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Psychology
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PSYCH 317
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Elizabeth Nilsen

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CHAPTER 1: INTRODUCTION TO NORMAL AND ABNORMAL BEHAVIOUR IN CHILDREN AND ADOLESCENTS IssuesthatresearchstudiesinACPseektoaddress:  DefiningwhatconstitutesN&ABbeh’forCdofdiffages,sexes,andethnic&cultural bg’s  Identifyingthecauses andcorrelatesofABCdbeh’  MakingpredictionsabtLToutcomes  Dvlp’gandeval’methodsforTxand/orPv Importantf/sthtdistinguishmostCdandAdl Ds:  WhenAd’sseekservicesforCd,oftennotclearwhose“problem”itis  ManyCdandAdlprob’sinvolvefailuretoshowexpecteddvlpmtal progress  Manyprobbeh’sshownbyCdandythsnotentirelyAB  Interventionsfor CdandAdl oftenintendedtopromotefurtherdvlpmt,ratherthanmerelytorestoreapreviouslvl off’n’g HistoricalViewsandBreakthroughs th Endof18 c.:  Churchattributedbeh’toCd’sinherentlyuncivilizedandprovocativenature  Onlyexplanation:possessionbythedevil and~forcesofevil  Formanygen’s,impliedviewofsocietythtCdare exclusiveproperty&responsibilityofparentsunchallengedbyanycountermvmt toseekmorehumaneTxforCd TheEmergenceofSocial Conscience  Until veryrecent changesinlaws&attitudes,Cd(+F,minoritygroupmembers,andpersonsw/sp’needs)wereoftenlastto benefit from society’sprosperityandwere1’ victimsofitsshortcomings  17 c.:JohnLockeatforefrontofEofSC - believedinindvdl rightsandexpressednovel opinionthtCdshouldberaisedw/thoughtandcare insteadofindifferenceandharshTx  19 c.:JeanMarcItard(andVictor—wildboyofAveyron) - 1 documentedefforttotreatseveredvlpmtal delay(“mental defectives”)ratherthansend toasylum th  19 c.:LetaHollingworth - arguedCdsufferingfrom emo’al andbeh’al prob’s1’lyduetoineptTxbyAd’sandlackofappropriate intellectual challenge - ledtodistinction:mental retardation(“imbeciles”)andpsychiatric/mental Ds(“lunatics”)  1745-1813:BenjaminRush - arguedCdincapableoftrueAd-likeinsanityb/cimmaturityofdvlp’g brainspreventedthem from retainingmental eventsthtcausedinsanity  moral insanity:non-intellectual formsofABCdbeh’  Distinction i↑ concern,w/2importantinfluences: - advancesingeneral med,physio,andneuro  moral insanityviewreplacedbyorganicdiseasemodel (morehumaneformsofTx) - growinginfluencesofphilosophiesofLockeetal.  childrenneedmoral guidance&support  i↑’d concernformoral edu,compulsoryedu,andimprovedhlthpractices  EarlyeffortstoassistCdprovidedfoundationforevolvingviewsofABCh’beh’aarofbio,env,psych,andcultural influences EarlyBiological Attributions  Publicgenerallydistrustedandscorned“mad”or“possessedbythedevil”  Prevailingpol’andsoc’climatesinfluencedef’sofACP  CliffordBeers(1909):soughttopreventmental diseasebyraisingstandardsofcareanddisseminatingreliableinfo  aar,detection&interventionmethodsbegantoflourish,basedonamoretempered,yetstill frightenedandill-informed),viewofafflictedindvdls  unfortunately,basedonbio’diseasemodel TFlimitedtopersonsw/mostvisibleandprominentDs  Earlyviewofpsychopathology:dvlpmtconsideredprogressiveandirreversible th  20 c.:revertedback tocustodial model andviewthtmental illnessandMRcouldbespread  preventativemeasures:eugenics(sterilization)andsegregation(institutionalization) EarlyPsychological Attributions  Psychshiftprompteddvlpmtofdiagnosticcategoriesandnew criminal offenses,expansionofdescriptionsofdeviantbeh’,and additionofmorecomprehensivemonitoringproceduresforidentifiedindvdls  2mjtheoretical paradigms: 1.) psychoanalytictheory 2.) behaviourism 1.)PsychoanalyticTheory  Freudwas1 togivemeaningtoconceptofmental Dbylinkingtochildhoodexp’s  Ratherthanfocusonsingularcases,emphasizedpersonalityandmentalhlthoutcomeshadmultipleroots  Freudshiftedviewfrom oneofCdasinnocent/insignificanttooneofhuman beingsinturmoil,strugglingtoachievectrl overbio’needsandtomakethemselvesacceptabletosocietyt/microcosm offamily  Daughter,AnnaFreud:notedhowCd’ssymptomsrelatedmoretodvlpmtal stagesthanAd’s  MelanieKlein:all actionscouldbe interpretedintermsofunconsciousfantasy  Bothwomen:madepossibleanalysisofyoungerCdandrecognitionofnonverbal comm’nforPt’sofall ages *note:currentnosologies—effortstoclassifypsychiatricDsintodescriptive categories—are essentiallynondvlpmtalintheirapproaches. Ratherthanattempting,asFreudianapproachdoes,todescribe dvlpmtofdisease incontextofdvlpmtofindvdl,nosologiesofDSM attempttofindcommondenominatorsthtdescribe manifestationsofD ateveryage 2.)Behaviourism  1900s:dvlpmtofevidence-basedTxforCd,yths,andfamilies –tracedt/ Pavlov’sexpmtal researchthtestbl’d foundationsforclassical conditioning  JohnWatson:fatherofbehaviourism(emphasisonpredictionandctrl ofhumanbeh’) - intent: explainFredu’sconceptsinscientificterms,basedonCC - e.g.LittleAlbert - knownfortheoryofemotions,whichheextrapolatedfrom NtoABbeh’ EvolvingFormsofTreatment  Psychodynamicapproaches(V)form ofTx  1945-1965:rapiddeclineofinstitutionalization - b/cRenéSpitzdiscoveredinfantsraisedininstitutionsw/oadultphyscontactandstimulationdev’d sever physandemo’problems  1950sand60s:beh’therapyemergedassystematicapproachtoTx(conditioningprinciples) ProgressiveLegislation  US:IndvdlswithDisabilitiesEducationAct(IDEA) - mandatesfreeandappropriatepubliceduforanychildw/sp’needinleastrestrictiveenv’fortht child  UNConventionontheRightsofPersonsw/Disabilities(2007) What is Abnormal Behaviourin Children andAdolescents?  TojudgewhatisAB,needtobesensitivetoeachchild’sstageofdevandconsidereachchild’suniquemethodsofcopingand ways ofcompensatingfordifficulties DefiningPsychological Disorders  Patternofbeh’,cog’,emo’,orphys’symptomsshownbyindvdl,associatedw/1/more: - showsomedegreeofdistress(e.g.fear/sadness) - beh’indicatessomedegreeofdisability(e.g.impairmentthtsubstantiallyinterferesw/or limits activityin1/moreimportantareasoff’n’g—phys,emo,cog,beh’) - suchdistressanddisabilityi↑ riskoffurthersuffering/harm (e.g.death,pain,disability,important lossoffreedom) LabelsDescribe Behaviour,NotPeople  Stigma=clusterof–veattitudesandbeliefsthtmotivatefear,rejection,avoidance,and discriminationwrtppl w/mental illnesses  ProbsshownbysomeCdmayberesultoftheirattemptstoadapttoAB/unusual circumstances Competence  Abilitytosuccessfullyadaptin env’ - variesacrosscultureandethnicity  Developmenttasks=includebroaddomainsofcompetencesuchasconductandacademicach’,tell how Cd typicallyprogressw/ineachdomainastheygrow Developmental Pathways  Sequenceandtimingofparticularbeh’sandpossiblerlnshpsbtwnbeh’sovertime - allowsvisualizationofdevasactive,dynamicprocessthtcanacc’forverydiffbeginnings&outcomes  Multifinality=variousoutcomesmaystem from ~beginnings  Equifinality=~outcomesstem from diffearlyexp’sanddev’al pathways  Assumptionstokeepinmind: - manycontributorstodisorderedoutcomesineachindvdl - contributorsvaryamongindvdlswhohaveD - indvdlsw/samespecificDexpressf/softheirdisturbanceindiff ways - pathwaysleadingtoanyparticularDarenumerousandinteractive,asopposedto1Dandstatic Risk andResilience Riskfactor=variablethtprecedes –veoutcomeofinterestandi↑’schancesoutcomewill occur Protectivefactor=personal/situational variablethtreduceschancesforchildtodevD  Resiliency:relatedtostrongself-confidence,copingskills,abilitytoavoidrisksituations,andabilitytofightofforrecoverfrom misfortune The Significance ofMental HealthProblemsAmong Children andYouths  Mountingevidence:“many,ifnotmost,lifetimepsychiatricDswill firstappearinchildhood/adolescence”  ProcessofdecidingwhichprobsmeritprofattentionandwhichonesmightbeoutgrowninvolvesgoodunderstandingofbothN andABCd’dev’andbeh’ TheChangingPictureofChildren’sMental Health  Past:describedinglobal termssuchasmaladjusted  LtdandfragmentedresourcesmeanCddN receiveappropriatemental hlthservicesatappropriatetime - sit’beginningtochangeb/cgreaterattentionpaidtoevidence-basedPvandTx  Disproportionatelyafflictedw/mental hlthprobs: - Cdfrom disadv↓ familiesandneighbourhoods  Cdfrom abusive/neglectful families  Cdreceivinginadequatechildcare  Cdbornw/verylowbirthweightduetomaternal smoking,diet,orabuseofalcohol &drugs  Cdborntoparentsw/mental illnessorsubstanceabuseprobs What Affects Rates andExpression of Mental Disorders? A Look at SomeKeyFactors  Newstressors(e.g.parental HIV,prematurity),social changes,medical advances(e.g.higherratesoffetal survival i↑ Cdw/ beh’/LD) PovertyandSocioeconomicDisadvantage Lowincometiedto:  lessedu  ltdresources  lowpayingjob  poornutrition  inadequatehlthcare  greaterexposuretovio’  sgl-parentstatus SexDifferences  KnownM&Fexpressprobsindiffways - dNkwhetherdiffscausedbydefinitions,reportingbiases,diffsinexpressionofD  SexdiffsnegligibleforCd<3 yrs(but i↑ w/age)  Boysshowh↑ ratesofearlyonsetDsthtinvolveneurodev’impairment  Girlsshowh↑ ratesofearlyonsetDsthtinvolveemo’Ds  Internalizingproblems=includeanxiety,dep,somaticcomplaints,andw/drawnbeh’s - starth↑ forgirlsthanforboys,butd↓ gradually&convergebyage18  Externalizingproblems=encompassmoreacting-outbeh’(agg’anddelinquentbeh’) - starth↑ forboysthanforgirls,butd↓ gradually&convergebyage18  