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64 Cards in this Set
- Front
- Back
Dx features of Enuresis
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* repeated voiding of urine during the day or at night into bed or clothes
* Most often involuntary by may sometimes be intentional * Happens AT LEAST 2X PER WEEK for AT LEAST 3 MONTHS or else must cause CLINICALLY SIGNIFICANT DISTRESS OR IMPAIRMENT in social, academic, or other important areas of functioning * 5 years old or metal age of 5 * Not due to substance or GMC |
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Subtypes of Enuresis
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* Nocturnal Type: most common subtype; only pees during nighttime sleep
- typically happens in first 1/3 (75%) of the night - sometimes happen in REM sleep when child is having a dream - 2:1=m:f ratio * Diurnal Only: only pees awake; more common in females than males; uncommon after age 9; Divided into 1)"URGE INCONTINENCE": sudden urge symptoms 2)"VOIDING POSTPONEMENT":ignore urges until pees, sometimes due to social anxiety or preoccupation with school or play; high rate of symptoms of disruptive behavior; usually happens in the early afternoon on school days * Nocturnal and Diurnal: combo of both above - 25-30% |
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Associated Features of Enuresis
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*Usually a primary prob; when secondary, it indicates worse pathology
*impairment associated with this is a function of the limitation on the kid's social activities, self-esteem, social ostricization, anger/ punishment/ rejection of caregivers *most have no coexisting mental disorder *most common comorbid disorder is encopresis * behavioral symptoms more likely than in kids without it *developmental delays, including speech, language, learning, and motor skill delays (esp. in Diurnal) |
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Etiology/ Predisposing Factors of Enuresis
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*Unclear
*Strong genetic component to nocturnal primary enurisis *Diurnal may be due to stressors *might be self-masturbatory (not supported w/ research) - delayed/ lax potty training - psychosocial stress - delay in dev't of circadian rhythms of urine prdoction->nocturnal polyuria, bladdar hyperactivity or reduced functional bladder capacities |
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Epidemiology of Enuresis
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- considerable varriations
- after age 10, proportion drops tremendously - after 18, less than 1% for boys and even less for girls - majority will be typical bedwetter - 5-10% of 5 year olds; 3-5% of 10 yr. olds; 1% of 15> |
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Course of Enuresis
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*PRIMARY: never established urinary continence; begins at age 5; about 3/4
*SECONDARY: after establishing urinary continence; most common between age 5 and 8 * After 5, the rate of spontaneous remission is 5-10% per year * most kids become continent by adolescence |
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Familial Pattern of Enuresis
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*75% of kids w/ enuresis have a first degree relative who has had the disorder
* risk is 5-7x greater for offspring * concordence rates higher for MZ than DZ twins * linked to chromosomes, but not sure how yet |
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Clincial Presentation of Enuresis
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* can vary by timing, magnitude, and frequency
* 99% will stop without tx * not really all that uncommon * important to get detailed info. * make child feel comfortable |
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Differentals for Enuresis
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* Medical Illness, Infection, Medication
*After Tx, enuresis may remain * Mental age criterion must be met (like for MR patients) |
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Interventions for Enuresis
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- 100% success rate
- 99% goes away w/ or w/out treatment - make parents understand it's not volitional - Assure parents that Tx will be successful - child shouldn't be punished or embarrassed - behavioral interventions work best - separate Tx for Nocturnal and Diurnal |
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Diurnal Intervention
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- easier to treat than nocturnal
- child put on schedule; try to use bathroom every 2 hours - child responsible for cleaning up accidents; with younger kids, star or sticker system can/ should be used |
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Nocturnal Intervention
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- Urine alarms (sensing device)
- dry bed training: wake child every hour, then adjust time -child cleans up - point, sticker system can be used for added motivation (added in dry bed training) - takes a few weeks |
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Meds for Enuresis?
