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64 Cards in this Set
- Front
- Back
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ADHD |
Persistant pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning/development |
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Symptoms of ADHD |
Inattention = Attention to details, can't listen, forgetful Hyperactivity = Fidgets, on the go, talks incessantly Impulsivity = Blurts out answer, interrupts, difficulty awaiting turn |
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DSM CRITERIA |
6+ of 9 inattention symptoms or 6+ of 9 hyperactivity or impulsivity symptoms
- Some symptoms seen before age 7 - Some impairment in 2 or more settings - Classifications: inattentive, hyperactive, impulsive, or combined |
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Predominantly Inattentive Type (PIT) |
- 5 inattentive symptoms and 5 hyperactive - 6 inattention and 0-1 hyperactive - PIT characteristics: sluggish cognitive tempo |
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Epidemiology--ADHD |
- Overall US pre. = 3-7% (wide estimates) - Sex differences: Males outnumber females 4-5:1 - Identified in many cultures, not often inconsistent prevalence rates |
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Comorbidity--ADHD |
Most common = ADHD+ODD/CD (Most severe) - More likely with hyperactive-impulsive or combined subtype - Anxiety, depression, some medical conditions, learning problems |
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ADHD Shifts in Emphasis |
CORE FEATURES: - 1950's - 60's = over-activity component - 1970's = additional problems - Recently = poor impulse control/disinhibition DEFICITS/Core features: Delay of gratification - Children sensitive to delay (trade larger for smaller reward, as long as it comes quickly) - Sonuga- Barke: Importance of studying children's performance under different conditions (timing, rewards)--> Impulsiveness vs. delay aversion |
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Barkley's Integrative Theory |
Argues that core deficit involves behavioral inhibition - Influences different aspects of "executive functioning" (e.g., planning, working memory, emotional self-control) |
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Etiology: Genetics--ADHD |
- Twin/adoption studies: substantial heritability (up to .80) - Molecular genetic studies: dopamine transporter gene, DRD4 (dopamine receptor 4) |
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Etiology: Proximal Psychosocial Factors--ADHD |
- Jacobvitz et al. (1995): Developmental perspective on attention problems - Emphasized gradual self-regulation from initial caregiver-orchestrated process - Results: Children with attention problems experienced greater parental intrusiveness/overstimulation in infancy |
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Etiology: Culture/TV |
- Gleick: our Faster society Christakins et al., 2004 study - National longitudinal survey of youth dataset - Early television exposure (ages 1 and 3) predicted attention problems at age 7 |
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ADHD ASSESSMENT |
Parent and Teacher reports: - Rating scales, structured interview, unstructured interview Child Reports: - Rating scales, unstructured interview Child Assessment: - Cognitive testing and Neuropsychological testing, continuous performance test (CPT) Observational Methods: - Classroom, clinic |
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Treatment options--ADHD |
1. Behavior Modification 2. CNS Stimulant medication 3. Combination of medication and behavior modification |
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Behavior Treatments |
Parent training: - Behavioral strategies taught to parents - Target specific problems of child (i.e., not following directions) not the symptoms of ADHD - Purpose is to increase positive behaviors and decrease negative ones - Charts, check lists, etc. Summer treatment program: - Intensive, full day behavioral interventions with social, academic, and sports skills training School-based intervention: - Behavioral strategies applied in classroom - classroom rules/structure, ignoring and praise, clear instructions |
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Parent Training |
House rules, + reinforcement, effective instructions, rewards and costs systems (charts, check lists, etc.), time out/work chores |
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School interventions |
Focus on classroom behavior, academic performance, and peer relationships - Work with teacher (classroom rules/structures, ignoring and praise, clear instructions, reward point system, daily report card, time-out) |
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MTA STUDY |
- Randomized clinical trial - 4 treatment conditions: 1. Medication management alone= methylphenidate (generic Ritalin)--approx. 50% > usual care 2. Behavior therapy alone = parent training + school intervention + STP 3. Combined treatment (meds + behavior) 4. Treatment "as usual" (community care) - 14 month state-of-the art, intensive treatments - Follow up at 24 and 36 months |
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Primary results for MTA study |
All 4 groups showed improvements - Combined (Med+Beh) vs. Meds: No difference overall, combined did best on 12 of 19 outcome measures - Combined vs. Behavior: Combined more reduction in ADHD symptoms, aggression, internalizing, reading achievement - Meds vs. behavior: Meds more reduction in ADHD symptoms--> findings didn't hold up for other areas (oppositional, peer relations, internalizing, academic achievement) |
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Additional Findings--MTA Study |
