Week 5 (Neural and Behavioral Development) Flashcards

1
Q

Mental disorders where developmental abnormalities are likely to be involved

A

Autism Spectrum Disorders (ASD)

Attention deficit hyperactivity disorder (ADHD)

Schizophrenia

Fetal Alcohol Syndrome (FAS)

Note: may be due to genetic associations, exposure of toxins

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2
Q

When is the “risk period” for exposure of CNS to toxins?

A

All throughout pregnancy and even through childhood and adolescence (brain weight increases 3 fold from birth to young adulthood!)

Significant develomental changes occur in cerebral cortex and in myelination until end of 2nd decade

Note: different from other developmental problems where toxin exposure during first trimester is worst

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3
Q

Embryonic regions of neural tube and the parts of the brain they give rise to

A

Forebain (prosencephalon) –> telencephalon –> cerebral hemispheres

Forebrain (prosencephalon) –> diencephalon –> thalamus and hypothalamus

Midbrain (mesencephalon) –> Mesencephalon –> midbrain

Hindbrain (rhombencephalon) –> metencephalon –> pons and cerebellum

Hindbrain (rhombencephalon) –> myelencephalon –> medulla

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4
Q

Spina bifida

A

Abnormal closure of neural tube during weeks 3 and 4

1/1000 births in US

Lack of folic acid intake before conception and during pregnancy

Spina bifida occulta: vertebrae do not fuse across the top; dura intact and no structural hermiation; hairs or dimple at level of defect; usually seen at lower vertebral levels

Meningocele: vertebrae do not fuse across the top; meningial coverings of spinal cord enlarged and bulge out under skin but spinal cord itself still in place

Meningomyelocele: vertebrae do not fuse across the top; cord itself is bulging out into skin area (serious vulnerability for permanent damage to spinal cord)

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5
Q

How/where does massive cell proliferation occur during embryogenesis?

A

Massive cell proliferation occurrs primarily in periventricular germinal zones (on one side of the neural tube)

Periventricular regions contain neural stem cells (NSC) that generate neural progenitors (embryonic stem cells, transition “stem” cells, multipotent neural stem cells, committed neural progenitors)

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6
Q

Cellular differentiation during development

A

NSCs in a particular region initially generate neurons then astrocytes then oligodendrocytes

Cellular differentiation is regulated by molecular signals that include protein growth factors (FGF, EGF, IGF, BMP, NGF, etc), retinoic acid (accelerates maturation of stem cells too early which is bad!), transmitters

Environmental toxins that interfere with or mimic these signaling mechanisms can disturb cell division/differentiation and cause developmental abnormalities

Different processes going on simultaneously in diff regions so toxins or ischemia may affect one region and not another, or may affect different regions at different times

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7
Q

Periventricular Leukomalacia (PVL)

A

Failure to develop white matter secondary to periventricular ischemia during gestation

Highest vulnerability during 26-36 weeks gestation

Premature infants at particular risk

Periventricular ischemia leads to loss of oligodendrocyte progenitor cells in periventricular tissue (and other things)

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8
Q

Juvenile and adult neurogenesis

A

Multipotent neural stem cells in periventricular regions of juvenile and adult CNS can be propagated in tissue culture and give rise to neurons, astrocytes and oligodendrocytes

Function in vivo not yet well established: give rise to certain neurons and glia, replace cells after injury or disease, tumor stem cell hypothesis (are adult NSC a source of cancer stem cells for glioma?)

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9
Q

NSCs in hippocampal dentate gyrus

A

NSCs persist throughout life in hippocampal dentate gyrus

New neurons are born and incorporated there throughout life (total number of neurons stays stable though because neurons die)

Neurons may be important in: formation of certain types of new memories, certain types of seizure disorders

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10
Q

Behavioral effects of chemotherapy

A

Chemobrain” when you get cognitive disturbances after chemotherapy

May be due to toxic effects on adult NSCs and reductions in adult hippocampal neurogenesis

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11
Q

Cell migration in the brain

A

Spatial organization in CNS is achieved by cell migration

Periventricular regions contain NSCs that generate neural progenitors that then migrate away

Cell migration guided by molecular cues (integrins, NCAMs, laminin, fibronectin, ephrins, semaphorins)

Neuroblasts and neurons migrate along processes of radial glia

Cell migration proceeds from inside (ventricular zone) to outside (surface of brain/pia) and occurs over a long period of time during gestation

Deeper layers of cortex (zone VI) form first, then V, then IV, then III, etc

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12
Q

When does generation of cortical neurons occur during gestation?

A

Cortical neurogenesis is from 2 months to at least 8 months of gestation

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13
Q

Radial glia

A

Guide neurons during development, then turn into astrocytes

Note: Alcohol causes premature transformation of radial glia into astrocytes, which disrupts migration of cortical neurons and disturbs cortical development

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14
Q

Growth of connections

A

Neural connections are formed by axonal migration

Axonal growth and migration are achieved by growth cones (contains machinery in it, and new membrane is added immediately behind the growth cone)

Direction of axonal migration controlled by positive and negative guidance cues that attract or repulse growth cones, in particular the filopodia

Guidance cues can be contact-mediated or diffusion-mediated

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15
Q

Synapse formation (synaptogenesis)

A

Mature synapses are complex structures with high densities of many different kinds of molecules (adhesion, structural, receptors, ion channels, second messengers)

Formation of individual synapses can occur quickly (minutes to hours) and begins with spine formation and interaction of adhesion molecules followed by accumulation of vesicles and other structural elements

Synaptogenesis begins during first trimester, continues throughout gestation and juvenile development, is ongoing to some degree throughout adult life (and aging) where it is an essential part of synaptic plasticity

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16
Q

Synapse density in cerebral cortex

A

Increases rapidly during 3rd trimester of gestation and first postnatal year

Peaks in visual and auditory cortices at 1 year postnatal

Peaks in frontal cortex at 4-5 years postnatal

Is subject to “pruning” after peaking

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17
Q

Myelination

A

In CNS, myelination achieved by oligodendrocytes

Oligodendrocytes derive from periventricular progenitors and migrate to where they are active

