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NYU / OTHER / CAMSUA 101 / When do anxiety disorders develop?

When do anxiety disorders develop?

When do anxiety disorders develop?

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School: New York University
Department: OTHER
Course: Child and Adolescent Psychopathology
Professor: Jess shatkin
Term: Fall 2017
Tags:
Cost: 50
Name: CAP Fall 2017 Final exam study guide
Description: Hi guys, here's the study guide for the final on Tuesday. I apologize for not putting it up earlier for those of you that took the alternate exam, but I just couldn't find the time to put it together. Just a disclaimer, it does not cover eating disorders and psychotic disorders. Again, wanted to make it as detailed as possible and still put it up before the weekend.
Uploaded: 12/16/2017
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Child and adolescent 


When do anxiety disorders develop?



psychopathology – Fall 2017  Final exam study guide - Sunčica Bruck 

1

ADHD 4

MTA Study ..................................................................................................................................................................................... 4 History of ADHD............................................................................................................................................................................. 4 Diagnostic criteria.......................................................................................................................................................................... 5 Functional criteria.......................................................................................................................................................................... 6 Natural History .............................................................................................................................................................................. 6 Making a convincing diagnosis...................................................................................................................................................... 6 Symptoms...................................................................................................................................................................................... 7 Prevalence ..................................................................................................................................................................................... 8 Subtypes and specifiers................................................................................................................................................................. 9 Age, gender and race differences.................................................................................................................................................. 9 Impairments in executive functioning......................................................................................................................................... 10 Brain areas affected in ADHD ...................................................................................................................................................... 11


How can i improve my careless mistakes?



We also discuss several other topics like When did john locke write “an essay concerning human understanding”?

Externalizing Disorders.........................................................................................................................................12 Oppositional-Defiant disorder..................................................................................................................................................... 12

Conduct disorder......................................................................................................................................................................... 12 Developmental progression model of delinquency .................................................................................................................... 13 Protective factors ........................................................................................................................................................................ 13 Risk factors .................................................................................................................................................................................. 14


What tests are given in a neuropsychological evaluation?



If you want to learn more check out What are the two different atrioventricular valves?

Anxiety .................................................................................................................................................................16 What is “normal” and what is pathological................................................................................................................................. 16

When do anxiety disorders develop ? ......................................................................................................................................... 17 How do fears develop ?............................................................................................................................................................... 18 The limbic system and anxiety (role of hippocampus and amygdala)......................................................................................... 18 Risk factors and protective factors.............................................................................................................................................. 18 Changes in child/adolescent anxiety diagnoses between DSM-IV & DSM-5............................................................................... 19 Generalized anxiety disorder (GAD)............................................................................................................................................ 20 Separation anxiety disorder (SAD)............................................................................................................................................... 21 Panic attacks................................................................................................................................................................................ 22 Panic disorder.............................................................................................................................................................................. 23 Social Anxiety Disorder................................................................................................................................................................ 24We also discuss several other topics like Define science.
Don't forget about the age old question of What drug works in the pituitary gland to decrease adh release?

2

Selective mutism ......................................................................................................................................................................... 25

Trauma (PTSD)......................................................................................................................................................26 Post-traumatic stress disorder .................................................................................................................................................... 26 If you want to learn more check out State the laws of thermodynamics.

Obsessive disorders..............................................................................................................................................27 Obsessions and Compulsions ...................................................................................................................................................... 27

Tourette’s and tic disorders ........................................................................................................................................................ 28 Trichotillomania........................................................................................................................................................................... 30

DEPRESSIVE DISORDERS.......................................................................................................................................30 DSM-5 Diagnostic criteria of the Major Depressive Disorder (MDD).......................................................................................... 30

History of perception of  depression in children and adolescents.............................................................................................. 31 Epidemiology ............................................................................................................................................................................... 31 Clinical presentation (signs of depression).................................................................................................................................. 32 Etiology........................................................................................................................................................................................ 33 A family history of depression is a major risk factor for the development of depression in other family members.................. 34 Clinical course.............................................................................................................................................................................. 34 Risk of developing bipolar disorder............................................................................................................................................. 34 BIPOLAR I  DIAGNOSTIC CRITERIA (DSM-5) ................................................................................................................................. 35 PEDIATRIC BIPOLAR DISORDER.................................................................................................................................................... 38If you want to learn more check out Who is daniel elazar?

3

ADHD

MTA STUDY 

M.T.A = Multimodal treatment of ADHD

• Multisite (6 sites) RCT designed to evaluate the leading treatments of ADHD including behavioral  therapy, medication or a combination of the two

• Four treatment arms evaluated

o Medication management (MED) : 28-day, double-blind placebo-controlled trial in which the  effects of 4 different doses of methylphenidate (the generic form of Ritalin)  

o were evaluated.

o Behavior therapy (BEH) : parent training, child-focused treatment, and a school-based  intervention

o Combined (COMB) : All of the treatments outlined above

o Community “control” (CC) :  

• Largest RCT (randomized control trial) ever of any childhood psychiatric disorder (included nearly  600 children ages 7-9)

Major findings of MTA

• Combination treatment and medication management alone both significantly superior to intensive  behavioural treatment alone and to routine community care in reducing primary ADHD symptoms • Although medication was found to be superior to behavioural treatment on core ADHD symptoms,  

this did not extend to other important areas of children's functioning such as oppositional behavior,  peer relations, and academic achievement

• Combined treatment and medication management treatment did not differ significantly in any of the  domains investigated. This suggests that for most children with ADHD, adding behavioral intervention  on top of well-conducted medication management is not likely to yield substantial incremental gains.

• Both combined treatment and medication treatment were superior to community care for parent and  teacher reports of primary ADHD symptoms while behavioral treatment was not.

HISTORY OF ADHD 

• First mentioned in 1902 by Sir George Still

• Throghout the first half of the past century thought to be the result of problems in utero, and the  diagnosis given was “minimal brain damage”

4

• From 1950s-1970s children with hyperactivity and impulsivity symptoms were thought to suffer from  a hyperkinetic or hyperactivity syndrome

o DSM-II (1968) – “hyperkinetic reaction of childhood”

• During the 1970s over 200 publications recognized the prevalence of a co-occuring symptom of  inattention in children suffering from severe hyperactivity and impulsivity, so the concept of the  disorder switches from that of hyperactivity to that of inattention – ADHD becomes “ADD with or  without hyperactivity” in the DSM-III in 1980

• ADD again renamed into ADHD with a series of mixed criteria in the DSM-III-R (1987) as researchers  realised that three symptoms (inattention, hyperactivity and impulsivity) were most often combined or  intertwined in some way  

• DSM-IV published (1994), and the diagnosis becomes “ADHD (predominantly inattentive type,  hyperactive/impulsive type, or combined type)”. Some symptoms must be present before age 7 • Most diagnostic criteria outlined in the DSM-5 remain the same as those in the DSM-IV but there are  some changes  

o Examples added to criterion items to facilitate application across the life span

o Cross-situational requirement strengthened to “several” instead of “some”

o Onset criterion changed from age 8 to age 12 (“symptoms that caused impairment were present  prior to age 12”)  

o Subtypes replaced with presentation specifiers that map directly to the prior subtypes o A comorbid diagnosis with autism spectrum disorder now allowed  

DIAGNOSTIC CRITERIA 

• Two general symptom categories - inattention and hyperactivity/impulsivity

• At least 6 symptoms from each of the domains must be present to meet the diagnostic criteria Inattention

▪ Makes careless mistakes/poor attention to detail

▪ Difficulty sustaining attention in tasks/play

▪ Does not seem to listen when spoken to directly  

▪ Difficulty following instructions  

▪ Difficulty organizing tasks/activities

▪ Avoids tasks requiring sustained effort

▪ Loses items necessary for tasks/activities

▪ Often forgetful

▪ Easily distracted by extraneous stimuli  

Hyperactivity/impulsivity  

▪ Fidgets

▪ Leaves seat  

▪ Runs or climbs excessively (or restless)

▪ Difficulty in engaging in leisure activities quietly

▪ “On the go” or “driven by a motor”

