Child and Adolescent Psychopathology 3.pdf
Child and Adolescent Psychopathology 3.pdf Psyc 5020
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This 17 page Class Notes was uploaded by aiy0001 on Sunday August 21, 2016. The Class Notes belongs to Psyc 5020 at Auburn University taught by Dr. Brestan-Knight in Spring 2016. Since its upload, it has received 4 views. For similar materials see Child and Adolescent Psychopathology in Psychology (PSYC) at Auburn University.
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Date Created: 08/21/16
Child & Adolescent Psychopathology Chapter 9: Conduct Problems Description Age inappropriate behaviors that violate family expectations Extreme: Violating societal norms and personal and property rights of others Can range from being annoying (such as temper tantrums) to serious antisocial behaviors (such as vandalism, fights with weapons, and even being cruel to animals) Types, Pathways, Causes, and Outcomes of Conduct Problems-All different because it’s so complex o Often associated with unfortunate family circumstances Very hardening because if the parent is in trouble with the law, they probably won’t bring them in and instead it’ll be the grandparents o Environmental factors Hanging out with the wrong group of kids o These circumstance don’t excuse these kinds of behaviors but it does tell us what the root of the problem is Context Antisocial behavioral appear and decline during normal development o Behaviors vary in severity from minor disobedience to fighting Typical for children to refuse what a parent tells them to do o These kinds of behaviors may range More common in boys Children who are very physically aggressive in early childhood maintain those behaviors over time o Depending on how people respond to their behavior, it can make the behavior more reinforcing Social and Economic Costs Conduct problems are the most expensive mental health problem in the US These children account for 50% of all crime and 30-50% of referrals Annual public costs-healthcare, education, juvenile justice-is about $10,000 per child Washington State Institute for Public Policy Save $4724 based on PCIT $1362 to treat one family Legal Perspectives-Juvenile Delinquency Legal definitions exclude antisocial behaviors of very young children occurring in home or school Have to actually break the law to be a juvenile delinquent Minimum age of responsibility is 12 in most states Only a subgroup of children who meet the legal definition of delinquency also meet a definition for a mental disorder Psychological Perspectives These problems fall on a continuous dimension o Externalizing dimension Rule breaking behavior Aggressive behavior o Overt-covert dimension o Destructive-nondestructive dimension 4 Categories of Conduct Problems Covert + Nondestructive (Status Violations) o Runaway, swearing, rule breaking, substance use Covert + Destructive (Property Violation) o Cruel to animals, vandalism, steals, fire setting, lying Overt + Destructive (Aggression) o Assault, blames others, fights, bullies, cruel Overt + Nondestructive (Oppositional Behavior) o Annoys, stubborn, touchy, argues, temper tantrums, angry Psychiatric Perspectives Viewed as a distinct mental disorder based on DSM symptoms o Disruptive behaviors are described as persistent patterns of antisocial behavior Diagnosis of antisocial personality disorder is relevant to understanding conduct problems and their adult outcomes Public Health Perspectives Legal + Psychological + Psychiatric perspectives with public health concepts of prevention and intervention Goal: To reduce injuries, deaths, personal suffering, and economic costs associated with youth violence Cuts across disciplines to understand conduct problems in youth and to determine how these problems can be treated and prevented DSM-5 Defining Features (Both of these have been found to predict future psychopathology and enduring impairment in life functioning) Oppositional Defiant Disorder o Age inappropriate recurrent patterns of stubborn, hostile, disobedient, and defiant behaviors o Usually appears by age 8 (not so much with older kids) o Negative effects on parent-child interactions o Diagnostic criteria Angry/Irritable Mood Often loses temper Touchy or easily annoyed Often angry or resentful Argumentative/Defiant Behavior Argues with authority figures or parents Actively defies or refuses to comply with requests from authority figures Often deliberately annoys others Often blames others for their mistakes Vindictiveness Has been spiteful or vindictive at least twice within the past 6 months o 25% if children show symptoms of ODD before developing COD Conduct Disorder o Repetitive, persistent pattern of more severe aggressive and antisocial acts o May have co-occurring problems of ADHD, academic deficiencies, and poor peer relations o Parents can acquire learned helplessness-why bother? Children’s problems spiral out even more-most of the time just testing the parent Teaching the parents how to be consistent o