PSYC330 - Abnormal Child Psyc - Exam 2

Excoriation Disorder (Skin-Picking Disorder)

• Characterized by recurrent skin picking resulting in skin lesions ‣ repeated attempts to stop skin picking ‣ significant distress or impairment in important areas of life functioning. ~

Selective Mutism

• Child fail to speak in specific social situations in which there is an expectation to speak, (e.g., at school), despite them speaking in other situations (ie may speak loudly and frequently at home or in other settings) • Lasts for at least one month (not the first month of school) ‣ The disturbance interferes with educational or work achievement or with social communication. ‣ This is not due to a lack of knowledge or lack of comfort w the language

Depressed Parents

• Children of depressed parents have poorer overall functioning ‣ Increased rates of MDD before puberty, which is the best predictor of later psychopathology.... ‣ Higher rates of phobias, panic disorder, and alcohol dependence as adolescents and adults ‣ Higher rates of physical injuries, sick visits, and inpatient care » Overall, negative long-term outcomes and impairments

OCD - Obssessive-Compulsive Disorder

• Children with OCD experience recurrent, time-consuming (taking more than one hour a day), & disturbing obsessions and compulsions ‣ Obsessions are persistent and intrusive thoughts, urges, or images that are experienced as intrusive and unwanted, and generally cause significant anxiety or distress ‣ Compulsions are repetitive, purposeful, and intentional behaviors (e.g., hand washing) or mental acts (e.g., repeating words silently) that are performed in response to obsessions in an attempt to suppress or neutralize them. » Obsessions are excessive and irrational and improbable events. » In children with OCD, most common obsessions focus on contamination, fears of harm to self or others, or concerns with symmetry/exactness, whereas in adolescents, sexual, somatic, and religious preoccupations also become more common » Compulsions can be: compelled to clean door handles, check for direct, engage in some ritual to reduce anxiety, excessive washing, repeating words, re-arranging. Certain compulsions are commonly associated with specific obsession ~

Disruptive Mood Dysregulation Disorder (DMDD) Features/Criteria

• Chronic, severe persistent irritability. T • Two Main clinical Features: ‣ Frequent verbal or physical temper outbursts that usually occur in response to frustration and are totally out of proportion to the provocation or situation. These outbursts must occur frequently (three or four times a week) over one year in at least two of three settings (i.e., at home, at school, with peers), and must be age-inappropriate. ‣ Severe irritability is a chronic, persistently irritable or angry mood that is present most of the day, nearly every day, betw the severe temper outbursts. This mood must have an onset prior to age 10 years; be present most of the day, nearly every day; be noticeable to others. » A diagnosis of DMDD cannot coexist with ODD or BP but can co-occur with MDD, ADHD, CD, or substance-use disorder » DMDD is a new depressive disorder in DSM 5 that is one we know the least about » Occurs mainly in males and school-aged children; has high comorbidity w anxiety, mood, disruptive behvr disorders; disrupts family and peer relationships and school performance ~

Behavioral and Learning Theories

• Classical conditioning ‣ Fears learned by association ‣ Little Albert • Operant conditioning ‣ Behavior will continue if it is reinforced! ‣ How is anxiety reinforced?

Pharmacological Treatment: Medications for Depression

• Common use: antidepressants ‣ Can shorten a depressive episode and return them to important developmental tasks • SSRIs (e.g., Prozac, Zoloft, Celexa, Lexapro) ‣ Compared to ADHD meds, it takes longer to needed to see whether SSRI is effective (4-12 weeks) ‣ Blocks the reuptake of serotonin, thereby increasing its availability in the synapse and stimulating the postsynaptic neuron. • Fluoxetine (Prozac) is the only FDA-approved treatment ‣ Now requires warning labels due to TADS findings » When considering an antidepressant for a child or adolescent, it is important to weigh the increased risk of suicidality with the possible benefits of the medication.

The child will either...

• Comply or noncomply • Desired Sequence in PDI for Compliance ‣ Direct Command --> Compliance --> Labeled Praise • If they don't comply: time out in a chair

OCD in the DSM 5

• DSM-5 includes OCD in a separate chapter with related disorders that are distinct from OCD but contain overlapping diagnostic features such as preoccupations and repetitive behaviors or mental acts in response to the preoccupations ~

Other Psychological Considerations

• Depression & OCD-like tendencies in AN ‣ Disorders related to serotonin imbalance • Variety of disturbances associated with BN ‣ Poor impulse control (e.g., ADHD), substance abuse, mood swings • 90% of individuals with eating disorders have another Axis I disorder ‣ Depression, anxiety, OCD, BPD most common

Intellectual and Academic Functioning in Depression

• Depression may be associated with impairments while performing nonverbal tasks that require attention, coordination, speed, or recall of emotionally coded information, such as facial expressions • Depression may also be associated with broad impairments in executive functions, for example, maintaining task goals in working memory ‣ Poor concentration and thinking ability, slowed movement or agitation, fatigue, insomnia, and somatic symptoms may lead to repeating a grade, being late or skipping school, failure to complete homework, and dissatisfaction with or refusal of school. ~

4 Features of Substances use disorder

• Diagnostic criteria reflect 4 features of this diagnosis: ‣ Criteria 1-4 (Impaired control) ‣ Criteria 5-7 (Social Impairment) ‣ Criteria 8-9 (Risky use) ‣ Criteria 10-11 (Pharmacological criteria)

Developmental Framework for Depression

• Difficult temperaments in babies - irritability • HPA Axis - Diff levels of serotonin • Temperament --> family difficulties that can impact interpersonal competence • Life stressors can be antecedents to depression • All of these can contribute to the development of depression

Substance-use disorders (SUDS)

• Disorders that occur during adolescence and include substance dependence and substance abuse that result from the self-administration of any substance that alters mood, perception, or brain functioning. ‣ Psychological dependence: to the subjective feeling of needing the substance to adequately function. ‣ Physical dependence occurs when the body adapts to the substance's constant presence ‣ Tolerance refers to requiring more of the substance to experience an effect once obtained at a lower dose. ‣ Withdrawal, an adverse physiological symptom that occurs when consumption of an abused substance is ended abruptly and is thus removed from the body. » There are 4 groups of symptoms in DSM5 that capture the core features of this diagnosis: impaired control; social impairment; risky use; and pharmacological criteria ~

Emotional Spirals

• Downward • Upward ‣ Examples? Ask to review def and examples of these spirals

Suicide and Depression

• Drug overdose and wrist cutting are among the most common methods for adolescents who attempt suicide. • adolescents with MDD had a fivefold increased risk of a first suicide attempt as compared with controls without MDD, and nearly 8% of them committed suicide within 15 years of their first episode of MDD • For adolescents who complete suicide, the most common methods are firearms (45%), suffocation (40%), and poisoning (8%) (CDC, 2013). • suicide ideation (thinking about killing oneself) is common across many diff types of psychological disorders but actual attempt are more common during depression • 60% of youths who are clinically depressed report having thoughts about suicide, and 30% attempt suicide by 17 years of age, with most attempts coming within the first year after the onset of suicidal thoughts. • the two strongest risk factors for suicidal behavior are consistent worldwide—having a mood disorder and being a young female • However, since girls typically do not use guns, they are usually less successful in completing suicide than boys. • Ages 13 and 14 are peak periods for a first suicide attempt by youths. Suicide prior to puberty is rare, most likely bc depression and substance abuse before puberty are also rare. In adolescents with depression, suicide attempts double during the teen years but show an abrupt decline after age 17 or 18 • Suicide is second leading cause of death in adolescents and young adults in US ~

Behavioral Activation

• Effective therapeutic technique for various types of psychopathology (ie depression) • Replacing unproductive time or maladaptive activities with important or enjoyable ones • Increased substance-free reinforcement

Cognitive Theories

• Enhanced attention to threat • Perception of threat activates dangerous thoughts and responses • Interpret ambiguous cues as threatening (sees everything/everywhere as dangerous) • In other words... ‣ "The world is a dangerous place" ‣ "I am unable to cope"

Social Skills

• Even if you have good social skills, you may not always use them when you are depressed • Or you may be too anxious to enjoy social situations • Focus on specific scenarios such as: ‣ Starting and maintaining a conversation ‣ Inviting someone to do something ‣ Leaving a group ‣ Communication about positive and negative feelings

Evidence-Based Treatment for OCD: Exposure with Response Prevention

• Exposing patients to stimuli that trigger obsessive fears while encouraging them to resist engaging in compulsive behaviors • The hypothesized mechanism is that, over repeated exposures, obsession-triggered anxiety decreases through the process of habituation • Over time, the individual learns that the feared consequences of not engaging in compulsion will not happen • E.g., Get dirty and then DON'T wash hands; Leave the house WITHOUT checking the stove or the locks; Go to bed WITHOUT specific ritual... and see what happens

Evidence-Based Treatment for Panic Disorder

• Exposure to panic symptoms (physical sensations) that provoke anxious thoughts and avoidance ‣ E.g., Spinning in a chair, running up stairs, breathing through a straw ("Interoceptive Exposure") • Anxiety related to physical symptoms decreases through the process of habituation • Over time, the individual learns that the feared consequences of the physical symptoms will not happen ‣ E.g., they will not have a heart attack, will not die, they can cope with physical symptoms etc.

Behavioral Therapy for Anxiety

• Exposure: having children face what frightens them, while providing ways of coping other than escape and avoidance. ‣ Exposure procedures have been used successfully with boys and girls of all ages from a variety of ethnic backgrounds. ‣ 75% of children with anxiety disorders are helped by this treatment • Graded exposure: Usually the process is gradual The child and therapist make a list of feared situations, from least to most anxiety-producing, and the child is asked to rate the distress caused by each situation on a scale from 1 to 10; ‣ The child is then exposed to each situation, beginning with the least distressing and moving up the hierarchy as the level of anxiety permits. • 2nd technique - Systematic desensitization: ‣ 1. teaching the child to relax; ‣ 2. constructing an anxiety hierarchy ‣ 3. and presenting the anxiety-provoking stimuli sequentially while the child remains relaxed. » With repeated presentation, the child feels relaxed in the presence of stimuli that previously provoked anxiety. • 3rd thecnq- flooding: exposure is carried out in prolonged and repeated doses (massed exposure). Thru the process, the child remains in the anxiety-provoking situation and provides anxiety ratings until the levels diminish. Flooding is typically used in combo with response prevention, which prevents the child from engaging in escape or avoidance behaviors. ‣ This procedure must be used carefully, esp with young children who may not understand the rationale. ~

Symptoms of Anxiety: Physical System

• Expressed thru 3 interrelated response systems: the physical system, the cognitive system, and the behavioral system. ‣ diff response systems are more dominant in certain anxiety disorders. ‣ In Physical System: the brain sends messages to sympathetic NS producing a fight/flight response » Chemical effects. Adrenaline and noradrenaline are released » Cardiovascular effects. increased Heart rate » Respiratory effects. Speed and depth of breathing increase » Sweat gland effects: sweating increases » Upset stomach/headache » Muscle tension » Vomiting

specfic phobia

• Extreme and irrational fear of clearly particular objects or situations for at least 6 months ‣ Must cause impairment • 5 subtypes: Animal, natural environment, blood-injection-injury, situational, other • Phobias are normative at certain ages, but this fear occurs at inappropriate ages and persists and is exaggerated, leading to avoidance of obj/event • Other most common anxiety disorder- 4-10% of children at some point » Specific phobias can occur at any age but seem to peak betw 10 and 13 years of age

Risk Factors for Use

• Family History (history of alcoholism; poor fam values) • Mental Health or Behavioral Issues (ADHD, ODD, depression/anxiety, to relieve symptoms or stress; poor sleep) • Trauma (present/past trauma) • Impulse Control Problems (poor inhibition) • Limited Involvement (poor parental monitoring) • Family Conflict (poor relationship quality; poor parental support; poor parent-teen communication)

BN Medical Complications

• Fatigue • Headaches • Puffy cheeks; enlargement of salivary glands • Dental problems • Finger calluses • Electrolyte imbalance • Dependence on laxatives = colon damage

Fear and Panic

• Fear is an immediate alarm reaction to current danger or life-threatening emergencies ‣ present-oriented emotional reaction to current danger marked by a strong escape tendency from sympathetic nervous system » anxiety is a future-oriented emotion characterized by feelings of apprehension and lack of control over upcoming events that might be threatening. Anxiety is frequently felt when no danger is actually present. • Panic is a group of physical symptoms of the fight/flight response that unexpectedly occur in the absence of any obvious threat or danger ~

Social Anxiety Disorder (Social Phobia)

• Fear of social or performance situations that expose the child to judgment & possible embarrassment • Worry about neg evaluation - Being embarrassed, looking stupid ‣ To be classified as SOC, their anxiety must occur in peer settings, not just when interacting with adults. • 1 to 3% of children and adolescents ‣ 20% of referred children have primary SoP diagnosis • Some level normative during adolescence • Peak Onset: most common in early to mid-adolescence ‣ Rare before age 10 » Youths with SOC are more likely than other children to be highly emotional; socially fearful; and inhibited, sad, and lonely.

Normal Fears, Anxieties, Worries, and Rituals

• Fears that are normal at one age can be debilitating a few years later. ie, fear of strangers may serve a protective function for infants and young children, but when it persists beyond a certain age it can interfere w the development of peer relations ‣ specific fears are common in older children; teens report that their fears cause them distress and significantly interfere with daily activities. Girls tend to have more fears than boys at almost every age • Various anxieties are evident by age 4 ‣ The most frequent symptoms in samples of children with normal anxieties are separation anxiety, test anxiety, overconcern about competence, excessive need for reassurance, and anxiety about harm to a parent • In moderate doses, worry can help children prepare for the future ‣ Children of all ages worry, but their forms and expressions change. Older children report a greater variety and complexity of worries and are better able to describe them than are younger children • Ritualistic, repetitive activity is extremely common in young children ‣ Normal ritualistic behaviors in young children include preferences for sameness in the environment (e.g., watching the same DVD over and over again), rigid likes and dislikes, preferences for symmetry (e.g., carrying a toy in each hand), awareness of minute details or imperfections in toys or clothes (e.g., being bothered by a thread on their sleeve), & arranging things so they are "just right" » research suggests that the neuropsychological mechanisms underlying compulsive, ritualistic behavior in normal development & those in OCD may be similar ~

Causes and Treatment for ARFID

• Feeding & eating disorders have long been associated with family disadvantage, poverty, unemployment, social isolation, and parental mental illness • Avoidant/restrictive food intake disorder and FTT during early infancy can be related to the poor quality of the caregiver-child attachment ‣ bc the mother-child relationship during the early stages of attachment is critical, eating disorders shown by infants and young children may be symptomatic of a fundamental problem in this relationship • Poverty, family disorganization, and limited social support contribute to the likelihood of malnutrition and growth failure • Mothers who have a history of disturbed eating habits and attitudes have been identified as a specific risk factor for avoidant/restrictive food intake disorder ~

Cogntive Biases and Distortions in Depression

• Feeling worthless, negative believes (I never do anything right) and attribution of failure (I am a failure) ‣ Neg thoughts that are self-critical and automatic, such as "I'm a real loser," "I'm ugly," or "I'm gonna fail," ‣ Devalue their own performance by not acknowledging their accomplishments. They dismiss praise when it is given and frequently make inaccurate interpretations of their experiences ‣ View themselves as ineffective in most areas of life and blame themselves for failure and rejection ‣ Many report hopelessness or neg expectations about the future and have diminished self esteem and suicide ideations ~

IPT-A

• Focus on depressive sx and interpersonal context • Based on literature on relationship between depression and social interactions • Collaborative approach • Parental involvement • Developmental relevance to adolescence • 3 phases: initial, middle, termination • 12 weeks on average, each 30-60 minutes IPT Themes ‣ Grief ‣ Interpersonal dispute ‣ Role transitions ‣ Interpersonal deficit ‣ Other family/relational problems

depression and anxiety disorders

• GAD, SAD, and SOC are more commonly associated with depression ‣ Children with anxiety and depression have an older age at presentation than children with only anxiety; in most cases symptoms of anxiety both precede and predict symptoms of depression ‣ Negative affectivity - a persistent neg mood, as reflected in nervousness, sadness, anger, and guilt. Positive affectivity refers to a persistent pos mood that includes states such as joy, enthusiasm, and energy. » Children with anxiety do not differ from children with depression in their neg affect, which suggests an underlying dimension of negative affectivity is common betw anxiety and depression » ALTHOUGH difference betw children who are anxious and those who are depressed may be the greater positive affectivity in those who are anxious. ~

Demographic Risk Factors

• Gender ‣ Females at greater risk ‣ Early pubertal maturation poses specific risk • Sexual orientation ‣ Homosexual males at higher risk • Ethnicity ‣ Caucasians at greatest risk • Athletes ‣ At higher risk • Women of higher SES more likely to diet and have a lower body weight ‣ Black women from high SES backgrounds report levels of body dissatisfaction similar to white women, suggesting that body dissatisfaction is associated more with SES than with ethnicity

Neurobiological Factors in Anxiety Disorders

• HPA Axis ‣ Regulation of stress/anxiety ‣ Cortisol secretion ‣ Early life stress can influence development of this system • Limbic system (amygdala) ‣ Larger volume in this area ‣ Overactivity of this brain region • Brain stem (danger signals) • The behavioral inhibition system is believed to be overactive in children with anxiety disorders.