5

▪ Talks excessively

▪ Blurts out answers before question is completed

▪ Difficulty waiting turn

▪ Interrupts or intrudes on others  

FUNCTIONAL CRITERIA  

• At least six symptoms from either or both main domains  

• Specify if inattentive, hyperactive-impulsive or combined type

• Persists for at least 6 months

• Several symptoms present prior to age 12

• Impairment in two or more settings (home, school, church, ball court etc)

• Must cause social/academic/occupational impairment  

NATURAL HISTORY 

Rule of thirds  

• ADHD thought to follow “rule-of-thirds”  

o Approximately one third of children demonstrate complete resolution and are not bothered  much by the disorder in adulthood

o One third demonstrate sustained inattention in adulthood  

o One third continue to experience symptoms in all domains and suffer other difficulties such as  ▪ Substance abuse

▪ Poor academic achievement  

▪ Oppositional defiance

▪ Sever conduct-disordered behaviour  

▪ Anti-social traits  

• Even though a third of children appear to generally outgrow their ADHD diagnosis, a majority of  children still maintain the diagnosis into adulthood

o Pre-pubertal aggression is the best predictor

Age-specific changes  

• Children ages 3 to 5 often identified as having hyperactive/impulsive symptoms

• Children ages 6-12 (school age) often identified as having combined symptoms (or just inattentive in the case of inattentive  type only)  

• Adolescents (13-18) usually complain about inattentiveness with restlessness

• Adults (18+) usually complain about inattentiveness with periodic restlessness

MAKING A CONVINCING DIAGNOSIS 

• No single test for identifying ADHD

• Assessing DSM-5 symptoms is at this time the most useful measure of ADHD

6

o ADHD should not be assessed in a one-to-one setting

o Many (most) children are able to sustain focus when attention is focused solely on them (video  games, therapy sessions, tutoring etc) , but have problems staying still during group activities  o Observation of all individuals interacting with the child are vital (teachers, clinicians, parents,  grandparents, Sunday school teacher, coach etc. )

• Neuropsychological tests can be useful in measuring symptom severity

o Most children with ADHD suffer impairments in executive functioning such as planning,  organizing, inhibiting impulsive responses, attention vigilance etc

o Neuropsychological tests usually focus on assessing spatial working memory, planning ability,  stop-task response suppression and naming speed

o CPT (Continuous performance task) most popular neuropsychological tests  

▪ Require the child to stay focused on a computerized task (pressing space whenever a  certain number or letter appears on screen) while other distractions are added in  

o Even though neuropsych. tests are sometimes useful, they are not a reliable diagnostic tool for  ADHD at the time  

• Diagnosis of ADHD is multifactorial 

o Relies on a thorough interview, collateral interviews with individuals who interact with the  child in multiple settings, an early age of onset, at least some symptoms in more than one  setting  

o The clinician should not only assess the three primary symptoms (inattentiveness, hyperactivity  and impulsivity) but also general behaviour, mood, anxiety, psychosis, trauma, vocal/motor  tics and substance abuse

o Also provide a full medical, educational, developmental, social and family history • Rating scales for collateral informants are useful because children are often not reliable when  describing their symptoms of ADHD (at least until adolescence)

o SNAP – Swanson, Nolan and Pelham Questionnaire for parents and teachers  

o The Connners scale for teachers, parents and affected adults

o The ADHD rating scale (ADHD-RS)

o The Vanderbilt ADHD rating scales for parents and teachers

o SKAMP (Swanson, Kotkin, Agler, M-Flynn and Pelham Scale) for teachers

SYMPTOMS  

• Two general symptom categories (six out of nine symptoms must be present in either or both categories  to satisfy diagnostic criteria)  

Inattention

▪ Makes careless mistakes/poor attention to detail

▪ Difficulty sustaining attention in tasks/play

▪ Does not seem to listen when spoken to directly  

▪ Difficulty following instructions  

▪ Difficulty organizing tasks/activities

▪ Avoids tasks requiring sustained effort

▪ Loses items necessary for tasks/activities

▪ Often forgetful

▪ Easily distracted by extraneous stimuli

7

Hyperactivity/impulsivity  

▪ Fidgets

▪ Leaves seat  

▪ Runs or climbs excessively (or restless)

▪ Difficulty in engaging in leisure activities quietly

▪ “On the go” or “driven by a motor”

▪ Talks excessively

▪ Blurts out answers before question is completed

▪ Difficulty waiting turn

▪ Interrupts or intrudes on others  

• Keep in mind that many of the symptoms are present in other disorders such as learning disorders,  oppositional defiant disorder and anxiety !

PREVALENCE 

• Approximately 1 in 20 children (5%) worldwide are affected by ADHD and 2.5% adults • According to international research, somewhere between 3-9% of schoolchildren are affected  • Recent research has shown an increase in prevalence

o 11% of children ages 7 to 11 have been given a diagnosis of ADHD ; up from 7.8% in 2003 – an increase of 42%

o Currently, 6.1% children are being medicated for ADHD, an increase from 4.8% in 2007 – an  increase of 27%  

• Over 80% children exhibit some sort of psychopathy as adults

o Over half continue to struggle with common symptoms of ADHD but other impairments also  develop – anxiety, learning disorders, substance abuse, mood disorders etc

• Males are more commonly affected than females  

o In the past, the majority of those diagnosed with ADHD were male, because it was thought that  ADHD was primarily a hyperkinetic disorder

o Today we understand that ADHD is not only a hyperkinetic disorder but also a disorder of  inattention, so now the discrepancy between males and females diagnosed is much smaller  (males are thought to be probably only twice more likely to be affected)  

• Girls, typically but not always, exhibit fewer externalizing behaviours, less conduct problems and less  hyperactive symptoms than boys  

• Girls also often show symptoms later than boys, and are usually more “politely inattentive” rather than  disruptive  

• Girls tend to have more functional impairment than boys  

o Increased rates of depression, eating disorders and suicide

• Sex paradox – Since girls are less commonly affected by ADHD, when they do develop the disorder,  it often appears a lot more clinically severe than with boys

o Since girls are less commonly affected by ADHD on a population level, it takes a greater  accumulation of vulnerability and risk factors for the disorder to develop

8

SUBTYPES AND SPECIFIERS  

Subtypes :

• Inattentive

• Hyperactive-impulsive

• Combined type

Specify if :  

• In partial remission : When full criteria were previously met, fewer than the full criteria have been met  for the past 6 months and the symptoms still result in impairment

• Current severity:

o Mild : Few, if any symptoms in excess of those required are present, and symptoms result in  no more than minor impairments

o Moderate: Symptoms of functional impairment between “mild” and “severe” are present o Severe: Many symptoms in excess of those required to make the diagnosis are present, or  several symptoms are particularly severe, or the symptoms result in marked impairment in  social or occupational functioning  

AGE, GENDER AND RACE DIFFERENCES  

Gender 

• Males are more commonly affected than females  

o In the past, the majority of those diagnosed with ADHD were male, because it was thought that  ADHD was primarily a hyperkinetic disorder

o Today we understand that ADHD is not only a hyperkinetic disorder but also a disorder of  inattention, so now the discrepancy between males and females diagnosed is much smaller  (males are thought to be probably only twice more likely to be affected)  

o 2:1 ratio in children and 1.6:1 in adults  

• Girls, typically but not always, exhibit fewer externalizing behaviours, less conduct problems and less  hyperactive symptoms than boys  

• Girls also often show symptoms later than boys, and are usually more “politely inattentive” rather than  disruptive  

• Girls tend to have more functional impairment than boys  

o Increased rates of depression, eating disorders and suicide

• Sex paradox – Since girls are less commonly affected by ADHD, when they do develop the disorder,  it often appears a lot more clinically severe than with boys

o Since girls are less commonly affected by ADHD on a population level, it takes a greater  accumulation of vulnerability and risk factors for the disorder to develop  

• No sex differences in volumetric changes of the brain

9

Culture-related differences 

• Clinical identification rates in the United states for African American and Latino population tend to  be lower than Caucasian populations

• African American children with ADHD are less likely to receive stimulants than Caucasian children  o The reasons aren’t entirely clear but there is no doubt in the fact that poor children and  children of ethnic minorities reap far less benefits from the society

