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Chapter XIII.docx

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Martha Mc Kay

Chapter XIII: Childhood Disorders - 1/3+ of all children suffer from significant emotional or behaviour disorder by the time they are 16; boys are more vulnerable than girls before age 16 - Some linked to major stressors in environment (poverty, violence, illicit drugs, unprotected sexual intercourse, discrimination and harassment) - Multiple risk factors: biological predispositions and environmental stressors Individual genes, teratogens, temperament, malnutrition Family substance use, unemployment, poverty, mental illness, domestic violence School / Community / Environment inferior education, neighbourhood violence, peer rejection, racism, disaster - Temperament: a childs arousability and general mood Difficult temperamentnegative interactions (may contribute, not create) - Resilient children: do not develop severe psychological symptoms or disorders despite facing major stressors - Resilient factors: Individual temperament, physical health, close bond with primary caregiver (healthy, competent adult to rely on), good school performance Family good prenatal care, education, good parenting skills, small family, financial stability School / Community / Environment good teachers/schools, good neighbourhood, supportive peers - Developmental psychopathology: try to understand when childrens behaviours cross the line from the normal difficulties or childhood into unusual or abnormal problems - Assessment: Informants Self; Parents; Family; Caregivers; Teachers Childs records and previous evaluations Tools Observation Interview Questionnaires Tests of intellectual, cognitive and academic functioning Externalizing/Behaviour Disorders Extreme inattention, hyperactivity, socially inappropriate behaviour Attention-Deficit / - Persistent pattern of inattention and/or hyperactivity-impulsivity Hyperactivity Disorder - Behaviour being driven and disorganized (ADHD) - More frequent and severe than expected - Some symptoms present before age 7 - Impairments observable in 2 settings - Subtypes: 1. Combined type: presence of 6 symptoms of inattention and 6 symptoms of hyperactivity-impulsivity 2. Predominantly inattentive type: 6 symptoms of inattention but 6- symptoms of hyperactivity-impulsivity; sluggish cognitive temple (slow retrieval of info from memory, slow processing of information, drowsiness, daydreaming, low level of alertness) 3. Predominantly hyperactive-impulsive type: 6 symptoms of hyperactivity-impulsivity but 6- symptoms of inattention - Many do poorly in school - 20-25% have serious learning disabilities - Some have extremely poor relationships, rejected by peer - Intrusive, irritable, demanding - 45-60% develop conduct disorder/abuse drugs/become juvenile delinquents - Prevalence: 1-7%; Boys > Girls (but rates differ by age group) - Boys tend to have more disruptive behaviour than girls - Symptoms persist into young adulthood for of the children - Diagnosed with ADHD as childrenincreased risk for ASPD, substance abuse, mood & anxiety disorders, marital problems, traffic accidents, legal infractions, frequent job changes as adults - Many grow out of ADHDnormal, healthy lives Inattention: - Does not pay attention to details and makes careless mistakes - Has difficulty sustaining attention - Does not seem to be listening when others are talking - Does not follow through on instructions or finish tasks - Has difficulty organizing behaviours - Avoids activities that require sustained effort and attention - Loses things frequently - Is easily distracted - Is forgetful Hyperactivity: - Fidgets with hands or feet and squirms in seat - Leaves his or her seat when it is inappropriate - Runs around or climbs excessively - Has difficulty engaging in quiet activities - Often acts as if driven by a motor - Often talks excessively Impulsivity: - Blurts out responses while others are talking - Has difficulty waiting his or her turn - Often interrupts or intrudes on others - Forderly referred to as minimal brain damage, but most do not have brain injury & those with brain injury do not develop ADHD Brain Deficits: - Differs in neurological functioning and cerebral blood flow - Areas of the brain most likely involved: frontal lobes, caudate nucleus (within basal ganglia), corpus callosum, and the pathways between these structures - Immaturity hypothesis: slower developing brainsunable to maintain attention & control behaviour - Explains why symptoms of ADHD decline with age - Dopamine: lower availability of D2/D3 receptor and dopamine transporter (DAT) in the midbrain - D2/D3 receptor associated with dimensions of inattention - Explains why attentional deficits most evident in tasks that are considered boring, repetitive, uninteresting, not intrinsically rewarding - Serotonin: not central to ADHD even if it play a role in impulsivity and aggressiveness Genetic Predisposition: - 10-35% of the immediate family members also likely to have the disorder - ASPD, alcoholism, and depression tend to run in families of ADHD children - Not clear what aspects are inherited - Molecular genetics: abnormality in dopamine transporter gene Prenatal & Birth Complications: - Maternal ingestions of large amounts of nicotine or barbiturates during pregnancy - Low birth weight or premature delivery - Difficult deliveryoxygen deprivation - Moderate to severe drinking by mothers during pregnancy - Exposure to high concentration of lead by ingesting lead-based paint as preschoolers - Gene-environment interactions are important - Stronger association between DAT1 and ADHD with maternal alcohol consumption during pregnancy - DAT1 associated with hyperactive-impulsive symptoms only in those exposed to maternal smoking during pregnancy Dietary Factors: - Large sugar consumptionnot supported - Subset of ADHD children have severe allergies to food additivesremoving these additives from dietsreduction in hyperactivity Disrupted Families: - Changes in residence or parental divorce - Fathers more prone to antisocial and criminal behaviours; interactions with mothers marked with hostility and conflict - Parental satisfaction and competence is lower in mothers of ADHD children - Mothers parenting behaviours are associated with the specific behaviours of the ADHD child - Even if actual parenting behaviour may not differ, parents of ADHD children still report lower parenting competence - Environmental adversity vs. genetic predisposition? - Family may not understand that ADHD child cannot voluntarily control his or her behaviour blame the child Drug Therapies: - Stimulants (Ritalin): increase dopamine levels in the synapses by enhancing release and inhibiting reuptake - Decreases demanding, disruptive, and non-compliant behaviour - Increases in positive mood, ability to be goal-directed, quality of interactions - Side effects: gastrointestinal upset, reduced appetite, insomnia, edginess; increase frequency of tics - Although drugs provide lasting improvement, adverse effects persist - Some abuse stimulants to get high (fake ADHD to get a prescription) - 20% increase in physician referrals for ADHD, 100.6% increase in Ritalin prescription - Increases recognition or inappropriate overuse of drugs? - Only 12% children meeting the diagnostic criteria received medication - 72% received drugs, but most did not have symptoms meeting the diagnostic criteriaboys & younger children especially likely to be prescribed in the absence of diagnostic symptoms - Clonidine & guanfacine: effect levels of norepinephrine - Help reduce tics - Increase cognitive performance - Side effects: dry mouth, fatigue, dizziness, constipation, sedation - Atomoxetine: inhibits the reuptake of norepinephrine - Antidepressants: prescribed particularly if they also have depression
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