11. Disorders of childhood Flashcards
Define abnormality in childhood and
adolescence
• Must occur from a developmental lens
– Defining deviation from norms can be complicated given the wide range of “normal” development
• Consider various influences on developmental outcomes
– Within child factors (e.g. temperament; cognitive abilities)
– Interpersonal factors (e.g. relationship stability and quality; peer experiences)
– Contextual factors (e.g. community; opportunities for stimulation and learning; SES)
Developmental Contextualism
how do personal characteristics (such as genetic endowment, physicality, temperament), coalesce with contextual influences (such as familial interactions, institutional structures, historical circumstances) to create individuality?
Developmental Psychopathology
The study of human development and the expression of “psychological disorders” in the context of normal developmental changes
what is developmental psychopathy concerned with?
– Using developmental norms to recognise “abnormality”
– Identifying risk and protective factors for developing psychopathology
– Understanding developmental needs at different points in time and the impact of unmet needs on development
– the impacts of psychopathology on development
– Interested in pathways to psychopathology: Less “What causes conduct disorder?” and more “What initiates and maintains individuals on a probabilistic path to conduct disorder and related outcomes?”
Risk factors
factors related to disordered outcomes –
that increase probabilistic risk.
Protective factors
promote competent development
and buffer the impact of risk processes
How do risk and protective factors affect the individual?
- Can have different impacts on different individuals – the same stressor/risk factor may be extremely potent for one person but not another
- Recall equifinality and multifinality
- The timing of risk and protective factors may also be significant
The significance of relationship
• The interpersonal context is significant in shaping neuronal activation and growth
• Patterns of interpersonal experience build the architecture of the brain
– Hebb’s law - Neurons that fire together, wire together
Relationships are the context for learning about…?
– Emotions
– Regulation
– Safety and predictability
DSM view of childhood disorders
there is a close relationship between presentations in childhood and adulthood
Criticisms of DSM-5 approach to childhood disorders
• DSM 5 identifies some features that may appear differently in children and adolescents
• DSM 5 does not provide much guidance on this
– Limited discussion of models of development
– Up to the clinician to be able to meaningfully apply and understand the individual within the context of development and experience
Categories of childhood disorders
Externalising disorders internalising disorders disorders of basic functions neurodevelopment disorders disorders of care
externalising disorders
- Oppositional Defiant Disorder
* Conduct Disorder
internalising disorders
- Separation Anxiety Disorder
- Selective Mutism
- Phobias
- OCD
- Depression
- Adjustment Disorders
- PTSD
Disorders of Basic Functions
- Sleep Disorders
- Nightmare
- Sleep terrors
- Eating Disorders
- Pica
- ARFID
- Elimination Disorders
- Enuresis
- Encopresis
Neurodevelopmental disorders
- Intellectual Impairment
- Autism Spectrum Disorders
- Attention DeficitHyperactivity Disorder
- Learning Disorders
- Tic Disorders
Disorders of care
- Reactive Attachment Disorder
* Disinhibited Social Engagement Disorders
Core features of externalising disorders
Rule violations are one the core features of
externalizing disorders –
determining the seriousness of rule breaking in externalising disorders
seriousness of rule breaking is considered in terms of frequency, intensity, pervasiveness and developmental norms
when are rule violations more of a problem in externalising disorders?
More of a problem when it is part of a syndrome or cluster of problems, rather than when it is an isolated symptom
Age and rule violating in externalising disorders
Children with externalizing disorders, typically break these rules at a younger age than is expected normally (e.g. primary school student experimenting with
drugs/alcohol )
rule breaking as a distinction between ODD and CD
The severity of the rule breaking is one key distinction between ODD and CD
Anger and aggression as a feature of externalising disorders
• Frequently angry – may be losing temper or becoming aggressive • Physical aggression • Verbal aggression/hostility • Criminal behaviours • Argumentativeness • Intent? - Intentional aggression is often considered to be more indicative of pathology
Oppositional Defiant Disorder Criteria
Angry/irritable mood
vindictiveness
argumentative/defiant behaviour
Angry/Irritable Mood criteria of ODD
- Often loses temper
- Touchy/easily annoyed
- Angry and resentful
argumentative/defiant behaviour criteria of ODD
- Often argues with authority figures or adults
- Actively defies or refuses to comply with requests from adults
- Deliberately annoys others
- Often blames others for mistakes or behaviour
Vindictiveness as a criteria of ODD
Spiteful or vindictive at least twice in 6 months
Conduct Disorder Criteria
aggression to people and animals
deceitfulness and theft
destruction of property
serious rule violations
aggression to people and animals as a criteria for CD
- Bullies, threatens or intimidates
- Initiates physical fights
- Used a weapon
- Cruelty to people
- Cruelty to animals
- Stolen while confronting a victim
- Forced someone into sexual activity
deceitfulness and theft as a criteria for CD
- Broken into someone’s house, building or car
- Lying to obtain goods/favours (conning)
- Stolen without confronting a victim (e.g. shoplifting)
destruction of property as a criteria for CD
- Deliberate fire setting with intent to cause damage
* Destruction of property
serious rule violations as a criteria for CD
- Stays out at night before 13 years of age
- Run away from home overnight
- Often truant from school before age 13
Life course Persistent Antisocial Behaviour
Some view that ODD, CD and Antisocial PD are
expressions of the same behaviour at different stages of development
• Is this too deterministic?