- For co occurring anxiety disorders: Behavior therapy is more beneficial (better than both medication and comb groups; 1/3 had comorbid anxiety disorders) - Combined group needed 20% lower dose than meds group (other studies show up to 60% lower dose for comb. treatments) - + parent child interactions decreased in med group - 2 year follow-up: stimulant height and weight suppression - 3 Year: No difference in treatment conditions (behavior treatment showed less substance use and delinquency) - All groups remained significantly impaired in peer relationships |
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Anxiety and Depression |
Both anxiety and depression are characterized by high levels of negative affect (neuroticism) - Tendency to experience negative emotions (personality factor in adults, temperament factor in children) --> Depression is characterized by anhedonia (inability to experience pleasure; lack of + affect) --> Anxiety disorders characterized by high levels of anxious arousal |
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Separation Anxiety Disorder (SAD) |
DSM CRITERIA: Developmentally inappropriate excessive anxiety concerning separation from home or from attachment figures - Specific examples: Persistent and excessive distress when separated or when separation is anticipated, worry about losing/harm befalling parents, school and sleep refusal, nightmares, somatic complains when separation is anticipated - Prevalence: 10% (highest anxiety disorder in youth) |
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Generalized Anxiety Disorder |
DSM Criteria: Excessive anxiety and worry, more days than not, for 6 months-->difficulty controlling the worry - In addition, at least one or more (for youth): restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance - Worry has to be about several things, not just a single event or topic - Prevalence: 3-6% |
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Phobias ("specific phobia") |
Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation - Exposure to feared object provokes panic response - Impairment in functioning of some kind, or marked distress - Duration 6+ months - Prevalence = 2-4% |
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Social Phobia/Social Anxiety Disorder |
Marked fear or anxiety about social situations involving possible scrutiny by others - Fear of negative evaluation - Persistant for 6+ months, not due to substance/medical condition/ not better accounted for - Prevalence in youth = 2-5% |
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Etiology of Anxiety Disorders |
Possible factors: - Shared genetic link across disorders (related to negative affect) as well as some disorder-specific genetic effects - Insecure attachment - Inhibited temperament - Over controlling/rigid parenting behavior - Self-reinforcing nature of avoidance (behaviorism) |
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Coping Cat Program |
Cognitive-Behavioral Intervention (Phil Kendall): GAD, SAD, social phobia, primarily for ages 7-13 but adaptations for adolescents - Strong research support - Elements include: cognitive reframing, relaxation training, exposure, rewards program |
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OCD--Criteria |
Either obsessions or compulsions Obsessions: Persistent thoughts/images that cause distress and are explained as intrusive - Note just excessive worry about real problems - Person attempts to ignore/suppress them, without success Compulsions: Repetitive behaviors or mental acts (e.g., counting) that a person feels driven to perform due to an obsession - Aimed at reducing distress, but are either extreme or not logically connected with what they are supposed to prevent |
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OCD Vicious Cycle |
Obsessions-->Distress-->Compulsions-->Relief |
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OCD Epidemiology |
- Overall prevalence: 2-3% (similar for youth and adults) - Clinic samples show gender imbalance, more boys diagnosed (but community samples show more even split; raises possibility of referral bias?) - Comorbidity: Various anxiety disorders, depression, eating disorders, tics/tourette's syndrome |
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OCD: Key Risk Factors/Processes |
Reasonably strong genetic and biological evidence - Indirect genetic evidence from family and twin studies (earlier onset shows stronger family/genetic linkage) - Serotonin broadly involved; SSRI's can be effective - Changes in brain functioning and structure - Behaviorist and learning processes (obsession/compulsion cycle as self-reinforcing) |
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PANDAS |
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections - Controversial/not yet included in DSM - Associated with sudden onset (or increase) of tics, OCD symptoms, and possibly involuntary motor - Must be following strep infection or scarlet fever - Usually relapses or remits to some degree - Some estimate up to 10-20% of OCD causes may be related to autoimmune response to infection(?) |
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Treatment of OCD |
Medication: - Nonspecific treatment: medications for OCD overlap with antidepressant and anti anxiety medication (Prozac, Paxil, Zoloft, Celexa, Lexapro, etc.) Psychotherapy: - Good evidence for effectiveness of Cognitive Behavioral Therapy |
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Psychotherapy Components |
Psychoeducational: Helping youth change perspective; separating the child from the disorder; "bossing back" the disorder; OCD thoughts as "junk mail from the brain" - Explaining habituation (i.e., 'what happens when you jump into a pool of water?') - This prepares youth for exposure response prevention - Direct cognitive strategies: Not directly trying to prevent obsessions just "note them and move on"; Challenging faulty assumptions and addressing "what ifs" |
