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Externalizing vs. Internalizing Disorders
- Externalizing Disorders: children have problems in conforming to expected norms; often cause problems for others
- Internalizing Disorders: children who experience subjective distress; others may be unaware of children's difficulties
For externalizing disorders, which are more likely to persist: problems beginning in childhood or in adolescence?
Key Features of Externalizing Disorders (5)
- Rule violations
- Negativity, anger, and aggression
- Deficits in attention
How does age affect rule violations in externalizing disorders?
Different ages violate different rules, but children with externalizing disorders violate rules at a younger age than normal (ex: many young people experiment with alcohol, but a very young child experimenting with alcohol could be a symptom of externalizing disorder)
Adolescent-limited vs. Life-course-persistent Externalizing Disorders
- Adolescent limited: ends along with the teen years
- Life-course-persistent: antisocial behavior continues into adulthood
What is an important predictor of future adult antisocial personality disorder (ASPD)?
Callousness: indifference to the suffering of others
Actions designed to hurt others in subtle ways (e.g. gossip, social exclusion)
Types of Conduct Problems: Two Dimensions and Four Categories
- Destructive vs. Non-Destructive
- Covert vs. Overt
- Covert/Destructive: Property destruction (stealing, arson, vandalism)
- Covert/Non-destructive: Status offenses (running away, truancy, cursing)
- Overt/Destructive: Aggression (animal cruelty, fighting, bullying)
- Overt/Non-destructive: Oppositional (tantrums, angry, defiant)
Three Main Externalizing Disorders
- Oppositional Defiant Disorder
- Conduct Disorder
ADHD: DSM-5 Criteria (4)
- Persistent pattern of inattention and/or hyperactivity
- For at least 6 months need at least 6 symptoms of inattention and/or hyperactivity & impulsivity
- Several symptoms must be present before age 12 in at least 2 settings
- Symptoms interfere with or reduce quality of functioning
Social Problems of Kids with ADHD (2)
- Seen negatively by peers; may be actively disliked or have difficulty maintaining friendships
- Parents and teachers may exhibit more negative and controlling behaviors or may show withdrawal and decreased responsiveness
Oppositional Defiant Disorder (ODD): DSM-5 Criteria (4)
- A pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness
- Needs at least 4 symptoms - over 6+ months; must be exhibited during interactions with at least one person who isn't a sibling
- Associated with distress for self or others OR causes significant impairment
- Cannot occur exclusively during psychotic, substance use, or mood disorder
Differences in Intent between ADHD and ODD
- ADHD: want to "be good" but are impulsive and have trouble behaving
- ODD: angrier and intentionally rebellious
Comorbidity of ADHD and ODD
50% of children with one also have the other
Conduct Disorder (CD): DSM-5 Criteria (4)
- Repetitive pattern of violating basic rights of others and/or major societal norms of - aggression to people and animals, destruction of property, deceitfulness or theft, serious rule violation
- Over 12 months and need at least 3 symptoms across 4 categories
- Disturbance causes clinically significant impairment in social, academic, or occupational functioning
- For those 18 years/older, criteria for antisocial personality disorder are not met
% of US adolescents with externalizing disorders at some point in their life?
Prevalence of externalizing disorders: Who has it more: boys or girls? How much more?
Boys; 2-10 times more
Prevalence of externalizing disorders (increases/decreases) with age.
-Problems may appear even before age ____
-Most commonly diagnosed ages?
-Prevalence in US vs. Europe?
- 3-9.5% in US lifetime; 1-2% in Europe
Prevalence Rates of ODD?
Prevalence Rates of CD?
About ____% of children with CD exhibit antisocial behavior into adulthood?
-Which externalizing disorders are associated with learning disabilities? What %?
-Which externalizing disorder is highly comorbid with internalizing disorders?
- -ADHD or ODD; about 25% of children with either have a learning disability
Three Types of Temperament. Which kind(s) predict development of externalizing disorders?
- Easy: friendly and obey most rules
- Difficult: unpredictable and challenging
- Slow-to-warm-up: shy and withdrawn
Difficult temperament during infancy or toddlerhood predicts externalizing disorders
ADHD and Biological Factors
- Large genetic component
- Chronic underarousal of the autonomic nervous system
- Neuropsychological abnormalities (soft signs)
Four Parenting Styles
- Authoritative: high control, high warmth
- Authoritarian: high control, low warmth (harsh)
- Indulgent: Low control, high warmth (too lax)
- Neglectful: low control, low warmth (the worst)
Children with serious conduct problems have which type of parents?
- Parent positively reinforces child's misbehavior by giving in to child's demands
- Child negatively reinforces parents by ending obnoxious behavior
- Ex: kid wants cookie, screams until he gets it
Etiology of Externalizing Disorders: Biological Factors (3)
- Difficult temperament
- Neuropsychological abnormalities
- Genetics (ADHD, less with ODD)
Etiology of Externalizing Disorders: Social Factors (10)
- Neglectful parenting style
- Negative attention (misbehaving to get attention)
- Peers, neighborhoods, media
- Family adversity
- Low income
- Lots of siblings
- Mothers tend to be more critical, poor parenting exacerbates, maternal warmth prevents
- Self-esteem (high)
Etiology of Externalizing Disorders: Psychological Factors (3)
- Self-control (deficits in delayed gratification)
- Over-interpreting peer aggression
- Deficits in moral reasoning
ODD is (more/less) genetically caused than ADHD
Genetic influences of ODD are greater for (early/late) onset antisocial behavior
MAO activity (MAOA) and CD
Child maltreatment predicts significantly more adolescent conduct problems if boys were genetically predisposed to low MAOA (rather than high MAOA)
Treatment of ADHD (3)
- Non-stimulants (antidepressants such as NERIs)
- Behavioral Family Therapy
"Paradoxical Effect" of Psychostimulants
- Lead to restless behavior when abused, but slow down children when given in small doses
- Actually, in appropriately small doses, psychostimulants improve attention and decrease motor activity in all ages
- So, not really a paradox
Treatment of ODD
Behavioral Family Therapy
Behavioral Family Therapy (BFT)
- Used to treat ADHD and ODD, but more effective for ODD
- Parent training; goal to reach authoritative parenting
- Positively reinforce good behavior; ignore or mildly punish bad behavior
Treatment of CD
- Multisystemic Therapy
- Residential programs
- Diversion (alternative to juvenile justice system)
- Used to treat CD
- Combines family treatment with coordinated interventions in other important contexts of the troubled child's life
- Lowers recidivism (repeat offending)
How are internalizing disorders categorized in the DSM-5?
