Child Psychopathology Exam 2
persistent depressive disorder
a depressive disorder associated with depressed or irritable mood; generally fewer, less severe, but longer-lasting symptoms than seen in major depressive disorder; and significant impairment in functioning
Dysphoria, anger, anhedonia, and excessive anxiety
are treated by educating the child about the relation between mood, thinking, and behavior, and by using anger management procedures, scheduling pleasant activities, and relaxation training
Interpersonal deficits
are treated using social skills training
Destructive-nondestructive dimension
ranges from acts such as cruelty to animals or physical assault to nondestructive behaviors such as arguing or irritability
hyperactive
constantly in motion
Coercion theory
contends that parent-child interactions provide a training ground for the development of antisocial behavior
overview of theories of depression: cognitive
depressive mindset; distorted or maladaptive cognitive structures, processes, and products; negative view of self, world, and future; poor problem-solving ability; hopelessness
life-course-persistent (LCP) path
describes children who engage in aggression and antisocial behavior at an early age and continue to do so into adulthood
Combined presentation (ADHD-C)
describes children who meet symptom criteria for both inattention and hyperactivity-impulsivity
predominantly hyperactive-impulsive presentation (ADHD-HI)
describes children who meet symptom criteria for hyperactivity-impulsivity but not inattention
predominantly inattentive presentation (ADHD-PI)
describes children who meet symptom criteria for inattention but not hyperactivity-impulsivity
adolescent-limited (AL) path
describes youths whose antisocial behavior begins around puberty and continues into adolescence, but who later cease these behaviors during young adulthood
Treatments for Youngsters with Depression: Interpersonal Psychotherapy for Adolescent Depression
explores family and interpersonal interactions that maintain depression. Family sessions are supplemented with individual sessions in which youngsters with depression are encouraged to understand their own negative cognitive style and the effects of their depression on others and to increase pleasant activities with family members and peers
overview of theories of depression: interpersonal
impaired interpersonal functioning related to grief over loss; role dispute and conflict; role transition; interpersonal deficit; single parenting; social withdrawal; interaction between mood and interpersonal events
overview of theories of depression: behavioral
lack or loss of reinforcement or quality of reinforcement or quality of renforcement; deficits in skills needed to obtain reinforcement
Inattentive
lacking the ability to focus or sustain one's attention. Children who are inattentive find it difficult to sustain mental effort during work or play and behave carelessly, as if they are not listening
Summary of Risk Factors for Antisocial Behaviors: Sociocultural
media portrayal of violence, cultural attitudes encouraging use of aggression, socialization of children for aggression
presentation type
refers to a group of individuals with something in common- symptoms, etiology, problem severity, or likely outcome-that makes them distinct from other groupings
Inattention
refers to an inability to sustain attention or stick to tasks or play activities, to remember and follow through on instructions or rules, and to resist distractions. -it also involves difficulties in planning and organization and in timeliness and problems in staying alert
alerting
refers to an initial reaction to a stimulus; it involves the ability to prepare for what is about to happen. It helps the child achieve and maintain an optimally alert attentional state
emotional regulation
refers to the process by which emotional arousal is redirected, controlled, or modified to facilitate adaptive functioning and the balance maintained among positive, negative, and neutral mood states
Tic disorders
sudden, repetitive, nonrhythmic motor movements or sounds such as eye blinking, facial grimacing, throat clearing, and grunting
Effective Treatments for Children with Conduct Problems: Parent Management Training
teaches parents to change their child's behavior in the home and in other settings using contingency management techniques. The focus is on improving parent-child interactions and enhancing other parenting skills
Treatments for Youngsters with Depression: Medication
treats mood disturbances and other symptoms of depression using antidepressants, especially selective serotonin reuptake inhibitors (SSRIs)
callous and unemotional interpersonal style
characterized by an absence of guilt, lack of empathy, uncaring attitudes, shallow or deficient emotional responses, and related traits of narcissism and impulsivity
four categories of conduct problems
(A) covert-destructive, or property violations; (B) overt-destructive, or aggression; (C) covert-nondestructive, or status violations; and (D) overt-nondestructive, or oppositional behavior. Children who display overt-destructive behaviors, particularly persistent physical fighting, are at especially high risk for later psychiatric problems and impairment in functioning
Several lives of evidence point to genetic influences as key causal factors in ADHD:
-ADHD runs in families. About 1/3 of the biological relatives of children with ADHD also have the disorder -adoption studies. Rates of ADHD are nearly three times higher in biological parents of children with ADHD, as compared with adoptive parents of children with ADHD -twin studies. Twin studies report extraordinarily high heritability estimates for ADHD, averaging about 75% for hyperactive-impulsive and inattentive behaviors, making ADHD among the most heritable of the childhood disorders -specific gene studies. Molecular genetic analysis suggests that specific genes may contribute to the expression of ADHD
Treatment of Depression
-cognitive-behavioral therapy and interpersonal psychotherapy have had the most success in treating depression in young people -SSRIs have been recommended as the first line of drug treatment for children with depression, but concerns have been raised about their use -a high priority needs to be given to programs aimed at preventing depression in young people
Core Characteristics
-DSM-5 uses two lists of symptoms to define ADHD. The first list includes symptoms of inattention, poor concentration, and disorganization. The second list includes symptoms of hyperactivity-impulsivity -children who are inattentive find it difficult to sustain mental effort during work or play and find it difficult to resist salient distractions while doing so -children with ADHD are extremely active, but unlike other children with a high energy level, they accomplish very little -children with ADHD are impulsive, which means they seem unable to bridle their immediate reactions or they may fail to think before they act -DSM specifies three presentation types of ADHD based on primary symptoms: predominantly inattentive, predominantly hyperactive-impulsive, or both -a diagnosis of ADHD requires the appearance of symptoms before age 12, a greater frequency and severity of symptoms than in other children of the same age and gender, persistence of symptoms, occurrence of symptoms in several settings, and impairments in functioning -although useful, the DSM criteria have several limitations; an important one is developmental insensitivity
A possible developmental pathway for ADHD
