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CHAPTER SIXTEENCHAPTER SIXTEENPsychological Disorders Psychological Disorders
of Childhoodof Childhood
Childhood DisordersChildhood Disorders Childhood psychopathology
Internalizing Disorders
Externalizing Disorders
ADHD, ODD, CD
Epidemiology
Etiology
Treatment
Childhood disorders outcome summary
Defining Defining Childhood Childhood
PsychopathologyPsychopathology Definitions of “normal” depend on age
Classification of many childhood disorders rests on our knowledge of normal childhood behavior
Childhood DisordersChildhood Disorders
Externalizing Disorders
problems in conforming to expected norms; often causes problems for others
Internalizing Disorders
experience of subjective distress; others often unaware of their difficulties
Childhood DisordersChildhood Disorders Childhood psychopathology
Internalizing Disorders
Externalizing Disorders
ADHD, ODD, CD
Epidemiology
Etiology
Treatment
Childhood disorders outcome summary
Diagnosing Internalizing Diagnosing Internalizing Disorders: Depression and Disorders: Depression and
AnxietyAnxiety Children can be diagnosed with “adult”
anxiety disorders (e.g., MDD, OCD, GAD)
Specific symptoms may differ from adults
Some symptoms may be absent due to children’s developmental differences
Difficulty in obtaining reliable information due to problems with self-reports
General symptoms Excessive distress associated with
separation Worry for separation and/or harm to
attachment figure School refusal Nightmares & complaints of physical
symptoms
Onset: before 18 years old
Duration: at least 4 weeks
Impairment
Separation Anxiety DisorderSeparation Anxiety Disorder
SAD is the most common anxiety disorder of childhood occurring in about 6% to 12% of all children
Equally common in boys and girls
About 80% to 90% of all children with SAD have another disorder (e.g., GAD, depression)
Children showing school refusal due to SAD tend to be younger, female, of lower SES, and from single parent families.
Separation Anxiety Disorder: Separation Anxiety Disorder: Prevalence & ComorbidityPrevalence & Comorbidity
Childhood DisordersChildhood Disorders Childhood psychopathology
Internalizing Disorders
Externalizing Disorders
ADHD, ODD, CD
Epidemiology
Etiology
Treatment
Childhood disorders outcome summary
Externalizing Disorders:Externalizing Disorders:Key FeaturesKey Features
rule violations
negativity, anger & aggression
impulsivity
hyperactivity
deficits in attention
Diagnosing Externalizing Diagnosing Externalizing DisordersDisorders
DSM-IV-TR divides externalizing disorders in to three major subtypes:
Attention deficit/hyperactivity disorder (ADHD)
Oppositional defiant disorder (ODD)
Conduct disorder (CD)
ADHD Diagnostic CriteriaADHD Diagnostic Criteria
Key features: hyperactivity, attention deficit and impulsivity symptoms begin before age 7 6 of 9 DSM-IV symptoms for 6 months symptoms visible across settings
Three subtypes Predominantly Inattentive Type Predominantly Hyperactive-Impulsive
Type Combined Type
ODD Diagnostic CriteriaODD Diagnostic Criteria
A pattern of negativistic, hostile and defiant behavior
e.g. loses temper, argues with adults, defies or refuses to comply with adults’ requests
Behavior causes significant impairment
Impairment last for at least 6 months
CD Diagnostic CriteriaCD Diagnostic Criteria Persistent and repetitive pattern of rule
violations/social norms
aggression to people, animals
destruction of property
deceitfulness or theft
serious rule violation
About 50% exhibit anti- social behavior into adulthood
Epidemiology: ADHDEpidemiology: ADHD
Problems may appear before age 3
Prevalence:
approximately 5% of school-age children
50-60% of children in special education
Some children continue to have ADHD as adults
The symptoms interfere with daily functioning in different ways over life
Epidemiology: ODD & CDEpidemiology: ODD & CD
Prevalence rates ODD about 5-7% Conduct Disorder about 2-4%
Higher in boys than girls
Etiology: Biological Etiology: Biological FactorsFactors
Behavior Genetics Recent study of 4000 Australian found
80% concordance for MZ twins, 40% for DZ twins in ADHD, suggesting a strong genetic component.
