Child Psychopathology

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Dx features of Enuresis: * repeated voiding of urine during the day or at night into bed or clothes
* Most often involuntary by may sometimes be intentional
* Happens AT LEAST 2X PER WEEK for AT LEAST 3 MONTHS or else must cause CLINICALLY SIGNIFICANT DISTRESS OR IMPAIRMENT in social, academic, or other important areas of functioning
* 5 years old or metal age of 5
* Not due to substance or GMC
Subtypes of Enuresis: * Nocturnal Type: most common subtype; only pees during nighttime sleep
- typically happens in first 1/3 (75%) of the night
- sometimes happen in REM sleep when child is having a dream
- 2:1=m:f ratio
* Diurnal Only: only pees awake; more common in females than males; uncommon after age 9; Divided into
1)"URGE INCONTINENCE": sudden urge symptoms
2)"VOIDING POSTPONEMENT":ignore urges until pees, sometimes due to social anxiety or preoccupation with school or play; high rate of symptoms of disruptive behavior; usually happens in the early afternoon on school days
* Nocturnal and Diurnal: combo of both above
- 25-30%
Associated Features of Enuresis: *Usually a primary prob; when secondary, it indicates worse pathology
*impairment associated with this is a function of the limitation on the kid's social activities, self-esteem, social ostricization, anger/ punishment/ rejection of caregivers
*most have no coexisting mental disorder
*most common comorbid disorder is encopresis
* behavioral symptoms more likely than in kids without it
*developmental delays, including speech, language, learning, and motor skill delays (esp. in Diurnal)
Etiology/ Predisposing Factors of Enuresis: *Unclear
*Strong genetic component to nocturnal primary enurisis
*Diurnal may be due to stressors
*might be self-masturbatory (not supported w/ research)
- delayed/ lax potty training
- psychosocial stress
- delay in dev't of circadian rhythms of urine prdoction->nocturnal polyuria, bladdar hyperactivity or reduced functional bladder capacities
Epidemiology of Enuresis: - considerable varriations
- after age 10, proportion drops tremendously
- after 18, less than 1% for boys and even less for girls
- majority will be typical bedwetter
- 5-10% of 5 year olds; 3-5% of 10 yr. olds; 1% of 15>
Course of Enuresis: *PRIMARY: never established urinary continence; begins at age 5; about 3/4
*SECONDARY: after establishing urinary continence; most common between age 5 and 8
* After 5, the rate of spontaneous remission is 5-10% per year
* most kids become continent by adolescence
Familial Pattern of Enuresis: *75% of kids w/ enuresis have a first degree relative who has had the disorder
* risk is 5-7x greater for offspring
* concordence rates higher for MZ than DZ twins
* linked to chromosomes, but not sure how yet
Clincial Presentation of Enuresis: * can vary by timing, magnitude, and frequency
* 99% will stop without tx
* not really all that uncommon
* important to get detailed info.
* make child feel comfortable
Differentals for Enuresis: * Medical Illness, Infection, Medication
*After Tx, enuresis may remain
* Mental age criterion must be met (like for MR patients)
Interventions for Enuresis: - 100% success rate
- 99% goes away w/ or w/out treatment
- make parents understand it's not volitional
- Assure parents that Tx will be successful
- child shouldn't be punished or embarrassed
- behavioral interventions work best
- separate Tx for Nocturnal and Diurnal
Diurnal Intervention: - easier to treat than nocturnal
- child put on schedule; try to use bathroom every 2 hours
- child responsible for cleaning up accidents; with younger kids, star or sticker system can/ should be used
Nocturnal Intervention: - Urine alarms (sensing device)
- dry bed training: wake child every hour, then adjust time
-child cleans up
- point, sticker system can be used for added motivation (added in dry bed training)
- takes a few weeks
Meds for Enuresis?: - antidepressants may be appropriate
- about 50% respond to meds, but cons are long term/ adverse side effects
Encopresis Basics: - pooping in inappropriate places
- usually involuntary, but may be intentional
- happens at least ONCE A MONTH for at least THREE months
- child must be at least 4 (or mental age of 4)
- not due to a substance or GMC except through a mechanism involving constipation
Encopresis Dx Picture: - involuntary: often related to constipation, impaction, and retention with subsequent overflow
- constipation may develop for psychological reasons leading to avoidance of pooping
Encopresis subtypes: - With Constipation and Overflow Incontinence: evidence of constipation on exam or history of stool freq. of less than 3 per week
-poorly formed, and leakage (mostly during the day)
* W/OUT CONSTIPATION & OVERFLOW INCONTINENCE: no evidence of prior problem; normally formed poo; intermittent soiling; feces may be in a prominant location; associated w/ ODD or CD; may be consewuence of anal masturbation; LESS COMMON
Associated features and disorders of Encopresis: - often feels ashamed and may wish to avoid situations that may lead to embarassment
- impairment affected by peer rejection, self esteem, caregiver response
- SMEARING feces may be intentional or accidental when child attempts to hide it
- when clearly deliberate, ODD or CD may be present
- many are also enuretic
Prevalence of Encopresis: - About 1/2 that of enuresis
- kids under 8: 2% of boys and 0.05% of girls
- 4-5:1 = m:f ratio
Course of Encopresis: PRIMARY: prior to child estavlishing fecal continence
SECONDARY: after child established fecal continence for at least 3-6 months prior to onset
- can persist intermittently for years
Other clinical info (from class) on encopresis: - diary prepared by parents and kid including diet and frequency
-rule out medical basis
suppositories NOT a good idea when behavior problem
- Approx. 1/2 encropretic day or night
- most don't report urge to deficate
-family problems and social difficulties for child
-assess impaired functioning
-may have to teach social skills
-find out about smearing
Increased incidence in MR and PDD (so make sure mental age is over 4!)