-Genetic risk for ADHD -prenatal alcohol or tobacco exposure, pregnancy complications -disturbances in dopamine transmission, abnormalities in the frontal lobes and basal ganglia -failure to adequately suppress inappropriate responses -cognitive deficits in working memory, self-directed speech, self-regulation -behavioral symptoms of inattention, hyperactivity, impulsivity -impairments in social and academic development -disruptions in parenting -oppositional and conduct disorder symptoms
Prevalence, Gender, and Course
-ODD is more prevalent than CD during childhood, but by adolescence the two occur about equally. The lifetime prevalence rates for ODD and CD are about 12% and 8% respectively -during childhood, conduct problems are about 2 to 4 times more common in boys than in girls. This difference narrows greatly in early adolescence, due mainly to a rise in covert nonaggressive antisocial behavior in girls, and then increases again in late adolescence and beyond -girls are more likely than boys to use indirect forms of relational aggression - for example, verbal insults, gossip, or third-party retaliation -there is a general progression of antisocial behavior from difficult early temperament and hyperactivity, to oppositional and aggressive behavior, to social difficulties, to school problems, to delinquent behavior in adolescence, to antisocial personality development, to criminal behavior in adulthood -the life-course-persistent path describes children who display antisocial behavior at an early age and who continue to do so into adulthood -the adolescent-limited path describes teens whose antisocial behavior begins around puberty and continues into adolescence and who later cease these behaviors in young adulthood -a significant number of children with conduct problems continue to experience difficulties as adults, including criminal behavior, psychiatric problems, social maladjustment, health and employment problems, and poor parenting of their own children
Accompanying Psychological Disorders and Symptoms
-a factor that makes ADHD so challenging is that children with the disorder have much higher than expected rates of other psychiatric disorders, particularly conduct problems, anxiety, and mood disorders -as many as 50% of children with ADHD also meet criteria for oppositional defiant disorder or conduct disorder -about 25% or more of children with ADHD experience excessive anxiety. The presence of co-occurring anxiety is associated with more social and academic difficulties, and greater long term impairment and mental health problems -as many as 20% to 30% children with ADHD experience depression or another mood disorder. Although depression may be partly related to demoralization as a result of their symptoms, it also can result from an elevated risk for depression in families of children with ADHD -the relation between ADHD and bipolar disorder is controversial. A diagnosis of childhood bipolar disorder disorder appears to sharply increase the child's risk for previous or co-occurring ADHD, but a diagnosis of ADHD does not appear to elevate the child's risk for bipolar disorder -children with ADHD may display motor coordination difficulties and tic disorders
Bipolar Disorder
-a recent surge in interest in the diagnosis of bipolar disorder (BP) in children and adolescents has generated considerable controversy surrounding difficulties in identifying the disorder in young people -youngsters with BP show periods of abnormally and persistently elevated, expansive, and/or irritable mood -they may display symptoms such as an inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, and reckless behavior -BP is far less common than MDD in young people, with lifetime prevalence estimates of 0.5% to 2.5% worldwide -BP has a peak age at onset in late adolescence and, unlike depression, affects males and females about equality -the most common accompanying disorders are ADHD, anxiety disorders, conduct problems, and substance abuse -very few studies have examined the causes of BP in children and adolescents. Family and gene studies with adults indicate that BP is the result of a genetic vulnerability in combination with environmental factors, such as life stress or disturbances in the family -brain-imaging studies of youngsters with BP point to abnormalities in regions of the brain involved in emotion regulation, including the amygdala and anterior cingulate cortex -BP in young people requires a multimodal treatment plan with education of the patient and the family about the illness, medication, and psychosocial interventions to address the youngster's symptoms and related psychosocial impairments
accompanying disorders and symptoms
-about 50% of children with CD also have ADHD. Despite the overlap, CD and ADHD appear to be distinct disorders -about 50% of children with conduct problems are diagnosed with depression or a co-occurring anxiety disorder. Symptoms of negative mood associated with ODD best account for the relationship between conduct problems and depression -anxiety related to shyness, inhibition, and fear may protect against conduct problems, whereas anxiety associated with negative emotionality and social avoidance/withdrawl based on a lack of caring about others may increase the child's risk for conduct problems
Several important features of antisocial behaviors in the context of normal development
-antisocial behaviors vary in severity, from minor disobedience to fighting -some antisocial behaviors decrease with age (e.g., disobeying at home), whereas others increase with age and opportunity (e.g., hanging around with kids who get into trouble). -antisocial behaviors are more common in boys than in girls during childhood, but this difference narrows in adolescence
To Diagnose ADHD using DSM-5, the symptoms must also:
-appear before age 12 -persist for more than 6 months -occur more often and with greater severity than in other children of the same age and sex -occur across two or more settings (e.g., home, school, other activities) -interfere with, or reduce the quality of, social, academic, or occupational functioning -not be better explained by another mental disorder (e.g., mood disorder, anxiety disorder)
Description and History
-attention-deficit/hyperactivity disorder (ADHD) is manifested in children who display persistent age-inappropriate symptoms of inattention, hyperactivity, and impulsivity that cause impairment in major life activities -ADHD can only be identified by characteristic patterns of behavior, which vary quite a bit from child to child -the behavior of children with ADHD is a constant source of stress and frustration for the child and for parents, siblings, teachers, and classmates; it also has high costs to society -the disorder that we now call ADHD has had many different names, primary symptoms, and presumed causes, and views of the disorder are still evolving
Associated Characteristics
