile and defiant behavior

e.g. loses temper, argues with adults, defies or refuses to comply with adults’ requests

Behavior causes significant impairment

Impairment last for at least 6 months

CD Diagnostic CriteriaCD Diagnostic Criteria Persistent and repetitive pattern of rule

violations/social norms

aggression to people, animals

destruction of property

deceitfulness or theft

serious rule violation

About 50% exhibit antisocial behavior into adulthood

Epidemiology: ADHDEpidemiology: ADHD

Problems may appear before age 3

Prevalence:

approximately 5% of school-age children

50-60% of children in special education

Some children continue to have ADHD as adults

The symptoms interfere with daily functioning in different ways over life

Epidemiology: ODD & CDEpidemiology: ODD & CD

Prevalence rates ODD about 5-7% Conduct Disorder about 2-4%

Higher in boys than girls

Etiology: Biological Etiology: Biological FactorsFactors

Behavior Genetics Recent study of 4000 Australian found

80% concordance for MZ twins, 40% for DZ twins in ADHD, suggesting a strong genetic component.

Neuropsychological Abnormalities

Food Additives and Sugar No evidence

Temperament

Etiology: Biological FactorsEtiology: Biological FactorsTemperamentTemperament

Easy

quickly form social relationships and follow discipline

Difficult

challenge parental authority

Slow-to-warm-up

shy & withdrawn

Etiology: Social FactorsEtiology: Social Factors

Peers, Neighborhoods, Television

Parenting styles

Coercion

Etiology: Social FactorsEtiology: Social FactorsParenting StylesParenting Styles

Etiology: Social FactorsEtiology: Social FactorsCoercionCoercion

Child wants a cookie

Parent says “no”

Child starts screamingParent gives in,

positively reinforcing child for throwing tantrum

Child stops screaming-Negatively reinforcing

parent for giving in

behavior is reinforced

Etiology: Psychological Etiology: Psychological FactorsFactors

Attachment Theory Secure attachments facilitate both

closeness and exploration Insecure (may be anxious, avoidant, or

disorganized) attachments predict later internalizing and externalizing problems and social difficulties

The “Strange Situation” Test

Self-Control

TreatmentTreatment ADHD:

psychostimulants (e.g. Ritalin, Adderral) antidepressants selective norepinephrine reuptake inhibitor

(e.g. Strattera) psychosocial treatment

ODD: behavior family

therapy

TreatmentTreatment

CD: Multisystemic

Therapy residential programs diversion programs

alternative to juvenile justice system




ADHD, ODD, CD

Epidemiology

Etiology

Treatment


Childhood Disorders: Childhood Disorders: EpidemiologyEpidemiology

Approximately 20% of children have a mental disorder

Anxiety Disorders 13%

Mood Disorders 6.2%

Externalizing Disorders 10.3%

Suicide

Gender differences Boys are more likely to be in treatment than girls Referral differences between children and adults

Childhood Disorders: Childhood Disorders: Course & OutcomeCourse & Outcome

Prevalence rates of internalizing disorders increase with age

Externalizing disorders often continue into adulthood, but antisocial behavior rarely begins during adult life better prognosis for later-onset CD better prognosis for ADHD if NOT

comorbid w/ CD or ODD

Optional Optional SlidesSlides

Etiological Factors Etiological Factors Common to Most or All Common to Most or All

Childhood DisordersChildhood Disorders

Difficult Temperament

Insecure Attachment

Ineffective Parenting Styles

Emotion Dysregulation

Emotion DysregulationEmotion Dysregulation

Children fail to learn to recognize and control their emotions

Additional Etiological Additional Etiological FactorsFactors

Family risk factors

Troubled peer relationships

Sociometric Ratings & Sociometric Ratings & Childhood DisordersChildhood Disorders

Popular: many “liked most,” few “liked least” nominations

Average: few “liked least” but not as many “liked most” as popular

Rejected: many “liked least,” few “liked most” (opposite of popular)

Neglected: few “liked least,” few “liked most”

Controversial: many “liked least” and many “liked most”

Arbitrary Inferenceconclusions drawn in the absence of sufficient evidence or of any evidence at all

ExampleA young girl approaches a playground and finds two children laughing. Before having a chance to say hello, the others walk away and look towards her direction. The young girl concludes that she is unattractive and that the other children were laughing at her.