• What impact might this view have on
intervention?
Family adversity risk factors of ODD and CD
– Low income – overcrowding in the home – maternal depression – parental antisocial behaviour – conflict between the parents – removal of the child from the home The risk did not increase substantially when only one risk factor was present, however it increased fourfold when 2 factors were present and further again with more factors
Social/Familial Risk Factors
• 4 Parenting approaches classified based on levels of warmth and discipline
• Children with serious conduct problems more likely to have parents
who are uninvolved/indifferent
Social/Familial Factors from a behavioural perspective
“Negative attention”
– Negative attention (e.g. being in trouble) is better than no attention
– Reinforced for doing the wrong thing – positive reinforcement (attention) increases likelihood of future misbehaviour
Social/Familial Factors from a relational perspective
– Replace “attention-seeking” with “connection-seeking”
– Children are reliant on parents to have their needs met
– If they are unable to connect and receive warmth, care and affection (an essential need), they will seek it out some form of response
Inconsistent expectations as a risk factor of ODD and CD
- Unpredictability in expectations of behaviour and discipline
- Frequent rule changes
- Differences in expectations between caregivers/contexts
- One caregiver may undermine the other (sometimes inadvertently)
Angry or aggressive punishment as a risk factor for ODD and CD
- Physical punishment
- Threat based parenting
- Use of hostility and anger to control
Relational risk factors
• Attachment insecurity and disorganisation in early childhood predict behaviour problems in later childhood and adolescence
• Attachment disorganisation is associated with highest levels of externalising problems (Lecompte & Moss, 2014; Dubois-Comtois, Moss, Cyr & Pascuzzo, 2013)
– Particularly controlling-punitive pattern of disorganisation
Social-cognitive processing biases as a risk factor of ODD and CD
– Children who are exposed to violence, hostility and anger learn to expect violence
– Hostile attribution bias – perceive others are likely to use violence/aggression
– leads to greater tendency to demonstrate aggressive behaviour
– An adaptive response when living in a threatening environment but maladaptive when there is no threat
Behavioural Family Therapy as treatment for ODD
– Goal is to move towards Authoritative parenting
– Teaches parents to be very clear and specific about behavioural expectations, monitor children’s actions closely, and systematically rewarding positive behaviours while ignoring or mildly punishing poor behaviour
– Punishment strategies should be firm but not angry, and rewards should far outweigh punishment
– Should also emphasise warmth, positive connectedness, shared time
effectiveness of BFT treatments for ODD
Research supports the short term effectiveness but long term outcomes are less certain and benefits are usually limited to those under the age of 12
– Parents are often stressed and live in adverse circumstances making it harder to implement
– BFT is less effective when parents are unhappily married, depressed, substance abusers, harsh/ critical with their children
– Treatment is more effective when parents get help to cope with their own stress
Attachment focused interventions as treatment for ODD
- Not typically studied in terms of particular disorders but results measured in terms of attachment security
- Relational focus – the caregiver-child relationship becomes the client
- Understanding the central dyadic problem
- Focus on promoting securogenic interactions between parent and child
- Increase the parent’s understanding of the child’s behaviour, and what they are communicating in terms of their needs
- Increase parent’s capacity to see and respond to these needs
- Increase parent’s awareness of how their own mental states/experiences impact their responses
- Reduce the reactivity to these states
- Many different models employ these princip
Multisystemic therapy as treatment for CD
– An intensive family and community based treatment
– Availability of staff 24/7 – intensive sessions, high frequency (often daily)
– Coordination between systems (e.g. justice, education, mental health)
– Target multiple factors contributing to the problem
• Housing
• Employment
• Schooling
• Parenting factors
• Mental health
Internalising Disorders
- Characterised by fears, anxiety, sadness and social withdrawal
- DSM 5 does not separate these out
Identification of Depression in Childhood/Adolescence
Can be hard to identify – adults seem to systematically underestimate the experience of depression among children and adolescents
• May appear as social withdrawal, statements about self worth, somatic complaints, irritability
Criteria for Depression in childhood/adolescence
– In children and adolescents, “depressed mood” can be an irritable mood.
– Failure to make expected weight gain can be considered as indicative of weight loss/change in appetite
The effect of parent’s depression on child prevalence
No correlation between parents’ and children’s’ ratings on a measure of depression (Kazdin, French & Unis, 1983)
– Children’s ratings usually characterized internal hopelessness, low self-esteem and internal attributions of negative events, whereas parents described external behaviour problems and disruption
Rates of Depression in childhood/adolescence
- Rates of depression increase dramatically in adolescence
- 35% of young women and 19% of young men suffer from at least 1 major depressive episode before age 19
- Up to 30% have some elevated depressive symptomatology at any time – may be subclinical, but increases risk for future episodes