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- antidepressants may be appropriate
- about 50% respond to meds, but cons are long term/ adverse side effects |
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Encopresis Basics
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- pooping in inappropriate places
- usually involuntary, but may be intentional - happens at least ONCE A MONTH for at least THREE months - child must be at least 4 (or mental age of 4) - not due to a substance or GMC except through a mechanism involving constipation |
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Encopresis Dx Picture
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- involuntary: often related to constipation, impaction, and retention with subsequent overflow
- constipation may develop for psychological reasons leading to avoidance of pooping |
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Encopresis subtypes
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- With Constipation and Overflow Incontinence: evidence of constipation on exam or history of stool freq. of less than 3 per week
-poorly formed, and leakage (mostly during the day) * W/OUT CONSTIPATION & OVERFLOW INCONTINENCE: no evidence of prior problem; normally formed poo; intermittent soiling; feces may be in a prominant location; associated w/ ODD or CD; may be consewuence of anal masturbation; LESS COMMON |
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Associated features and disorders of Encopresis
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- often feels ashamed and may wish to avoid situations that may lead to embarassment
- impairment affected by peer rejection, self esteem, caregiver response - SMEARING feces may be intentional or accidental when child attempts to hide it - when clearly deliberate, ODD or CD may be present - many are also enuretic |
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Prevalence of Encopresis
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- About 1/2 that of enuresis
- kids under 8: 2% of boys and 0.05% of girls - 4-5:1 = m:f ratio |
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Course of Encopresis
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PRIMARY: prior to child estavlishing fecal continence
SECONDARY: after child established fecal continence for at least 3-6 months prior to onset - can persist intermittently for years |
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Other clinical info (from class) on encopresis
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- diary prepared by parents and kid including diet and frequency
-rule out medical basis suppositories NOT a good idea when behavior problem - Approx. 1/2 encropretic day or night - most don't report urge to deficate -family problems and social difficulties for child -assess impaired functioning -may have to teach social skills -find out about smearing Increased incidence in MR and PDD (so make sure mental age is over 4!) -spontaneous remission is common, but don't wait for it |
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Tx for encopresis
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- 100% effective almost
- primary takes longer than secondary - teaching independent toilet training is most effective - educate child and family - diary -devise plan for family in writing and explain - parents check clothing regularly - regular trips to the bathroom and sitting for 15 minutes - teaching child to clean uo - kid cleans up accidents - medical intervention may also be needed |
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Firesetting Basics
(can't dx pyromania before 18) |
- seen as impulse control problem
- symptom of conduct disorder - referrals come when child repeatedly starts fires, most often out of curiousity - they seek out incenduary devices - repeated pattern - sometimes done in ager, aggression, retaliation - most common reason kids give that is that it is pretty or they like firetrucks - can be passive -> aggressive - trouble establishing relationships - usually carry Conduct DIsorder Dx - Older firesetters more likely to have CD or be aggressive - many have history of abuse - perhaps kids are expressing emotion (fire, rage)? - less postive affect or affection in the home |
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Tx for firesetting
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- difficult
- many hospitals won't take them |
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Associated Features of firesetting
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- academic problems
- truancy - behavior problems - impulsive behaviors - family stressors may trigger recidivism is high (even in juvi cases where it is >25%) - most persistent predictor of conduct disorder - can be mild, moderate, or severe - early onset is more often the rule than the exception - can be legal and psychological repercussions - associated with maturity problems and other psychopathology |
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prevalence of firesetting
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- 3% of general population
- 10:1 m:f ration inpatient population - most are average intellectual functioning |
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Treatment for Firesetting
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- earlier the better
- may need to include anger management - may include social skills training -family Tx may help - firesetting behaviors need to be dealt with separately and specifically - parent training - young kids might be taught to set contained fires to satisfy their curiosity - may assess level of supervision child needs |
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ADHD Basics
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-used to call it minimal brain damage or Hyperkenetic
- PERSISTENT PATTERN of INATTENTION and/ or HYPERACTIVITY-IMPULSIVITY more frequently displayed and more severe than normal - some symptoms that cause impairment have to have been present prior to age 7 (even though often diagosed after that) - must be IMPAIRMENT in TWO SETTINGS AT LEAST - Clear evidence of interference with developmentally appropriate social, academic, or occupational functioning - doesn't occur exclusively during a PDD, schizophrenia, or other psychotic disorder |
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DX pic for ADHD - inattention
