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Chapter 15

PSY240 Chapter 15.docx

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Hywel Morgan

CHAPTER 15 Externalizing Problems: - Disorders of the undercontrolled Behaviour. - Disruptive behaviour disorder - Unable to control activity level, impulses and have difficulty concentrating. - ADHD, CDD and ODD. - More disturbing to children than to the children Internalizing Problems: - Disorders of overcontrolled behaviour - Anxiety, GAD, SAD, Selective mutism. - Problematic for the person, yet a pose a few problems for people around them. Comorbidity: - Two or more disorders occur together in the same individual - A rule in mental health, not an exception - Individual meets the diagnostic criteria for more than one disorder (can be due to over lap of symptoms) Homotypic Comorbidity: - A person receiving same diagnosis in the future. - A disorder that is comorbid with another disorder in the same class (externalising (ODD) and later developing another externalizing (CD)) Heterotypic Comorbidity: - A person that a disorder that is comorbid with a disorder from a different class ( externalising to internalising) Attention Deficit/ Hyperactivity Disorder (ADHD) - Externalising disorder - One of the most common childhood and adolescent disorder - Distrubtive behaviour, unable to concentrate/ focus and inability controlling activity or impulsiveness level. - Hyperactive = Motor + Verbal - Behaviour = Impulsive or Erratic - Emerge in early childhood, most get better as brain matures - 1/3 retain ADHD till adulthood Gene-Environment Interaction - G X E - “Any Phenotypic Event” (observable characteristics) = Gene + Environment - Nature via Nurture - For example: Prenatal smoking. Diathesis-Stress (Disorder- Stress) Perspective - Environment stress has greatest toll on the person with genetic vulnerability - Predisposed to a disorder genetically, yet environmental factor can encourage the expression of gene - Interaction underlies all onset of disorders - Although one (gene or stress) may be more important than the other (no 50% each) - For example, Homozygous for Dopamine receptor gene in prefrontal are “vulnerable”, with inconsistent parenting (environment stress), kids likely to have ADHD or ODD. Methylphenidate (Ritalin)  ADHD - Stimulant Medication - Most frequently subscribed medicine for ADHD - Act on other neurotransmitters to increase their activity to compensate for level of other neurotransmitters that cause abnormal behaviour. - For example, in ADHD, increasing neurotransmitters that encourage more vigilant or calm behaviour, and decrease aggressive Oppositional Defiant Disorder (ODD) - Unable to comprehend that their behaviour is not correct - Refuse to follow instructions, Arguments, temper tantrums, annoying other, spiteful and vindictive - Blame others for their behaviour - Hostile behaviour - Difficult to manage: Negativistic behaviour and poor attitude - Diagnosed by 8 years - DSM V: Separate irritable moods from defiant behaviour. Irritable mood can lead to mood and anxiety disorder Conduct Disorder (CD) - Violating the rights of others - Opposing laws/ rules - Hostile behaviour - DSM IV TR: o Aggression towards people/animals o Theft o Violation of rules o Destruction of property Assortative Mating - Mating with people with same disorder (people drawn to people like them) - For Example: Two CD people date, marry and mate creating children with high genetic predisposition to CD. Such parents have more negative behaviour, poor parenting etc (environment + genetics) Mood Stabilizers - “Stabilize” one’s “mood” - Psychotropic medications - Treat mood disorders; extreme mood swings - For example: CD patients take in lithium (a mood stabilizer), works well with in inpatients. Neuroleptics - Antipsychotic Medication - For example: Risperidone , improve symptoms of outpatients in CD, Coercive process - Child negative behaviour diminishes the parents negative behaviour - Averse reactions used to control the behaviour of another individual. - For example, Crying or whining to stop parental conflict Separation Anxiety Disorder (SAD) - Internalization - Unique to childhood - Children have the fear of “separation” from caregiver or to whom the child is emotionally attached to. - Panic and excessive anxiety at the thought of separation - Symptom: Distress - heightened insecurity - Calm with caregiver - Distress inward Homotypic Continuity: - An underlying developmental disorder, that may change but the ways it manifested stays the same. - Same diagnosis in the future - Internal to external and vice versa. Heterotypic Continuity - Underlying disorder stays the same, yet the manifestation of it changes. - Different diagnosis in the future - For example, prediction of one disorder from another. Delibrative Self Harm (DSH) - Purposely Physically injure oneself but not cause death - 9.7 % = Attempted suicide - 29.9 % = suicidal thoughts - Males more likely to commit suicide - Females 4 x more to participate in DSH - Comorbidity: o Depression and one other psychiatric disorder - History; o Environmental factor: family member similar behaviour o Prior similar behaviour o Likelihood of occurrence, increases with chemicals and fire arms. - Cognitive Behavioural Therapy: o Your Life Counts o Helping youth growing through difficulties Behavioural Inhibition - Children display withdrawal or fear from new situations - Occurs through life - Temperament in early childhood that may be related to anxiety disorders in later life - Atypical response of autonomic system to new situations - Avoid others Selective Serotonin Reuptake Inhibitors - Fluvoxamine, parexetine (Paxil) and fluxotine(Prozac) and sertaline (Zoloft) - Class of anti depressants - Prevent reuptake for NT. So that NT reach optimal use. Selective mutism - Social anxiety - Person capable of speaking chooses not to speak in social situations. - Problem = can’t do talk therapy - CBT Historical Perspective What is the current mode to evaluate children? Study family and children, using various scientific methods involving genetics, neuroimaging etc. The medical condition, has