Diagnostic criteria Aggression to people and animals Destruction of property Deceitfulness or theft Serious violations of rules (before the age of 13) o Lots of research on callous lack of empathy-common across all conduct disorders in kids o MildModerateSevere o Commonly a precursor to antisocial personality disorder Age of Onset of COD Childhood onset-Before the age of 10 and mostly in boys o More aggressive symptoms o Account for most illegal activity long term o Persists in antisocial behavior over time Adolescent onset-As likely to be in girls as in boys o Over time behavior becomes in the normal range (fade out after the teenage years) o Less likely to commit violent offenses or persist in their antisocial behavior over time Nearly half of all children with CD have no prior ODD diagnosis Most children who display ODD do not progress to more severe CD Charles Manson burglarized a string of liquor stores and escaped from juvie at age 13 Chapter 10: Depressive Disorders + Bipolar Spectrum of Mood Disorders DepressionExtreme mania 2 General Categories o Depressive disorders of excessive unhappiness and loss of interest in activities o Bipolar disorder-mood swings from deep sadness to high elation Depression A pervasive unhappy mood More severe than the occasional blues or mood swings everyone experiences Children o Cannot shake their sadness: Interferes with daily routines, social relationships, school performance, and overall functioning o Often accompanied with anxiety or conduct disorders o Often goes unrecognized or untreated Chance to go on to depression later in life and affects big events Devalue self + Devalue world + Devalue future History Psychology used to have the view than children could not be depressed We now know that depression in children is not masked but it may be overlooked Psychodynamic Theory: Depression is viewed as the conversion of aggressive instinct into depressive affect o Results from the actual or symbolic loss of a love object o Children and adolescents were believed to have inadequate development of the superego Depression in Young People We actually expect children to experience depression during the teenage years Suicide is a serious concern in teens 90% of children with depression show significant impairments in daily functions-jumping to negative conclusions about themselves Physical being could be at risk as well as sleep (could be sleeping too much or not at all) Depression and Development Experience and expression of depression change with age o Children under 7 is not as easily identified but are still pretty sensitive Preschoolers o Somber, tearful, lacking exuberance (not the norm usually for children), anxious, clingy and whiny behaviors School aged children o All of the above, but also quite irritable and experiences tantrums Preteens o All of the above, but could also blame themselves, lack social connectedness, low self-esteem Anatomy of Depression A continuum in adults (mild, moderate, severe depression) Symptom: Feeling sad or miserable o Common with all ages, occurs without existence of a serious problem Syndrome: Group of symptoms that occur together more often than by chance o Mixed symptoms of depression and anxiety Disorder o Major Depressive Disorder (MDD) Minimum duration: 2 weeks Depressed mood, loss of interest Children Easily overlooked because other behaviors attract more attention Irritableness is more common in children than adults Significant weight loss (when there’s no effort) Insomnia or hypersomnia Restless or slowed down (loss of energy) Inability to concentrate Feelings of worthlessness or guilt Suicidal ideations Protective factors: Children, religion o Dysthymic Disorder (Eyeore) Also known as Persistent Depressive Disorder (PDD), which is chronic depression Less severe but longer lasting symptoms (of a year or more) Poor emotion regulation-constant feelings of sadness, low self esteem Lower prevalence rates than MDD o MDD + Dysthymic is known as Double Depression Prevalence 2-8% of children ages 4-18 experience MDD Depression is rare among preschool and school aged children (1- 2%) The sharp increase in adolescence may result form biological maturation at puberty interacting with developmental changes Comorbidity 90% of people with depression have one or more other disorders and 50% have 2 or more Anxiety (GAD), specific phobias, and separation anxiety disorders (more common in younger children), dysthymia (double depression with MDD), conduct problems, ADHD, substance use disorders Depression and anxiety are more visible as separate, co- occurring disorders 60% of adolescents with MDD have comorbidity with personality disorders (especially borderline) o Pathways to comorbid conditions may differ by disorder and sex Onset May be gradual or sudden o Will usually have a history of milder episodes that do not meet diagnostic criteria Usually between 13-15 years Average episode lasts eight months o Longer duration if a parent has a history of depression Outcome Chance of reoccurrence