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INATTENTION
- in all settings -lack of attn to details; careless errors -messy work w/out much thought -difficulty sustaining attn. in tasks or play, and don't complete things - daydreaming, not listening to/ hearing what's being said - freq. shifts from one activity to another (uncompleted) - fail to meet rewuests or instructions or to complete schoolwork, chores (only due to inattention - difficulty organizing tasks and activities - avoid and dislike tasks tat require sustained attn - materials often lost and work habits disorganized - easily distracted by irrelevant stimul - forgetful in daily activities - frequent shifts on conversation, not listening to conversation |
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Dx pic for ADHD - Hyperactivity
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- fidgitiness, squirming
- not remaining seated - running or climbing - can't play quietly or enjoy leisure activities - "on the go" or "driven by a motor" - excessive talking - varies with age (less active the older we get) |
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Dx pic for ADHD - Impulsivity
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- impatience
-difficulty in delayed responses - blurting out answers - difficulty awaiting one's turn - freq. interupting and intruding on others - grab things from others - make comments out of turn - fail to listen to directions - touch things they aren't supposed to touch - may lead to accidents and to engage in potentially dnagerous situations without thinking |
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Addition Dx pic for ADHD
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- attentional and behavioral manifestations usually appear in MULTIPLE CONTEXTS (at least 2 needed)
- however, it isn't likely for someone to show the same level in different contexts or the same level within a context all the time - symptoms worsen when there is nothing novel or in situations that reqiure a lot of attention -more likely to occur in a group setting - get info from many sources and various situations in each setting |
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Assessment Issues for ADHD
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- 50% of girls amd 80% of boys = what teachers would say are ADHD
- MUST account for DEVELOPMEMT - don't have norms, so we can't really do this. - probably not going to get info from kid - get info from parents and teacher -> if info. doesn't match, probably isn't correct diagnosis - specifics, close-ended ?s -paper and pencil tests; Tom Achenbauch-age 4-18 - CBCL/TRF/YSR(11+); can't dx with one of these, but it is a screening tool and a way to measure severity and change over time; Conners scales |
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Subtypes of ADHD
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- ADHD, Combined Type
- ADHD, Predominantly Hyperactive-Impulsive Type - ADHD, Predominantly Inattentive Type |
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Associated Features of ADHD
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- vary depending on age and developmental stage
- low frustration tolerance - temper outbursts, bossiness, stubborness, escessive and frequent insistance that requests be met - mood lability -demoralization -dysphoria rejection by peers -poor self esteem - academic failure - accidnet prone - learning disabilities - family relationship problems - underactivity of certain brain functions -poor self-esteem seen as intrusive, irritating, and insensitive - likely to be aggressive (which will be BAD Px) - later in life probs = employment probs, academic underachievement, relationship probs, divorce rates > |
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Associated Dx of ADHD
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- -comorbid ODD = worse prognosis (in terms of function)
- comorbidity with CD is also really bad |
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Etiology of ADHD
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- we don't know
- risk factors include: - pre/ peri- natal probs - lead poisoning - malnutrition - early health probs - inconsistent research on biological findings and genetic vulnerability - more first degree relatives of chilren with ADHD will have ADHD - twin concordance rates are also suggestive - it's genetic and environmental |
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Prevalence of ADHD
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M:F RATIOS
- GENERAL POP: 3:1 - CLINICAL: 10:1 - girls get overlooked b/c their presentation is less annoying that boys in that they are less likely to be aggressive or learning disabled PREVALENCE: - 7-8% of gen. population |
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Course of ADHD
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- chronic
- evidence it appeared before age 7 and for a minimum of 6 months - usually dx in elementary school (girls later) - 1/3 will normalize by adolescence; 2/3 will have i nadolescence; some of those will continue into adulthood - looks different in child/ adolesc/ adult - doesn't just go away - Dx prior to 6 is mistake |
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Differentials for ADHD
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- MR: only if symptoms are excessive of child's mental age
- understimulating environments - PDD's: distinguish from impulsivity or hyperactivity you see in those disorders - Psychotic Disorder - Mood and Anxiety disorders: these kids tend to not be aggressive or impulsive like ADHD kids - learning disabilty, ADHD, or both? GMC like hyperthyroidism Mania: bipolar is episodic, not chronic and pre-pubital mania is very rare while ADHD is not |
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Tx of ADHD
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MEDS
- meds studied more than any other intervention for 40 years - some kids need 'em, some don't - most effective form of Tx - work with kids pediatrician - stimulant most commonly used (75% postitive response) - doesn't cure, just helps them to calm down and focus, to gain control so other aread can be handled * educational management * most work done e/ parents * NO standard psychotherapy * teaching parental tips, maybe family Tx * once Dx is received, child can receive benefits under the ADA |
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Oppositional Defiant Disorder basic information