Age specific differences  

• Children ages 3 to 5 often identified as having hyperactive/impulsive symptoms • Children ages 6-12 (school age) often identified as having combined symptoms (or just inattentive in  the case of inattentive type only)  

• Adolescents (13-18) usually complain about inattentiveness with restlessness

• Adults (18+) usually complain about inattentiveness with periodic restlessness

IMPAIRMENTS IN EXECUTIVE FUNCTIONING 

• Executive functions - “command and control” function

o “Conductors” of cognitive skills

• Executive functions include:

o Inhibition

o Shift

o Emotional control

o Initiation

o Working memory

o Planning/organization

o Completing tasks

o Self-monitoring

o Organization of materials

• Most children with ADHD have significant impairments in executive functioning such as  o Ability to maintain attentional vigilance

o Utilizing working memory

o Inhibiting responses

o Organizing  

o Completing tasks  

• Neuropsychological tests usually identify impairments in spatial working memory, planning ability,  stop-task response suppression, naming speed, ability to navigate mazes

10

BRAIN AREAS AFFECTED IN ADHD 

• Numerous areas implicated in some way, such as  

o Dorsolateral prefrontal cortex

o Dorsal anterior cingulate cortex

o Striatum

o Parietal cortex

• Areas involved in coordinating activities of multiple brain regions are smaller in ADHD • The caudate nucleus and globus pallidus (striatum), which contain a large number of dopamine  receptors are smaller in ADHD than in control groups

• Posterior lobes (occipital lobes) are smaller in ADHD groups  

• Smaller total cerebral (-3.2%) and cerebellar (-3.5%) volumes

o These volumetric abnormalities persist with age, except the changes found in the caudate  nucleus  

• Smaller brain volumes in all regions regardless of medication status (cortical white & gray matter) • Children who are unmedicated show roughly the same differences in brain abnormalities as children  who are medicated  

o This shows that medication treatment is not responsible in any way for these changes • Decreased cortical thickening in the anterior cingulate cortex – a key region involved in cognitive  control  

• Another possible cause of ADHD lies within the genetic code

o Rare mutations in the human thyroid receptor beta gene on Chromosome 3 resulted in  symptoms suggestive of ADHD  

o Dopamine transporter gene on Chromosome 5 has also been implicated as a possible genetic  cause of ADHD  

o Dopamine receptor D4 gene on Chromosome 11 and dopamine receptor D5 gene on  chromosome 4 have also been implicated  

o A number of other genes that code for enzymes that impact dopamine and norepinephrine have  shown a modest association with ADHD  

• There is a three-to five-times-greater likelihood that if a child is affected a parent is also affected

11

EXTERNALIZING DISORDERS  

OPPOSITIONAL-DEFIANT DISORDER 

• Pattern of negativistic, angry/irritable mood, argumentative/defiant behavior, or vindictiveness  lasting at least 6 months as evidenced by at least four symptoms of any of the following categories,  and exhibited during interaction with at least one individual who is not a sibling

Angry/irritable mood

1. Often loses temper

2. Is often touchy or easily annoyed

3. Is often angry and resentful

Argumentative/defiant behaviour

4. Often argues with authority figures or with adults (for children and adolescents)  5. Often actively defies or refuses to comply with requests from authority figures or with rules 6. Often deliberately annoys others

7. Often blames others for his or her mistakes or misbehaviour

Vindictiveness

8. Has been spiteful or vindictive at least twice within the past 6 months  

CONDUCT DISORDER 

• A repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate societal norms or rules are violated, as manifested by the presence of three or more of the  following criteria in the past 12 months, with at least one criterion present in the past six months Aggression to People and Animals  

1. Often bullies, threatens or intimidates others

2. Often initiates physical fights

3. Has used a weapon that can cause serious physical harm to others

4. Has been physically cruel to people

5. Has been physically cruel to animals

6. Has stolen while confronting a victim

7. Has forced someone into sexual activity

Destruction of Property

8. Has deliberately engaged in fire setting in intention of causing serious damage

12

9. Has deliberately destroyed others’ property (other than by fire setting)

Deceitfulness or Theft

10. Has broken into someone else’s house, building or car

11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others) 12. Has stolen items of nontrivial value without confronting a victim  

Serious violations of rules

13. Often stays out at night despite parental prohibitions, beginning before age 13 years  14. Has run away from home overnight at least twice while living in the parental or parental surrogate home,  or once without returning for a lengthy period

15. Is often truant from school, beginning before age 13 years  

DEVELOPMENTAL PROGRESSION MODEL OF DELINQUENCY 

• A theoretical model of delinquency (Patterson, DeBarshe and Ramsey 1989) which suggests that  poor parental management in early childhood inadvertently supports the development of child  behavior problems

• By middle childhood, this poorly behaved child is rejected by their peers and suffers academic  failure

• This leads to commitment to deviant peer groups and furthers the likelihood of delinquency  

PROTECTIVE FACTORS 

• Major protective factors :  

o Good relations with at least one parent

o Good peer relations

o Good parental monitoring

• Controlling risk factors is the most effective step toward intervention

13

• Some early intervention programs in preschools (such as Head Start) have shown to be effective in  decreasing rates of later delinquency  

o Programs such as these teach interpersonal-problem-solving skills, emotional management etc RISK FACTORS 

Biological  

• In utero complications

• Maternal smoking  

• Birth problems  

o However, it is not clear with the three above, if the risk factor is related to problems in utero  or are simply related to an overall chaotic environment  

• Decreased frontal lobe glucose metabolism

o Connected with violent behaviour  

• Frontal lobe brain damage

o Associated with aggression

• Orbitofrontal damage

o Associated with impulsive aggression  

• Impairments in amygdala functioning  

o Problems in processing social cues, such as interpreting facial expressions  

o Connection between the amygdala and PFC may aid in suppression of negative emotions, so  if either of the two is damaged the individual may become impulsive and aggressive • Low levels of 5-HIAA (serotonin metabolite) in the cerebrospinal fluid  

o Linked with current and future aggression  

o Blood serotonin is higher in boys with childhood onset CD vs adolescent onset CD and  positively associated with violence in adolescence

• Low salivary levels of cortisol  

o Associated with oppositional defiant disorder  

• Testosterone

o Has only been variably associated with aggression  

• Altered autonomic nervous system function

o Boys with ODD : Lower baseline heart rate but higher heart rate when exposed to induced  frustration  

o Lower galvanic skin response in boys with ODD  

• Exposure to neurotoxins

o Lead  

▪ Preventable risk factor

▪ High levels of lead in 11 year old children are associated with increased aggression  and delinquency scores  

o Organophosphate

o Food additives

o Pesticides  

• Genetic predisposition seems a highly likely contributory factor to many externalizing disorders  o However, no specific gene has been identified so far

14

Psychological/Functional

• Having a “difficult” temperament ( is predictive of developing an externalizing behaviour  o “Difficult temperament” – great deal of negative emotion, inflexibility, wilful and impulsive  way of responding

• Insecure attachments are often noted with children with early-onset conduct problems o Attachment theory – infants must establish secure attachments in order to promote normal  social and emotional development  

o Research is equivocal

• Evidence of neuropsychological impairment found among some children with severely disruptive  behaviour, and while low verbal IQ is a possible precursor, the research has not controlled well for  ADHD, which itself greatly contributes to the development of ODD/CD  

• While in boys, disruptive behaviour is often a risk factor for the subsequent development of a reading  disorder, in girls the opposite happens – reading disorders may promote disruptive behaviours more • Behavioural inhibition (shyness) decreases the risk of later delinquency  

• Socially withdrawn boys have a higher risk of later delinquency

o Boys who do not relate well to peers, but not due to shyness

• Social cognition impairment

o Boys with disruptive behaviour disorders demonstrate a lack of understanding of others’ point  of view, have a self-centred understanding of other persons’ points of view, and have an  egocentric way of describing their peers  

o Problems encoding social cues

o Boys and girls with CD have less empathy, and empathy is known to mediate aggressive  behaviour  

