Reading §
- Identify the current issues associated with assessing and treating children and adolescents with mental health problems.
- Issues with assessing
- The opinion of the child’s difficulties can differ by the informant. Teachers have been shown to be better respondents than parents about severity of ADHD and social functioning. Parents have been shown to be the most comprehensive respondents about disruptive behaviour, although they under-report conduct symptoms compared to the child. Adolescents are the most accurate respondents with respect to anxiety.
- These developmental and informant factors specific to children and youth emphasize the importance of comprehensive assessment of symptoms and global functioning from multiple informants in this population.
- Regardless of the type of disorder, all diagnoses require that the child show evidence of persistent impairment in multiple settings, which can be directly attributed to the symptoms of disorder.
- Describe the prevalence of common childhood mental disorders (ADHD, disruptive behaviour disorders, and anxiety disorders) and their comorbidities.
- One in five youth have a psychiatric disorder. Forty percent of these youth have multiple disorders (comorbidity). Having a childhood disorder substantially increases the risk for developing another disorder (heterotypic continuity) or continuing to have the same disorder (homotypic continuity).
- Some disorders appear to be more common in boys prior to puberty (ADHD) and in girls following puberty (anxiety disorders and mood disorders). Although conduct disorders are more common in boys before puberty, the rates are more similar across sex in adolescence.
- ADHD can be diagnosed in 2% of preschoolers and 6% of children and adolescents. ADHD is 10 times as prevalent in clinical samples. The prevalence of ODD (3 to 6%) and CD (1 to 10%) is similar to ADHD, although more difficult to estimate as many studies do not clearly distinguish the prevalence of ODD from CD (and many do not account for the comorbid condition ADHD). Anxiety disorders are also common, but rates vary by disorder, with the most common presentation being separation anxiety disorder (5% of children) and the least common being social anxiety disorder (1% of children).
- Identify the symptoms and clinical features of common childhood mental disorders.
- ADHD
- ADHD is a neuropsychiatric disorder that reflects problems with executive functions, such as the regulation of attention, behaviour, and motivation. The two broad areas of symptom impairment are hyperactivity/ impulsivity and inattention. The DSM recognizes ADHD subtypes (now called specifiers) where some children appear more hyperactive or more inattentive and can be classified as such, although most children with ADHD have both hyperactivity/impulsivity and inattention.
- ODD & CD
- ODD and CD describe youth who have persistent difficulties of reacting negatively toward others with hostility or defiance as a primary problem (ODD) or engaging in behaviour that result in deliberate physical or emotional harm to others (CD). It is clear that these diagnoses describe the behaviour of the youth and not so much their underlying difficulties, such as comorbid disorders (ADHD, anxiety, or learning disabilities) or the difficult social circumstances they live in. For example, recent research suggests there may be a subgroup of ODD youth who struggle with high levels of irritable mood, and a group of CD youth who have psychopathic tendencies.
- Anxiety Disorders
- Children with anxiety disorders experience all of the following difficulties: mental preoccupations with worries or fears, behavioural or mental actions directed toward avoidance of the perceived source of fear or worry, and physical distress (headaches, tension) because of the worry. What differs across the types of anxiety disorders is the focus of the fear or worry. For example, being worried about a parent’s safety is consistent with separation anxiety, being worried about potential embarrassment is consistent with social anxiety, and being worried about unpredictable events is consistent with generalized anxiety.
- Explain how biological, psychological, and environmental factors can work together to increase the risk of developing these common childhood mental disorders.
- Mental disorders present as a result of multiple risk processes that involve components of disturbed biology, environment, and psychological factors. The timing of occurrence of disorder and the severity of the disorder are related to the ways these factors exert their effects for a particular child. It is therefore false to assume that any one factor is causal. When describing a mental disorder and its presentation, it is important to consider how biological, environmental, and psychological factors are of relevance for that child. For example, most children with ADHD have a family history, attesting to its inherited genetic component, and their symptoms typically respond to stimulant medication, suggesting a biological basis for the disorder. Symptoms of ADHD are worse in unstructured environments (such as lunchtime versus in class), attesting to the influence of context in shaping behaviour. Many children with ADHD are difficult to parent or teach and experience difficulties with peers, and their self-esteem is often affected. It is important to intervene in all these areas to help the child with ADHD.
- Environmental
- More so than adults, children and youth are influenced by their environments and the lives of others around them because they have less autonomy for their decisions. This reality can also influence the presentation of impairment or symptoms.
- It is important to consider the impact of life stressors and family context on a child’s symptoms. The impact of treatment or cognitive and emotional development on symptom persistence is also important to consider as children continue to grow and mature.
- Risks
- New research suggests that sources of “risk” are not as clear-cut as previously assumed. Specifically, differential susceptibility theory and biological sensitivity to context theory suggest that sources of vulnerability can not only increase the risk of poorer outcomes, but they can also be associated with more positive outcomes in the context of more supportive environments.
- Perfectionism is characterized by self-imposed high standards that are hard to achieve. Perfectionism is common among youth, affecting close to one in five teens. Given perfectionism’s strong relation to depression, it is generally suggested that the targeting perfectionism should be a treatment goal when dealing with depressed clients.
- Identify evidence-based psychological and pharmacological treatments for common childhood mental disorders.