-besides their primary difficulties, children with ADHD display other problems, such as cognitive and learning deficits, speech and language impairments, motor incoordination, medical and physical concerns, and social problems -children with ADHD display deficits in executive functions, the higher-order mental processes that underlie the child's capacity for planning and self-regulation -children with ADHD score slightly lower in IQ tests, but most are of normal intelligence. Their difficulty is in applying their intelligence to everyday life situations -Children with ADHD experience school performance difficulties, including lower grades, a failure to advance in grade, and more frequent placements in special education classes. -many children with ADHD have a specific learning disorder, typically in reading, spelling, or math -some children with ADHD report a higher self-esteem than is warranted by their behavior, referred to as a "positive bias" -they often have speech and language impairments and have difficulty using language in everyday situations -they may experience many health-related problems, including enuresis and encopresis, asthma, obesity, eating problems, and sleep disturbances and tend to be accident-prone. The costs of and medical service use in those with ADHD are high -They experience numerous social problems with family members, teachers, and peers
Several key features of CD
-children with CD engage in severe antisocial behaviors. Greg set fires and tried to suffocate his 2 year old brother. He also displayed less severe problems, such as noncompliance and temper tantrums, but these weren't the main reasons for referral. DSM-5 includes severity ratings for CD of "mild," "moderate," and "severe" based on the number of symptoms in excess of the three required to make the diagnosis or the amount of harm caused to others -they often have co-occurring problems such as ADHD, academic deficiencies, and poor relations with peers -their families often use child-rearing practices, such as harsh punishment, that contribute to the problem and often have their own problems and stresses, such as marital discord, psychiatric problems, and unemployment. Greg's mother had a history of depression and his father was frequently unemployed -their parents feel these children are out of control, and they feel helpless to do anything about it. Greg's parents want to give him up or put him in a boarding school.
Persistent Depressive Disorder [P-DD] (Dysthymia)
-children with P-DD display a depressive or irritable mood for most of the day, on most days for at least 1 year. While depressed, they also experience a number of somatic and cognitive symptoms -about 5% of children and adolescents have an episode of P-DD by the end of adolescence -the most common disorders accompanying P-DD are superimposed MDD, anxiety disorders, CD, and ADHD -the most common age at onset for P-DD is between 11 and 12 years, with an average episode length of between 2 and 5 years -almost all young people eventually recover from their P-DD, but many will develop MDD -children who recover from their P-DD differ from other children mainly on measures of psychosocial functioning -P-DD is a revised category in DSM-5 that combines the previous DSM-IV categories of Dysthymic Disorder and MDD- Chronic. This was done because of the lack of differences between youths with a dysthymic disorder and those with a chronic type of major depression
Overview of Mood Disorders
-children with mood disorders suffer from extreme, persistent, or poorly regulated emotional states- for example, excessive unhappiness, irritability, or swings in mood from deep sadness to high elation -mood disorders are common and are among the most persistent and disabling illnesses in young people -there are two major types of mood disorders: depressive disorders and bipolar disorders
DSM-5: Defining Features
-children with oppositional defiant disorder display an age-inappropriate pattern of stubborn, hostile, and defiant behaviors that reflect symptoms of emotionality and temperamental activity. ODD symptoms can be grouped into three dimensions: negative affect, defiance, and vindictiveness -conduct disorder describes children who display severe aggressive and antisocial acts involving inflicting pain upon others or interfering with the rights of others through physical and verbal aggression, stealing, or committing acts of vandalism -children who display childhood- onset CD are more likely to be boys, show more aggressive symptoms, account for a disproportionate amount of illegal activity, and persist in their antisocial behavior over time -children with adolescent-onset CD are as likely to be girls as boys and do not display the severity or psychopathology that characterizes the childhood-onset group -there is much overlap between CD and ODD. However, most children who display ODD do not progress to more severe CD -persistent aggressive behavior and conduct problems in childhood may be a precursor of adult antisocial personality disorder, a pervasive pattern of disregard for, and violation of the rights of others -a subgroup of children with conduct problems display psychopathic features, including callous-unemotional traits such as lacking in guilt, not showing empathy, and not displaying feelings or emotions. These children also display a preference for novel and perilous activities and a diminished sensitivity to cues for danger and punishment when seeking rewards -DSM-5 uses the specifier "with limited prosocial emotions" to describe youth with CD who display a pattern of interpersonal and emotional functioning involving a lack of remorse or guilt, empathy, or concern about performance
Executive functions are varied and include:
-cognitive processes, such as working memory, mental computation, planning and anticipation, flexibility of thinking, and the use of organizational strategies -language processes, such as verbal fluency and the use of self-directed speech -motor processes, such as allocation of effort, following prohibitive instructions, response inhibition, and motor coordination and sequencing -emotional processes, such as self-regulation of arousal level and tolerating frustration
Causes
-conduct problems in children are best accounted for by multiple causes or risk and protective factors that operate in a transactional fashion over time -adoption and twin studies indicate that genetic influences account for about 50% of the variance in antisocial behavior. -genetic contributions to overt forms of antisocial behavior, such as aggression, are stronger than for covert acts, such as stealing or lying -antisocial behavior may result from an overactive behavioral activation system and an underactive behavioral inhibition system. Low levels of cortical arousal and autonomic reactivity and deficits in the amygdala, prefrontal cortex, and other brain regions play an important role, particularly for childhood-onset/persistent CD -many family factors have been implicated as possible causes of children's antisocial behavior, including marital conflict, family isolation, violence in the home, poor disciplinary practices, a lack of parental supervision, and insecure attachments -family instability and stress, parental criminality and antisocial personality, and antisocial family values are risk factors for conduct problems -the structural characteristics of the community provide a backdrop for the emergence of conduct problems by giving rise to community conditions that interfere with the adoption of social norms and the development of productive social relations -school, neighborhood, and media influences are all potential risk factors for antisocial behaviors, as are cultural factors, such as minority group status and ethnicity
Description of Conduct Problems
-conduct problems or antisocial behavior(s) are age inappropriate actions and attitudes of a child that violate family expectations, societal norms, and the personal or property rights of others. These children display problems in the self-control of emotions and behaviors -the nature, causes, and outcomes of conduct problems in children are wide-ranging, requiring that we consider several different types and pathways -many different children with severe conduct problems grow up in extremely unfortunate family and neighborhood circumstances
