Final Exam Flashcards
DSM classification broadly identifies mood disorders as either:
Unipolar: a single depressive mood experience
Bipolar: involves mania and depression
2 separate categories of mood disorders
Depressive disorders
Bipolar and related disorders
Major depressive disorder (MDD) is defined by the presence of: (8)
- one or more major depressive episodes or irritable mood episodes
- loss of pleasure (anhedonia)
- change in weight or appetite
- sleep problems
- fatigue or loss of energy
- feelings of worthlessness or guilt
- difficulty thinking or concentrating
- thoughts of death or suicidal thoughts and behaviour
DSM diagnostic criteria of MDD
- must have 6 out of 8 symptoms
- symptoms must be present for at least 3 consecutive days and must last for at least 2 weeks
- must cause individual clinically significant stress or impairment
Persistent depressive disorder (dysthymia) diagnostic criteria
- same symptoms of MDD but symptoms are less severe and more chronic
- symptoms must be present for at least 1 year
- must be clinically significant and cause distress or impaired functioning
- along with 2 or more of the following symptoms:
Poor appetite or overeating
Sleep disturbances
Low energy or fatigue
Low self esteem
Difficulty concentrating or making decisions
Feelings of hopelessness
When can MDD appear in children
Depression can start as early as preschool
What is the most prevalent form of affective disorder among children and adolescents?
Major depressive disorder (MDD)
Epidemiology of depression (clinical vs community)
-Clinical sample: rates in children range from 80% MDD
-Community sample: rates in children range from 0.4-2.5%
-Lifetime prevalence rates of diagnosable depressive disorders are 20-30%
-Typically occurs more in females than in males after the age of 12
SES, ethnic, and cultural considerations for depression
- research suggests that lower SES associated with higher rates of depression
- possible influences on income on MDD:
Chronic stress (on mood and physical symptoms of MDD)
Family disruption
Environmental adversities
Racial and ethnic discrimination
Biological influences on depression (genetics- family history of depression)
- highly heritable but not the only factor
- higher rates in first degree adult relatives
- genetic effects may influence personality and temperament
Biological influences of depression (neurochemistry and brain functioning)
- serotonin, norepinephrine, acetylcholine
- builds on research that finds certain classes of medication are effective as antidepressants
- low levels of serotonin and norepinephrine are results of too much reabsorption by the neuron and the breakdown of neurotransmitter too efficiently
Social-psychological influences on depression (2)
Separation and loss
- can produce adverse circumstances including lack of care, changing in family structure, socioeconomic problems
Cognitive and interpersonal perspective
- interpersonal skills, cognitive distortions, views of self, control beliefs, self regulation, and stress
- the way a person relates to others, is viewed by others, and view themselves contributes to how depression developed and/or is maintained
Impact of parental depression
Children from homes with a depressed parent are:
- greater risk of developing MDD and other disorders
- less likely to get treatment
Garber and Flynn (2001): longitudinal study of children with depressed mothers - findings
Possible that behaviour of depressed parents may be accompanied by anger, frustration, and hostility
- alters the parent’s ability to parent effectively
- parents may be detached, withdrawn, and inattentive
- depressed behaviour is maintained by parent-child interactions
Assessments of depression
Self report measures
- children’s depression index (CDI)
- revised children’s anxiety and depression scale
Parental/teacher measures
- behaviour assessment system for children (BASC)
Observations and clinical judgment
For children, might not use the DSM; would instead use evidence based on that particular child
Treatment of depression (medications and CBT)
Medications
- past: tricyclic antidepressants
- present: SSRIs and second-generation antidepressants
CBT and interpersonal psychotherapy
- challenge maladaptive thoughts and negative attributions, teach problem solving/coping skills
- understand interpersonal issues and problem solving
Bipolar disorder definition
Involves the presence of mania as well as depressive symptoms
Mania and euphoria definitions
Mania: period of abnormally elevated euphoric mood
Euphoria: characterized by inflated self esteem, high rates of activity, speech and thinking, distractibility, exaggerated feelings of physical and mental well being
DSM-5 criteria for manic episode
Persistent elevated, and expansive or irritable mood
3 of the following:
- inflated self esteem
- decreased need for sleep
- more talkative than usual
- thoughts racing
- distractibility
- psychomotor agitation
- excessive pleasure seeking
Types of bipolar disorder
Bipolar I: involves a history of MDD and mania
Bipolar II: involves a history of MDD and hypomania (euphoric mood that is shorter in duration - about 4 days - and less severe than manic episodes)
Cyclothymic disorder: chronic but less severe fluctuations in mood. Does not meet criteria for depression or BPD
Comorbidity of bipolar disorder and ADHD?