Resilienceinboys=householdsw/Mrolemodel,structure,rules,andsomeencouragemtofemo’ expressiveness  Resilienceingirls=householdsthtcombinerisktakingand(i)w/supportfrom Fcaregiver RaceandEthnicity  OnceeffectsofSES,sex,age,andreferral status arectrl’dfor,fewdiffsinrateofACPsemergeinrelationtorace/ethnicity  Neglectofmajorityculturetoinclude/understandthoseofminorities  inappropriatelymisplacedminoritiesincriminal andjuvenilejusticesys’s Culture  Influencesmeaning giventobeh’s,waystheyarerespondedto,formsofexpression,andtheiroutcomes ChildMaltreatmentandNon-Accidental Trauma  Non-accidental trauma=victim ofvio’atschool orbeingexposedtovio’actsinhomes/neighbourhoods Special IssueConcerningAdolescentsandSexual MinorityYouths  Substanceabuse,riskysexual beh’,vio’,accidental injuries,mental hlthprobs  I↑drisk-takingbeh’s  H↑mental hlthratesforLGByths,givenstigmaandprejudicethtexistinmanypartsofsociety LifespanImplications  Costlyintermsofeco’impact(communityresourcesandlossofproductivity)andhumansuffering(Cdandfamily/friends) CHAPTER 2: THEORIES AND CAUSES Theoretical Foundations  Etiology=studyofcausesofchildhoodDs;considershowbio, psych,andenvprocessesinteractto produceoutcomesobsv’dOT UnderlyingAssumptions 1. ABdevismultiplydtrmnd 2. Childandenvareinter(d) 3. ABdevinvolvescontinuitiesanddiscontinuities *note:keepinmind,age isarbitrarywaytosegment continuoussequencesofdev 1.)AbnormalDevelopmentisMultiplyDetermined  Havetolookbeyondcurrentsymptomsandconsiderdevpathwaysandinteractingeventstht,OT,contributetoexpression ofparticularD 2.)ChildandEnvironmentAre Interdependent  Inter(d)= howthey(child&env)influenceeachother  NatureANDnurture  Transaction=dynamicinteractionofchild&env(bothactivecontributorsto(mal)adaptivebeh’) 3.)AbnormalDevelopmentInvolvesContinuitiesandDiscontinuities  Continuity=devchangesgradual andquantitative,andthtfuturebeh’patternscan bepredicted from earlierpatterns  Discontinuity=devchangesareabruptandqualitative,andthtfuturebeh’poorlypredictedby earlierpatterns  +/-vefactors caninfluence(dis)continuityofdevOT AnIntegrativeApproach  Bioandpsychmodelsbothmulti-causal  OT,mjACPth’havebecomecompatiblew/oneanother Developmental Considerations  CommongroundofdiffDs:indicationofadaptational failurein1/moreareasofdev  Adaptational failure=failuretomaster/progressinaccomplishingdevmilestones  CausesandoutcomesofABCd’beh’operateindynamicandinteractivewaysOT OrganizationofDevelopment  Perspectivethtearlypatternsofadaptation(e.g.infanteyecontactandspeechsounds)evolveOTw/structureandtransform into higher-orderf’ns(e.g.speechandlang)  Impliesactive,dynamicprocessofcontinual changeandtransformation  Sensitiveperiods=windowsoftimeduringwhich envinfluencesondev(good&bad)areenhanced - notonlyopportunities;learningcantakeplaceatothertimes  Child’scurrentabilities/limitationsinfluencedbyprioraccomplishments Developmental PsychopathologyPerspective  DescribesandstudiesDsofchildhood,adolescence,andbeyondinmanneremphasizingimportanceofdevprocessesandtasks  Emphasizesroleofdevprocesses,importanceofcontext,andinfluenceofmultiple&interactingeventsinshaping(mal)adaptive dev  Frameworkincludes:psych,psychiatry,soc,neurosci Biological Perspectives Neural PlasticityandtheRoleofExperience  Neuralplasticity=malleability;brain’sanatomical differentiationisuse-(d) e.g.dev’gbrainiswork-in-progresswhileenvissupervisor  Brainmaturesinorganized,hierarchal processbuildingonearlierf’n’g: 1.)primitive:basicsensoryandmotorskills 2.)frontal cortex:planninganddecisionmaking(5-7yrs) 3.)cerebellum:motorskills(5-7yrs) 4.)pubertal dev(9-11yrs) adolescentdev GeneticContributions  Possessedtraitisaarofinteractionofenvandgeneticfactors  Expressionofgeneticinfluencesismalleableandresponsivetosocenv The Nature ofGenes  dN producebeh’/emotion/passingthought  producestendenciestorespond toenvincertainways(geneticvulnerabilities,predispositions)  rarelyareoutcomesinevitable BehaviouralGenetics  investigatespossibleconnectionsbtwngeneticpredispositionandobsv’dbeh’(takesenv&geneticinfluenceintoacc’) MolecularGenetics  Assessesassoc’nsbtwnvariationsinDNA sequencesandvariationsinparticulartrait/traits  OffersmoredirectsupportforgeneticinfluencesonACP  ~andmultipleinteractivegenes(polygenic)morelikelythecausethansinglegene  Geneticinfluences probabilisticmorethandeterministic - envandgeneticshaveequal importance Neurobiological Contributions BrainStructure andFunction  Braindividedinto:brainsteam andforebrain(telencephalon)  Brainstem:atbaseofbrain;autonomicf’ns necessarytostayalive - lowestpart=hindbrain - hindbrain: -containsmedulla,pons,andcerebellum -essential regulationofautonomicactivities(e.g.breathing,HB,digestion) - cerebellum:motorcoordination - midbrain:coordinatesmvmtw/sensoryinput;housereticularactivatingsys’(RAS)—arousal andtension - top=diencephalon(belowforebrain) - diencephalon:thalamusandhypothalamus(regulationofbeh’andemo);f’ns1’lyasrelay btwnforebrainandlowerpartsofbrainstem  Forebrain:sp’z’df’ns - base=limbic(/border)sysandbasal ganglia - limbicsys:hippocampus,cingulatedgyrus,septum,amygdale—regulateemo’al exp’sand expressions,roleinlearningandimpulsectrl,regulatesbasicdrives(sex,agg,food) - basal ganglia:caudatenucleus—regulates,organizes,andfiltersinforelatedtocog,emo, mood,andmotorf’n(implicatedinADHD,motorDs,andOCD) - cerebral cortex:largestpartofforebrain;givesusourdistinctlyhumanqualities—looktofuture andplan,toreason,tocreate;2hemispheres—leftforverbal andcog,rightfor soc’perceptionandcreativity  Lobef’ns: - frontal lobes:self-ctrl,judgment,emoregulation,restrictedinteenyrs;mostofteninDs - parietal lobes:integrateauditory,visual andtactilesignals;immatureuntil age16 - temporallobes:emomaturitystill dev’gafterage16 - corpuscallosum:intelligence,consciousness,self-awareness;reachesfull maturityin20s The Endocrine System  LinkedtoanxietyandmoodDs  Adrenal glands:produceepinephrine(akaadrenaline)inresponsetostresswhichenergizesusand preparesbodyforpossiblethreat/challenge  Thyroidgland:producesthyroxine—neededforproperenergymetabolism andgrowth(eatingDs)  Pituitarygland:regulatingvarietyofhormones,estrogenandtestosterone  Hypothalamic-pituitary-adrenal (HPA)axis:whenstimulated… 1.)secretes corticotrophin-releasinghormone(CRH) 2.)stimulatespituaryglandtosecreteandrenocorticotropichormone(ACTH)intobloodstream 3.)ACTHcausesadrenal glandstoreleasecortisol (stresshormonethtarousesbodytomeet challengingsituation) 4.)feedbackloop  cortisol modulatesstressresponsebyactingonhypothalamustoinhibit cont’dreleaseof CRH Neurotransmitters  ~biochem currentsinbrain;makemeaningful connectionsthtservelargef’ns  NeuronsmoresensitivetoonetypeofNTclustertogethertoform braincircuits—pathsfrom onepartofbraintoanother  Psychoactivedrugsworkbyi↑/dDflowofvariousNTs  MjNTsystems: 1.)benzodiazepine-GABA (anxietyD) - reducesarousal andmoderatesemoresponses - linkedto feelingsofanxietyanddiscomfort 2.)dopamine(SCZ,moodDs,ADHD) - mayactasswitchthtturnsonvariousbraincircuits,allowingNTstoinhibit/facilitate emo/beh - involvedinexploratory,extroverted,and pleasure-seekingactivity 3.)norepinephrine(regulates/modulatesbeh’tendencies) - facilitates/ctrlsemergencyreac’nsandalarm responses - playsroleinemoandbeh’regulation 4.)serotonin(regulatoryprobslikeeating/sleepDs,OCD,SCZ,moodDs) - playsroleininfoandmotorcoordination - inhibitsCd’stendencytoexploresurroundings - moderatesandregulates#ofcritbeh’s(e.g.eating,sleeping,expressinganger) PsychologicalPerspectives Emotional Influences  From birth,central f/ofinfantactivityandregulation - Cdlooktoemo’expressionandcuesofcaregiverstoprovidethem w/infoneededtoformulatebasic understandingofwhat’sgoingon  Emotionstell uswhattopayattentiontoandwhattoignore - int’monitors,guidancesys,motivationforaction EmotionReactivityandRegulation  Emotionreactivity=indvdl diffsinthresholdandintensityofemo’al exp’,whichprovidescluesto indvdl’slvl ofdistressandsensitivitytoenv’  Emotionregulation=enhancing,maintainingorinhibitingemo’al arousal;usuallyforpurpose/goal  Probsinregulation=weak/absentctrl structures(e.g.troubleconcentratinginclass)  Probsindysregulation=existingctrl structuresoperatemaladaptively(e.g.fearful ofsituation evenwhennoreasontofear) TemperamentandEarlyPersonalityStyles  Temperament=child’sorganizedstyleofbeh’thtappearsearlyindev(e.g.fussiness,fearfulness) whichshapeschild’sapproachtoenv&v.v.  