Psyc 352 Iv

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XX. Internalizing Problems: Depression/Suicide
A. Statistics
1. Frequency of depression in adolescence

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1) Other than substance use disorders, the most common mental disorder for young people, 1 out of 33 meet criteria at any time. 25% have symptoms regularly (not most extreme levels); > 1/3 of children have very seriously thought about suicide. Inc over yrs (why? Level of dep inc, or more comfortable reporting b/c stigma dec)

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2. DSM-IV Diagnostic Criteria vs. Feeling down

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Depressed: not not report feeling distraught but rather Numb. Major dep episode: 2 wk per where most of time almost all of time -> loss of pleasure in anything (big and small like coffee). 5% weight gain or loss, esp high carb. Insomnia/hypersomnia (12 hrs/day everyday) nearly every day. 1) Agitations, or slightly more likely: 2) slow down physically Ex. slump more than usu: seem lethargic, almost hard to talk, low energy. Fatigue, worthlessness, excessive guilt. Problems concentrating, recurrent thoughts of death. (meet any 4 of 8?)

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Depression effects

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20% fatality rate if term. 2 wk per: 1/5 chance you will die as a result of dep in lifetime, mainly suicide. (or, cancer treatment stop early, alcoholism, accidents as covert suicides or distracted). Long term mortality rate may change w/ medic (not sure: either no effect or slightly inc risk if suicde in adol=> agitated reac by some, leads to suicide thoughts).

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B. Risk factors for depression
1. Age
2. Gender and depression.

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Prior to adol: not as easily dep (used to think not possible),less freq, lack nec cog abilities (recurrent neg thoughts dwelled on, not focused as long), hormonal changes dec likelihood? stress inc later. Age 13: same for both genders, then females have twice rate of males. Age 15,16 difference begins (hormonal diff plausbile but mostly occur at age 12, 13; other theories).

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3. Nolen-Hoeksema’s theory: Ruminative coping strategies

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Introspect: why am I unhappy today? Bad if consis, what is wrong w/ me? Feel bad about feeling bad about, etc. Girl's strategy more than boys. Freq of strategy does not influence dep unless much stress. Girls experience more psychosocial stress in adol (1/4 report sexual assault/abuse before 21, will earn less later). Boys not as dep but more likely to abuse substances and be violent. Rival hypoth: hormonal changes.

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4. Biology - Depression as a "brain disease."

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Absolutely a biol basis; heritable, predisposition (even if adopted), can be medically treated. Recog has been useful in reducing stigma. Problem: saying it happens in brain means nothing (ex. enjoying football is biol...) Everything happens in brain through chemicals and neurons. Is depression more biol based than merely changes in brain? See changes-> responsive to certain medications. People mourning have very similar patterns of change. Not the same as getting the flu...Normal people taking dep medic have slight mood elevations.

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4. Biology - Depression as a "brain disease." cont.

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Due to seratonin in brain. Ex. weak car battery: needs rechargign activiies. Depressed: pull back from activities making more depressed. Heritable: increased likelihood for dep. Also a social aspect, despite good batteries, if not used... Pharmocological Therapies: SSRIs inc free serotonin in brain. But dep people do not appear to suffer from serotonin deffiencies, helps but not main/only problem.

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Peer factors

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1) Withdrawn from soc activities, 2) Angry 3) Dependent behavior; all three linked to depression/risk factors. Angry/irritable interactions; depressed indiv are difficult to be around. Dependent-> very open w/ peers and friendly but very clingy.

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C. Treatment
1. Pharmacological Therapies

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Range of drug therapies (ex. SSRIs, prozac, trisic, haoi inhib) 1) Not drugs getting abused b/c take about 6 wks to work. Not particularly dangerous/addictive, no rebound effect. Change serotinon levels in a day but see no effects for up to 6 wks. 2) Efficacy (2/3 to 70% exp improvement in symptoms of dep, 40% exp improvement from placebos) Actually 30% effective; but prozac gives side effects... Placebo effect comes in before 6 wks, maybe first wk always due to placebo effect from prozac.

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1. Pharmacological Therapies
(Worth trying in conjunction w/ other therapy, black box warnings for suicide)

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Depression in mind and therefore placebos can be effective, motivation. 90% of research for drugs is funded by drug companies, only publish positive results, decreased today but still bias. Does clearly work for some people. Untreated controls: moderate results. Side effects: weight changes, sexual functioning (desire, performance), dry mouth (can switch drugs for lower side-effects). Suicides (very dep to begin w/? Metaanaly: small but real pattern to inc suicidal thought/beh. 1) More energy (most dangerous time for suicide when a little better) 2) effect can be to make more agitated: dramatically worse.