• Early physical maturation in girls

o Not in boys  

Social  

• Poor parenting  

o Parental psychopathology might be more predictive of development of a disruptive behaviour  disorder than poor parenting  

o Poor monitoring

o Inconsistent and harsh punitive measures  

o Coercion

o Differential treatment of siblings

• Assortative mating  

o = individuals with similar phenotypes are more likely to mate  

o Females offenders are more likely to cohabit or marry male offenders than male offenders are  to select female offenders

▪ Female offenders are also more likely to have a child who is a product of two offenders,  than is a male offender, and the risk for this child might be both environmental and  genetic

• Child abuse

15

o Both physical and sexual abuse have been found to increase the likelihood of developing ODD  or CD

o Harsh/abusive parenting  

o Boys are more likely to respond to sexual abuse with internalizing problems but are equally or  more likely than girls to develop conduct problems

o Abused children may have difficulties interpreting social cues the same way as other children • Peer effects

o Children spend 1/3 of their time with their peers  

o Chronically abused children are more likely to be rejected by peers

▪ While normal peers will generally reject those with a conduct disorder, they will, at the  same time reinforce this behaviour by compliance and passivity  

o Aggressive boys may be more likely to be rejected by peers than girls  

• Socioeconomic factors

o Growing up in poor/disadvantaged neighbourhoods

o Increased availability of drugs

o Witnessing adults involved in criminal activity  

o Community disorganization  

o Racial prejudice  

Anxiety

WHAT IS “NORMAL” AND WHAT IS PATHOLOGICAL 

• All children experience anxiety  

• 10% - 32% children and adolescents suffer from a diagnosable anxiety disorder • There are many children who suffer significant anxiety but do not meet the diagnostic criteria for an  anxiety disorder  

o Studies have found that 40% grade-school children suffer from separation anxiety o 40% children ages 6 to 12 have 7 or more fears that trouble them

o 30% children worry about their competence and require considerable assurance o20% of grade-school children are shy, afraid of heights, anxious  

about public speaking and social acceptance  

• Some anxiety is useful as it motivates us into action

• Yerkes and Dodson (1998) proposed a model to explain the  

relationship between the level of arousal and level of performance  

oAs one’s level of arousal or stress increases, so does the level of  

performance, up to some optimum point

oAt one point, however, when the level of arousal exceeds the  

optimum point, one’s level of performance decreases

16

Tools for distinguishing between typical anxiety between pathological anxiety  

1. OBJECT

⮚ Is this issue something the child should be worrying about ?  

2. INTENSITY

⮚ Is the degree of distress reasonable or realistic given the child’s developmental stage and the  object/event?

3. IMPAIRMENT

⮚ Does the stress interfere with the person’s daily functioning ?

o Social functioning – unable to make friends

o Academic functioning – failing classes, missing school, etc

o Family functioning – creating conflicts within the family  

4. COPING SKILLS/ABILITY TO RECOVER

⮚ Is the child able to recover from the stress even when the trigger isn’t present?  ⮚ Does the child worry about future occurrences?  

⮚ Does the distress occur across multiple settings ?  

• Fear and worry are normative experiences  

o Infants commonly fear loud noises, being startled, strangers (between 8-10 months) o Toddlers may be afraid of imagery of creatures and monsters and separation from their parents  and siblings  

o School-age children often worry about injuries and natural disasters (volcanos, hurricanes etc)  and may also interpret ambiguous situations more negatively and doubt their competence and  ability (for example, misreading a facial expression or viewing a remark made by a peer as  criticism). Children at this age are more likely to experience attribution bias.  

o By the time children reach adolescence, their fears and worries tend to mirror those of adults  more closely and are usually related to school capabilities and issues of physical and mental  health

• Clinicians must be able to distinguish between developmentally normal and abnormal anxieties and  fears

• Children with high levels of anxiety in early life are more likely to suffer from anxiety as they age  whereas children who are more eager and confident to explore around the age of 5 are less likely to  manifest anxiety later

WHEN DO ANXIETY DISORDERS DEVELOP ? 

• Somewhere between 6% to 20% of children suffer at least one major anxiety disorder prior to age 18  • Anxiety disorders are the most common psychiatric disorders among adolescents  o 32% of 13 to 18 year olds with a median age of onset at 6 years

o However, these numbers might be a lot larger because there are many kids who experience  anxiety disorders that do not fit DSM-5 criteria but still cause significant impairment • Mothers tend to over-report anxiety  

o There is often a low concordance between child and parent reports of anxiety

17

HOW DO FEARS DEVELOP ? 

• Most specific fears (phobias) are learned responses  

o Related to a paired or mispaired internalization of cues from a past anxiety  

• Some fears have roots in genetically fixed patterns developed by evolution (such as snakes)  • Children sometimes learn to mimic their caretakers’ responses when interpreting internal states of  pain, anxiety or stress  

• Over time children may come to label a host of external cues as potentially threatening and certain  internal sensations as fearful

THE LIMBIC SYSTEM AND ANXIETY (ROLE OF HIPPOCAMPUS AND AMYGDALA) 

AMYGDALA

• The “fear hub” of the brain  

• Receives neural projections from many areas of the brain and plays a key role in orchestrating the  brain’s response to sensory input by sending projections to motor, autonomic and neuroendocrine  systems  

• Anxiety is believed to be recognized at the site of amygdala

HIPPOCAMPUS  

• Storage site of emotional or cognitive memories  

• Highly sensitive stress which prevents it from accurately storing some information o So it may promote certain cognitive disorders associated with anxiety disorders  • Smaller in individuals diagnosed with PTSD  

o Shrunk by cortisol  

RISK FACTORS AND PROTECTIVE FACTORS 

RISK FACTORS

• Behavioral inhibition and shyness

o Behavioral inhibition is the tendency to be unusually withdrawn or timid and to show fear  and withdrawal in novel, unfamiliar social and non-social situations  

o Those who are only withdrawn in social situations are shy  

o Children who are behaviorally inhibited are more likely to have multiple psychiatric  disorders and two or more anxiety disorders (especially Avoidant D/O, Separation Anxiety  D/O, and Agoraphobia)

o Behavioral inhibition is a risk factor for developing anxiety disorders in children  

• Upbringing  

o If role models react by overprotecting the child, he/she will never learn to survive in new  situation, and overtime, this shyness may develop into social anxiety.

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o Shy parents might also unintentionally set an example by avoiding certain social interactions.  A shy child who watches this learns that socializing is uncomfortable, distressing, and  something to avoid.

o Inherited genes have an effect on how someone senses and regulates anxiety. Also, most people  who develop social anxiety, have always had a shy temperament.

o Insecure attachments (specifically anxious/resistant attachment) to primary caregivers also  increases a risk of developing an anxiety disorder

o Low socio-economic status

PROTECTIVE FACTORS  

• Problem-solving and distraction strategies  

• Sophisticated coping skills  

• Consistent home/family routine

• High family support

• High self-esteem and feelings of self-worth

• Consistent physical activity  

• Secure attachment style

CHANGES IN CHILD/ADOLESCENT ANXIETY DIAGNOSES BETWEEN DSM-IV & DSM-5 • DSM-IV disorders include:  

1. Separation Anxiety Disorders

2. Panic Disorder

3.Specific Phobia

4.Social Phobia (Social Anxiety Disorder)

5.Obsessive-Compulsive Disorder

6. Posttraumatic Stress Disorder  

7.Acute Stress Disorder  

8. Generalized Anxiety Disorder

• DSM-5 disorders include  

1. Separation Anxiety Disorder

2. Selective Mutism

3. Specific Phobia

4. Social Anxiety Disorder

5. Panic Disorder

6. Generalized Anxiety Disorder

7. Unspecified Anxiety Disorder

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GENERALIZED ANXIETY DISORDER (GAD) 

Generalized Anxiety Disorder (DSM-5 definition) 300.02 (F41.1)

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6  months, about a number of events or activities (such as work or school performance).  

B. The individual finds it difficult to control the worry.  

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least  some symptoms having been present for more days than not for the past 6 months): Note: Only one item  required in children.  

1. Restlessness, feeling keyed up or on edge.  

2. Being easily fatigued.  

3. Difficulty concentrating or mind going blank.

4. Irritability.

5. Muscle tension.  

6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).  

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social,  occupational, or other important areas of functioning.  