Treatment and Prevention
-considerable efforts to help children and adolescents with conduct problems have led to several approaches with some proven success -the focus of parent management training is on teaching parents to change their child's behavior in the home -the underlying assumption of problem-solving skills training is that faulty perceptions and appraisals of interpersonal events trigger antisocial responses. The focus is on changing behavior by changing the way the child thinks in social situations -multisystemic therapy is an intensive approach that is carried out with all family members, school personnel, peer, juvenile justice staff, and other individuals in the adolescent's life -recent efforts have focused on trying to prevent conduct problems through intensive programs of early intervention/prevention -the degree of success or failure in treating antisocial behavior depends on the type and severity of the child's conduct problem and related risk and protective factors
Depressive disorders
-depression in young people involves numerous and persistent symptoms, including impairments in mood, behavior, attitudes, thinking, and physical functioning -for a long time it was mistakenly believed that depression did not exist in children in a form comparable to depression in adults -it is now known that depression in young people is prevalent, disabling, and often under-referred -the way in which children express and experience depression changes with age -it is important to distinguish between depression as a symptom, a syndrome, and a disorder -three types of DSM-5 depressive disorders are major depressive disorder (MDD), persistent depressive disorder [P-DD], or dysthymia, and disruptive mood dysregulation disorder (DMDD)
Causes of Depression
-depression is likely a final common pathway for interacting influences that predispose a child to develop the disorder -family and twin studies and specific gene studies suggest that what may be inherited is a vulnerability to depression and anxiety and that certain environmental stressors may be required to express these disorders -youngsters with depression may experience heightened reactions to stress that increase their vulnerability to depression. Studies of neurobiological correlates have focused on limbic and prefrontal neural circuits; teh HPA axis; sleep abnormalities; growth hormone; variants in BDNF, which is involved in nerve growth and development; and the brain neurotransmitters serotonin, dopamine, and norepinephrine. -families of children with depression display anger and conflict, greater use of control, less effective communication, more overinvolvement, and less warmth and support than families of children who are not depressed -children of depressed parents experience increased rates of depression before puberty; higher rates of phobias, panic disorder, and alcohol dependence as adolescents and adults; and other negative health outcomes. -depression is associated with both severe stressful life events, such as a move to a new neighborhood, and less severe stressful events or daily hassles, such as criticism from a teacher or an argument with a boyfriend. -young children who experience prolonged periods of emotional distress and sadness may have problems in regulating their negative emotional states and may be prone to the development of depression
The DSM-5 criteria for ADHD have a number of limitations:
-developmentally insensitive. -categorical view of ADHD
Differences in brain function between children with and without ADHD
-differences on psychophysiological measures, suggesting diminished arousal or arousability -differences on measures of brain activity during vigilance tests, suggesting underresponsiveness to stimuli and deficits in response inhibition -differences in blood flow to the prefrontal regions of the brain and the pathways connecting these regions to the limbic system and cerebellum, suggesting decreased blood flow to these regions
Approximate ordering of the different forms of disruptive and antisocial behavior from childhood through adolescence
-difficult temperament -hyperactivity -overt conduct problems aggressiveness/ oppositionality -withdrawl -poor peer relationships -academic problems -covert or concealing conduct problems -association with deviant peers -delinquency (arrest)
Disruptive Mood Dysregulation Disorder (DMDD)
-disruptive mood dysregulation disorder (MDD) is characterized by frequent and severe temper outbursts and chronic, persistently irritable or angry mood -DMDD is a new disorder in DSM-5, and it is the one we know the least about -the development of the DMDD category was a response to increasing rates of bipolar disorder diagnoses in young children; it was intended to provide an alternative to diagnosing BP in young children too frequently -further research and clinical data are needed to determine whether the DMDD diagnosis will prove to be reliable, valid, and useful in clinical practice
Developmental coordination disorder
a condition characterized by marked motor incoordination and delays in achieving motor milestones
Context, Costs, and Perspectives
-for most children, antisocial behaviors appear and then decline during normal development, although children who are most aggressive maintain their relative standing over time -costs to the educational, health, social service, criminal justice, and mental health systems that deal with youth make conduct problems one of the most costly mental health problems in North America -from a legal perspective, conduct problems are defined as criminal acts that result in apprehension and court contact and are referred to as "delinquency" -from a psychological perspective, conduct problems fall along a continuous dimension of externalizing behavior, which includes a mix of impulsive, overactive, aggressive, and rule-breaking acts -from a psychiatric perspective, conduct problems are viewed as distinct categories of mental disorder based on DSM symptoms. These are called disruptive, impulse control, and conduct disorders, and include oppositional defiant disorder (ODD) and conduct disorder (CD) -a public health perspective cuts across disciplines and blends the legal, psychological, and psychiatric perspectives with public health concepts of prevention and intervention
associated characteristics
-many children with conduct problems show cognitive, verbal, and language deficits, despite their normal intelligence -these children experience a variety of school difficulties, including academic underachievement in language and reading, which may result from co-occurring ADHD -general family disturbances, and disturbances in parenting practices and family functioning, are among the strongest and most consistent correlates of conduct problems -children with conduct problems have interpersonal difficulties with peers, including rejection and bullying. Their friendships are often with other antisocial children -antisocial behavior may be related to an inflated, unstable, and/or tentative view of self -youths with conduct problems engage in many behaviors that place them at high risk for health-related problems, including personal injuries, illnesses, sexually transmitted diseases, and substance abuse
Theories of Depression