Controlling Your Thoughts

• Identify "activating events" or "triggers" of down mood and/or maladaptive coping • Identify thoughts (negative vs. objective/positive) ‣ Challenge these and replace with more accurate, (typically more positive) thought ‣ Engage in an activating event or activity • Identify underlying negative beliefs about self, others, future ‣ Core of depression: Negative sense of self

Active Problem Solving... Instead of the "Spin Cycle"

• Identify the problem and your goal(s) • Cognitive sorting (attention shifting): ‣ Is it worth spending time and energy thinking about this? How important is this to me or for my life? ‣ Is there anything I can do about it? • Generate solutions, choose the best (pros & cons) • Break down solution into manageable steps • Start the first step toward the solution ‣ Allow for "healthy breaks" when problem-solving • Evaluate how the solution worked, try another one

Prevalence and Comorbidity Of GAD

• In general, the disorder is equally common in boys and girls, with a slightly higher prevalence in older adolescent females ‣ happens in 3 to 6% of children ‣ The average age at onset for GAD is in early adolescence 10-14 years ‣ Older children present with a higher # of symptoms and report higher levels of anxiety and depression than younger children, but these symptoms may diminish with age

READING - Adolescent Substance Use Disorders Substance-related and addictive disorders

• In the DSM-5, these disorders encompass 10 classes of drugs: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, tobacco, and other (or unknown) substances ~

TADS STUDY cont...

• Included Standard components (from CWD-A): ‣ Psychoeducation about depression and causes » Family included ‣ Goal setting ‣ Mood monitoring ‣ Pleasant activities ‣ Social problem-solving ‣ Cognitive restructuring • Flexible components: ‣ Relevant social skills deficits (e.g., communication, assertiveness) ‣ Conjoint family sessions to address child/family concerns Outcome Measures • Primary: Combined tx (CBT+Med) fared best ‣ CDRS-R adolescent/parent interview- CGI • Suicidal behavior: ‣ Ideation: Small protective effect for conditions incl. CBT ‣ Harm-related behavior » Protective effect for CBT » Elevated risk in SSRI-treated groups- ‣ Attempts » Small n but greater risk in SSRI groups suggested RESULTS • Overall, combined CBT+Medication compared to either CBT or Med alone, which did better than placebo • Suicidal ideation ‣ Comb>Fluoxetine>CBT>Placebo • Harm-related behavior seemed to be higher in med conditions • Suicide attempts also seemed to be related to med but low n (low # of ppl had the suicide attempts but It was enough for them to put the warning)

Sleep Hygiene (Healthy Sleep Practices)

• Includes: ‣ Routines ‣ What we eat/drink and when ‣ Light exposure/screens ‣ Getting ready for bed ‣ Physical activity

Additional Risk Characteristics

• Increased sensation seeking preference for novel, complex, and ambiguous stimuli (some teens require more intense activities to be stimulated) • Positive attitudes about substance abuse and having friends with similar attitudes • Perceiving oneself to be physically older (so hanging out w older ppl) than same-age peers and striving for adult social roles • School disconnectedness

Family Involvement

• Increasing knowledge • Improving attachment • Improving communication • Building coping skills

Non-Pharmacological Evidence-Based Treatment for Depression

• Individual or Group Cognitive-Behavioral Therapy (CBT) ‣ With or without family involvement • Interpersonal Therapy (IPT) ‣ Explores family and interpersonal interactions that maintain depression. Youths w depression are encouraged to understand their own neg cognitive style & the effects of their depression on others & increase pleasant activities w family & peers

DON'T Skills: Avoid Questions

• Informational: Who, When, Why, What, Where, How • Unintentional: Inflections, Tags • Hidden: Indirect Commands (Do you want to do this?) ‣ We avoid questions bc: » Questions take lead of the conversation » Can suggest disapproval (You put it where?") » Can suggest you are not listening » Rapid-fire questioning prevents child from talking

Cognitive Disturbances in Anxiety Disorders

• Intelligence and Academic Achievements ‣ typically normal intelligence; little evidence of a relationship betw anxiety and IQ ‣ Excessive anxiety may be related to deficits in attention, executive functions, working memory, and speech or language which can interfere with academics ‣ Youths with anxiety disorders, particularly SOC, may also fail to reach their academic potential because they drop out of school prematurely • Threat-related attentional biases ‣Those with anxiety disorders selectively attend to info that may be potentially threatening or dangerous - a tendency referred to as anxious vigilance or hypervigilance • Cognitive errors and biases: ‣ Highly anxious children often use rules in the face of less obvious threats more often, suggesting that their perceptions of threats activate danger-confirming thoughts » Altho threat-related attentional biases and cognitive errors and biases are associated with anxiety in children, the precise nature of these errors and their role in causing anxiety has not yet been established ~

Assessment of anxiety disorders

• Interviews: ADIS-P and ADIS-C • Questionnaires/Rating Scales • Self-monitoring ‣ Situation and anxiety rating • Behavioral Observation • there are anxiety monitoring SUD ratings to measure anxiety in diff situations • What factors relate to the development and maintenance of anxiety disorders? Negative reinforcement of the behavior --anxiety -> avoidance --> reduces anxious feelings --> reinforces the anxiety behavior in future

How is depression different in children?

• Irritable mood vs. depressed mood • Assessment difficulties ‣ Historical factors (wasn't believed to occur in children in past) ‣ Cognitive factors (Children can say how they're feeling, or have a harder time reflecting on future or their symptoms) ‣ Non-specificity of symptoms - E.g., irritability (assessment helps get all Sx experiencing) ‣ Some symptoms are developmentally normative - where do you draw the line?

Primary and Secondary Control Enhancement Training (PASCET)

• John Weisz and his colleagues (2003) developed a 15-session, individualized CBT-based program for youths 8 to 15 years of age who have depression. In treatment sessions and in take-home assignments, youths learn and practice two types of coping skills: ‣ 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. ‣ Secondary control skills (THINK skills) for altering the subjective impact of stressful life events (e.g., altering their negative thoughts and feelings). » Tries to help child change conditions that are changeable and to change the subjective impact of those that are not

Do Skills: Imitate

• Join in the child's appropriate play • Whenever possible, play with the toys the child is playing with • If the child switches to a new activity, follow along! • Keep play at the child's developmental level • Why Imitate? ‣ Helps keep the attention and comments focused on the child ‣ Allows the child to lead ‣ Makes play fun for the child ‣ Shows approval of the activity ‣ Teaches the child how to play well with others (can model/show appropriate behaviors)

Self-esteem deficits in CP

• Low self-esteem, unstable view of self. They overestimate their social competence and acceptance by others. Any threat to their biased view of self may lead to aggression. ‣ Youths with conduct problems may experience high self-esteem that over time permits them to rationalize their antisocial conduct ~

Genetics and Fam Risk

• MDD and Bipolar Disorder run in families ‣ Single best predictor is family history; higher risk for children whos parents have depression • Moderate genetic influence ‣ 35 -75% heritability estimates across twin studies ‣ 65% heritability rates for Bipolar Disorder (twin studies) • Inherited vulnerability to depression ‣ Temperament style = low positive affect, low approach/ interest/sociability, higher negative reactivity, irritability

Gender and Depression

• MDD and DYS look similar in boys and girls ‣ Altho depression occurs more frequently in girls, Sx presentation is generally quite similar for the two sexes • There is a large gender difference in rates: ‣ Equally common in preschoolers (ages 3-5 yrs) and school-age children (ages 6-11 yrs) ‣ But, girls 2x as likely as boys to have depression starting from age 11/12 and continuing thru adulthood • Girls generally more interpersonally-oriented, higher rejection sensitivity, and more ruminative coping styles (thinking in spin cycle without prob solving) than boys • Hormonal changes in estrogen and testosterone may affect brain function; non-normative changes such as early maturation may lead to isolation from one's peer group ‣ Research also suggests that increased levels of testosterone and estrogen at puberty when occurring in combo with social stress increases the risk for depression in girls

Course of Depression

• MDD is episodic ‣ Avg duration of MD episode is 8-9 months; ‣ 40% of children remit within 6 months of onset, 80% remit within a year of onset ‣ Almost all eventually recover from their initial depressive episode, but the disorder itself does not go away • Average duration of dysthymia is 3 years ‣ Note: In double depression, low-grade depressive symptoms are present for several years, with periods of MD episodes on top • Risk for recurrence is moderate to high (54% or 72% in 3 or 5 years, respectively) • The onset of depression in adolescence may be gradual or sudden. • About 1/3 of adolescents with MDD will develop BP (bipolar switch) ‣ History of depression during the school yrs also increases the risk for later delinquency, tobacco use, substance-use disorder, suicide behavior, school dropout, poor work record, marital probs

CWD-A Skills Components

• Mood monitoring (Take a second to reflect on how we feel so we can see a pattern & catch ourselves from slipping to avoid a deep slump; if we monitor our feelings It can help us see what happened before that triggered or helped) • Social skills (knowing how to use ppl/friend interactions to make us feel better) • Pleasant activities (that we enjoy and impact our mood) • Relaxation (sometimes ppl will be tense; get into relaxed state) • Constructive Thinking (controlling and challenging thoughts) • Communication • Negotiation and Problem Solving • Maintaining gains

Parenting/Family Influences

• More hostility; Controlling; Intrusive; Low support and warmth ‣ Fams of children with depression display more punitive behavior; These families display more anger and conflict, greater use of control, poorer communication, and less warmth and support » Fam probs precede and may be directly related to development of depressive symptoms • Mothers who suffer from depression create a child-rearing environment with neg mood, irritability, helplessness, less emotional flexibility, unpredictable displays of affection. ‣ children of depressed mothers show cognitive and social deficits, emotional delays, insecure attachments, and less positivity. They display early signs of a cognitive vulnerability to depression. » Just by treating moms depression with meds the kids with own disorders can better or do not develop any disorders

Bulimia Nervosa

• Much more common than anorexia • Self-evaluation unduly influenced by weight and shape • recurrent Binge episodes ‣ where they experiences loss of control in eating ‣ Consumes an unusually large amount of food in a short period of time •Binge is followed by Inappropriate compensatory behvrs to counteract binge episodes ‣ E.g., self-induced vomiting, laxative use, fasting, or excessive exercise • Medical consequences of chronic bulimia: fatigue, headaches, and puffy cheeks (due to enlarged salivary glands). The permanent or significant loss of dental enamel in teeth due to the acidic contents from vomit. In females, menstrual irregularity or amenorrhea ; Electrolyte imbalances due to purging

Other environmental factors triggering depression

• Negative life events (accidents, natural disasters, health problems, divorce, crime, family financial problems) • Life transitions/changes • Interpersonal losses/ rejections • Peer teasing/bullying • Daily hassles

Neurobiological Influences

• Neurotransmitters ‣ Serotonin, dopamine, and norepinephrine deficiencies in mood disorders ‣ Anti-depressants increase levels of these neurotransmitters in the brain » which then Impacts sleeping, eating, emotion regulation; which are symptoms of depression • Abnormalities in the structure & function of several brain regions ‣ Alterations prefrontal networks; lowered reward system activity; smaller volume In the amygdala, hippocampus, and thalamus • Hormonal and neuroendocrine systems ‣ HPA System - hypercortisolism linked to depression in school-age children; HPA dysregulation

Prevalence and comorbidity of OCD

• OCD in children and adolescents is about 1% to 2.5%, suggesting that it occurs about as often in young people as in adults ‣ OCD is about 2x as common in boys » most common comorbidities: anxiety disorders, ADHD, ODD, vocal and motor tics, which improve or remit in the second decade of life. • Other anxiety disorders (42%) • ADHD (19.6%) • Tic disorders (10.7%) • Depression/PDD (10.7%) • ODD/CD (8.9%

OCD Criteria for Obsessions and Compulsions

• Obsessions ‣ Unwanted, repetitive, intrusive thoughts, impulses, or images ‣ Beyond typical daily concerns ‣ Cause significant distress for individual • Individual tries to ignore or suppress obsessions ‣ Typically understood to be generated by own mind (as opposed to psychosis) ‣ In children, may be less well-formed • Compulsions: ‣ Repetitive behaviors or mental acts done in response to obsessions ‣ Usually conducted in a stereotypic or "rules-based manner" ‣ Behavior not realistically related to fear ‣ Behavior performed to reduce distress or prevent feared happenings

Developmental background

• Occasional sleep difficulties are almost ubiquitous ‣ Usually they do not cause severe impairment, however, it is not uncommon for sleep difficulties to have a major impact of health and well-being ‣ Sleep is critical for all stages of life but esp during childhood and adolescence » By age 2, brain has reached 90% of its adult size and most of its maturational advances have occurred during sleep (Anders et al., 2000) » By age 5, children still spend more time asleep than social interactions, exploration of environment, or any other single wake activity (Dahl, 2007). Why? » Sleep disturbances critical for developmental and related to child psychopathology

SAD Prevalence and Comorbidity

• One of the two most common anxiety disorders to occur during childhood (4-10% of children) ‣ Common in both boys and girls, altho it is more prevalent in girls. ‣ About 2/3s of children with SAD have another anxiety disorder, and about half develop a depressive disorder following the onset of SAD • Has one of the earliest onset: 7-8 years • Persists into adulthood for more than 1/3

PCIT Assessment

• Ongoing assessment of child behavior ‣ Therapy continues until the child is within normal range on a standardized measure ‣ Sometimes limited sessions can be effective • Ongoing assessment of parent behavior ‣ Behavioral Mastery criteria (parent mastered behavior on their own)

Prevention of Depression in Children and Adolescents

• Other large-scale prevention efforts (e.g., Columbia Teen Screen) have been directed at the early detection of high school students at risk for depression and suicide to ensure that these students receive help ‣ Prevention efforts have also focused on providing cognitive-behavioral prevention to adolescents at risk for depression by virtue of having a parent with a history of a depressive disorder. » Depressed parents and their children are taught a wide array of problem-solving and coping skills. The goals of the program are to educate families about depression, to increase awareness of the impact of stress and depression on functioning, to help families recognize and monitor stress, to facilitate the use of effective ways of coping with stress, and to improve parenting skill » Preventive programs like these have the potential to protect unaffected children of depressed parents from developing the disorder and to improve outcomes for children with depression who are currently receiving treatment. ~

PDD onset and outcome

• P-DD develops about 3 years earlier than MDD, around 11 to 12 years of age. • Since P-DD frequently precedes MDD, it could be a precursor to its development. ‣ Childhood-onset P-DD has a prolonged duration, with an average episode length of 2 to 5 years. ‣ Almost all children eventually recover from PDD ‣ It is not known whether deficits in psychosocial functioning precede or follow PDD • Early onset and extended duration of PDD make It a serious prob. Since early-onset P-DD is almost always followed by MDD and sometimes by BP, its early diagnosis may help identify children at risk for later mood disorders and has important implications for prevention. ~

DSM CRITERIA for Persistent Depressive Disorder (Dysthymia)

• P-DD is a "new" category in DSM-5; it combines Dysthymic Disorder and MDD-Chronic. This was done bc of the lack of differences betw youths with a dysthymic disorder and those with a chronic type of major depression. ‣ Children with P-DD are characterized by poor emotion regulation, which includes constant feelings of sadness, feelings of being unloved and forlorn, self-deprecation, low self-esteem, anxiety, anger, and temper tantrums ‣ Some may experience double depression, in which MDD is superimposed on the child's previous P-DD, causing the child to present with both disorders ‣ One study found that children with either MDD or P-DD alone did not differ in their clinical features, demographics, or associated characteristics; However those with both disorders were more severely impaired than children with just one of them ~

Family influences on Anxiety

• Parenting practices - discipline and their own modeling of anxious behaviors; ‣ Parent's own stress and anxiety ‣ Parents of anxious children are often described as overinvolved, overprotective, overcontrolling, or limiting of their child's independence. Also, have diff expectations ‣ Insecure attachments may be a risk factor for the development of later anxiety disorders ‣ Nonspecific link to anxiety disorders • Sometimes parents can negatively reinforce the anxiety when they remove the demand or give attention to the anxiety and therefore the anxiety remains (look at the picture to see the pathway & descriptions)

The Role of the Family in Anxiety Treatment

• Parenting practices that help ‣ Attention for bravery (ie praise) ‣ External reinforcement ‣ Coaching coping statements & relaxation ‣ Modeling • Greater parental involvement in modeling, reinforcing coping techniques, the inclusion of parental anxiety-management strategies, inclusion of parent skills training » Family treatment for OCD provides educ about the disorder & helps fams cope w their feelings (helplessness, frustration, disappointment)

How can parents help their children with anxiety?

• Parents should have positive reinforcement by the way they give attention: Give validation and nonverbal cues like smiling ‣ "I know you can do It"; "This must be so frightening. I will be back in one hour, you are so brave" ‣ Then act as a coach by giving confidence by having a positive mantra for the child: You can do it! & exposing the child gradually ‣ WIth gradual exposure and diff attention, It may reduce anxiety

Onset, course, outcome of OCD

• Persistent and intrusive thoughts, impulses, or images that are excessive and irrational AND/OR • Repetitive and intentional behaviors or mental acts to neutralize or reduce anxiety ‣ 2 to 3% of children ‣ Typical Onset: 9-12 years ‣ Serious and chronic disorder\ ‣ No longer under Anxiety Disorders in DSM-5 • Their parents' accommodation to the child's OCD by modifying family routines, facilitating avoidance, and engaging in the child's compulsions to reduce obsessional stress is common and has been linked to increased functional impairment and poorer OCD treatment outcomes

Post-Traumatic Stress Disorder (PTSD)*no longer under Anxiety Disorders in DSM-5

• Persistent anxiety following an overwhelming traumatic event (experienced or witnessed) that threatens one's life or body ‣ 3 core features: ‣ Re-experiencing (e.g., nightmares in children, flashbacks for others) ‣ Avoidance of associated stimuli/emotional numbing ‣ Overarousal (e.g., exaggerated startle response) • Onset: any time following trauma; lasts more than 1 month • Some characteristics increase likelihood of developing PTSD ‣ Nature of traumatic event ‣ Preexisting child characteristics ‣ Social support available

Can Marijuana Use Lead to Problems, too?