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a  medication) or another medical condition (e.g., hyperthyroidism).  

F. The disturbance is not better explained by another medical disorder (e.g., anxiety or worry about having  panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination  or other obsessions in obsessive-compulsive disorder, separation from attachment figuresin separation anxiety  disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa,  physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder,  having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or  delusional disorder).

CLINICAL PRESENTATION  

• Chronic, excessive worrying in a number of areas  

o Academic performance, health/safety, world events, family, social interactions  o Worry is most often present and not limited to just one situation or object

• At least one associated somatic symptom  

• Affected children are often perfectionists, seek attention and reassurance

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SEPARATION ANXIETY DISORDER (SAD) 

Separation Anxiety Disorder (DSM-5 definition) 309.21 (F93.0)

A ) Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom  the individual is attached, as evidenced by at least three of the following:

1. Recurrent excessive distress when anticipating or experiencing separation from home or from  major attachment figures.

2. Persistent and excessive worry about losing major attachment figures or about possible harm to  them, such as illness, injury, disasters, or death.

3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being  kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. 4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere  because of fear of separation.

5. Persistent and excessive fear of or reluctance about being alone or without major attachment  figures at home or in other settings.

6. Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a  major attachment figure.

7. Repeated nightmares involving the theme of separation.

8. Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting)  when separation from major attachment figures occurs or is anticipated.

A. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and  typically 6 months or more in adults.

B. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or  other important areas of functioning.

C. The disturbance is not better explained by another mental disorder, such as refusing to leave home  because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations  concerning separation in psychotic disorders; refusal to go outside without a trusted companion in  agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety  disorder; or concerns about having an illness in illness anxiety disorder.

• Children with SAD typically grow up within close-knit families and upon separation they become sad,  withdrawn, apathetic and have difficulty concentrating  

• Specific fears that come with SAD commonly mirror the developmental level of the child  o Younger children might fear monsters while older children might fear airplanes or natura  disasters  

o Adults with SAD are usually fearful of changes, such as starting a new job or moving and are  overly worried about their children and spouses  

• SAD might develop after a major life change or stress

o For example a death in the family, move to a new place, etc

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• Approximately 4% children (ages 6-12) and 1%-2% adults are thought to be affected  • Girls are typically more affected than boys  

• Usually this anxiety disappears over time and children recover by adulthood

PANIC ATTACKS 

• Not a diagnosis ! (Not a disorder)  

o Given that about 1 in 40 adults experience them at least once in their lifetime  

• An abrupt surge of intense discomfort that reaches a peak within minutes and during which time four  or more of the following symptoms occur  

1. Palpitations, pounding heart or accelerated heart rate

2. Sweating

3. Trembling or shaking

4. Sensations of shortness or breath or smothering  

5. Feelings of choking

6. Chest pain or discomfort

7. Nausea or abdominal distress

8. Feeling dizzy, unsteady, light-headed or faint

9. Chilld or heat sensations

10. Paresthesias (numbness or tingling sensations)

11. Derealization (feelings of unreality) or depersonalization (being detached from oneself) 12. Fear of losing control or “going crazy”

13. Fear of dying  

• Individuals typically report a desire to leave

• 3 types of panic

1. Unexpected – Happen “out of the blue”, with no specific trigger. The occurrence of  unexpected panic attacks is required to be diagnosed with a panic disorder. Situationally  bound panic attacks can happen during panic disorders, but are also common in the  context of other anxiety disorders  

2. Situation predisposed – occur in anticipation of trigger situation (before a flight, or  examination etc)

3. Situation bound – occur only during certain settings/situations  

• Uncommon before puberty  

• Onset is typically around adolescence and 30 years of age

o Adolescents are typically better at describing the experience after it has ended, than  younger children are  

• Children generally report physical symptoms of a panic attack, rather than the psychological  symptoms, and will all of a sudden appear frightened or upset for no reason  

o Young children may not be able to articulate the fears they feel, and the experience o Luckily, panic attacks are very rare in young children

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PANIC DISORDER  

Panic disorder (DSM-5 definition)  

300.01 (F41.0)

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense  discomfort that reaches a peak within minutes, and during which time four (or more) of the following  symptoms occur:

1. Palpitations, pounding heart or accelerated heart rate

2. Sweating

3. Trembling or shaking

4. Sensations of shortness or breath or smothering  

5. Feelings of choking

6. Chest pain or discomfort

7. Nausea or abdominal distress

8. Feeling dizzy, unsteady, light-headed or faint

9. Chilld or heat sensations

10. Paresthesias (numbness or tingling sensations)

11. Derealization (feelings of unreality) or depersonalization (being detached from oneself) 12. Fear of losing control or “going crazy”

13. Fear of dying  

B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing  control, having a heart attack, “going crazy”).

2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to  avoid having panic attacks, such as avoidance of exercise or unfamiliar situations). 3. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of  abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary  disorders).

4. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not  occur only in response to feared social situations, as in social anxiety disorder; in response to  circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in  obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic  stress disorder; or in response to separation from attachment figures, as in separation anxiety  disorder).

• “Fear of fear itself”  

• Generally viewed as a chronic disorder  

o Recidivism is generally elevated in psychiatric treatment centers

• Peak of onset is about 15 – 19 years of age  

• Comorbidity with other anxiety disorders is common

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o 15% to 30% individuals with panic disorders experience social phobia or GAD  o 2% to 20% experience specific phobias  

o OCD affects about 10%

o PTSD may occur in 10% or more

o SAD and hypochondriasis is common

o Up to ½ of community samples have comorbid agoraphobia, but the co-occurrence is much  higher in clinical samples

• Rates of coexisting major depressive disorders are also high

o Between 10% to 65% panic sufferers affected  

o Usually the depression follows panic or co-exists  

o In a minority of those affected, depression precedes the panic

• Substance abuse is also common, as many of those affected misuse alcohol and drugs to ease their  anxiety  

• Can occur with or without agoraphobia  

o Agoraphobia – fear of open spaces – fear of places where escape might be difficult (or  embarrassing) or in which help might not be available in the event of having an unexpected  or situationally predisposed panic attack or panic-like symptoms  

o Fear of being outside the home alone, standing in crowds, standing on a bridge, standing in  line etc  

SOCIAL ANXIETY DISORDER 

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to  possible scrutiny by others. Examples include social interactions (e.g., having a conversation,  meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of  others (e.g., giving a speech).

Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

B. The individual fears that he or she will act in a way or show anxiety symptoms that will be  negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend  others).

C. The social situations almost always provoke fear or anxiety.

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or  failing to speak in social situations.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the  sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

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G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social,  occupational, or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g.,  a drug of abuse, a medication) or another medical condition.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder,  such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury)  is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specify if:

Performance only: If the fear is restricted to speaking or performing in public.

• As with any specific phobia, the individual must experience excessive anxiety, and maybe even a panic  attack, when exposed to a social situation  

• Common physical signs of SAD include

o Palpitations

o Sweating

o Gastrointestinal symptoms (diarrhoea or vomiting)  

• Individuals are often passive, often hypersensitive to rejection and criticism ; and tend to demonstrate  low self-esteem and feelings of inferiority  

PREVALENCE

• Generally, women tend to suffer from SAD more often than men  

• 5% of children

• 12-month prevalence about 7%

• Lifetime prevalence 3-13%

• Tends to start during adolescence. According to Montgomery (1995)

o 40% of social phobias start before the age of 10 and 95% before the age of 20. o Early onset of social anxiety may lead to more serous risks in academic and social settings.