Neuropsychological Abnormalities
Food Additives and Sugar No evidence
Temperament
Etiology: Biological FactorsEtiology: Biological FactorsTemperamentTemperament
Easy
quickly form social relationships and follow discipline
Difficult
challenge parental authority
Slow-to-warm-up
shy & withdrawn
Etiology: Social FactorsEtiology: Social Factors
Peers, Neighborhoods, Television
Parenting styles
Coercion
Etiology: Social FactorsEtiology: Social FactorsParenting StylesParenting Styles
Etiology: Social FactorsEtiology: Social FactorsCoercionCoercion
Child wants a cookie
Parent says “no”
Child starts screamingParent gives in,
positively reinforcing child for throwing tantrum
Child stops screaming-Negatively reinforcing
parent for giving in
behavior is reinforced
Etiology: Psychological Etiology: Psychological FactorsFactors
Attachment Theory Secure attachments facilitate both
closeness and exploration Insecure (may be anxious, avoidant, or
disorganized) attachments predict later internalizing and externalizing problems and social difficulties
The “Strange Situation” Test
Self-Control
TreatmentTreatment ADHD:
psychostimulants (e.g. Ritalin, Adderral) antidepressants selective norepinephrine reuptake inhibitor
(e.g. Strattera) psychosocial treatment
ODD: behavior family
therapy
TreatmentTreatment
CD: Multisystemic
Therapy residential programs diversion programs
alternative to juvenile justice system
Childhood DisordersChildhood Disorders Childhood psychopathology
Internalizing Disorders
Externalizing Disorders
ADHD, ODD, CD
Epidemiology
Etiology
Treatment
Childhood disorders outcome summary
Childhood Disorders: Childhood Disorders: EpidemiologyEpidemiology
Approximately 20% of children have a mental disorder
Anxiety Disorders 13%
Mood Disorders 6.2%
Externalizing Disorders 10.3%
Suicide
Gender differences Boys are more likely to be in treatment than girls Referral differences between children and adults
Childhood Disorders: Childhood Disorders: Course & OutcomeCourse & Outcome
Prevalence rates of internalizing disorders increase with age
Externalizing disorders often continue into adulthood, but antisocial behavior rarely begins during adult life better prognosis for later-onset CD better prognosis for ADHD if NOT
comorbid w/ CD or ODD
Optional Optional SlidesSlides
Etiological Factors Etiological Factors Common to Most or All Common to Most or All
Childhood DisordersChildhood Disorders
Difficult Temperament
Insecure Attachment
Ineffective Parenting Styles
Emotion Dysregulation
Emotion DysregulationEmotion Dysregulation
Children fail to learn to recognize and control their emotions
Additional Etiological Additional Etiological FactorsFactors
Family risk factors
Troubled peer relationships
Sociometric Ratings & Sociometric Ratings & Childhood DisordersChildhood Disorders
Popular: many “liked most,” few “liked least” nominations
Average: few “liked least” but not as many “liked most” as popular
Rejected: many “liked least,” few “liked most” (opposite of popular)
Neglected: few “liked least,” few “liked most”
Controversial: many “liked least” and many “liked most”
Arbitrary Inferenceconclusions drawn in the absence of sufficient evidence or of any evidence at all
ExampleA young girl approaches a playground and finds two children laughing. Before having a chance to say hello, the others walk away and look towards her direction. The young girl concludes that she is unattractive and that the other children were laughing at her.
Cognitive Responses to Failure: Examples
Selective Magnification and Minimization
exaggerations in evaluating performance
Example 1A young boy makes a couple of mistakes while trying out for a school play; he believes that he will never get the part for which he is auditioning (magnification).