• Persistent marijuana use in adolescence is associated with neuropsychological impairments across a range of functional domains. • Stopping use does not fully restore neuropsychological functioning, suggesting particular harm for the adolescent brain.

Causes & treatments of Pica

• Pica may appear during the first and second years of life, even among otherwise normally developing infants and toddlers. ‣ Bc of the risk of lead poisoning or of obstruction in their intestine, pica can become a very serious » There is no evidence, except in cases of intellectual disability, that genetic factors play a role in the etiology of the disorder. » no conclusions can be drawn about the relative success of any treatment for pica » Said to help child when we emphasize desirable behave thru operant conditioning; Also , positive forms of attention, provide additional stimulation and are beneficial, bc the disorder often is related to inadequate interaction with caregiver ~

Pleasant Activities

• Pleasant social activities and success activities have the greatest impact on mood • Choose activities that are in line with your values • Encourage small increase (shaping) and problem-solve difficulties that may arise- E.g., tension may interfere with enjoyment • Graph pleasant activities and mood to see positive correlation • Achieve a balance between things you MUST DO and things you WANT TO DO

Additional Consequences of Abuse

• Poor schoolwork • Loss of friends • Problems at home • Lasting legal problems • Alcohol and drug abuse is a leading cause of teen death or injury related to car accidents, suicides, violence, and drowning. • Substance abuse can increase the risk of pregnancy & sexually transmitted diseases (STDs), including HIV, due to unprotected sex • Girls who report dating aggression are 5x more likely to use alcohol; boys are 2.5x more likely to be in such relationships • Substance use is also a risk factor for unhealthy weight control & obesity, suicidality, mood and anxiety disorders • Experimentation is common in teens, but It can: lower inhibitions, reduce judgment, and increase the risk of physical harm and sexual assault ‣ May influence the practice of, many high-risk behaviors: unsafe sex, smoking, drinking and driving

Expression of Depression Varies Across Development

• Preschool children: withdrawn, tearful, irritable, low positive emotions, anhedonia, excessive guilt, morose death themes in play, and extreme fatigue. They lack the bounce and enthusiasm in their play. They may display excessive clinging and whiny behavior and fear separation or abandonment. Neg and self-destructive verbalizations & physical complaints (ie stomach aches) • School-age children: More disruptive behavior (Increased irritability, disruptive behavior, temper tantrums); somatic complaints (weight loss, headaches, and sleep disturbances); Academic difficulties and peer problems. Suicide threats may also begin • Preteens and teens: Increasing cognitive distortions, persistent sadness (more like typical adult depression); Show similar Sx to young children but increased self-blame and expressions of low self-esteem. May also experience an inability to sleep or may sleep excessively. Disturbances in eating. Increased irritability, loss of feelings of pleasure or interest, worsening school performance. Physical symptoms (ie excessive fatigue; feelings of loneliness, guilt, and worthlessness; suicidal thoughts, plans, & attempts)

Characteristics of anxiety disorders

• Prevalence - 5 to 15% • High comorbidity among childhood Anxiety Disorders • Significant impairment ‣ School ‣ Family ‣ Peers ‣ Chronic course when left untreated

Prevalence of EDs

• Prevalence of anorexia nervosa and bulimia among adolescents is 0.3% & 0.9%, respectively • Persons with anorexia are 15% or more below normal weight and engage in binge eating only occasionally • Those with bulimia are within 10% of normal weight and binge frequently; then purge to control their weight • EDs can overlap with other mental disorders: anxiety, mood, and substance use disorders, obscuring some features and sometimes leading to misdiagnosis • Young men show some of the same clinical features as young women. However, are less preoccupied with food, & instead want to be more muscular » Eating disorders have long been considered a prob affecting primarily women; young men may be underdiagnosed

Prevalence of ARFID

• Prevalence rates of ARFID are unknown, but feeding problems are considered common based on parental reports ‣ If not identified early, this can have lasting effects on growth and development. The disorder is equally common among males and females. ‣ Food avoidance and restriction can arise at any age, but it usually begins in childhood ‣ if the onset occurs during the first 2 yrs, it can lead to malnutrition and have serious developmental conseqs. If there is no medical reason for the failure to gain weight, such early onset often is associated with poor caregiving, which may include abuse and neglect » feeding disorders can lead to, or be the result of, a failure to thrive. Failure to thrive (FTT) - serious growth and nutritional problems in infants ~

BN Clinical Features

• Prevalence: 1% among female adolescents ‣ 30:1 female to male ratio • Onset = late adolescence - early adulthood ‣ LOC eating or preoccupation with weight earlier ‣ Binge eating often develops after restrictive dieting ‣ Can follow a chronic course or occur intermittently, with pds of remission • "All or nothing" thinking • Guilt and shame are common • High rates of comorbid depression, SUD, and personality disorders • Patients with bulimia may have a greater chance of recovery than patients with anorexia—betw 50% & 75% show full recover

Sleep-wake disorders

• Primary sleep disorders are a results of the body's inability to regulate functions related to sleep mechanisms, rather than sleep problems caused from other primary psychological disorders, medications or medical disorders. • DSM-5 includes two categories of sleep disorders: ‣ 1. Dyssomnias (insomnia disorders, narcolepsy, breathing-related sleep disorder, circadian rhythm sleep disorder) ‣ 2. Parasomnias (Nightmare disorder, NREM sleep arousal disorders, sleep terrors, sleepwalking)

Theories of Depression

• Psychodynamic:Actual (ie death) or symbolic (ie neglect/rejection) loss of a love object (e.g., mother). individual's rage toward the love object is then turned against the self. High levels of maladaptive guilt and shame at ages 3-5. Loss of self-esteem • Attachment: A parent's consistent failure to meet the child's needs = insecure attachment, creates distorted internal working models of self and others; may a view of the self as unworthy and unloved, and a view of others as threatening or undependable. An insecure attachment may lead to difficulties in regulating emotion, which in turn may become a risk factor for later depression • Behavioral: A lack of response-contingent positive reinforcement. ‣ This lack of reinforcement or quality of reinforcement due to: youth may be unable to experience available reinforcement, bc of interfering anxiety; changes in the environment, such as the loss of a significant person in the child's life, so a lack of availability for rewards; or youth may lack the skills needed to have rewarding and satisfying social relationships. • Cognitive: Depressive mindset and distorted structures - neg cognitions, attributions, misperceptions, and deficiencies in cognitive problem-solving skills. Poor prob-solving and hopelessness; When something bad happens, they think that they are responsible (internal attribution), that the reason they are to blame will not change over time (stable attribution). They then attribute positive events to something outside themselves (external), which is not likely to happen again (unstable). • Self-Control Theories: Youths have difficulty organizing their behavior in relation to long-term goals and as displaying deficits in self-monitoring, self-evaluation, and self-reinforcement. • Interpersonal models view disruptions in interpersonal relationships, esp with family and peers, as the onset and maintenance of depression; Impaired interpersonal functioning related to grief, conflict, role transitioning, single parenting, and social withdrawal; Interaction betw mood & interpersonal events • Socioenvironmental models emphasize the relationship betw stressful life events & depression. Significant more psychosocial adversity creates vulnerability; Social support, coping, and appraisal as protective factors • Neurobiological models: focus on genetic vulnerabilities & neurobiological processes, including the effects of early experiences such as stress, child maltreatment, or maternal depression on child's developing brain. Neurochemical abnormalities, abnormal brain structures/fxns.

-Evidence-Based Treatments for ODD/CD: Parent Training Components

• Psychoeducation about Coercive Cycle ‣ Be sensitive; make sure not to blame parent • Structure/routines - Antecedent • Clear rules/expectations - Antecedent • Attending/rewards - Consequence • Planned ignoring - Consequence • Effective commands - Antecedent • Time out/loss of privileges - Consequence • Point/token systems - Consequence • Daily school-home report card - Antecedent/Consequence (sets up expectations to lead to success)

Developmental Considerations

• Rates typically peak around late adolescence than decline during young adulthood. • Adolescents are more likely to show cognitive and affective features associated with substance abuse • Disorientation, mood swings (Brown et al., 2013) • Do SUDs in adolescence differ from those of adults? ‣ Patterns and risk factors for substance use » Adolescents drink less often but engage in heavy episodic drinking at higher rates than adults.

Prevention: Positive Parenting Prevents Drug Use

• Research by the National Institute on Drug Abuse shows the important role that parents play in preventing children from starting to use drugs. • 5 Parenting Skills ‣ Communication ‣ Encouragement ‣ Negotiation ‣ Setting Limits ‣ Supervision • Family-based approaches try to modify neg interactions betw family members, improve communication & develop effective problem-solving skills to address areas of conflict

Anorexia Nervosa Subtypes

• Restricting Type ‣ Loses weight thru diet, fasting, or excessive exercise • Binge-Eating/ Purging Type ‣ Episodes of binge-eating, purging, or both

SAD Onset, Course, and Outcome

• SAD has the earliest reported age at onset (7 to 8 years) ‣ SAD occurs after a child has experienced major stress, such as moving to a new neighborhood, entering a new school, death or illness in the family, or an extended vacation ‣ they may lose friends as a result of their repeated refusal to participate in activities away from home. Their school performance may suffer as a result of frequent school absences ~

Prevalence and Comorbidity of SM

• SM is rare, may occur in about 0.7% of all children in community samples ‣ Most common co-occurring disorders: other anxiety disorders (ie SOC and specific phobia) ‣ Other comorbidities: communication, elimination, & oppositional disorders • Avg age at onset is about 3 to 4 years. ‣ The persistence of SM is variable; many children seem to "outgrow" the disorder. • 3 subgroups of children with SM: ‣ 1. anxious—mildly oppositional; ‣ 2. anxious—communication delayed; ‣ 3. exclusively anxious ~

Medications for Anxiety disorders

• Selective serotonin reuptake inhibitors (SSRIs) ‣ a # of controlled studies have found SSRIs to be effective in managing the symptoms of anxiety for youths with SOC, SAD, and GAD, with effects comparable to those in CBT ~

Social and Peer Problems in Depression

• Significant disruptions in their relationships. Have few friends or close relationships, feel lonely and isolated, feel that others do not like them, display extensive impairments in their social skills • In the first pathway, depressive symptoms promote socially helpless behavior and subsequent neglect by peers. In the second pathway, depressive symptoms promote aggressive behavior and subsequent rejection by peers. ‣ Social withdrawal is common in youths with depression. They often spend significant amounts of time alone, show little interest in seeing friends, and engage in few activities. ‣ Youths who are depressed use ineffective styles of coping in social situations. For example, they use less active and problem-focused coping and more passive, avoidant, ruminative, or emotion-focused coping » Depressed teens make poor choices in dealing with probs turning to alcohol/drugs ~

Benson Approach

• Sit quietly, close your eyes • Focus on your breathing (low and slow) • Say calming word as you breath out • Progressively relax your muscles • Do this for 10 to 20 minutes per day • For younger children, teach "balloon breathing" and practice with blowing bubbles/tissues, use games to teach muscle relaxation...

Adolescent-Onset CD

• Socialized (likely to occur with friends) - hanging out with the wrong friends • Stronger environmental contribution • Less violent • More girls than early onset • May not fully desist • Can get caught in "snares" (ie arrest, teen pregnancy, drug use/drug trouble, etc.)

Child Directed Interaction (CDI)

• Special Time: Follow the child's lead ‣ 5 minutes in the home every day where the child leads the play ‣ includes DONT SKILLS: Parents avoid these skills during those five minutes ‣ Includes DO's SKILLS: Parents should include these skills during those 5 minutes and we want them to do more of

Sleepy Kids

• Students need more sleep ‣ 6/10 middle schoolers don't get enough sleep ‣ 7/10 high schoolers don't get enough sleep ‣ Kids 6-12th grade need 9-12 hrs; teens 13-18 need 8-10hrs

Generalized Anxiety Disorder (GAD)

• Subject experiences chronic or exaggerated worry and tension, almost always anticipating disaster, even in the absence of an obvious reason to do so. ‣ Accompanied by physical symptoms: trembling, muscle tension, headache, & nausea. • Worry about many events/activities on most days that last at least 6 months ‣ Not only social in nature • Excessive and uncontrollable anxiety

Panic attack

• Sudden and overwhelming period of intense fear or discomfort that is accompanied by 4 or more physical and cognitive symptoms characteristic of the fight/flight response ‣ Usually short, with symptoms reaching max intensity in 10 mins then diminishing slowly over the next 30 minutes or the next few hours. ‣ Although they are brief, they can occur several times a week or month ~

Family and Genetic Risk to Anxiety Disorders

• Tendency to be inhibited/tense/fearful is inherited ‣ Environmental influences also play a role • 33% of variance in anxiety disorders accounted for by genetic influences (runs in fams) • Risk is not specific to particular anxiety disorders (except OCD) • Genes related to the serotonin system implicated • Likely multiple genes involved

Relaxation

• Tension can get in the way of our ability to enjoy social activities • 2 approaches to relaxation: ‣ Progressive Muscle Relaxation (Jacobson technique) ‣ Benson Relaxation Technique

Addiction vs. Normal Experimentation (Use v Disorder)

• The frequency, the dangerous situations they are putting themselves in, the drugs they are using matter • Lifetime rates indicate that 73% of youth have used alcohol and 48% have used illicit drugs by their senior year of high school. • In the past year, only about 23% of youth meet diagnostic criteria for a substance use disorder (alcohol or drug) by 20 years old • Addiction occurs when repeated use of drugs changes how a person's brain functions over time

Pathways

• The 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 ‣ A significant # of children with conduct problems, particularly those on the LCP path, do go on as adults to display criminal behavior, psychiatric problems, social maladjustment, health problems, lost productivity, and poor parenting of their own children • The 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. ~

School refusal behavior

• The refusal to attend classes or difficulty remaining in school for an entire day. ‣ children who resist going to school in the morning but eventually attend, those who go to school but leave at some point during the day, those who attend with great dread that leads to future pleas for nonattendance, those who miss the entire day ‣ School refusal is common in boys and girls, and it occurs most often betw the ages of 5 and 11 ‣ Children who refuse school may complain of a headache, upset stomach, or sore throat just before it's time to leave for school, then "feel better" when permitted to stay at home, only to feel "sick" again the next morning » School refusal often follows a period at home during which the child has spent more time than usual with a parent; or may follow a stressful event such as a change of schools, an accident, or the death of a relative or family pet. » For many children, fear of school is really a fear of leaving their parents—separation anxiety. However, school reluctance and refusal can occur for many reasons ~

Multi-systemic therapy

• Therapist meets regularly with child, family, and other significant individuals • "Problems don't have business hours so therapist teams are on call 24 hours per day" • Relapse prevention • Therapists have smaller number of clients • Significantly reduces rates of criminal offending ‣ intensive intervention that targets family, peer, school, and community systems; it has been effective in the treatment of SUDs among delinquent adolescents • Aims to modify neg interactions betw family members, improve communication, and develop effective problem-solving skills to address areas of conflict ‣ MST views the youth as embedded within multiple interconnected systems

Bulimia Nervosa cont...

• Thinking is rigid and absolutistic (all-or-nothing attitude) ‣ The individual either feels completely in control or completely out of control • Medical consequences are severe but not as severe as consequences resulting from anorexia

CBT Model: Depression

• Thoughts interconnect with behaviors and feelings (change one --> we change the other) • If we change thoughts to positive, and we engage in more positive behaviors, we can have more positive feelings

General Reasons

• To fit in (Culture impacts) • To feel good • To feel better • To do better • To experiment • Reasons for Prescription Medication Use: ‣ Easy to get in medicine cabinets 62% ‣ Available everywhere 52% ‣ Not illegal 51% ‣ Easy to get with other people's prescriptions 50% ‣ Can claim to have a script if you get caught 49%• Safer than illegal drugs 43% ‣ Less shameful than street drugs 33% ‣ Easy to purchase on internet 32% ‣ Fewer side effects than street drugs 32% ‣ Parents don't care as much if you get caught 21%

Panic Disorder (PD)

• Unexpected ("out of the blue") recurrent panic attacks and worry about future panic attacks or the implications of the attack (e.g., going to die or go crazy) ‣ Not in the context of another anxiety disorder (e.g., phobia) • Symptoms are NOT physically harmful but many go to ER bc they feel like they're having a heart attack • With or without Agoraphobia • 1% of teens ‣ 3 to 4% of teens have panic attack(s); You can have PANIC ATTACKS without having PD • Onset: 15 to 19 years (95% postpubertal) • Lowest remission rate for anxiety disorders

DO Skills: Praise

• Unlabeled: "Nice job, buddy!"; "Thank you!" • Labeled: "Nice job sharing your car!" ; "Thank you for putting your toy away." ‣ the more specific It is the the more effective • Why Praise? ‣ Compliments a child on their behavior ‣ Make both you and your child feel good! ‣ Labeled praises: » More effective; lets the child know exactly what you like » Behavior that is praised is more likely to be repeated » Boosts child's self-esteem

How we experience anxiety

• We are programmed to detect and react to signs of anxiety in ourselves and in others. Anxiety is both expected and normal at certain ages and in certain situations ‣ Anxiety often happens when we do something important, and in moderate doses it helps us think and act effectively. ‣ Anxiety is an adaptive emotion that readies children both physically and psychologically for coping with ppl, objs, or events that could be dangerous to their safety or well-being. ‣ Some anxiety is good, too much is not • When children experience fears beyond a certain age, in situations that pose no real threat or danger, and to an extent that interferes with daily activities, anxiety becomes a serious prob » anxiety involves an immediate reaction to perceived danger or threat— the fight/flight response. ~

Depression in infants

• We know the least about depression in infants ‣ Anaclitic depression: infants raised in a clean but emotionally cold institutional environment displayed reactions that resembled depression. They displayed weeping, withdrawal, apathy, weight loss, and sleep disturbance. They showed an overall decline in development, and in some cases, death. It was attributed to an absence of mothering and the lack of opportunity to form an attachment, but other factors, such as physical illness and sensory deprivation, may also have played a role ~

Prevention: Identification

• While 88% of pediatricians are screening, only 23% are using a validated tool. • Using a validated screening instrument is essential bc research shows that the use of personal or clinical judgment alone underestimates the number of adolescents who are using. • Even experienced physicians can fail to detect substance use disorders when they rely on clinical impressions, which tend to focus on readily apparent, late-stage signs like school problems.