-spontaneous remission is common, but don't wait for it
Tx for encopresis: - 100% effective almost
- primary takes longer than secondary
- teaching independent toilet training is most effective
- educate child and family
- diary
-devise plan for family in writing and explain
- parents check clothing regularly
- regular trips to the bathroom and sitting for 15 minutes
- teaching child to clean uo
- kid cleans up accidents
- medical intervention may also be needed
Firesetting Basics (can't dx pyromania before 18): - seen as impulse control problem
- symptom of conduct disorder
- referrals come when child repeatedly starts fires, most often out of curiousity
- they seek out incenduary devices
- repeated pattern
- sometimes done in ager, aggression, retaliation
- most common reason kids give that is that it is pretty or they like firetrucks
- can be passive -> aggressive
- trouble establishing relationships
- usually carry Conduct DIsorder Dx
- Older firesetters more likely to have CD or be aggressive
- many have history of abuse
- perhaps kids are expressing emotion (fire, rage)?
- less postive affect or affection in the home
Tx for firesetting: - difficult
- many hospitals won't take them
Associated Features of firesetting: - academic problems
- truancy
- behavior problems
- impulsive behaviors
- family stressors may trigger
recidivism is high (even in juvi cases where it is >25%)
- most persistent predictor of conduct disorder
- can be mild, moderate, or severe
- early onset is more often the rule than the exception
- can be legal and psychological repercussions
- associated with maturity problems and other psychopathology
prevalence of firesetting: - 3% of general population
- 10:1 m:f ration inpatient population
- most are average intellectual functioning
Treatment for Firesetting: - earlier the better
- may need to include anger management
- may include social skills training
-family Tx may help
- firesetting behaviors need to be dealt with separately and specifically
- parent training
- young kids might be taught to set contained fires to satisfy their curiosity
- may assess level of supervision child needs
ADHD Basics: -used to call it minimal brain damage or Hyperkenetic
- PERSISTENT PATTERN of INATTENTION and/ or HYPERACTIVITY-IMPULSIVITY more frequently displayed and more severe than normal
- some symptoms that cause impairment have to have been present prior to age 7 (even though often diagosed after that)
- must be IMPAIRMENT in TWO SETTINGS AT LEAST
- Clear evidence of interference with developmentally appropriate social, academic, or occupational functioning
- doesn't occur exclusively during a PDD, schizophrenia, or other psychotic disorder
DX pic for ADHD - inattention: INATTENTION
- in all settings
-lack of attn to details; careless errors
-messy work w/out much thought
-difficulty sustaining attn. in tasks or play, and don't complete things
- daydreaming, not listening to/ hearing what's being said
- freq. shifts from one activity to another (uncompleted)
- fail to meet rewuests or instructions or to complete schoolwork, chores (only due to inattention
- difficulty organizing tasks and activities
- avoid and dislike tasks tat require sustained attn
- materials often lost and work habits disorganized
- easily distracted by irrelevant stimul
- forgetful in daily activities
- frequent shifts on conversation, not listening to conversation
Dx pic for ADHD - Hyperactivity: - fidgitiness, squirming
- not remaining seated
- running or climbing
- can't play quietly or enjoy leisure activities
- "on the go" or "driven by a motor"
- excessive talking
- varies with age (less active the older we get)
Dx pic for ADHD - Impulsivity: - impatience
-difficulty in delayed responses
- blurting out answers
- difficulty awaiting one's turn
- freq. interupting and intruding on others
- grab things from others
- make comments out of turn
- fail to listen to directions
- touch things they aren't supposed to touch
- may lead to accidents and to engage in potentially dnagerous situations without thinking
Addition Dx pic for ADHD: - attentional and behavioral manifestations usually appear in MULTIPLE CONTEXTS (at least 2 needed)
- however, it isn't likely for someone to show the same level in different contexts or the same level within a context all the time
- symptoms worsen when there is nothing novel or in situations that reqiure a lot of attention
-more likely to occur in a group setting
- get info from many sources and various situations in each setting
Assessment Issues for ADHD: - 50% of girls amd 80% of boys = what teachers would say are ADHD
- MUST account for DEVELOPMEMT
- don't have norms, so we can't really do this.
