CHAPTER SIXTEEN Psychological Disorders of Childhood

Childhood Disorders  Childhood psychopathology  Internalizing Disorders  Externalizing Disorders  ADHD, ODD, CD  Epidemiology  Etiology  Treatment  Childhood disorders outcome summary

Defining Childhood Psychopathology  Definitions of “normal” depend on age  Classification of many childhood disorders rests on our knowledge of normal childhood behavior

Childhood Disorders  Externalizing Disorders  problems in conforming to expected norms; often causes problems for others  Internalizing Disorders  experience of subjective distress; others often unaware of their difficulties

Childhood Disorders  Childhood psychopathology  Internalizing Disorders  Externalizing Disorders  ADHD, ODD, CD  Epidemiology  Etiology  Treatment  Childhood disorders outcome summary

Diagnosing Internalizing Disorders: Depression and Anxiety  Children can be diagnosed with “adult” anxiety disorders (e.g., MDD, OCD, GAD)  Specific symptoms may differ from adults  Some symptoms may be absent due to children’s developmental differences  Difficulty in obtaining reliable information due to problems with self-reports

 General symptoms  Excessive distress associated with separation  Worry for separation and/or harm to attachment figure  School refusal  Nightmares & complaints of physical symptoms  Onset: before 18 years old  Duration: at least 4 weeks  Impairment Separation Anxiety Disorder

 SAD is the most common anxiety disorder of childhood occurring in about 6% to 12% of all children  Equally common in boys and girls  About 80% to 90% of all children with SAD have another disorder (e.g., GAD, depression)  Children showing school refusal due to SAD tend to be younger, female, of lower SES, and from single parent families. Separation Anxiety Disorder: Prevalence & Comorbidity

Childhood Disorders  Childhood psychopathology  Internalizing Disorders  Externalizing Disorders  ADHD, ODD, CD  Epidemiology  Etiology  Treatment  Childhood disorders outcome summary

Externalizing Disorders: Key Features  rule violations  negativity, anger & aggression  impulsivity  hyperactivity  deficits in attention

Diagnosing Externalizing Disorders  DSM-IV-TR divides externalizing disorders in to three major subtypes:  Attention deficit/hyperactivity disorder (ADHD)  Oppositional defiant disorder (ODD)  Conduct disorder (CD)

ADHD Diagnostic Criteria  Key features: hyperactivity, attention deficit and impulsivity  symptoms begin before age 7  6 of 9 DSM-IV symptoms for 6 months  symptoms visible across settings  Three subtypes  Predominantly Inattentive Type  Predominantly Hyperactive-Impulsive Type  Combined Type

ODD Diagnostic Criteria  A pattern of negativistic, hostile and defiant behavior  e.g. loses temper, argues with adults, defies or refuses to comply with adults’ requests  Behavior causes significant impairment  Impairment last for at least 6 months

CD Diagnostic Criteria  Persistent and repetitive pattern of rule violations/social norms  aggression to people, animals  destruction of property  deceitfulness or theft  serious rule violation  About 50% exhibit anti- social behavior into adulthood

Epidemiology: ADHD  Problems may appear before age 3  Prevalence:  approximately 5% of school-age children  50-60% of children in special education  Some children continue to have ADHD as adults  The symptoms interfere with daily functioning in different ways over life

Epidemiology: ODD & CD  Prevalence rates  ODD about 5-7%  Conduct Disorder about 2-4%  Higher in boys than girls

Etiology: Biological Factors  Behavior Genetics  Recent study of 4000 Australian found 80% concordance for MZ twins, 40% for DZ twins in ADHD, suggesting a strong genetic component.  Neuropsychological Abnormalities  Food Additives and Sugar  No evidence  Temperament

Etiology: Biological Factors Temperament  Easy  quickly form social relationships and follow discipline  Difficult  challenge parental authority  Slow-to-warm-up  shy & withdrawn

Etiology: Social Factors  Peers, Neighborhoods, Television  Parenting styles  Coercion

Etiology: Social Factors Parenting Styles

Etiology: Social Factors Coercion Child wants a cookie Parent says “no” Child starts screaming Parent gives in, positively reinforcing child for throwing tantrum Child stops screaming- Negatively reinforcing parent for giving in behavior is reinforced

Etiology: Psychological Factors  Attachment Theory  Secure attachments facilitate both closeness and exploration  Insecure (may be anxious, avoidant, or disorganized) attachments predict later internalizing and externalizing problems and social difficulties  The “Strange Situation” Test  Self-Control

Treatment  ADHD:  psychostimulants (e.g. Ritalin, Adderral)  antidepressants  selective norepinephrine reuptake inhibitor (e.g. Strattera)  psychosocial treatment  ODD:  behavior family therapy

Treatment  CD:  Multisystemic Therapy  residential programs  diversion programs  alternative to juvenile justice system

Childhood Disorders  Childhood psychopathology  Internalizing Disorders  Externalizing Disorders  ADHD, ODD, CD  Epidemiology  Etiology  Treatment  Childhood disorders outcome summary

Childhood Disorders: Epidemiology  Approximately 20% of children have a mental disorder Anxiety Disorders13% Mood Disorders6.2% Externalizing Disorders10.3%  Suicide  Gender differences  Boys are more likely to be in treatment than girls  Referral differences between children and adults

Childhood Disorders: Course & Outcome  Prevalence rates of internalizing disorders increase with age  Externalizing disorders often continue into adulthood, but antisocial behavior rarely begins during adult life  better prognosis for later-onset CD  better prognosis for ADHD if NOT comorbid w/ CD or ODD