Earlybuildingblockofpersonality  31’dimensionsoftemperamentrelevanttoriskofABCh’dev: 1.)positiveaffectandapproach:“easychild”whoisgenerallyapproachableandadaptabletoenv 2.)fearful/inhibited:“slow-to-warm-upchild”whoiscautious 3.)negativeaffectorirritability:“difficultchild”whoispredominantly –veandnotadaptable Behavioural andCognitiveInfluences AppliedBehaviourAnalysis(ABA)  BasedonSkinner’s classicstudies  F’nal approachtobeh;examinesrlnshpbtwnbeh’anditsantecedentsandconsequences  Basedon41’operantlearningprincipels:+/-reinforcement,extinction,punishment ClassicalConditioning  Pavlov;Watson’sLittleAlbert  Explainsacquisitionofdeviantbeh’onbasisofpairedassociationsbtwnpreviouslyNSandUCS SocialLearningandConditioning  Considerovertbeh’sandroleofpossiblecogmediators  Beh’maybelearnedbyconditioningandalsoindirectlyt/obsv’al learning  Social cognition=howCdthinkabtthemselvesetal,resultinginformationofmental rep’nsof themselves,theirrlnshps,andtheirsocial world(rep’nsnotfixed) Family, Social, andCultural Perspectives  Sharedenvironment=env’factors thtproduce~itiesindevoutcomesamongsiblingsinsamefamily  Non-sharedenvironment=env’factorsthtproducebeh’al diffsamongsiblings  Cultural ideology/identitygovernshowCdshouldbetreated(sanctioningofcorporalpunishment),whattheyshouldbe taught,andwhatgoalsareimportanttoach’ Infant-CaregiverAttachment  Attachment=processofestbl’gandmaintainingemo’al bondw/parents/othersig’indvdls; ongoingprocess(typicallystartsage6-12mths)andprovidesinfantsw/secure, consistentbasefrom whichtoexploreandlearnabttheirworld  I-crlnshphelpsinfantregulatebeh’andemo’s,especiallyunderconditionsofthreat/stress  Internal workingmodel ofrlnshps:whatchildexpectsfrom othersandhowhe/sherelatestoothers  Types: - secure - insecure(anxious,avoidant) - insecure(anxious,resistant) - disorganize,disoriented TheFamilyandPeerContext  Familysys’theoristsargueitisdifficulttounderstand/predictbeh’ofparticularfamilymember(suchasachild)inisolationfrom otherfamilymembers  Mannerinwhichfamilyasaunitdealsw/(a)typical stressesplaysinstrumental roleinCd’sadjustmentandadaptation CHAPTER 3: RESEARCH  Research=systematicwayoffindinganswersto q’ns A Scientific Approach  Parentsandpro’sworkingw/Cdtend tointerpretandrelateinfoaccordingtoownbeliefsys’sandexp - maysometimesbecomefirmlyestbl’d(i)ofwhethertheyaresupportedbyfacts  Goodreasonstobesceptical abtACPresearch: 1.)“experts”frequentlydisagree 2.)researchstudiesinmainstreammediafrequentlyoversimplifiedandpresentedpoorly 3.)findingsinconf’w/oneanother 4.)ledtodiffrecommendationsregardinghowCdw/probsshouldbehelped 5.)evenw/ consensus,manyparents/pro’sdismissaarofencounteredexceptions  Keepinmind:accumulationoffindingsadvancesthefield When Scienceis Ignored  Facilitatedcommunication=procedureforteachingCdw/autism andotherimpairmentstocomm’ e.g.providemanual assistancebylightlyholdingchild’shand/wrist/arm totype/pointtoletters  Pseudoscience=demonstrationsofbenefitbasedonanecdotes/testimonials;child’sbaselineabilitiesand possibilityofspontaneousimprovementare ignored;relatedscientificproceduresare disavowed - Fcomm’meetscriteria The ResearchProcess Theory/Previous Research Hypotheses/Predictions General Approach to Research Data Collection Identifying the Sample Data Analysis Selecting the Measures Interpretation of Findings Research Design and Procedures CommonResearchQuestionsandTopics  Basedonth’sofatypical devandbeh’  Whenlittle/noth’knowledgeavailable,maydevq’nw/oexplicitprediction e.g.AremoreCddepressedthesedaysthanagenerationago? Nature andDistributionofChildhoodDisorders  Epidemiological research=studyofincidence,prevalence,andco-occurrenceofCdDsand competenciesinclinic-referred andcommunitysamples  Incidencerates =extent towhichnewcasesofDappearoverspecifiedperiod  Prevalencerates= all cases(new/existing)obsv’dduringspecifiedperiodoftime -estimatesvarydependingondefinition(e.g.sgl/multiplesymptoms) -dependsifcasesaredef’daspatternsofsymptoms/f’n’gimpairment/both  lesscases ID’difboth  Casedefcomplexb/cCddN refer themselves Correlates,Risks,andCauses  Mostresearchdesignedtoanswerq’nsabtrlnbtwnC, R/P&C  Correlates=variablesassoc’datparticularptintimew/noclearproofoneprecedesother  Riskfactor=variablethtprecedesoutcomeofinterestandi↑’schancesof–veoutcome  Protectivefactor= +vevariablethtprecedesoutcomeofinterestandd↓’schancesof–veoutcome  Risk/protectiveresearchreq’slargesamplesandmultipledomainsoff’n’g(phys,intellectual,psychosoc)—necessaryb/c: 1.)onlysmall proportionofCdatriskforprobwill actuallydevD 2.)areasofchildf’n’gthtwill beaffected&hownotknowninadvance 3.)agesatwhichDmay(re)occuralsonotknowninadvance  Causes=influences,(in)directlyt/othervariables,occurrenceofbeh’/Dofinterest ModeratingandMediatingVariables  Moderatorvariables=influencedirection/strengthofrlnshpofvariablesofinterest =has(i)effectonexistingrlnshpbtwn2variables  Mediatorvariables=process/mechanism/meanst/whichvariableproducesparticularoutcome = acc’forsome/all ofapparentrlnshpbtwn2variables Outcomes  Oneofthemostimportantresearchtopicsinthefieldtoday Interventions  Q’n:Howeffectiveareourmethodsfortreating/preventingCdprobs?  IDfactorsthtinfluencereferral/Txprocess  Understandhowprocesses (e.g.Cd-therapistrlnshp)contributetoTxoutcomes  AssessingacceptabilityofequivalentformsofTxtoCd,parents,andteachers  Randomizedctrl’dtrials(RCTs)  Treatmentefficacy=ifTxcanproducechangesunderwell-ctrl’dconditions  Treatmenteffectiveness=ifTxcanbeshowntoworkinclinical practice Methods of Studying Behaviour Standardization,Reliability,andValidity  Standardization=applicationofcertainstandard/normstoTMtoensureconsistencyinwayit’susedby diffassessorsandacrossmsmtoccasions  Reliability=degreetowhichmsmtobtainedusingsameTMisconsistentOT/acrossassessors - internal consistency=all partsofmethodofmsmtcontributeinmeaningful waytoinfoobtained - interrater reliability=variousppl(andnotsgl obsv’r/clinician)mustagree - test-retestreliability=resultsneedtobestableovertime  Validity=degreetowhichTMmeasureswhatitisdesignedtomeasure - facevalidity=extenttowhichitappearstoassessconstructofinterest - constructvalidity=ifscoresonmeasurebehaveaspredictedbyth’/pastresearch - convergent validity=corr’lnbtwnmeasuresexpectedtoberelated - discriminantvalidity=degreeof corr’lnbtwnmeasuresnotexpectedtoberelated - criterion-relatedvalidity=howwell measurepredictsbeh’insettingswhereexpectedtodoso Reporting  Self-reportmeasure=child/parentwill provideinfoabtownbeh’,feelings,andthoughts  Informant-reportmeasure=personwell-acquaintedw/child(usuallyparent/teacher)will provideinfoabt child’sbeh/feelings/thoughtsbasedonhis/herobsv’nsofchild  Inaccuraciesaar:recall failure,selectiverecall/bias,intentional distortions  Essential thtreportingmethod usedbesensitivetolangandcultural bgofpersonbeingeval’d ResearchStrategies Internal validity=howmuchparticularvariable(Ioextraneousinfluences)acc’sforresults/changes/groupdiffs  Threats:maturation,effectsoftesting,subject selectionbiases External validity=degreetowhichfindingscanbegeneralized/extendedtoppl/settings/times/measures/char’s  Threats:char’sofPtpsthtapplytosomeandnotothers,reactivityofsubjectstoptp’ginresearch, setting,timewhenmsmtsweremade IdentifyingtheSample  Careful defofsamplecritforcomparabilityoffindingsacrossstudiesandclearcomm’namongresearchers  Considercomorbidities  Mustbesensitivetosettingandsourceofreferral  TFrandom selection General ResearchStrategies  Choicedependsonresearchq’n,natureofDunderinvestigation,andavailabilityofresources Non-experimentalandExperimentalResearch  Trueexperiment=researchasmax’ctrl over(iv)/conditionsofinterestandcanuseRA,include neededctrl conditions,andctrl possiblesourcesofbias  Correlational studies=examinerlnshpsamongvariablesbyusingcorrelationcoefficient  Natural experiments=akaquasi-expmtal designsorknown-groupcomparisons;comparisons madebtwnconditions/Tx’sthtalreadyexist Analogue Research  Evalsspecificvariableofinterestunderconditionsthtonlyresemble/approx’desiredgeneralizedsit ResearchDesigns  …=stratsusedtoexamineq’nsofinterest Single-Case ExperimentalDesigns  Frequentlyusedtoeval’impactofclinical Tx - systematicrepeatedassessmentofbeh’OT - replicationofTxeffectsw/insamesubjectOT - ptpsservingasownctrl byexp’gall Txconditions  A-B-A-Breversal design=baselineofbeh’taken(A)–interventionphase(B) –return-to-baseline phase(A)–interventionreintroduced(B)  Multiple-baselinedesign=diffresponsesofsameindvdl ID’sandmeasuredOTtoprovidebaseline againstwhichchangesmaybeeval’d *critf/:changemustoccuronlywhenTxinstituted,andonlyforbeh’/sit/indvdl targetofTx QualitativeResearch  Narrativeacc’s,description,interpretation,context,andmeaning Ethical andPragmatic Issues  Standardsattempttostrikebalancebtwnsupportingfreedom ofsci’inquiryandprotectingrightsofprivacyandoverall welfareof researchptps InformedConsentandAssent  Informedconsent= req’sall ptpsbefullyinformedofnatureorresearchandrisks,benefits,expected outcomes,andalt’sbeforetheyagreetoptp(optiontow/draw)  Assent=childshowssomeform ofagreementtoptpw/onecessarilyunderstandingfull sig’ofresearch, whichmaybebeyondyoungerCd’scogcapabilities;aroundage7 VoluntaryParticipation  Roleofresearcher req’sbalancingsuccessful recruitingw/notplacingpressureonpotential ptps  Volunteerismitself=biasingfactor - indvdlswhoagreeobviouslydifferfrom thosewhoareapproachedbutrefuse CHAPTER 4 – ASSESSMENT, DIAGNOSIS, AND TREATMENT Clinical Issues The Decision-Making Process  Clinical assessment = systematic PS‘g strats to understand Cd w/ disturbances and their family and school env - are meaningful to extent tht they result in practical and effective interventions  Idiographic case formulation = obtain detailed understanding of indvdl Cd/family as unique entity  Nomothetic formulation = broad general