Maintenance of Anxiety: Avoidance

• With avoidance we negatively reinforce the anxiety when we avoid the situation. If we avoid the situation, then our anxious feelings reduce but then we never face the fear • The "safety" behavior is the avoidance • This can lead to long-term probs bc they never face the fear, and continue to feel anxiety that may get worse

If dangerous/destructive behavior occurs during Special Time

• You stop play immediately. ‣ Child gets upset bc they enjoy their time. But if you explain you were doing x so we had to stop, we can try again tomorrow, It will allow them time to reflect and try again later.

Health-related problems in CP

• Young people with conduct problems engage in behaviors that place them at high risk for personal injuries, illnesses, drug overdoses, sexually transmitted diseases, substance abuse, and physical problems as adults ‣ Adolescent substance abuse is related to the imminent dangers of accidents, violence, school dropout, family difficulties, and risky sexual behavior ~

agoraphobia

• characterized by marked fear or anxiety in certain places or situations (i.e., being in a crowd, being outside the home alone) ‣ The individual fears or avoids these situations bc of thoughts that escape might be difficult, or help might not be available, if they were to experience panic-like or other incapacitating symptoms ~

CD and Age of Onset

• childhood-onset conduct disorder: display at least one symptom of the disorder before age 10, whereas those with adolescent-onset conduct disorder do not ‣ Those with childhood-onset CD are more likely to be boys, show more aggressive symptoms, be involved n more illegal activity, and persist in their antisocial behavior over time (more severe) ‣ Youths diagnosed with adolescent-onset CD are likely to be girls & do not display the severity or psychopathology that characterizes the childhood-onset group. They are less likely to commit violent offenses or persist in their antisocial behavior as they get older. » Age at onset does make a difference. ~

Treatments for Anxiety Disorders

• directed at modifying four primary problems ‣ Distorted information processing ‣ Physiological reactions to perceived threat ‣ Sense of a lack of control ‣ Excessive escape and avoidance behaviors » most commonly used treatments for anxiety disorders: behavior therapy, cognitive-behavioral therapy (CBT), family interventions, and medications.

Social & Emotional Deficits

• display low social performance and high social anxiety, and their parents, teachers, and peers are likely to view them as anxious and socially maladjusted • Those with SOC, may also be less popular with their peers • children with anxiety disorders are more likely to see themselves as shy and socially withdrawn and to report low self-esteem, loneliness, and difficulties in starting and maintaining friendship • more likely to have anxious friends than non-anxious friends, which may result in a contagion of anxiety symptoms betw friends • Young children with social anxiety may display lower levels of theory of mind (ToM), which is consistent with the idea that a lack of social understanding and deficits in regulating emotions may contribute to their social difficulties ~

Disruptive Mood Dysregulation Disorder (DMDD)

• frequent and severe temper outbursts that are extreme overreactions to the situation or provocation • chronic, persistently irritable or angry mood that is present between the severe temper outbursts. ~

AN Clinical Features

• 0.2-0.5% of young females ‣ 11:1 female-to-male ratio ‣ but could be that many males are underdiagnosed • Onset most common at ages 14 and 18 ‣ Pre-adolescent --> adolescent transition ‣ Adolescent --> young adult transition • Rigid, ritualistic thinking & behaviors • High comorbidity with OCD and depression (serotonin) ‣ The rate of mortality (5%); betw 6% & 10% die from medical complications or suicide ‣ of the survivors, fewer than 1/2 show full recovery, 1/3 show fair improvement, and 1/5 continue on a chronic course » is a leading cause of death for females 15 to 24 years old in the general population

Intervention: Sleep-wake schedule

• 1. Determine a schedule that will allow enough sleep for age • 2. A consistent schedule is critical for body clock ‣ Limiting drastic shifts to routines on weekends (try to stay consistent in rhythms and sleep times in weekdays AND weekends) ‣ Most important to keep wake time consistent, regardless of prior night sleep • 3. Gradual goals work better

4 major cognitive components in Coping Cat Treatment:

• 1. Recognizing anxious feelings and somatic reactions • 2. Identifying cognitions in anxiety-provoking situations • 3. Developing a coping plan • 4. Practice and reinforcement

Evidence-Based Treatments for Adolescent Eating Disorders: Maudsley Model: 3 Phases

• 1. Refeeding the adolescent ‣ Parents placed in charge of refeeding with support and reinforcement of therapist ‣ Siblings are encouraged to be supportive of patient ‣ "Family meal" assessment tool • 2. Negotiations for a new pattern of relationships ‣ Cannot advance to this phase until weight gain is achieved ‣ Family issues which impact parents' ability to ensure pt's weight gain are addressed • 3. Termination ‣ Focus shifts to encourage healthy parent-child relationship ‣ Issues of autonomy, family boundaries, and preparation for an adolescent's departure from home are raised here

Maudsley Model: 3 Tasks

• 1. To obtain and sustain cooperation from all family members ‣ Raise family's anxiety - Ie let them know of the potential for death ‣ Separating disorder from the adolescent ("externalize illness") --> "This isn't your daughter, this is the anorexia talking" • 2. To assess family organization and interactions re: eating and the patient's symptoms • 3. To intervene to help family members change how they respond to the eating disorder to facilitate eating and weight gain in the patient

Controlling your Thinking

• 2 approaches: ‣ 1. Increasing positive and decreasing negative thoughts » Should have at least twice as many positive thoughts as negative thoughts ‣ 2. Thinking more constructively » Identify thoughts (negative and positive) » Identify "activating events"/triggers » Identify underlying beliefs ("I am a failure") » Counteract neg thoughts or select a course of action for activating events (Challenge those thoughts what is the evidence that you are not a failure?; » Create a plan - reach out to a friend, find resources like if you failed a test reach out to TA, etc.)

Specific Phobia - Prevalence and Comorbidity

• 20% of all youths experience specific phobias at some time in their lives, and those with this disorder tend to have multiple phobias ‣ very few of these children are referred for treatment ‣ children are at increased risk for the phobic disorder exhibited by their parent • Specific phobias, particularly blood phobia, are more common in girls than boys ‣ most common co-occurring disorders with a specific phobia: another anxiety disorder and depressive disorders ~

TADS STUDY

• 4 Groups: ‣ Placebo ‣ CBT alone ‣ Fluoxetone alone ‣ CBT+Fluoxetine • PROBLEMS ‣ Blindness of: participant and clinicians ‣ Not blind to CBT status ‣ Knew CBT alone did not include active meds ‣ Knew CBT+fluoxetine incl active meds = Placebo effects • SAMPLE ‣ 439 12-17 y/o participants with stable and pervasive MDD ‣ IQ above 80 ‣ Exclusionary criteria: severe S/I, conduct d/o, 2 failed SSRI trials, failed CBT tx ‣ Could not have been on antidepressants prior to consenting ‣ Were not asked to discontinue other forms of therapy

Well-Established Treatment For Anxiety: Cognitive-Behavioral Therapy

• 70-80% of participants = reductions in anxiety sx/disorders relative to control treatments • Restructuring the distorted, maladaptive cognitions that add to anxiety by doing feared activities/ experiencing feared situations ‣ Investigating the evidence ‣ Use of coping self-talk: "I can do it! I am brave!" ‣ Experiencing habituation of anxiety in feared situation ‣ My anxiety decreases, it wasn't so bad, I can handle it! ‣ Cognitive changes --> behavioral changes and vice versa » It informs them on the nature of anxiety, identifies triggers and cognitive distortions; » Practices prob-solving skills and social skills and rationalizing cognitions; » Setting realistic goals and rehearsing for a real-life situation

Age, Sex and Ethnicity

• A certain amount of substance use during adolescence is normative behavior; ‣ researchers find that alcohol use before age 14 is a strong predictor of subsequent alcohol abuse or dependence, especially when early drinking is followed by the rapid escalation in the quantity of alcohol consumption • Past studies found girls typically use fewer types of drugs and use them less often than boys, but recent. studies show girls caught up & rates are equivalent ‣ also, rates of diagnoses for SUDs no longer differ significantly betw boys and girls » For many years, black or African American youths had substantially lower rates of illicit drug use. However, the differences have narrowed, primarily due to increased marijuana use among African American students. ‣ Hispanic seniors have the highest rate of lifetime usage for cocaine, heroin, crystal methamphetamine ~

Binge Eating Disorder (BED)

• A disorder that involves periods of excessive eating with a feeling of a loss of control. Similar to bulimia without the compensatory behaviors ‣ Involves pds of eating more than other people would, accompanied by feeling of loss of control ‣ Affects 1.5%-3% of adolescents ‣ Has negative health correlates ‣ individuals with BED are often overweight or obese

Pica

• A form of ED in which the infant or toddler persists in eating inedible, nonnutritive substances (ie chips of paint, insects, hair, etc) ‣ This disorder is one of the more common and usually less serious ‣ infant or young child who eats inedible, nonnutritive substances for a period of 1 month or longer may have more serious probs » Is more prevalent among institutionalized children & adults, esp. persons with more severe impairments and intellectual disability » The degree of severity is related to the degree of environmental deprivation and intellectual disability in individuals suffering from ~

Prevalence and Comorbidity of SOC

• A lifetime prevalence of 6% to 12% and affects nearly 2x as many girls as boys ‣ Research suggest that adolescent females may have an increasing biological sensitivity to being evaluated by peers, which may, over time, increase their vulnerability to developing SOC. • Adolescents with SOC also suffer from other anxiety disorders or major depression. They may use alcohol and drugs as a form of self-medication to reduce their anxiety and are at risk for later substance-use problems ‣ SOC is rare in children under the age of 10, and it generally develops after puberty, with the most common age at onset in early- to mid-adolescence » As adults, individuals with SOC continue to experience impairment in role functioning, relationship probs, educational difficulties, and poorer overall quality of life ~

Major Depressive Disorder (MDD)

• A minimum duration of two weeks, and is associated with depressed or irritable mood, loss of interest or pleasure, other symptoms (e.g., sleep disturbances, difficulty concentrating, feelings of worthlessness), and significant distress or impairment in functioning.

Reading / Lecture- Ch 11: Anxiety and obsessive compulsive disorders anxiety

• A mood state with strong neg emotion and bodily symptoms of tension in which the child apprehensively anticipates future danger or misfortune ‣ Children who experience excessive and debilitating anxiety are said to have anxiety disorder » Many youths with anxiety disorders suffer from more than one type, simultaneously or at separate times » Anxiety disorders in DSM-5 include 7 categories: SAD, Specific phobia, SOC, Selective Mutism, PD, Agoraphobia, GAD ~

Motivational Interviewing

• A patient-centered and directive approach • Addresses ambivalence and discrepancies betw a person's current values and behaviors and their future goals » the type of treatment depends on levels of use and the individual's home environment.

In adolescence: Anorexia Nervosa

• A severe eating disorder characterized by: ‣ refusal to maintain a minimally normal body weight ‣ an intense fear of gaining weight ‣ a significant disturbance in perception & experiences of body size. ‣ Weight loss is accomplished thru a very restricted diet, purging, and/or exercise. ‣ They may become obsessed with measuring themselves • DSM-5 subtypes ‣ Restricting type: individual loses weight thru diet, fasting, or excessive exercise ‣ Binge-eating/purging type

Temperament: Behavioral Inhibition (BI)

• A type of temperament characterized by: ‣ Low threshold to novelty and withdrawal from novel stimuli in infancy ‣ Tendency to be fearful and anxious as toddlers ‣ Tendency to be shy or withdrawn in novel or unfamiliar situations as young children • Stable inhibition across infancy and early childhood predicts adolescent social anxiety disorder (Chronis-Tuscano et al., 2009) ‣ Risk may be moderated by overprotective parenting (high on warmth and control) (Lewis-Morrarty et al.) • Treatment for this: the ability to delay one's initial reactions to events or to stop behavior once it has begun. ‣ a predisposing factor for the development of later anxiety disorders, particularly SOC

Diagnostic Criteria for Bulimia Nervosa

• A) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: ‣ (1) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most ppl would eat during a similar period of time and under similar circumstances ‣ (2) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) • (B) Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; the misuse of laxatives, diuretics or enemas, or other medications; fasting; or excessive exercise. • (C) The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months. • (D) Self-evaluation is unduly influenced by body shape and weight. • (E) The disturbance does not occur exclusively during episodes of anorexia nervosa. ‣ Specify if partial remission or full remission ‣ Specific severity (frequency of inappropriate compensatory behaviors)

Diagnostic Criteria for Binge Eating Disorder

• A) Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: ‣ (1) Eating, in a discrete period of time (e.g., within any 2-hr pd), an amount of food that is definitely larger than what most would eat in a similar period of time under similar circumstances. ‣ (2) A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating). • B) The binge eating episodes are associated with three (or more) of the following: ‣ (1) Eating much more rapidly than normal ‣ (2) Eating until feeling uncomfortably full ‣ (3) Eating large amounts of food when not feeling physically hungry ‣ (4) Eating alone bc of feeling embarrassed by how much one is eating ‣ (5) Feeling disgusted with oneself, depressed, or very guilty afterward. • (C) Marked distress regarding binge eating is present. • (D) The binge eating occurs, on average, at least once a week for 3 months. • (E) The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa. ‣ Specify if partial or full remission ‣ specify severity (based on the frequency of episodes of binge eating)

Diagnostic Criteria for Anorexia Nervosa (must meet A-C criteria)

• A) Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected. (B) Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even tho at a significantly low weight. (C) Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. ‣ Specify if: Restricting type or Binge eat/purging type ‣ Specify if: in partial remission ‣ Specify Severity based on BMI (Mild, Moderate, Severe)

Diagnostic Criteria for Substance-Use Disorder

• A. A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period ‣ 1. Substance is often taken in larger amounts or over a longer period than was intended. ‣ 2. There is a persistent desire or unsuccessful effort to cut down or control substance use. ‣ 3. A great deal of time is spent in activities necessary to obtain substance, use the substance, or recover from its effects. ‣ 4. There is a craving or a strong desire or urge to use the substance. ‣ 5. Recurrent substance use results in failure to fulfill major role obligations at work, school, or home (e.g., poor performance related to substance use; substance-related absences; neglect of children or household). ‣ 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. ‣7. Important social, occupational, or recreational activities are given up or reduced bc of substance use. ‣ 8. There is recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use). ‣ 9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological prob that is likely to have been caused or exacerbated by the substance. ‣ 10. Tolerance, as defined by either or both of the following: » A need for markedly increased amounts of substance to achieve intoxication or desired effect. » Markedly diminished effect with continued use of the same amount of the substance. ‣ 11. Withdrawal, as manifested by either of the following: » The characteristic withdrawal syndrome for a substance. » The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. » Specify if in remission; If in a controlled envmt; severity level

Diagnostic Criteria for Seperation Anxiety Disorder (SAD)

• A. Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by at least three of the following: ‣ 1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. ‣ 2. Persistent and excessive worry about losing attachment figures or about possible harm to them ‣ 3. Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation ‣ 4. Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. ‣ 5. Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or other setting ‣ 6. reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure ‣ 7. Repeated nightmares of separation ‣8. complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated. • B. Fear, anxiety, or avoidance is persistent • C. disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. • D. disturbance is not better explained by another mental disorder ~

Diagnostic Criteria for GAD

• A. Excessive anxiety and worry, occurring more days than not for at least 6 months, about a # of events or activities (such as work or school performance). • B. The person finds it difficult to control the worry. • C. The anxiety and worry are associated with *three (or more)* of the following six symptoms: (NOTE: *Only one item is required in children*) ‣ Restlessness or feeling keyed up or on edge ‣ Being easily fatigued ‣ Difficulty concentrating or mind going blank ‣ Irritability ‣ Muscle tension ‣ Sleep disturbance • D. It causes significant distress or impairment in functioning • Disturbance not due to other substances (meds, drug use) or med condition • E. Disturbance not explained by another mental disorder ~