Very few axon tracts myelinated at birth, most occurs after birth and proceeds until end of teenage years

Many developmental milestones (walking, talking) correlate with myelination

Disturbances in myelination result in functional defects

Myelination can be assessed in vivo during childhood development using MRI

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18
Q

What happens to white and grey matter throughout childhood and adolescence

A

White matter increases and grey matter decreases

Not losing neurons, but losing synapses, which accounts for decrease in grey matter

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19
Q

Obesogens

A

Environmental toxins that may cause fetus to grow up to be obese

Pesticides (fungicides), phthalates (shampoos, cosmetics), BPA (in plastic), about 20 substances total

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20
Q

Developmental age groups

A

Infancy: 0-12 months

Toddlers: 12-36 months

Preschool: 3-5 years

School-age: 6-12 years

Adolescence: 13-18 years

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21
Q

Behaviorism

A

John Watson said “give me a dozen healthy infants…I can train them to become anything I want–doctor, lawyer, artist, thief, etc”

Emphasis on nurture over nature

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22
Q

Jean Piaget

A

Nature and nurture are interactive and inseparable

Cognitive development occurs in stages and each stage contingent on the one before

Each stage represents qualitative change in cognitive conceptual structures, not just an increase in knowledge

Schemas: building blocks of knowledge (dog is four legged and furry –> later on…that barks and slobbers)

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23
Q

Piaget’s cognitive stages

A

Sensorimotor (0-2 years): infant explores world through direct sensory and motor contact; object permanence and separation anxiety develop during this stage

Preoperational (2-6 years): child uses symbols (words and images) to represent objects but does not reason logically; has ability to pretend; is egocentric

Concrete operational (7-12 years): child can think logically about concrete objects and can add and subtract; understands conservation

Formal operational (12-adult): adolescent can reason abstractly and think in hypothetical terms

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24
Q

Erik Erikson’s stages of psychological development

A

Basic trust vs. mistrust (0-1 years): children develop sense of trust when caregivers provide reliable care; success leads to trust

Autonomy vs. shame and doubt (1-3 years): children need to develop a sense of personal control over skills; success leads to autonomy

Initiative vs. guilt (3-5 years): children need to begin to assert power and control over their environment; success leads to sense of purpose

Industry vs. inferiority (5-11 years): children need to cope with new social and academic demands; success leads to sense of competence

Ego identity vs. role diffusion (11-21 years): teens need to develop sense of self and personal identity; success leads to ability to stay true to oneself

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25
Q

Temperament in infancy

A

Way in which child interacts and responds to his/her environment

Can change over time with environment

Easy, slow-to-warm-up, difficult = 40%, 15%, 10%

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26
Q

Gross motor developmental milestones

A

Infancy:

6 weeks: controls head when held upright

4 months: rolls front to back

6 months: rolls back to front and sits unattended

9 months: pulls to stand

12 months: starts to walk unattended

Toddlers:

15 months: crawl up stairs, walk backwards

18 months: walk stairs with help and run

24 months: ball skills and walk on tip-toes

30 months: jump

36 months: alternate feet up stairs

Preschool:

3 years: use of utensils, broad jump, gallop (most show hand preference by age 3)

4 years: alternate feet down stairs, hop and skip

5 years: balance 10 seconds on one foot and print letters

School age: refined coordination for sports/fine arts

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27
Q

Fine motor developmental milestones

A

Infancy:

6 weeks: reaches for objects

4 months: grasps objects

6 months: transfers objects across midline and puts objects in mouth

9 months: plays pat-a-cake and uses refined pincer grasp

12 months: tower of 3 blocks

Toddlers:

18 months: scribble

24 months: put on garments

36 months: 9 blocks; bridge of blocks; R/L preference

School age: cursive, typing

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28
Q

Language developmental milestones

A

Infancy:

1 month: responds to directed call

3 month: coos

6 months: babbles (mama, dada) inappropriately

9 months: mama and dada appropriately

12 months: follows simple commands, at least 1 word

Toddlers:

2 years: 2 words; 50% intelligible; follow 2-step commands

3 years: 3 words (phrases); 75% intelligible; follow multi-step commands

4 years: 4 words (sentences); 100% intelligible

Preschool: conversation, feelings, talk about past

School age: inferences, jokes, sarcasm, reading

Adolescence: comprehend double meanings, make inferences

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29
Q

Social-emotional developmental milestones

A

Infancy:

3 months: responsive smile

6 months: sense of self and attachment with caregiver

9 months: separation and stranger anxiety

12 months: beginning of empathy

Toddler: increasing anxiety over separation and seek extra support when returning, but as comfort level with separation increases, length of separation increases

Preschool:

3 years: toilet trained, know own age and gender, play imaginative, take turns, share

4 years: interactive play in small groups, pretend social scenarios and role playing

4-5 years: simple board games, follow rules

School age: accomplishment, best friend, segregate by gender, sportsmanship

Adolescence: peer group sets standard, individuality from parents, romantic relationships, hobbies, etc

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30
Q

Cognition developmental milestones

A

Infancy:

0-4 months: modify/regulate primitive reflexes

4-8 months: manipulate objects meaningfully

7 months: attention span is 5 minutes

9 months: object permanence

8-12 months: goal-directed behavior

Toddlers:

12-18 months: cause and effect

15 months: functional play (push the car) and early representational play (toy phone)

18-24 months: symbolic representation and body parts

24 months: start of simple concepts (size, color, number)

Preschool:

3-4 years: identify colors

4-5 years: identify complex body parts

5-6 years: understand abstract symbols (letters, numbers)

School age: conservation, reasoning, organization (HW), active working memory, attn span 1 hour

Adolescence: abstract thinking, hypotheses, deductive reasoning, speculate and consider alternative possibilities (can lead to idealism)

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31
Q

Assessment tools

A

Parent questionnaires and examiner based assessments

Early development: Denver Developmental Assessment and Mullen scales of Early Learning (ages 0-5)

Cognitive assessments: WPPSI (ages 3-7), WISC-IV (ages 6-16)

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32
Q

How do neural circuits develop?