inferences tht apply to large groups of indvdls Developmental Considerations  Age and gender  Culture - culture-bound syndromes = recurrent patterns of maladaptive beh‘s and/or troubling exp‘s specifically assoc‘d w/ diff cultures/localities (e.g. mal de ojo / “evil eye” – bad things caused by hateful look)  Normative information Purposes of Assessment i.) Description and Diagnosis  Clinical description = summarizes unique beh‘s, thoughts and feelings tht make up f/s of child‘s psych D - attempts to estbl basic info abt Cd‘s (and parents‘) complaints 1.) describe intensity, frequency and severity of prob 2.) age of onset and duration of difficulties 3.) get full pic of diff symptoms and their configuration  Diagnosis = analyzing info and drawing conclusions abt nature/cause of probs; assigning formal diagnosis - taxonomic diagnosis = formal assignment of cases to specific categories drawn from DSM or empirically derived cases - problem-solving analysis = ~ to clinical assessment; diagnosis as process of gathering info used to understand nature of indvdl‘s prob, its possible causes, Tx options, and outcomes ii.) Prognosis and Treatment Planning  Prognosis = formulation of predictions abt future beh‘ under specified conditions  Tx planning and eval‘n = using assessment info to generate plan to address Cd‘s prob and eval‘ its effectiveness - may involve further specification and msmt of possible contributors to prob, determination of resources and motivation for change, and recommendations for Tx‘s likely to be most feasible, acceptable and effective Assessing Disorders  Multidisciplinary teams: psych, physician, edu sp‘ist, speech pathologist, soc‘ worker  Multimethod assessment approach = emphasizes importance of obtaining info from diff informants in variety of settings and using variety of methods tht include interviews, obsv‘ns, q‘naires, and tests  Comprehensive assessment req‘s some consideration to eval‘g child‘s S&W Clinical Interviews  Obtain info and set stage for collaboration and coop‘n among Cd, family, and other parties  Interviewee encouraged to tell stories w/ min guidance  Interview may obsv nonverbal comm‘ns  Depending on child‘s age, may want to adopt child-friendly approach tht fits w/ dev status, nature of prob, and interview purpose  Developmental and family history: - child‘s birth and related events - child‘s edu hist - child‘s dev‘ milestones - adolescent‘s occupational info and rlnshps - child‘s medical hist - description of presenting probs - family char‘s - parents‘ expectations - child‘s interpersonal skills  Pros of unstructured interviews: rich source of hypotheses  Cons of unstructured interviews: lack of standardization may result in low reliability and selective/biased gathering of info  Semi-structured interview = specific q‘ns designed to elicit info in relatively consistent manner regardless of who interviewer is - can be cpu administered  fun and less threatening to kids Behavioural Assessment  … = strat for eval‘g child‘s thoughts, feelings, and beh‘s in specific settings (then using info to formulate hypotheses)  Target beh‘s = 1‘ probs of concern  ABCs  Beh‘ analysis / f‘nal analysis of beh‘ = general approach to organizing and using assessment info in terms of ABCS across many lvls - goal: ID as many factors as possible tht contribute to child‘s prob beh‘s, thoughts and feelings  Checklists and rating scales e.g. Child Behaviour Checklist (CBCL) by Thomas Achenbach  Beh‘al obsv‘n and recording - get baseline - 2‘ benefits: teach parents better obsv‘n skills, assessing parental motivation, and providing parents w/ realistic estimates of child‘s rate of responding and feedback regarding effects of Tx Psychological Testing  Test = task/set of tasks given under standard conditions w/ purpose of assessing some aspect of child‘s knowledge/skill/personality  Although many tests ―normed‖, they were w/ narrow and ltd samples TF may not be appropriate w/ indvdls from other groups  Clinicians commonly use: - dev scales - intelligence and edu tests (WISC-IV) - projective tests - personality tests (MMPA-A, PIC-2) - neuropsych tests  Developmental tests = assess infants/young Cd for purposes of screening, diagnosis and eval‘n of early dev  Screening = ID of Cd at risk, who are then referred for more thorough eval‘n  Intelligence (Wechsler) = ―overall capacity of indvdl to understand and cope w/ world around him‖  Projective tests = present child w/ ambiguous stimuli (e.g. inkblots) and asked to describe what he/she sees - idea: child will ―project‖ own personality on ambiguous stimuli  Neuropsychological assessment = attempts to link brain f‘n‘g w/ objective measures of beh known to depend on intact CNS Classification and Diagnosis  Classification = sys for rep‘g mj categories/dimensions of ACP and boundaries and rel‘ns among them Categories and Dimensions  Categorical classification = sys‘s based 1‘ly on informed professional consensus - classical/pure categorical approach assumes every diagnosis has clear underlying cause - more compatible w/ clinical purposes  Dimensional classification = assumes tht many (i) dimensions/traits of beh exist, and tht all Cd possess them to varying degrees - BUT, insensitive to contextual influences TF often tailored to Cd‘s unique circumstances and dev‘ opportunities - more preferred by those conducting psych research  Externalizing beh‘ = agg‘/rule-breaking beh‘s  Internalizing beh‘ = anxious/w/drawn/depressed beh‘s The Diagnostic and Statistical Manual (DSM)  Multiaxial system = classification sys consisting of several axes (domain) of info abt child/adolescent tht may assist clinician in planning Tx of D  Axis I Clinical Ds Other conditions tht may be focus of clinical attention Axis II Personality Ds Mental retardation Axis III General medical conditions Axis IV Psychosoc‘ and env‘ probs Axis V Global assessment of f‘n‘g  PDs share common criteria: - enduring pattern of inner exp‘ and beh‘ tht deviates noticeably from expectations of indvdl‘s culture - enduring pattern of unusual thinking, feeling, or beh‘g is inflexible, and pervasive across wide range of sit‘s, resulting in clinically sig‘ distress/impairment in f‘n‘g …additional considerations: - PD cat‘s may be applied to Cd/adolescents in those relatively unusual instances when indvdl‘s particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be ltd to particular dev stage or ep of Axis I D - to diagnose PD to < 18 yrs, f/s must have been present for at least 1 yr (exception: antisoc PD)  Criticisms: - failing to capture complex adaptations, transactions, and setting influences we have ID‘s as crucial to understanding and treating ACP - gives less attention to Ds of infancy and childhood than adulthood, and fails to capture interrlnshps and overlap known to exist among many childhood Ds - lack of emphasis on sit and contextual factors - improper usage of DSM  Pros of diagnostic labels: - help clinicians summarize and order obsv‘ns (facilitate comm‘n) - descriptive labels are consistent w/ natural tendency to think in terms of categories - assists clinicians in locating descriptive relevant body of detailed research and clinical data, and facilitates future research  Cons of diagnostic labels: - stigmatization - can influence child‘s view of themselves and his/her beh‘ Treatment Intervention  … = encompasses many diff th‘s and practices directed at helping child and family adapt more effectively to present and future  Cover wide range of actions from prevention to maintenance  Prevention = efforts directed at d↓‘g chances undesired future outcomes will occur  Treatment = corrective actions tht will permit successful adaptation by eliminating/reducing impact of undesired outcome tht has already occurred  Maintenance = efforts to i↑ adherence to Tx OT to prevent relapse/recurrence of prob Cultural Considerations  Cultural compatibility hypothesis = Tx likely to be more effective when compatible w/ cultural patterns of child and family Treatment Goals  Building Cd‘s skills for adapting to facilitate LT adjustment, rather than on merely eliminating prob beh‘s or briefly reducing subjective distress  Outcomes related to child f‘n‘g, family f‘n‘g, and of societal importance Ethical and Legal Considerations  APA code for practice: (a) selecting Tx goals and procedures in best interests of client (b) making sure client ptp‘n is active and voluntary (c) keeping records tht document effectiveness of Tx in achieving its objectives (d) protecting confidentiality of therapeutic rlnshp (e) ensuring qualifications and competencies of therapist  i↑ emphasis on involving Cd, depending on dev lvl, as active partners in decision making of own psych/med Tx  Provision of services concerns: limited in scope (e.g. 1 hr per week cannot realistically expect lasting impact)  Interventions concerns: intrusive, expensive, and not supported by data  Education for all Handicapped Children Act and IDEA-2004 - to ensure all CWD have /a free, appropriate public edu tht