Optional Slides

Etiological Factors Common to Most or All Childhood Disorders  Difficult Temperament  Insecure Attachment  Ineffective Parenting Styles  Emotion Dysregulation

Emotion Dysregulation  Children fail to learn to recognize and control their emotions

Additional Etiological Factors  Family risk factors  Troubled peer relationships

Sociometric Ratings & Childhood Disorders  Popular: many “liked most,” few “liked least” nominations  Average: few “liked least” but not as many “liked most” as popular  Rejected: many “liked least,” few “liked most” (opposite of popular)  Neglected: few “liked least,” few “liked most”  Controversial: many “liked least” and many “liked most”

Arbitrary Inference conclusions drawn in the absence of sufficient evidence or of any evidence at all Example A young girl approaches a playground and finds two children laughing. Before having a chance to say hello, the others walk away and look towards her direction. The young girl concludes that she is unattractive and that the other children were laughing at her. Cognitive Responses to Failure: Examples

Selective Magnification and Minimization exaggerations in evaluating performance Example 1 A young boy makes a couple of mistakes while trying out for a school play; he believes that he will never get the part for which he is auditioning (magnification). Example 2 The same boy gets the part that he is hoping to have in a school play; he believes that the teacher just made a mistake in choosing him (minimization). Cognitive Responses to Failure: Examples

Continuity ADOLESCENCE AGE PRESCHOOL Difficult Temperament Hyperactivity Aggressiveness Withdrawal Poor Peer Relationships Academic Problems Covert Conduct Problems Deviant Peer Association DELIINQUENCY

Stacking BRAIN IMPAIRMENT HYPERACTIVITY/ATTENTION PROBLEMS OPPOSITIONAL PROBLEMS AGGRESSIVE BEHAVIORS MOTHER’S DRUG USE POOR SOCIAL SKILLS PEER PROBLEM DELINQUENCY TIME COGNITIVE PROBLEMS ACADEMIC PROBLEMS POINTS OF INTERVENTION Loeber, 1990

Special Topic Childhood Depression

 Myths about childhood depression  Children can’t get depressed  Childhood depression is rare  Childhood depression is “just a phase”

 Distressed infants show symptoms such as:  lethargy  eating and sleep problems  irritability  decreased attention & emotional expression Developmental Differences

 Preschoolers may demonstrate:  irritability and anger  sad facial expressions and crying  anhedonia  somatic complaints, lethargy  eating and sleep problems Developmental Differences

 Middle Childhood (6-12)  Unhappiness, decreased, socialization, sleep problems, irritability, lethargy.  Beginning around age 9, aggression, self-reports of low self-esteem & helplessness, suicidal ideation  Adolescence  Similar to middle childhood, plus pessimism, feelings of worthlessness and apathy, comorbid substance abuse, eating disorders, antisocial behavior Developmental Differences

 Intellectual functioning  Interpersonal difficulties Areas of Impairment

 Elementary school  2-4% of community sample, 8-15% of inpatients  Adolescence  7% of community sample  Gender Differences  Pre-puberty, either no gender difference or slightly higher rates in boys  By age 15, gender difference parallels that of adults: rates among girls are twice those among boys Epidemiology

 Having a parent with a psychological disorder, especially a mood disorder, increases children’s risk of depression  Genetic/Biological Vulnerability  May be similar to the vulnerability for adult depression. Etiology: Familial & Biological Factors

 Depressed kids have more distorted cognitions than non- depressed kids  Learned Helplessness Model Depressed youth more likely to report:  Higher “personal helplessness” and “universal helplessness”  More internal, global, and stable attributional style for negative events. Etiology: Cognitive Factors

 Vulnerabilities to Depression  Failing to form stable, secure attachments with parents  Abrupt separation of human and primate from mothers Etiology: Attachment

 Kids from divorced or single-parent families are at an increased risk  Hostile, tense, and punitive communication patterns within the family are more common among depressed youth Etiology: Home Environment

 Difficult to use adult treatments with kids because they have limited memory, attentional, and verbal capabilities  Because of kids’ involvement with family, family therapy may be crucial Treatment

 Cognitive Restructuring  Focuses on identifying and changing cognitions  Role Playing  Acting out interpersonal problems to improve kids’ abilities to find solutions  Antidepressants  No more effective than placebo Treatment (cont’d)

End of Special Topic

Fear & Anxiety in Children  Children develop different fears for the first time at different ages; the onset may be sudden and may have no apparent environmental cause.  Some fears are both common and relatively stable across different ages.  Other fears become less frequent as children grow older.

 Behavior Therapy  Main technique for behavior therapy for anxiety disorders is exposure  Cognitive Behavioral Therapy  Teaches children to understand how their thinking contribute to their anxiety symptoms and how to modify their maladaptive thoughts  Family Intervention  Anxiety disorders often occur in family context Treatment of Childhood Anxiety Disorders

 Distress expressed following separation from an attachment figure  A normal developmental phase  Children who fail to “outgrow” separation anxiety may be diagnosed with Separation Anxiety Disorder (SAD) Separation Anxiety

Age of Onset, Developmental Course & Outcome  The earliest reported age of onset for SAD is 7 to 8 years, but children are often referred around 10 to 11 years  SAD typically progresses from mild to severe avoidance  SAD may be chronic or the onset may be sudden in a child who did not show any prior signs of a problem.