A

Incorporates mechanisms that are able to deal with targeting errors and with influences that derive from interactions with the environment

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33
Q

Regressive events

A

Prominent features of neural development

Naturally occurring cell death

Pruning exuberant connections and synapses (reduction in grey matter during childhood and adolescence)

Combinations of synaptic plasticity and regressive events during juvenile development allow interactions with the environment to “sculpt” neural systems in permanent or long lasting ways: “critical periods,” language, ocular dominance, colonization of “unused” cortex

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34
Q

Naturally occurring cell death

A

Plays central role in the formation of neural circuits

More neurons are born than are needed

Only those neurons survive that make connections to appropriate target neurons

Survival is determined by retrograde transport of trophic factor produced by target cells!

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35
Q

Neurotrophic growth factors (NTF) produced by target neurons

A

Neuronal survival is supported by neurotrophic growth factors (NTF) that are produced by target neurons and are retrogradely transported by input neurons

Afferent (signaler) neuron must be active in order to cause target neuron to secrete NTF though!

External (environmental) factors that influence target neural activity can alter trophic factor production and influence circuit development!

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36
Q

Pruning exuberant axonal connections

A

Pruning of connections plays a central role in the formation of neural circuits

More connections are made than are needed

Only appropriate connections are maintained

Maintenance of connections is determined by neural activity and by trophic factors produced by target cells

Axons can overshoot their normal targets by long distances and send out many exuberant branches that are either pruned or in some cases persist on the basis of activity dependent interactions.

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37
Q

How can environment affect neuronal survival?

A

Environmental factors that influence target cell activity and trophic factor production can sculpt circuit development by influencing afferent neuronal survival and the maintenance of connections

Environmental factors that influence target cell activity by the afferent neuron can regulate trophic factor production by the target neuron, which in turn can sculpt circuit development by influencing afferent neuronal survival and synaptic connections

If no activity, whole connection pruned

If weak activity, synapses may be pruned

If highly active, synapse strengthened

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38
Q

NGF

A

Founding member of the neurotrophin family

Can activate multiple signaling pathways that influence different cellular processes (PI3 kinase for cell survival and ras and PLC pathways for neurite outgrowth and neuronal differentiation)

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39
Q

Other molecules that act as developmental growth factors

A

BDNF, NT3, NT4/5

These are structurally related to NGF but also have other functions in mature animals (other than developmental growth factors)

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40
Q

Neurotrophins

A

NGF, BDNF, NT3, NT4/5, CNTF, FGFs, IGF, EGF, thrombospondin (produced by astrocytes)

Capable of complex signalling interactions that can influence many different cellular activities during development and after maturity (cell survival, neurite outgrowth and neuronal differentiation, activity-dependent plasticity, cell cycle arrest, cell death)

Different neurotrophins, alone or in combination, help to determine final pattern of connectivity of sensory neurons in the peripheral nervous system by mediating target effects on regressive effects that determine which neurons and terminals survive pruning

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41
Q

Molecules other than neurotrophic factors that have effects on developing nervous system

A

Steroids (sex and adrenal)

Thyroxin

Transmitters

Etc

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42
Q

Synapse plasticity and synapse formation

A

New growth in the form of terminal sprouting, dendritic branching and synapse formation are important aspects of juvenile neural development that add substantially to tissue volume

Synapse formation also “sculpted” by environmental interactions or influenced by exposure to hormones, toxins and other molecules

Note: neuropil fills space between neurons with dendritic branches and synapses, which is a lot of space, so changes in neuropil volume (which correlates with synapse density) can be measured in MRI scans

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43
Q

Synaptic pruning in adolescents with schizophrenia

A

Adolescents with schizophrenia have decreased grey matter in cortex

This loss may correlate with increased synaptic pruning and decreased synaptic density

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44
Q

Critical periods in development

A

Developmental windows in which anatomical connections and functional properties of neural cells and circuits can be modified by experience (AKA environmental interactions during juvenile development can have permanent effects on CNS structure)

Changes (increases or decreases) in activity during the brief developmental “critical periods” can cause permanent changes in CNS structure

Critical periods are windows of opportunity–activity that occurs after a critical period has passed will not be able to establish the normal adult pattern of structure

Loss of activity in adults does not alter the established structural pattern in adults in the same way as loss of activity during the critical period

The time of critical period varies with systems

Examples at the behavioral level: parent imprinting in birds, language in humans (learn language with no accent if 3-7yo)

Example at the cellular level: visual system

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45
Q

Critical period for primary visual cortex

A

Evidence for environmental regulation (pruning) of afferent axon terminals in ocular dominance columns in the primary visual cortex

During development, projections from both eyes initially overlap, followed by progressive segregation of projections into separated domains for each eye by pruning of exuberant collateral branches (this segregation requires stimulation in the form of light activation of the retina)

If light activation of retina and pathways is blocked in one eye during critical period of development (2-3 months), then the pathways of the activated eye survive, while those of the un-activated eye are pruned

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46
Q

Clinical therapy for amblyopia based on recognition of critical period importance

A

Amblyopia is abnormal development of visual cortex due to deprivation of vision in one or both eyes during childhood due to strabismus, congenital cataract or other causes

Untreated strabismus can lead to domination of visual cortex development by one eye, with consequent failure of development of binocular vision

Treatment consists of achieving binocular stimulation of the visual cortices by use of eye patches (over dominant eye) or glasses (or surgery to adjust extra-ocular muscles)

Treatment is most effective when initiated before 5 years of age, and is somewhat effective in teenagers and less so in adults

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47
Q

Colonization of “unused” cortex

A

In sighted people, V1 is the primary visual cortex

In the blind (from birth), V1 can be used for verbal memory

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48
Q

Mental disorders where developmental abnormalities are known or suspected

A

Autism Spectrum Disorders (ASD)

Attention deficit hyperactivity disorder (ADHD)

Schizophrenia

Fetal alcohol syndrome (FAS)

(Drugs of abuse)

Potential causes include genetic associations and exposure to toxins, the timing during development of which determines symptoms

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49
Q

Variety of developmental abnormalities in autism spectrum disorders (ASD)