SELECTIVE MUTISM 

• Repeated refusal to speak in specific social situations where speaking is expected (e.g., at school)  despite speaking in other situations

• Duration of at least one month with significant disturbance

• According to the DSM-IV, not an anxiety disorder, but was added to the DSM-5

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• Usually evident by 5 years of age

• Children with SM are generally shy, socially isolated, fearful of embarrassment and oppositional at  home  

Trauma (PTSD)

POST-TRAUMATIC STRESS DISORDER  

• Development of characteristic symptoms following exposure to one or more traumatic events. • Symptoms typically occur within 3 months of the trauma  

• There are different types of trauma 

o Child maltreatment 

o Witnessing or being a victim of community violence  

o Natural disasters 

o Motor vehicle collisions 

o War and Terrorism

o Disasters

o Complex trauma – a result of exposure to numerous different traumatic events that impact  more than one aspect of the child’s life

PREVALENCE

• Lifetime prevalence – 1%-14%

• About 3.5% adults in the US affected  

• Child abuse – over 3 million reports

o Studies of 30%-40% sexual abuse

o About 10% physically abused

• Single-incident disaster – 10%  

• Motor vehicle collisions are the most common form of unintentional injury among children  • Most children back to baseline after about 2-3 weeks after the event  

• Manifests differently with age

o Young children will typically demonstrate symptoms of separation anxiety, avoidance,  nightmares and some somatic symptoms, learning disorders, agitation etc

o Older children might exhibit similar symptoms, and in addition to that: high-risk behaviour,  difficulty sleeping, negative cognitions etc

• Children often exhibit signs of guilt and personal responsibility due to the egocentric point of view  children often have

o These guilty thoughts and feelings of responsibility might lead to irrational thoughts and  beliefs

• Traumatic events experienced prior to age 11 are 3x more likely to result in PTSD

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• Psychological impact of traumatic events tends to persist or worsen over time in children • Parents tend to underestimate both the intensity and duration of their children’s stress reactions ROLE OF HIPPOCAMPUS IN PTSD

• Storage site of emotional or cognitive memories  

• Highly sensitive stress which prevents it from accurately storing some information o So it may promote certain cognitive disorders associated with anxiety disorders and distortion  of memories after traumatic events

• Smaller in individuals diagnosed with PTSD because it fails to regenerate neurons due to the stress of  the traumatic memory (influx of cortisol)

• War veterans have shown an 8% reduction in the right hippocampus (no differences in other parts of  the brain)

ROLE OF AMYGDALA IN PTSD

• The “fear hub” of the brain  

• Receives neural projections from many areas of the brain and plays a key role in orchestrating the  brain’s response to sensory input by sending projections to motor, autonomic and neuroendocrine  systems  

• Hyper-responsive in PTSD  

• Important not only because of its relationship with the hippocampus, but also because it may impair the individual’s ability of accurately assessing threat  

MEDIAL PFC IN PTSD  

• Inhibits stress response and emotional reactions via its impact on the amygdala • Reduction in volume in individuals with PTSD  

Obsessive disorders

OBSESSIONS AND COMPULSIONS 

OBSESSIONS

• Recurrent, persistent, unwanted thoughts, impulses or images

• Intrusive, cause distress

• Examples

o Contamination (most common)  

o Inappropriate sexual thoughts

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o Violent thoughts, religious fears or “blasphemous” thoughts

• Young children do not have to identify fears as irrational

• Children are also often very ashamed of their intrusive thoughts ; so symptoms are usually there  before the disorder is actually clinically diagnosed

COMPULSIONS  

• Repetitive behaviors or mental acts (praying, counting)

• Person feels driven to perform in response to obsession or rigid rules

• Performed to neutralize obsessive thoughts or prevent some dreaded situation • Not connected in realistic way

• Provide temporary relief

• Not performing causes marked increase in anxiety

• Examples

o repetitive and excessive hand washing (most common)  

o checking doors

o arranging objects

o counting items

TOURETTE’S AND TIC DISORDERS 

TICS

• A sudden, rapid, non-rhytmic, recurrent stereotyped motor movement or vocalization  • May be simple (involving only a few muscles and sounds) or complex (involving multiple muscle  groups, bouts and sentences or words)

• A simple motor tic is very brief – generally lasting only about several hundred milliseconds o Blinking

o Head jerking

o Opening the mouth

o Sucking the lips

o Shrugging shoulders

• Some motor tics (such as crunching the toes) are hard to observe/notice

• A complex motor tic lasts longer, typically seconds or even longer

o Pulling clothes

o Jumping

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o Skipping

o Sticking out the tongue  

o Tensing muscle groups  

o Copropraxia – sudden uncontrollable offensive gestures (such as flipping someone off) o Echopraxia – involuntairy mirroring of someone else’s movements  

• Simple vocal tics – brief sounds

• Complex verbal tics – language based  

o Changes in volume

o Blurting out phrases, words, sentences etc

o “Lalias”

▪ Palialia – Repeating one’s own words or sounds

▪ Echolalia – repeating others’ words or sounds

▪ Coprolalia – involuntary utterance of socially objectionable phrases/words  

(experienced by fewer than 10% of individuals that suffer from tics)  

TOURETTE’S SYNDROME

• First case reported by French physican Itard

o Marquise de Dampierre

o Marquise suffered motor tics, coprolalia and echolalia from the age of 7  

• George Gilles de la Tourette described nine cases of the syndrome in 1885, one of which was  Marquise de Dampierre  

• Throughout much of the 20th century, Tourette’s was believed to have a psychogenic origin. More  recent research, however, has resulted in a return to Tourette’s initial impression of the disorder as a  nonprogressive, hereditary neurological condition

• Typically begins with a simple tic, such as a facial tic (blinking, for example)

• The tics persist and generalize to other parts of the body

• Eventually, explosive vocalizations (throat clearing, hiccupping, snorting etc) ensue • Most individuals claim that the tics are irresistible but that they can supress them  • Generally disappear during sleep or intense sexual arousal  

• Individuals may feel the need to perform the tic repeatedly or in a specific way until it has been done  “just right”

DSM-5 DIAGNOSTIC CRITERIA FOR TOURETTE’S

• Both multiple motor and one or more vocal tics have been present at some time during the illness,  although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped  motor movement or vocalization.)

• The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a  period of more than 1 year, and during this period there was never a tic-free period of more than 3  consecutive months.

• The onset is before age 18 years.

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• The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a  general medical condition (e.g., Huntington’s disease or postviral encephalitis).

TRICHOTILLOMANIA  

• Chronic hair pulling resulting in hair loss

• Categorized under the new obsessive-compulsive and related disorders chapter in the DSM-5  • Most cases begin in childhood or adolescence  

• Individuals typically report a build-up of tension before hair pulling, or while resisting pulling, that is  relieved when hair is pulled (along with a sense of fulfilment, happiness, release, satisfaction etc)  • Most common sites of pulling are : scalp, eyebrows, eyelashes  

o But other areas can be affected too  

o May even pull hair from dolls, pets, clothes, rugs etc

• Equally common among boys and girls, but more common with women than men with a ratio of  10:1

• Prevalence is unknown but it is estimated that it is somewhere between 0.6% to 4% o Most researchers accept it is around 1%

DEPRESSIVE DISORDERS

DSM-5 DIAGNOSTIC CRITERIA OF THE MAJOR DEPRESSIVE DISORDER (MDD) 

A. Five (or more) of the following symptoms have been present during the same 2-week period and  represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or  (2) loss of interest or pleasure.

• Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g.,  feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In  children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly  every day (as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body  weight in a month), or decrease or increase in appetite nearly every day. (Note: In children,  consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely  subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

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7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly  every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by  subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific  plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important  areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or another medical condition.