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2. Cognitive-Behavioral treatments

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Film: ordinary people. Premise: dep due to thinking patterns. Seek to identify distorted ways of thnking. Exaggerations: drains to battery. Challenge beliefs. Ex. people thinking boy was weird, actually withdrawn, w/ neg thoughts, say stupid things: 1/2 what people say makes little sense in casual conversations. Slightly slower than prozac, effect in 8 - 10 wks.

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3. Interpersonal Therapies

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Unhealthy/distorted Ex tease in new situations->depressed. Other things to do when uncomfortable, dep may be driven by Environment. (Also helps w/ suicidal risks of drug therapies.)

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4. Family Therapies

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4. Change ways parents behave that support dep; rewarding ex. did nothing outside of house->turned down volunteer job.

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5. Efficacy

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All these therapies wk more than placebos (control: self help bks) w/ several dep (70% drugs vs 60% therapies drugs better) Multiple approaches best. Not all dep has a situational causal but becomes a cycle by not encouraging in environment. Also low activity can lower brain chem levels. Adolescents more likely to have drugs and therapy vs 70 yrs ago w/ insurance companies. Most drugs not 'validated' for adol but still prescribed.

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Firlm, dead poets society

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- Role of impulsivity for adol (lack of perspective-taking) Black hole of thinking->constricted mental processes/option. Role of guns: availability, thinking of other methods slow down, less lethal (such as drugs) Impact on others makes a diff if know and care about effect.

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3rd death reason

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(But, auto accidents maybe w/ suidal components. Homocides also reckless beh 1/10 tenth graders have attempted. Of all attempters (50:1) do not succeed 98%. Older adults more likely to succeed. 1995: present->suicide rates inc x4. [More dep suicide less stigmaticized->likely to be listed on death certif. Gun avail. More media coverage->seems more like an option. Ex eulogies->better place, right dec->message to other children. 500 people attended funeral. Some evidence that due to media attention suicides occur in clusters (contagion)

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Risk

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Dep, 2nd substance abuse (loose inhib in already drunk) History in family, exposure in environ/media to suicide. Extensive family conflict. Stress around achievement (only one option). Stress around sexuality (esp gays, less a risk factor today). More than one greatly inc lik; attempted suicide->see how lethal method->gun vs not thought how/choke. Some attempts only as gestures->may be more lethal than recog (tylenol overdose easy to kill self) Distorted thinking process: only one way.

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Intervention/Prevention

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Always ok to ask if thought about suicide. Idea not given to them, may instead break down sense of isolation. Help from others is essential even if sworn to secrecy. In therapy, confidentiality does not appy, must take steps to help. Constricted thinking of few options usu expands by discussing feelings. Helps to share feelings w/ someone else. Do not nec say it will be fine.

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Intervention/Prevention

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Helps to recog trouble->I will be here to help. Calmly discuss vs showing alarm (while taking seriously) How to get help? Emergency rooms have psychiatric help 24 hrs/day. They can determine how serious (not your task), Interven/talking can make a large diff-usu a matter of broaching the issue.

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A. Statistics
1. One million teenage females/year become pregnant
2. 1 in 4 teenage girls will become pregnant before the age of 18.
4. Pregnancy resolutions:

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2. 80-90% unintended, 2-3% planned preg. 4. 10% recog adol preg end in miscarr (same for adults) Maybe closer to 1/3 but most after 5-10 days.

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4. Pregnancy resolutions:

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Of rest, 45% terminate via abortion 35% are unintended births (of 45%) 10% are intended births. 3/4 of all teen births are out of wedlock.

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Consequences of Adolescent Childbearing. 1) Econ & Educ Correlates of childbearing

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Views w/ most attention (but outdated...) - Serious conseq->lower educ attainment (true w/ correl) Dramatically likelihood to be poor & uneduc. 10-30 bill dollars/yr for society plus child's lifetime income lost. (1/2 of Iraq war costs) Lose 110,000 of future income for teen mothers.

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3. Updated views on costs:

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Based on correl; not random who has babies, linked to educ success & poverty more likely to get preg & keep. Instead compare preg teen preg at 17 to siblings not having babies. Then compare 18 w/ baby to 22 w/ baby->lose time in both from educ & work force. Rel modest costs of keeping children. Mostly would have been poor anyway; less costs.