A

Neuropathological evidence for multiregional dysregulation of neurogenesis (increased brain mass, increased regional cell densities, reduced neuronal size), neuronal migration (heterotopia (abnormal neuronal groups), dysplasia of cortical architecture (dyslamination)), synapse development (abnormal signaling in post-synaptic spines and dysregulation of glutamate signaling in Fragile X)

Imaging evidence for increased brain mass, abnormal myelination

Etiologies are not certain: evidence for complex genetic influences, but also ASD symptoms from single gene mutations (Fragile X syndrome with FMR1 and Rett syndrome with MECP2)

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50
Q

Similarities between ADHD and FAS

A

ADHD and FAS exhibit abnormalities of cerebral cortex development that result in certain cortical regions having either increased or decreased cortical thickness relative to controls

This suggests it may be possible to identify cortical changes associated with behavioral phenotypes and eventually may help with diagnosis or therapy

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51
Q

Environmental factors that may be essential to development during critical periods

A

Social interactions

Training and learning

Exposure to toxins

Essential nutrients

Hormones

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52
Q

The attachment relationship

A

Emotional or affective bond between infant and caregiver

Nature of attachment relationship is thought to reflect the quality of interaction between infant and caregiver, not to be reflective of attributes of either the infant or caregiver alone

Thus, each attachment relationship is unique to a particular dyad

Caregiver functions (ideally) as a secure base and as a safe haven

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53
Q

Secure base and safe haven

A

Caregiver functions (ideally) as both of these

Secure base: when a child trusts that (s)he has a sensitive, responsive, dependable caregiver, (s)he is able to venture out and explore the world around him/her

Safe haven: when a child trusts that (s)he has a sensitive, responsive, dependable caregiver, (s)he will seek comfort or reassurance from that caregiver when (s)he feels distressed or threatened

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54
Q

Attachment behavior

A

Organized system of behaviors (not just single behavior) that infant uses to maintain interaction, proximity, connection with caregiver

Activated under conditions of threat

Serves a protective function, evolutionarily adaptive

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55
Q

Attachment figures

A

Can be primary and secondary

Historically, mothers were considered a priori to be primary attachment figure, but now is increased recognition that other caregivers can be primary attachment figures (fathers, grandparents, child care providers)

As childcare duties are dispersed across more caregivers, child may develop more than one primary attachment figure

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56
Q

Attachment theory

A

John Bowlby’s assumptions

Early infant-caregiver interactions are viewed as a foundation for other social relationships established in childhood, adolescence, and adulthood

Patterns of dyadic regulation between infant and caregiver give rise to the child’s ability to self-regulate

Quality of attachment relationship (secure vs. insecure) reflects differences in these patterns of dyadic regulation

Quality of child’s early attachment relationships will have implications for patterns of adaptation throughout the life span, with regards to behavioral, social, emotional, cognitive functioning

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57
Q

Development as a relational process

A

Early development is inextricably embedded in the infant-caregiver relationship

The human infant relies on caregiver not just for sustenance but for external regulation of physiological states

Over time we learn to regulate ourselves, but this ability to self-regulate originates in large part in the context of earliest relationships with caregivers

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58
Q

Capacities of newborn infants

A

Just a few hours after birth, infants will show preference for mother’s face over a female stranger’s and that preference will occur even with relatively little viewing of the mother

By 1-2 days of life, infants can recognize mother’s smell

As early as 3rd day, infants can discriminate mother’s voice

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59
Q

Development of attachment relationship between mother and newborn infant

A

Mutual regulation: mothers and newborn infants help regulate physiological responses of one another

Ideally a synchrony develops between infant and caregiver: the “dance” that occurs between parent and child during brief, but emotionally intense, playful interactions

Notably, much of infant-caregiver interaction involves mismatched states: the key is not whether infant and caregiver are always in sync, but whether there are attempts to repair interactions

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60
Q

Strange situation

A

Lab procedure to develop methodology for assessing patterns of infant-caregiver interaction in order to provide empirical validation for attachment theory

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61
Q

Infant attachment classifications

A

Secure: 65%; actively explores environment, shares experience w/caregiver, visibly upset during separation (esp second separation), actively greets parent upon reunion; if upset, seeks proximity to caregiver and can be soothed by caregiver; once comforted, returns to exploration

Avoidant: 20%; readily explores environment, but minimal display of affect or using parent as secure base; minimal apparent distress during separations; little or no proximity seeking upon reunion, possible active avoidance; may stiffen, lean away, prefers to interact with toys

Ambivalent/resistant: 15%; exploration is of poor quality, often visibly distressed even before separation; extreme distress during separations; mixes proximity seeking with resistance upon reunion, cannot be soothed

Disorganized: 15%; behavior lacks any apparent goal or intention; displays of contradictory behavior, often simultaneously; incomplete, interrupted movements; odd postures, stereotypes, freezing, stilling, fear grimaces

62
Q

Infant attachment, parenting and child’s emotional regulation

A

Secure: parent responds sensitively and consistently; child feels comfortable expressing range of emotions; child can be soothed, and learns to soothe self

Avoidant: parent is rejecting, minimizes child’s distress, may mock or express resentment at child’s expression of distress; child learns to suppress emotional needs

Ambivalent/resistant: parent is inconsistently available, may alternate between being neglectful and intrusive; may use threats of abandonment as a means of control; child learns to heighten, exaggerate distress

Disorganized: parent may be abusive, or caregiver has been traumatized themselves: frightening or frightened behavior; child has no clear consistent strategy for regulating emotions

63
Q

Internal working models

A

Clear set of expectations about availability, responsiveness, and sensitivity of their primary caregiver(s)

Mechanism that provides for continuity in attachment across the life span

Are carried forward into other social relationships and used to appraise interactions and guide behavior in the context of those relationships

64
Q

Infant attachment and childhood outcomes

A

Secure: better social skills, more elaborative play, more independent exploration, better cognitive skills and academic outcomes

Avoidant: more hostile and less empathetic with peers, more conflict in play, more easily frustrated

Ambivalent: more vulnerable to bully, show empathy but difficulty with boundaries, elicit nurturance from more competent peers and from teachers, more inhibited in play, restricted exploration during play