Cognitive Responses to Failure: Examples

Selective Magnification and Minimization

exaggerations in evaluating performance

Example 1A young boy makes a couple of mistakes while trying out for a school play; he believes that he will never get the part for which he is auditioning (magnification).

Example 2The same boy gets the part that he is hoping to have in a school play; he believes that the teacher just made a mistake in choosing him (minimization).

Cognitive Responses to Failure: Examples

Special TopicSpecial TopicChildhood Depression

Childhood Depression

Myths about childhood depression

Children can’t get depressed

Childhood depression is rare

Childhood depression is “just a phase”

Distressed infants show symptoms such as:

lethargy

eating and sleep problems

irritability

decreased attention & emotional expression

Developmental Differences

Preschoolers may demonstrate: irritability and anger

sad facial expressions and crying

anhedonia

somatic complaints, lethargy

eating and sleep problems


Middle Childhood (6-12) Unhappiness, decreased, socialization, sleep

problems, irritability, lethargy. Beginning around age 9, aggression, self-reports of

low self-esteem & helplessness, suicidal ideation

Adolescence Similar to middle childhood, plus pessimism,

feelings of worthlessness and apathy, comorbid substance abuse, eating disorders, antisocial behavior


Intellectual functioning

Interpersonal difficulties

Areas of Impairment

Elementary school 2-4% of community sample,

8-15% of inpatients

Adolescence 7% of community sample

Gender Differences Pre-puberty, either no gender difference or

slightly higher rates in boys By age 15, gender difference parallels that of

adults: rates among girls are twice those among boys

Epidemiology

Having a parent with a psychological disorder, especially a mood disorder, increases children’s risk of depression

Genetic/Biological Vulnerability May be similar to the

vulnerability for adult depression.

Etiology: Familial & Biological Factors

Depressed kids have more distorted cognitions than non-depressed kids

Learned Helplessness Model

Depressed youth more likely to report: Higher “personal helplessness” and

“universal helplessness” More internal, global, and stable

attributional style for negative events.

Etiology: Cognitive Factors

Vulnerabilities to Depression

Failing to form stable, secure attachments with parents

Abrupt separation of human and primate from mothers

Etiology: Attachment

Kids from divorced or single-parent families are at an increased risk

Hostile, tense, and punitive communication patterns within the family are more common among depressed youth

Etiology: Home Environment

Difficult to use adult treatments with kids because they have limited memory, attentional, and verbal capabilities

Because of kids’ involvement with family, family therapy may be crucial

Treatment

Cognitive Restructuring Focuses on identifying and changing cognitions

Role Playing Acting out interpersonal problems to improve

kids’ abilities to find solutions

Antidepressants No more effective than placebo

Treatment (cont’d)

End of Special TopicEnd of Special Topic

Fear & Anxiety in Children Children develop different fears for the first time at Children develop different fears for the first time at

different ages; the onset may be sudden and may have different ages; the onset may be sudden and may have no apparent environmental cause.no apparent environmental cause.

Some fears are both common and relatively stable Some fears are both common and relatively stable across different ages.across different ages.

Other fears become less frequent as children grow Other fears become less frequent as children grow older.older.

Behavior Therapy Main technique for behavior therapy for anxiety

disorders is exposure

Cognitive Behavioral Therapy Teaches children to understand how their thinking

contribute to their anxiety symptoms and how to modify their maladaptive thoughts

Family Intervention Anxiety disorders often occur in family context

Treatment of Childhood Treatment of Childhood Anxiety DisordersAnxiety Disorders

Distress expressed following separation from an attachment figure

A normal developmental phase

Children who fail to “outgrow” separation anxiety may be diagnosed with Separation Anxiety Disorder (SAD)

Separation Anxiety

Age of Onset, Developmental Course & Outcome

The earliest reported age of onset for SAD is 7 to 8 years, but children are often referred around 10 to 11 years

SAD typically progresses from mild to severe avoidance

SAD may be chronic or the onset may be sudden in a child who did not show any prior signs of a problem.

chapter sixteen psychological disorders of childhood

Documents

disorders adhd

childhood disorders

disorders problems

attention slide

adult anxiety disorders

adulthood slide

prevalence comorbidity

impulsivity symptoms