Ch 13 (lesson 16): childhood disorders Flashcards
disorders of Childhood
- attention deficit disorder
- conduct disorder
- depression and anxiety disorders
- learning disability
- communication disorders
- motor disorders
- intellectual development disorder
- autism spectrum disorder
Developmental psychopathology
area of psychopathology that studies disorders within context of normal child development
relationship btwn child and adult psychopathology
- some disorders are unique to children
- eg: separation anxiety disorder
- some disorders are primarily childhood disorders, but may continue into adulthood
- eg: adhd
- some disorders are present in children and adults
- eg: depression
symptoms can be quite different in adulthood than in childhood
DSM-5 childhood disorders- 2 chapters
- Neurodevelopmental disorders
- Disruptive, Impulse Control, and Conduct disorder
changes in DSM-5 from DSM-IV-TR
- name changes
- eg: mental retardation –> intellectual developmental disorder
- DSM-5 combined some disorders
- eg: autistic disorder, aspergers, childhood disintegrative disorder, and pervasive developmental disorder —> combined into autism spectrum disorder
the more prevalent childhood disorders are often divided into two domains:
- Externalizing disorders (outward-directed behavior such as aggressive, noncompliant, over-active, impulsive)
- Internalizing disorders (inward focused experiences/ behavior like depression, social withdrawel, anxiety)
Externalizing disorders
contains:
- ADHD
- conduct disorder
- oppositional defiant disorder
characterized by:
- outward-directed
- aggressiveness
- noncompliance
- over-activity
- impulsiveness
- more common in boys
internalizing disorders
contains
- childhood anxiety
- mood disorders
characterized by
- inward behaviors and experiences
- depression
- anxiety
- social withdrawal
- more common in girls
Attention Deficit/Hyperactivity Disorder
can include:
- Excessive levels of activity (Hyperactivity)
- fidgeting, squirming, running around when inappropriate, incessant talking
- Distractibility + difficulty concentration
- careless mistakes, cannot follow instructions, forgetful
DSM-5 criteria of AD/HD
either A or B:
- A. 6+ manifestations of inattention at least 6 mo
- eg: careless mistakes, not listening well, not following instructions, distraction, forgetful
- B. 6+ manifestations of hyperactivity-impulsivity at least 6 mo
- eg fidgeting, running about, “driven by a motor”, interrupting/intruding, incessant talking
- some of the above present b4 age 12
- present in 2+ settings
- sig impairment
- 17+, only 5 signs
ADHD presentation specifiers
- predominantly inattentive
- predominantly hyperactive-impulsive
- combination of both presentations
ADHD or Conduct Disorder? (differential diagnosis)
adhd:
- more off-task behavior, cog and achievement deficits
conduct disorder:
- more aggressive, act out in most settings, antisocial parents, family hostility
if have both:
- worst features of each manifest
- most serious antisocial behavior
- most likely rejected by peers
- poorest academic acheivement
- poorest prognosis
prevalence, gender differences, comorbidity, beyond childhood
- comorbidity: anxiety + depression (30% adhd have)
- prevalence- 3-7%, now 8-11%
- more common in boys (maybe due to boys more externalized/ aggressive)
- persistence beyond childhood:
- 65%- 85% still exhibit symptoms
- 60% adults continue to meet criteria in remission
girls w ADHD
Hinshaw et al- large diverse study on girls w adhd
- girls tended to be combined or inattentive type
combined type had:
- more disruptive behavior than inattentive type
- more comorbid diagnoses of conduct disorder or oppositional defiant disorder than w/out ADHD
- viewed more neg by peers than inattentive or w/out ADHD
Inattentive type:
- viewed more neg than girls w/out ADHD
- exhibit neurological deficits (poor planning, prob solving)
- have symptoms of EDs and Substance abuse by adolescence
Etiology of ADHD- Genetic factors
- adoption and twin studies
- heritability estimates 70-80%
- two dopamine genes implicated *
- DRD4 (dopamine receptor gene)
- DAT1 (dopamine transporter gene)
- *either gene assoc. w/ increased risk ONLY when prenatal maternal nicotine or alc use is present
not one single gene, many genes interacting w eachother and enviro
Etiology of ADHD- Neurobiological factors
- Dopaminergic areas smaller in kids w ADHD
- frontal lobes, caudate neucleus, globus pallidus
- Poor performance on tests of frontal lobe function (exec functioning, impulsivity)
Etiology ADHD- Prenatal + Perinatal factors
- Low birth weight
- can be mitigated by later maternal warmth