emphasizes sp‘ edu and related services designed to meet their unique needs and prepare them for employment and (i) living - to ensure rights of CWD and parents of such Cd are protected General Approaches to Treatment  Eclectic = use diff approaches to Tx for Cd w/ diff probs and circumstances, and see most of these approaches as having value - 70% of practicing clinicians Psychodynamic Treatments  ACP dtrmn‘d by underlying (un)conscious conf‘s  Focus: help child dvlp awareness of unconscious factors tht may be contributing to probs e.g. play therapy Behavioural Treatments  Assumes many ACP beh‘s are learned  Focus: re-educating child; changing child‘s env by working w/ parents and teachers e.g. +ve reinforcement, time-out, modeling, systematic desensitization Cognitive Treatments  ACP aar of deficits &/or distortions in child‘s thinking—perceptual biases, irrational beliefs, faulty interpretations  Focus: changing faulty cognitions, dvlpt more rational and adaptive forms of thinking Cognitive-Behavioural Treatments  ACP aar of faulty thought patterns + faulty learning & env‘ exp‘s  Focus: ID maladaptive cognitions and replace them w/ more adaptive ones, teach use of both cog and beh coping strats in specific sit‘s, and help child learn to regulate own beh‘ Client-Centered Treatments  ACP aar soc‘/env‘ circumstances imposed on child and interfere w/ basic capacity for personal growth and adaptive f‘n‘g  interference causes loss/impairment in SE and emo‘ well-being  more probs  Focus: relate to child in empathic way, provide unconditional/nonjudgmental/genuine acceptance of child as indvdl, therapist dN serve as mj adviser/coach but instead respects child‘s self-directing abilities Family Treatments  ACP as manifestations of disturbances in family rlns  Focus: family issues underlying prob beh‘s - depending on prob, focus on: family interaction, comm‘n, dynamics, contingencies, boundaries, alliances Biological Treatments  ACP aar bio impairment/dysf‘n  Focus: pharmacological/bio approach to Tx Combined Treatments  Use of 2/more interventions, each of which can stand on own as Tx strat Treatment Effectiveness  Best practice guidelines = systemically dev‘d statements to assist practitioners and patients w/ decisions regarding appropriate T(s) for specific clinical conditions - intended to offer recommendations on most effective and cost-effective Tx  Two main approaches used to dev BPG: 1.) scientific approach—via review of current research findings 2.) expert-consensus approach—opinions of experts to fill in gaps in sci‘ lit‘  Good news: - changes ach‘d by Cd receiving Tx > Cd not receiving Tx - avg child treated better off at end than at least 75% of those who dN receive Tx - Tx shown to be equally effective for Cd w/ int‘z‘g and ext‘z‘g Ds - Tx effects tend to be lasting, w/ effects at follow-up (~6mths) ~ to immediate following Tx - effects 2x as large for probs specifically targeted in Tx as they are for changes in nonspecific areas of f‘n‘g - more outpatient therapy sessions Cd receive = more improvement seen in symptoms  Bad news: limitations - most research falls under research therapy TF must be wary (clinic therapy less structured and more flexible than research therapy, and uses relatively more nonbeh‘al methods) - studies of clinic therapy suggest conventional services for Cd may have limited effectiveness  few studies exist of child therapy outcomes in settings where typically conducted, TF premature to draw any conclusions CHAPTER 5 – ATTENTION-DEFICIT / HYPERACTIVITY DISORDER (ADHD) Description and History Description  Cd who display persistent age-inappropriate symptoms of inattention, hyperactivity, and impulsivity tht are sufficient to cause impairment in mj life activities History  1902 (George Still): symptoms arose out of poor ―inhibitory volition‖ and ―defective moral ctrl‖  1917-1926: - influenza  Cd who suffered birth trauma / head injury / exposure to toxins displayed beh probs  brain injured child syndrome - 1940: label erroneously applied to Cd w/ ~ beh‘s but w/o evidence of brain damage  minimal brain damage/dysf‘n (MBD)  1950: hyperkinesis–attributed to poor filtering of stimuli entering brain  led to definition of hyperactive child syndrome—motor overactivity considered main f/ of ADHD  1970: inclusion of deficits in attention and impulse ctrl  1980: sharp rise in use of stimulants  Recently: emphasis of poor self-regulation, difficulty inhibiting beh‘ and motivational deficits as central impairments Core Characteristics Inattention (IA)  Attentional capacity = amnt of info we can remember and attend to for ST - CWADHD dN have deficit in AC—can remember same amnt of info for ST as others  Selective attention = ability to concentrate on relevant stimuli and not be distracted by noise in env  Distractibility = deficit in selective attention - CWADHD more likely than others to be distracted by highly salient and appealing stimuli  Sustained attention (aka vigilance) = ability to maintain persistent focus OT or when fatigued - 1º attention deficit in ADHD  Alerting = initial reac‘n to stimulus, and involves ability to prepare for what is abt to happen - may respond too quickly in sit‘s req‘g slow and careful approach and too slowly in sit‘s req‘g quick response Hyperactivity-Impulsivity (HI) Hyperactivity  Activity is essentially energetic, intense, inappropriate and not goal-directed  Difficulty inhibiting motor activity Impulsivity  Unable to bridle immediate reac‘ns or think before acting  Hard to stop ongoing beh or to regulate beh in accordance w/ demands of sit or wishes of others  Difficulty resisting immediate temptations and delaying gratification  Cognitive impulsivity–disorganization, hurried thinking, need for supervision  Behavioural impulsivity–calling out in class or acting w/o consideration of consequences - predicts rule-breaking beh‘ TF sign for conduct probs Subtypes  Predominantly inattentive type (ADHD-PI) - drowsy, easily confused, may have LD, process info slowly, find it hard to remember things, low academic ach‘mt, soc‘ly w/drawn, may display mood Ds  Predominantly hyperactive-impulsive type (ADHD-HI) - display probs in inhibiting beh and in beh persistence, most likely to be agg‘, defiant, rejected by peers, suspended - usually younger then CWADHD-C, not yet known whether actually 2 distinct subtypes or same Cd at diff ages  Combined type (ADHD-C) - display probs in inhibiting beh and in beh persistence, most likely to be agg‘, defiant, rejected by peers, suspended - most often referred for Tx Additional DSM Criteria  Appear before age 7  Occur more often and w/ greater severity than in other Cd of same age and sex  Cont‘ for 6+ mths  Occur across several settings  Produce sig‘ impairments in child‘s soc/academic performance What DSM Criteria Don‘t Tell Us  Dev‘ly insensitive  Cat‘ view of ADHD (when ADHD is more dimensional than cat‘al)  Req‘mt of onset before age 7 is unsupported  Req‘mt of persistence for 6mths may be too brief for young Cd  Req‘mt tht symptoms must be demonstrated across at least 2 env‘s confounds settings w/ informants - may unfairly limit diagnosis for some Cd aar diffs of opinion btwn informants Associated Characteristics Cognitive Deficits Executive Functions  Underlie child‘s capacity for self-regulation—self-awareness, planning, self-monitoring, self-eval‘n  Cognitive processes = working memory, mental computation, planning and anticipation, flexibility of thinking, use of org‘z‘al strats  Language processes = verbal fluency, comm‘n, use of self-directed speech  Motor processes = allocation of effort, following prohibitive instructions, response inhibition, motor coordination and sequencing  Emotional processes = self-regulation of arousal lvl, tolerating frustration, mature moral reasoning  Viewed as key deficit in ADHD - NOT uniquely assoc‘d w/ ADHD - dN occur in all CWADHD, suggesting is only important component Intellectual Deficits  Difficulty not in lack of intelligence, but rather in applying intelligence to everyday life sit‘s  Lower IQ scores can be direct result of ADHD symptoms on test-taking beh‘ Impaired Academic Functioning  Frequently have lower productivity, grades, and scores on ach‘mt tests  Findings: academic skills of CWADHD are impaired before they enter Gr. 1 Learning Disorders  Have specific LD, typically reading/spelling/math  Diff pathways: - cog/intellectual deficits - conduct probs - genetic link—findings suggest 2 Ds are transmitted (i)‘ly w/in families Distorted Self-Perceptions  Positive illusory bias = exaggeration of one‘s competence - self-protective f‘n to cope every day despite frequent failures - reflects diminished self-awareness aar impairments in exec f‘ns or not knowing what constitutes (un)successful performance  SE may vary w/ subtype, comorbidities, and area of performance being assessed Speech and Language Impairments  Comprehension difficulties and inappropriate use of lang in everyday sit‘s  Char‘d by speech production errors, fewer pronouns