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4. Effects on children

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Film: for keeps. Large on children vs teen parents w/ some income & educ loss (happens anyway). Lack of time, money, knowledge. 1) Health problems more likely->not b/c of teenage bodies but lack of prenatal medical care (preventative vitamins). 2) Less stimulating home environ, more educ difficulties over time->lower levels of cog. devel. Difficulties socially adjusting. More in need to school special services. Are higher welfare rates for teenage parents, but most effects are for children. This problem w/ the 25% preg underest problem (not counting the 50-70% risky beh).

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C. Use of Contraception:
1. Sexually experienced adolescents

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1. 72% of 15-17 yr olds sexually exp use regularly 1/3 of those use 100% of time. 2. 40% do not use at first intercourse (only a little lower for 20s if first time). 3) Reasons for nonuse (bk out of date): Not not getting access (1980s battle...) Not primarily educ & understanding. Primary reason: were not expecting to have sex not prepared. Responsibility for preventing preg->women bear 90% of costs esp if not married. Almost all of risk factors apply to women. Relatively cost-free to men.

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D. Antecedents of Risky Sexual Behavior
1. Literature shows not a few strong antecedents, but many, many weak antecedents.

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1. (Diff populations-> span among preg vs narrower if having babies) (Upper mddle class less likely to have babies...) But many, many weak antecedents, most are risk factors. 2. Distal antecedents & close.

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Biological

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Higher levels of testos in males (greater fertility or more likely to have sexual activity) probably the latter. Lower levels of puberty for both genders.

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4. Social/environmental

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Middle class same risk almost. Poverty or not two-parent-headed; parent's lack of educ; mother's or sister's exp as an adol mother; poor child rearing prac/lack of supervision. Sexually abused more lik to be sexually active. Less relig affil; higher drug/alcohol use; more aggressive as a child; doing poorly in school; lower expec for future. All account for tiny percents of variance. There are about 20 factors predicting but not strong predictors of all alone.

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6. PROXIMAL ANTECEDENTS

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Values about sexual beh->dec likelihood. Willing to have sex as adol. Say you plan to have sex and get preg (better predictors)

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Cultural/Societal

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1) Males->causing preg before 18: 1/20 vs 1/4. Large likelihood that from an older guy (that leads to preg) 20,21-> 16-18 girls (vs having sex w/out preg).

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Cultural/Societal
2. Ethnicity

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Higher for black youths vs white (then hisp, then white). About same rates as in 1958 (did not have reliable/accessible birth control. More likely to lead to an early marriage). Drop off 25-30% since 1991 like juv delinq; related to substance abuse? AIDS changes thinking about sexual beh (problems w/ multiple sexual partners->changed attitudes)

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Cultural/Societal
2. Ethnicity

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Reasons: drops 3/4 do to use of contracep, 1/4 due to abstinence accoutns for dec in preg. International comparisons: Netherlands (6/1000 per yr) Sweden (13/1000/yr) Norway; Great Britain 32, US x10 as in Netherlands. Theories: in netherlands less ambiv about sexual beh use contracep at much higher rates (vs have sex more). Not that freer view is better, but leads to dramatically lower preg (Ex IEDs implanted) [In a yr->90% get preg if regularly have unprotec sex]

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E. Pregnancy Prevention - What works?
1. Sex Education?

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1) Sexual ed: how explicit to be (will implicitely say; should? Counterside: teach contracep. How explicit to be. Simbple, direct educ has No Effect on contracep/preg rates. Those most at risk pay least attention. Often taught by gym teachers w/ extra time vs comfortable.

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Life/social skills:
- AIDS prevention has small effects (dying risk vs preg)

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Assertiveness w/ practice: small effects. - wks better for risky sex & preg prevention.

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2. Abstinence-based programs?
4. "School-based health centers"

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2. No evidence that these work vs federal mandates to be primarily absin based. No Effects. 4. Fad from 1980s,90s-> did not really work.

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5. Youth Development Programs

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Best programs: volunteer wk linked to discussions of that service; school based. Ex. Jr league of Am started program, after school. Talked about sex 1/15 if curruc. 50% reduc in yr for preg rates (vs random control) highly sig, less suspended, failing, preg. Why? 20 diff risks: children take care of themselves in more mature ways. Those volunteering: doing things that matter. Part of community changes self-views Noted as 16 silver bullets to fix world. Reasons: see themselves as future adults.