60%-90% of children
FIND (frequency, intensity, number, duration) criteria for BD (Kowatch et al. 2005)
-Exceedingly happy or silly (no apparent reason)
- Intense outbursts or anger/hostile
-Frequent irritable moods
-Less sleep than usual (full of energy)
-State of grandiose views of their abilities and plans
-Intense concentration on activity but becomes increasingly disorganized
-Rapid/unintelligible and difficult to follow speech
-Flight of ideas
-Poor judgement
Epidemiology of BD - Blader and Carlson (2007)
National representative sample (0-19yo) of doctor visits for mental health related issues = 6.67% in 2002-03
Between 1996-2004: children = 1.4 to 7.3 per 10000; teens = 5.1 to 20.4 per 10000
Prevalence of BD
0-6% in a community sample of children and adolescents
Distribution of males and females are equal
No significant cultural/ethnic differences
Less prevalent in prepubertal youth
Diagnostic challenges of BD
-Same diagnostic criteria are used for adults and children
-Children tend to have very short episodes, very frequent mood shifts, mixed mood, chronic difficulty in regulating moods
-Children present with co-morbid problems
-Mania in adolescents - associated with antisocial behaviour
BD developmental course
- in some children, major depressive disorder may be an early stage of bipolar disorder —> more likely in those youngsters with an earlier onset of depression
- experience relatively early onset of affective difficulties
(Median duration for manic episode = 10.8 months; first affective episode = 11.75 years) - retrospective and prospective studies suggest that these children continue to show symptoms of affective disorders, social and academic impairment
Risk factors and stoplights of BD
Family history of bipolar disorder (genetics)
- biological siblings and parents (immediate family members)
- adult twins and adoption demonstrate a strong genetic component
- multiple genes affecting amygdala and hormonal and neurotransmitter process, but shared with other disorders
Environmental stressors
- stressful life events, family relationships, parenting styles
Assessment of BD
Structured diagnostic interview: K-SADS
Mania scales: Young Mania Rating Scales and GBI
Parent/teacher/self-interviews
Treatment of BD
Pharmacotherapy is the first and most effective treatment
Family involvement in treatment is very important
Conduct problems listed in the DSM-5
Oppositional defiant disorder
Conduct disorder
Intermittent explosive disorder
Antisocial personality disorder
Pyromania and kleptomania
Antisocial personality disorder
Pervasive pattern of disregard of and violation of rights of others
Met criteria for CD before the age of 15
ADHD—> ODD —> CD—> APD
Oppositional defiant disorder - DSM-5 criteria
A pattern of negativistic, hostile, and defiant behaviour
Under age 5: symptoms have to occur on most days. Over age 5: symptoms have to occur at least once a week
Has to impair functioning (ex. Academically, socially)
At least 3 of these behaviours present for at least 6 months:
- loses temper
- touchy and easily annoyed
- angry and resentful
- argues with adults
- actively defies or refuses to comply with adult request/rules
- deliberately annoys others
- blames others for own mistakes
- is spiteful or vindictive
Conduct disorder - definitions
A pattern of repetitive and persistent acts of violence that violates the basic rights of others and goes against societal norms
Mild, moderate, or severe
Limited prosocial emotions (feeling guilty or not)
DSM-5 symptoms of conduct disorder
At least 3 of these behaviours are present during the last 12 months with at least one of them present in the last 6 months:
Aggression toward people or animals
- bullies, threatens, or intimidates
- initiates physical fights
- has used a weapon
- is physically cruel to people or animals
- has stolen while confronting a victim
- has forced someone into sexual activity
Destruction of property
- engaged in fire setting with the intent to cause damage
- has deliberately destroyed other’s property
Deceitfulness or theft
- has broken into house, building, or car
- often lies to obtain goods or favours or to avoid obligations
- has stolen items of nontrivial value without confronting victim
Serious violation of rules
- stays out at night despite parent prohibitions
- has run away from home overnight at least twice
- is often truant from school - beginning before age 13
Empirically derived externalizing behaviours associated with CD (2 types of behaviours)
Two syndromes:
- aggressive behaviour: argues a lot, destroys things, purposefully disobedient, fights
- rule-breaking behaviour: breaks rules, lies, steals, is truant
Children can exhibit one or both of these problems
Aggressive behaviour carries a higher degree of heritability than rule breaking behaviour
Gender differences in conduct problems
Expressed differently in boys and girls
Aggression in boys:
- defined as an intent to hurt or do harm to others (ex. Hitting, pushing, or threatening behaviours)
Aggression in girls:
- more directed to hurting another person’s feelings (relational aggression)
- ex. leaving someone out of play/excluding from peer group, telling a person you won’t like them unless they do as you say, lying about someone so others won’t like her
Epidemiology of conduct problems
Rate 1%-15% of ODD
Rate 2%-10% of CD
Comparable across countries
Developmental paths of conduct problems
Loeber’s 3 pathways model:
Authority conflict
- stubborn behaviour, defiance, disobedience, truancy
Covert
- property damage, lying, fire setting, theft, burglary
Overt