and conjunctions, tangential and unrelated comments, abandoned utterances, and unclear links Medical and Physical Concerns Health Related Problems  Common: sleep disturbances—resistance, difficulty falling asleep, fewer total hours asleep, involuntary sleep mvmt - may be related to meds or comorbidity  Overlap exists btwn ADHD and DCD - developmental coordination disorder (DCD) = condition char‘d by marked motor incoordination  20% of CWADHD have tic disorders—sudden, repetitive, non-rhythmic motor mvmts/sounds Accident-Proneness and Risk Taking  ADHD is sig‘ risk factor for early initiation of cigarette smoking, substance abuse, and risky sexual beh‘s Social Problems Family Problems  Maternal mental hlth probs  Less instrumental support  Parenting stress and less parenting  Siblings feel victimized competence  Slightly higher rates of marital conf‘, separation  Fewer contacts w/ extended family and divorce members  i↑‘d alcohol consumption by parents  Caregiver strain Peer Problems  Cd can be bothersome, stubborn, soc‘ly awkward, and soc‘ly insensitive  Often see own beh more favourably than perceived by others  Soc‘ probs may i↑ risk of later Ds  Once labelled ―ADHD‖ by peers, -ve process begins whereby child suffers more –ve Tx and rejection by peers  Not deficient in soc‘ reasoning/understanding - simply dN apply knowledge during soc‘ exchanges Accompanying Psychological Disorders and Symptoms  ODD and CD  Anxiety Ds - exp‘ greater LT impairment and mental hlth probs than either condition alone - overall rlnshp reduced/eliminated during adolescence  Mood Ds - may be f‘n of family risk for one D i↑‘g risk for other Prevalence and Course  Most common referral in NA (alone or comorbid) Gender  More in B than G - but in adolescence, overall rate d↓s for both  Possible in girls, unrecognized/unreported b/c teachers may fail to recognize and report inattentive beh unless accompanied by disruptive symptoms normally assoc‘d w/ boys  G more likely than B to display IA/disorganized symptoms - sluggishness, drowsiness, tendency to daydream, anxiety, depression, and hyperverbal rather than hyperactive motor beh‘ SES and Culture  All soc‘ classes, although slightly more in lower than higher  ID‘s all around the world and expression, assoc‘d f/s, impairments, and outcomes ~ wherever it occurs Course and Outcome Infancy  Parents‘ recollections may be coloured by child‘s later difficulties  Most infants w/ difficult temperament dN dev‘ ADHD TF cannot use as early sign Preschool  Appearance of HI symptoms  Those w/ HI and oppositional beh‘ for at least 1 yr likely to cont‘ to difficulties into middle childhood and adolescence  Severe ADHD-related symptoms + disruptions in parent-child rlnshp = especially predictive of cont‘g ADHD beh patterns Elementary School  Classroom demands for sustained attention and goal-directed persistence are formidable challenges  Usually ID‘d at this time  HI beh‘s present in preschool cont w/ some decline  ODD beh‘s may i↑/dev‘ Adolescence  Many dN outgrow probs when they reach adolescence, and sometimes probs can get much worse  HI behs decline sig‘ly, BUT still occur more than peers w/o ADHD Adulthood  Better outcomes for those w/ less severe – mild ADHD  able to outgrow/adapt  Adults w/ ADHD previously undiagnosed may not realize/know despite growing awareness Theories and Causes  Interrelated th‘s emphasize deficits in: motivation, arousal lvl, self-regulation, and response inhibition  Current research: genetic and neurobio factors, followed by bio and env shaping expression of ADHD symptoms Genetic Influences  ADHD runs in families  Results of adoption, twin, and specific gene (dopamine regulation, DRD4) studies Pregnancy, Birth, and Early Development  Early factors tht predict later symptoms (not specific) to ADHD: - birth complications, low birth weight, malnutrition, early neuro insult/trauma, diseases of infancy  Findings: cigarette smoking during pregnancy assoc‘d w/ ADHD  Findings: exposure to alcohol before birth  IA, HI, and assoc‘d impairments in learning and beh‘ Neurobiological Factors  Research btwn CW and w/o ADHD shows diffs on/in: - psychophysio measures suggest diminished arousal/arousability - measures of brain activity during vigilance tests, suggesting under-responsiveness to stimuli and deficits in response inhibitions - blood flow to prefrontal regions of brain and pathways connecting regions to limbic sys, suggesting d↓‘d blood flow to regions  Brain abnormalities: - 1ºly in frontostriatial circuitry of brain (prefrontal cortex and basal ganglia)—assoc‘d w/ attention, exec f‘ns, delayed responding, response org‘zn; lesions in area ~ to ADHD symptoms  Recent findings: smaller total and right cerebral volumes and smaller cerebellum  supports growing notion tht deficits may involve cerebellar-prefrontal-striatal network  Recent findings: delay in brain maturation (and not deviance)  Caution: small sample sizes Diet, Allergy, and Lead  Sugar DN cause hyperactivity  Research dN support role of food additives as 1º cause  Rlnshp btwn lead and ADHD is weak Family Influences  Family influences may lead to ADHD symptoms or to greater severity of symptoms - goodness of fit = match btwn child‘s early temperament and parent‘s style of interaction  Family probs may result from interacting w/ child who is impulsive and difficult to manage  Family conf‘ is likely related to presence, persistence, or later emergence of assoc‘d ODD/CD symptoms Treatment  1º approach combines stimulant meds, parent mgmt training, and edu intervention Medication Stimulants  Other meds: noradrenergic drugs, tricyclic antidepressants, antihypertensives  Stimulants come in several types, including short- and long-acting forms  Most effective: - dextroamphetamine (Dexedrine/Dextrostat) - methylphenidate (Ritalin)  *most commonly used  Meds alter activity in frontostriatal region of brain by affecting NTs (dopamine) in region  Produces dramatic i↑‘s in sustained attention, impulse ctrl, and persistence of work effort, and d↓‘s task- irrelevant activity and noisy and disruptive beh‘s  Side effects: reduced appetite, weight loss, slowing of expected gains in height and weight, i↑ in HR and BP, probs falling asleep - careful monitoring  often can be eliminated by reducing dosage  *note: not a cure Parent Management Training (PMT)  Provides parents w/ variety of skills to help them: - manage child‘s oppositional and noncomplicant beh‘s - cope w/ emo‘al demands of raising CWADHD - contain prob so it dN worsen - keep prob from adversely affecting other family members  First taught abt ADHD so they understand bio‘al bsis of D and dN blame themselves  Given set of guiding principles  Taught beh‘ mgmt principles and TM‘s  Encouraged to spend time each day sharing an enjoyable activity w/ child  Learn to reduce own levels of arousal t/ relaxation/meditation/exercise  To date, PMT has focused mainly on teaching parents to manage overt disruptive beh rather than changing underlying deficits Educational Intervention  Whenever possible, preferable to keep CWADHD in class w/ peers  Focus: managing IA and HI beh‘s tht interfere w/ learning, and providing classroom env tht capitalizes on child‘s strengths  Teacher and child can set realistic goals and objectives and set up mutually agreed upon reward system - disruptive/off-task classroom beh may be punished w/ response-cost procedures—loss of privileges/points/activities/time-out  Many strats for instructing CWADHD are simply good teaching methods Intensive Interventions 2 examples of programs tht have provided intensive Tx to CWADHD and families: i.) Summer Treatment Program  By William Pelham and colleagues for ages 5-15 in camp-like setting \  Engage in classroom and recreational activities w/ other Cd, 360 hrs of day-Tx into period of 8 weeks  adv↑: max‘s opportunities to build effective peer rlns in normal settings and provides continuity to academic work to ensure gains from school not lost  coordinated w/ stimulant med trials, PMT, soc‘ skills training and edu interventions ii.) The Multimodal Treatment (MTA) Study of Children with ADHD  first large, randomized clinical trial for CWADHD  age 7-9 RA to one of four Tx groups: 1.) medication mgmt—psychostimulant meds 7 days a week 2.) behavioural Tx—35 sessions of PMT, up to 10 teacher and school visits per year, ptp‘n in intensive 8-week STP 3.) combined beh‘al Tx and meds—both meds and beh Tx 4.) routine community Tx—Tx as it was routinely delivered in community care (in fact, 66% of Cd in group received stim‘ meds)  Findings: all groups showed reductions in ADHD symptoms OT, w/ sig‘ variations in amnt of change i.) meds > beh‘ and community ii.) combined = meds (in regards to core symptoms), BUT had modest benefits for non-ADHD symptoms in regards to +ve f‘n‘g  Combined > meds > beh‘ > community  24 mth follow up: combined showed most benefits  36 mth follow up: all groups showed equal benefits  Findings: indicate effects of meds and beh‘ Tx‘s either decline/cease