Disorganized: wary and withdrawn, views peers as threatening, play characterized by catastrophic themes, enhanced response to stress

65
Q

Infant attachment and socioemotional well-being in adolescence and adulthood

A

Secure attachment in infancy predictive of greater social competence during adolescence

Disorganized attachment in infancy predictive of hostility in romantic relationships in early adulthood, two decades later and predictive of conduct disorder, self-injurious behavior, and dissociative symptoms at age 17

Ambivalent attachment in infancy predictive of anxiety disorders at age 17

66
Q

Infant attachment and health outcomes in childhood and adulthood

A

Insecure attachment in toddlerhood related to obesity at 4 1/2 years old

Girls who were insecure as infants have shown an earlier onset of puberty then those who were secure as infants

Insecure attachment in infancy predicted higher rates of inflammation-based illness 30 years later

67
Q

Evidence-based interventions to promote secure attachment relationships

A

Focus is on enhancing the quality of the caregiver-child relationship and the child’s environment

Fostering parental sensitivity

Teaching parent to read and respond appropriately to child’s emotional cues

Teaching parent how to help child develop emotional regulation skills

Increasing stability and support in the child’s environment

Tend to be relatively short term, focused, and with clearly defined goals

Targeted populations: maltreating families, parents with substance abuse problems, depressed mothers, adolescent mothers, preterm infants, children in foster care and adopted children, children with prenatal alcohol exposure

68
Q

Perinatal mood and anxiety disorders (PMADs)

A

Onset during pregnancy and up to one year after delivery

Not to be confused with the “baby blues”

Major depressive disorder

Anxiety disorders (OCD, panic disorder, general anxiety disorder)

Bipolar disorder

Postpartum psychosis

69
Q

How common is maternal depression?

A

MDD: 3-5%

Low-income or minority women: 30-40%

Incidence 3x higher in postpartum

70
Q

Risks to mother of depression

A

Infrequent and late-entry prenatal care

Appetite disruptions

Sleep disturbances, fatigue

Increased risk of substance use and smoking

Suicidal thoughts and/or actions

71
Q

Risks to fetus/neonate of depression

A

Pre-term delivery

Low birth weight

Lower Apgar scores

Elevated “stress hormones”

72
Q

Risks to infant of depression

A

Increased crying and irritability

Decreased duration of breastfeeding

Increased risk of child abuse and neglect

Poor attachment to mother (emotional disconnection, less face-to-face, less skin-to-skin)

73
Q

Long-term effects of disrupted attachment

A

Cognitive delays

Poor social/emotional development

Affect dysregulation

Behavior disorders

Anxiety/depression

Substance abuse

Poor adult relationships

74
Q

High risk populations for PMADS in the hospital

A

Antepartum: high risk OB (particularly inpatient), infertility hx, perinatal loss hx, crisis pregnancy

Postpartum: traumatic delivery, adoption

NICU moms

PICU moms (child abuse/neglect)

Teen moms/single moms

Substance abusers

Domistic violence survivors

75
Q

The universal message

A

“You are not alone

“You are not crazy

“With the right help, you will feel better

76
Q

What are the risks with SSRIs in pregnancy?

A

Birth defects? Paxil (paroxetine) has possible increased risk of heart defect (FDA black box warning); possible uptick in spontaneous abortion (miscarriage)

Medical risks? Increased risk of preterm delivery, HTN, poor neonatal adaptation (PNA), question of increased risk of persistent pulmonary hypertension of the newborn (PPHN)

Long-term developmental effects? Little data, but what we have is reassuring; autism data under investigation

77
Q

Guidelines for perinatal antidepressant use

A

Use only when necessary and appropriate

Do not avoid if woman truly needs

Minimize number of exposures

Use lowest possible dose

Consider breastfeeding early and often

78
Q

Guidelines for antidepressant use during breastfeeding

A

Consider early in pregnancy or even before

Safest medications are sertraline (Zoloft), paroxetine (Paxil) and nortriptyline

Use lowest possible EFFECTIVE dose

Sleep disturbance heightens risk for relapse

It’s OK not to breastfeed

79
Q

Genetics of autism

A

60% monozygotic twin concordance

20% chance of having second child with ASD

However, 20% of individuals with AS have identifiable genetic disorders (Fragile X, tuberous sclerosis, Rett syndrome)

80
Q

Neurobiology of autism

A

Early dysregulation of brain growth: rapid early growth (white and gray matter), plateaus at age 2-4, likely affects long range connectivity

Aberrant connectivity (local overconnectivity and regional underconnectivity)

30% have macrocephaly

Most brain regions implicated

81
Q

DSM-IV TR criteria for autistic disorder

A

1) Qualitative impairments in social interaction
2) Qualitative impairments in communication
3) Restricted, repetitive and stereotyped patterns of behavior, interests and activities
4) Delay or abnormal functioning in at least one of the following areas, onset before age 3: social interaction, language as used in social communication, symbolic or imaginative play
5) Not better accounted for by Rett’s disorder or childhood disintegrative disorder

82
Q

DSM-IV TR diagnostic criteria for Asperger’s disorder

A

1) Qualitative impairments in social interaction
2) Restricted, repetitive and stereotyped patterns of behavior, interests and activities
3) Disturbance causes clinically significant impairment in functioning
4) No clinically significant general delay in language
5) No clinically significant cognitive or adaptive delay

83
Q

DSM IV-TR criteria for PDD (pervasive developmental disorder)-NOS

A

Severe and pervasive impairment in the development of reciprocal social interaction PLUS impairment in either verbal or non-verbal communication skills

OR

presence of stereotyped behavior, interests and activities

84
Q

Autism Spectrum Disorder (ASD)

A

In DSM-V, will have only ASD instead of autistic, asperger’s and PDD-NOS

85
Q

DSM-V ASD

A

A) Persistent deficits in social communication and social interaction across contexts

B) Restricted, repetitive patterns of behavior, interests, or activities

C) Symptoms present in early childhood (doesn’t have to be before age 3)

D) Symptoms limit/impair everyday functioning

E) Severity rating for each subdomain

F) Specifier for cause (ie Fragile X)