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- recurrent pattern of NEGATIVISTIC, DEFIANT, DISOBEDIENT, and HOSTILE BEHAVIOR toward authority figures ther persists for at least 6 months and is characteried by at lest FOUR of the following behaviors:
- losing temper - arguing with adults - actively defying or refusing to comply with the requests of adults or rules - diliberately doing things that will annoy other people - blaming others for own mistakes or behavior - touchy and easily annoyed by others - angry and resentful - spiteful or vindictive - happens more freq. than compared to norms for age, dev and cause impairments in functioning - no Dx if happens exclusively during a psychotic or mood disorder or if cruteria are made for CD or AS-PD |
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ODD Dx features
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- negativistic and defiant behaviors are expressed by persistent stubborness, resistance to directions, unwillingness to compromise, give in, or negotiate with adults or peers
Defiance - deliberate or persistent testing of limits, usually by ignoring orders arguing, or failing to except blame -Hostility: deliberately annoying others or verbal aggression (usually w/out physical like in CD) - usually always in the home setting, but may not be seen in school or community (b/c symptoms are more evident with people the child knows well) - usually don't see their own behavior as oppositional but rather as a response to unreasonable demands or circumstances |
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Associated Features and Disorders of ODD
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- vary as a function of age and severity of ODD
- in MALES, more prevalent in those who had problematic temperments in preschool or high motor activity - may be low (or inflated) self-esteem in school years, along with mood lability, low frustration tolerance, swearing, precocious use of alcohol, tobacco, or drugs often conflicts with parents, teachers and peers - vicious cycle where parent and child bring out the worst in each other |
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Etiology of ODD
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- don't know
- more prevalent in fams where childcare was often disrupted by several different caregivers or in fams that used harsh, inconsistent, or neglectful child-rearing practices are used - ADHD is commonly comorbid - also associated with learning disorders and defiant disorder |
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Specific Age and Gender Features of ODD
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- be very careful Dx-ing ODD during the developmental periods of preschool and adolescent kids because transient oppostional behavior is common then
- The # of oppositional symptoms tends to increase with age - More prevelent in males than females before puberty, but equal afterwards - symptoms generally same in both genders, except males may have more confrontational behavior and more persistent symptoms |
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Prevalence of ODD
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- 70-80% overlap with ADHD
- 2-16% = prevalence rate, but it is not meaningful because the range is so larger |
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Course of ODD
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- Usually evident by age 8 and no later than early adolescence
- symptoms often emerge in home setting but may spread over time - typically gradual onset, over months or years - often developmental antecedent to conduct disorder, childhood-onset type, but not all - symptoms must be present for at least 6 months - stable behavior in asolescence - # of symptoms increases with age |
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Risk Factors for ODD
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- the way parents react to a child's behavior
- closely linked with ADHD - poor parenting/ child bahevior |
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4 Factor Model of Underlying causes of ODD
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1) Parent's tempermemnt: inconsistent parenting stratregies- ehrn opp. beh. is established through intermittent reinforcement, extinguishing it is very difficult
2) Child Temperment - born with it, and some are more emotional, overactive, inattentive, etc. 3) (Parents) Child Management Skills: - especially when parents don't monitor their kid's activities 4) Family Stress - internal and external events affecting family can aid in the development and maintenance of IDD |
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Tx for ODD
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- limit setting
- rigorous behavioral approaches - teaching parents to set limits, how to use reinforcement, punishment, extinction, and negotiation to handle kid's behavior - establish with parents that you will be working with them, not their kid really - successful if family is comliant and motivated which you should tell them mearly on so they have no excuse if it doesn't work - marital or individual Tx for parents may be an appropriate suggestion |
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Prognosis for ODD
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- better the sooner they get treatment
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Differentials for ODD
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- normal development/ behavior
- CONDUCT DISORDER: ODD won't show aggression towards people or animals or destroy property. etc.; ODD is primary risk factor for CD, but you don't have to have ODD first -ADHD: can ADHD/ODD/ or both (same patterns of behaviors; impulsivity, inattention; low self esteem; low frustration tolerance) -Depression: some may have both - PTSD: may sometimes look like ODD because it is how they are responding to trauma |
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Conduct disorder basic info
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- basic rights of others or major age-appropriate societal norms or rules are violated