- maternal tobacco and alc use
- exposure to tobacco in utero
- may damage dopaminergic system resulting in behavioral disinhibition
etiology of ADHD- Enviornmental toxins
- Limited evidence that food additives/ coloring may have small impact on hyperactive behavior
- no evidence that refined sugar causes ADHD
Etiology of ADHD- parent-child relationships
- parents give more commands/ have more neg interactions
- family factors-
- interact w genetic and neurobiological factors
- contribute to or maintain ADHD behaviors, not cause them
treatment of ADHD- meds
Stimulants (ritalin, adderall, concerta, strattera)
- reduce disruptive behavior
- improve interactions
- improve goal-directed behavior/ concentration
- reduce aggression
side effects:
- loss of appetite
- weight
- sleep probs
Treatment ADHD- meds plus behavioral treatment
- slightly better than meds alone
- improved social skills, meds alone don’t
- 3 year followup found superior benefits of meds by themselves didn’t persist
treatment of ADHD- behavioral/ psych treatment
psych treatment:
- parental training
- change in classroom mgmt
- behavior monitoring and reinforcement of approp. behavior
treatment of adhd- behavior treatment- classroom structure
supportive classroom structure:
- brief assignments
- immediate feedback
- task-focused style
- breaks for exercise
Conduct Disorder (CD)
- pattern of engaging in behaviors that violate social norms/ rights of others/ often illegal
- aggression
- cruelty towards ppl/animals
- damaging property
- lying
- stealing
- vandalism
- oft w viciousness, callousness, lack of remourse
Oppositional Defiant Disorder (ODD)
- ODD behaviors don’t meet criteria for CD (esp extreme physical aggressiveness) but displays pattern of defiant behavior
- argumentative
- loses temper
- lack of compliance
- deliberately aggravates others
- Hostile, vindictive, spiteful, or touchy
- blames thers
- comorbid w ADHD, learning and communication disorders
- disruptive behavior of ODD more deliberate than ADHD
- Most often diagnosed in boys, but may be as prevalent in girls
- 8.3% prevalence
Intermittent explosive disorder (IED)
- recurrent verbal or physical aggressive outbursts that are fare out of proportion
- diff from conduct disorder, because the outburts are impulsive, not preplanned
DSM-5 criteria for Conduct disorder
- repetitive and persistent behavior pattern that violates basic rights of others/ social norms
- 3+ in the last 12 mo, atleast 1 in last 6 mo
- A. aggression to ppl or animals
- B. destruction of property
- C. deceitfulness or theft
- D. serious violation of rules
- significant impairment is social, academic, occupational func.
- includes a “limited prosocial emotions” diagnostic specifier for kids w callous, unemotional traits
Conduct disorder, comorbidity
- substance abuse common
- unclear whether in precedes or is concomitant
- Comorbid w anxiety and depression
- 14-45%
- CD precedes anxiety and depression (but phobias and social anxiety precedes it)
Prevalence of conduct disorder
- 7% preschool children exhibit symptoms
- boys 4-16%
- girls 1.2-9%
Conduct disorder-2 types
- Life-course-persistent pattern of antisocial behavior
- 10-15x more likely in boys
- Life-course-persistent pattern of antisocial behavior
- Adolescence-limited
- maturity gap btwn physical maturation and rewarding adult behaviors
- Adolescence-limited
follow up longitudinal studies of life-course-persistent type show more severe probs into adulthood including:
- academic underacheivement
- neurophyscological
- ADHD
- family psychopathology
- poorer physical health
- lower SES
- violent behaviors
Etiology of Conduct disorder- factors
- social factors
- psychological factors
- neurobiological factors
interaction between all three to develop conduct disorder
Etiology of CD- Genetic factors
- Heritability likely plays a part
- twin study mixed results
- genetics played role in rule-breaking behavior in wealthy areas, not as much in poor areas
- adoption studies focused on criminal behavior, not conduct disorder
- meta-analysis of twin + adopt studies suggest 40-50% heritability of antisocial behavior
- genetics stronger influence when behaviors begin in childhood (rather than adolescence)
- genetics and environment-
- abuse as child PLUS low MAOA activity most likely to develop CD
Etiology of CD- Neurobiological factors
- poor verbal skills
- difficulty w executive functioning
- Low IQ
- Lower levels of resting skin conductance and heart rate– suggests lower arousal levels (less anxious of doing bad/getting caught)
txtbook adds
- those w callous/ unemotional traits: deficits in regions that support emotion, especially empathy