G) Modifier for other important factors (ie seizure disorder)

H) Assessment of overall impairment

86
Q

DSM-V Social communication disorder (SCD)

A

Impairment of pragmatics

Diagnosed based on difficulty with social uses of verbal and nonverbal communication which affects functional development of social relationships and discourse comprehension (combined social and communication instead of separating them like DSM-IV)

Cannot be explained by low abilities in word structure, grammar or general cognitive ability

Symptoms must be present in early childhood

ASD must be ruled out for SCD diagnosis

87
Q

Co-morbidities and clinical features of ASD

A

Core: social impairment, repetitive behaviors/restricted interests, speech/communication deficits (autism only)

Psychiatric sx: social phobia, ADHD, aggression, OCD

Cognitive?: expressive/receptive language disorders, intellectual disability

Other: immune dysfunction, sleep disturbance, motor problems (apraxia), macrocephaly, GI disturbance, epilepsy (EEG abnormalities)

88
Q

Sleep impairment in ASD

A

Very common (80%)

Most commonly insomnia

Delayed sleep onset, night awakening, early morning awakening, reduced need for sleep

Longer sleep latency, increased duration of stage 1 sleep, decreased non-REM sleep (stages 2-4), abnormal REM sleep

“Bad sleepers” have worse cognitive ability, affective problems, hyperactivity, etc

89
Q

Epilepsy in ASD

A

Abnormal EEGs in up to 50%

Epilepsy in 30%

No primary seizure type

Two peaks: early childhood and adolescence

ASD + intellectual disability = more likely to have epilepsy than ASD alone

More common in ASD girls

90
Q

Motor impairment in ASD

A

Repetitive behaviors part of diagnostic criteria (both because of insistence on sameness and repetitive behaviors)

More severe over development

More predominant in children with severe language impairment

Motor delay, hypotonia (improves over time), incoordination, gait impairment (toe walking common), apraxia, motor planning, postural control

No studied treatments for motor impairments except Risperidone for repetitive behaviors

91
Q

Infant motor data for ASD

A

Gross motor function at age 6 months significantly correlated with visual reception, receptive language and requesting at 12 months

92
Q

Psychiatric comorbidities of ASD

A

ADHD (cannot formally diagnose in ASD): inattention, hyperactivity

Anxiety (particularly as children get older)

OCD

Excessive repetitive behaviors

Irritability/behavioral problems

93
Q

Screening for ASD

A

At 18 months: M-CHAT, PDDST-II, Autism Screening Questionnaire

Immediate referral if: fails screening (“no” to 2 questions), no babbling/pointing by 12 mo, no spontaneous single words by 16 mo, no 2-word spontaneous phrases by 24 mo, any loss of language or social skills at any age, esp before 24 mo

94
Q

Diagnostic workup for ASD

A

Neuropsychological to test IQ, behavioral or emotional problems, learning profile

Genetics: karyotype, Fragile X, MECP2 mutation, chronosomal microarray analysis

MRI only if abnormal neuro exam or global developmental delay

EEG only if concern for seizures or language regression

95
Q

Treatment for autism

A

Treatment intensity more than 25 hrs/wk

High staff:student ratio

Teachers with special expertise

Individualized programs for each child

Behavioral treatment: ABA, PRT, DIR/floortime, JASPER

Pharmacotherapy: FDA approved for 5-16yo with ASD for irritability: Risperidone, Aripripazole (Abilify)

No medications shown to change social interaction or communication (core deficits)

96
Q

Treatment for sleep impairment

A

Behavioral interventions: bedtime routines, reinforcement and extinction, parent training

Pharmacologic: melatonin (3-6mg at bedtime), clonidine, trazadone

97
Q

Treatment for epilepsy

A

Because of heterogeneity, there is no gold standard treatment

Early recognition and treatment important

Anti-epileptics:

Leviteracitam: behavioral side effects

Valproid acid: liver toxicity

Benzodiazepines: drowsiness

Lamotrigine: SJS

98
Q

What is the significance of reductions in synaptic density and increases in myelination that occur throughout childhood and adolescence?

A

Get increased efficiency at the cost of decreased plasticity

As we get older, less used connections die away (synaptic pruning) but more used circuits are insulated with myelin, which increases conduction speed

99
Q

Are changes in the brain related to changes in cognitive functioning?

A

Yes!

Thick cortex = worse vocabulary

In kids with superior intelligence, their cortical thickness peaks later, which means they had more time for synaptic plasticity before pruning/making brain more efficient

100
Q

Changes in functional activation (fMRI) over development

A

Children have more diffuse activation whereas adults have more focal organized activation

This is thought to reflect decrease in plasticity and increased efficiency, and maybe the synaptic pruning/increased myelination

101
Q

Brain changes in FASD

A

Cortex is thicker in FASD (more is not better!)

102
Q

Brain changes in autism

A

In general: distal brain regions don’t communicate well, and there is excessive local information processing

Time course of development is altered

Evidence for early brain overgrowth followed by reduced growth trajectory

Autistic children begin life with larger amygdala, then develop at reduced rate

Abnormal growth of white matter: late-myelinating white matter compartments overdeveloped while earlier myelinating deep/bridging zones and longer range pathways less developed –> problems in long-range connections in the brain

Abnormal cortical folding in inferior frontal gyrus, inferior sensory and motor strips, pars opercularis (containing mirror neuron system for immitating)

Lower response to reward

103
Q

Brain changes in ADHD

A

Fronto-striatal network abnormalities

Increased prefrontal gray matter in hyperactivity in ADHD

104
Q

Dyslexia

A

Difficulty with written language (reading and spelling)

Differences in how brain processes written and/or spoken language

Many brain regions involved in reading, and dyslexic patients show structural differences from controls in these regions

105
Q

What does testosterone do to the brain?