Diagnostic Criteria for Specific Phobia

• A. Marked and persistent fear of an object or situation (flying, heights, animal, etc)/ • B. Exposure provokes immediate anxiety response. In children, Fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. • C. The phobic object or situation is actively avoided or endured with intense fear or anxiety. • D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context. • E. The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more. • F. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • G. The disturbance is not better accounted for by another mental disorder ~

Diagnostic Criteria for Social Anxiety Disorder

• A. Marked fear or anxiety about social situations in which the individual is exposed to possible scrutiny by others (ie social interactions in having convos or meeting unfamiliar ppl), being observed, performing in front of others • B. individual fears that he/she will act in a way or show anxiety symptoms that will be negatively evaluated (ie be humiliated, rejected) • C . Social situation evokes fear or anxiety • D. The social situations are avoided or endured with Intense fear/anxiety • E. The fear or anxiety is out of proportion to the actual danger posed by the social situation and to the sociocultural context. • F. The fear, anxiety, or avoidance is persistent, lasting for 6 months or more. • G. The fear, anxiety, and avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. • H. The fear, anxiety, and avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. • I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder • J. If another medical condition (e.g., Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive. » Specify if Performance only: If the fear is restricted to speaking or performing in public. ~

Diagnostic Criteria for Agoraphobia

• A. Marked fear/anxiety for two or more: ‣ public transportation ‣ open spaces ‣ enclosed spaces ‣ standing in line ‣ being outside the home alone • B. Individual avoids these situations • C. The Situations always provoke fear or anxiety • D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety. • E. Anxiety not proportional to real danger • F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. • G. Causes Significant distress/impairment in social, occupational, or other important areas of functioning. • H. Not better explained by another mental disorder ~

Diagnostic Criteria for OCD

• A. presence of obsessions, compulsions, or both: Obsessions defined by 1 & 2: ‣ 1. recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and cause marked distress ‣ 2. individual attempts to ignore or suppress such thoughts or to neutralize them w/ some other thought or action (i.e., by performing a compulsion) Compulsions are defined by 1 & 2: ‣ 1. repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly ‣ 2. behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive • B. obsessions or compulsions are time-consuming - take 1+ hr per day or cause significant distress • C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or other medical conditions. • D. The disturbance is not better explained by the symptoms of another mental disorder. ~

Components of Relapse Prevention

• Activities for Brain Recovery ‣ Sleep, exercise • Addressing Triggers and Neural Causes ‣ Completely change room or whatever place teen used substance ‣ Avoid whenever possible all triggers that teen can identify in the immediate stages of recovery, 1-3 months (songs, movies, Netflix, video games, places routes you take, to get places, pictures on phone, old text, movies) ‣ Clean out phone and change number ‣ Have behavioral plan for unexpected cueing (cues that can trigger relapse)

Prevalence and Comorbidity of Agoraphobia

• Adolescent females are about 2x as likely as to experience panic attacks, and a consistent association has been found betw panic attacks and stressful life events ‣ Other comorbid conditions include mania and hypomania, ADHD, and ODD ‣ The most common comorbidities for agoraphobia are other anxiety disorders (e.g., PD, specific phobias, and SOC), major depressive disorder, PTSD, & alcohol-use disorder » Findings generally support SAD as a strong predictor of PD. However, SAD also predicts other anxiety disorders so It may be an early marker for anxiety disorders in general, rather than a specific risk factor for PD » PD and agoraphobia are stable and over time and have one of the lowest rates of complete remission for any of the anxiety disorders. ~

Risks of Substance Use

• Affect the growth and development of teens, esp brain development. ‣ Occur more frequently with other risky behaviors, such as unprotected sex and dangerous driving ‣ Contribute to the development of adult health problems, such as heart disease, high blood pressure, and sleep disorders

ethnicity and culture in depression

• African American and Hispanic youths both had significantly higher rates of depression. However, only Hispanic youths with depression showed an elevated risk for impaired functioning. • Nonwhite (African American, Hispanic, and Asian) adolescents reported more symptoms of depression than white adolescents However, these differences likely reflect differences in socioeconomic status (SES), since lower SES and depression are related. • In females, initial rates of depressive symptoms were highest for Hispanic and Asian teens and lowest for Whites » Depression in preadolescent children is equally common in boys and girls, but the ratio of girls to boys is 2:1 to 3:1 after puberty. » The relationship betw depression and race/ethnicity during childhood and adolescence is an understudied area. ~

Seperation Anxiety Disorder (SAD)

• Age-inappropriate and excessive anxiety about being apart from parents or away from home or being alone • Fear that harm will befall them or their caregiver leading to separation • Normal to have this from 7 months thru preschool but SAD goes beyond this age ‣ To avoid separation, they may fuss, cry, scream, or threaten suicide if the parent leaves (altho serious suicide attempts are rare)

Symptoms of Anxiety: Behavioral System

• Aggression and a desire to escape the threatening situation, but social constraints may prevent fulfilling either impulse. ‣ Instead these impulses show up as foot tapping, fidgeting, irritability, or avoidance by getting a doctor's note, even faking illness. ‣ More symptoms: Crying/screaming, Nail biting; Trembling voice; Tantrums » Avoidance behaviors are negatively reinforced; they are strengthened when they are followed by a rapid reduction in anxiety

Substance Use Among Teens

• Alcohol, marijuana, and tobacco are substances most commonly used by adolescents (but there's been a decline in tobacco use) .• By 12th grade, about 2/3s of students have tried alcohol. • About half of 9th thru 12th-grade students reported ever having used marijuana (marijuana is most commonly used by high HS seniors) • About 4/10 9th thru 12th grade students reported having tried cigarettes • Among 12th graders, close to 2 in 10 reported using prescription medicine without a prescription. • 9 out of 10 ppl with Substance probs started using in adolescence ‣ drug and alcohol use among youth appears to be on the decline, likely due to active prevention and education.

AN Medical Complications

• Amenorrhea • Dry, yellowish skin • Lanugo (fine, fuzzy hair); hair loss • Sensitivity to cold • Cardiac problems • Chronic dehydration; electrolyte imbalance; potassium depletion (increases risk for renal failure and cardiac problems) • Retardation of bone growth

Causes of Depression

• An interplay of genetics, neurobiology, fam, cogntive, emotional, interpersonal, and envmt factors ‣ Genetic risk influences neurobiological processes. These early dispositions increase exposure to and are shaped by negative experiences within the family and continue to exert influence throughout development. ‣ Neg family experiences may also create an inconsistent emotional and social environment, which makes it difficult for the child to effectively regulate emotions and interpersonal behavior & to cope with stress ‣ Cognitive, emotional, and interpersonal probs may lead directly to depression, or they may elicit conflict, rejection by others, and social isolation, which will eventually lead to depression ~

Treatment and Prevention of SUD

• Approximately half of the adolescents receiving treatment for SUDs relapse within the first 3 months after treatment, and only 20% to 30% remain abstinent at 1 year ‣ More promising treatments for adolescent substance abuse are those that involve the larger systems affecting the adolescent's behavior, such as peers, family, and school climate ‣ Other effective methods focus on personality factors linked to alcohol abuse, such as hopelessness, anxiety sensitivity, impulsivity, and sensation seeking ~

Avoidant/restrictive food intake disorder (ARFID)

• Avoidance or restriction of food intake, leading to significant weight loss (or failure to maintain normal growth) and/or nutritional deficiency. ‣ One or more of four features must be present: significant weight loss, significant nutritional deficiency, dependence on enteral feeding (i.e., use of a feeding tube) or oral nutritional supplements, or marked interference with psychosocial functioning » This disorder does not apply to children who lack adequate food or to children who lack food because of cultural practices. » Some children manifest this by avoiding or restricting food based on its sensory characteristics, such as appearance, color, taste, smell, or temperature. all kids do this at times, but if it leads to weight loss or nutritional deficiency this disorder may be present.) ~

Coping with Depression Course-Adolescents (CWD-A)

• Based on Lewinsohn's theory • Depression results from an imbalance between positive and negative interactions with the environment • You may not be able to control all negative events in your life, but you can control your reactions to these events • Learning to control your mood is a skill

Reinforced Exposure

• Based on principles of operant conditioning ‣ Avoidance results in negative reinforcement: (1) decrease in anxiety and (2) "preventing" feared consequence • Induce child to try successive approximations of the activities they fear and reward child for doing so with praise or external reinforcers ‣ Anxiety increases initially and the child eventually habituates (i.e., "worry hill" or "cold pool") ‣ Reinforcement makes it more likely that they will repeat approach behavior ‣ Once they face the behvr the child realizes the event wasn't that bad

Treatments for Young Ppl 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. • Cognitive Therapy Focuses on helping the youth 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 thought patterns are recognized, the child is taught to change from a negative, pessimistic view to a more positive, optimistic one. • Cognitive-Behavioral Therapy (CBT) The most common and effective form. Combines elements of behavioral and cognitive therapies in an integrated approach. Attribution retraining may also be used to challenge the youth's pessimistic beliefs. • Interpersonal Psychotherapy for Adolescent Depression (ITP-A) (def above, same thing but for adolescents) • Medication Use antidepressants, especially selective serotonin reuptake inhibitors (SSRIs). ~

CBT for anxiety cont..

• Behavioral strategies include: ‣ Modeling ‣ In-vivo exposure ‣ Roleplay ‣ Relaxation training ("robot > ragdoll") ‣ Reinforced practice • STIC (Show that I can") Tasks ‣ Practice skills taught in therapy outside session (exposures)

Theoretical Models: Diathesis-Stress

• Biological models ‣ Genetic (prev history of depression) ‣ Brain/neurochemistry/HPA system (low serotonin) ‣ Inherited temperament style (difficult temperament with irritability) • Cognitive models ‣ Information processing (how are they processing the world) ‣ Cognitive schemas (Beck) ‣ Attributional style/control-related beliefs (if something bad happens they take responsibility for It; if something good happens they attribute It outside themselves) • Behavioral & Interpersonal Models ‣ Interpersonal relationships (poor peer skills and poor friendships no one wants to be around them so they feel unlikeable) ‣ Social problem solving ‣ Coping ‣ Achievement and school-related Fx/competence models (if feeling depressed and not doing well in school they don't feel like they are achieving or don't feel competent) • Affect Model ‣ Low PA, high NA (Low pos affect & high neg affect --> Low PA associated w depression) ‣ Emotional regulation (poor in depression)

Causes of Eating Disorders:

• Biology: neurobiological factors play a minor role in anorexia and bulimia. BUT, may contribute to the maintenance of the disorder ‣ Individual who disrupts their normal regulation may cause biological changes that create more disruption ‣ Biological vulnerability interacts with social and psychological factors • Genetics: Eating disorders tend to run in families, esp among female relatives ‣ Heritability: Anorexia 58-88% ; Binge eating 46% • Neurobiological Factors: serotonin imbalance ‣ Biochemically similar to those with OCD • Social/Psychological Factors: , There is an emphasis on physical appearance: see worth, happiness, & success determined by physical appearance. ‣ influenced by Personality: Family messages; Peers; Media • Family Influences: alliances, conflicts, or interactional patterns within a family. Family overemphasis on weight and dietary control. ‣ Other trauma esp those involving a threat to personal safety (e.g., witnessing domestic violence, assaults, kidnapping) are very common in men and women with EDs, as well as those with other psychiatric disorders) • Psychological Dimension: struggle for autonomy, competence, control, and self-respect; Some have considered anorexia to be a type of phobic avoidance disorder ‣ Adolescents with anorexia are described as being obsessive and rigid, showing emotional restraint, preferring the familiar, having a high need for approval, showing poor adaptability ‣ Adolescents w/ bulimia exhibit obsessive-compulsive behaviors

Screening, Brief Intervention, and Referral to Treatment (SBIRT)

• Brief Screening ‣ Screening to Brief Intervention (S2BI) -> screening to determine if at risk and provide referrals to help ‣ Brief Screener for Tobacco, Alcohol, and other Drugs • Brief Intervention ‣ A short dialogue (lasting from a few secs to several minutes) betw the pediatric care provider and the patient that focuses on preventing, reducing, or stopping substance use. ‣ A brief intervention should be tailored to the level of use identified by the screener. ‣ For adolescents who do not use substances, for those who report infrequent substance use, and for those who report frequent use.

Gender, ethncity, culture in anxiety

• By age 6, twice as many girls as boys have experienced symptoms of anxiety, and this discrepancy persists through childhood, adolescence, and young adulthood ‣ This suggests that female vulnerability to anxiety is related to genetic and related neurobiological differences, as well as to varying social roles and experiences • There is support for a higher prevalence of anxiety in ethnic minority groups in the US ‣ African American children generally report more symptoms of anxiety than do white children ‣ It has been found that symptoms of anxiety are higher in children of parents with fewer yrs of formal education, suggesting that variations in child anxiety across racial/ethnic groups may also be accounted for by group differences in parental education • Increased levels of fear in children are found in cultures that favor inhibition, compliance, and obedience » Children's ethnicity and culture may affect the expression and developmental course of fear and anxiety, how anxiety is perceived by others, and expectations for treatment. ~

Take Home Points: Youth Anxiety Treatments

• CBT is a very effective treatment for most anxiety disorders (70-80% improvement rates), and is the first-line treatment for anxiety disorders • Medication (SSRIs, typically) combined with CBT may be indicated for more pervasive and impairing anxiety disorders

Body Dysmorphic Disorder (BDD)

• Characterized by a preoccupation with defects or flaws in physical appearance that are not observable or appear slight to others. ‣ the individual engages in repetitive behaviors (e.g., mirror checking, excessive grooming, seeking reassurance) or mental acts (comparing her or his appearance to others) » causes significant distress or impairment in important areas of life functioning (e.g., social, occupational). ~

Trichotillomania (Hair-Pulling Disorder)

• Characterized by recurrent pulling out of one's hair, resulting in hair loss (not attributable to another medical condition) ‣ They have repeated attempts to decrease or stop hair pulling ‣ Suffer significant distress or impairment in functioning ~

Diagnostic Criteria for 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, manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: ‣ Aggression to Ppl and Animals (1. Bullies/threatens others, 2. Initiates physical fights, 3. Used a weapon that can cause physical harm like brick, knife, gun, bat, etc., 4. Physically cruel to ppl, 5. Physically cruel to animals, 6. Has stolen While confronting a victim like mugging, armed robbery, extortion, 7. Forced someone into sexual activity) ‣ Destruction of Property (8. Deliberately engaged in fire setting with the intention to cause damage, 9. Deliberately destroyed others' property other than by fire setting) ‣ Deceitfulness or Theft (10. Broken into a house, building, or car, 11. Lies to obtain goods/favors or avoid obligations, 12. Stole items of nontrivial value without confronting victim - ie shoplifting) ‣ Serious Violations of Rules (13. Stays out despite parent prohibitions begins before age 13, 14. Runs away from home overnight at least twice or at least once without returning for a lengthy pd, 15. truant from school beginning before age 13) •The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. • If the individual is 18 years or older, criteria are not met for Antisocial Personality Disorder. • Specify if: Child has limited prosocial emotions; Lacks remorse or guilt; Callous - lack of empathy; Unconcerned about performance; Shallow or deficient effect ‣ Plus specifiers based on onset type (childhood onset is more severe) » DSM severity ratings of Mild, moderate, & severe are based on # of symptoms in excess of the 3 required to make the diagnosis or the amount of harm caused to others

Parents and child sleep interactions

• 1. Independent sleep: parents can get into the habit of helping their child fall asleep (TV on for teen) • 2. Children may rely on these habits to fall asleep • 3. Bidirectionality relationship (parents' sleep impacts child sleep and vice versa) • 4. Gradual changes

Negative Reinforcement Cycle in OCD

• By performing the compulsion, the child never gets a chance to see that the bad thing was not going to happen. • This strengthens and maintains the obsessions and compulsions. • Treatment focuses on not performing the compulsion.

CBT Model: Anxiety

• Changing our thoughts, changing behavior - facing It not avoiding, and helps reduce negative feelings

Symptoms of Anxiety: Cognitive System

• Children may find it difficult to focus on everyday tasks bc their constant search for threat or danger consumes their attention. • When these children can't find proof of danger, they may turn their search inward: "If nothing is out there, then something must be wrong with me." Or they may distort the situation: "Even though I can't find it, I know there's something to be afraid of." ‣ Activation of the cognitive system may lead: to feelings of apprehension, nervousness/worry, difficulty concentrating, panic, thoughts of being scared or hurt, Thoughts of incompetence/ inadequacy

Examples of Socio-Cognitive Tx Models

• Coping Power (Lochman @ Alabama) copingpower.comcopingpower.com • Problem Solving Skills Training (Kazdin @ Temple) yaleparentingcenter.yale.edu • Often combined with parent training

Social and economic costs of CP

• One of the most costly mental health probs in North American ‣ Extreme pattern of antisocial behavior occurs in only about 5% of children. These children cause considerable and disproportionate amounts of harm, accounting for over 50% of all crime in the US, & about 30% to 50% of clinic referrals » More teenagers in the US die from firearm injuries than from all diseases combined ~

DO Skills: PRIDE

• Praise • Reflect • Imitate • Describe • Enjoy

READING/LECTURE - Eating Disorders Feeding/Eating Problems

• Quite normative early in development • 20 to 62% require professional intervention ‣ 1 to 3% of children end up having persistent problems ‣ Early feeding probs are predictive of later eating disorder

Developmental Pathway for Anxiety Disorders

~

Do Skills: Describe

• A behavior description describes what the child is doing ‣ You're racing your cars around the track! • Not what you (the parent) are doing ‣ I'm parking my race car in the garage. • Not what the toys are doing ‣ Lightning McQueen takes the lead! » "You ___" statements • Why do we Describe? ‣ Shows you are interested and paying attention ‣ Models speech and teaches vocabulary and concepts ‣ Helps increase child's attention span and persistence with activity (continuing on w their activity) ‣ Encourages child to slow down and think about their actions (instead of jumping onto the next activity)

Genetics in these Behavioral Disorders

• Account for 50% of the heritability in CD ‣ Genetic contribution higher for: » Life-course persistent pattern » Callous-unemotional traits • Genetics may be related to: ‣ Difficult temperament ‣ Impulsivity ‣ Tendency to seek rewards or insensitivity to punishment • Gene-environment interactions ‣ E.g., maltreated kids with low-active MAOA » Genes don't determine behvr!