entirely when Tx stops Additional Interventions  Family counselling and support groups  Indvdl counselling CHAPTER 6 – CONDUCT PROBLEMS Description of Conduct Problems  Conduct problem(s) and antisocial beh(s) = terms used to describe wide range of age-inappropriate actions and attitudes of a child tht violate family expectations, societal norms, and personal/property rights of others Context, Costs, and Perspectives Context  AS beh‘s appear and then decline during normal dev - few refrain from AS beh entirely, and those tend to be excessively conventional, trusting, anxious, and socially incompetent— not well-adjusted  AS beh‘s vary in severity, from minor disobedience to fighting  Some AS beh‘s d↓ w/ age whereas others i↑ w/ age & opportunity  AS beh‘s more common in boys than girls during childhood, but diff narrows in adolescence Social and Economic Costs  Most costly mental hlth prob in NA  Teens in US: - die more from firearm injuries than from all diseases combined - are 2x likely as adults to be victims of vio‘  Lifetime costs to society for one youth to leave HS for life of crime and substance abuse estimated ~$2m Perspectives Legal  Legally, defined as delinquent or criminal acts  Juvenile delinquency = Cd who have broken law, anything from sneaking into movie w/o ticket to homicide - legal def‘s depend on laws tht change OT or differ across locations  No clear boundaries exist btwn delinquent acts tht are reac‘n to env conditions (e.g. high-crime neighbourhood) and those that result from factors w/in child (e.g. impulsivity)  Only subgroup of Cd who meet legal def‘ of delinquency will also meet def‘ for mental D (req‘s child to display persistent pattern of AS beh rather than 1 or 2 isolated acts) Psychological  CP falls along cont‘ous dimension of ext‘z‘g beh—includes mixture of impulsive, overactive, agg‘ and rule- breaking acts - subdimensions: rule-breaking beh‘ and aggressive beh‘ - (i) dimensions: overt-covert dimension, destructive-nondestructive dimension Psychiatric  Disruptive beh‘ Ds = persistent patterns of AS beh‘, rep‘d by categories of ODD and CD Public Health  Approach cuts across disciplines and brings together policy makers, scientists, professionals, communities, families, and indvdls t understand CPs in youths and dtrmn how they can be treated and prevented DSM-IV-TR: Defining Features Oppositional Defiant Disorder (ODD)  Age-inappropriate recurrent pattern of stubborn, hostile, and defiant beh‘s Conduct Disorder (CD)  Repetitive and persistent pattern of severe aggressive and antisocial acts tht involve inflicting pain on others or interfering w/ rights of others t/ phys and verbal agg‘n, stealing, or committing acts of vandalism  Often have co-occurring probs (e.g. ADHD, aca‘ deficiencies, poor rlns w/ peers)  Childhood-onset CD = display at least 1 symptom before age 10 - more likely to be boys, show more agg‘ symptoms, acc‘ for disproportionate amnt of illegal activity, persist in AS beh OT  Adolescent-onset CD = display at least 1 symptom after age 10  ODD symptoms typically emerge 2-3 yrs before CD  New cases of CD almost always preceded by ODD, and nearly all CWCD cont‘ to display ODD symptoms  + early CD, adults w/ ASPD may also display psychopathy—pattern of callous, manipulative, deceitful and remorseless beh  Less likely than peers to show affective empathy/embarrassment, suggesting failure to inhibit emotions and actions in accordance w/ social conventions  Subgroup: callous and unemotional interpersonal style = lacking in guilt, not showing empathy/emotions, related traits of narcissism and impulsivity , lack of BI Associated Characteristics Cognitive and Verbal Deficits  Most have normal intelligence, but many score lower IQ scores (possibly b/c of co-occurrence of ADHD)  Verbal IQ consistently lower suggesting specific and pervasive deficit in lang‘  in turn affecting: receptive listening, reading, problem solving, expressive speech & writing, memory for verbal material  may increase child‘s vulnerability to effects of hostile family env‘ School and Learning Problems  Little evidence tht aca‘ failure is 1º cause of C problems, particularly in early childhood  Underach‘mt + C probs will influence each other OT: - lose interest in school - associate w/ delinquent peers Self-Esteem Deficits  Little support tht low SE is 1º cause  Related to inflated, unstable, and/or tentative view of self  Any increment in SE may, OT, permit rationalization of AS conduct Peer Problems  Soc‘ rejection by elementary school peers strong risk factor for adolescent C probs  i↑ if involved w/ AS/deviant peers  Unfortunately, many well-intentioned  Reactive-aggressive Cd have hostile attributional bias, whereas proactive-aggressive Cd dN Family Problems  Among strongest and most consistent correlates  General family disturbances = parental mental hlth probs, family hist of AS beh, marital discord, family instability, ltd resources, AS family values  Specific disturbances in parenting practices and family f‘n‘g = excessive use of harsh discipline, lack of supervision, lack of emo‘al support and involvement, parental disagreement abt discipline  Parents may exhibit soc-cog deficits ~ to those of Cd, which suggest tendency of AS Cd to infer hostile intent may mirror soc perceptions of parents  Collab‘n of sibs in one another‘s deviant beh‘ can be as pwrful as deviant peer rlnshps in heightening risk for later C probs Accompanying Disorders and Symptoms ADHD  Common underlying factor (impulsivity, poor self-reg‘n, temperament) may lead to both ADHD and CD  May contribute to its persistence and escalation to more severe forms  May lead ot childhood onset (strong indicator of cont‘g probs)  BUT, CD less likely than ADHD assoc‘d w/ cog impairments, neurodev‘ ABities, IA in classroom, and h↑ rates of accidental injuries Depression and Anxiety  Hypothesis: rln may depend on type of anxiety - anxiety related to shyness, inhibition, and fear may protect against C probs - anxiety related to –ve emotionality and soc‘ avoidance/w/drawal based on lack of caring abt others may i↑ risk for C probs Prevalence, Gender, and Course Prevalence  ODD either declines/stays constant from early childhood to adolescence  CD i↑s from childhood to adolescence Gender  Childhood M > F  narrows greatly in early adolescence due mainly to rise in covert nonagg‘ behs  M > F in late adolescence  Boys remain more vio‘-prone than girls t/o life span  Gender diffs may be partly related to definitions of C problems tht place strong emphasis on phys agg‘n Developmental Course and Pathways  From preschool to adolescence: difficult temperament  hyperactivity  overt C probs/agg  w/drawl  poor peer rlnshps  aca probs  covert/concealing C probs  assoc‘n w/ deviant peers  delinquency (arrest)  Most Cd w/ C probs show diversification—add new forms of AS beh‘ OT rather than simply replacing old beh‘s  Across cultures, mj C probs become more frequent during adolescence  Life-course-persistent (LCP) path = Cd who engage in agg‘n and AS beh‘ at early age and cont‘ into adulthood - underlying disposition remains, but way it is expressed changes w/ new ―opportunities‖ - assoc‘d w/ family hist of ext‘z‘g Ds and often perpetuated by progressive accumulation of consequences  Adolescent-ltd (AL) path = AS beh begins around puberty, cont‘s into adolescence, but later desist from behs during young Ad‘hood - less extreme AS beh than LCP, less likely to drop out of school, and have stronger family ties - delinquent activity often related to temp‘ sit‘ factors - cont‘n of AS beh often result of snares—outcomes of AS beh tht close door to getting good job, pursuing higher edu‘n, attracting partner  AS beh‘ stable for LCP (who cont‘ on same road), but unstable for AL Adult Outcomes  M: at risk for criminal beh, work probs, substance abuse  F: likely to exp‘ depression, suicidal beh‘, hlth probs Causes Genetic Influences  Strength higher for LCP than for AL  May be related to difficult temperament, impulsivity, tendency to seek rewards, or insensitivity to punishment tht combine to create AS ―propensity‖/‖personality‖  Moderate susceptibility  Low-active MAOA more likely to dev AS beh‘ than maltreated Cd w/o this genotype Neurobiological Factors  Behavioural activation system (BAS) = ~ ―gas pedal‖; stimulates beh in response to signals of reward/non-punishment  Behavioural inhibition system (BIS) = ~ ―brakes‖; produces anxiety and inhibits ongoing beh‘ in presence of novel events, innate fear stimuli, and signals of non- reward/punishment  Low levels of cortical arousal and low autonomic reactivity seem to play central role in AS beh Family Factors  Reciprocal influence = child‘s beh‘ both influenced by and influences beh‘ of others  Coercion theory = parent-child X‘ns provide training ground for dev of AS beh‘; 4-step escape-conditioning sequence child learns from to use i↑‘ly intense forms of noxious beh  Reinforcement trap: 1.) parent reacts -vely to child‘s beh‘ 2.) child argues back to may, OT, reduce