- They are not; rather, children can qualify for "adult" disorders of anxiety and depression
- Slightly different criteria for children, though
Problems with recognizing and assessing internalizing disorders (3)
- Symptoms go unnoticed/misinterpreted
- Difficult to obtain information (children may not be able to explain how they feel)
- Conflicting accounts between child and parents
Developmental Differences in Symptoms of Childhood Depression: Infants, Preschoolers, Middle Childhood (6-12), Adolescence
- Infants: Lethargy, feeding and sleep problems, irritability, decreased attention and emotional expression
- Preschoolers: irritability, anger, sad facial expressions, somatic complaints, lethargy, crying, anhedonia, sleep and eating problems
- Middle Childhood: Unhappiness, decreased socialization, sleep problems, irritability, lethargy, school problems; beginning at age 9 - aggression, self-reports of low self-esteem and helplessness, suicidal ideation
- Adolescence: similar to middle childhood, plus pessimism, feelings of worthlessness and apathy, comorbid substance abuse, eating disorders, antisocial behavior
Epidemiology of Childhood Depression: Elementary School
2-4% of community sample; 8-15% of inpatients
Epidemiology of Childhood Depression: Adolescence
7% of community sample
Epidemiology of Childhood Depression: Gender Differences
- Pre-puberty: either no gender difference or slightly higher in boys
- By age 15: gender difference parallels adults (rates among girls are twice those among boys)
Etiology of Childhood Depression (5)
- Genetic/biological vulnerability similar to vulnerability for adult depression
- Having a parent with a psychological disorder
- Failing to form stable, secure attachments with parents
- Separated/divorced families
- Hostile, tense, punitive communication
Do cognitive models of depression developed for adults apply to children (e.g. Beck's cognitive theory/learned helplessness model)?
Evidence suggests they do. Children tend to view negative events as internal (their fault) and positive events as external (it wasn't them that did something good)
Difficulties in Treating Childhood Depression (2)
- Kids have limited memory, attentional, and verbal capabilities
- Family involvement is often crucial, but parents may not be understanding or may contribute to the depression
Treatment of Childhood Depression
- Combo of CBT and medication (Prozac (fluoxetine)) works best
- More likely to respond if treated early
- Comorbidity reduces effectiveness of treatment
Risk of suicidality in antidepressant use in kids?
- Maybe; at beginning of treatment, children must be closely monitored
- Comprehensive review suggests that benefits outweigh risks
Characteristics of anxiety disorders in children (6)
- Unrealistic fears
- Pervasive feelings of inadequacy
- Sleep disturbances
- Fear of school
Separation Anxiety Disorder
- Not a disorder at 8-15 months
- After that, developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached
Separation Anxiety Disorder is more common in (boys/girls)
Recovery of kids from separation anxiety disorder?
50% recover in 4 yrs without treatment
Associated Factors of Separation Anxiety Disorder (3)
- Life stress
- Parental overprotection and intrusiveness
Bipolar Disorder in kids is often comorbid with what?
- Disinhibited social engagement disorder
people eating non-food substances (usually in addition to actual food)
Disinhibited social engagement disorder (DSED)
having inappropriate relationships with people (e.g. climbing on a stranger's lap for comfort)
Parenting Style that Increases Anxiety in Children?
Authoritarian - produces compliant but anxious kids, associated with internalizing disorders
Attachment Styles (characterized by children's behavior from separation from parent and reunion with parent)
- Secure: distressed at separation; reunion - approaches caregiver and easily soothed, returns to play quickly
- Avoidant: may or may not show distress at separation; reunion - ignores caregiver, appears uninterested
Attachment Styles and Childhood Disorders
- Secure: facilitates closeness and exploration
- Insecure/Avoidant: predicts internalizing and externalizing disorders and social difficulties
Etiology of Internalizing Disorders: Psychological Factors (2)
- Emotional regulation
- Role reversal - children who take on parental roles are at an increased risk of IDs
Peer Sociometric Ratings
- Popular: receive many "liked most" and few "liked least"
- Average: receive few "liked least" and some "like most"
- Neglected: few "least", few "most"
- Rejected: many "least", few "most"
- Controversial: many "least", many "most
Sociometric Ratings Associated With Childhood Disorders
- Rejected: associated with externalizing disorders
- Neglected: associated with internalizing disorders
- Controversial: associated with teen pregnancy
At least ____% of children have a mental disorder
(Boys/Girls) are more likely to be in treatment for mental disorders
Prevalence rates of internalizing disorders (increase/decrease) with age
Difference in suicide between teens and adults
Teens: more impulsive, often related to some family conflict
Externalizing disorders (often/rarely) BEGIN in adult life
Rarely; but externalizing disorders often continue into adulthood