- amygdala, ventral striatum, prefrontal cortex
Etiology of CD- Psych factors
- deficient moral development, lack of remorse
- modeling and reinforcement of aggressive behavior
- harsh and inconsistent parenting
- lack of parental monitoring
- Cognitive bias: neutral acts by others perceived as hostile
dodge’s cognitive theory of aggression- CD
—> ambiguous act interp. as hostile –>
aggression toward others –>
retaliation from others –>
further angry aggression towards others –>
Etiology of CD: Peers, Sociocultural
- Peer influences associated w CD
- Rejection by peers
- Affiliation w deviant peers
-Sociocultural factors
- poverty
- urban enviro
- higher rates of delinq. acts among PoC males linked to living in poorer neighborhoods rather than race
txtbook adds-
- social selection view: kids w CD choose to be assoc. w likeminded peers, thus cont. antisocial behavior
- social influence view: being around devient peers helps initiate antisocial behavior
both correct
treatment of Conduct disorder- Family Interventions
Family Interventions
- Family check-ups (FCU) assoc. w less disruptive behavior
- Parental mgmt training (PMT)
- teach parents to reward prosocial behavior
- positive reinforcement for pos behaviors, time-out and loss of privileges for aggressive or antisocial behavior
treatment of Conduct disorder- Multisystemic therapy (MST)
Multisystemic therapy (MST)
- Deliver intensive community-based services
- incorporates behavioral, cog, family-systems, and case-mgmt techniques
- emphasizes individual and family strenghs
- identifying social context for the conduct prob
- using present-focused and action-oriented interventions
- interventions that require daily/weekly efforts by family members
treatment is provided in homes, schools, local recreational centers to maximize chances that improvement will carry into the daily lives of children/their familiies
treatment of Conduct disorder- prevention program
types- Head start, Fast Track
goal: to prevent conduct disorder before it develops
- Fast track- impressive reductions in later psychopathology w brief intervention
Depression and Anxiety in children/adolescents- Comorbidity
- often co-occur w ADHD and CD
- also co-occur w eachother
- early research suggested depression and anxiety can be distinguished from each other the same way as in adults
- depression: high neg affect, low pos affect
- anxiety: high neg affect but not low levels of pos affect
- more recent research calls this into question
Symptoms of Depression shared by children, adolescents, and adults
- depressed mood
- inability to experience pleasure
- fatigue
- probs concentrating
- suicidal ideation
Symptoms of Depression specific to children and adolescents
- higher rates of suicide attempts
- higher rates of guilt
- lower rates of
- early morning awakening
- early morning depression
- loss of appetite
- weight loss
prevalence of depression in children/ adolescents
- 1% preschoolers
- 2-3% under 12
- 15.9% adolescent girls, 7.7% adolescent boys
Etiology of Depression- Genetic factors
- Having depressed parents = 4x increase in risk of developing depression in childhood
- there are risks of this involving genes and the environment
- gene-enviro interaction- ppl w short allele of serotonin transporter gene AND sig interpersonal stressful life events more likely to have depressive episode
-interpersonal factor esp. important in adolescent girls
Etiology of Depression- Early adversity/ life events
kids w depression (15-20) more likely to have experienced early adversity and neg life events
Etiology of Depression- Family and relationship factors
- a parent who is depressed
- parental rejection modestly assoc. w depression
- children w depression and their parents interact in negative ways
- less warmth
- more hostility
Etiology of depression- Cog distortions and neg attributional style
- cog distortions and neg attributional style, hopelessness theory
- stable attributional style
- develops by early adolescence
- by 8th/9th grade attributional style serves as cog diathesis for depression
Etiology of Depression- Brain factors
- HPA axis and release of cortisol
- cortisol levels on awakening predicted onset of of MDD
- cortisol in depressed ppl assoc. w smaller hippocampus volume
- grew more slowly btwn early + mid adolescents for those who developed depression
treatment of depression- meds
- SSRIs more effective than tricyclics
- Meta-analysis show medications most effective for anxiety other than OCD
- less effective for depression and OCD
Concerns abt meds:
- side effects including diarrhea, nausea, sleep probs, agitation