A

Testosterone affects with cortex thickness

In boys, cortex gets thicker as testosterone increases

In girls, cortex gets thinner as testosterone increases

106
Q

Criteria for ADHD

A

6 out of 9 of innatentive symptoms and/or 6 out of 9 of hyperactive/impulsive symptoms

Symptoms present more often than not; chronic course

Some sx begun before age 7

107
Q

Diagnosing ADHD

A

No objective test

Several rating scales and questionnaires (Connors’ SNAP, SWAN) that are structured ways of asking about the DSM criteria

Must take developmental context into account

One 30 min encounter with a paient does not rule anything in or out

108
Q

Prognosis of ADHD

A

30-60% of people diagnosed with ADHD as children will continue to meet criteria for disorder as adults

In short term, medication results in significant improvement in academic functioning

In long term, academic benefits of medication are modest and medicated children with ADHD still do not perform as well as neurotypical peers, on average

Hyperactive/impulsive symptoms tend to improve by adulthood, but inattentive symptoms remain

109
Q

Co-morbidities of ADHD

A

Oppositional defiant disorder (ODD)/conduct disorder (25-33%)

Learning disorder/language disorder (25%)

Anxiety disorder (13%)

MDD (11%)

Substance abuse disorder (20-25%)

110
Q

Why treat ADHD?

A

Patients less likely to engage in criminal behavior than unmedicated patients

111
Q

Two main classes of ADHD medications

A

Stimulant: methylphenidate (concerta, ritalin) and mixed amphetamine salts (adderall, vivance)

Non-stimulant: atomoxetine, guanfacine, clonidine

112
Q

Side effects of ADHD treatment

A

Most common is appetite suppression

Insomnia, mood changes, increase in tics, cardiac arrhythmias

Long term stimulant use associated with slightly decreased height in children

113
Q

Non-pharmacological treatment for ADHD

A

Classroom or workplace modification, behavioral therapy, social skills training, psychoeducation

114
Q

Learning disorders criteria

A

DSM definition: discrepancy between aptitude and achievement in a particular skill

Federal IDEA standards: if child does not meet grade-level standards for the categories listed below and does not respond to evidence based intervention

115
Q

What does Federal law require if a child fails a state assessment exam?

A

Child must be given an evidence-based intervention in that area

If child does not respond to that intervention, evaluation is done and diagnosis of LD can be given

116
Q

Co-morbidities of learning disorders

A

38% with LD have ADHD

50% with LD also have ASD

Other: anxiety, ODD, conduct disorder

117
Q

Treatment for LDs

A

Tier 1: general classroom remediation

Tier 2: small group instruction

Tier 3: individual instruction, special education

No specific pharmacotherapy for LD, but treating co-morbid conditions always makes things better

118
Q

Genetics of ADHD and LDs

A

Both ADHD and reading disorder seem to have heritability of 60%

Hundreds of risk genes for ADHD, and overlap between risk genes for ASD, schizophrenia and ADHD

Candidate genes exist for reading disorder, with some overlap for risk with speech disorders

119
Q

Neurobiology of ADHD and LD

A

ADHD results from dysfunction of DA circuits in PFC, resulting in diminished executive function

Imaging studies have shown differences in L hermisphere occipito-temporal cortex and cerebellum between patients with reading disorder and controls; several candidate genes are involved in neuronal migration

120
Q

Appetite regulation

A

Interplay of neurochemical signaling in homeostatic and reward pathways

1) Direct regulation by stimulation or suppression of appetite in the hypothalamus in response to molecular signals from viscera
2) Indirect regulation by influencing the reward value of food in the mesolimbic reward pathway
3) Indirect modulation by higher brain systems

121
Q

Different signals that lead to appetite and feeding behavior

A

Cognitive input (desired body image, concepts of health, stress, etc) –> contextual information (cerebral cortex, amygdala, hippocampal formation) –> hypothalamus (compares input to biological set points) <–> mesolimbic reward pathways –> appetite and feeding behavior

Sensory inputs (visceral and somatic sensory pathways, chemosensory and humoral signs) –> hypothalamus (compares input to biological set points) <–> mesolimbic reward pathways –> appetite and feeding behavior

Note: biological set points are plastic and are established during development and can be influenced by habits and by environmental toxins

122
Q

Hypothalamic homeostatic centers that regulate appetite

A

Ventro-medial areas drive satiety (lesions cause hyperphagia and obesity)

Dorso-lateral areas drive feeding (lesions cause hypophagia and starvation)

123
Q

Orexigenic neuromodulators and anorectic neuromodulators in hypothalamic pathways

A

Orexigenic neuromodulators stimulate appetite: orexin, NPY, AgRP from hypothalamus; ghrelin from stomach

Anorectic neuromodulators inhibit appetite: histamine and alphaMSH from hypothalamus; leptin from adipocytes; insulin from pancreas

Appetite is directly regulated by neurochemical signaling in hypothalamic pathways

124
Q

How do hormones released by viscera (leptin, insulin, ghrelin) influence appetite?

A

They travel via circulation to modulate hypothalamic circuits

Leptin and insulin act on hypothalamic arcuate nucleus to suppress appetite

125
Q

How does leptin mediate “reward” associated with images of food?

A

If no leptin, nucleus accumbens activation by visual images of food is higher (will get more reward from looking at food)

Indirect regulation by influencing reward value of food by controlling DA release

Direct regulation by stimulation or suppression of appetite

126
Q

Do other things modulate reward circuits and influence appetite and feeding behavior?

A

Yes, neurochemical inputs of many kinds and from many sources (including higher brain centers like cortex, amygdala, etc) modulate reward circuits

Histamine, GABA, leptin, insulin are inhibitory

Ghrelin, orexin, glutamate, endocanabinoids are excitatory

Exogenous neurochemicals (drugs, meds) can also influence these pathways

127
Q

Negative feedback regulation of energy balance and glucose

A

Defects in negative feedback predispose to weight gain and insulin resistance

Fat mass and pancreas (producing insulin and leptin) feed back into hypothalamus which interacts with biological set points and reward system and perceived value of food and regulates food intake, energy expenditure and glucose production in the liver

Neurocentric model linking obesity, insulin resistance and T2DM: reduced neuronal insulin/leptin favors positive energy balance and hepatic insulin resistance

128
Q

What mediates anorexia in cancer and infections?