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PTSD |
Criteria: Exposure to or witnessing an event involving actual or threatened death or serious injury to self or loved ones + each below for 1 month or more... - Intrusion of the event into life through dreams, flashbacks, or intense distress at reminders - Avoidance of stimuli associated with the event and/or general "numbing" - Negative mood associated with event/reminders - Increased arousal, such as difficulty sleeping or concentrating, or exaggerated startle response |
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PTSD Symptoms in youth |
For major disasters, re-experiencing symptoms/intrusive thoughts are most common, especially in aftermath (1-2 months post event) - Followed by anxiety/arousal, then by avoidance/numbing - Suggests intrusive thoughts may be most "benign" or normative reaction (?) |
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Acute Stress Disorder |
Symptoms similar to PTSD that occur within 1 month of a traumatic event and last for at least 3 days (and up to a month) - Attempts to capture "middle ground" between more-severe diagnosis of PTSD and "normal" response to very stressful circumstances - May blur line of what is a "normal" response to an abnormal situation |
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PTSD Prevalence in Youth |
Overall prevalence for one adolescent epidemiological study: 3.7% for boys, 6.3% for girls - Rates higher for those experiencing life threatening events (30-40% = rape victims, 40-90% child soldiers) - Variability in prevalence also reflects variability in exposure to traumatic events Life threatening accident: LP = 25 m, 13.8 female; ptsd risk = 6.3 m, 8.8 f Natural disaster: LP 18.9 m, 13.8 f; ptsd risk = 3.7 m, 5.4 f Threatened with weapon: LP = 19 m, 6.8 f; ptsd = 1.9 m, 32.6 f Physical attack: LP = 11.1 m, 6.9 f; ptsd = 1.8 m, 21.3 f Rape: LP = 0.7 m, 9.2 f; ptsd = 65 m, 45.9 f |
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Gender Differences in PTSD |
Factors that might contribute to greater prevalence in females: - Type of trauma experienced - Younger average age of trauma exposure - Stronger perceived loss of control - Higher levels of dissociation - Less social support - Higher levels of substance use coping --> Gender-specific psychobiological mechanisms (e.g., differences in hormonal stress reactivity) |
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PTSD Risk Factors |
- Pre existing factors: trait anxiety, behavioral inhibition - Aspects of event exposure: degree of loss/disruption/threat, event proximity (i.e., Washington DC Sniper - Processing and coping factors: Positive vs. negative coping - Social support: Parents, friends, classmates, teachers |
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Intervention--PTSD |
Intervention may be most appropriate long-term rather than immediately after the event - Questionable evidence for Critical Incident Stress Debriefing, and some evidence for iatrongenic effects (little evidence that it helps) - For youth, important to focus on supporting social networks, teachers, good coping strategies, and intervening to help/support parents |
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Example Treatment of PTSD |
Cognitive Processing Therapy - Related to CBT--emphasized connections between thoughts and feelings - More focus on "integrating" experience of trauma, into a person's life - Changing schemas about the event and its impact Example Activities: "Write at least one page on what it means to you that you experienced this trauma - Writing and rewriting trauma - Challenging faulty thinking patterns - Explore major themes of safety, trust, power, etc. |
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Hurricane Katrina |
- Social support from outside the family (neighbors, churches, aid organizations) = lower PTSD symptoms
- Avoidant coping (repression) = higher PTSD symptoms - Trait anxiety interacted with aspects of anxiety sensitivity (esp. regarding concerns about "keeping in control") to predict PTSD symptoms |
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Major Depressive Disorder |
Change in functioning that causes distress and/or impairment, lasts 2+ weeks, and includes 5+ of the following, one of which must be #1&2 1. Depressed mood, most of the day, nearly every day (can be irritable mood in children) 2. Markedly diminished interest in usual activities 3. Significant weight or appetite change (not dieting) 4. Insomnia or hypersomnia n.e.d. 5. Psychomotor agitation or retardation, n.e.d. 6. Fatigue or loss of energy n.e.d. 7. Feeling worthless or excessive guilt, n.e.d. 8. Trouble thinking/concentrating, n.e.d. 9. Recurrent thoughts of death or of suicide |
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Epidemiology--Mood Disorders |
Around 6% (but range); majority will be MDD, generally increases with age and lifetime prev in adolescents is 20% - Gender differences emerge (greater prevalence in females), especially in adolescence - Comorbidity: anxiety disorders, conduct disorder, ADHD, substance use problems |
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Persistent Depressive Disorder or Dysthymia (for youth) |
Depressed mood most of the day, more days than not, for at least one year (2yrs in adults) 2+ of the following: - Poor appetite/overeating - Insomnia or hypersomnia - Low energy or fatigue - Low self-esteem - Poor concentration or difficulty making decisions - Feelings of hoplessness |
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New Depressive Disorder--DSM-5 |
Disruptive Mood Dysregulation Disorder - Severe recurrent temper outbursts, inconsistent with developmental level (6-8 only) - 3+ times per week/12+ months/2+ settings and severe in at least one - Backstory: to deal with perceived over diagnosis of Bipolar Disorder in youth |