- possibility of increased risk of suicide attempts
treatment of depression- psychotherapy
- IPT (interpersonal therapy)
- Focuses on peer pressures, transition to adulthood, and issues related to independence
- CBT
- More effective for white adolescents, those w good coping skills already, and those w recurrent depression
-Psychotherapy generally only modestly effective w kids and adolescents
- CBT no better than other therapies
treatment of depression- two types of preventative interventions
- selective prevention programs
- target kids based on family and enviro risk factors
- universal prevention programs
- targeted towards large groups, provide info about depression
Anxiety in Children and Adolescents
- Anxiety disorder
- more severe and persistent worry
- must interfere w functioning
- most childhood fears disappear but adults w anxiety disorders report feeling anxious as children
- unlike adults, kids don’t need to regard their anxiety/ fear as unreasonablw
- 3-5% prevalence
Separation Anxiety Disorder
- worry about parental or personal safety when away from parents
- typically observed when child begins school
- associated w development of other internalizing and externalizing disorders later
social anxiety disorder
- extremely shy and quiet
- selective mutism
- refusal to speak in unfamiliar social setting
- 1% prevalence
- Etiology
- often overestimation of threat
- underestimation of coping ability
- poor social skills
PTSD
- Exposure to trauma
- chronic physical or sexual abuse
- community violence
- natural disasters
- symptom categories
- flashbacks, nightmares, intrusice thoughts
- avoidance
- neg cognitions and moods
- hyperarousal and vigilance
differ from adults:
- may exhibit agitation instead of fear/hopelessness
OCD
- prevalence 1-4%, more common in boys
- symptoms similar to those in adults
- most common obsessions:
- contamination from dirt/germs
- aggression
- thoughts about sex/religion (more common in adolescence)
Etiology of anxiety disorders- Genetics
- Heritability 29-50%
- Genetics play stronger role in separation anxiety in context of more neg life events
Etiology of anxiety disorder- parenting, attachment, etc
- parenting plays small role
- 4% variance
- parental control and overprotectiveness more so than parental rejection
- emotion regulation and attachment probs also play a role
- overestimate danger, underestimate ability to cope
- perception of lack of acceptance/ being bullied risk factor in anxiety and social phobia
etiology of anxiety disorders- PTSD
- family stress and coping style
- past experience w trauma
- parent reactions to trauma can help lessen child’s distress
treatment of Anxiety Disorders - Exposure
- Exposure to feared object
- reward approach behavior
CBT Kendall’s Coping Cat
- shows to be effective in two randomized clinical trials
- 7-13
- Cognitive restructuring
- develop new ways to think about fears
- Psychoeducation
- Modeling and exposure
- skills training and practice
- relapse prevention
- family involved in treatment
txtbook:
Coping Cat focuses on:
- confrontation of fears
- development of new ways to think about fears
- exposure to feared situations
- relapse prevention
treatment of anxiety- OCD
- CBT + Zoloft
Specific Learning Disorder (Learning Disability?- slide show)
- Evidence of inadequate development in specific area of academic, language, speech, or motor skills
- not due to intellectual disability, autism, physical disorder, or deficient educational opportunities
- usually average or above avg intelligence
- often identified and treated in school
- reading disorders more common in boys
DSM-5 criteria for Specific learning disorder
- Difficulties in learning basic academic skills (reading, math, or writing) inconsistent w age/ schooling/intelligence
- persists atleast 6 mo
- sig intereference w academic achievement or activities
specifiers of Specific Learning Disorder
- Reading impairment (Dyslexia) (5-15%)
- written expression impairment
- math impairment (dyscalculia)
Communication DIsorders
- Speech Sound disorder (formerly phonological disorder)
- Childhood-onset Fluency Disorder (formerly stuttering)
- Social (pragmatic) communication Disordr
-Language Disorder
Speech Sound Disorder
formerly phonological disorder
- correct comprehension and sufficient vocabulary use
- unclear speech and improper articulation
Childhood-onset fluency Disorder (stuttering)
Disturbance in verbal fluency characterized by one or more of the following speech patterns:
- frequent repetitions or prolongation of sounds
- long pauses btwn words
- substituting easy words for thos that are difficult to articulate