Kendall's "Coping Cat"

• Addresses biological, cognitive, and behavioral aspects of anxiety which are relevant for all core anxiety disorders (GAD, SAD, SoP) • Cat is the coping model that children can relate to ‣ Cat starts as scared-y cat which turns into a Coping cat

Done Correctly, Time-Out is Highly Effective

• Keeps child from stimulating activities (takes them out of exciting activities) • Can be done immediately after inappropriate behavior ‣ if you have good sequence/good play then time out is difficult bc the child wants to go back! Once they are done with time out they still have to comply with the command or they stay in time out ‣ If they finally follow through w the command they get a huge praise

Sleep Article (Becker et al., 2016): Sleep Review focus on the introduction, results and discussion sections.

SUMMARY • Research suggests that intraindividual variability (IIV) of sleep/ wake patterns (sometimes referred to as sleep variability or night-to-night variability) regularly occurs and may have implications for adjustment. Clinical sleep recs may not only need to address overall sleep duration and sleep habits but also the stability of sleep duration and timing. Future research should pertaining to the causes, mechanisms, moderators, & outcomes of sleep IIV in youth INTRODUCTION • The majority of research has focused on sleep duration, and studies convincingly demonstrate that insufficient sleep is associated with adverse cognitive, behavioral, mental health, and physical health consequences in youth. • Sleep IIV may be common and relevant in childhood and adolescence given the rapid developmental maturation, complex familial and peer systems, and environmental demands occurring during these developmental periods. However, children's sleep IIV has received little attention RESULTS • The 52 studies published betw 2000 and 2015. There has been a recent increase in the # of studies examining sleep IIV in children & adolescents • Most studies (69%) were conducted in the US in predominantly non-Hispanic White samples, with remaining studies conducted in Brazil (4), Australia (3), Israel ( 3), Denmark ( 2), Canada (2), Germany ( 1), and Japan (1). ‣ The developmental span from infancy thru late adolescence was represented, including two studies (4%) conducted with infants/toddlers (ages 0-2), 9 with preschool-aged children (ages 3-5), 23 with school-aged children (6-12), and 18 with adolescents (13-18). Almost three-fourths of studies focused on youth from the general community or school-based samples, with most other studies including youth with mental health or physical health conditions ( 14). • Studies assessed daily sleep using actigraphy (36), parent- completed sleep diaries ( 19), and youth-completed sleep diaries ( 20). one study used daily phone calls to the adolescent and their parent. • Sleep IIV variables are described in six categories: duration IIV (including sleep duration, time-in-bed, and total sleep time variables), onset IIV (including bedtime and sleep onset latency variables), waking IIV (including wake time and wake onset variables), quality IIV (including sleep efficiency, night wakings, and nocturnal movement variables), habits IIV (including sleep habits, night routines, and sleep schedule variables), and sleepiness IIV • Quality: 77% of studies were judged to have good sample representativeness, 79% were judged to make appropriate inferences and conclusions, 96% used well-validated measures for assessing sleep IIV, and 100% used well-validated measures for assessing correlates. Approx. one-fourth of studies examined sleep IIV based on measuring sleep for 14+ days. PRIMARY FINDINGS : sleep IIV, findings from the 52 studies were grouped into eight themes • Theme A: development (11) - Compared sleep IIV across diff age groups. Separate studies indicate that duration IIV is approximately 1 h in school-aged children & approx 1.5 h in adolescence ‣ Acebo et al. found greater sleep quality IIV in 36-month-old children as compared to both younger or older children, which the authors suggest may be due to a reorganization of the sleep/wake system around three years of age. One study found older age to be significantly associated with both onset IIV and waking IIV whereas another study found no association between age and onset IIV. Another study found mixed findings across age groups depending on the child's race and sex, with non-White boys aged 9-11 having the greatest duration IIV ‣ Moore et al. found the association betwe age and duration IIV to remain significant when controlling for demographic and environmental variables. Another study found adolescents to have greater onset IIV and waking IIV compared to teachers with the same morning school start time ‣ In a longer longitudinal study across the transition from high school to college, there was no change in onset IIV, whereas waking IIV increased over time ‣ Puberty Status: Two of the studies that examined age also examined pubertal status in relation to sleep IIV. Moore et al. found more advanced pubertal status during adolescence to be associated with duration IIV, but not after controlling for various demographic and environmental variables. • Theme B: All nine studies examining sleep IIV in relation to race/ethnicity were conducted in the US, where race/ethnic differences may be relevant. Four studies found at least some evidence for greater sleep IIV among non-White youth as compared to White youth, whereas five studies found no race/ethnicity differences in sleep IIV. Importantly, one study found the association betw non-White race and duration IIV to remain significant after controlling for parent education, family income, and neighborhood distress. ‣ Consistent with this latter finding, a series of studies by El-Sheikh and colleagues found the income-to-needs ratio to be generally unassociated with onset IIV or habits IIV though in one study family economic hardship was significantly associated with children having greater onset IIV ‣ Among studies that used a composite measure of SES, one did not report an association with duration IIV when the composite included family income and parent ed measured five years prior to the sleep assessment [48]. In contrast, two other studies using more indicators to assess SES found lower SES to be associated with greater onset IIV and greater duration IIV ‣ Black children whose families were worse off financially had greater onset IIV than other Black children, whereas no significant effect was found for White children regardless of family income-to-needs ratio. ‣ Family structure and functioning El-Sheikh et al. did not find single-parent status to be associated with chil- dren's onset IIV, Troxel et al. found a complex association. White adolescents from two-parent homes had lower onset IIV compared to White adolescents from single-parent homes, whereas no association was found between family structure and onset IIV for Black adolescents. ‣ Sleep environment: Sleep environment is associated with sleep IIV. Buckhalt et al. found that sharing a bedroom is associated with greater onset IIV and greater waking IIV. Storfer-Isser et al. found that a poorer sleep environment (e.g., falling asleep while listening to loud music, watching television, with lights on) was associated with greater duration IIV amongst adolescents. Spruyt et al.found more adaptive bedtime routines (e.g., bedtime hugs, putting on pajamas) to be associated with less duration IIV and less quality IIV. ‣ Fuligni and Hardway similarly found that more time spent socializing with friends and playing a computer outside of school were significantly associated with greater dura- tion IIV, whereas time spent studying, watching television, or helping the family were unassociated with duration IIV. ‣ Community Factors: One study found community poverty to be unassociated with onset IIV. Another study found more neighborhood distress to be significantly correlated with duration IIV, though this association was no longer significant when controlling for other demographic and environmental variables. In a three-month longitudinal study of children exposed to violence (either intimate-partner or community violence), Spilsbury et al. found that children who were physically assaulted during the violent event did not differ in duration IIV from children who were not physically assaulted. • Theme C: Physical Factors and Health (n=18) In Sex: Studies have not found sex differences in sleep IIV in preschool-aged or school-aged children. There is some indication that females may have greater onset IIV and greater duration IIV. Another study also conducted with adolescents did not find any sex difference in duration IIV. ‣ BMI: No relation was found betw sleep IIV with BMI in three studies conducted with school-aged children. In contrast, in a community sample of adolescents greater duration IIV was significantly associated with higher BMI. Nevertheless, these and other studies have found sleep IIV to be associated with some adverse metabolic and nutrition outcome. ‣ Other: Having asthma was significantly associated with greater onset IIV in children but not with duration IIV in adolescents • Theme D; Psychosocial, Emotional, Behavioral Functioning ‣ Studies examining sleep IIV in relation to anxiety and depressive symptoms report mixed findings. In a sample of preschool-aged children, both onset IIV and waking IIV were associated with greater parent-reported inter- nalizing problems, and onset IIV was also associated with more anxious/depressed behaviors specifically. In adolescence, some studies report no association betw duration IIV and mood. However, two larger studies link greater duration IIV to greater adolescent anxiety/depression. Finally, one study conducted with youth exposed to a violent event did not find an association betw duration IIV and PTSS specifically ‣ Behavioral functioning (6). Studies generally report a significant association betw sleep IIV and poorer behavioral functioning. Bates et al. found both duration IIV and onset IIV to be associated with poorer teacher-rated preschool adjustment and behavior, whereas having a late bedtime, mean nightly sleep duration, and total daily sleep was unassociated with preschool functioning. In another preschool study, greater onset IIV was positively associated with a measure of behavioral reactivity, although waking IIV was unassociated with teacher-rated inattention problems. In contrast, another study showed that preschoolers' waking IIV, but not onset IIV, was associated with more parent-rated inattention probs. however, a longitudinal study of Mexican- American adolescents found duration IIV to be pos associated w adolescent self-ratings of engaging in risky behavior • Theme E; Cognition and Learning Studies examining sleep IIV in relation to children's intellectual ability report mixed findings. Araújo et al. did not generally find an association betw onset IIV and children's visuospatial IQ scores. Similarly, Suratt et al. [44] did not find an association betw duration IIV & children's scores on an intelligence subtest but did find greater duration IIV to be associated with poorer performance on subtests measuring word knowledge and verbal reasoning. Buckhalt et al. also found waking IIV and onset IIV to be associated with lower overall IQ. Further, children with lower overall working memory performance were particularly vulnerable to the previous night's sleep quality • Theme F: Neurodevelopment Disorders Hvolby et al. found children with ADHD to have greater onset IIV. In contrast, two other studies did not find evidence for greater sleep IIV (i.e., duration IIV, onset IIV, or waking IIV) in children with ADHD compared to children without ADHD, and another study did not find diagnosis/medication of ADHD to be associated with adolescents' duration IIV. Findings are mixed in whether taking medica- tion for ADHD or having a comorbid psychiatric diagnosis impacts sleep IIV in children with ADHD ‣ Snoring (1). Among children with adenotonsillar hypertrophy, those who snored most nights had greater duration IIV than chil- dren who did not snore on most nights •Theme H: sleep interventions (5) Sousa and colleagues evaluated a one-week sleep hygiene program delivered to students in 11th. McHale et al. examined whether a workplace intervention designed to reduce employees' work-family conflict impacted the duration IIV of employees' children in a group- randomized trial ‣ No change in duration IIV was found in children whose parents received the intervention, whereas children in the control group had increased duration IIV from baseline to follow-up one year later. Children with ADHD and initial insomnia had decreased onset IIV following a brief sleep hygiene intervention DISCUSSION • Overall, effect sizes tended to be small and results were mixed across many domains. • There is greater duration IIV and onset/waking IIV with more advanced pubertal status and age, suggesting that adolescence may be a developmental period when sleep IIV may be particularly impactful • Second, sleep IIV was frequently associated with poorer behavioral functioning, including externalizing behavior, aggression, inattention, and risky behavior • Spending more time with friends can be a positive aspect of peer functioning and social acceptance, but those friends could engage in and encourage externalizing behaviors (e.g., delinquency, alcohol/substance use, risk-taking) that may themselves be associated with greater sleep IIV. • In sum, in children and adolescents sleep IIV is correlated with a wide range of outcomes

Alcohol Consequences

• Abnormalities have been seen in brain structure volume, white matter quality, and activation to cognitive tasks, even in youth with as little as 1-2 years of heavy episodic drinking and consumption levels of 20 drinks per month, especially if >4-5 drinks are consumed in a single occasion. ‣ Research suggests that heavy drinking may be physically more dangerous at 15 than at age 20, bc it may disrupt ongoing neurodevelopmental processes

PDI: The 8 Rules of Effective Commands

• Direct Rules • Positively Stated rules • One rule at a time --> child more likely to comply • Specific commands so they know what they are doing • Appropriate level commands for their age (they should know how to do It) • Calm, polite tone • Explain the command before or after (most of the time kids want to know the why and use It as a way to prevent doing the command) • Only when Necessary give a command

FEAR Plan Steps

• F: Feeling frightened? ‣ Identifying physiological cues that alert the child that s/he is feeling anxious • E: Expecting bad things to happen? ‣ Identifying anxious thoughts • A: Attitudes & actions that will help ‣ Challenging anxious thoughts and using coping self-statements ‣ Reconceptualizing situation as less threatening ‣ Planning and problem solving • R: Results & rewards ‣ Self-evaluation and rewards from self and therapist

Systematic Review Sleep IIV: Define IIV

• 1) duration IIV (including sleep duration, time-in-bed, and total sleep time variables) • 2) onset IIV (including bedtime and sleep onset latency variables) • 3) waking IIV (including wake time and wake onset variables) • 4) quality IIV (including sleep efficiency, night wakings, and nocturnal movement variables) • 5) habits IIV (including sleep habits, night routines, and sleep schedule variables) • 6) sleepiness IIV • IIV of sleep is distinct from mean sleep duration and therefore it is important to: ‣ 1. Examine factors related to IIV ‣ 2. Mechanisms of IIV ‣ 3. Directionality of these relations ‣ 4. Put within a developmental context » Unlikely a "one size fits all" (Findings can vary for individual; Findings can differ across studies)

Diagnostic Criteria for ODD

• 1. A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by at least four symptoms from any of the following categories, and exhibited during interaction with a least one individual who is not a sibling. ‣ Categories: Angry/Irritable Mood (1. Losing temper, 2. touchy & easily annoyed, 3.Resentful); Argumentative/Defiant Behavior (4. argues with authority figures/adults/children, 5. defies requests from authority figures/ defies rules, 6. deliberately annoys others, 7. blames others for his mistakes); Vindictiveness (8. spiteful or vindictive) • 2. The disturbance in behavior is associated with distress in the individual or others in his or her immediate social context (e.g., family peer group, work colleagues), or it impacts neg on social, educational, occupational, or other important areas of functioning. • 3. The behvrs do not occur during the course of other psychotic, substance-use, depressive, or bipolar disorder • Doesn't have to be present in two settings » Symptoms of ODD can be grouped into three dimensions: negative affect (angry/irritable mood), defiance (defiant/headstrong behavior), and hurtful behavior (vindictiveness) » DSM-5 uses severity ratings for ODD of "mild," "moderate," or "severe," depending on whether symptoms are present in one, two, or three or more settings.

Guiding MST Principles

• 1. Assessing how identified probs are maintained by the family's current social environment • 2. Emphasizing the positive aspects of family systems during treatment contacts • 3. Focusing interventions on increasing responsible behavior and decreasing irresponsible behavior • 4. Orienting interventions toward current, specific probs that can be easily tracked by family members • 5. Designing interventions to target interaction sequences both within and across the systems that maintain target • 6. Fostering developmentally appropriate competencies of youth within such systems as school, work environments, and peer groups • 7. Designing intensive interventions that require continuing effort by the youth and family on a daily or weekly basis • 8. Evaluating intervention plans and requiring treatment team accountability for positive outcomes • 9. Promoting generalization across time by teaching caregivers the skills to address probs across multiple contexts

How to Ignore Negative Attention-Seeking Behavior

• 1. Ignore (don't give facial experiences, turn away, etc.) • 2. Distract (play with other toys, play with your own toys) • 3. Model the Opposite (ignoring the bad behvr and showing the behavior you want - if the child is crashing the cars, demonstrate slow driving) • 4. Praise the opposite (once they slow their cars own, immediately praise the behavior) ‣ The more immediate the praise is, and the more clear the praise is to the behavior = the better » When parents ignore It allows the child to learn to regulate on their own

Systematic Review Sleep IIV: Becker et al., 2017

• 1. Research has typically focused on typical sleep/sleep duration, but emerging evidence suggests sleep variability is critical in healthy sleep functioning • 2. IIV (intraindividual variability) of sleep associated with age, non-White race, ADHD/ASD, anxiety, depression, inattention, body weight, stress, cognitive functioning, and poor sleep habits/functioning

Stimulants and sleep medication

• 1. Stimulants can cause insomnia ‣ Not much evidence to suggest a differentiation across stimulants • 2. Most likely when starting new med or changing dose ‣ May resolve with time ‣ Pre-existing sleep difficulties are important consideration (sleep varies in individual based on their history) • Melatonin? ‣ Stimulated by darkness » Get light during the day » OTC: reduces sleep onset (dietary supplement not very regulated) » Other OTC options (e.g., antihistamines, tryptophan, vitamin » limited to no support • Prescription sleep medications ‣ Typically last resort, limited research, no FDA-approved med for primary sleep disorders

Comorbidity

• 50% also have ADHD ‣ More Aggressive ‣ Greater persistence ‣ Earlier onset of CD (due to a share predisposition, & ADHD may lead to child onset of CD) ‣ Impulsivity plus disregard for rules/rights of others • 1/3 depression or anxiety disorder ‣ Is anxiety protective? (can be to reduce risky behaviors if anxious to participate in It) » Co-occurring anxiety has been identified as a protective factor that inhibits aggressive behavior but other studies have found that anxiety increases the risk for later antisocial behavior. For BOYS ONLY, cortisol is associated with more aggressive behavior

Experimental sleep protocol study (Becker et al., 2019)

• 72 adolescents with ADHD entered 3-week sleep protocol using an experimental crossover design. ‣ Ended with 48 with complete sleep protocol and sleep data • Actigraphy + sleep diaries • Parent and adolescent self-report measures on sleep, psychopathology (ADHD/SCT/ODD) and CPT (continuous performance test; sustained/selective attention) • Sleep restriction week findings: ‣ 1. Parent-reported increases in inattention and opposition ‣ 2. Both parent and adolescent reported increases in SCT/CDS (cognitive disengagement) symptoms, greater daytime sleepiness ‣ 3. Adolescents reported decreased hyperactivity-impulsivity ‣ 4. No differences in CPT, parent-reported Hyperactivity-Impulsivity, or adolescent reported inattentive symptoms • Studying sleep is difficult! ‣ How do you do It while staying ethical? You are sleep-depriving ppl, esp if its children, what are the harms and benefits? ‣ Could harm their development depending on how long the study goes on! but we could learn a lot from these studies

The two-process model of sleep

• A normal (green and blue) and delayed circadian rhythm (dotted lines). ‣ Process S indicates sleep pressure; Process C indicates the circadian rhythm ‣ some ppl have delayed indications of their rhythm so sleep later, etc.

antisocial personality disorder and Psychopathy (ASPD)

• 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 remorse) ‣ As many as 40% of children with CD develop APD as young adults ‣ adolescents with APD may also display psychopathic features, a pattern of callous, manipulative, deceitful, and remorseless behavior—the more menacing side of human nature ‣ Signs of lack of conscience occur as young as 3-5

ASPD cont...