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Risk Factors of Clinical Depression (youth) |
Disrupted attachment - Bowlby and failure to thrive - Spitz: "anaclitic depression" in infancy Cognitive distortions - Beck's negative triad (self, world, future) - Internal, stable, and global attributions for negative events GENE ENVIRONMENT INTERACTION: 5-HTT (serotonin transporter) gene interacts with stressful life events to predict depression |
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Capsi et al. (2003) |
Studied the 5HTT - Against maltreatment - With two short alleles, you had an increased likelihood for depression - Much more vulnerable if you had two short - No gene environment correlation |
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Family Factors |
Depressed Parents - Some evidence that family environmental factors at least partially mediate links between maternal depression and child outcomes - Genetics play a role too ALSO, evidence that social competence in youth may mediate links between quality of parenting and later outcomes in adulthood |
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Gender Differences in Adolescent Depression |
Double risk for females only in adolescence - Causes the same but increase for girls - Greater risk due to challenges |
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Treatment of depression |
Medication - older = tricyclics - newer = SSRIs (issues = placebo response, increased suicidality)-->effectiveness outweighs risks Psychotherapy Or a combination!
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Psychotherapy |
Cognitive-Behavioral Therapy Interpersonal Therapy - Focuses on the fact that depression occurs in the context of interpersonal relationships - Common problem areas: grief, interpersonal role disputes, role transitions, interpersonal deficits, issues arising in single parent families |
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Examples of maladaptive cognitions |
- Overgeneralization: holding extreme beliefs on the basis of a single incident - Magnification/exaggeration: overestimating the significance of (negative) events - Polarized thinking: all or nothing view of world |
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"Middle Phase": Steps of Cognitive Therapy for Adolescent Depression |
Step 1: Increasing awareness of emotional variability 2. Detection of automatic thoughts 3. Identification of beliefs 4. Evaluation of automatic thoughts and beliefs 5. Changing maladaptive thoughts and beliefs |
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Treatment for Adolescents with Depression Study (TADS) |
- NIMH, funded, multi-site research program (similar to MTA study for ADHD) - 439 adolescents aged 12-17, with MDD - Start of study: avg 98th% in symptoms - 4 groups: medication only, CBT only, combination, and placebo only - 36-week trial (243 of 327 treated part. remained in study until the end); placebo group ended after week 12 |
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Results of TADS |
- Combined group showed fastest drop in symptoms, followed by meds only, then CBT - Combination group showed 85% response - Combination and med group showed improvement - CBT = less effective, mitigated against suicidality |
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Mediators and Moderators--TADS Study |
Improvement in depression symptoms mediated impact on functioning - Poorer outcome predicted by: age (older), severity, chronicity, comorbidity, low therapeutic expectations Outcome moderated by: - Income (high income families benefit from CBT more so than comb.) -Unclear why this is |
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Bipolar Disorder: Description |
Bipolar = depressive + manic episode - DSM Manic episode: Abnormally persistently elevated, expansive, or irritable mood (one week +), plus 3 or more: grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility - Dysfunction |
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Childhood Bipolar: Prevalence and Comorbidities |
- Prev. is low, estimated at 0.4-1.2% (equal m & f prev). - Common comorbid diagnoses: ADHD, disruptive behavior disorders, substance abuse, anxiety and learning disorders |
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Controversy 1: ADHD or Bipolar |
Can be very difficult to tell apart, especially in preadolescent children - Symptoms that overall: distractibility, excessive talking, and more activity - Symptoms that might distinguish BP: elated mood, grandiosity, decreased need for sleep |
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Controversy 2: Continuity? |
Very little research that has followed child bipolar patients longitudinally into adulthood - Evidence for multifinality: Adult bipolar, depression, and ADHD |
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Controversy 3: Treating Pre Bipolar |
Issue: Having a manic episode may prime the brain for future episodes - First may be stress induced - Untreated bipolar = many risks Some recommend medication and/or therapy for those with strong family history (potential problems) |
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Child Bipolar Etiology |
- High family transmission rates - Vulnerability and life stress - Abnormal Amygdala - Early sexual abuse |
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Bipolar Treatment |
Medications: - Lithium = mood stabilizer (toxicity and need for close monitoring) - SSRI's = may trigger manic episodes - Other mood stabilizers (problem = weight gain, diabetes) Family focused therapy (FFT) - Interactions with bipolar youth and families - Increase recognition of symptoms and reduce expressed emotion |