- repeating whole words
Social (pragmatic) communication disorder
- persistent difficulty with verbal + non-verbal communication
- limits effective communication, social relationships, academic achievement, or occupational performance
- not explained by low cog ability
- must be present in early childhood
language disorder
- Persistent deficits in comprehension production of language
- substantially below age level
- beginning in early development period, not due to other disorders/ conditions
Motor Disoders
- Developmental Coordination Disorder (fka motor skills disorder
- Marked impairment in dev. of motor coord
- repetitive, seemingly purposeless, oftem rhythimical motor behavior
- interferes w normal activities
- onset in “early dev. periods”
Sterotypic Movement Disorder
Involves one or more vocal and multiple motor tics (sudden rapid movement/vocalization)
- onset before 18
tourrette’s Disorder
at least on motor or vocal tic, not both
- must be present for > 1 year
- onset before 18
Persistent (chronic) motor or vocal tic disorder
one or more motor and or vocal tics, present < 1 year
- onset before 18
provisional tic disorder
tic disorder symptoms causeing distress/ impairment but not meeting other criteria
Other Specified tic disorder
or “Unspecified tic disorder”, if reason is unspecified
Etiology of Dyslexia- Genetic Factors
- Evidence from family and twin studies show heritable component
- genes for dyslexia are genes associated w typical reading abilities (generalist genes)
Etiology of Dyslexia- Problems in language processing
- deficient PHONOLOGICAL AWARENESS
- inadequate left temporal, parietal, occipital activation
- phonological awareness : includes perceiving spoken language and its relation to printed words, detedcting syllables, recognizing rhyme
- difficulties in speech perception
- difficulties in analysis of sounds and their relationship to printed words
- difficulty recognizing rhyme and alliteration
- problems naming familiar objects rapidly
- delays learning syntactic rules
Parts of brain implicated in dyslexia
- frontal lobe
- temporal lobe
- parietal
- sometimes occipital too
Etiology of Dyscalculia- Genetic and biological
- Evidence from twin studies suggest common genetic factors underlie both reading and math defecits
- intraparietal sulcus implicated
- has different cog deficits from dyslexia
- kids w only dyscalculia don’t have deficits in phonological awareness
treatment of reading/writing disorder
- mulitsensory instruction in listening, speaking, writing skills
- readiness skills in younger kids in preparation for learning to read
- phonics instruction
treatment of communication disorders
- fast forWard
- computer games and audiotapes that slow speech sounds
Intellectual Disability (Intellectual Developmental Disorder?)
- fka mental retardation in DSM-IV-TR
- not preferred due to stigma
- followed the guidelines of American Association on Intellectual and Developmental Disabilities
AAIDD definition of Intellectual Disability:
- characterized by sig limitations both in intellectual functioning and in adaptive behavior as expressed in conceptual , social and practical adaptive skills
- began before 18
- Five assumptions Essential to the App. of the definition
- limitations in func considered w/in context of community enviro typical of person’s age/peers/culture
- valid assess. considers cult. and linguistic diversity as well as differences in communication/sensory/motor/ behavioral factors
- w/in indvl limitations coexist w strengths
- purpose of describing limitations is to develop profile of needed supports
- w aprop. personalized supoorts over sustained period, life func of person w intellec. disability generally will improve
Intellectual Disability- DSM-5
- Intellectual deficit of 2 or more std deviation in IQ below the avg score for age + culture- typically below 70
- sig deficits in adaptive func relative to age + culture in 1+ area:
- communication
- social participation
- work or school
- independence and home/community
- requiring need for support at school/work/ind. life
- onset during development
Intellectual disability- Dsm-5 changes
- explicit recog that IQ score consirdered w/in cultural context
- adaptive func also assessed/ considered w/in age/culture
- no longer distinguish mild, mod, severe ID based on IQ scores alone
Etiology of Intellectual Disability- neurobiological factors
- Down syndrome
- chromosomal trisomy 21- extra copy of chromosome 21 ( 47 instead of 46)
- Fragile-X syndrome
- mutation in fMR1 gene on X chromosome
- Recessive-gene disease
- Phenylketonuria (PKU)
- Maternal infectious disease, esp during 1st trimester