- ADHD
- ADHD: Evidence-based psychological interventions should be provided to all families who have a child with ADHD. These include caregiver psychoeducation, parent-training programs to help parents facilitate more functional behaviour patterns, and school-focused interventions, including psychoeducational testing for learning difficulties and providing classroom modifications to facilitate attention. Pharmacological treatments for ADHD include short- and long-acting derivatives of methylphenidate, dextroamphetamine, and amphetamine. These compounds work by increasing the sensitivity of dopamine receptors in the prefrontal cortex. Children treated with these medications require close medical monitoring. These treatments do not cure ADHD but help reduce symptoms and should be used in concert with psychological interventions.
- ODD & CD
- ODD and CD: Four diverse treatment methods have been shown to be helpful for ODD and CD: (1) teaching problem-solving skills, (2) pharmacological interventions, (3) parent management training, and (4) schooland community-based treatments. With the exception of pharmacological interventions, these methods help to break the coercive effect of the youth’s behaviour on families and peers by teaching others how to respond to the behaviour or increasing the youth’s sensitivity to the effects of his or her behaviour on others. Pharmacological interventions are generally focused on the treatment of comorbid conditions (ADHD or anxiety).
- Anxiety
- Anxiety disorders: Cognitive-behavioural therapy (CBT) has been shown to be effective for the treatment of childhood anxiety disorders. CBT should include a parent component as many parents have anxiety themselves or reinforce the child’s avoidance behaviour. Medications for treatment of anxiety in children and youth include antidepressant medications (serotonin specific reuptake inhibitors), and are used as an adjunct to CBT or as a means of reducing anxiety sufficiently to allow participation in CBT.
- Mood
- Disruptive mood dysregulation disorder is classified as a mood disorder in the DSM-5 but it represents a perfect intersect between externalizing and internalizing problems. If a child’s symptoms meet diagnostic criteria for both DMDD and ODD, the diagnosis of DMDD is given.
Lecture §
PDF:
- Externalizing vs. Internalizing
- Externalizing problems: disorders of undercontrolled behaviour
- Internalizing problems: disorders of overcontrolled behaviour
- Separation anxiety disorder (SAD), selective mutism, reactive attachment disorder (RAD), Anxiety Disorders, mood disorders, including Disruptive mood dysregulation disorder (DMDD)
- Disruptive mood dysregulation disorder represents a perfect intersect between externalizing and internalizing problems
- Externalizing: ADHD
- 2/3 of the children with ADHD lose diagnosis into adulthood
- Symptoms: What are the 3 common symptoms of ADHD?
- Motorically and often verbally hyperactive
- Have problems maintaining their focus in conversations and activities
- They show impulsive or erratic behaviour
- Diagnostic: What are the 3 types of ADHD and their (3) common symptoms?
- Listed in the Neurodevelopmental Disorders section
- (ADHD-I):
- ADHD predominantly inattentive presentation
- More common in girls than in boys
- Easily Distracted
- Unorganized
- Difficulty listening
- (ADHD-H):
- ADHD predominantly hyperactive/impulsive presentation
- 3× more common in boys than in girls
- Difficulty sitting still
- Rush through tasks
- Make rash decisions
- (ADHD-HI):
- ADHD combined presentation
- 3× more common in boys than in girls
- Symptoms of both presentations
- Etiology: What are the 4 category of causes
- Brain structure (What are the 5 deficits in brain)
- Decreased brain size (3−8% reduction)
- Abnormalities in the metabolism of Dopamine and noradrenergic neurotransmitters + in the functioning of genes that regulate them
- Abnormalities of the Prefrontal Cortex
- Abnormalities of the Basal Ganglia
- Genetics (What is the heritability rate)
- Prenatal & psychosocial Risks (What are the 3 risk factors)
- Prenatal toxin exposure
- Poor diet, mercury, and lead exposure
- Pregnancy and delivery complications
- Exposure to alcohol and maternal smoking
- Gene-environmental interactions
- Assessment: What are the 4 common assessment used
- Report from parents & teacher
- Self-report (adolescent + adults)
- Clinical interview
- Valid and reliable tools
- WISC (IQ test)
- NEPSY (developmental NEuroPSYchological Assessment)
- Test of Everyday Attention (TEA, TEAch)
- Treatment: What are the most effective treatment and the multimodal approaches?
- Help children to enhance their deficient self-motivation and working memory
- 80% of people with ADHD have positive effect with medication
- Stimulants: (What are the 2 common stimulant medications)
- Ritalin (methylphenidate)
- Dexedrine (dextroamphetamine)
- How does the medications effect
- Increase release of Dopamine
- Can increase anxiety
- Non-drug interventions
- Parent training, behavioural classroom management)
- Treatment: What are other 4 intervention techniques
- Psychoeducational interventions
- Caregivers/teachers are educated about the symptoms, course of the disorder, and deficits associated with ADHD and how they can facilitate the use of the child’s strengths
- Parent training
- Teach behaviour modification/behaviour therapy principles to parents
- Focus on positive parent-child interactions and communication skills
- Academic skill facilitation and remediation
- School-focused interventions
- Other treatments
- Family therapy, cognitive-behavioral therapy, individual psychotherapy, social skills training (all less effective)
- Study: Mind Wandering or Simply Blanking
- [@vandendriesscheAttentionalLapsesAttentionDeficit2017]
- Children with ADHD report more mind blanking than controls
- Ritalin reverts the level of mind blanking to baseline
- Mind wandering more than focused attention
Questions §
- So is ADHD just a slower development manifestation of prefrontal cortex?