Example 2The same boy gets the part that he is hoping to have in a school play; he believes that the teacher just made a mistake in choosing him (minimization).
Cognitive Responses to Failure: Examples
Special TopicSpecial TopicChildhood Depression
Childhood Depression
Myths about childhood depression
Children can’t get depressed
Childhood depression is rare
Childhood depression is “just a phase”
Distressed infants show symptoms such as:
lethargy
eating and sleep problems
irritability
decreased attention & emotional expression
Developmental Differences
Preschoolers may demonstrate: irritability and anger
sad facial expressions and crying
anhedonia
somatic complaints, lethargy
eating and sleep problems
Developmental Differences
Middle Childhood (6-12) Unhappiness, decreased, socialization, sleep
problems, irritability, lethargy. Beginning around age 9, aggression, self-reports of
low self-esteem & helplessness, suicidal ideation
Adolescence Similar to middle childhood, plus pessimism,
feelings of worthlessness and apathy, comorbid substance abuse, eating disorders, antisocial behavior
Developmental Differences
Intellectual functioning
Interpersonal difficulties
Areas of Impairment
Elementary school 2-4% of community sample,
8-15% of inpatients
Adolescence 7% of community sample
Gender Differences Pre-puberty, either no gender difference or
slightly higher rates in boys By age 15, gender difference parallels that of
adults: rates among girls are twice those among boys
Epidemiology
Having a parent with a psychological disorder, especially a mood disorder, increases children’s risk of depression
Genetic/Biological Vulnerability May be similar to the
vulnerability for adult depression.
Etiology: Familial & Biological Factors
Depressed kids have more distorted cognitions than non-depressed kids
Learned Helplessness Model
Depressed youth more likely to report: Higher “personal helplessness” and
“universal helplessness” More internal, global, and stable
attributional style for negative events.
Etiology: Cognitive Factors
Vulnerabilities to Depression
Failing to form stable, secure attachments with parents
Abrupt separation of human and primate from mothers
Etiology: Attachment
Kids from divorced or single-parent families are at an increased risk
Hostile, tense, and punitive communication patterns within the family are more common among depressed youth
Etiology: Home Environment
Difficult to use adult treatments with kids because they have limited memory, attentional, and verbal capabilities
Because of kids’ involvement with family, family therapy may be crucial
Treatment
Cognitive Restructuring Focuses on identifying and changing cognitions
Role Playing Acting out interpersonal problems to improve
kids’ abilities to find solutions
Antidepressants No more effective than placebo
Treatment (cont’d)
End of Special TopicEnd of Special Topic
Fear & Anxiety in Children Children develop different fears for the first time at Children develop different fears for the first time at
different ages; the onset may be sudden and may have different ages; the onset may be sudden and may have no apparent environmental cause.no apparent environmental cause.
Some fears are both common and relatively stable Some fears are both common and relatively stable across different ages.across different ages.
Other fears become less frequent as children grow Other fears become less frequent as children grow older.older.
Behavior Therapy Main technique for behavior therapy for anxiety
disorders is exposure
Cognitive Behavioral Therapy Teaches children to understand how their thinking
contribute to their anxiety symptoms and how to modify their maladaptive thoughts
Family Intervention Anxiety disorders often occur in family context
Treatment of Childhood Treatment of Childhood Anxiety DisordersAnxiety Disorders
Distress expressed following separation from an attachment figure
A normal developmental phase
Children who fail to “outgrow” separation anxiety may be diagnosed with Separation Anxiety Disorder (SAD)
Separation Anxiety
Age of Onset, Developmental Course & Outcome
The earliest reported age of onset for SAD is 7 to 8 years, but children are often referred around 10 to 11 years
SAD typically progresses from mild to severe avoidance
SAD may be chronic or the onset may be sudden in a child who did not show any prior signs of a problem.