• A subgroup of children with CD are at risk for extreme antisocial and aggressive acts and for poor long-term antisocial and aggressive acts and for poor long-term outcomes outcomes ‣ Display callous and unemotional (CU) interpersonal » Lack guilt and empathy; do not show emotions; display narcissism and impulsivity; and lack behavioral inhibition • Different developmental processes may underlie behavioral and emotional problems behavioral and emotional problems

Depression as a symptom, syndrome, disorder

• A symptom: depression refers to feeling sad or miserable. ‣ often occur without the existence of a serious prob, and they are relatively common at all ages. ‣ symptoms of depression are temporary, related to events in the environment, and not part of any disorder. • A syndrome refers to a group of symptoms that occur together more often than by chance. ‣ Along with sadness, the child may display a reduced interest or pleasure in activities, cognitive and motivational changes, and somatic and psychomotor changes. ‣ The occurrence of depression as a syndrome is far less common than isolated depressive symptoms, and it often includes mixed symptoms of anxiety and depression • Disorder: Depression comes in several forms - Major Depressive Disorder (MDD), Persistent Depressive Disorder (P-DD or Dysthmia) and Disruptive Mood Dysregulation Disorder (DMDD) »The common characteristic of all depressive disorders: the presence of sad, empty, or irritable mood, along with somatic and cognitive symptoms that interfere with the individual's functioning. The differences among depressive disorders are related to their duration, timing, associated features, or presumed causes. ~

Childhood-Onset CD (prior to age 10)

• ADHD • Neuropsychological /executive functioning deficits • Poor academic achievement • Parental psychopathology • Family discord • Insecure attachment • Early peer rejection • Undersocialized • Hostile attributions • More aggressive/violent • Predominantly boys • Persistence of behavior across development

Social and learning probs

• Academic underachievement, special ed placement, dropout, suspension, expulsion • Little evidence that academic failure is the cause for Conduct probs; More likely that a common factor like the neurophysiological or lang deficit, lack of self-control, or socioeconomic, underlies both conduct probs and school difficulties • Children with poor academic skills are increasingly likely to lose interest in school and to associate with delinquent peers. By adolescence, the relationship between conduct problems and underachievement is firmly established, which may lead to anxiety or depression in young adulthood ~

Systematic Review: Becker et al., 2017 cont...

• Adolescent sleep and IIV of sleep is diff than infants, children and adults. What are some important contexts for this population to consider in research? ‣ a. (extracurriculars, impact of social media/internet-connected devices, social functioning, school start times, etc.) • How do we contextualize the growing importance of sleep IIV in a college environment, where norms around going out late on weekends and going to bed later during the week are more common and students "catch up" on weekends/Sundays? ‣ How should we approach this in clinical settings? ‣ Is it feasible to focus on stability in college? --> You want to focus on the prob, implementing intervention; finding a middle ground

Conduct problems and antisocial behaviors

• Age-inappropriate actions and attitudes that violate fam expectations, societal norms, and personal or property rights of others ‣ These youth display a variety of disruptive and rule violating behvrs from whining, swearing, temper tantrums, to more serious antisocial behaviors like vandalism, theft, and assault ‣ Children with severe conduct probs frequently (not always) grow up in unfortunate fam and neighborhood circumstances where they experience physical abuse, neglect, poverty, and exposure to criminal activity ‣ these child show probs in the self-control of emotions and behaviors ~

DSM Disruptive Behavior Disorders (DBDs): Oppositional Defiant Disorder (ODD)

• Age-inappropriate recurrent pattern of stubborn, hostile, disobedient, and defiant behvr ‣ Usually appears around age 8, & included in the DSM to capture early displays of antisocial and aggressive behvr by preschool and school-age children • ODD behaviors can have extremely neg effects on parent-child interactions. ‣ Child and adolescent ODD also have a variety of social and interpersonal difficulties in early adulthood, including poor functioning with peers and poor romantic relationships

Cognitive Models of ODD/CD

• Aggression is not caused by environmental events, but rather the manner in which events events are processed and interpreted ‣ E.g., hostile attributional bias (Dodge) ‣ These cognitions lead to aggressive responses • Information processing models ‣ Recognizing that there is an interpersonal problem (rather than just getting mad) ‣ Thinking of alternative solutions rather than responding impulsively ‣ Thinking out steps needed for a particular solution ‣ Anticipating outcomes of the various solutions

Intervention: Relaxation and coping

• Anxiety and rumination at bedtime may inhibit onset of sleep ‣ 1) Relaxation training » a) Diaphragmatic breathing » b) Progressive muscle relaxation » c) mindfulness ‣ 2) Cognitive therapy » a) Scheduled rumination time and setting timers » b) Challenging unhelpful thoughts ‣ 3) Exposure therapy (usually for little ones) » a) Games and slow practice to work on facing fears of being in the dark and using coping skills

Gender Differences in ASPD

• Apparent by 4 years • For Boys: ‣ Rates 2-4x higher ‣ Earlier age of onset ‣ Greater persistence ‣ Often use more physical aggression » When there is physical aggression in girls during childhood, it does not seem to forecast continued physical violence • Overall rate difference decreases in adolescence and then increases again • Adult outcomes different • Possible reasons for these differences ‣ Differential causal factors ‣ Testosterone ‣ Hostile attribution bias differences ‣ CD and ODD criteria emphasize physical aggression » Girls often engage in "relational aggression" (gossiping, lying, ie mean girls)

5 Primary Cognitive Deficits

• Attributional biases ‣ Over-perceive hostile intent by others • Distorted perceptions of interpersonal interactions ‣ Underestimate own aggressiveness ‣ Overestimate others' responsibility for the conflict • Faulty emotion identification ‣ Mislabel affective arousal as anger • Restricted range of social problem solving strategies ‣ Rely on physical rather than verbal expression • Maladaptive expectancies ‣ Expect that probs cannot be resolved through non-aggressive means

Theories that Explain PCIT

• Authoritative" parenting style (Baumrind) ‣ High demandingness, high responsiveness • Attachment Theory • Behavioral principles ‣ Social Learning theory • Patterson's coercion model ‣ Parent gives demand -> child doesn't comply --> parent withdraws command and gives in --> child is reinforced as they get what they want and parent reinforced as they don't have to deal with the bad behavior and they enter this cycle

DON'T Skills: Avoid Commands

• Avoid Commands ‣ Direct Commands: "Sit down."; "Hand me the car." ‣ Indirect Commands: "Can you sit down?"; "Let's put the car away." » We avoid commands bc it takes lead away from the child; it attempts to direct the play; Play can stop being enjoyable if child does not obey

Intervention: Managing child sleep routines and behaviors

• Bedtime is often parent's most dreaded part of their day as this can frequently be met with stalling, resistance to bedtime, or failing to stay in bed once put to bed • Parents can (interventions): ‣ a. Bedtime chart with reinforcement ‣ b. Praise for compliance ‣ c. Reduce reinforcing poor sleep hygiene behaviors (giving a lot of attention when they get out of bed) » removing sarcastic comments/criticism around sleep habits (can make child feel bad when they need the sleep) ‣ Improve own sleep routines and behaviors and consistency around bedtime routine

Public Health perspective on Conduct Problems

• Blends the legal, psychological, and psychiatric perspectives with public health concepts of prevention and intervention. • Goal: to reduce the number of injuries and deaths, personal suffering, and economic costs associated with youth violence and other antisocial behavior, ‣ brings together policy makers, scientists, professionals, communities, families, and individuals to understand conduct problems in youths and determine how they can be treated and prevented ~

Two Phases of Treatment

• Child Directed Interaction (CDI) ‣ CDI Coach (learn about It) --> CDI Coach (practice the strategies) • Parent Directed Interaction (PDI) ‣ PDI Teach --> PDI coach

Parent Directed Interaction (PDI)

• Children Need Structure ‣ Consistency; Predictability; Follow Through » Say what you mean, and mean what you say » Follows the 8 Rules of Effective Commands

Multidimensional Tx Foster Care (Chamberlain)

• Community-based program for severe and chronic delinquent behavior in adolescents • Alternative to institutional/residential care • Placed in foster care for 6-9 months • Foster parents receive 20 hrs of pre-service training to learn behavioral strategies • Daily and weekly support from program supervisors • The youth get weekly therapy to work on anger management, problem-solving, social skills, vocational planning • Also regular meetings with a psychiatrist for med mgmt • Meanwhile, bio parents receive intensive behavioral Parent Training, designed to promote reintegration (bring them back together) • Superior to traditional group care for chronically delinquent youth (Cheaper also than what is typically done ie putting kids in juvenile jail system)

Psychiatric Perspective of Conduct Problems

• Conduct probs are defined as distinct mental disorders based on DSM-5 symptoms. DSM-5 contains the general category of Disruptive, Impulse-Control, and Conduct Disorders. ‣ Oppositional defiant disorder (ODD) and Conduct DIsorder (CD) are included in this. They are often referred to as conduct problems or disruptive behvr disorders. » Both categorical (psychiatric) and dimensional (psychological) perspectives have proven validity for classifying conduct probs in youth ~

Psychological Perspective on CP

• Conduct probs fall along a continuous dimension of externalizing behaviors. Children at the upper extreme of the dimension are considered to have conduct problems ‣ The externalizing dimension consists of two subdimensions, labeled "rule-breaking behavior" and "aggressive behavior" » Rule-breaking behaviors: running away, setting fires, stealing, skipping school, using alcohol and drugs, and committing acts of vandalism. » Aggressive behaviors: fighting, destructiveness and disobedience, showing off, being defiant, threatening others, and being disruptive at school. • Two additional independent dimensions of antisocial behavior have been identified: ‣ overt-covert and destructive-nondestructive » Overt-covert dimension ranges from overt visible acts such as fighting to covert hidden acts such as lying or stealing. Children w overt antisocial behavior tend to be neg, irritable, and resentful in their reactions to hostile situations and experience higher levels of family conflict » Those displaying covert antisocial behavior are less social, more anxious, and more suspicious of others and come from homes that provide little family support. Most children with conduct problems display both overt and covert behaviors. ~

Guest Lecture: Parent-Child Interaction Therapy (Dr. Lorenzo) PCIT

• Created for children 2-8 yrs old • Behavioral Parenting Interventions ‣ Helps foster positive parent-child interactions ‣ Discipline: time out and consistency ‣ Skill practice

Limited Prosocial Emotions

• DSM-5 uses the specifier "with limited prosocial emotions" (LPE) to describe youths with CD 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. ~

Social Learning Theory

• Describes the ways in which child behaviors are reinforced and maintained • "Coercive cycle" of negative interaction patterns explains reinforcement and reinforcement and maintenance of child conduct problems • Foundation for the evidence-based treatments for this • If a parent makes a demand, the child negatively reacts, and then eventually parent gets tired and withdraws the command or gives in; the child learns that by their strong response they can get what they want and the command goes away ‣ Child and parent negative reinforced: the bad behavior is taken away neg reinforcing parent; the neg behavior is maintain, neg reinforce in child

Comorbidities/co-occurring psychopathology

• Do sleep problems cause other disorders or do disorders cause sleep problems? They are bidirectional. Those with psychopathology are most likely to have sleep disturbances ‣ ADHD, Depression, Anxiety, ASD, conduct problems • What else may cause sleep disturbances? ‣ Disruption in brain's arousal and regulatory systems ‣ Stress related-events ‣ Family routines ‣ Underlying transdiagnostic factors (e.g., irritability, hyperactivity)

Multisystematic Therapy for Children/adolescents antisocial behavior (MST) (Henggeler)

• For adolescents with serious antisocial/delinquent behavior that combines treatments as needed to provide an individualized, intensive family and community-based intervention, with the goal of promoting responsible behavior and preventing out-of-home placement. • Treatments include cognitive-behavioral approaches, behavior therapies, parent training, pragmatic family therapies, and pharmacological interventions that have a reasonable evidence base • MST is provided in the family's natural environment with a typical length of 3-5 months. ‣ You do not take the child out of this environment or home; you work with their family/school etc for months ‣ Thus, treatment is carried out with all family members, school personnel, peers, juvenile justice staff, and other individuals in the child's life • Families are usually in contact with the MST therapist more than once per week (in person or by phone), and therapists are always available to assist families • Superior to no tx or community treatment

Family probs

• General family disturbances include parental mental health problems, a family history of antisocial behavior, marital discord, family instability, limited resources, and antisocial family values. • Specific disturbances in parenting practices and family functioning include excessive use of harsh discipline, lack of supervision, lack of emotional support and involvement, and parental disagreement about discipline. • High levels of conflict are common in families of children with conduct problems. So are poor parenting practices such as ineffective discipline, negative control, inappropriate use of punishment and rewards, failure to follow through on commands, and a lack of involvement in child rearing ‣ There is also a lack of fam cohesion, which is reflected in emotional detachment, poor communication and problem-solving, low support, and fam disorganization. ‣ Household chaos: characterized by high noise levels, crowding, people coming and going all the time—and a lack of predictability and family routines is also associated with child conduct problems ~

Intervention: Sleep Hygiene (Healthy Sleep Practices)

• Goal: ‣ 1) to eliminate the sleep deprivation ‣ 2) to restore a more normal sleep-wake routine. • Strategies: ‣ Consistency ‣ Daytime physical activity (not too close to bedtime) ‣ Avoid meals too close to bedtime ‣ Shutting down devices an hour before bedtime ‣ Calming bedtime routine ‣ Using bed only for sleep ‣ Limiting naps (if napping keep it to late morning/early afternoon and short naps; naps can create bad cycles bc you nap and then go to bed later - try to keep your naps short) ‣ Sleep tracking/monitoring to increase awareness • Sleep is self-regulatory behavior, without consistent schedules in college and much, if any, caregiver scaffolding around routines

Callous-Unemotional (CU) Traits

• Greater number and variety of conduct problems • Lack of behavioral inhibition ‣ Preference for novel and dangerous activities ‣ Diminished sensitivity to danger/punishment cues when seeking rewards • More frequent police contact • Stronger parental history of APD • More likely to progress to adult psychopathy • Less responsive to treatment • Note: There is a specifier for CU traits in DSM-5

Treatments: Problem-Solving Skills Training (PSST)

• 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. ~

What if the child misbehaves?