- physical violence, bullying, and sever forms of violence (rape, attacks, strong arm)
Aggression as a learned behaviour
Children can clearly learn to be aggressive by being rewarded for such behaviour
Can also learn through exposure to aggressive models - vicarious learning
Can build the child’s repertoire and lead to disinhibition of aggression
- family violence is a source of modelled aggression
- parents who punish their children physically serve as models of aggressive behaviour
Children who exhibit excessive or antisocial behaviours - likely to have siblings/parents/grandparents with histories of conduct problems and records of aggressive and criminal behaviour
Family variables in conduct disorder
Low family SES
Marital disruption
Poor quality parenting
Parental abuse and neglect
Parenting style
Handing down non-effective parenting from generation to generation
Stressors that impact parenting quality
Parental psychopathology: alcoholism or other parental psychopathology can impact parental effectiveness
Biological influences of CD
Aggressive and conduct disorder related behaviours tend to run in the family
Longitudinal studies suggest a genetic component to CD
Inherited characteristics (body build, temperament, sensitivity to alcohol, irritability, sensation seeking, impulsivity) make an individual prone to conduct disorders
- mediated by social conditions, family variables, and social learning experiences
Assessment of CD
Parent completes Likert scale
36 items for CD
Steps in the cognitive processing of social-emotional cues (CD) (5 steps)
Encoding (looking for and attending to aggression)
Interpreting (misinterpreting of own and others’ emotions)
Looking for alternative responses
Selecting a specific response
Enacting the response
Youth with conduct problems display these problematic social-cognitive processes: (5)
Poorer problem solving skills
Attribute hostile intent to neutral actions
Generate fewer responses - and those generated are aggressive
Expect that aggressive responses will produce positive outcomes
Label arousal in conflict situations as “anger”
Pharmacological interventions for ODD and CD
With co-morbid ADHD: stimulant medications
Mood stabilizers: for extreme aggression and conduct disorder behaviours but works best with parent training and other interventions
Parent training interventions for ODD and CD
Best option!
Common features of parent training programs:
- how to give commands
- how to reinforce behaviours
- how to discipline and ignore
- prepare for difficult situations
Incredible Years Training Series
- parenting skills for use with children diagnoses with ODD and CD
- comes with standardized videos to model parenting skills
Cognitive problem solving skills
- targets the interpersonal and social-cognitive aspects of CD behaviour
- used in children 4-8 years of age
- taught to cope with stressful situations
- taped vignettes and discussions
- uses child sized puppets, colouring books, and cartoon stickers and prizes
Parent and child programs are superior in combination
3 types of ADHD
ADHD predominantly inattentive subtype
ADHD predominantly hyperactive/impulsive subtype
ADHD combined type
ADHD diagnoses are provided to those who: (5)
Symptoms are present before the age of 12
Symptoms are displayed for at least 6 months
Behaviours go beyond that expected developmentally
Impairment identified in social/academic functioning
Symptoms must occur in at least 2 different settings
ADHD primary & secondary features
Primary features:
- inattentive
- hyperactive/impulsive
Secondary features:
- motor skills
- intelligence
- cognition (executive functioning skills)
- adaptive functioning skills
- social behaviour
- sleep (lack of sleep)
- accidents (very accident prone)
Parents and teachers often report that children who are inattentive: (5)
Jump around from one task to another
Does not attend to what is being said
Is easily distracted
Daydreams
Has difficulty concentrating
Confirmed ADHD children pay less attention to their peers; they have a reduced capacity for: (2)
Selective attention
Sustained attention
Parents and teachers often report that hyperactive children are: (3)
Restless
Fidgety
Unable to sit still
Objective measures of hyperactivity can be measured using:
Actigraphs: little accelerometers that register movements in different planes
What time of day does hyperactivity increase?
In the afternoon
Parents and teachers often report that impulsivity in children appears as:
Difficulty controlling their own behaviour
Ex. The child might act without thinking, interrupt others, cut in line, engage in dangerous behaviours, appear careless and irresponsible, immature and rude
Motor coordination problems in children with ADHD (4) + how many children diagnosed with ADHD have these problems?
Clumsiness
Delay in motor milestones
Poor performance in sports
Difficulties with fine motor coordination and timing (particular difficulty in tasks involving complex movements and sequencing, like dancing)
About 50% for children with ADHD have motor coordination problems
Intelligence and ADHD
Overall, children perform worse on intelligence tests
Many have co-morbid learning difficulties/disorders
Reduced academic achievement
56% need tutoring
30% have to repeat a grade
30-40% end up I’m at least 1 special education placement
10-35% fail to graduate high school
Cognition and ADHD
Neuropsychological deficits cluster around executive functioning skills (ie. inhibition, working memory, sustained memory, etc.)
Executive functioning skills include those involved in goal-directed behaviour and are involved in planning, organizing, and self-regulation
