Adolescence & early adulthood (02.03.2020) Flashcards
What is adolescence?
- phase between childhood &
adulthood - Pubertal development may be start of adolescence
- expanding to 10-25?
Adulthood definition
- Adulthood: legally, culturally variable
* UN: children < 18 years
4 main categories of changes that happen from childhood to adulthood?
- Cognitive/Emotional
- Peers
- Biology
- Famlily
Cognitive/emotional changes that occur in the transition form childhood to adulthood?
- emotional change
- Reasoning - more abstract
- Greater knowledge / awareness of world
- Identity – of self, family, ethnicity
Peer changes that occur in the transition form childhood to adulthood?
- Peer activities / confiding
- Sexual relationships
- Peer group influences
values and behaviour (pro / anti -social)
Biological changes that occur in the transition form childhood to adulthood?
- puberty/endocrine changes - secondary physical growth
Family changes that occur in the transition form childhood to adulthood?
- challenging rules
- discipline needs reasoning
- less confiding and intimacy in parents.
Adrenarche
- precursor of puberty
Starts:
• Females: 6-9 years
• Males: 7-10 years
- Rise in adrenal 19- carbon steroid production, dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEAS).
- Manifests clinically as the appearance of axillary and pubic hair, usually about age 8.
- Role uncertain -?Precursor to puberty
Endocrine control of puberty and adrenarche
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Female and Male age difference in puberty
- girls usually 2 years ealrier
- in females the growth spurt is an early event in puberty and in males it is a late event.
Tanner stages of Puberty
- wide ranges for things to occur
- different for boys and girls
- looks at hair (pubic and armpit) as well as development of secondary genital characteristcs.)
How has the age of puberty changed over the years?
- decreased (17 -> 12)
- due to better nutrition
- due to obesity
Psychological changes
- Cognition e.g. morality, higher levels of cognitive thinking
- Identity (incl. gender identlty, religious beliefs)
- Increased self-awareness
- Affect expression and regulation
Social Changes in adolescence
• Family - parental surveillance, confiding
- Peers
- Increased importance
- More complex & hierarchical
- More sensitive to acceptance & rejection
- Romantic relationships
- Social role – education, occupation, etc
=> these are often factors that contribute to mental health problems.
Wider Social Influences
- School
- Work
- Culture (“teen” subculture; migration/culture)
- now also social media (re less sleep, exercise; cyberbullying, not time spent but how harmful it is is critical)
- Social influences eg unemployment, poverty/affluence, housing, neighbourhood effects
Brain development In adolescence
- pruning
- Grey, white & dopaminergic pathway changes increase vulnerability to risk taking
- there is a mismatch between….. rewatch
- reward driven activities are more dominant then the regulatory, cognitive control integration (the risk assessment is wrong, they do not take more risks)
What is the link with mental health?
- in young children
- in adolescence a majority of mental health problems begin to manifest
Self awareness/comparison to others
- girls are far more vulnerable to social media effects then boys (comparing themselves to others)
- mental health disorders make it worse
Name some disorders that commonly start in adolescence
- Anorexia nervosa
- Mood disorders
- Antisocial behaviour
When do emotional disorders usually show?
17-19 years of age mainly
Anorexia nervosa
- A. Restriction of energy intake relative to requirements leading to significantly low body weight in the context of age, sex, developmental trajectory and physical health.
- B. Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain.
- C. Disturbance in experience of weight/shape, undue influence of wt/shape on self-evaluation, or persistent lack of recognition of seriousness of low body weight
- D.Amenorrhoea NOT in DSM-5!
- Subtypes: Restrictingvs.Binge-eating/Purge
This is the only eating disorder where weight is a category.
What is the biggest risk factor for eating disorders?
- being female (boys have the same feelings but are less likely to act on them (I,e, diet)
- males tend to want more muscle weight
- after that, dieting behaviour.