some biological bases along with environment factors. Obtain a more global picture of the child: developmental, medical, social and educational. When was the first problem identified and studied in children When going was made mandatory for children, it allowed the examination of children with mental deficits. Who wrote the 1 book on child psychiatry, and when 1935 – Leo Kannar`s provided a framework to asses children What were child guidance clinics? USA and England, initiation of guidance clinics in schools. These clinic include psychiatrist, psychologists etc, to work on educational psychology. What were the first forms of research in childhood disorders? Descriptions of children with infantile autism and behavioural manifestations of deficient maternal care and overprotection. When it regular documentation of childhood behavioural problems begin 1960 What was the first comprehensive population survey? Isle of Wight Study, involving 9-11 years old. What is the relationship between DSM and childhood disorders? Incorporated in DSM in 1980. What is the treatment based on? Family therapy and psychoanalytic therapy by Anna freud and Melanie Klien. What is the current zeitgeist? Since 1960, it is the use of medications. Yet important to examine the side effects on developing bodies and minds. Current Issues What are issues in studying child psychology? 1. Age variation in symptoms 2. What is normal behaviour based on a child`s age 3. What constitutes a disorder in a child, and how long, and severe must it be, to get treatment What about youth Less Autonomy, as influenced by environment and people around them What can be a bias in research? Usually parents and teachers who report the problem, yet their different sources thus both rarely talk about the same symptoms. Prevalence Childhood disorders and DSMIV-TR Disorders usually first diagnosed in childhood, infancy and adolescence. Yet anxiety and mood disorders not included as they are the same disorder in childhood and adult. What percentage of youth with one psychiatric disorder, met the diagnostic criteria for another 40% What are prevalence rates for ADHD, Anxiety and CD in a lab study? - ADHD = 3.3 % - CD = 3.3 % - Anxiety = 6.5 % Most common disorders in North America in children ADHD, CD or ODD and anxiety. What is average community prevalence? 14. 3 % or 800 000 children and youth have a mental disorder that gives them stress. How many youth met the criteria for impairment across lifetime? 1 out of 4 or 5 What about prevalence in elementary school 1 in 5 What is the age of onset dependent on? The type of disorder. Female and male differentiations Female: - Mood, anxiety , eating Male: - Behavioural,, substance abuse ADHD ADHD was earilier known as Minimal brain dysfunction and Hyperkinetic syndrome of childhood. 1970: ADD (Attention Deficit Disorder). Neuropsychiatric Disorder. DSM 3: 1. Functional impairment 2. Symptoms before age 7 Clinical Description Classification of Symptoms: Subtypes 1) Hyperactivity 2) Inattention 3) Impulsivity Types: 1) ADHD -1 (Girls) - Academic problems (math) - Problem: listening, learning & remembering - Difficulty in organization - Difficulty in motor control - Social Problems 2) ADHD – H and ADHD – H1 - (3x boys > Girls) - High comorbidity rates - Get into trouble - Intrupt others - Talk to self - React impulsively much more than ADHD1 - Adult: Decrease hyperactivity - Adult: Continue to figit 3) ADHD – H1 (3x boys > Girls) Validity of ADHD Subtypes are unstable over time thus removal. subtypes DSM V: - All youth with ADHD have the combined type - Clarify and specifically show what the most persistent subtype of the past 6 months. - No subtype, instead guidance on how to code the predominant subtype Comorbidity 50 % have another psychiatric disorder Most common: - ODD - CD ( 40 – 60%) - Learning Disorder (25%) - Anxiety (25%) - Substance abuse (40%) - Depression (30%) Prevalence 2% = Preschool 6% = School going kids and youth 4% = Adults Overall ADHD = Boys > Girls Developmental Most children with ADHD, need management help even in Trajectory youth and adulthood Adulthood: - Comparable education and IQ - Low attention at job - Increase likelihood of motor accident - Low IQ - Early parents - STD’s - High rate of divorce st Etiology Introduction 1 large study on ADHD: Multimodal study of treatment of ADHD Brain Most complication brain function: sustain attention (To study in childhood) - Reduced brain size  Abnormal in prefrontal cortex (higher motor functioning) and basal ganglia (learning, memory, emotion) and cerebellum (lack of motor control – unable to balance) - Neurotransmitters: Dopamine & Noradrenergic ( Abnormality in above brain regions = genes that regulates these transmitters) - Dopamine = Attention (basal + frontal) Gene 50% + = ADHD – Genes Study = genes involved with dopamine No particular gene for ADHD Parental Risk Prenatal toxin = ADHD factors - Anti-depressants - Smoking - Poor diet - Antihypertensives - Caffeine - Mercury and lead - Complications at birth Psychological - Low socio-economic risk factor - Low parental mental health - Foster care - Maltreatment ADHD: large families, large distress  ADHD ADHD: Treatment improves family stress Gene- - Dopamine in prefrontal cortex environmental - Genetic predisposition + maternal smoking = ADHD - 480 DAT-1 risk allele symptoms present for kids with ADHD and prenatal smoking. Assessment and Introduction - More than 1 clinician assessment Treatment - Symptoms surveillance - Clinical Interview - Direct communication with teachers for school behaviour Pharmaceutical 80% better with stimulant medication (all subtypes): - Increase release of dopamine and noradrenergic, and prevent their reuptake Ritalin Atomoxetine: - Alters norepinephrine - Get better Side effects: loss of appetite, headaches, increasein blood pressure etc. Several years: low height and weight Stay on meds from child to adult  Clinician recommend No benefit on academic function Work best with other therapies Short and long acting derivatives of methylphenidate, dextroamphetamine and amphatemine. Reduce symptoms
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