SPECIFIERS – Severity, psychosis , anxious distress , mixed features ,melancholic features ,atypical features,  peripartum, seasonal, catatonia

HISTORY OF PERCEPTION OF DEPRESSION IN CHILDREN AND ADOLESCENTS 

• Case reports of childhood depression date back to the 17th century  

• Melancholia in children was first reported in the mid-19th century

• The existence of depression prior to 1960 was seriously doubted because it was felt that children’s  immature superego would not permit the development of mood disorders

• Research from Europe and NIMH funded American studies in the 1970’s increased the awareness &  acceptance of childhood depression

PSYCHOANALYTIC THEORY  

• Freud and many other psychoanalysts at the time, understood the superego as something that would  cause guilt and punish bad behavior among other things

• Psychoanalytic theorists posited that depression results from an intrapsychic conflict between the  ego and a persecutory superego

• Psychoanalysis held that the superego was formalized only after resolution of the Oedipal Conflict,  which occurred by late adolescence

• By this theory, then, children could not experience intrapsychic conflict and, ergo, could not  develop mood disorders

EPIDEMIOLOGY 

PREVALENCE

• 1% preschool children

• 2% school age pre-pubertal children

• 4% to 8% for adolescents

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• Lifetime prevalence among adolescence is 15-20%

• 40% MDD among children on neurology wards with unexplained headaches (Ling et al, 1970);  • 7% of general pediatric inpatients (Kashani et al, 1981)

• 28% of children in psychiatric clinics (Carlson & Cantwell, 1980)

• 59% of child psychiatry inpatients (Petti, 1978)

• 27% of adolescent inpatients (Robbins et al, 1982)

• Prevalence increases during adolescence, possibly due to:

1. Biological factors (e.g., sexual maturation)

2. Environmental factors (e.g., increased social/academic expectations, more chance of exposure  to negative events)

3. Psychological & cognitive factors (e.g., increased autonomy and abstract thinking) • Since 1940, each successive generation has been at higher risk for MDD

GENDER RATIO  

• 1:1 female to male ratio in childhood  

• 2:1 female to male ratio by adolescence

• 1.5:1 – 3:1 female to male ratio from adolescence onward

CLINICAL PRESENTATION (SIGNS OF DEPRESSION) 

• DSM-5 Criteria do not differ for children & adolescents

• Generally, children show fewer neurovegetative signs than adults

o Instead of depressed mood might experience irritability  

o More symptoms of anxiety than with adults

o Depression is expressed as temper tantrums & behavior problems

o Fewer delusions and serious suicide attempts

o By middle childhood, preoccupations w/death, lowered self-esteem, social  withdrawal/rejection, & poor school performance

• Depressed adolescents show more similar signs of depression as adults  

o More cognitive components to their depression than children

o Guilt and hopelessness become apparent

o More sleep & appetite disturbances, delusions, suicidal ideation & attempts

o Compared to adults, still more behavior problems and fewer neurovegetative difficulties

NEUROVEGETATIVE SIGNS OF DEPRESSION

• Sleep disturbance (Hypersomnia or insomnia)

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• Fatigue

• Weight loss/gain

• Change in appetite

• Loss of interest/pleasure  

• Psychomotor retardation or agitation  

• Suicidality

• Difficulty concentrating  

ETIOLOGY 

PSYCHODYNAMIC THEORY  

• Those who are depressed suffer from a severe and unrelenting superego that causes them to be  extremely critical, guilty and prohibitive of their own fantasies, feelings and actions  

ATTACHMENT THEORY  

• Insecure early attachments lead to depression. Those with depression never adequately bonded to their  primary caregivers and as a result feel lost and alone

BEHAVIORAL THEORY  

• Depressed individuals never learned to obtain adequate reinforcement, so they cannot gain pleasure  from life

COGNITIVE THEORY  

• Depressed individuals struggle with a negative or depressive mindset and have a distorted view of the  world  

SELF-CONTROL THEORY

• Deficits in self-monitoring and self-evaluation cause depression  

SOCIOENVIRONMENTAL THEORY

• Environmental and social triggers such as a loss of a significant other, parent or job, and other negative  circumstances can predispose or even cause depression  

BIOLOGICAL EXPLANATIONS  

• About 70% of adults suffering from severe depression do not show normal suppression of cortisol  secretion, showing an alteration in their stress response

• Neuroendocrine abnormality at the level of hypothalamus (largely regulated by serotonin, dopamine  and norepinephrine)

• Too little neurotransmitter catecholamine as a cause of depression

• Decreased slow-wave sleep, decreased REM latency and longer periods of REM sleep occur less often  in depressed children and adolescents

• Less major serotonin metabolite (5-HIAA) in the CNS

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• Genetic inheritance (about 1/3 of the risk is thought to be genetic)

o 35% to 75% identical twins share the diagnosis  

o A family history of depression is a major risk factor for the development of depression in other  family members  

o Children of parents with depression have about 2-4x the risk of having depression (Beardslee  et al, 1998; Weissman et al, 1997)

• Adults with one or two copies of the short allele of the serotonin transporter gene exhibit more  depressive symptoms, diagnosable depression and suicidality in response to stressful life events, than  do adults with two copies of the long allele

o Reasons for this aren’t entirely clear but one explanation is that those carrying the short allele  serotonin transporter gene are less able to employ the part of the limbic system important for  processing emotion in order to manage the negative emotions expressed by the amygdala  

CLINICAL COURSE 

• Median duration of clinically referred children and adolescents typically about 7 – 9 months • Samples drawn from the community: 1 – 2 months

• psychiatric disorders, poor psychosocial functioning

• About a 50% relapse

• 90% of MDD episodes remit within 1-2 years after onset

o Remission of 2 weeks – 2 months with only 1 clinically significant symptom

• 40 – 60% of youth with MDD experience relapse after successful treatment of acute episode (indicates  the need for continual treatment)

PREDICTORS OF INCREASED DURATION: depression severity, comorbidity, negative life events,  parental

PREDICTORS OF RELAPSE : natural course of MDD, lack of compliance, negative life events, rapid  decrease/discontinuation of therapeutic treatment

RISK OF DEVELOPING BIPOLAR DISORDER  

• 20 – 40% of depressed children & adolescents develop bipolar disorder within 5 years of index episode  of MDD

• The risk is really high because a depressive episode often turns out to be due to a bipolar disorder (and  is later followed by mania)  

PREDICTORS OF BIPOLAR I ONSET:  

• Early onset MDD

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• Psychomotor retardation

• Psychotic features

• Family history of bipolar disorder

• Family history of psychotic depression

• Heavy familial loading for mood disorders

• Pharmacologically induced (hypo)mania

BIPOLAR DISORDER  

BIPOLAR I DIAGNOSTIC CRITERIA (DSM-5) 

For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The  manic episode may have been preceded by and may be followed by hypomanic or major depressive  episodes.

MANIC EPISODE

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and  abnormally and persistently increased activity or energy, lasting at least 1 week and present most of  the day, nearly every day (or any duration if hospitalization is necessary).

B.During the period of mood disturbance and increased energy or activity, three (or more) of the  following symptoms (four if the mood is only irritable) are present to a significant degree and represent a  noticeable change from usual behavior:

• Inflated self-esteem or grandiosity.

• Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

• More talkative than usual or pressure to keep talking.

• Flight of ideas or subjective experience that thoughts are racing.

• Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli),  as reported or observed.

• Increase in goal-directed activity (either socially, at work or school, or sexually) or  psychomotor agitation (i.e., purposeless non-goal-directed activity).

• Excessive involvement in activities that have a high potential for painful consequences (e.g.,  engaging in unrestrained buying sprees, sexual indiscretions, or foolish business  

investments).

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C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational  functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic  features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a  medication, other treatment) or another medical condition

HYPOMANIC EPISODE

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and  abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present  most of the day, nearly every day.

B. During the period of mood disturbance and increased energy and activity, three (or more) of the  following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change  from usual behavior, and have been present to a significant degree:

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

3. More talkative than usual or pressure to keep talking.

4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external  stimuli), as reported or observed.

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or  psychomotor agitation.

7. Excessive involvement in activities that have a high potential for painful consequences  (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business  investments).

B. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the  individual when not symptomatic.

C. The disturbance in mood and the change in functioning are observable by others.

D. The episode is not severe enough to cause marked impairment in social or occupational functioning  or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.

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E. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a  medication, other treatment) or another medical condition .

Note: Criteria A–F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder  but are not required for the diagnosis of bipolar I disorder.

MAJOR DEPRESSIVE EPISODE

A. Five (or more) of the following symptoms have been present during the same 2-week period and  represent a change from previous functioning; at least one of the symptoms is either (1) depressed  mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report  (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful).  (Note: In children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,  nearly every day (as indicated by either subjective account or observation).

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of  body weight in a month), or decrease or increase in appetite nearly every day. (Note: In  children, consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others; not merely  subjective feelings of restlessness or being slowed down).

6. Fatigue or loss of energy nearly every day.

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)  nearly every day (not merely self-reproach or guilt about being sick).

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by  subjective account or as observed by others).

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a  specific plan, or a suicide attempt or a specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other  important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or another medical  condition.