• If the child engaged in Dangerous & Destructive behaviors ‣ Hitting, Kicking, and Throwing Toys • If the child engaged in Annoying & Obnoxious behaviors ‣ Whining, Yelling, Using Profanity » IGNORE these

Persistent Depressive Disorder (P-DD) (formerly Dysthymia)

• Is characterized by symptoms of depressed mood that occur on most days, and persist for at least one year ‣ Associated with depressed or irritable mood, fewer/less severe symptoms but longer-lasting/more chronic symptoms (at least one year) than MDD; significant impairment in functioning. ‣ Child with P-DD also displays at least two somatic or cognitive symptoms • Characterized by poor emotion regulation ‣ Constant feelings of sadness, of being unloved and forlorn, self-deprecation, low self-esteem, anxiety, irritability, anger, and temper tantrums ‣ Children with both MDD and P-DD are more severely impaired than children with just one disorder » Often harder to weave out ODD and ADHD with this disorder bc sx are so persistent

Reading/ Lecture - Chapter 9: Conduct Problems Different Terms, Similar Behaviors

• Juvenile Delinquency (legal terms) • Externalizing (CBCL) • ODD/CD ( in DSM) • Aggression (overt hitting, fighting) • Rule-Breaking (covert Rule-Breaking (covert stealing, lying, truancy) • Antisocial behavior ‣ They display similar behaviors but are defined differently across perspectives

DSM Criteria for Major Depressive Disorder

• Key features: sadness, loss of interest or pleasure in nearly all activities, irritability, plus a number of additional specific symptoms that are present during the same two-week period • A) 5 or more of the following during the same 2 week period and a change from rpev functioning; at least one of the symptoms is either: depressed mood or loss of interest or pleasure ‣ 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others ‣2. Diminished interest or pleasure in all, or almost all activities of the day nearly every day ‣3. Significant weight loss when not dieting or weight gain ‣4. Insomnia or hypersomnia ‣5. Psychomotor agitation or retardation ‣ 6. Fatigue or loss of energy ‣ 7. Feelings of worthless or excessive or inappropriate guilt (may be delusional) everyday ‣ 8. Diminished ability to think or concentrate or indecisiveness (want to weave out ADHD) ‣ 9. Recurrent thoughts of death, recurrent suicidal ideation without a plan, suicide attempt, or a specific plan for committing suicide • B) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • C) Not attributable to the physiological effects of a substance or to another medical condition (Criteria A-C represents MDD) • The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder • Has never had a manic episode or hypomanic episode (once they have an episode It becomes BPD) » DSM-5 also provides for severity ratings of "mild," "moderate," or "severe" based on the number of symptoms in excess of those required to make the diagnosis

Legal Perspective of Conduct Problems

• Legally, CP probs defined as delinquent or criminal acts. • Juvenile delinquency: children who have broken a law, ranging from sneaking into a movie without paying to homicide. ‣ includes property crimes (e.g., vandalism, theft, breaking and entering) and violent crimes (e.g., robbery, aggravated assault, homicide). ‣ Involves apprehension and court contact and excludes the antisocial behvr of very young children that occurs at home or school • The minimum age of criminal responsibility ranges from 7 to 12 years in most states, but this has fluctuated over the yrs in relation to society's tolerance or intolerance of antisocial behavior in youth. ‣ we must ask whether these behaviors are understandable (objectionable) adaptations to a hostile environment— the most common reason that youths give for carrying a weapon is self-defense • A legal def of delinquency may result from one or two isolated acts, whereas a mental health def usually requires the child to display a variety and persistent pattern of antisocial behaviors. ~

Prevalence and Co-morbidity of Depression

• Lifetime prevalence rates ‣ MDD <1% preschoolers; 2% school-age children; 4-6% adolescents ‣ P-DD 1% children; 5% adol ‣ Lifetime prevalence estimates—whether a young person has ever been depressed—range from 11% to 20% • Co-morbidity (in clinic-referred samples) ‣ MDD = 90% also have ANX, CD, ADHD, Substance Use, DYS, or BPD » NOTE: 50% have 2 or more co-morbid disorders » The extent to which youth with MDD experiences ODD or CD seems to be directly related to the presence of irritable mood ‣ P-DD = 50% also have ANX, CD, or ADHD » 70% also have MDD (double depression) • Generally, other disorders precede depressive disorders in cases of co-morbidity. ‣ The presence of a co-occurring disorder is significant bc it can increase the risk for recurrent depression, the duration & severity of depressive episodes, & increase the risk for suicide attempts. ‣ The presence of another disorder also decreases response to treatment and is related to less effective treatment outcomes

Risks/ Etiology (antisocial behaviors)

• Mutilple causes = Multiply Determined! • Genetics: Genetic contributions for aggression • Neuroiologial Causes: Antisocial behavior may result from an overactive behavioral activation system (BAS) and an underactive behavioral inhibition system (BIS). ‣ Low levels of cortical arousal and autonomic reactivity and deficits in the amygdala, prefrontal cortex in CD • Prenatal factors & birth complications: Maternal smoking/alcohol use • Family factors: marital conflict, family isolation, violence, poor disciplinary practices, lack of parental supervision, insecure attachments; Family instability; parental criminality; antisocial family values • Socio-cognitive information processing: Generate aggressive solutions; Hostile attributional bias • Peer Influences • Broader envmnt influences/Culture: The structural characteristics of the community/ the conditions that interfere with the adoption of social norms and the development of productive social relations. ‣ School, neighborhood, and media influences are all potnetial risk factors for antisocial behavior, as are cultural factors, such as minority group status and ethnicity.

ODD and CD - Separate Disorders

• Nearly half of all children with CD have no prior ODD diagnosis • Most children who display ODD do not progress to more severe CD • For most children, ODD: ‣ Is an extreme developmental variation ‣ Is a strong risk factor for later CD ‣ Does not signal an escalation to more serious conduct problems • Since ODD symptoms emerge first, it is possible that they are precursors of early onset CD symptoms for some children • Symptoms of ODD typically emerge 2 to 3 years before CD symptoms ‣ about 6 years of age for ODD versus 9 years for CD

DON'T Skills: Avoid Criticism

• Negative Statements: No, Don't, Stop • Says what NOT to do: "Stop that"; "Don't run" • Pointing out mistakes: "That's not red." • Sarcasm: "Oh, sure It is." ‣ We avoid criticism bc: » Tells child what not to do instead of what to do » Can encourage misbehavior (bc they know It will give them attention) » Suggests disapproval » Lowers child's self-esteem » Makes play less enjoyable

PCIT background & features

• Originally developed for children 2-7 years •Developed by Sheila Eyberg in 1970s • Evidence from numerous clinical trials • FEATURES ‣ work with Parent and child together ‣ Live, immediate feedback (in-vivo coaching; parent wear a headphone and gets guided through) ‣ Emphasis on restructuring social interaction patterns ‣Assessment/Data driven ‣At-home practice ‣ Empirically supported

Peer Problems in CD

• Poor social skills, poor self-regulation to understand others, hihg peer aggressiveness, rejected by peers • Children with conduct probs are able to make friends but those friends are like-minded antisocial individuals ‣ Involvement with antisocial peers becomes increasingly stable during childhood and supports the transition to adolescent criminal acts such as stealing, truancy, and substance abuse • Display hostile Attributional bias: Likely to attribute hostile intent to other children, esp when the intention is unclear (ie if another child accidentally bumps into them, a reactive-aggressive child who reacts defensively to provocation is likely to think the child did It on purpose) ~

Incredible Years (Webster-Stratton)

• Programs designed to reduce behavior problems and aggression, and increase social competence in 2-10 year old children • Uses video vignettes w positive/negative parenting examples to get discussion going • Parent, child and school components tested in all possible combinations • Parent training ‣ 13 group sessions, watch videotaped vignettes serve as stimuli for focused problem-solving group discussions and share experiences; give praise to parents to serve as modeling; do "homework" to practice skills at home with child • Child training ‣ 22-week videotaped program for 3-8-year-olds that models social & problem-solving skills ‣ After watching video vignettes that model behaviors, discuss feelings, generate ideas for effective responses, and role play alternative scenarios, praise children - "I like how you are using a quiet raised hand"

destructive-nondestructive dimension

• Ranges from acts such as cruelty to animals or physical assault to nondestructive behaviors such as arguing or irritability. ‣ crossing the overt-covert w the destructive-nondestructive dimension results in four categories of conduct problems: » covert-destructive, or property violations; » overt-destructive, or aggression; » covert-nondestructive, or status violations; » overt-nondestructive, or oppositional behavior. ~

DO skills: Reflect

• Reflect appropriate talk • Repeat/paraphrase statements ‣ Child: That crayon is blue. ‣ Parent: Yes, that is a blue crayon! » Child's message can be extended, elaborated on • Why Reflect? ‣ Allows child to lead conversation ‣ Shows that you are listening ‣ Shows acceptance and understanding of what the child is saying ‣ Improves and increases child's speech

Iatrogenic Effects of Group Tx

• Reinforcement of deviant values • such as Affiliation w peers who model antisocial behvr & values • Increased opportunities for criminal activity • Stronger identification with delinquent subculture • Enhanced self-efficacy for, increased acceptance of, and skewed beliefs about the prevalence of delinquent behaviors • May not be a prob if intensive behavioral program in place

Conduct Disorder (CD)

• Repetitive and persistent pattern of severely aggressive and antisocial acts that involve inflicting pain on others or interfering with the rights of others thru physical and verbal aggression, stealing, or vandalism. ‣ Often have co-occurring problems ie ADHD, academic deficiencies, poor peer relations ‣ Families often use child-rearing practices, such as harsh punishment, that contribute to the problem. Their parents feel these children are out of control, and they feel helpless to do anything about it ‣ Both CD and ODD predict future psychopathology and enduring impairment in life functioning • DSM Symptoms of CD in 4 dimensions: ‣ Aggression to people and animals (e.g., bullying, physical cruelty) ‣ Destruction of property (e.g., fire setting, vandalism) ‣ Deceitfulness or theft (e.g., conning, shoplifting) ‣ Serious violations of rules (e.g., truancy, running away from home)

Comorbidities/co-occurring psychopathology cont..

• Roughly 70% of children with ADHD report problems with sleep ‣ Used to be a core diagnostic criteria in DSM-III but no longer is. However, still considered a prevalent symptom and area of interest for those with ADHD ‣ Students with ADHD more likely to have greater sleep variability and more likely to "pull all-nighters" (Becker et al., 2017) ‣ Fucito et al., 2017 suggest sleep intervention may be a foot-in-the-door strategy » Starting with sleep intervention can help decrease some symptoms & sleep can be intervened and measured • Sleep disruptions can affect daily functioning including inattention, emotion regulation, executive functioning, academic functioning, overall quality of life and mood, depression and oppositional behaviors

Do Skills: Enjoy

• Shows that you are happy to play with the child ‣ Shows you are interested, enthusiastic, and playful tone of voice ‣ Laughter ‣ Physical affection (e.g., hugs, back rubs) ‣ Statements indicating your enjoyment » Makes Special Time more fun and meaningful

Terms around sleep

• Sleep is a very broad construct, what do we mean? It could mean... ‣ Duration? ‣ Variability (intraindividual variability; IIV)? ‣ Efficiency (time asleep/time in bed)? ‣ Sleep onset latency (SOL; how long to fall asleep)? ‣ Evening circadian preference (night owl/early bird)? ‣ Sleep disturbances and awakenings ‣ Objective sleep quality (time spent in deep, restorative REM sleep/stage 3; measured with EEG, polysomnography [coming into a sleep lab and usually more accurate], actigraphy [like apple watch/Fitbit])? ‣ Subjective sleep quality (how I feel when I wake up)? ‣ Pros and cons of methods? (some are more accurate than others but envmnt of sleep matters! We fall asleep faster when in our own bed and room; some ppl do not like going into labs or wearing watches bc its uncomfortable which impacts sleep) ‣What do you think is the most important? If you were designing a study right now examining sleep in students with ADHD or Anxiety, what would you make sure to include and why? - depends on what you're interested in

Frequencies for Common ODD/CD

• Some behaviors are normative during: ‣ Preschool (Terrible twos more disobedience) ‣ Adolescence (puberty and acting out) ‣ At what point do these behaviors become a problem? Getting in fights often and hanging out around; kids who are referred for ODD and CD get in trouble and disobey more at home throughout their ages at higher rates than nonreferred kids

Developmental Trajectory of DBDs

• Starts with w difficult temperament displays an increase in hyperactivity and impulsivity with weak emotion-regulation skills = heightened risk for forms of oppositional & aggressive behaviors that peak in preschool • Preschoolers with ODD display stubbornness, temper tantrums, irritability, and spitefulness. Discipline problems and poor self-control/ poor emotion regulation • Enters school: impulsivity and attention probs may result in academic fails • Ages 8 to 12: behaviors such as fighting, bullying, fire setting, vandalism, cruelty to animals & ppl, and stealing emerge. • Delinquent behavior shows a dramatic rise in mid-adolescence and peaks around age 17 ‣ Ages 12 to 14: property destruction, running away from home, truancy, mugging, breaking and entering, use of a weapon, forced sex occur with increasing frequency • By age 18, many young ppl with conduct problems display antisocial personality development • Among the most common childhood disorders, CD stands out as the strongest predictor of adverse outcomes in adult functioning ‣ males and females experience different but poor adult outcomes.

Treatments: Parent Management Training (PMT)

• 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 (e.g., parent-child communication, monitoring, and supervision). » PMT has been most effective with parents of children younger than 12 years of age ; PMT can produce short-term gains, its long-term effectiveness is less clear ~

PCIT (Eyberg)

• Uses in-vivo coaching to provide individual parent support and feedback in session • Parenting skills are coded by the therapist (ongoing ax) • Parents have to meet mastery to pass to the next stage of treatment/to end treatment • CDI: Child-Directed Interaction ‣ PRIDE Skills: praise, reflect, imitate, describe, enthusiasm • PDI: Parent Directed Interaction ‣ Time out procedure

Associated Characteristics

• Verbal & Language Deficits • School & Learning Problems ‣ Language and reading • Self-Esteem Deficits ‣ Inflated, unstable • Peer Problems ‣ Rejection and bullying ‣ Friendships with antisocial peers • Family Problems ‣ General family discord, parent psychopathology, etc. ‣ Harsh and inconsistent parenting

Cognitive and Verbal Deficits for Children with CP

• Verbal IQ is lower than performance iQ in children with CD suggesting a specific deficit in lang; ‣ Verbal & lang deficits may contribute to conduct problems by interfering with the development of self-control, emotion regulation, or the labeling of emotions in others, which may lead to a lack of empathy • Bc ODD/CD and ADHD frequently co-occur, the observed deficits in EF in these children could be due to the presence of co-occurring ADHD ‣ Cool cognitive executive functions (ie attention, working memory, planning, and inhibition) and hot executive functions (involve incentives and motivation) ‣ Cool EF are more characteristic of children with ADHD, and hot executive function deficits are more characteristic of children with conduct problems ~

NICK'S GUEST LECTURE: Sleep in children and adolescents Regulatory functions of sleep

• What's going on while we sleep? ‣ "tuning instruments in a large orchestra" • Circadian rhythm and sleep drive ‣ As the light starts to go down, melatonin release happens ‣ As the day progresses, we may start to slow down • Brain plasticity: process the day and remember in the future ‣ During infancy/toddlerhood there is more synaptic pruning etc that happens in sleep ‣ Health: immunity, mood/depression, metabolism, blood pressure, etc. • Both stage 3 and REM are critical for restorativeness

Reading/Lecture - Ch 10: Depression Depression

• When can it start? ‣ Typical onset is 13-15 years (MDD) ‣ Earlier onset = best predictor of later psychopathology • What does it look like? ‣ Changes with age/development ‣ More common among adolescents than children, but rates may be somewhat underestimated in young children due to assessment difficulties (young children cant explain their emotional states and you have to tease out diff disorders like ODD) • When is it a diagnosable disorder? ‣ Syndrome is present, lasting at least two weeks ‣ Sx cause significant distress/impairment; they can't seem to shake off feelings of sadness and hopelessness and impacts daily functions (ie school performance) • Children express and experience depression differently at diff ages. ‣ depression is not clearly recognizable as a clinical disorder using DSM criteria until children are older. ‣ Depression in children under the age of 7 is diffuse and less easily identified.

Treatments for EDs

• increasing support for family-based interventions for adolescents with anorexia ‣ on an outpatient basis (ie CBT) • Pharmacological treatments, altho they are not the initial treatment of choice (ie SSRIs, Prozac) ‣ however, no drug has proved useful or effective for treating Sx of anorexia & none improved long-term weight maintenance, changed a distorted self-image, or prevented relapse; There are antidepressants useful in treatment of bulimia, but probably not as the initial treatment of choice. •Family-based interventions help restore healthy communication patterns » The most effective therapies for bulimia involve CBT delivered individually or by involving the family unit. » Cognitive-behavioral therapists change eating behaviors by rewarding or modeling appropriate behaviors, and by helping patients change distorted or rigid thinking patterns that may contribute to their obsession. ~

Hoarding Disorder

• persistent difficulty discarding or parting with possessions, regardless of their actual value ‣ This difficulty is due to a perceived need to save the items and distress associated with discarding them. ‣ This results in an accumulation of possessions that clutter active living areas and substantially compromises their intended use. » causes significant distress or impairment in important areas of life functioning (e.g., social, occupational, maintaining a safe environment). ~

Diagnostic Criteria for Panic Disorder

•A. Recurrent unexpected panic attacks. Abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and during which time 4+ of the following symptoms occur: ‣ palpitations/tachycardia ‣ sweating ‣ trembling/shaking ‣ feelings of choking ‣ chest pain/discomfort ‣ nausea/abdominal distress ‣ feeling dizzy ‣ chills or heat sensations ‣ paresthesias (numbness or tingling) ‣ derealization or depersonalization ‣ fear of losing control/"going crazy" ‣ fear of dying » culture-specific symptoms may be seen (tinnitus, sore neck, headache, uncontrollable screaming or crying) •B. at least one of the attacks has been followed by 1+ months of: ‣ worry about additional panic attacks or their consequences ‣ significant maladaptive behavior related to the attacks • C. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition • D. The disturbance is not better accounted for by another mental disorder. ~

Systematic Review Sleep IIV: Becker et al., 2017 cont..

Defining criteria (Age range, articles examing, defining variables, etc.) • 1) children or adolescents (mean age 18 y) • 2) empirical study (not a review, commentary, or letter to editor) • 3) peer-reviewed article • 4) assessed sleep daily for at least three days • 5) quantitatively examined sleep IIV in relation to non-sleep-related factors.