A

Same neurochemical signaling in reward and homeostatic pathways, which are influenced by pro-inflammatory cytokines

Pro-inflammatory cytokines stimulate anorectic and inhibit orexigenic pathways

129
Q

Key ponts about eating disorders

A

Eating disorders relatively rare among general population

Anorexia nervosa most common among young women

All eating disorders associated with increased risk of mortality

Binge eating most common in men and older people

130
Q

DSM-IV criteria for anorexia nervosa

A

Refusal to maintain body weight at or above a minimally normal weight for age and height (more than 85% of what is expected)

Intense fear of gaining weight or becoming fat, even though underweight

Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial or seriousness of current low body weight

In postmenarcheal females, amenorrhea (absence of at least 3 consecutive)

131
Q

Types of anorexia nervosa

A

Restricting type: during current episode of anorexia nervosa, person has not regularly engaged in binge-eating or purging behavior

Binge-eating/purging type: during current episode of anorexia nervosa, person has regularly engaged in binge-eating or purging behavior

132
Q

Medical signs of starvation

A

Bone: Ca2+ loss –> osteoporosis

Cardiac abnormalities, arrhythmia

Constipation (gut slows)

Orthostatic blood pressure changes

Amenorrhea

Electrolyte abnormalities (K+)

Renal compromise or failure

Body hair increases

Cognitive impairment

Cortisol regulation altered

133
Q

Relationship between AN/BN and leptin, ghrelin, BDNF, endocannabinoids

A

These appetite modulators affect non-homeostatic cognitive, emotional and rewarding component of food intake as well as non food-related reward

AN/BN pathophysiologically linked to dysfunctions of reward mechanisms

Development and/or maintenance of aberrant non-homeostatic behaviors such as self-starvation and binge eating may be due to changes in appetite modulators

134
Q

Epidemiology for AN

A

Incidence highest in females 15-19

Not clear if incidence is rising, although it might be in that age group

5 year recovery rate is 67%

Highest mortality rate of any mental disorder: 5% per decade

20% of those deaths are suicide

135
Q

DSM-IV criteria for bulemia nervosa

A

Recurrent episodes of binge eating, characterized by:

1) Eating, in a discrete period of time (within 2 hour period) an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
2) A sense of lack of control over eating during the episode

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise

The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months

Self-evaluation is unduly influenced by body shape and weight

The disturbance does not occur exclusively during episodes of AN

136
Q

Types of BN

A

Purging type: during current episode of BN, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Nonpurging type: during the current episode of BN, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

137
Q

Epidemiology of BN

A

Median onset at 12.4 years

Lifetime prevalence in US is 0.6%

88% report at least one other Axis I disorder

53% report suicidal thoughts

More prevalent in girls than boys

138
Q

Binge eating disorder

A

New diagnosis in DSM-V

Common in US adolescents

Diagnosis requires binging at least once a week for 3 months

No compensatory behavior, so may be overweight

139
Q

Eating disorder NOS

A

Very common diagnosis now using DSM-IV, but after DSM-V broadens AN and BN and adds binge eating disorder, won’t be used as much

140
Q

Body dysmorphic disorder

A

Not about eating per se but appears related in terms of distortion of body image

Focus on some aspect of appearance which is seen as ugly

Fixed delusion

Has fMRI similar to those of AN

Can lead to plastic surgery, with chronically dissatisfied result

141
Q

What causes eating disorders?

A

Way of coping with emotions and feelings of failure

Anorexia uses control of food, exercise and the body to combat a sense of losing control and to succeed

Binging uses food to try to soothe or get pleasure and then lose control

Both anorexia and bulimia have disordered focus on weight

Cultural expectations contribute to this, but certain temperaments will be more susceptible

Heredity is also a factor, as is learning in a family

142
Q

“Typical” temperaments

A

Anorexia: hard-working, perfectionist, demanding of self; when confronted with challenges of adolescence feels a bit overwhelmed and works even harder; usually has lost weight on purpose or with an illness, and discovers the power of control over the body

Bulimia: emotional, somewhat impulsive, may have a history of loss or trauma; may have binged or purged with others who were doing it casually (very common at college)

143
Q

Treatment of AN

A

Re-feeding is first, as this can be a medical emergency, but must be done gradually, even if by tube

Structured eating (learn to eat, but also tolerate feeling of fullness) and limited activity at first

Tolerative changes in body (which are not cosmetic at first)

Family therapy to change interactions about food and to change how family is controlled

Gradually add in appropriate activity

Work on self image about body, but only after patient is able to think clearly

144
Q

Treatment of BN

A

Prevent purging by observing after meals

Teach emotional regulation techniques

Treat co-morbid disorders

Family therapy similar to that for AN

Fluoxetine has been found to be useful in decreasing binging by over 50% in an open trial

CBT has been found to be helpful, and may be the treatment of choice for adults

145
Q

Stages of coming out

A

Sensitization: recognition of same-sex attraction (childhood - teens)

Identity confusion and experimentation

Identity assumption: self-ID as LGB and disclosure to friends, parents, family (late teens)

Identity commitment: LGB lifestyle and engagement in LGB community

146
Q

Teen milestones

A

Girls:

First aware 10-11

First L sex 15-17

ID 14-17

Disclosure 16-19

Boys:

First aware 9-13

First L sex 13-17

ID 12-17

Disclosure 16-20

147
Q

Sex-centered pattern vs. identity-centered pattern

A

Sex-centered pattern: may be associated with more internalized homophobia and risky sex, more heterosexual early experiences, M>F

Identity-centered pattern: childhood recognition, socio-historical change, F>M (80% L)

148
Q

Gender differences in homosexuals

A

Females have later first awareness, same-sex experience, self-identification than males

Females have more heterosexual experience and bisexual identity

Females more identity-centered development

Recently more females with bisexual ID

149
Q

Predictors of serious substance abuse in LGB

A

Parental physical abuse

Parents discourage gender-atypicality

Parents LGB insults

Gay verbal abuse

Gender atypicality in childhood

Family h/o SA

Being open with family (!)

150
Q

Protective factors

A

Family support (PFLAG)

Friends’ support

Internet support

Project 10 and GSA at school

Supportive school administration