- behavior falls into these 4 groupings: 1) aggressive conduct that cause or threatens physical hard to other people or animals 2) Non-aggressive conduct that causes loss or property or damage to it 3) deceitfulness or theft 4) serious violation of rules - At least 3 behaviors have been present in the past 12 months with at least one present in the last 6 months - clinical functional impairment -CD may be Dx-ed in kids over 18, but only if AD-PD is not met -behavior in a variety of settings -rely on other informants since client will usually minimize their behavior |
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Dx features of ODD
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- initiate aggressive behavior or react aggressively
- bullying, threatening, or intimidating behavior - initiate freq. phys. fights - use a weapon - physically cruel to people and animals - steal while confronting a victim - force someone into sexual activity - fire setting w/ intention of causing serious damage - deliberately destroying others property - breaking and entering - freq. lying or breaking promises to obtain goods or avoid debts - stealing items of non-trivial value without confronting the victim -before 13, staying out past curfew - pattern of running away, 2x or 1x for an extended time - truancy prior to age 13 (absent from work with no reasom) |
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Subtypes of CD
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Both occur in mild, moderate, and severe form
CHILDHOOD ONSET TYPE - onset of at least one criterion of CD ptior to age 10 - usually male - freq. display physical aggession towards others - disturbed peer relationships - may have had ODD in early childhood and usually meet full criteria for CD by puberty - many also have ADHD - more likely to have persistent conduct disorder and develop anti-social personality disorder ADOLESCENT ONSET TYPE - no criteria met prior to age 10 - less likely to display aggressive behavior - more normative peer relationships - less likely to have persistent CD and development of antisocial PD - ratio of males to females is is lower for adolescent than childhood onset type UNSPECIFIED ONSET |
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Severity specifers of CD
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MILD:
few if any conduct problems in excess of those required, and those that are present cause relatively minor harm to others MODERATE the # of conduct probs and effects on others are intermediate between mild and severe SEVERE many conduct probs in excess of what is required or conduct causes considerable harm to others |
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Associated Features of CD
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- little empathy and little concern for other's feelings, etc.
- often misperceive intentions of others as hostile and respond with aggression - callous and lack appropriate feelings of guilt or remorse - hard to tell, because they learn to fake guit - narc and blame others for their misbahavior - low self-esteem despite projected "tough" image or overly inflated - poor frustration tolerance, irritability, temper outbursts, and recklessness - higher accident rates - early onset of sexual behavior, drinking, smoking, and drugs (risky beh) - school expulsion, legal difficulties, STDs, unplanned pregnancy, or physical injuries - suicide ideation/ attempts/ completions higher - lower than avg. intelligence, esp. verbal IQ |
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Associated Disorders of CD
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- Learning or Communication
- Anxiety - Mood - Substance-Related Disorders |
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predisposing risk factors for CD
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- parental rejection and neglect
- difficult infant temperment - inconsistent and harsh parenting - physical or sexual abuse - lack of supervision - early institutional living - frequent changes in caregivers - large fam size - mom smoked while pregnant -peer rejection - association with delinquents - neighborhood exposure ti violence - certain familial psychopathology SES NOT A RISK FACTOR |
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Course of CD
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- chronic
- beh. for at least SIX months - stable over time - symptoms vary with age and increase over time with cognitive and sexual development - onset as early as 5 or 6; after age 26 is rare and most will show prior to 16 |
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Prognosis of CD
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- confrontational behavior = worse Px
- sig. amt. remit byadulthood (55%) leaving 45% in adulthood -The earlier the presentation = worse Px - BEST PROGNOSTIC INDICATOR OF WORST OUTCOME - more likely to get divorced more than once |
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Epidemiology of PD
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- rates vary as a function of definition and different international definitions
- US has higher rates of ADHD while Britain has higher rates of ODD (because of def. issues) PREVALENCE: * Girls: 3% * Boys: 7-8% * M:F Ratio = 2/3:1 * earlier onset for boys than girls * boys more likely referred for aggression while girls are referred for sexual behavior |
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Intervention for CD
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- ohysical aggression needs to be addressed with kids
needs to be multifaceted, no single Tx works - family issues must be addressed - school probs need to be treated - indiv. Tx, group Tx, or residential Tx - NO MEDS TO FIX BEHAVIOR (only used to mediate aggression when severe) - parental training - social skills training - problem solving training and challenging hostile attributions (older kids) - CBT approaches, anger management, and impulse control training w/ adolescents - broader strategies too involving community, school, etc. |
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Differentials for CD
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ODD
-If they meet the criteria for CD, they have CD ADHD - CD show pattern of violating rights of others that ADHD kids don't show - criteria for both disorders can be met MANIA - now "misdiagnosis of choice" - CD kids are often reckless and irritable like manic ones, but: mania is episodic while CD is chronic PSYCHOSIS - are they responding to delusions or hallucinations? ADJUSTMENT DISORDER W/ DISTURBANCES OF CONDUCT - if they meet CD criteria, then stressor isn't relavant to Dx (it can be noted on Axis 4) |