Childhood & Adolescence

Childhood & Adolescence I. ISSUES A. Child vs. Adult Psychopathology - Problems less severe/frequent in childhood - Same problem can look different - Some problems primarily in childhood

B. Types of Disorders 1. Internalizing (overcontrolled) = problems within - Less noticed by adults - More common in girls

2. Externalizing (undercontrolled) = manifested externally - Mostly boys - More referred for tx

C. Normal vs. Abnormal Development - Normal at one age = abnormal at another - Period of rapid change - Harder to determine pathology in children “Normal” is age-dependent

D. Child problems are reciprocal 1. Blame the child - Infant temperament 2. Blame the parents - Schizophrenogenic & refrigerator mothers

3. Reciprocal process - difficult kids elicit worse caregiving & vice versa - Intervention = parent-child interaction

E. Children are dependent on others - more likely to get victimized - need parent/teacher involvement

II. Behavioral Disorders 1. Attention- Deficit Hyperactivity Disorder(ADHD) Description • Inattention - especially sustained attention • Hyperactivity • Impulsivity

Inattentive Type • Impulsive-Hyperactive Type • Combined Type • Adult ADD (not an actual dx)

Common complications • Learning problems • Discipline (-> ODD) • Poor peer relations

Prevalence • 3-6% • Boys • Over-diagnosed?

Etiology • Nervous system problem - smaller brain (e.g, frontal lobe) BAS & BIS • Polygenetic – 1 DA receptor implicated • Prenatal smoking • NOT sugar • Parenting can exacerbate, cannot cause

Treatment - 1/3 recover • Stimulant medication - ↑ DA – blocks reuptake - agonist for BIS - works for 75% - few side effects - effects are immediate - reduces inattention & impulsivity -> focus in classroom & at sports -> improves peer relations & self-esteem - cannot teach good behavior

Behavior therapy - Teach appropriate behavior via rewards & punishments - Parent training - School involvement - Must continue for long period • Best = Medication + behavior tx

Summer ADHD Program - point system - parental involvement - double-blind medication trials

Oppositional Defiant Disorder (ODD) & Conduct Disorder (CD) Description • ODD - negativitist, hostile, defiant • CD - truancy, fire-setting, theft, aggression, cruelty

Prevalence • 9% boys • 2% girls

Etiology Family • Parenting: criticism & poor monitoring (indifference) • Parent modeling of poor self-control & antisocial tendencies • Stressful events (divorce)

Cognitive skills • hostile attributions • poor problem-solving Biology • some genetic evidence • lower baseline arousal

Treatment • Parent training - time out/lose privileges & positive reinforcement • Negotiation with adolescents • Cognitive treatments - problem-solving, self-control • Family Systems Therapy

III. Cognitive Disorders Autism (on spectrum – to Asperger’s) 1. Inability to relate to other people - little communication - lack of affection/interest in others - self-absorption

2. Absent or deficient speech ~ ½ = no speech, primitive gestures ~ ½ = some words with oddities (e.g., echolalia)

3. Behavior limited, rigid stereotyped, self-stimulatory behaviors self-injurious & aggressive preservation of sameness

MR & LD = common

Prevalence • 4-5 in 10,000 (rare) • 75-80% are boys

Etiology • 1940s: Kanner: innate inability to relate (biological) • 1950s: Refrigerator mother => withdrawal (environment) • Current: neurological basis prenatal or birth complications

Treatment • Difficult; poor prognosis • 5% capable of jobs • Still emotionally isolated • Rest = mild care-taking skills • Best: if speak before 5, higher IQ, & mild symptoms

Institutionalization is common • Behavior modification - reinforce social behaviors - sign language - parents & teachers as co-therapists • Aversive conditioning • Facilitation

IV. Anxiety & Mood Disorders Anxiety • School Phobia (not a dx) • Separation Anxiety • Specific fears or phobias • Others as in adults (e.g., GAD) • Fears are common - Extreme degree or duration, impairment

Prevalence • very common to uncommon • equal in boys & girls

Etiology • Biology: fearful, anxious temperament • Learning: observe others’ fears - parents reinforce fears - overprotective parental style

Treatment Behavioral • Flooding • Systematic desensitization • Reward for success Cognitive • Re-appraisal of feared situation • Relaxation strategies

Behavioral therapy = most effective • Medication - not well-documented in kids • ** Best = include parents

Depression • Like adults - sad, crying, hopeless, low self-worth, sleep & appetite problems, lethargy • Unlike adults - behavioral problems, clinging, delinquency

Few consistencies - more like adults than not - similar to adult bereavement (with precipitant)

Prevalence • 5-10% boys & girls, more in teens • equally common in boys & girls

Etiology Biological • possible genetic predisposition Learning • learned helplessness • reduced reinforcers

Cognition • Unrealistically negative • Poor coping • Poor social skills

Treatment • Play therapy (psychodynamic) - child works through conflicts via play - no evidence for efficacy • Social skills training • Increase pleasant activities

Cognitive therapy – errors & coping • Medication - somewhat effective for children - less effective for adolescents • Change the environment*

V. Eating Disorders Anorexia • refusing to eat due to fear of weight gain • distorted body image • life-threatening

Bulimia - bingeing & purging • distorted body image • not usually life-threatening • often normal weight • Key = lack of control

Prevalence • Anorexia – 1-3 % of 12-18 year-olds • Bulimia - ~ 5% of teens/young adults (4.5% female, .5% male)

Etiology • Need for control • Identity issues - independence from parents - fear of growing sexuality • Societal pressures for thinness

Treatment • Family therapy - break power struggle - appropriate separation • Cognitive therapy - Identify & express emotions - Boost self-esteem - Change irrational beliefs Different issues for anorexia and bulimia • Hospitalization - IV fluids & goal weights

VI. Elimination Disorders • Enuresis & Encopresis - wetting/soiling self beyond usual age (~5) • Primary = hasn’t yet learned control vs. - Secondary = learned control but lost

Nighttime is more common - Daytime = maybe serious problem • Sense of no self-control (low self-esteem)

Prevalence • Enuresis: 15-20% of 5-year-olds 5% of 10-year-olds • Encopresis: .3-8% of children usually secondary • Boys

Etiology • Conflict with parents - self-control • Emotional disturbance - anxiety, stress, family disruption • Failure to learn - associate full bladder/bowel with toilet

Treatment • Eliminate biological causes • Deal with emotional disturbance • Behavioral techniques - wake in night after urination (Wee Alert) - praise for success - mild punishment for wetting/soiling • Prevent: relaxed & positive toward toileting

Childhood & Adolescence