- cytomegalovirus, toxoplasmosis, rubella, herpes simplex, HIV, syphilis
- lead/mercury poisoning
Treatment of Intellectual Disability- residential, behavioral
- Residential treatment
- small- med sized community residences
- Behavioral treatments
- language, social, motor skills training
- method of successive approximation (shaping) to teach basic self-care skills for severe cases (holding a spoon, toilet)
- applied behavioral analysis- applying behavioral learning theory to learn new skills
- Cognitive treatments
- problem-solving strategies
- computer-assisted instruction
Autism Spectrum Disorder- DSM-5 vs IV-TR
- DSM-5 combines multiple diagnoses into Autism Spectrum disorder:
- Autistic disorder
- Aspergers Disorder
- pervasive developmental disorder not otherwise specified
- childhood disintegrative disorder
- research didn’t support distinctive categories
- share similar clinical features- vary only in severity
- DSM_5 includes clinical specifiers relating to severity and extent of language impairment
`DSM-5 criteria for Autism spectrum disorder
total of 6+ items from A, B, and C below w at least 2 from A, 1 each from B and C
A. Deficits in Social communication/interactions:
- deficits in nonverbal behavior (eye contact, facial expression, body lang)
- deficits in dev of peer relationships
- deficits in social/emotional reciprocity (not approaching others, not having back-and-forth, reduced sharing of interests/emotions)
B. Restricted, repetitive behavior patterns/interests/activities
- stereotyped or repetitive speech motor movements, use of objects
- excessive adherence to routines, rituals in verbal/nonverbal behavior, resistance to change
- v restricted interests abnormal in focus, such as parts of objects
- hyper or hypo-reactivity to sensory input or unusual interest in sensory enviro
C. onset in early childhood
D. symptoms limit and impair functioning
characteristics of autism
- profound problems w social world
- theory of mind
- communication deficits
- repetitive and ritualistic acts
autism - profound problems w social world
- rarely approached by others, may look through people
- problems in joint attention
- pay attention to different parts of face- neglect eye contact
- this likely contributes to difficulties in perceiving emotion in other people
autism- theory of mind
theory of mind
- understanding that other people have different desires, beliefs, intentions, emotions
- crucial for understanding and successfully engaging in social interaction
- typically develops btwn 2.5-5 yrs
- children w ASD seem not to achieve this developmental milestone- atleast to same degree
autism-communication deficits
- kids w ASD have evidence of early language disturbances
- Echolalia: immediate or delayed repetition of what was heard
- pronoun reversal
- literal use of words
ASD- repetitive and ritualistic acts
- extremely upset when routine altered
- engage in obsessional play
- engage in ritualistic body movements
- become attached to inanimate objects
ASD- comorbidity, prevalence, prognosis
Comorbidity:
- IQ> 70 common
- kids w intellectual disability score poorly on all parts of IQ test, ASD score poorly on subtests related to language, tasks requiring abstract thought, symbolism, sequential logic
- anxiety
- specific learning disorder
prevalence
- 1/110 kids
- found in all SES, ethnic, racial groups
- diagnosis of ASD remarkably stable
prognosis
- kids w higher IQ who learn to speak b4 6 have best outcomes
Etiology of ASD- genetic
- heritability: .80
- twin studies: 47-90% for MZ twins, 0-20% for DZ
- genetic flaw- deletion of chromosome 16
Etiology ASD- Neurobiological factors
- Brain size
- although normal size at birth, brains of autistic adults/kids are bigger than normal
- pruning of neurons not occurring
-“overgrown” areas include frontal, temporal, cerebellar - linked to language, social, emotional func.
-abnormally sized amygdalae predicted more difficulty in social behavior/communication
Treatment of ASD
- Psych treatments more promising than drugs
- Earlier treatment = better outcomes
Behavioral treatments:
- Intensive Operant Conditioning (dramatic, encouraging results)
- using reinforces to teach kids appropriate responses, motor behavior etc.
- Parent training and education
- Pivotal Response Treatment
- focus on increasing motivation and responsiveness rather than on discrete behaviors
- Joint Attention Intervention and symbolic play used to improve attention and expressive skills
treatment for ASD- meds
Haloperidol (Haldol)
- antipsychotic
- reduces aggression and motor behavior
- doesn’t improve language and interpersonal relationships