Prediction of Eating Problems
• Adolescent eating problems (symptoms) associated with:
- Earlier pubertal maturation, & higher body fat
- Concurrent psychological problem e.g. depression (negative feelings, hating oneself, others, the world)
- Poor body image
- Specific cognitive phenotypes
Neuropsychology of Anorexia Nervosa Executive Function deficits
- Association anorexia nervosa and ASD
- Weak central coherence in ED’s
- Global processing difficulties [review]
- Poorer global processing =>Weak central coherence (2 tests for central coherence shown; you don’t really see the bigger picture)
- ## difficult to distinguish the effects of starvation and predisposing chatacteristc traits before
Treatment for eating disorders
…..most young people who have parental/carer support with AN should be offered AN focussed family therapy (FT-AN or FBT) in conjoint, separated or multifamily format as
- first line treatment on an outpatient or
- if too sick, day patient basis, following a brief (<3 week admission) for medical stabilisation if needed
- from NICE guidelines
Prognosis of eating disorders
- About 40% respond to first line interventions alone
- Up to 80% recover overall within 5 years
- Around 30% develop binge eating at some point during recovery (different prognosis)
- Around 20% run a more chronic course
- Mortality e.g. at 20 years: 5-10% of which 1 in 5 is suicide (this is higher than e.g. diabetes)
- Duration of illness predicts recovery therefore adolescent onset better prognosis because earlier help seeking
- Early treatment response is the only robust predictor of outcome but more extreme social difficulties are a factor
Depression in adolescence
- the more symptoms the more impairment
Symptoms in depression
Core:
• Low mood/sadness
• Loss of enjoyment (anhedonia)
• Loss of energy
- Changes to:
- Appetite / Weight-up /down )
- Sleep-(up/down)
- Concentration
- Thoughts: Pessimism, Guilt
- Self esteem/confidence
- Libido
- Psychomotor agitation/retardation
- Self harm / Suicide
Depression - clinical threshold
- Symptoms pervasive (e.g. all the time and not only in a specific environment)
- Impairing
- Present for at least 2 weeks
- Symptoms and impairment -> distinguish mild, moderate & severe
Types of depression
- Depressive episode (~ 50% recur) -> single episode
- Recurrent depression (with times where it gets better)
- Dysthymia (persistent mild depression)
- Bipolar depression
- Psychotic depression
- Atypical depression
- Seasonal affective disorder (SAD)
- ?Inflammatory subtype
Depression associated problems
• Increased risk of self-harm
• Association with anxiety disorders; eating disorders [females];
conduct problems; substance misuse
• Familial aggregation (genetic and learning)
Pre-pubertal Depression
2 main types:
1st:
• More common presentation is with co-morbid behavioural problems, parental criminality, parental substance abuse and family discord
• Course of this resembles that of children with conduct disorder
• No increased risk of recurrence in adult life
2nd
• Less common
• highly familial with multigenerational loading for depression
• High rates of anxiety and bipolar disorder and
• Recurrences of depression in adolescence and adulthood
Adolescent Depressive Disorder
- Irritability instead of sadness/low mood Especially in boys
- Somatisation: somatic complaints and social withdrawal are common
- Psychotic symptoms rare before mid-adolescence
Adolescent Depressive Disorder - outcome
- Short term
- High rates of persistence and recurrence (20% in 1 yr)
- Long term
- Significant continuity adolescenceadulthood
- Adolescent Depressive Disorder
- 40-70% recurrence in adulthood
- 2-7x increased risk as an adult
• Impairment relationships/education in adulthood
Dev. changes and vulnerability to depression
Biological changes: genetics, puberty, brain growth
Social changes: peer, mails, social world
Life events: losses
-> these lead to vulnerability to depression (either directly or through psychological/cognitive emotional changes (more advanced and efficient; more intense/fluctuant mood; self concept, autonomy.)
Treatments for depression
Mild depression
• Cognitive behavioural therapy [Individual or group] • Interpersonal psychotherapy for adolescents
• Brief Psychosocial Intervention
Moderate-Severe Depression
• Antidepressants e.g. SSRI’s: fluoxetine • Could be SSRI + CBT
• Combined treatment -> highest rate of symptomatic remission in 37% combined vs 20% fluoxetine alone
Conduct Disorder
(CD) - ICD-10
- Repetitive & persistent (> 6 months) pattern of dis-social, aggressive or defiant behaviour
- Frequency & severity beyond age appropriate norms.
- No sharp dividing line!