-psychodynamic theories presume that depression results from the actual or symbolic loss of a love object and view depression as the conversion of aggressive instinct into depressive affect -attachment theories focus on insecure attachment, a view of the self as unworthy and unloved, and a view of others as threatening or undependable as risk factors for later depression, particularly in the context of stressful interpersonal relationships -behavioral views emphasize the importance of learning, environmental consequences (particularly a lack of response-contingent reinforcement), and skills deficits during the onset and maintenance of depression -cognitive theories of depression focus on the relation between negative thinking and mood, with the underlying assumption that how young people view themselves and their world will influence their mood and behavior -other theories of depression have emphasized the role of deficits in self-control, interpersonal disturbances, stressful life events, and genetic and neurobiological processes
Adolescents learn that depression can have many causes, including inherited tendencies, stress, and excessive negative thinking. Relaxation training is then used to quickly provide a successful experience and some immediate relief. Subsequent sessions include the following components:
-self-change skills, such as self-monitoring of mood and behavior, and ways to establish realistic goals, are taught -pleasurable activities and opportunities for reinforcement are increased -positive thinking is increased by identifying, challenging, and changing negative cognitions -training in social, communication, and problem-solving skills is integrated throughout the program -specific skills are taught, such as conversational skills, ways to plan social activities, and ways to make friends -goal setting is used to identify short- and long-term life goals and potential barriers to these goals -final sessions emphasize integrating the skills learned and making plans for the future
Steps in the Thinking and Behavior of Aggressive Children in Social Situations
-step 1: encoding. socially aggressive children use fewer cues before making a decision. When defining and resolving an interpersonal situation, they seek less information about the event before acting -step 2: interpretation. socially aggressive children attribute hostile intentions to ambiguous events -step 3: response search. socially aggressive children generate fewer and more aggressive responses and have less knowledge about social problem solving -step 4: response decision. Socially aggressive children are more likely to choose aggressive solutions -step 5: enactment. Socially aggressive children use poor verbal communication and strike out physically
Coercive Parent-Child Interaction: Four-step escape conditioning sequence
-step 1: raising her voice, Paul's mother scolds, "Why are you sitting in front of the tv when you should be doing your homework?" -step 2: Paul snaps back, "school is boring, my teachers are stupid, and I don't have any homework to do." Paul's arguing has the immediate effect of punishing his mother for her scolding and, over time, may reduce her efforts to do something about his homework and school problems -step 3: Paul's mother withdraws her demand for him to complete his homework, allowing herself to be satisfied that he does not have any homework to do. She lowers her voice and says, "Does Mrs. Smith still put everyone to sleep in her English class?" The mother's withdrawal of her demand for homework reinforced Paul's arguing and increases the chances that the next time she makes an issue of homework, he will argue with her. Over time, Paul may also turn up the volume of his negative reactions by shouting or throwing things -step 4: as soon as Paul's mother withdraws her demand, Paul stops arguing and engages in neutral or even positive behavior. He says "You're sure right about Mrs. Smith, Mom. It's tough to keep your eyes open in her class." Paul, by ceasing his noxious behavior, reinforces his mother for giving in and increases the likelihood that she will do so again in response to his arguing and protests
Prevalence and Course
-the best estimate is that ADHD affects about 5% to 9% of all school-age children -the diagnosis of ADHD is about two to three times more common in boys than in girls -girls with ADHD have a significant disorder; clinic-referred girls with ADHD display many of the same features and outcomes as boys with ADHD -ADHD occurs across all socioeconomic levels and has been identified in every country where it has been studied -symptoms of ADHD change with development. A difficult temperament as an infant may be followed by hyperactive-impulsive symptoms at 3 to 4 years of age, which are followed, in turn, by the increasing visibility of symptoms of inattention around the time that the child begins school -although some symptoms of ADHD may decline in prevalence and intensity as children grow older, for many individuals ADHD is a lifelong and painful disorder
Major Depressive Disorder (MDD)
-the key features of MDD are sadness, loss of interest or pleasure in nearly all activities, and irritability, plus many specific symptoms that are present for at least 2 weeks -the overall prevalence of MDD annually for youths 4 to 18 years of age is between 2% and 8%, with rates that are low during childhood but increase dramatically during adolescence. The likelihood that a youth has ever had MDD is higher, from 10% to 20% more. -the most frequent accompanying disorders in young people with MDD are anxiety disorders, persistent depressive disorder, conduct problems, ADHD, and substance-use disorder -almost all young people recover from their initial depressive episode, but about 70% have another episode within 5 years and many develop bipolar disorder -depression in preadolescent children is equally common in boys and girls, but the ratio of girls to boys is about 2:1 and to 3:1 after puberty -the relationship between depression and race/ethnicity during childhood and adolescence is an understudied area
Theories and Causes
-theories about possible mechanisms and causes for ADHD have emphasized deficits in cognitive functioning, reward/motivation, arousal level, and self-regulation -there is strong evidence that ADHD is a neurodevelopmental disorder; however, biological and environmental risk factors together shape its expression -findings from family, adoption, twin, and specific gene studies suggest that ADHD is inherited, although the precise mechanisms are not yet known -many factors that compromise the development of the nervous system before and after birth may be related to ADHD symptoms, such as pregnancy and birth complications, maternal smoking during pregnancy, low birth weight, malnutrition, maternal alcohol or drug use, early neurological insult or trauma, and diseases of infancy -ADHD appears to be related to abnormalities and developmental delays in the frontostriatal circuitry of the brain and the pathways connecting this region with the limbic system, the cerebellum, and the thalamus -neuroimaging studies tells us that in children with ADHD there is a structural difference or less activity in certain regions of the brain, but they don't tell us why -the known action of effective medications for ADHD suggests that several neurotransmitters are involved, with most evidence suggesting a selective deficiency in the availability of both dopamine and norepinephrine -psychosocial factors in the family do not typically cause ADHD, although they are important in understanding the disorder. Family problems may lead to a greater severity of symptoms and relate to the emergence of co-occurring conduct problems -ADHD is likely the result of a complex pattern of interacting influences, perhaps giving rise to the disorder through several nervous system pathways