for a child is 25% in one year, 40% in 2 years, and 70% in 5 years Many recover from an initial episode, but the disorder does not go away About 1/3 develop bipolar within 5 years after onset of depression Gender Differences None until puberty and after, females are 2-3 times more likely to suffer from depression Symptom presentation is similar Physical, psychological, and social changes are related to the emergences of sex differences in adolescence Theories of Depression Psychodynamic o The development of an internal working model that is disrupted somehow o Conversion of a aggressive instinct into a depressive affect Results in the symbolic loss of a “love” object Attachment o Insecure attachment to caregiver early in life and distorts view of relationships in future Behavioral o Lacks activities in life that are reinforcing o Learning and environmental consequences and how you respond to them Shaping process o Explains the onset and how the behavior is maintained Cognitive o Relationship between negative thinking and mood o Hopelessness Theory People who have this depressive way of thinking blame themselves for negative events in their life Has to do with their attribution of the situation o Beck’s Cognitive Model Depressed individuals make negative interpretations of life events 3 areas of cognitive problems Information processing biases Negative outlook regarding themselves, the world, and the future (the negative cognitive triad) Negative cognitive schemata (the person has a negative set on their view of life) o Flat affect-can carry over to you! Causes of Depression Due to many interacting influences, multiple pathways to depression are likely Genetic risk o Influences neurobiological processes and is reflected in early temperament that is characterized by: Being overly sensitive to negative stimuli High negative emotionality Disposition to feeling negative affect o Early dispositions are shaped by negative experiences in the family Developmental Framework for Depression Core: Emotional regulation/dysregulation o Genetics + family experiences + Life stress + depression Treatment of Depression Fewer than half of children with depression receive help for their problem o Rates vary with racial and ethnic backgrounds Cognitive Behavioral Therapy (CBT) o Most successful in treating children & adolescents o Usually have homework assignments o Self-monitoring o More effective with older children-have to have some level of cognitive sophistication Interpersonal Psychotherapy for Adolescent Depression (new wave of therapy) o Focusing on interpersonal communication o Has also been effective o Family sessions included Medications o With the exception of SSRI’s (which have problematic side effects) medications have had side effects and have been less effective than the previous treatments o Have been known to increase suicide rates just from taking anti-depressants Chapter 10: Bipolar Disorder BD Class of different diagnoses from depression Period of elevated, irritable moods (mania) accompanied by times of depression o Elation and euphoria can quickly change to anger & hostility if behavior is impeded May all be experienced simultaneously o Mania episodes are not always times of productivity BD in young people o Controversial-originally didn’t recognize that BD happened in children o Hard to pick out because the beginning features look a lot like other problems o History of psychotic symptoms and suicidal ideation/attempts are common o Significant impairment in functioning including previous medications, treatments, and even hospitalization o Mania Volatile, erratic changes in mood Cycles are much shorter when going from depressive to mania (adults are more in phases) Pressured speech, racing thoughts, flights of ideas Symptoms o Restlessness, agitation, sleeplessness, pressured speech (conversation items don’t match up), flight of ideas, racing thoughts, sexual disinhibition, surges of energy, expansive grandiose beliefs Types o Bipolar I Pure mania Gambling, spending everything Most severe form o Bipolar II (Hypomania) Still have manic episodes but not as intense o Cyclothymic Cycles through manic and depressive episodes Prevalence o 0.5-2.5% of 7-21 year olds Difficult to make an accurate diagnosis o Bipolar II and cyclothymic disorders are more likely in young people Rapid cycling through episodes are more common o Environment is an important factor o Extremely rare in young children; rate increases after puberty Comorbidity o High rates of co-occuring disorders (most typical are anxiety disorders and conduct disorders) Chapter 11: Anxiety PCIT is used to treat anxiety problems Anxiety: A mood state that is characterized by negative emotions and bodily symptoms of tension in anticipation of future danger or misfortune Worried about things that are going to happen in the future Running commentary in their mind Symptoms of tension respond well to relaxation techniques More than one type of anxiety disorder can occur at once All of us have anxiety! Moderate