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• New to DSM-5:

o DMDD (listed under Depressive D/O)

o Bipolar D/O fall between Psychotic D/O and Depressive D/O

• Euthymia is a “normal” non-depressed state ; reasonably positive

• Dysthmia is a low-grade depressive state  

• Mixed episode is a state that is a sort of combination of depression and mania; with symptoms of  both states present at the same time  

o Crying and laughing silmutaneously  

• Cyclothymia mood disorders between hypomania and low-grade depression  

PEDIATRIC BIPOLAR DISORDER 

DIAGNOSTIC DILEMMAS  

1. The centrality of irritability – most individuals with BPD have clear symptoms of euphoria and elation  during hypomanic episodes, not just irritability, whereas children are almost wholly irritable during  hypomanic episodes  

• recommending a diagnosis of BP if the child meets DSM criteria with irritability as a core symptom,  even in the absence of elation, grandiosity, and episodicity

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• versus unmodified DSM criteria

2. Children with BPD almost always exhibit other disorders alongside BPD (learning disorders, ADHD,  autism etc) so it is difficult to discern what the core problem is  

3.Episode length

• Usually, episodes of mania or depressive episodes can last for days, weeks even, but with children  they are very brief, lasting hours  

• Harder to separate “abnormal” from “normal”

• Many of the symptoms are the same as in many other common disorders such as o ADHD

o Anxiety  

o Adjustment disorder

o Dysthymic disorder

o Unipolar depression  

o ODD/CD  

• Among the existing research on children with BPD, there is very little background information about these  children (abuse, trauma, emotional attachment, etc)

Most salient indicators of BPD in children

• Elation  

o More than just being wound up on sugar

o Inappropriate affect/response to negative material

o For example, a normal child being extremely elated on their birthday or for a trip is not  indicative of an impairment. However, an 8 year old repeatedly giggling or laughing for no  reason, despite correction or suspension might be indicative of child mania

• Decreased need for sleep  

o Up late or early often with increased goal directed behaviour  

o Normally children sleep for about 9-10 hours and will be tired the next day if they don’t get  enough. An 8 year old who is up until 2AM re-arranging their room and then wakes up  restful the next day at 6 AM might be indicative of child mania  

• Grandiosity  

o Difficult to assess in children, because boastfulness, opposition and even delusions are  somewhat common with young children,  

o Many young children will truly believe when they report that they can beat their dad in a  wrestling match, but this is most likely not a symptom of mania ; However, a 12 year old  who reports having discovered secret propulsion and building a spaceship, and spending all  waking hours on this – might be indicative of child mania  

• Hypersexuality

o Drawings, inappropriate touching, exposing self

o A 7 year old playing “doctor” with a peer, or a 12 year old sneaking a look at internet porn is  probably not indicative of mania ; but a 7 year old rubbing their crotch during school despite  correction might be

EPIDEMIOLOGY

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• The epidemiological statistics are often contradictory and controversial  

• Well-executed, large, community-based epidemiological studies using standardized diagnostic tools  continue to identify low and stable rates of bipolar disorder (bellow 1.5%) among children between 9  to 24

• Several studies, however, show an increase in prevalence of inpatient mental health treatment of  youth diagnosed with bipolar disorder  

o One study (Moreno et al. Arch Gen Psych 2007) found a 40-fold increase in national trends  in visits with a diagnosis of BPD from 1994/1995 – 2002/2003

▪ The increase in adults, however, was only 1.8-fold

▪ The results from other Western cultures (such as England and Ireland) which use the  same tools of measurement, reported a much lower prevalence  

o One study found a 500% increase in diagnoses among children and adolescent inpatients  between 1990 and 2000, and another study found a 300% increase in diagnoses among  children inpatients and 250% increase in diagnoses among adolescent inpatients

▪ However, psychiatrically hospitalized children are more likely to receive a diagnosis  of BPD than children in the community  

▪ But still….  

DISRUPTIVE MOOD DYSREGULATION DISORDER (DMDD) 

• New in the DSM-5  

• Represents the DSM’s effort to more accurately classify children and adolescents who have been  mistakenly diagnosed with BPD  

o Children who present with the primary symptoms of chronic and severe irritability and  frequent temper-outbursts, but also demonstrate symptoms of ADHD, LD, ODD/CD, mood  instability, anxiety and PTSD

o These children are often difficult to treat and have been, in the recent years, given a  presumptive diagnosis of BPD, even though they do not meet all the criteria for the disorder  

SUBSTANCE ABUSE DISORDERS

DEFINITIONS  

ADDICTION – A cluster of cognitive, behavioural, and physiological signs that indicate compulsive use of  a substance and inability to control intake despite negative consequences  

DEPENDENCE – Upon cessation of the drug an individual experiences pathological signs and symptoms (tolerance and withdrawal)  

TOLERANCE – Requiring a markedly increased dose of the substance to achieve the desired effect ; feeling  a markedly reduced effect when the regular does is consumed  

WITHDRAWAL - A drug specific syndrome that occurs when blood or tissue concentrations of a substance  decline in someone who had maintained a prolonged use

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EPIDEMIOLOGY 

• Approximately 9% adolescents ages 12 to 17 are considered in need of treatment for alcohol or  substance abuse  

• About 10% to 12% individuals will, at some point in their lifetime, be addicted to a drug or alcohol  • Nearly 9% of the total population age 12 and older meet criteria for substance dependence abuse  • Nearly 2,8 million abuse or are dependent on both alcohol and illicit drugs

• Nearly 4.5 million are dependent on or abuse illicit drugs but not alcohol

• Nearly 14.9 million are dependent on or abuse alcohol but not ilicit drugs  

• Illicit drug use peaks at adolescence and early adulthood (22% of 18-20 year olds report use in the  past month and so does 19% 21-25 year old and 16% of 16-17 year olds)  

o Greater use in adolescence translates to greater use in adulthood (the earlier you start, the  more likely it is that it will persist in later life)  

MOST ABUSED SUBSTANCES  

• The substances most abused by teens are painkillers, stimulants, sedatives and tranquilizers  • Marijuana is the most widely used illicit drug but rarely the first used  

o Over 90% new marijuana users have first tried cigarettes or alcohol, making alcohol and  cigarettes the true gateway drugs (a-HA!)  

• 1.5 million people used cocaine (2013),

o Decrease from around 2.4 million in 2007

• Hallucinogens were used by 1.3 million people (2013) – mostly ecstasy and LSD  • 6.5 million people or 2.5% of the population aged 12 or older abused prescription drugs (pain  relievers, tranquilizers, stimulants, sedatives etc)  

EFFECTS OF EARLY DRUG USE  

• Studies have shown a dramatic relationship between age of first drug use and subsequent drug  abuse/dependence

o Early first use (13 and younger) triples odds of drug dependence compared to the odds of drug  dependence after first use in 21 and older  

• Strongest predictor of drug dependence is prior drug use  

• Each year delayed, the risk of alcohol dependence is reduced by 14%

• If risk factors are discovered and treated early enough then adolescent SUDS can be prevented  

DOPAMINE AND SUBSTANCE ABUSE 

• Dopamine is a neurotransmitter that helps regulate motivations of behaviours necessary for survival  o Food intake increases dopamine

o Sexual activity increases dopamine

o Social interaction increases dopamine  

o Drugs of abuse increase dopamine (which is essential to their reinforcing effects)  

D1 receptors turn our attention to what matters

• What we think of as a “pleasure molecule”

• Suggest that pleasure might be on its way

o Which to our brain is more pleasurable than pleasure

D2 receptors turn our attention to what isn’t good for us

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• Lower numbers of D2 receptors in drug users

o They will experience less of a negative “signal” from exposure to the drug

Dopamine is more about drug “wanting” than drug “liking”

People who have more D2 receptors would find MP (methylphenidate) unpleasant  

- The more a drug is available the less people are excited about it  

- Know to list risk factors for drug addictions

- Parental monitoring one of the best protective factors  

CRAFT SCREENING TOOL 

• One of the most clinically relevant screening tools of substance abuse

• Six-item verbally administered screening tool  

• If a child or adolescent answers a YES to two or more questions, then further investigation into  substance use patterns is necessary

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