Treatment
-there is no cure for ADHD, but a variety of treatments can be used to help children cope with their symptoms and any secondary problems that may arise over the years -the primary approach to treatment combines stimulant medication, parent management training, and educational intervention -stimulants are the most effective treatment for managing symptoms of ADHD; however, their limited long-term benefit raises important issues about their clinical uses that are yet to be resolved -parent management training provides parents with a variety of skills to help them manage their child's oppositional and defiant behaviors and cope with the difficulties of raising a child with ADHD -educational interventions focus on managing inattentive and hyperactive-impulsive behaviors that interfere with learning and on providing a classroom environment that capitalizes on the child's strengths -findings from the MTA study, a landmark controlled comparison of intensive treatments for ADHD, suggest that for children with uncomplicated ADHD, medication may be the best treatment option; however, for those with ADHD and oppositional symptoms, poor social functioning and ineffective parenting, combining medication and behavioral treatment may be the best option -additional interventions for ADHD include family counseling and support groups, and individual counseling for the child
Associated Characteristics of Depressive Disorders
-youngsters with depression have normal intelligence, although certain symptoms such as difficulty concentrating, loss of interest, and slowness of thought may negatively affect intellectual functioning -they perform more poorly than others in school, score lower on standard achievement tests, and have lower levels of grade attainment -they often experience deficits and distortions in their thinking, including negative beliefs, attributions of failure, and self-critical automatic negative thoughts -almost all youngsters with depression experience low or unstable self-esteem -youngsters with depression have few friends and close relationships, feel lonely and isolated, and feel that others do not like them -they experience poor relationships and conflict with their parents and siblings, who in turn may respond in a negative, dismissing, or harsh manner -most youngsters with depression report suicidal thinking, and about 30% who think about killing themselves actually attempt it
The nine principles of multisystemic therapy
1. finding the fit: the primary purpose of assessment is to understand the "fit" between the identified problems and their broader systemic context 2. positive and strength-focused: therapeutic contacts emphasize the positive and use systemic strengths as levers for change 3. increasing responsibility: interventions are designed to promote responsible behavior and decrease irresponsible behavior among family members 4. present-focused, action-oriented, and well defined: interventions are present-focused and action-oriented, targeting specific and well-defined problems 5. targeting sequences: interventions target sequences of behavior within and between multiple systems that maintain identified problems 6. developmentally appropriate: interventions are developmentally appropriate and fit the developmental needs of the youth 7. continuous effort: interventions are designed to require daily or weekly effort by family members 8. evaluation and accountability: intervention efficacy is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes 9. generalization: interventions are designed to promote treatment generalization and long-term maintenance of therapeutic change by empowering caregivers to address family members' needs across multiple systemic contexts`
disruptive mood dysregulation disorder
A DSM-5 depressive disorder characterized by: (1) frequent and severe temper outbursts that are extreme over-reactions to the situation or provocation; and (2) chronic, persistently irritable or angry mood that is present between the severe temper outbursts
ACTION acronym
A= always find something to do to feel better C= catch the positive T= think about it as a problem to be solved I= inspect the situation O= open yourself to the positive N= never get stuck in the negative muck
Impaired Executive Functions in ADHD and Examples of Resulting Impairments
Impaired Executive Function: 1. organize, prioritize, and activate Resulting impairment: 1. trouble getting started, difficulty organizing work, misunderstand directions Impaired executive function: 2. focus, shift, and sustain attention Resulting impairment: 2. lose focus when trying to listen, forget what has been read and need to reread, easily distracted Impaired executive function: 3. regulate alertness, effort, and processing speed resulting impairment: 3. excessive daytime drowsiness, difficulty completing a task on time, slow processing speed impaired executive function: 4. manage frustration and modulate emotion resulting impairment: 4. very easily irritated, feelings hurt easily, overly sensitive to criticism impaired executive function: 5. working memory and accessing recall resulting impairment: 5. forget to do a planned task, difficulty following sequential directions, quickly lose thoughts that were put on hold impaired executive function: 6. monitor and regulate action resulting impairment: 6. find it hard to sit still or be quiet, rush things, slapdash, often interrupt, blurt things out
Externalizing Behavior
a continuous dimension of behavior that includes a mixture of impulsive, overactive, aggressive, and delinquent acts
sluggish cognitive tempo (SCT)
a cluster that includes symptoms such as daydreaming, trouble staying awake/alert, mentally foggy/easily confused, slow processing of information, stares a lot, spacey, loses train of thought, forgets what was going to say, and appearing lethargic, hypoactive, or even sleepy
irritability
a common symptom of major depressive disorder and disruptive mood dysregulation disorder characterized by easy annoyance and touchiness, an angry mood, and temper outbursts
major depressive disorder
a form of depressive disorder characterized by five or more mood, cognitive, psychomotor, or somatic symptoms that have been present during the same 2-week period; at least one of the symptoms is either depressed mood most of the day, nearly every day, or markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
Disruptive behavior disorders
a general term used to describe repetitive and persistent patterns of antisocial behavior such as oppositional defiant disorder and conduct disorder
anhedonia
a negative mood state characterized by a lack of enjoyment in anything one does and a loss of interest in nearly all activities
dysphoria
a negative mood state characterized by prolonged bouts of sadness
oppositional defiant disorder
a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months and exhibited during interaction with a least one individual who is not a sibling
Positive Bias
a person's report of higher self-esteem than is warranted by his or her behavior. This exaggeration of one's competence may, for example, cause a child with ADHD to perceive their relationships with their parents no differently than do control children, even though their parents see things in a more negative light.