anxiety helps us to think and act more efficiently; works as a good motivator; more control in a situation o Innate in us is a fight//flight response-having an actual physical response that is aimed at escaping potential harm Often have these responses to events that are no way going to harm us Can occur in the absence of real danger Elementary school years comes a level of sophistication in anxiety: Thinking outside of themselves of what could be possible threats to them Fears that are normal at one age can be debilitating a few years later A fear defined as normal depends on its effects on the child and how long it lasts Number and types of fears change over time Fear: Present oriented, occurs in the face of real danger marked by a strong desire to escape Panic: Physical symptoms of a fight//flight response that occur in the absence of a real danger or threat Anxiety Response Systems (all interrelated) 1. Physical System a. Brain sends messages to the sympathetic nervous systemfight//flight response 2. Cognitive System a. Activation leads to feelings of apprehension, nervousness, difficulty concentrating, and panic 3. Behavioral System a. Aggression is coupled with a desire to escape the threatening situation Normal Anxieties Separation, test taking, excessive concern about competence, excessive need for reassurance, anxiety about harm to a parent Girls display anxiety more than boys but symptoms tend to be similar o Suggests genetic influences in girls and related neurobiological differences o Differences start around age 10 Some specific anxieties decrease with age Nervous and anxious symptoms may remain stable over time Normal Worries Worry serves a function in normal development Children with anxiety don’t necessarily worry more but they worry more intensely Categories of Anxiety Disorders 1. Separation Anxiety Disorder (SAD) 2. GAD 3. Specific Phobia 4. Social Anxiety Disorder 5. Panic Disorder 6. Agoraphobia 7. Selective Mutism Developmental Pathways for Anxiety Disorders Genetic influences Insecure attachment-Parenting style Inborn temperament-Early child rearing environment Psychological vulnerabilityStressors + Parenting style o Not feeling like they have control Arousal and avoidance Experience of anxiety is pervasive across cultures S.A.D Suggests insecure attachment Distinguished by age inappropriate excessive and disabling anxiety about being a part from parents or being away from home G.A.D Worrying excessively about everyday minor occurrences Accompanied by at least one somatic symptom (headache, stomach ache, muscle tension) Worrying can be episodic or continuous Women are more likely to be diagnosed Treatment: CBT + Behavior Therapy + Medication Selective Mutism Consistent failure to talk in specific school situations (where there is expectation for speaking) Disturbance duration is at least 1 month Failure to speak is not attributable to a lack of knowledge, comfort with, or inability to speak the language Diagnostic Features Child doesn’t initiate speech or reciprocally respond when spoke to by others Will speak at home with immediate family members but as soon as there is a situation where they are uncomfortable, they shut down and is noticeably different-High social anxiety o Avoid eye contact, hide behind parents Excessively shy, fear of social embarrassment (I don’t want people to hear me talk), negative temperament (moody), temper tantrums, mild oppositional behavior Can co-occur with a communication disorder (if anxiety impairs them from being able to speak) Very co-morbid with social anxiety disorder Prevalence Very rare! 7% No differences in sex or race Average age of onset: 3-4 o More likely to occur in young children than any other age Disturbance may not come to attention until entry into school (increased social interactions and performance tasks) Some kids may outgrow their selective mutism o But if they have social anxiety disorder, their symptoms may remain Risk Factors (all interrelated) Temperamental o Negative affect-more difficult to manage o Tend to have a lot of behavioral inhibition-not the ones who try out the new things first, more cautious and seek out reassurance o Parental history of shyness, social isolation, social anxiety Environmental o Parental social inhibition o Overprotective or more controlling parents Genetic o Gene-environment interaction More susceptible to environmental influences May have undetected problems that cause anxiety-learning disorders, language delays, non-native language speakers Culture Related Issues Definitely take into account the child’s native language o If comprehension is adequate but communication still lacks, SM is a possible diagnosis Differential Diagnoses Communication Disorders Neurodevelopmental Disorders-ASD, Schizophrenia o Established capacity to speak in some situations Social anxiety disorder o Both diagnoses may be present, but need to know if it’s more broad or not Maintaining Factors Child gets question asked-child gets anxious-parent comes to the