- probably not going to get info from kid
- get info from parents and teacher -> if info. doesn't match, probably isn't correct diagnosis
- specifics, close-ended ?s
-paper and pencil tests; Tom Achenbauch-age 4-18 - CBCL/TRF/YSR(11+); can't dx with one of these, but it is a screening tool and a way to measure severity and change over time; Conners scales
Subtypes of ADHD: - ADHD, Combined Type
- ADHD, Predominantly Hyperactive-Impulsive Type
- ADHD, Predominantly Inattentive Type
Associated Features of ADHD: - vary depending on age and developmental stage
- low frustration tolerance
- temper outbursts, bossiness, stubborness, escessive and frequent insistance that requests be met
- mood lability
-demoralization
-dysphoria
rejection by peers
-poor self esteem
- academic failure
- accidnet prone
- learning disabilities
- family relationship problems
- underactivity of certain brain functions
-poor self-esteem
seen as intrusive, irritating, and insensitive
- likely to be aggressive (which will be BAD Px)
- later in life probs = employment probs, academic underachievement, relationship probs, divorce rates >
Associated Dx of ADHD: - -comorbid ODD = worse prognosis (in terms of function)
- comorbidity with CD is also really bad
Etiology of ADHD: - we don't know
- risk factors include:
- pre/ peri- natal probs
- lead poisoning
- malnutrition
- early health probs
- inconsistent research on biological findings and genetic vulnerability
- more first degree relatives of chilren with ADHD will have ADHD
- twin concordance rates are also suggestive
- it's genetic and environmental
Prevalence of ADHD: M:F RATIOS
- GENERAL POP: 3:1
- CLINICAL: 10:1
- girls get overlooked b/c their presentation is less annoying that boys in that they are less likely to be aggressive or learning disabled
PREVALENCE:
- 7-8% of gen. population
Course of ADHD: - chronic
- evidence it appeared before age 7 and for a minimum of 6 months
- usually dx in elementary school (girls later)
- 1/3 will normalize by adolescence; 2/3 will have i nadolescence; some of those will continue into adulthood
- looks different in child/ adolesc/ adult
- doesn't just go away
- Dx prior to 6 is mistake
Differentials for ADHD: - MR: only if symptoms are excessive of child's mental age
- understimulating environments
- PDD's: distinguish from impulsivity or hyperactivity you see in those disorders
- Psychotic Disorder
- Mood and Anxiety disorders: these kids tend to not be aggressive or impulsive like ADHD kids
- learning disabilty, ADHD, or both?