Quality of life
a person's subjective perception of their position in life as evidenced by their physical, psychological, and social functioning
antisocial personality disorder
a pervasive pattern of disregard for, and violation of, the rights of others, including repeated illegal behaviors, deceitfulness, failure to plan ahead, repeated physical fights or assaults, reckless disregard for the safety of self or others, repeated failure to sustain work behavior or honor financial obligations, and a lack of remorese
Conduct Disorder (CD)
a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested in symptoms of aggression toward people and animals, destruction of property, deceitfulness or theft, or serious violations of rules
adolescent-onset conduct disorder
a specific type of conduct disorder for which individuals show no symptom characteristic of conduct disorder prior to age 10 years
frontostriatal circuitry of the brain
a structure of the brain consisting of the structure of the brain consisting of the prefrontal cortex and the basal ganglia; associated with attention, executive functions, delayed response, and response organization. Abnormalities within this structure have been linked to ADHD
Depressive ruminative style
a style of thinking displayed by depressed individuals; it is characterized by a narrow and passive focus on negative events for long periods of time
"with limited prosocial emotions"
a term used in DSM-5 to describe youths with conduct disorder who display a persistent and typical pattern of interpersonal and emotional functioning involving at least two of the following three characteristics: lack of remorse or guilt; callous - lack of empathy; and unconcerned about performance
bipolar disorder
a type of mood disorder characterized by an ongoing combination of extreme highs and extreme lows. An episode of mania is an abnormally elevated or expansive mood, and feelings of euphoria are an exaggerated sense of well-being. The highs may alternate with lows, or both extremes may be felt at about the same time
mania
abnormally elevated or expansive mood, increased goal-directed activity and energy, and feelings of euphoria
impulsive
acting without thinking
overview of theories of depression: psychodynamic
actual or symbolic loss of love object (e.g., caregiver) that is loved ambivalently; anger toward love object turned inward; excessive severity of the superego; loss of self-esteem
Treatments for Youngsters with Depression: Behavior therapy
aims to increase behaviors that elicit positive reinforcement and to reduce punishment from the environment. May involve teaching social and other coping skills, and using anxiety management and relaxation training
Executive functions
are cognitive processes in the brain that activate, integrate, and manage other brain functions. They underlie the child's capacity for self-regulation functions such as self-awareness, planning, self-monitoring, and self-evaluation.
Overt-covert dimension
an independent dimension consisting of a continuum of antisocial behavior ranging from overt forms such as physical aggression at one end, to covert forms (i.e., hidden or sneaky acts) at the other. The overt forms of antisocial behavior correspond roughly to those on the aggressive subdimension of the externalizing dimension, whereas the covert behaviors correspond roughly to those on the delinquent subdimension of the externalizing dimension
Effective Treatments for Children with Conduct Problems: Multisystemic Therapy
an intensive approach that draws on other techniques such as PMT, PSST, and marital therapy, as well as specialized interventions such as special education, and referral to substance abuse treatment programs or legal services
Summary of Risk Factors for Antisocial Behaviors: Family
antisocial family values, parental antisocial or criminal behavior, paternal antisocial personality disorder, maternal depression, paternal substance abuse, marital discord, teen motherhood, single parenthood, family stress/conflict/instability, chaotic household, large family, low socioeconomic status, low education of mother, family carelessness in permitting access to weapons
Cognitive distortions and negative and self-critical thinking
are addressed by using cognitive- restructuring procedures and training in effective problem-solving and self-control procedures
Childhood-onset conduct disorder
display at least one symptom of the disorder before age 10
Stimulant medications
drugs that alter the activity in the frontostriatal region of the brain by impacting three or more neurotransmitters important to the functioning of this region - dopamine, norepinephrine, and epinephrine, and possible serotonin. Stimulant medications are commonly used for the management of symptoms of ADHD and its associated impairments
Summary of Risk Factors for Antisocial Behaviors: Peers
early peer aggression, rejection by peers, association with deviant siblings, association with deviant peers, bullying
Treatments for Youngsters with Depression: Cognitive Therapy
focuses on helping the youngster with depression become more aware of pessimistic and negative thoughts, depressogenic beliefs and biases, and causal attributions of self-blame for failure. Once these self-defeating though patterns are recognized, the child is taught to change from a negative, pessimistic view to a more positive, optimistic one
Parent management training
focuses on teaching both effective parenting practices and strategies for coping with the challenges of parenting a child with ADHD -manage their child's oppositional and noncompliant behaviors -cope with the emotional demands of raising a child with ADHD -contain the problem so that it does not worsen -keep the problem from adversely affecting other family members
Secondary control skills (Think skills)
for altering the subjective impact of stressful life events (e.g., altering their negative thoughts and feelings).