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6. The Teen Outreach Example - Barriers to Dissemination

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- 1994 data pub; 1997 data pub showing effect. (sense of autonomy, the more the better) The kinds of wk: does not predict but didif they Choose. Mandated by states->'mandated volunteer wk' loses effects. Ex. Trying to get clinton admin involved; jr league-> repub would say fed govt not nec. Monica Lewin problem->Clinton did not want to champion teen preg. Many schools do have volunteer opportunities (should be more effective). Mandated prog typically did not discussions. Not same exp.

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XXII. Child Abuse/Runaways/Eating Disorders/Course
B. Eating Disorders - Overview
1. Anorexia and Bulimia

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1. Def: being 10% below middle ofideal weight range (20% below: life threatening) 15-25% long term fatality rate. 3-4% eating disorders; 1% (higher among college age females, high achieving) anorexia (intensely afraid), 3% bulimia (vomitting to control calorie intake typically flowing bingeing (ex gallon of ice cream; cake) becomes less difficult. Not effective for calorie reduc (1/2-2/3, 1/3 of intake) Many already absorbed. Physical dangerous: destruc to digestive track (throat, mouth) Throws off electrolyte balance & heart rhythm... (usu die of heart attacks)

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Causes:

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Achiever's problem: usu highly successful pressure for perfection problem w/ autonomy (emeshment w/ parents) control of life, gain autonomy. Able to discipline themselves. Often a reaction to stress & trauma. Self sufficiency (not wanting to be dep on others) Anxiety or anger driven? Rebellion? Physiologically->some heritable or ease of not focusing on food.

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6. Treatments

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Medic not effective for anorexia. Bulimia: some success w/ very high does of anti-dep (feel less a needed binge and purge). Family therapies: most success, food becomes control battle (refuse to eat in front of parents) Extreme-> hospital; eat or feeding tube. Est control to other areas. Est relationships (old adol, adults...) (Bulimia->no distinct body shape vs anorexia)

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Obesity

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30% of teesn are overweight (15% over med weight) Long-term health risks. Toxic society in terms of food; x15 teens are obese than anorexic).

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Child abuse

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Invis problem; 300,000 adol/yr reportedly abused (and many not reported) Film: This Boy's Life (true story) Correlates: lack of parental educ little exposure to parenting skills. Prescence of step parent. High degree of marital strife (usu phy) or just conflict. Ethnicity is not related. Family size (usu large families->serious abuse) Age 0-5: risk factor as a well. Adolescence: risk factor.

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Sequelae

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School problems, running away, difficulty w/ peers (conflict approaches; overlearns from family interac, anticip danger) Repeating cycle of abuse-> 30% go on to abuse children, most do not, higher rate than normal population. Best way to prevent cycle: relat to learn from past esp (therapy; non-abusive parent, spouse->safety...) Treatments-> mainly specific problems. First) out of situation.

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E. Sexual Abuse
1. Statistics

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25% girls, 10% boys-> in adol (nonvol sexual activity) Similar problems as phy abused-> expected to go on w/ life. Often become hypersexual. Male adol often abuse others (ex if w/ other males may be abused)

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2. Sexual Harassment

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Much more common; vs teasing (rather completely ignore them harrassment; intended to hurt) Reduce harassment: way to reduce likelihood of school/violence vs metal detec.

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Runaway:
- Homeless:
- Foster care:

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Staying away overnight w/out permission. - No fixed residence; may stay with other friends, buildings. Living on streets->eating income: prostit (for male and female), drugs. - Odds higher to be abused than in general popul (paid $7/night) Disaster. May not have jobs, poor, may earn money (2,3 kids about $600/month)

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- Foster care:
Causes:

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- Esp problematic if beaten, may leave. Adol w/ stress esp difficult to care for (insecurity) Push limits to see what they are to tolerate of. Ex. 12 diff families. - Sexual abuse reason, extreme parental neglect; serious drug problems; parents who lost control of children.

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Effect

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If runaway after sexually abuse; likely to be abused more (ex prostit; homeless, males and females). HIV risks, criminally victimized; educ decreases; difficult forming a trusting relationship.

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Final thought

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Biol, family issues, risks, vs media. Very resilient; "Beginner's Mind" Eastern phil. Awkward yet open to learning, willing to take risks. Life more comfortable as adults.