GMC like hyperthyroidism
Mania: bipolar is episodic, not chronic and pre-pubital mania is very rare while ADHD is not
Tx of ADHD: MEDS
- meds studied more than any other intervention for 40 years
- some kids need 'em, some don't
- most effective form of Tx
- work with kids pediatrician
- stimulant most commonly used (75% postitive response)
- doesn't cure, just helps them to calm down and focus, to gain control so other aread can be handled
* educational management
* most work done e/ parents
* NO standard psychotherapy
* teaching parental tips, maybe family Tx
* once Dx is received, child can receive benefits under the ADA
Oppositional Defiant Disorder basic information: - recurrent pattern of NEGATIVISTIC, DEFIANT, DISOBEDIENT, and HOSTILE BEHAVIOR toward authority figures ther persists for at least 6 months and is characteried by at lest FOUR of the following behaviors:
- losing temper
- arguing with adults
- actively defying or refusing to comply with the requests of adults or rules
- diliberately doing things that will annoy other people
- blaming others for own mistakes or behavior
- touchy and easily annoyed by others
- angry and resentful
- spiteful or vindictive
- happens more freq. than compared to norms for age, dev and cause impairments in functioning
- no Dx if happens exclusively during a psychotic or mood disorder or if cruteria are made for CD or AS-PD
ODD Dx features: - negativistic and defiant behaviors are expressed by persistent stubborness, resistance to directions, unwillingness to compromise, give in, or negotiate with adults or peers
Defiance - deliberate or persistent testing of limits, usually by ignoring orders arguing, or failing to except blame
-Hostility: deliberately annoying others or verbal aggression (usually w/out physical like in CD)
- usually always in the home setting, but may not be seen in school or community (b/c symptoms are more evident with people the child knows well)
- usually don't see their own behavior as oppositional but rather as a response to unreasonable demands or circumstances
Associated Features and Disorders of ODD: - vary as a function of age and severity of ODD
- in MALES, more prevalent in those who had problematic temperments in preschool or high motor activity
- may be low (or inflated) self-esteem in school years, along with mood lability, low frustration tolerance, swearing, precocious use of alcohol, tobacco, or drugs
often conflicts with parents, teachers and peers
- vicious cycle where parent and child bring out the worst in each other
Etiology of ODD: - don't know
- more prevalent in fams where childcare was often disrupted by several different caregivers or in fams that used harsh, inconsistent, or neglectful child-rearing practices are used
- ADHD is commonly comorbid
- also associated with learning disorders and defiant disorder
Specific Age and Gender Features of ODD: - be very careful Dx-ing ODD during the developmental periods of preschool and adolescent kids because transient oppostional behavior is common then
- The # of oppositional symptoms tends to increase with age
- More prevelent in males than females before puberty, but equal afterwards
- symptoms generally same in both genders, except males may have more confrontational behavior and more persistent symptoms
Prevalence of ODD: - 70-80% overlap with ADHD
- 2-16% = prevalence rate, but it is not meaningful because the range is so larger
Course of ODD: - Usually evident by age 8 and no later than early adolescence
- symptoms often emerge in home setting but may spread over time
- typically gradual onset, over months or years
- often developmental antecedent to conduct disorder, childhood-onset type, but not all
- symptoms must be present for at least 6 months
- stable behavior in asolescence
- # of symptoms increases with age
Risk Factors for ODD: - the way parents react to a child's behavior
- closely linked with ADHD
- poor parenting/ child bahevior
4 Factor Model of Underlying causes of ODD: 1) Parent's tempermemnt: inconsistent parenting stratregies- ehrn opp. beh. is established through intermittent reinforcement, extinguishing it is very difficult
2) Child Temperment
- born with it, and some are more emotional, overactive, inattentive, etc.
3) (Parents) Child Management Skills:
- especially when parents don't monitor their kid's activities
4) Family Stress
- internal and external events affecting family can aid in the development and maintenance of IDD
Tx for ODD: - limit setting
- rigorous behavioral approaches
- teaching parents to set limits, how to use reinforcement, punishment, extinction, and negotiation to handle kid's behavior
- establish with parents that you will be working with them, not their kid really
- successful if family is comliant and motivated which you should tell them mearly on so they have no excuse if it doesn't work
- marital or individual Tx for parents may be an appropriate suggestion
Prognosis for ODD: - better the sooner they get treatment
Differentials for ODD: - normal development/ behavior
- CONDUCT DISORDER: ODD won't show aggression towards people or animals or destroy property. etc.; ODD is primary risk factor for CD, but you don't have to have ODD first
-ADHD: can ADHD/ODD/ or both (same patterns of behaviors; impulsivity, inattention; low self esteem; low frustration tolerance)
-Depression: some may have both
- PTSD: may sometimes look like ODD because it is how they are responding to trauma
Conduct disorder basic info: - basic rights of others or major age-appropriate societal norms or rules are violated
- behavior falls into these 4 groupings:
1) aggressive conduct that cause or threatens physical hard to other people or animals
2) Non-aggressive conduct that causes loss or property or damage to it
3) deceitfulness or theft
4) serious violation of rules
- At least 3 behaviors have been present in the past 12 months with at least one present in the last 6 months
- clinical functional impairment
-CD may be Dx-ed in kids over 18, but only if AD-PD is not met
-behavior in a variety of settings
-rely on other informants since client will usually minimize their behavior
Dx features of ODD: - initiate aggressive behavior or react aggressively
- bullying, threatening, or intimidating behavior
- initiate freq. phys. fights
- use a weapon
- physically cruel to people and animals
- steal while confronting a victim
- force someone into sexual activity
- fire setting w/ intention of causing serious damage
- deliberately destroying others property
- breaking and entering
- freq. lying or breaking promises to obtain goods or avoid debts
- stealing items of non-trivial value without confronting the victim
-before 13, staying out past curfew
- pattern of running away, 2x or 1x for an extended time
- truancy prior to age 13 (absent from work with no reasom)
Subtypes of CD: Both occur in mild, moderate, and severe form
CHILDHOOD ONSET TYPE
- onset of at least one criterion of CD ptior to age 10
- usually male
- freq. display physical aggession towards others
- disturbed peer relationships
- may have had ODD in early childhood and usually meet full criteria for CD by puberty
- many also have ADHD
- more likely to have persistent conduct disorder and develop anti-social personality disorder
ADOLESCENT ONSET TYPE
- no criteria met prior to age 10
- less likely to display aggressive behavior
- more normative peer relationships
- less likely to have persistent CD and development of antisocial PD
- ratio of males to females is is lower for adolescent than childhood onset type
UNSPECIFIED ONSET
Severity specifers of CD: MILD:
few if any conduct problems in excess of those required, and those that are present cause relatively minor harm to others
MODERATE
the # of conduct probs and effects on others are intermediate between mild and severe
SEVERE
many conduct probs in excess of what is required or conduct causes considerable harm to others
Associated Features of CD: - little empathy and little concern for other's feelings, etc.
- often misperceive intentions of others as hostile and respond with aggression
- callous and lack appropriate feelings of guilt or remorse
- hard to tell, because they learn to fake guit
- narc and blame others for their misbahavior
- low self-esteem despite projected "tough" image or overly inflated
- poor frustration tolerance, irritability, temper outbursts, and recklessness
- higher accident rates
- early onset of sexual behavior, drinking, smoking, and drugs (risky beh)
- school expulsion, legal difficulties, STDs, unplanned pregnancy, or physical injuries
- suicide ideation/ attempts/ completions higher
- lower than avg. intelligence, esp. verbal IQ
Associated Disorders of CD: - Learning or Communication
- Anxiety
- Mood
- Substance-Related Disorders
predisposing risk factors for CD: - parental rejection and neglect
- difficult infant temperment
- inconsistent and harsh parenting
- physical or sexual abuse
- lack of supervision
- early institutional living
- frequent changes in caregivers
- large fam size
- mom smoked while pregnant
-peer rejection
- association with delinquents
- neighborhood exposure ti violence
- certain familial psychopathology
SES NOT A RISK FACTOR
Course of CD: - chronic
- beh. for at least SIX months
- stable over time
- symptoms vary with age and increase over time with cognitive and sexual development
- onset as early as 5 or 6; after age 26 is rare and most will show prior to 16
Prognosis of CD: - confrontational behavior = worse Px
- sig. amt. remit byadulthood (55%) leaving 45% in adulthood
-The earlier the presentation = worse Px
- BEST PROGNOSTIC INDICATOR OF WORST OUTCOME
- more likely to get divorced more than once
Epidemiology of PD: - rates vary as a function of definition and different international definitions
- US has higher rates of ADHD while Britain has higher rates of ODD (because of def. issues)
PREVALENCE:
* Girls: 3%
* Boys: 7-8%
* M:F Ratio = 2/3:1
* earlier onset for boys than girls
* boys more likely referred for aggression while girls are referred for sexual behavior
Intervention for CD: - ohysical aggression needs to be addressed with kids
needs to be multifaceted, no single Tx works
- family issues must be addressed
- school probs need to be treated
- indiv. Tx, group Tx, or residential Tx
- NO MEDS TO FIX BEHAVIOR (only used to mediate aggression when severe)
- parental training
- social skills training
- problem solving training and challenging hostile attributions (older kids)
- CBT approaches, anger management, and impulse control training w/ adolescents
- broader strategies too involving community, school, etc.
Differentials for CD: ODD
-If they meet the criteria for CD, they have CD
ADHD
- CD show pattern of violating rights of others that ADHD kids don't show
- criteria for both disorders can be met
MANIA
- now "misdiagnosis of choice"
- CD kids are often reckless and irritable like manic ones, but: mania is episodic while CD is chronic
PSYCHOSIS
- are they responding to delusions or hallucinations?
ADJUSTMENT DISORDER W/ DISTURBANCES OF CONDUCT
- if they meet CD criteria, then stressor isn't relavant to Dx (it can be noted on Axis 4)

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