primary control skills (ACT skills)
for changing objective events in their lives (e.g., changing the activities they engage in, learning to relax) to conform with their wishes
Summary of Risk Factors for Antisocial Behaviors: Child
genetic risk, prenatal and birth complications, exposure to lead and other toxins, low arousal and reactivity, anterior and posterior cingulate cortex development, functional and structural deficits in prefrontal cortex, reduced amygdala activity, blunted emotional and cortisol reactivity, insensitivity to stress, fearlessness/low anxiety, difficult temperament, emotion dysregulation, attention-deficit/hyperactivity disorder, insecure/disorganized attachments, childhood onset of aggression, social avoidance and withdrawal, social-cognitive deficits, lowered verbal intelligence and verbal deficits, executive functioning deficits
Effective Treatments for Children with Conduct Problems: Problem-Solving Skills Training
identifies the child's cognitive deficiencies and distortions in social situations and provides instruction, practice, and feedback to teach new ways of handling social situations. The child learns to appraise the situation, change his or her attributions about other children's motivations, be more sensitive to how other children feel, and generate alternative and more appropriate solutions
overview of theories of depression: attachment
insecure early attachments; distorted internal working models of self and others
Distractibility
is a term commonly used to indicate a deficit in selective attention. Children with ADHD are much more likely than others to be distracted by stimuli that are highly salient and appealing
euphoria
is an exaggerated sense of well-being
Selective attention
is the ability to concentrate on relevant stimuli and ignore task-irrelevant stimuli in the environment
attentional capacity
is the amount of information we can remember and attend to for a short time.
negative cognitive triad
negative views about oneself, the world, and the future that are characteristic of youngsters with depression. These views maintain feelings of helplessness, undermine the child's mood and energy level, and are related to the severity of depression
Summary of Risk Factors for Antisocial Behaviors: Neighborhood and Community
neighborhood disadvantage and poverty, disorganized neighborhoods, gang membership, availability of weapons
overview of theories of depression: neurobiological
neurochemical and receptor abnormalities; neurophysiological abnormalities; neuroendocrine abnormalities; genetic variants; abnormalities in brain structure and function; effects of early experience on the developing brain
Sustained attention
or vigilance, is the ability to maintain a persistent focus over time on unchallenging, uninteresting tasks or activities or when fatigued.
Summary of Risk Factors for Antisocial Behaviors: School
poor academic performance, weak bonding to school, low educational aspirations, low school motivation, poorly organized and functioning schools
Summary of Risk Factors for Antisocial Behaviors: Ineffective Parenting
poor supervision and monitoring, inconsistent discipline, avoidance of discipline due to concerns about the child's reaction, harsh discipline and maltreatment, discordant parent-child interactions, poor communication and problem solving, low parental involvement, parental neglect, low parental warmth, parental hostile attributional bias
overview of theories of depression: self-control
problems in organizing behavior toward long-term goals; deficits in self-monitoring, self-evaluation, and self-reinforcement
Behavioral inhibition system
produces anxiety and inhibits ongoing behavior in the presence of novel events, innate fear stimuli, and signals of nonreward or punishment
hopelessness theory
proposes that depression-prone individuals tend to make internal, stable, and global attributions to explain the causes of negative events
negative cognitive schemata
stable structures in memory, including self-critical beliefs and attitudes, that guide information processing in a way that is consistent with the negative self-image of the subject. These cognitive schemata are rigid and resistant to change even in the face of contradictory evidence
social selection hypothesis
states that people who move into different neighborhoods differ from one another before they arrive, and those who remain differ from those who leave. For individuals with antisocial traits, this creates a community organization that minimizes productive social relations and effective social norms, leading to the antisocial behavior becoming the rule
Behavioral activation system
stimulates behavior in response to signals of reward or nonpunishment
overview of theories of depression: socio-environmental
stressful life circumstances and daily hassles as vulnerability factors; social support, coping, and appraisal as protective factors
Goodness of fit
the match between the child's early temperament and the parent's style of interaction
Treatments for Youngsters with Depression: Cognitive-Behavioral Therapy
the most common form of psychosocial intervention. Combines elements of behavioral and cognitive therapies in an integrated approach. Attribution retraining may also be used to challenge the youngster's pessimistic beliefs
depressogenic cognitions
the negative perceptual and attributional styles and beliefs associated with depressive symptoms
relational aggression
verbal insults, gossip, tattling, ostracism, threatening to withdraw one's friendship, getting even, or third-party retaliation rather than physical forms of aggression
psychopathic features
which are defined as a pattern of callous, manipulative, deceitful, and remorseless behavior - the more menacing side of human nature
reciprocal influence
which means that the child's behavior is both influenced by and influences the behavior of others
hostile attributional bias
which means that they are more likely to attribute hostile and mean-spirited intent to other children, especially when the intentions of others are unclear