parent‘s efforts 3.) parent w/draws 4.) child learns from exp‘ and repeats  Research supports rlnshp btwn insecure attachments and AS beh  Family instability and stress - amplifier hypothesis = stress amplifies maladaptive predispositions of parents, thereby disrupting family mgmt practices and compromising parents‘ ability to be supportive of their Cd  Parental criminality and psychopathology Societal Factors  Social selection hypothesis = ppl who move into diff neighbourhoods differ before they arrive, and those who remain differ from those who leave Treatment and Prevention Parent Management Training (PMT)  Teaches parents to change child‘s beh‘ at home and in other settings using contingency mgmt tm‘s  Focus: improving parent-child Xns and enhancing other parenting skills  Produces ST gains, but LT effectiveness less clear  Key f/s: - minimal/no direct intervention of therapist w/ child - parents learn procedures to change parent-child Xns, promote +ve child beh‘, d↓ AS beh - parents learn new ways to ID, define, and obsv‘ child‘s prob beh‘s - Tx session cover effective use of commands; ways to set clear rules; use of praise, tangible rewards, or tokens for desired beh‘; use of mild punishment such as TO from reinforcement or loss of privileges, negotiation, contingency contracting - sessions allow parents to see how new TM‘s are implemented, to practice using then, and to review progress in home - hmk assignments used to promote generalization of skills learned in Tx to home and other settings - progress in Tx carefully monitored, and ongoing adjustments made as needed Problem-Solving Skills Training (PSST)  Identifies child‘s cog deficiencies and distortions in soc sit‘s and provides instruction, practice, and feedback to teach new ways of handling soc sit‘s  Child learns to appraise sit‘, change his/her attributions abt other Cd‘s motivations, be more sensitive to how other Cd feel, and generate alt and more appropriate sol‘ns  However, alt‘n of cog processes may not necessarily lead to changes in beh  Key f/s: - emphasizes child‘s thinking, although beh‘s tht result from thinking also viewed as important - self-statements used to direct attention to aspects of prob tht lead to effective sol‘ns - Tx uses structured tasks—games, school activities, stories - child learns to apply cog P-S skills to real-life sit‘s - therapist plays active role in Tx, giving examples of cog processes and providing feedback and priase - Tx combines modeling, practice, RP‘g, beh‘al contracts, reinforcement, and mild punishment - Tx emphasizes extension of P-S to child‘s everyday life t/ use of hmk and parent involvement Multisystemic Treatment (MUST)  Intensive approach tht draws on other TM‘s (e.g. PMT, PSST, marital therapy) as well as sp‘z‘d interventions (e.g. sp‘ edu) and referral to substance abuse Tx programs or legal services  Tx carried out w/ all family members, school personnel, peers, juvenile justice staff, and other indvdls in child‘s life  Guiding principles: - assessment focuses on understanding ―fit‖ btwn ID‘d probs and broader concern - interventions present-focused and action-oriented, targeting specific and wel-defined probs - interventions focus on beh‘ transactions w/in / btwn multiple systems - interventions dev‘ly appropriate and fit needs of youth - interventions req‘ daily and weekly effort by family members - interventions eval‘d cont‘ly from multiple perspectives - interventions designed to promote generalization and LT maintenance - interventions emphasize +ve, and use systemic strengths as levers for change - interventions designed to promote responsible beh‘ and d↓ irresponsible beh Preventive Interventions Main assumptions:  C probs can be treated more easily and more effectively in younger than older Cd  By counteracting risk factors and strengthening protective factors at young age, possible to limit/prevent escalating dev trajectory of i↑‘d agg‘n, peer rejection, SE deficits, CD, and aca‘ failure commonly obsv‘d in Cd w/ childhood-onset C probs  In long run, preventive interventions will reduce substantial costs to edu, criminal justice, hlth, and mental hlth systems assoc‘d w/ C probs Main conclusion:  Degree of success/failure in treating antisocial beh‘ depends on type & severity of child‘s C prob and related risk/protective factors CHAPTER 7 – ANXIETY DISORDERS Description of Anxiety Disorders  Anxiety = mood state char‘d by strong –ve emotion and bodily symptoms of tension in which child apprehensively anticipates future danger/misfortune - strong -ve emotion and element of fear  Anxiety disorders = exp‘ excessive and debilitating anxieties Experiencing Anxiety  Neurotic paradox = self-defeating beh‘ e.g. knows there is little to be afraid of, but still terrified and does everything possible to escape/avoid sit’  Symptoms of anxiety expressed t/ 3 interrelated response systems: i.) physical system ii.) cognitive system iii.) behavioural system i.) Physical System  Activation of SNS: - chemical effects - sweat gland effects - cardiovascular effects - other phys effects (e.g. pupils widen, salivation decreases, muscle tension) - respiratory effects ii.) Cognitive System  Subjective feelings of apprehension, nervousness, difficulty concentrating, panic iii.) Behavioural System  Agg‘n, irritability, fidgeting  Avoidance, escape Anxiety Versus Fear and Panic  Fear = immediate alarm reac‘n to current danger or life-threatening emergencies - present-oriented emotional reac‘n  Anxiety is a future-oriented emotional reac‘n  Panic = group of phys symptoms of F/F response tht unexpectedly occur in absence of any obvious threat/danger Normal Fears, Anxieties, Worries, and Rituals  Since Cd and their env‘s constantly change, fears tht are normal at one age can be debilitating a few yrs later  Most frequent anxiety symptoms in normal samples: separation anxiety, test anxiety, over concern about competence, excessive need for reassurance, anxiety about harm to parent - disposition to be anxious may remain stable OT, even though objects of Cd‘s fears change  Worries can help prepare for the future - D  more intense and frequent  Rituals help young Cd gain ctrl and mastery over soc and phys env and make their world more predictable and safer Separation Anxiety Disorder  Age-inappropriate, excessive, and disabling anxiety abt being apart from parents/home  Fear new sit‘s, may display phys complaints (e.g. rapid HB, dizziness), and fuss/cry/scream to avoid separation  OT, may become i↑‘ly w/drawn, apathetic and depressed  risk for other anxiety Ds  One of the 2 most common anxiety Ds  Earliest reported age of onset (7-8 yrs)  Generally progresses from mild to severe  Aca‘/soc‘ probs may dev aar of missed instruction and peer Xn at school  Cog-beh Tx usually emphasizes immediate return ot school and other routines, and must take into acc‘ specific f‘ns being suerved by school refusal beh‘s Generalized Anxiety Disorder  Chronic/exaggerated worry and tension abt almost everything  Almost constant anticipation of disaster even though nothing seems to provoke it—apprehensive expectation  Worrying often accompanied by phys symptoms—e.g. trembling, musc tension, headache, nausea  Cont‘ to worry even when evidence contradicts their concern  Intolerance of uncertainty  may result in impaired decision-making under conditions of uncertainty  Suggested tht severre GA symptoms persist OT Specific Phobia  Extreme and disabling fear of specific objects/sit‘s tht pose little/no danger  Phobia = child‘s fear occurs at inappropriate age, persist, is irrational/exaggerated, leads to avoidance of object/event, and causes impairment in normal routines Social Phobia (Social Anxiety)  Marked/persistent fear of being focus of attention/scrutiny, or of doing sth tht will be intensely humiliating  Youngsters more likely than other Cd to be highly emotional, socially fearful and inhibited, sad, and lonely  Frequently exp‘ soc‘ly distressing events w/ which they are unable to cope effectively - partly due to lack of soc‘ skills  Generalized social phobia = fear most soc‘ sit‘s, afraid ot meet/talk w/ new ppl, avoid contact w/ anyone outside family, and find it extremely difficult to attend school, ppt in rec activities, or socialize  Repeating cycle: anticipate awkwardness and poor perf  further anxiety  further i↑‘s nervousness and phys symptoms  Most common 2º diagnosis Selective Mutism  Fail to talk in specific soc‘ sit‘s, even though they may speak loudly and frequently at home/other settings  Suggested it is extreme type of soc‘ phobia rather than unique D - premature to conclude: most Cd fail to talk b/c socially anxious, but may be other reasons as well Obsessive-Compulsive Disorder  Repeated, intrusive, and unwanted thoughts tht cause anxiety, often accompanied by ritualized beh‘ to relieve this anxiety  Obsessions = persistent and intrusive thoughts/ideas/impulses/images - much more than heightened worries - focused
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