rescue-negative reinforcement Treatment Options CBT o Contingency management-breaking that cycle o Shaping GesturingwhisperingFull voice Yes no questionsclose ended questions (removes the anxiety component of being wrong)open ended questions o Stimulus Fading Gradually increasing the number of people in the room o Systematic desensitization Bravery ladder Easiest thing at the bottom and go up the ladder as things get harder Last one: talking in front of your classmates o Social skills training o Self modeling Go to the school and have the kid walk around with the parent Play the video for them over and over o Cognitive Better for children 7+ Identifying anxiety symptoms Challenging anxiety thoughts Developing coping skills o Parent child and family interventions (training the parent) VDI: verbal directed interaction Labeled praise for brave talking, describe, direct prompts to talk, wait 5 s for response Avoid: yes no questions, indirect commands to talk, negative talk, enabling Medications o SSRI’s+ treatment Speech language therapy Sequence of PCIT CDI-Parents follow the child o Play therapy skills o Warm and accepting parent-child interaction Not an overnight process o Differential attention PDI-Parents lead o Continue showing warmth A lot of times they pay attention to the negatives o Contingency management “If you want this thing to happen this other thing has to happen first” o Limit-setting Telling their kid that their behavior is not okay o Consistency o Effective commands Something that a lot of parents don’t know how to do CDI Relationship enhancement phase Following the child lets the parent view the child in new ways Children begin to enjoy parent-child interaction Parents learn to shape new child behavior Child’s new behavior reinforces the parents’ positive behaviors What NOT to do o No commands Commands attempt to lead o No questions Often hidden commands and take away from the lead of the child Can suggest disapproval o No criticisms “You’re a bad girl” “That doesn’t go that way” Pointing out mistakes instead of correcting them Lowers self-esteem and makes interaction unpleasant What TO do o Praise Unlabeled v. labeled (helpful for children with behavior problems because it tells them what to do) o Reflect Repeating or paraphrasing (with the emotion) Allows the child to lead the conversation and shows that the parent is listening and understands o Imitation Doing the same thing the child is doing Teaches the parent how to play Good to be at the same level as the child Teaches the child how to play by taking turns and such o Description Describing exactly what the child is doing o Enjoyment Express enjoyment when playing with the child- smiling, positive touch, tone of voice Ignore inappropriate attention seeking behaviors Stop play for aggressive or destructive behavior-always want to make sure the parent feels safe Homework o Practice + Play + Therapy o Special time for 5 min. a day Some take 2 session, others more PDI Effective discipline strategies-how to give effective commands and use time out Homework o Starts as part of special time o Slowly generalize these skills General generalization from clinic minding exercises to real life discipline 3 major components of effective discipline o Begins with effective command Giving effective commands Being direct-giving the child no illusion of choice “Please take your hand out of the cookie jar” Making it easier for the child to follow Makes it clear that the child needs to do something Positively stated Tells the child what to do rather than not to do Avoids criticisms-no, don’t stop, quit Given one at a time Helps parent to know when the child is complying Helps the child to remember-often don’t have the attention span for multiple things (and giving praise right away-more opportunities) Specific Tells the child exactly what to do Avoids vague commands (behave, be careful) Should be developmentally appropriate Simple and understandable for their age Matches language and ability (Please put the cars away) Should be polite and respectful Neutral tone of voice preceding with “Please” Generalizes because teachers talk this way too Use only when necessary Too many could frustrate the child We can sometimes give choices instead of commands o Involves effective follow through after every command Key features of discipline phase o Consistency o Predictability o Following through Explanations should be used before a command or after the child has complied Gives child attention for compliance Increases listening Decreases dawdling and distraction Parent Follow Through 5 seconds for dawdling Explain the warning Did they comply or not? Do not repeat commands If child complies o Labeled praise o Thank you for… Time out warning is given Chair: 3 min. + 5 sec. of silence at end o If earlier, could lead to superstitious behaviors o Must have 50% of body weight on chair Time out room o More aversive than the chair o 1 min. + 5 sec. of quiet at end
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