Conduct Disorder: behaviours
Oppositional behaviour, defiance Tantrums Excessive levels of fighting or bullying, assault Running away from home Truancy Cruelty to animals Stealing Destructiveness to property Fire-setting
Conduct Disorders: types
- CD confined to the family context
- Unsocialized CD (worst prognosis)
- Socialized CD
- Oppositional CD
- Depressive CD
- Hyperkinetic CD
What is the commonest psychiatric disorder in childhood?
- Conduct Disorder is commonest psychiatric disorder of childhood.
- National Survey of Child Mental Health (2017)
- About one in twenty (4.6%) 5 to 19 year olds had a behavioural disorder, with rates higher in boys (5.8%) than girls (3.4%)
- Increases with age
- More common in urban than rural communities
Anti-social behaviour
• Adolescent-limited
• Life course persistent
Intervention in Conduct Disorder
- Should be targeted at major modifiable risk factors and should begin at an early age
- Managing underlying hyperactivity
- Parenting programmes
- Cognitive problem-solving skills training
- Interventions at school
- Multi-systemic therapy
Prognosis of CD
- 40% of 7 and 8 year olds with CD became recidivist delinquents as teenagers.
- Over 90% of recidivist juvenile delinquents had conduct disorder as children.
- Predictor of
- Antisocial PD in adulthood (~50%)
- Alcoholism & drug dependence
- Unemployment and relationship difficulties
- Intergenerational transmission
- HENCE IMPORTANCE OF PREVENTION!
Summary
- Psychosocial factors mediate the relationship between pubertal development and onset of emotional, behavioural, eating & weight controlling behaviours.
- Biological, temperamental and neuropsychological factors are implicated in vulnerability
- Treatment improves the outcome (v natural history)
What is happening with the incidence of ADHD and Autism?
it is increasing
Developmental mismatch hypothesis
Grey, white & dopaminergic pathway changes increase vulnerability to risk taking
Don’t necessarily take more risks but are less likely to think about the consequences
What is the link of adolescence and mental health?
- 1/10 children ages 5-16 have a diagnosable condition
- 50% of all the mental health problems are established by the age of 14
- 75% of all mental health problems are established by the age of 24
Why is mental health important?
- big impact in global burden of disease
- non-communicable disease
Formulation Framework
Factors:
- Predisposing
- Precipitating (e.g. bullying, relationship problems, puberty, adverse life event, bereavement)
- Perpetuating (e.g. isolation, feeling of control, social media, family, positive reactions to ED)
- Protective
Individual, Biological, Psychological, Systemic
Etiology of anorexia nervosa
- genetic factors and other prenatal factors such as hormones determine traits and cognitive style
- this includes: OPID (obsessionally, perfectionism, Inflexifility, deficits in social cognition) -> this occurs during childhood/ adolescence
- these lead to diet and this starts a vicious cycle:
diet -> weight loss -> starvation induced changes -> increased anxiety, depression and obsessionally -> weight loss…..
- starvation induced changes can lead to chronic illness
- recovery can occur (after weight loss)
- in adolescence there are other things that take place: Brain development, hormones, stressful life events, cultural values.
Prediciton of eating problems
Adolescent eating problems (symptoms) associated with:
• Earlier pubertal maturation, & higher body fat
• Concurrent psychological problem e.g. depression
• Poor body image
• Specific cognitive phenotypes
Neuropsychology of anorexia nervosa
- weak global coherence in anorexia nervosa and other eating disorders
- e.g. cannot find a number in the test with many 9s and you have to find the 8
- lack of global coherence when recreating a complex set of shapes, they see the smaller shapes but not the global picture.
Prognosis in anorexia nervosa
- About 40% respond to first line interventions alone
- Up to 80% recover overall within 5 years
- Around 30% develop binge eating at some point during recovery
- Around 20% run a more chronic course
- Mortality e.g. at 20 years: 5-10% of which 1 in 5 is suicide
- Duration of illness predicts recovery therefore adolescent onset better prognosis because earlier help seeking
- Early treatment response is the only robust predictor of outcome but more extreme social difficulties are a factor
Treatment of anorexia nervosa
…..most young people who have parental/carer support with AN should be offered AN focussed family therapy (FT-AN or FBT) in conjoint, separated or multifamily format as first line treatment on an outpatient or if too sick, day patient basis, following a brief (<3 week admission) for medical stabilisation if needed
